Posted Date: Apr 27, 2014
Expert-reviewed information summary about the difficult emotional responses many cancer patients experience. This summary focuses on normal adjustment issues, psychosocial distress, and adjustment disorders.
Patients may have feelings of anxiety and distress while being screened for a cancer, waiting for the results of tests, receiving a cancer diagnosis, being treated for cancer, or worrying that cancer will recur (come back).
Anxiety and distress may affect a patient's ability to cope with a cancer diagnosis or treatment. It may cause patients to miss check-ups or delay treatment. Anxiety may increase pain, affect sleep, and cause nausea and vomiting. Even mild anxiety can affect the quality of life for cancer patients and their families and may need to be treated.
Some patients living with cancer have a low level of distress and others have higher levels of distress. The level of distress ranges from being able to adjust to living with cancer to having a serious mental health problem, such as major depression. However, most patients with cancer do not have signs or symptoms of any specific mental health problem. This summary describes the less severe levels of distress in patients living with cancer, including:
Nearly half of cancer patients report having a lot of distress. Patients with lung, pancreatic, and brain cancers may be more likely to report distress, but in general, the type of cancer does not make a difference. Factors that increase the risk of anxiety and distress are not always related to the cancer. The following may be risk factors for high levels of distress in patients with cancer:
Screening is usually done by asking the patient questions, either in an interview or on paper. Patients who show a high level of distress usually find it helpful to talk about their concerns with a social worker, mental health professional, palliative care specialist, or pastoral counselor.
This summary is about adjustment to cancer, anxiety, and distress in adults with cancer.
See the following PDQ summaries for information on depression and post-traumatic stress disorder:
Living with a diagnosis of cancer involves many life adjustments. Normal adjustment involves learning to cope with emotional distress and solve problems caused by having cancer. Patients with cancer do not make these adjustments all at once, but over a period of time as their disease and treatment change. Patients may need to make adjustments when they:
Patients find it easier to adjust if they can carry on with their usual routines and work, keep doing activities that matter to them, and cope with the stress in their lives.
Coping is the use of thoughts and behaviors to adjust to life situations. The way people cope is usually linked to their personality traits (such as whether they usually expect the best or worst, or are shy or outgoing).
Coping methods include the use of thoughts and behaviors in special situations. For example, changing a daily routine or work schedule to manage the side effects of cancer treatment is a coping method. Using coping methods can help a patient deal with certain problems, emotional distress, and cancer in his or her daily life.
Patients who adjust well are usually very involved in coping with cancer. They also continue to find meaning and importance in their lives. Patients who do not adjust well may withdraw from relationships or situations and feel hopeless. Studies are being done to find out how different types of coping methods affect the quality of life for cancer survivors.
Distress can occur when patients feel they are unable to manage or control changes caused by cancer. Patients with the same diagnosis or treatment can have very different levels of distress. Patients have less distress when they feel the demands of the diagnosis and treatment are low or the amount of support they get is high. For example, a health care professional can help the patient adjust to the side effects of chemotherapy by giving medicine for nausea.
The following factors affect how a patient copes with the stress of cancer:
The coping skills needed will change at important points in time. These include the following:
The process of adjusting to cancer begins before learning the diagnosis. Patients may feel worried and afraid when they have unexplained symptoms or are having tests done to find out if they have cancer.
A diagnosis of cancer can cause expected and normal emotional distress. Some patients may not believe it and ask, "Are you sure you have the right test results?" They may feel numb or in shock, or as if "This can't be happening to me". Many patients wonder, "Could I die from this?"
Many patients feel they are not able to think clearly and may not understand or remember important information that the doctor gives them about the diagnosis and treatment options. Patients should have a way to go over this information later. It helps to have someone with them at appointments, bring a tape recorder, or make a second appointment to ask the doctor questions and go over the treatment plan. See Talking with the Health Care Team in the PDQ summary on Communication in Cancer Care for more information.
As patients accept the diagnosis, they begin to feel symptoms of distress, including:
When patients receive and understand information about cancer and their treatment options, they may begin to feel more hopeful. Over time, by using ways to cope that have worked in the past and learning new ways to cope, patients usually adjust to having cancer. Extra professional help to deal with problems such as fatigue, trouble sleeping, and depression can be helpful during this time.
