August 09, 2019
3 min read

Psychiatric disorders, stress increase risk for cervical cancer mortality

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Donghao Lu, MD, PhD
Donghao Lu

Women with cervical cancer who experienced psychiatric disorders and stress around the time of diagnosis demonstrated higher rates of cancer-specific mortality than women without such distress at diagnosis, according to study results published in Cancer Research.

“Emerging evidence indicates that psychological distress might affect the progression of many cancer types, for instance through reduced cellular immunity response induced by chronic stress. It suggests that stress may play a particularly strong role in solid malignancies with infection related etiology, such as cervical cancer,” study author Donghao Lu, MD, PhD, postdoctoral researcher in the department of medical epidemiology and biostatistics at Karolinska Institutet in Stockholm, said in an interview with HemOnc Today. “Moreover, our previous work suggested a role of psychological distress in the risk of oncogenic infection of human papillomavirus, cervical dysplasia and invasive cervical cancer. In the present follow-up study, we studied the relationship between stress and cervical cancer diagnosis.”

In the nationwide cohort study, Lu and colleagues evaluated records of 4,245 women in Sweden diagnosed with cervical cancer between 2002 and 2011.

They used Swedish personal identification numbers to connect the women to the Swedish Patient Register, which includes data on hospital discharge records and specialist visits.

With these data, the researchers identified women who had been clinically diagnosed with stress-reaction and adjustment disorders, depression, or anxiety disorder, as well as those who faced a stressful life event — including death or illness in the family, divorce or joblessness — no more than 1 year prior to cancer diagnosis.

Using Sweden’s Causes of Death Register, researchers determined that 1,392 of the women died during a mean 4.4 years of follow-up, including 1,005 who died due to cervical cancer.

The researchers calculated the HRs of cancer-specific death among women who experienced psychological distress compared with those not exposed to such distress, controlling for socioeconomic factors, tumor characteristics and treatment approach.

Results showed 1,797 women (42.3%) had either a stress-related disorder or faced stressful life events 1 year before cancer diagnosis or later. Mean age at cancer diagnosis was 53.9 years.

A statistical analysis adjusted for year of diagnosis, stage, histology and other factors showed women who experienced either a stress-related disorder or stressful life event demonstrated a 33% increased risk for cancer-specific mortality (HR = 1.33; 95% CI, 1.14-1.54) compared with those not exposed to stress. Women with stress-related disorders had a 55% greater likelihood of dying of cervical cancer (HR = 1.55; 95% CI, 1.2-1.99), whereas those exposed to a stressful life event appeared 20% more likely to die of cervical cancer (HR = 1.2; 95% CI, 1.02-1.41).

The correlations were driven primarily by distress occurring 1 year before or after cancer diagnosis (HR = 1.3; 95% CI, 1.11-1.52), but not after that time (HR = 1.12; 95% CI, 0.84-1.49).


The researchers acknowledged several limitations to the study. The surrogates used for severe psychological distress may not have fully elucidated the distress experienced by women with cervical cancer. Additionally, by using specialist care-based diagnoses to define stress-related disorders, researchers may have overlooked less symptomatic women not treated by specialists. Lastly, women who experienced stressful life events not examined in the study, such as financial hardship due to sickness-related absences, were categorized as unexposed.

The association between stress and cervical cancer prognosis is not necessarily causal, Lu said, noting several possible explanations for this link.

“Experimental studies suggest that psychological stress modulates tumor growth and progression through the dysregulation of oncogenes, angiogenesis, inflammation and host immune responses operated by the hypothalamic-pituitary-adrenal axis and sympathetic nervous system,” Lu told HemOnc Today. “In addition, psychological distress may influence cancer survival through delayed diagnosis or altered treatment. However, the association we found remained robust after extensive adjustment for tumor characteristics and mode of diagnosis/treatment.”

Lu said these findings may justify monitoring the psychological health of patients with cervical cancer.

“Our findings may support that oncologists or gynecologists perform active evaluation of psychiatric status on return visits to see how patients with cervical cancer are doing, not only somatically but also mentally,” he said. “If confirmed in other populations/countries, psychological screening/intervention may be considered as an integral component in cervical cancer care.”  – by Jennifer Byrne

For more information:

Donghao Lu, MD, PhD, can be reached at Karolinska Institutet, Nobels väg 12A, Box 281, Stockholm 17177, Sweden; email:

Disclosures: The researchers report no relevant financial disclosures.