By Dr. Dawn-Elise Snipes
Each year millions of Americans are diagnosed with cancer. Nearly 500,000 of those will be diagnosed with breast or prostate cancer. Many of our patients will have, or have had cancer. It is important to understand the range of emotions, causes of distress and interventions available to help them.
There are many things that affect how a patient adjusts to cancer. It is difficult to predict how a person will cope. The following factors influence how a patient adjusts to cancer: The type of cancer, cancer stage, and chance of recovery.
The phase of cancer such as newly diagnosed, being treated, in remission, or recurrent cancer.
Individual coping abilities.
Friends and family available to support the patient.
The patient’s age.
The availability of treatment.
Beliefs about the cause of cancer.
Adjusting to a diagnosis of cancer is an ongoing process in which the patient learns to cope with emotional distress, solve cancer-related problems, and gain control over cancer-related life events. To add to the stress, patients are faced with many challenges that change as the disease and its treatment change. There are, however, certain predictable times when a patient is more likely to experience significant crisis. These include hearing the diagnosis, receiving treatment, completing treatment, hearing that the cancer is in remission, hearing that the cancer has come back, and becoming a cancer survivor. Each of these events involves specific coping tasks, questions about life and death, and common emotional challenges.
Patients are better able to adjust to a cancer diagnosis if they are able to continue fulfilling normal responsibilities, cope with emotional distress, and stay actively involved in activities that are meaningful and important to them. In counseling, patients can learn to develop coping strategies to change problem situations, manage emotional distress, and understand what impact cancer may have on his or her life. Patients who adjust well are usually committed to recovery and actively involved in coping with cancer.
Distress can occur when a person feels that he or she does not have the resources to manage or control the cancer. Patients who have the same diagnosis and are undergoing the same treatment may have very different experiences and ways of expressing distress. Anxiety and depression are common among patients with cancer. It is important, however, to ferret out whether the anxiety and depression are solely emotionally based or are caused/made worse by insomnia, fatigue, pain or side effects of medication.
Anxiety is a normal reaction to cancer and may increase feelings of pain, interfere with one’s ability to sleep, cause nausea, and interfere with the patient’s (and his or her family’s) quality of life. Persons with cancer will find that their feelings of anxiety increase or decrease at different times. Contrary to what one might expect, patients with advanced cancer experience anxiety due not to fear of death, but more often from fear of uncontrolled pain, being left alone, or dependency on others. Many of these factors can be alleviated with treatment. Helping patients identify their own cycles and plan for those times is a useful activity in therapy.
Patients may benefit from other treatment options for anxiety, including: psychotherapy, group therapy, family therapy, participating in self-help groups, hypnosis, and relaxation techniques such as guided imagery, or biofeedback. Medications may be used alone or in combination with these techniques. It is important not to avoid anxiety-relieving medications for fear of becoming addicted. A side benefit of many of the antianxiety medications is that they cause muscle relaxation which can often ease some of the aches and pains patients are experiencing.
While some patients become anxious, others become depressed, and even others are both anxious and depressed. Depression affects about 15% to 25% of cancer patients. Affecting men and women with cancer equally. People with cancer will experience different levels of distress. Issues which may contribute to depression in cancer patients include:
Fear of death.
Interruption of life plans.
Changes in body image and self-esteem.
Changes in social role and lifestyle.
Money and legal concerns
Guilt at not being around for their children
Regret for delaying diagnosis
Survivor guilt (If the patient survives and his/her friend does not)
People diagnosed with cancer will react to these issues in different ways and may not experience serious distress. It is also important to remember that patients and their family members or caregivers need to be evaluated for depression throughout their treatment. Children are also affected when a parent with cancer develops depression, and often develop emotional and behavioral problems.
There are many misconceptions about cancer and how people cope with it, such as the following:
All people with cancer are depressed.
People with cancer should be shielded from stress
Depression in a person with cancer is normal.
Treatment does not help the depression.
Everyone with cancer faces suffering and a painful death.
Depression and anxiety are always mental health issues
Sadness and grief are normal reactions to the crises faced during cancer, and will be experienced at times by all people. Because sadness is common, it is important to distinguish between normal levels of sadness and depression. An important part of cancer care is the recognition of depression that needs to be treated. This is depression that causes a person to lose pleasure in most activities more often than not for at least two weeks and can be accompanied by sleep and appetite changes, suicidal thoughts, confusion and difficulty concentrating. Counselors with a knowledge of cancer and cancer treatment can help people deal with their depression. Specific goals of these therapies include the following:
Assist people diagnosed with cancer and their families by answering questions about the illness and its treatment, explaining information, correcting misunderstandings, giving reassurance about the situation, and exploring with the patient how the diagnosis relates to previous experiences with cancer.
