Leitlinienprogramm OnkologiePsycho-oncology

10. Specifics of Individual Diagnosis Groups and Their Treatment – Psycho-oncology

Version 2.0 · May 2023 · AWMF 032-051OL
Leitlinienprogramm Onkologie · Deutsche Krebsgesellschaft · Deutsche Krebshilfe · AWMF

10.1 · Consensus-based Recommendation · checked 2023

All patients with specific impairments shall be diagnosed according to recommendations 7.1. to 7.6. with regard to the specific psychosocial stress.

Consensus
Consent (95%)

At this point, reference should be made to specific physical impairments and the resulting mental burdens of individual tumor diagnoses resulting from the tumor condition or the respective tumor-specific treatment. Depending on their specific characteristics, these can have an impact on the mental state and/or social situation of patients. These include, in particular, treatment-related sexual dysfunction, stress due to the permanent creation of a stoma, impairment due to high-dose chemotherapy followed by stem cell transplantation, removal of the larynx, as well as treatment-related impairment of patients with gastrointestinal tumors, patients with non-small-cell bronchial carcinoma after lung resection, and patients with brain tumors. Special treatment situations may also arise in young adult cancer patients, so-called ‚Adolescents and Young Adults‘ (AYAs), geriatric cancer patients, and people living with a cancer diagnosis (Cancer Survivors). In the context of all these specific burdens, there could arise psycho-oncological treatment needs, which are briefly discussed below.

10.1 Sexual Disorders

10.2 · Consensus-based Recommendation · checked 2023

Patients with sexual disorders should be offered sexual counseling in addition to the recommendations in Chapter 8.

Consensus
Strong consensus (100%)

Sexual dysfunction falls under the specific impairments that can occur in connection with various cancers. They basically have an influence on the patient's self-esteem, body image, and perceived sexual attractiveness, and thus also their quality of life. In particular, the sexual functions, such as appetence, lubrication, dyspareunia, erection or orgasm can be impaired, accompanied by negative effects on the relationship of the couple.

 

10.1.1 Sexual Dysfunction Associated with Breast Cancer and Gynecological Tumors

As a result of treatment, disorders of sexual function and body image and, consequently, self-esteem may occur. In addition, loss of fertility can result from the treatment of gynecological tumors. It should be taken into account that the gynecological treatment situation differs from many other medical interventions in that a particularly self-related, emotional area is touched [936], [937].

The recommendations of the following guidelines apply to the treatment of patients with gynecologic tumors:

S3 Guidelines:

S2k Guidelines:

In patients with breast carcinoma, negative effects on body image after surgical breast cancer treatment are common [938]. Especially during the first year after the diagnosis, patients experience worry and uncertainty due to physical changes [939]. The extent to which patients experience different levels of body image distress after mastectomy, BET and reconstruction is not uniformly described in the literature [940], [941], [942], [943], [944], [945], [946].

Patients also show lower satisfaction with their sexuality. Radiation therapy treatment may also affect body image in association with radiation fibrosis, increased skin pigmentation, or dilation of blood vessels. As a result of adjuvant chemotherapy and depending on the agents administered, patients feel impaired by sexual dysfunction such as decreased appetence, lack of vaginal lubrication, or dyspareunia. Antiestrogen use can lead to typical menopausal symptoms, with vaginal dryness, in particular, causing pain during sexual intercourse [947].

In the case of cervical carcinoma, patients' sexuality is particularly affected if extensive surgery had to be performed and adhesions in the surgical area or shortening of the vagina have occurred. In addition, surgery-related nerve injury can interfere with lubrication. Radiation therapy treatment can cause radiation fibrosis or fistula formation and make vaginal tissue more susceptible to infection. All of these treatments, as well as pain, can make sexual intercourse very difficult [948], [949].

In patients with endometrial carcinoma, depending on the stage of the tumor, a surgical procedure is performed in which the uterus, ovaries and fallopian tubes are removed and, if necessary, followed by radiation and/or chemotherapeutic treatment, depending on the initial situation. These interventions can massively affect the patients' sexual activity (see above).

The treatment of ovarian carcinoma, which usually involves bilateral ovariectomy, can result in atrophy and inadequate dilatation of the vulva as well as inadequate lubrication due to the estrogen deficiency that occurs. In addition, adhesions may occur in the surgical area and, as a result, pain may occur during sexual intercourse. Removal of the ovaries results in menopause in patients who had menstrual periods before the operation and is accompanied by typical menopausal symptoms [950].

In patients with vulvar carcinoma, radical vulvectomy usually leads to massive impairment of normal sexual intercourse and dyspareunia [951].

10.1.2 Sexual Dysfunction Associated with Urologic Tumors in Men

Numerous effects on sexuality can be expected from existing treatment methods in the uro-oncology. This also applies to surgical measures, especially when neuronal structures that are essential for sexual sensation and sexual responsiveness (e.g., in the context of radical prostatic vesiculectomy or cystectomy) are compromised or removed. Changes in body image associated with surgical procedures (e.g., semicastratio, complete or partial penectomy) should also be considered as causes. Radiation and chemotherapeutic agents also have a negative effect on sexual function and fertility [952]. Finally, various hormone therapies (especially LHRH analogues) should be mentioned which may cause sexual dysfunction.

For the treatment of patients with urologic tumor diseases, the recommendations of the following S3 guidelines apply:

Treatment of prostate cancer may directly affect sexual functioning. If a prostatic vesiculectomy is performed for a localized tumor, this may be associated with loss of erectile function. Accordingly, patients are often concerned about the sexual consequences of the disease and its therapy [953], although the fears regarding sexual impairment are often greater than those regarding the actual dysfunction [954].

Tal et al. [954] described in their meta-analysis the proportion of patients who regained erectile function after radical prostatectomy. A total of 22 high-quality studies (n = 4,983) were identified. The rate of patients who regained normal erectile function postoperatively was found to be 58%. The surgical procedure (open vs. laparoscopic) had no influence. Age showed a protective character. Even with nerve-sparing procedures, surgery carries a risk of sexual dysfunction that is difficult to assess. However, the ability to orgasm is not necessarily lost. Radiation therapy treatment may cause vascular damage to the blood vessels in the corpus cavernosum, resulting in erectile dysfunction, pain during ejaculation, or inflammatory changes. As a result of surgery as well as hormone treatment in advanced stages, there is a decrease or even complete disappearance of sexual desire [955], [956], [957], [958].

It stands to reason that bladder cancer has an impact on sexual satisfaction and functioning. Botteman et al. [959] note the lack of studies on this topic and state that impairment in sexual quality of life is common in both superficial and invasive bladder cancer. If a cystectomy has been performed for bladder cancer, sexual dysfunction is a significant problem. Depending on the radical nature of the surgery, men experience erectile dysfunction and even impotence. [960], [961], [962].