As patients go through treatment for cancer, they use coping strategies to adjust to the stress of treatment. Patients may have anxiety or fears about:
Patients usually adjust well when they can compare short-term discomfort to long-term benefit (for example living longer) and decide, "It's worth it". Questions that patients may ask during treatment include, "Will I survive this?"; "Will they be able to remove all the cancer?"; or "What side effects will I have?" Finding ways to cope with problems caused by cancer such as feeling tired, getting to and from treatment, and changes in work schedule is helpful.
Finishing cancer treatment can cause mixed feelings. It may be a time of celebration and relief that treatment has ended. But it may also be a time of worry that the cancer could come back. Many patients are glad that treatment has ended but feel increased anxiety as they see their doctors less often. Other concerns include returning to work and family life and being very worried about any change in their health.
During remission, patients may become stressed before follow-up medical appointments because they worry that the cancer has come back. Waiting for test results can be very stressful.
Patients who are able to express both positive and negative emotions are more likely to adjust well. Patients are more able to cope with the emotional stress of finishing treatment and being in remission when they:
Sometimes cancer comes back and does not get better with treatment. The treatment plan then changes from one that is meant to cure the cancer to one that gives comfort and relieves symptoms. This may cause great anxiety for the patient. The patient may feel shock and be unable to believe it at first. This may be followed by a period of distress such as depression, trouble focusing, and being unable to stop thinking about death. Signs of normal adjustment include:
Patients slowly adjust to the return of cancer. They stop expecting to be cured of cancer and begin a different kind of healing. This healing is a process of becoming whole again by changing one's life in many ways when faced with the possibility of death. It is very important that patients keep up hope while they adjust to the return of cancer. Some patients keep up hope through their spirituality or religious beliefs. (See the PDQ summary on Spirituality in Cancer Care for more information.)
Patients adjust to finishing cancer treatment and being long-term cancer survivors over many years. As treatments for cancer have gotten better, cancer has become a chronic disease for some patients. Some common problems reported by cancer survivors as they face the future include:
Most patients adjust well and some even say that surviving cancer has given them a greater appreciation of life, helped them understand what is most important in their life, and stronger spiritual or religious beliefs.
Some patients may have more trouble adjusting because of medical problems, fewer friends and family members to give support, money problems, or mental health problems not related to the cancer.
Almost all patients living with cancer have feelings of distress. Feelings of distress range from sadness and fears to more serious problems such as depression, panic, feeling uncertain about spiritual beliefs, or feeling alone or separate from friends and family.
Patients who are in distress during any phase of cancer need treatment and support for their distress. Patients are more likely to need to be checked and treated for distress during the following periods:
Studies have shown that patients who are having trouble adjusting to cancer are helped by treatments that give them emotional and social support, including:
These types of treatment may be combined in different ways for one or more sessions. Studies have shown that patients with cancer who receive such therapies receive benefits compared to those who do not receive these therapies. Benefits include having lower levels of depression, anxiety, and disease- and treatment-related symptoms, as well as feeling more optimistic. Patients who have the most distress seem to get the most help from these therapies. However, patients who received these therapies did not live longer than those who did not receive them.
Causes of adjustment disorders in cancer patients include the following:
An adjustment disorder usually begins within three months of a stressful event and lasts no longer than six months after the event is over. Some patients may have a chronic adjustment disorder because they have many causes of distress, one right after another.
An adjustment disorder may become a more serious mental disorder such as major depression. This is more common in children and adolescents than in adults. (See the PDQ summary on Pediatric Supportive Care for more information.)
Individual (one-to-one) and group counseling have been shown to help cancer patients with adjustment disorders. Counseling may include treatment that focuses on the patient's thoughts, feelings, and behaviors. The following may help patients cope:
Counseling should be tried before medicine. Some patients are not helped by counseling or have a more severe mental health problem, such as severe anxiety or depression. These patients may be helped by an antianxiety or antidepressant medicine along with counseling. (See the PDQ summary on Depression for more information.)
Check NCIâs list of cancer clinical trials for U.S. supportive and palliative care trials about adjustment disorder that are now accepting participants. The list of trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Studies show that almost half of all patients with cancer say they feel some anxiety and about one-fourth of all patients with cancer say they feel a great deal of anxiety. Patients living with cancer find that they feel more or less anxiety at different times. A patient may become more anxious as cancer spreads or treatment becomes more intense.
