MHGCJ – 2021

Mental Health: Global Challenges Journal

https://mhgcj.org ISSN 2612-2138

Mental health sequelae of bone cancer: A

narrative review

Christos Tsagkaris ¹, Dimitra Desse ², Emmanouela Dionysia Laskaratou ³

Novel Global Community Educational Foundation, 2270 Hebersham, Australia

; Faculty of Medicine, University of Crete, Heraklion,

Greece

; University Hospital of Heraklion, Department of Orthopedics, Heraklion, Greece

Abstract

Introduction: Bone cancer causes a significant mental health burden. Although the mental

health implications of cancer as a whole have been widely discussed, there is limited evidence

regarding the psychiatric and psychological sequelae of malignant and benign bone neoplasms

in particular.

Purpose: To summarize the scientific literature, present relevant knowledge gaps and discuss a

number of recommendations. Methodology: The authors searched Pubmed/Medline and

Google Scholar with keywords (mental health, bone cancer, musculoskeletal neoplasms,

psychiatric comorbidities). When appropriate, MeSH terms and Boolean operators were used.

Relevant peer reviewed studies published in English, French or German until 05 May 2021 were

included.

Results and Discussion: Loss of mobility, decrease of physical activity, chronic pain and

amputations in combination with patient’s previous psychiatric history, socioeconomic conditions,

cancer biology and treatment-related side effects undermine the mental wellbeing of patients

and carers. Since March 2020, the COVID-19 pandemic has posed an additional burden, which

is yet to be comprehensively evaluated.

Conclusion: More research and solid action towards the integration of mental health care into

the management of bone cancer is crucial.

Keywords

cancer, bone cancer, osteosarcoma, mental health, depression, anxiety

Address for correspondence:

Christos Tsagkaris, Novel Global Community Educational Foundation, 2270 Hebersham,

Australia. chriss20x@gmail.com

This work is licensed under a Creative Commons Attribution-

NonCommercial 4.0 International License (CC BY-NC 4.0).

©Copyright: Tsagkaris, Desse, Laskaratou, 2021

Licensee NDSAN (MFC- Coordinator of the NDSAN), Italy

doi: https://doi.org/10.32437/mhgcj.v4i1.131

Submitted for publication: 5

May 2021

Revised: 26 August 2021

Accepted for publication: 16

October 2021

MHGCJ – 2021

Mental Health: Global Challenges Journal

https://mhgcj.org ISSN 2612-2138

Introduction

Bone malignancies are among the least

common types of cancer. In terms of incidence,

they have accounted for approximately 0.2% of

all new cancer cases in 2021. 0.3% of all cancer

mortality is associated with bone and joint tumors

according to the Surveillance, Epidemiology, and

End Results (SEER) Program of the National Cancer

Institute of the United States of America (NCI,

2021). Malignant bone cancers are either primary

or secondary. Primary bone tumors, namely

chondrosarcoma, osteosarcoma, Ewing’s

sarcoma, chondrofibrosarcoma, malignant giant

cell bone tumor and malignant fibrous

histiocytoma, are rarer (Franchi, 2012). Secondary

bone tumors usually derive from breast, lung and

prostate primary tumors. Bones constitute the third

most common metastatic sites (Jayarangaiah ,

Kemp, Theetha Kariyanna, 2021).

Mental health conditions are quite prevalent

among patients with cancer affecting at least

30% of them. Cancer associated emotional

distress, loss of functionality, change of body

image, uncertainty, treatment side effects,

chronic pain and disease progression contribute

to the development of mental health conditions

such as anxiety disorder, depression, dementia

and substance use among patients with cancer

(Niedzwiedz, Knifton, Robb, Katikireddi, Smith,

2019). On top of these, cancer-induced

alterations in neurotransmission, hormone

secretion and hepatic function can affect

patients’ conscious and unconscious mental

activity (Dai et al., 2020). Although, several aspects

of mental health have been investigated in the

context of particular types of cancer or neoplastic

disease as a whole, to date little is known about

mental health and bone cancer.

Purpose

The purpose of this review is to provide an

overview of the available research in the fields,

present the knowledge gaps, discuss their

implications in contemporary research and

clinical practice and outline relevant

recommendations.

Results and Discussion

Aspects of mental health in bone cancer

During the last years, a limited number of

clinical, observational and cross-sectional studies

have evaluated the impact of bone cancer on

mental wellbeing of patients and patients’

cohabitants, the biological underpinnings and

certain clinical aspects of bone cancer.

Sachsenmaier and colleagues (2015) assessed

the mental health implications of bone sarcoma

by means of a structured questionnaire. In a total

of 66 eligible participants, 53% of patients

reported an optimistic attitude and 37.5%

reported emotional steadiness. Female patients

and patients with less than two offsprings were

more prone to pessimistic ideas. Well-educated

and married patients were more likely to seek

psychological consultation. Elderly patients had a

higher likelihood to experience feelings of isolation,

while relationship trouble within families was

common (Sachsenmaier, Ipach, Kluba, 2015;

Storey et al, 2019). In a critical review of evidence

published until 2017, Storey and colleagues

investigated the effect of bone sarcoma in mental

health and quality of life of 8,823 patients reported

in a sum of 12 studies. Their analysis indicated that

relapse rates was the most common cause of

anxiety and depression. Painful tumors were

strongly associated with psychiatric comorbidity

leading to worse quality of life, higher levels of

perceived stress and even marginalization.