Two older reviews of sexual function after testicular tumor specifically address the question of what disorders are common after testicular cancer. Jonker-Pool et al. [963] indicate that ejaculatory dysfunction (44%) is particularly common. A decrease in sexual activity, orgasmic disturbances, dissatisfaction with sexuality, and a reduction in sexual appetence are shown by 19 to 24% in retrospective studies and 9 to 18% in prospective studies. A systematic review by Nazareth et al. [964] also reports that the odds ratio for impaired ejaculatory ability is 28.6% at two years postintervention. The rate for orgasmic dysfunction is reported to be 4.6 and the rate for erectile dysfunction is 2.5. A large proportion of patients with testicular carcinoma already have spermatogenesis disorder at the time of diagnosis. If chemotherapy is required, approximately one-quarter of patients remain azoospermic. If patients were fertile at diagnosis, only half regain normal spermiogenesis after two years. If damage to the sympathetic border cord occurs due to removal of the retroperitoneal lymph nodes, this can lead to loss of antegrade ejaculation [957].

Surgical therapy is usually chosen for the treatment of penile carcinoma. Depending on the extent of the disease, surgery ranges from removal of the tumor to complete penile amputation. Penile carcinoma has a massive impact on sexual functioning and satisfaction. In a study by Romero et al. [965], it was shown that as many as 55.6% of patients maintained erectile function and sexual intercourse took place. 2/3 of patients reported sexual desire equivalent to that before surgery. In contrast, only one-third of patients had sexual intercourse with a frequency and satisfaction similar to that before surgery. The reason for impaired sexuality was often shame because of postoperative penile length and the absence of the glans penis. In a review by Maddineni et al. [966], a frequency of impaired sexual function is described in about 2/3 of those affected [967].

 

10.1.3 Sexual Disorders associated with Malignant Lymphomas and Leukemias

Patients suffering from malignant lymphoma who receive intensive chemotherapy, possibly in combination with radiation therapy, must expect damage to their sexual organs. Chemotherapy affects the function of the ovaries in women and the testicles in men. The extent of impairment and the length of recovery depend on the total dose of agents administered, as well as the age and general physical condition of the patient's body.

Chemotherapeutic treatment of acute lymphoblastic leukemia (ALL) or acute myeloid leukemia (AML) shows impairment of sexual function in men. For example, germinal cell aplasia with azoospermia occurs after induction chemotherapy, although this usually resolves in the 2nd year of maintenance therapy. High-dose chemotherapy combined with total body irradiation usually has irreversible consequences on fertility. Irreversible germinal cell aplasia occurs. In women, ovarian insufficiency occurs in many cases.

10.1.4 Sexual Dysfunction associated with an Ileostomy, Colostomy, or Urostomy

The creation of an ileostomy, colostomy or urostomy usually means a radical change in the patient's life. In connection with this, many stoma carriers experience a strong negative perception of their body image. As a result, the affected patients are challenged to come to terms with their changed body image. This is all the more difficult the more massive the disfigurement is perceived to be and the more impairing the functional limitations (e.g. in the sexual sphere) are. It is precisely this outwardly visible body change caused by a stoma that often makes acceptance difficult and leads to adjustment disorders and even persistent depression. For some of those affected, feelings of shame and disgust, as well as fear of dirt and odor, or the fear of uncontrollable noise development become a great psychological burden, which in turn has a serious inhibiting effect on the need for intimacy. In this respect, stoma patients often feel that their sexual life is negatively burdened by the stoma [968], [969]. The patient's self-esteem can be significantly reduced by a stoma, so that physical, sporting and social activities, as well as taking up a job, are experienced as difficult and stressful and lead to mental impairments.

10.2 Impairments after High-dose Chemotherapy Followed by Allogeneic Stem Cell Transplantation

High-dose chemotherapy followed by allogeneic stem cell transplantation, together with „conditioning“ and subsequent transfusion of the stem cells, can trigger a specific, serious immunological complication, the so-called GvH reaction (Graft versus Host Disease, GvHD for short). Transplantation-associated problems manifest as severe infections and changes in the mucous membranes of the gastrointestinal tract and liver, as well as visible changes in the skin. These external changes can lead to feelings of shame and impaired self-esteem and promote withdrawal behavior and social isolation. In addition to the effects of transplantation, such as pronounced fatigue, the loss of libido and sexual dysfunction, and, for younger patients, the often unfulfillable desire to have children, place an enormous mental burden [970], [971], [972].

10.3 Impairments After Removal of the Larynx in Laryngeal Carcinoma

If the larynx is removed as a result of laryngeal carcinoma, the mental distress caused by such an operation is associated with drastic consequences for the rest of life. In addition to a limited sense of smell and taste, the permanent loss of the voice is in the foreground, and with it, the loss of the ability to communicate and thus the associated social functioning. This can lead to a severe impairment of self-esteem and social isolation. With appropriate aids, patients can learn to communicate again. Nevertheless, for many patients, a permanent impairment of quality of life remains [973].

The follow-up appointments are also often associated with anxiety and stress for the patients and their relatives, as these appointments lend particular weight to the disease that has been experienced and give rise to uncertainty as to whether they will remain tumor-free.

The psychosocial problems described here also apply, with slight differences, to patients with other head and neck tumors, such as pharynx or oral cavity, who are also an important target group for psycho-oncological support.

10.4 Specific Burdens Resulting from the Treatment of Patients with Gastrointestinal Tumors

Patients with esophageal cancer who have undergone surgery or conservative radiochemotherapy quite often suffer from dysphagia and weight loss. Reflux due to the lack of cardia function is also common. It is also possible that the nerves of the vocal cords may be damaged, thus resulting in impaired voice production.

Pronounced reflux symptoms can also cause major problems for gastric cancer patients who have undergone subtotal resection or gastrectomy whereby the cardia has been removed.

The side-effects of surgery in patients with colon carcinoma are often diarrhea and voiding dysfunction, or even incontinence as well as meteorism. After adjuvant chemotherapeutic treatment, severe neurological sequelae often develop which may cause long-term stress to the patient and lead to occupational disability [974].

Patients with a rectal cancer can also experience a multitude of highly stressful side effects as a result of a multimodal treatment, some of which permanently restrict their quality of life. These also include considerable problems with defecation, which leads to great uncertainty among patients and in many cases prevents them from going about their daily lives outside their own homes and participating in a social life. 

Patients with pancreatic cancer who have undergone surgery often have a disturbance of the exocrine and endocrine functions of the pancreatic remnant. This leads to digestive disorders such as diarrhea, fatty stools, and meteorism, as well as various degrees of diabetes mellitus.

A large part of the treatment-related sequelae that patients with gastrointestinal tumors suffer from can have an enormous impact on their quality of life. In particular, the experienced loss of control over excretory functions is accompanied by pronounced feelings of shame and insecurity. This can have a considerable impact on sexuality and relationships, as well as on social and professional activities. In light of this, depressive and anxiety-related disorders among patients with gastrointestinal tumors can be explained. A prospective study by Krauß and colleagues at the University Hospital for Surgery in Leipzig shows that 19% of patients fulfilled the criteria of one or more mental disorders according to ICD10, of which 10% had an immediate relevance for psycho-oncological treatment [974].

For the general treatment of patients with gastrointestinal tumors, the recommendations of the following S3 guidelines apply:

10.5 Specific Burdens of Patients with Bronchial Carcinoma after Lung Resection

In addition to surgical pain and decreased physical activity tolerance, the cardiac load also increases for these patients together with increasing lung parenchymal loss and associated decreased oxygen uptake. Increasing degrees of exercise-induced dyspnea, exacerbated by exercise or fatigue-induced tachycardic arrhythmias, are often associated with disturbances in self-concept and body image, sexuality, and overall major limitations in social interactions. Experiencing these highly stressful physical limitations often triggers marked anxiety and depression, necessitating psycho-oncological co-treatment [975], [976].