For some patients feelings of anxiety may become overwhelming and affect cancer treatment. This is especially true for patients who had periods of intense anxiety before their cancer diagnosis. Most patients who did not have an anxiety condition before their cancer diagnosis will not have an anxiety disorder related to the cancer.
Patients are more likely to have anxiety disorders during cancer treatment if they have any of the following:
It may be hard to tell the difference between normal fears related to cancer and abnormally severe fears that can be described as an anxiety disorder. The diagnosis is based on how symptoms of anxiety affect the patient's quality of life, what kinds of symptoms began since the cancer diagnosis or treatment, when the symptoms occur, and how long they last.
Anxiety disorders cause serious symptoms that affect day-to-day life, including:
In addition to anxiety caused by a cancer diagnosis, the following may cause anxiety in patients with cancer:
Anxiety from these causes is usually managed by treating the cause itself.
When patients who had an anxiety disorder in the past are diagnosed with cancer, then the anxiety disorder may come back. These patients may feel extreme fear, be unable to remember information given to them by caregivers, or be unable to follow through with medical tests and procedures. They may have symptoms including:
Phobias are fears about a situation or an object that lasts over time. People with phobias usually feel intense anxiety and avoid the situation or object they are afraid of. For example, patients with a phobia of small spaces may avoid having tests in small spaces, such as magnetic resonance imaging (MRI) scans.
Phobias may make it hard for patients to follow through with tests and procedures or treatment. Phobias are treated by professionals and include different kinds of therapy.
Patients with panic disorder feel sudden intense anxiety, known as panic attacks. Symptoms of panic disorder include the following:
A panic attack may last for several minutes or longer. There may be feelings of discomfort that last for several hours after the attack. Panic attacks are treated with medicine and talk therapy.
Obsessive-compulsive disorder is rare in patients with cancer who did not have the disorder before being diagnosed with cancer.
Obsessive-compulsive disorder is diagnosed when a person uses persistent (obsessive) thoughts, ideas, or images and compulsions (repetitive behaviors) to manage feelings of distress. The obsessions and compulsions affect the person's ability to work, go to school, or be in social situations. Examples of compulsions include frequent hand washing or constantly checking to make sure a door is locked. Patients with obsessive-compulsive disorder may be unable to follow through with cancer treatment because of these thoughts and behaviors. Obsessive-compulsive disorder is treated with medicine and individual (one-to-one) counseling.
Patients with generalized anxiety disorder may feel extreme and constant anxiety or worry. For example, patients with supportive family and friends may fear that no one will care for them. Patients may worry that they cannot pay for their treatment, even though they have enough money and insurance.
A person who has generalized anxiety may feel irritable, restless, or dizzy, have tense muscles, shortness of breath, fast heart beat, sweating, or get tired quickly. Generalized anxiety disorder sometimes begins after a patient has been very depressed.
There are different types of treatment for patients with anxiety disorders, including methods to manage stress. Ways to manage stress include the following:
Patients with anxiety disorders need information and support to understand their cancer and treatment choices. Psychological treatments for anxiety can also be helpful. These include the following:
Other treatments used to lessen the symptoms of anxiety include the following:
Using different methods together may be helpful for some patients. (See the Psychological and Social Distress section of this summary for more information.)
Antianxiety medicines may be used if the patient doesnât want counseling or if itâs not available. These medicines relieve symptoms of anxiety, such as feelings of fear, dread, uneasiness, and muscle tightness. They may relieve daytime distress and reduce insomnia. These medicines may be used alone or combined with other therapies.
Although some patients are afraid they may become addicted to antianxiety medicines, this is not a common problem in cancer patients. Enough medicine is given to relieve symptoms and then the dose is slowly lowered as symptoms begin to get better.
Studies show that antidepressants are useful in treating anxiety disorders. Children and teenagers being treated with antidepressants have an increased risk of suicidal thinking and behavior and must be watched closely. (See the Treatment section of the PDQ summary on Depression for more information.)
Check NCIâs list of cancer clinical trials for U.S. supportive and palliative care trials about anxiety disorder that are now accepting participants. The list of trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
Editorial changes were made to this summary.
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Jan 20, 2015 - A brief mindfulness-based intervention has a positive short-term effect on psychological and behavioral measures as well as proinflammatory signal markers in younger breast cancer survivors, according to a study published online Dec. 23 in Cancer.