Amputations were identified as a key factor in

mental health deterioration, although a limited

number of patients reported self– esteem

improvement following amputation procedures

(Storey et.al., 2019). The latter was consistent with

the findings of Gil et al. (2018), who assessed the

mental health implications of amputations by

means of a retrospective study involving 46

patients with metastatic osteosarcoma and

reported pain remission and improved self–

confidence following amputation (Gil et al, 2019).

The psychobiological aspects of bone cancer

have been addressed by He and colleagues

(2019) in an 84-months long clinicolaboratory

study investigating the expression of mental

health–related proteins in chondrosarcoma tissue

samples. Their study showed that death-domain-

associated (DAXX) protein, dopamine D3 receptor

(DRD3) and disrupted-in-schizophrenia-1 (DISC1)

protein were highly expressed in moderately,

poorly differentiated and metastatic

osteosarcoma tumors. On the contrary, their

expression was significantly lower in tissue samples

of osteochondroma, a benign tumor. Further

analysis associated the presence of these proteins

with worse survival rates and outcomes and

suggested them as potential chondrosarcoma

biomarkers (He et al, 2019).

A recent study by Groot et al. (2021) analyzed

the responses of 47 patients – patient cohabitants’

pairs to a series of questionnaires with an eye on

quality of life, pain, depression, and anxiety.

Patients and their cohabitants – who presumably

MHGCJ – 2021

Mental Health: Global Challenges Journal

https://mhgcj.org ISSN 2612-2138

acted as informal carers – scored similarly for

quality of life. Nevertheless, higher levels of

depression and anxiety linked with an

overestimation of the patients’ burden were

detected among the patients’ cohabitants (Groot

et al, 2021). Finally, Bartels et al. (2021) attempted

to map the impact of the COVID-19 pandemic on

the emotional status of patients with bone

metastases in a sub-study of the PRESENT cohort.

Statistical analysis of the responses of 169 patients

to a structured questionnaire indicated that 28%

of patients experienced significant levels stress

and anxiety associated with the course of the

pandemic and the related restrictive measures.

39% of the patients had similar feelings regardless

of the lockdown situation, while 29% did not

mention such feelings. On these grounds the

researchers concluded that the pandemic has

affected the psychosocial wellbeing of the

majority of patients with bone metastases (Bartels,

2021).

Knowledge gaps and the way forward

It appears that the interest in the mental health

implications of bone cancer has increased in the

last 5 years. Nevertheless, the available evidence

is still scarce and heterogeneous. Most studies

agree that bone cancer leads to a quality of life

deterioration and undermines patients’ and carers’

mental wellbeing (Sachsenmaier, Ipach, Kluba,

2015; Storey, 2019; Gil, 2019). Interestingly, it

seems that amputations can affect patients’

mental wellbeing positively, to the extent that they

relieve them of chronic pain and discomfort

(Sachsenmaier, Ipach, Kluba, 2015; Storey, 2019).

On top of these, biomolecules implicated in

mental health disorders have been associated

with bone cancer and are further assessed as

biomarkers.

Evidently, there is a lack of clinical studies

assessing the effectiveness of psychosocial

interventions (individual or group oriented

psychotherapy and counseling, psychiatric

medication, ergotherapy sessions etc) in

supporting bone cancer patients’ and carers’

mental wellbeing (Lingens, Schulz, Bleich;. 2021).

During the COVID-19 pandemic digital

psychosocial interventions can be implemented

and assessed. Telehealth has already been used

to perform neuropsychological tests and monitor

patients with dementia, who did not have access

to physical healthcare facilities due to COVID-19

restrictions (Carotenuto, Traini, Fasanaro, Battineni,

Amenta, 2021). Moreover, the impact of

amputations and other forms of treatment, such

as radiotherapy and chemotherapy, should be

assessed in the mental wellbeing of specific

vulnerable patients’ groups such as children and

refugees. Taking into account the cultural factors

contributing to pain and disease perception, it is

also important to compare patients and carers’

attitudes in different continents, countries and

social contexts. The aforementioned should also

be investigated among healthcare workers.

Simultaneously, there is a clear need for more

research about the biological interconnection of

bone cancer and mental health disorders. Such

research can yield biomarkers and potential

therapeutic targets with multiple applications in

oncology and psychiatry.

Currently, the way forward appears twofold

encompassing research and clinical interventions.

Research needs to address the knowledge gaps,

preferably by means of large-scale studies.

Retrospective research appears as the optimal

means to assess the potential effects of particular

mental health indicators and interventions.

Intention – to – treat analysis can be used to

evaluate the potential effects of mental health

oriented treatment strategies across different study

groups. Systematic reviews and metanalysis of the

generated evidence can be performed in regular

intervals, in order to inform researchers in the field,

administrators and policymakers. Clinical

interventions can be based on the existing

knowledge and psychosocial care practices in

cancer. In this context, the concept of a

multidisciplinary cancer team including mental

health specialists and practitioners should be

enhanced (Silbermann, 2013). Healthcare

providers and insurance agencies should also take

action to provide patients with bone cancer with

access to mental health services. Finally, yet

importantly, patients’ organizations, civil society

and health bodies should advocate for the

integration of mental health into bone cancer

management.

Conclusions (and Future Work)

Mental health increases the burden of bone

cancer. Recent studies have illustrated the

psychosocial implications of bone cancer towards

patients and carers and its potential biological

underpinnings. More research and solid action

towards the integration of mental health care into

the management of bone cancer is crucial.

Conflict of interest

The author declares that she has no conflict of

interests.

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