The follow-up appointments are also often associated with anxiety and stress for the patients and their relatives, as these appointments lend particular weight to the disease that has been experienced and give rise to uncertainty as to whether they will remain tumor-free.

10.6 Specific Burdens on Patients with Brain Tumors

Brain tumor patients and their relatives suffer not only from the burdens of cancer, such as a limited prognosis and the stressful therapies, but also from the fact that the self, one's own identity, is affected. Therefore, the neurological and neuropsychological limitations have a different quality than physical symptoms. In addition to motor function, sensory function, or speech; memory, attention or personality can also be affected and have a significant negative impact on everyday life and the quality of life. Regardless of the tumor grade, fatigue, lack of drive, memory difficulties, sleep disturbances and stress are among the most serious problems during the course of the disease [977].

Acutely, there are always crisis events in the course of the disease. Goebel reports that 23% of the patients had an acute stress reaction according to DSM-IV criteria at the beginning of therapy and another 4% had subsyndromal values. 57% of patients reported that discovering the tumor or receiving the diagnosis was the most stressful event [978]. A prospective screening study of 472 patients undergoing brain tumor surgery showed depressive symptoms in 7% and anxiety symptoms in 12% during the inpatient postoperative course, with a threshold score of ≥11 on the HAD scale. However, subjective distress was 63% on the Distress Thermometer (≥5) regardless of the size of the diagnosed brain tumor [979]. In the outpatient setting, progression anxiety has a high rate of about 40%. Regardless of sociodemographic data and tumor characteristics, the greatest worries are those about one's family and fear of medical treatment. Additionally, patients with high progression anxiety scores were more anxious and depressed and reported a poorer quality of life [980].

Over the long-term, the pooled prevalence of psychosocial distress was 38.2% in a meta-analysis by Liu [981]. The pooled prevalence for depression of brain tumor patients was 21.7% and remained unchanged over the long-term course [982].

Not only the patients suffer from the aforementioned problems and symptoms, but also the social environment as well. A review by Applebaum shows that relatives of brain tumor patients are already particularly burdened at an early stage of the disease. Existential issues are: identity, isolation, responsibility and guilt, fear of death, meaning of the disease and spirituality [983].

Established screening instruments can also be applied to brain tumor patients, although only the Distress Thermometer has been validated for brain tumor patients [471]. The problem list has recently been adapted to the special distress factors of neuro-oncological patients and, among other items, has been supplemented by the subject „Epilepsy“ as well as by the rubric „Neuropsychological Problems“ [984]. Within the framework of a multicentric study, the stress thermometer adapted for neuro-oncological patients will be validated in the German-speaking region in the near future. 

The effectiveness of general psycho-oncological interventions is well documented. However, there are hardly any specific offerings for brain tumor patients. In the review by Pan-Weisz, only two RCT’s (home-based psychosocial intervention and individualized acupuncture with standardized rehabilitation, respectively) showed an improvement in health-related quality of life. Overall, the development and evaluation of specific interventions has clearly remained behind those of more common cancers, but first small studies encourage that, for example, physical activity [985], [986], [987] of brain tumor patients is safely feasible and beneficial.

10.7 Specific Burdens on Young Adult Cancer Patients (AYAs)

The specific burdens on AYAs relate in particular to fertility and family planning issues [988]. They may also have to deal with loss of autonomy, changes in relationships, and interruptions in education. In some cases, this may be coupled with financial losses and economic problems [989], [990]. When addressing fertility issues, questions of sexuality or sexual dysfunction, sexual identity, body image, and contraception must also be considered.

In particular, therapy must be coordinated on a multidisciplinary basis [991]. In young breast cancer patients, it must be considered that the rate of genetic related cancers is higher than in older women and also requires special counseling and planning with regard to family planning aspects. More often (than in older women > 40 years), tumors are also diagnosed at more advanced tumor stages [991]. Promoting social integration of AYAs after a cancer illness is important to prevent social isolation and to maintain or restore the patient's quality of life. If the opportunities to participate in social life remain largely unrestricted, this has a positive effect on psychological well-being. Psychosocial interventions to improve participation opportunities should be offered to particularly vulnerable patients and should be age-specific [992],[993].

It should be noted that long-term AYA survivors can also develop long-term depression and anxiety (see Chapter 10.9), which means that the cancer diagnosis can also have a decisive impact on their future.

The Internet and social media are an important source of information for this group of patients [994].

10.8 Specific Burdens on Older Cancer Patients

More than half of all cancer patients are older than 65 years [995]. However, as this group of patients is underrepresented in studies [996], there is little concrete data on their needs during cancer treatment [997]. Although coping with cancer is often better in older people than at a younger age (see above) [998], the parallel occurrence of age-related co-morbidities can pose an independent stress factor. Consequently, this may lead to increased distress, depression and anxiety [999]. The effects of aging in combination with cancer may cause an increased vulnerability to anxiety and depression [1000]. Increased suicidality should be taken into account in older cancer patients, as older cancer patients have the highest rate of completed suicide [1001], [751]. At the same time, depression decreases the adherence to therapy and thus the prognosis the patient as well. However, it is often difficult to correctly diagnose depression in elderly patients and to adequately treat it consecutively, the episodes are often more severe and recurrences occur more frequently [1002]). The symptomatology may vary in older people („depression without sadness“) [1003].

A geriatric assessment can help to identify specific features [1004].

10.9 Specific Burdens on People Living with a Cancer Diagnosis (Cancer Survivors)

10.3 · Consensus-based Statement · new 2023

Long-term cancer survivors may continue to suffer from ongoing emotional, physical and functional problems, and unmet needs that significantly impact the quality of life many years after treatment and diagnosis of their disease.

Consensus
Strong consensus (100%)
10.4 · Consensus-based Recommendation · new 2023

The emotional, physical, functional, and social problems of long-term cancer survivors should be identified in the various care settings in order to determine a need for counseling and treatment and to offer the appropriate provision of care.

Consensus
Consent (81%)
10.5 · Consensus-based Recommendation · new 2023

The interventions outlined in Chapter 8 shall also be offered to long-term cancer survivors in long-term follow-up care.

Consensus
Strong consensus (97%)

The working group „Long-term survival after cancer“ (WG LONKO) in the National Cancer Plan bases its definition of „Survivor“ on that of the National Coalition for Cancer Survivorship (NCCS), according to which every patient with a cancer diagnosis is a cancer survivor. However, a classification into different phases makes more sense: pre/post-treatment, acute, intermediate and long-term survivorship. Survivor status includes cancer-free survival, sustained remission, and living with (chronic) cancer. The close social network of the patients is referred to as „secondary survivors“.

Most long-term cancer survivors cope very well with their life after the disease and therapy, but a substantial proportion suffers from persistent cancer-associated anxiety, post-traumatic stress, as well as anxiety disorders or depression that impair the (health-related) quality of life [1005],[1006].

Long-term survivors suffer from emotional (anxiety, depression, sexual or body image disorders), physical (fatigue, cognitive impairment, neurotoxicity), and functional problems (limited mobility), of which 38% reported problems in all domains. Only 7% reported having no problems. 63% of respondents reported unmet needs in all three areas, and 79% received no help for these [1007]. Long-term survivors are at increased risk for persistent severe psychological distress, anxiety, and depression even 5 and10 years after therapy ([1008], [1009], [1010], [1011].

Psychological stress and anxiety may even increase over the years following the initial diagnosis [1012] [1013] or their intensity does not diminish with time ([1014]). Anxiety and distress affect all survivor groups (young adults, employed, childhood cancer survivors, adult long-term survivors) and all entities, but the quality of study data varies considerably [1006]. In the CCCS (Childhood Cancer Survivor Study), 11% of survivors showed anxiety or depressive symptoms compared to only 5% of healthy siblings [D'Agostino, Norma Mammone et al. 2016]. The corresponding Danish study, which examined longitudinal outcomes, found that just under 9% of adult CCS had persistent depression and just under 5% had anxiety ([1016]). Among hematologic AYAs, for example, 28% met criteria for depression, 23% for anxiety disorder, and 13% for PTSD [1017]. Other studies arrive at inconsistent results due to differences in populations, methods, and measurement tools.

Among older survivors (> 40 years), 18-20% have anxiety symptoms [1018], [1019], [1020]. Posttraumatic stress symptoms are common, whereas manifest disorder is rare. However, a meta-analysis showed that PTSD is more common among survivors than healthy controls [1021]. Up to 80% of former patients suffer from recurrence anxiety [1022], especially at follow-up appointments [1023]. According to a meta-analysis [1024], 16% of survivors in a non-palliative situation suffer from manifest depression.

Cancer-related cognitive impairments such as impaired short-term memory, executive function, attention or processing speed are also common symptoms reported by cancer survivors and negatively affect their quality of life (in terms of returning to work, social relationships, self-satisfaction). Most of the data here come from studies with breast cancer patients after chemotherapy [1025]. Cognitive complaints are reported in more than 50% of cases, but these can only be objectified in 15-25% of cases [1026]. There is also evidence that modern hormonal therapies, immune, or targeted therapies have an impact on cognitive abilities [1027], [1026]. It remains unclear whether the deficits result from the disease itself, therapy, and/or psychological factors. Factors such as age, genetic polymorphisms, and psychosocial components appear to predispose to a higher risk of cognitive dysfunction [1026].

Fatigue is the most common and distressing symptom complex described by cancer patients during the course of their disease, from diagnosis to the end of life. During active tumor treatment (chemotherapy and/or radiotherapy), 80-90% of patients report fatigue; at the time of diagnosis about 40% [1028]. However, hormone therapies, targeted therapies, or immunotherapies are also discussed as a cause of fatigue, especially if they are administered as combination therapy [1029]. One third of patients report persistent fatigue even several years after the end of therapy [1030].

References

[936] Dörfler, Daniela, Störungen der weiblichen Sexualfunktion bei onkologischen Patientinnen, in Onkologische Rehabilitation: Grundlagen, Methoden, Verfahren und Wiedereingliederung, Crevenna, Richard , Editor. 2020, Springer: Berlin, Heidelberg. p. 237-248., https://doi.org/10.1007/978-3-662-57982-4_13

[937] Tiechl, Johanna, Marth, Christian, Sexualität nach der Therapie gynäkologischer Malignome, in Praxisbuch Gynäkologische Onkologie, Petru, EdgarFink, DanielKöchli, Ossi R. and Loibl, Sibylle, Editors. 2019, Springer: Berlin, Heidelberg. p. 267-273., https://doi.org/10.1007/978-3-662-57430-0_21

[938] Jabłoński, Marcin J., Mirucka, Beata, Streb, Joanna, Słowik, Agnieszka J., Jach, Robert, Exploring the relationship between the body self and the sense of coherence in women after surgical treatment for breast cancer, Psycho-Oncology, 2019. 28(1): p. 54-60., http://www.ncbi.nlm.nih.gov/pubmed/30286514

[939] Rezaei, Maedeh, Elyasi, Forouzan, Janbabai, Ghasem, Moosazadeh, Mahmood, Hamzehgardeshi, Zeinab, Factors Influencing Body Image in Women with Breast Cancer: A Comprehensive Literature Review, Iranian Red Crescent Medical Journal, 2016. 18(10):, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5291938/

[940] Jacobsen, P. B., Roth, A. J., Holland, J. C., Surgery, in Psycho-oncology, Holland, J. C. , Editor. 1998, Oxford University Press: New York. p. 257-268.

[941] Archangelo, Silvania de Cassia Vieira, Sabino Neto, Miguel, Veiga, Daniela Francescato, Garcia, Elvio Bueno, Ferreira, Lydia Masako, Sexuality, depression and body image after breast reconstruction, Clinics (Sao Paulo, Brazil), 2019. 74: p. e883., http://www.ncbi.nlm.nih.gov/pubmed/31166474

[942] Gass, Jennifer, Mitchell, Sunny, Hanna, Michael, How do breast cancer surgery scars impact survivorship? Findings from a nationwide survey in the United States, BMC Cancer, 2019. 19(1): p. 342., https://pubmed.ncbi.nlm.nih.gov/30971201/

[943] Jendrian, Svenja, Steffens, Katharina, Schmalfeldt, Barbara, Laakmann, Elena, Bergelt, Corinna, Witzel, Isabell, Quality of life in patients with recurrent breast cancer after second breast-conserving therapy in comparison with mastectomy: the German experience, Breast Cancer Research and Treatment, 2017. 163(3): p. 517-526., http://www.ncbi.nlm.nih.gov/pubmed/28324266

[944] Lam, Wendy W. T., Li, Wylie W. Y., Bonanno, George A., Mancini, Anthony D., Chan, Miranda, Or, Amy, et.al. Trajectories of body image and sexuality during the first year following diagnosis of breast cancer and their relationship to 6 years psychosocial outcomes, Breast Cancer Research and Treatment, 2012. 131(3): p. 957-967., http://www.ncbi.nlm.nih.gov/pubmed/21971728

[945] Sun, Young, Kim, Sung-Won, Heo, Chan Yeong, Kim, Dongwon, Hwang, Yoonsun, Yom, Cha Kyong, et.al. Comparison of quality of life based on surgical technique in patients with breast cancer, Japanese Journal of Clinical Oncology, 2014. 44(1): p. 22-27., http://www.ncbi.nlm.nih.gov/pubmed/24277749

[946] Rosenberg, Shoshana M., Tamimi, Rulla M., Gelber, Shari, Ruddy, Kathryn J., Kereakoglow, Sandra, Borges, Virginia F., et.al. Body image in recently diagnosed young women with early breast cancer, Psycho-Oncology, 2013. 22(8): p. 1849-1855., http://www.ncbi.nlm.nih.gov/pubmed/23132765

[947] Burstein, Harold J., Lacchetti, Christina, Anderson, Holly, Buchholz, Thomas A., Davidson, Nancy E., Gelmon, Karen A., et.al. Adjuvant Endocrine Therapy for Women With Hormone Receptor–Positive Breast Cancer: ASCO Clinical Practice Guideline Focused Update, Journal of Clinical Oncology, 2019. 37(5): p. 423-438., https://ascopubs.org/doi/10.1200/JCO.18.01160

[948] Klee, M., Thranov, I., Machin Prof, D., The patients' perspective on physical symptoms after radiotherapy for cervical cancer, Gynecologic Oncology, 2000. 76(1): p. 14-23., https://pubmed.ncbi.nlm.nih.gov/10620435/

[949] Li, C., Samsioe, G., Iosif, C., Quality of life in endometrial cancer survivors, Maturitas, 1999. 31(3): p. 227-236., https://pubmed.ncbi.nlm.nih.gov/10340282/

[950] Norton, Tina R., Manne, Sharon L., Rubin, Stephen, Carlson, John, Hernandez, Enrique, Edelson, Mitchell I., et.al. Prevalence and predictors of psychological distress among women with ovarian cancer, Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology, 2004. 22(5): p. 919-926., https://pubmed.ncbi.nlm.nih.gov/14990648/

[951] Andersen, B. L., van Der Does, J., Surviving gynecologic cancer and coping with sexual morbidity: an international problem, International Journal of Gynecological Cancer: Official Journal of the International Gynecological Cancer Society, 1994. 4(4): p. 225-240., https://pubmed.ncbi.nlm.nih.gov/11578412/

[952] Monga, Uma, Sexual Functioning in Cancer Patients, Sexuality and Disability, 2002. 20(4): p. 277-295., https://doi.org/10.1023/A:1021609530248

[953] Knight, Sara, Latini, David, Sexual Side Effects and Prostate Cancer Treatment Decisions, Cancer journal, 2009. 15(1): p. 41-4., https://pubmed.ncbi.nlm.nih.gov/19197172/

[954] Tal, Raanan, Alphs, Hannah H., Krebs, Paul, Nelson, Christian J., Mulhall, John P., Erectile Function Recovery Rate after Radical Prostatectomy: A Meta-Analysis, The Journal of Sexual Medicine, 2009. 6(9): p. 2538-2546., https://pubmed.ncbi.nlm.nih.gov/19515209/

[955] Fritzsche, K., Diederich, D., Schultze-Seemann, W., Psychoonkologie des Prostatakarzinoms. Psychosoziale Belastungen und Behandlungsansätze: Eine systematische Literaturübersicht, Z Psychosom Med Psychother, 2008. 54: p. 329-353.

[956] Fischer, C., Hauck, E. W., Hochreiter, W. W., Krause, W., Lohmeyer, J., Ludwig, D., et.al. Erkrankung der männlichen Geschlechtsorgane, in Männermedizin, Schill, Wolf-BernhardBretzel, Reinhard and Weidner, Wolfgang, Editors. , Urban & Fischer: München.

[957] Richter, D., Geue, K., Matthes, A., Berberich, H. J., Alexander, H., Strauß, B., et.al. Fertilität und Krebs – Skizzierung des Problemfeldes, PPmP - Psychotherapie · Psychosomatik · Medizinische Psychologie, 2010. 61(06): p. 246-253., https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0030-1268424

[958] Treiber, U., Sattel, H., Dinkel, A., Marten-Mittag, B., Westenfelder, K., Hatzichristodoulou, G., et.al. Psychosoziale Belastungsfaktoren bei Patienten mit Prostatakarzinom nach radikaler Prostatekotomie, 2010.

[959] Botteman, M. F., Pashos, C. L., Hauser, R. S., Laskin, B. L., Redaelli, A., Quality of life aspects of bladder cancer: a review of the literature, Quality of Life Research: An International Journal of Quality of Life Aspects of Treatment, Care and Rehabilitation, 2003. 12(6): p. 675-688., http://www.ncbi.nlm.nih.gov/pubmed/14516177

[960] Somani, B. K., Gimlin, D., Fayers, P., N'Dow, J., Quality of Life and Body Image for Bladder Cancer Patients Undergoing Radical Cystectomy and Urinary Diversion—A Prospective Cohort Study With a Systematic Review of Literature, Urology, 2009. 74(5): p. 1138-1143., https://pubmed.ncbi.nlm.nih.gov/19773042/

[961] Hedgepeth, R. C., Gilbert, S. M., He, C., Lee, C. T., Wood, D. P., Jr., Body image and bladder cancer specific quality of life in patients with ileal conduit and neobladder urinary diversions, Urology, 2010. 76(3): p. 671-675., https://pubmed.ncbi.nlm.nih.gov/20451964/

[962] Philip, J., Manikandan, R., Venugopal, S., Desouza, J., Javlé, P. M., Orthotopic neobladder versus ileal conduit urinary diversion after cystectomy--a quality-of-life based comparison, Annals of the Royal College of Surgeons of England, 2009. 91(7): p. 565-569., https://pubmed.ncbi.nlm.nih.gov/19558757/

[963] Jonker-Pool, Grieteke, Van de Wiel, Harry B. M., Hoekstra, Harald J., Sleijfer, Dirk Th, Van Driel, Mels F., Van Basten, Jean P., et.al. Sexual Functioning After Treatment for Testicular Cancer—Review and Meta-Analysis of 36 Empirical Studies Between 1975–2000, Archives of Sexual Behavior, 2001. 30(1): p. 55-74., https://doi.org/10.1023/A:1026468707362

[964] Nazareth, I., Lewin, J., King, M., Sexual dysfunction after treatment for testicular cancer: a systematic review, Journal of Psychosomatic Research, 2001. 51(6): p. 735-743., http://www.ncbi.nlm.nih.gov/pubmed/11750296

[965] Romero, Frederico Ramalho, Romero, Karen Richter Pereira dos Santos, Mattos, Marcus Augusto Elias de, Garcia, Carlos Ricardo Camargo, Fernandes, Roni de Carvalho, Perez, Marjo Deninson Cardenuto, Sexual function after partial penectomy for penile cancer, Urology, 2005. 66(6): p. 1292-1295., http://www.ncbi.nlm.nih.gov/pubmed/16360459

[966] Maddineni, Satish B., Lau, Maurice M., Sangar, Vijay K., Identifying the needs of penile cancer sufferers: a systematic review of the quality of life, psychosexual and psychosocial literature in penile cancer, BMC urology, 2009. 9: p. 8., http://www.ncbi.nlm.nih.gov/pubmed/19664235

[967] Dräger, D. L., Milerski, S., Sievert, K. D., Hakenberg, O. W., Psychosocial effects in patients with penile cancer : A systematic review, Der Urologe. Ausg. A, 2018. 57(4): p. 444-452., http://www.ncbi.nlm.nih.gov/pubmed/29476193

[968] Zettl, S., Hartlapp, J., Sexualstörungen durch Krankheit und Therapie. Ein Kompendium für die ärztliche PraxisSpringer, 1997., https://link.springer.com/book/10.1007/978-3-642-60809-4

[969] Englert, G., Belastungen, Unterstützungs- und Informationsbedarf von Stomaträgern, ILCO-PRAXIS, 2004. 31: p. 41-46.

[970] Andrykowski, M. A., McQuellon, R. P., Psychosocial Issues in Hematopoietic Cell Transplantation, in Thomas' Hematopoietic Cell Transplantation, Appelbaum, F. R.Forman, S. J.Negrin, R. S. and Blume, K. G., Editors. 2009, Wiley-Blackwell. p. 497-507.

[971] Mosher, C. E., Redd, W. H., Rini, C. M., Burkhalter, J. E., DuHamel, K. N., Physical, psychological, and social sequelae following hematopoietic stem cell transplantation: a review of the literature, Psycho-Oncology, 2009. 18(2): p. 113-127., https://pubmed.ncbi.nlm.nih.gov/18677717/

[972] Tierney, D. K., Sexuality after Hematopoietic Cell Transplantation, in Thomas' Hematopoietic Cell Transplantation, Appelbaum, F. R.Forman, S. J.Negrin, R. S. and Blume, K. G., Editors. 2009, Wiley-Blackwell. p. 519-531., https://doi.org/10.1002/9781118416426.ch34

[973] Singer, S., Danker, H., Dietz, A., Kienast, U., Pabst, F., Meister, E. F., et.al. Sexual Problems After Total or Partial Laryngectomy, The Laryngoscope, 2008. 118(12): p. 2218-2224., https://pubmed.ncbi.nlm.nih.gov/19029864/

[974] Krauß, O., Hauss, J., Jonas, S., Leinung, S., Halm, U., Albani, C., et.al. Psychische Begleiterkrankungen bei Krebspatienten in der Viszeralchirurgie, Der Chirurg, 2011. 82(3): p. 263-270., https://link.springer.com/article/10.1007/s00104-011-2075-y

[975] Hopwood, P., Stephens, R. J., Depression in patients with lung cancer: prevalence and risk factors derived from quality-of-life data, Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology, 2000. 18(4): p. 893-903., https://pubmed.ncbi.nlm.nih.gov/10673533/

[976] Carlsen, Kathrine, Jensen, Anders Bonde, Jacobsen, Erik, Krasnik, Mark, Johansen, Christoffer, Psychosocial aspects of lung cancer, Lung Cancer (Amsterdam, Netherlands), 2005. 47(3): p. 293-300., https://pubmed.ncbi.nlm.nih.gov/15713512/

[977] Armstrong, Terri S., Vera-Bolanos, Elizabeth, Acquaye, Alvina A., Gilbert, Mark R., Ladha, Harshad, Mendoza, Tito, The symptom burden of primary brain tumors: evidence for a core set of tumor- and treatment-related symptoms, Neuro-Oncology, 2016. 18(2): p. 252-260., http://www.ncbi.nlm.nih.gov/pubmed/26289592

[978] Goebel, Simone, Strenge, Hans, Mehdorn, H. Maximilian, Acute stress in patients with brain cancer during primary care, Supportive Care in Cancer: Official Journal of the Multinational Association of Supportive Care in Cancer, 2012. 20(7): p. 1425-1434., http://www.ncbi.nlm.nih.gov/pubmed/21717272

[979] Rapp, Marion, Schipmann, Stephanie, Hoffmann, Kira, Wiewrodt, Rainer, Steiger, Hans-Jakob, Kamp, Marcel, et.al. Impact of distress screening algorithm for psycho-oncological needs in neurosurgical patients, Oncotarget, 2018. 9(60): p. 31650-31663., https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6114967/

[980] Goebel, Simone, Mehdorn, Hubertus Maximilian, Fear of disease progression in adult ambulatory patients with brain cancer: prevalence and clinical correlates, Supportive Care in Cancer: Official Journal of the Multinational Association of Supportive Care in Cancer, 2019. 27(9): p. 3521-3529., http://www.ncbi.nlm.nih.gov/pubmed/30684045

[981] Liu, Fangkun, Huang, Jing, Zhang, Liyang, Fan, Fan, Chen, Jindong, Xia, Kun, et.al. Screening for distress in patients with primary brain tumor using distress thermometer: a systematic review and meta-analysis, BMC Cancer, 2018. 18(1): p. 124., https://pubmed.ncbi.nlm.nih.gov/29394923/

[982] Huang, Jing, Zeng, Chao, Xiao, Juxiong, Zhao, Danwei, Tang, Hui, Wu, Haishan, et.al. Association between depression and brain tumor: a systematic review and meta-analysis, Oncotarget, 2017. 8(55): p. 94932-94943., http://www.ncbi.nlm.nih.gov/pubmed/29212279

[983] Applebaum, Allison J., Kryza-Lacombe, Maria, Buthorn, Justin, DeRosa, Antonio, Corner, Geoff, Diamond, Eli L., Existential distress among caregivers of patients with brain tumors: a review of the literature, Neuro-Oncology Practice, 2016. 3(4): p. 232-244., https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6657396/

[471] Goebel, Simone, Mehdorn, H. Maximilian, Measurement of psychological distress in patients with intracranial tumours: the NCCN distress thermometer, Journal of Neuro-Oncology, 2011. 104(1): p. 357-364., http://www.ncbi.nlm.nih.gov/pubmed/21188470

[984] Goebel, Simone, Knuth, Carina, Damm, Matthias, Linden, Daniel, Coburger, Jan, Ringel, Florian, et.al. Towards the targeted assessment of relevant problems: Optimization of the distress Thermometer for adult neuro-oncological patients, Psycho-Oncology, 2020. 29(12): p. 2057-2066., https://onlinelibrary.wiley.com/doi/abs/10.1002/pon.5564, https://onlinelibrary.wiley.com/doi/full/10.1002/pon.5564

[985] Gehring, Karin, Stuiver, Martijn M., Visser, Eva, Kloek, Corelien, van den Bent, Martin, Hanse, Monique, et.al. A pilot randomized controlled trial of exercise to improve cognitive performance in patients with stable glioma: a proof of concept, Neuro-Oncology, 2020. 22(1): p. 103-115., http://www.ncbi.nlm.nih.gov/pubmed/31755917

[986] Troschel, Fabian M., Brandt, Ralf, Wiewrodt, Rainer, Stummer, Walter, Wiewrodt, Dorothee, High-Intensity Physical Exercise in a Glioblastoma Patient under Multimodal Treatment, Medicine and Science in Sports and Exercise, 2019. 51(12): p. 2429-2433., http://www.ncbi.nlm.nih.gov/pubmed/31730561

[987] Troschel, Fabian M., Ramroth, Christian, Lemcke, Lars, Clasing, Jens, Troschel, Amelie S., Dugas, Martin, et.al. Feasibility, Safety and Effects of a One-Week, Ski-Based Exercise Intervention in Brain Tumor Patients and Their Relatives: A Pilot Study, Journal of Clinical Medicine, 2020. 9(4): p. 1006., https://www.mdpi.com/2077-0383/9/4/1006

[988] Levine, Jennifer M., Kelvin, Joanne Frankel, Quinn, Gwendolyn P., Gracia, Clarisa R., Infertility in reproductive-age female cancer survivors, Cancer, 2015. 121(10): p. 1532-1539., http://www.ncbi.nlm.nih.gov/pubmed/25649243

[989] Parsons, Helen M., Harlan, Linda C., Lynch, Charles F., Hamilton, Ann S., Wu, Xiao-Cheng, Kato, Ikuko, et.al. Impact of cancer on work and education among adolescent and young adult cancer survivors, Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology, 2012. 30(19): p. 2393-2400., http://www.ncbi.nlm.nih.gov/pubmed/22614977

[990] Parsons, Helen M., Schmidt, Susanne, Harlan, Linda C., Kent, Erin E., Lynch, Charles F., Smith, Ashley W., et.al. Young and uninsured: Insurance patterns of recently diagnosed adolescent and young adult cancer survivors in the AYA HOPE study, Cancer, 2014. 120(15): p. 2352-2360., http://www.ncbi.nlm.nih.gov/pubmed/24899580

[991] Johnson, Rebecca H., Anders, Carey K., Litton, Jennifer K., Ruddy, Kathryn J., Bleyer, Archie, Breast cancer in adolescents and young adults, Pediatric Blood & Cancer, 2018. 65(12): p. e27397., http://www.ncbi.nlm.nih.gov/pubmed/30156052

[992] Shannon, C., Smith, I. E., Breast cancer in adolescents and young women, European Journal of Cancer (Oxford, England: 1990), 2003. 39(18): p. 2632-2642., http://www.ncbi.nlm.nih.gov/pubmed/14642925

[993] Partridge, Ann H., Gelber, Shari, Peppercorn, Jeffrey, Sampson, Ebonie, Knudsen, Katherine, Laufer, Marc, et.al. Web-Based Survey of Fertility Issues in Young Women With Breast Cancer, Journal of Clinical Oncology, 2004. 22(20): p. 4174-4183., https://pubmed.ncbi.nlm.nih.gov/15483028/

[994] Fergie, Gillian, Hunt, Kate, Hilton, Shona, What young people want from health-related online resources: A focus group study, Journal of youth studies, 2013. 16(5): p. 579-596., https://pubmed.ncbi.nlm.nih.gov/24748849/

[995] Howlader, N., Noone, A. M., Krapcho, M., Garshell, J., Neyman, N., Altekruse, S. F., et.al. SEER Cancer Statistics Review, 1975-2010. Surveillance, Epidemiology. and End Results, SEER, 2012., https://seer.cancer.gov/archive/csr/1975_2010/index.html

[996] Crome, Peter, Lally, Frank, Cherubini, Antonio, Oristrell, Joaquim, Beswick, Andrew D., Clarfield, A. Mark, et.al. Exclusion of older people from clinical trials: professional views from nine European countries participating in the PREDICT study, Drugs & Aging, 2011. 28(8): p. 667-677., http://www.ncbi.nlm.nih.gov/pubmed/21812501

[997] Freedman, Rachel A., Partridge, Ann H., Emerging Data and Current Challenges for Young, Old, Obese, or Male Patients with Breast Cancer, Clinical Cancer Research, 2017. 23(11): p. 2647-2654., https://pubmed.ncbi.nlm.nih.gov/28572259/

[998] Zabora, J., BrintzenhofeSzoc, K., Curbow, B., Hooker, C., Piantadosi, S., The prevalence of psychological distress by cancer site, Psycho-Oncology, 2001. 10(1): p. 19-28., http://www.ncbi.nlm.nih.gov/pubmed/11180574

[999] Kurtz, Margot E., Kurtz, J. C., Stommel, Manfred, Given, Charles W., Given, Barbara, Physical Functioning and Depression Among Older Persons with Cancer, Cancer Practice, 2001. 9(1): p. 11-18., http://www.redi-bw.de/db/ebsco.php/search.ebscohost.com/login.aspx%3fdirect%3dtrue%26db%3daph%26AN%3d5466523%26site%3dehost-live

[1000] Hopko, Derek R., Bell, John L., Armento, Maria E. A., Robertson, Sarah M. C., Hunt, Melissa K., Wolf, Nicole J., et.al. The Phenomenology and Screening of Clinical Depression in Cancer Patients, Journal of Psychosocial Oncology, 2007. 26(1): p. 31-51., https://pubmed.ncbi.nlm.nih.gov/18077261/

[1001] Erlangsen, Annette, Stenager, Elsebeth, Conwell, Yeates, Physical diseases as predictors of suicide in older adults: a nationwide, register-based cohort study, Social Psychiatry and Psychiatric Epidemiology, 2015. 50(9): p. 1427-1439., http://www.ncbi.nlm.nih.gov/pubmed/25835959

[751] Rabe, A., van Oorschot, B., Jentschke, E., Suizidalität bei Krebspatienten, Der Onkologe, 2020. 26(2): p. 163-168., https://doi.org/10.1007/s00761-020-00712-x

[1002] Saracino, Rebecca M., Nelson, Christian J., Identification and treatment of depressive disorders in older adults with cancer, Journal of Geriatric Oncology, 2019. 10(5): p. 680-684., http://www.ncbi.nlm.nih.gov/pubmed/30797709

[1003] Gallo, J. J., Rabins, P. V., Lyketsos, C. G., Tien, A. Y., Anthony, J. C., Depression without sadness: functional outcomes of nondysphoric depression in later life, Journal of the American Geriatrics Society, 1997. 45(5): p. 570-578., http://www.ncbi.nlm.nih.gov/pubmed/9158577

[1004] Wildiers, Hans, Heeren, Pieter, Puts, Martine, Topinkova, Eva, Janssen-Heijnen, Maryska L. G., Extermann, Martine, et.al. International Society of Geriatric Oncology consensus on geriatric assessment in older patients with cancer, Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology, 2014. 32(24): p. 2595-2603., http://www.ncbi.nlm.nih.gov/pubmed/25071125

[1005] Kenyon, Megan, Mayer, Deborah K., Owens, Anna Kate, Late and long-term effects of breast cancer treatment and surveillance management for the general practitioner, Journal of obstetric, gynecologic, and neonatal nursing: JOGNN, 2014. 43(3): p. 382-398., http://www.ncbi.nlm.nih.gov/pubmed/24690072

[1006] Yi, Jean C., Syrjala, Karen L., Anxiety and Depression in Cancer Survivors, The Medical clinics of North America, 2017. 101(6): p. 1099-1113., https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5915316/

[1007] Shakeel, Saad, Tung, Jasmine, Rahal, Rami, Finley, Christian, Evaluation of Factors Associated With Unmet Needs in Adult Cancer Survivors in Canada, JAMA network open, 2020. 3(3): p. e200506., http://www.ncbi.nlm.nih.gov/pubmed/32142127

[1008] Hoffman, KE, McCarthy, EP, Recklitis, CJ, Ng, AK, Psychological distress in long-term survivors of adult-onset cancer: results from a national survey., Arch Intern Med, 2009. 169 (14)(14): p. 1274-81., https://pubmed.ncbi.nlm.nih.gov/19636028/

[1009] Maass, S. W. M. C., Boerman, L. M., Verhaak, P. F. M., Du, J., de Bock, G. H., Berendsen, A. J., Long-term psychological distress in breast cancer survivors and their matched controls: A cross-sectional study, Maturitas, 2019. 130: p. 6-12., http://www.ncbi.nlm.nih.gov/pubmed/31706438

[1010] Lu, Donghao, Andersson, Therese M. L., Fall, Katja, Hultman, Christina M., Czene, Kamila, Valdimarsdóttir, Unnur, et.al. Clinical Diagnosis of Mental Disorders Immediately Before and After Cancer Diagnosis: A Nationwide Matched Cohort Study in Sweden, JAMA oncology, 2016. 2(9): p. 1188-1196., http://www.ncbi.nlm.nih.gov/pubmed/27124325

[1011] Dunn, Jeff, Ng, Shu Kay, Holland, Jimmie, Aitken, Joanne, Youl, Pip, Baade, Peter D., et.al. Trajectories of psychological distress after colorectal cancer, Psycho-Oncology, 2013. 22(8): p. 1759-1765., http://www.ncbi.nlm.nih.gov/pubmed/23125004

[1012] Mehanna, H. M., De Boer, M. F., Morton, R. P., The association of psycho-social factors and survival in head and neck cancer, Clinical otolaryngology: official journal of ENT-UK ; official journal of Netherlands Society for Oto-Rhino-Laryngology & Cervico-Facial Surgery, 2008. 33(2): p. 83-89., http://www.ncbi.nlm.nih.gov/pubmed/18429854

[1013] Loge, J. H., Abrahamsen, A. F., Ekeberg, O., Hannisdal, E., Kaasa, S., Psychological distress after cancer cure: a survey of 459 Hodgkin's disease survivors, British Journal of Cancer, 1997. 76(6): p. 791-796., http://www.ncbi.nlm.nih.gov/pubmed/9310248

[1014] Koch, L, Jansen, L, Herrmann, A, Stegmaier, C, Holleczek, B, Singer, S, et.al. Quality of life in long-term breast cancer survivors - a 10-year longitudinal population-based study., Acta Oncol, 2013. 52 (6)(6): p. 1119-28., https://pubmed.ncbi.nlm.nih.gov/23514583/

[1016] van der Geest, IM, van Dorp, W, Hop, WC, Neggers, SJ, de Vries, AC, Pieters, R, et.al. Emotional distress in 652 Dutch very long-term survivors of childhood cancer, using the hospital anxiety and depression scale (HADS)., J Pediatr Hematol Oncol, 2013. 35 (7)(7): p. 525-9., https://pubmed.ncbi.nlm.nih.gov/24060834/

[1017] Muffly, Lori S., Hlubocky, Fay J., Khan, Niloufer, Wroblewski, Kristen, Breitenbach, Katherine, Gomez, Joseline, et.al. Psychological morbidities in adolescent and young adult blood cancer patients during curative-intent therapy and early survivorship, Cancer, 2016. 122(6): p. 954-961., http://www.ncbi.nlm.nih.gov/pubmed/26749023

[1018] Mitchell, Alex J., Ferguson, David W., Gill, John, Paul, Jim, Symonds, Paul, Depression and anxiety in long-term cancer survivors compared with spouses and healthy controls: a systematic review and meta-analysis, The Lancet Oncology, 2013. 14(8): p. 721-732., https://pubmed.ncbi.nlm.nih.gov/23759376/

[1019] Boyes, Allison W., Girgis, Afaf, D'Este, Catherine A., Zucca, Alison C., Lecathelinais, Christophe, Carey, Mariko L., Prevalence and predictors of the short-term trajectory of anxiety and depression in the first year after a cancer diagnosis: a population-based longitudinal study, Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology, 2013. 31(21): p. 2724-2729., http://www.ncbi.nlm.nih.gov/pubmed/23775970

[1020] Jarrett, N., Scott, I., Addington-Hall, J., Amir, Z., Brearley, S., Hodges, L., et.al. Informing future research priorities into the psychological and social problems faced by cancer survivors: a rapid review and synthesis of the literature, European Journal of Oncology Nursing: The Official Journal of European Oncology Nursing Society, 2013. 17(5): p. 510-520., http://www.ncbi.nlm.nih.gov/pubmed/23619278

[1021] Swartzman, Samantha, Booth, Josephine N., Munro, Alastair, Sani, Fabio, Posttraumatic stress disorder after cancer diagnosis in adults: A meta-analysis, Depression and Anxiety, 2017. 34(4): p. 327-339., http://www.ncbi.nlm.nih.gov/pubmed/27466972

[1022] Beckjord, Ellen Burke, Reynolds, Kerry A., van Londen, G. J., Burns, Rachel, Singh, Reema, Arvey, Sarah R., et.al. Population-level trends in posttreatment cancer survivors' concerns and associated receipt of care: results from the 2006 and 2010 LIVESTRONG surveys, Journal of Psychosocial Oncology, 2014. 32(2): p. 125-151., http://www.ncbi.nlm.nih.gov/pubmed/24364920

[1023] Ozga, Melissa, Aghajanian, Carol, Myers-Virtue, Shannon, McDonnell, Glynnis, Jhanwar, Sabrina, Hichenberg, Shira, et.al. A systematic review of ovarian cancer and fear of recurrence, Palliative & Supportive Care, 2015. 13(6): p. 1771-1780., http://www.ncbi.nlm.nih.gov/pubmed/25728373

[1024] Mitchell, Alex J., Chan, Melissa, Bhatti, Henna, Halton, Marie, Grassi, Luigi, Johansen, Christoffer, et.al. Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: a meta-analysis of 94 interview-based studies, The Lancet. Oncology, 2011. 12(2): p. 160-174., http://www.ncbi.nlm.nih.gov/pubmed/21251875

[1025] Ahles, Tim A., Root, James C., Ryan, Elizabeth L., Cancer- and Cancer Treatment–Associated Cognitive Change: An Update on the State of the Science, Journal of Clinical Oncology, 2012. 30(30): p. 3675-3686., https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3675678/

[1026] Lange, M., Joly, F., Vardy, J., Ahles, T., Dubois, M., Tron, L., et.al. Cancer-related cognitive impairment: an update on state of the art, detection, and management strategies in cancer survivors, Annals of Oncology: Official Journal of the European Society for Medical Oncology, 2019. 30(12): p. 1925-1940., http://www.ncbi.nlm.nih.gov/pubmed/31617564

[1027] Joly, Florence, Heutte, Natacha, Duclos, Brigitte, Noal, Sabine, Léger-Hardy, Isabelle, Dauchy, Sarah, et.al. Prospective Evaluation of the Impact of Antiangiogenic Treatment on Cognitive Functions in Metastatic Renal Cancer, European Urology Focus, 2016. 2(6): p. 642-649., http://www.ncbi.nlm.nih.gov/pubmed/28723499

[1028] Horneber, Markus, Fischer, Irene, Dimeo, Fernando, Rüffer, Jens Ulrich, Weis, Joachim, Cancer-related fatigue: epidemiology, pathogenesis, diagnosis, and treatment, Deutsches Arzteblatt International, 2012. 109(9): p. 161-171; quiz 172., http://www.ncbi.nlm.nih.gov/pubmed/22461866

[1029] Naidoo, J., Page, D. B., Li, B. T., Connell, L. C., Schindler, K., Lacouture, M. E., et.al. Toxicities of the anti-PD-1 and anti-PD-L1 immune checkpoint antibodies, Annals of Oncology: Official Journal of the European Society for Medical Oncology, 2015. 26(12): p. 2375-2391., http://www.ncbi.nlm.nih.gov/pubmed/26371282

[1030] Fabi, Alessandra, Falcicchio, Chiara, Giannarelli, Diana, Maggi, Gabriella, Cognetti, Francesco, Pugliese, Patrizia, The course of cancer related fatigue up to ten years in early breast cancer patients: What impact in clinical practice?, Breast (Edinburgh, Scotland), 2017. 34: p. 44-52., http://www.ncbi.nlm.nih.gov/pubmed/28500901