Assist with problem solving, improve the patient’s coping skills, and help the patient and family to develop additional coping skills. Explore other areas of stress, such as family role and lifestyle changes, and encourage family members to support and share concern with each other.
Ensure that the patient and family understand that support will continue when the focus of treatment changes from trying to cure the cancer to relieving symptoms. The health care team will treat symptoms to help the patient control pain and remain comfortable, and will help the patient and his or her family members maintain dignity.
When the depression or anxiety is being made worse by symptoms or medication, the counselor can advocate for the client, help the client communicate with his/her physician and educate the client about possible interventions.
Fatigue occurs in 14% to 96% of people with cancer, and has physical, psychological, and behavioral causes. People with cancer may describe it in different ways, such as saying they feel tired, sluggish, weak, exhausted, weary, worn-out, heavy, or slow. To be treated effectively, fatigue related to cancer and cancer treatment needs to be distinguished from other kinds of fatigue.
Fatigue can become a very important issue in the life of a person with cancer. It may affect the person’s self-esteem, his or her daily activities and relationships with others, and whether he or she continues treatment. Some of these treatments may include adjusting the dosages of pain medications, administering red blood cell transfusions or blood cell growth factors, diet supplementation with iron and vitamins, use of antidepressants or stimulants, exercise, and helping the patient identify a reasonable schedule so as not to tire too quickly.
Since fatigue is the most common symptom in people receiving outpatient chemotherapy, patients should learn ways to manage the fatigue. According to the American Cancer Society, patients should be taught the following:
The difference between fatigue and depression
Possible medical causes of fatigue (dehydration, electrolyte imbalance, breathing problems, anemia)
To observe their rest and activity patterns during the day and over time
To engage in attention-restoring activities (walking, gardening, bird-watching)
To recognize fatigue that is a side effect of certain therapies and medications
To participate in exercise programs that are realistic
To identify activities which cause fatigue and develop ways to avoid or modify those activities
To identify environmental or activity changes that may help decrease fatigue
The importance of eating enough food and drinking enough fluids
Respiratory therapy may help with breathing problems
To schedule important daily activities during times of less fatigue, and cancel unimportant activities that cause stress
To avoid or change a situation that causes stress
To observe whether treatments being used to help fatigue are working
Pain is another major cause of insomnia, anxiety and depression. Counselors can work with physicians and patients to create a comprehensive pain management plan.
Physical Interventions include:
Muscle/bone pain may be treated with heat (a hot pack or heating pad); cold (flexible ice packs); massage, pressure, and vibration (to improve relaxation); exercise (to strengthen weak muscles, loosen stiff joints, help restore coordination and balance, and strengthen the heart); changing the position of the patient; restricting the movement of painful areas or broken bones; stimulation; controlled low-voltage electrical stimulation; or acupuncture.
Thinking and behavior interventions give patients a sense of control and help them develop coping skills to deal with the disease and its symptoms. Beginning these interventions early in the course of treatment is useful so that patients can learn and practice the skills while they have enough strength and energy.
Thinking and Behavioral interventions include:
Relaxation and imagery: Simple relaxation techniques may be used for episodes of brief pain (for example, during cancer treatment procedures).
Hypnosis: Hypnotic techniques may be used to encourage relaxation and may be combined with other thinking/behavior methods. Hypnosis is effective in relieving pain in people who are able to concentrate and use imagery and who are willing to practice the technique regularly.
Redirecting thinking: Focusing attention on distractors other than pain or negative emotions including counting, praying, or saying things like “I can cope,” music, television, talking, listening to someone read, or looking at something specific. Patients can also learn to monitor and evaluate negative thoughts and replace them with more positive thoughts and images.
Support groups and religious counseling: Since depression tends to increase pain, and pain tends to increase depression, support groups help many patients. Many online support groups for patients and their families can be helpful for those patients who have restricted movement. Visit: www.acor.org/
Finally, sleep problems can contribute to depression, anxiety and the patient’s ability to manage pain. Sleep disorders that are related to cancer may be treated by eliminating the cancer and side effects of cancer treatment. To promote rest and treat sleep disorders the following may be considered:
Create an environment that decreases sleep interruptions and promotes sleep by:
Dimming or turning off lights.
Adjusting room temperature.
Keeping bedding, chairs, and pillows clean, dry, and wrinkle-free.
Using bedcovers for warmth.
Placing pillows in a supportive position.
Encouraging the patient to dress in loose, soft clothing.
Encourage regular bowel and bladder habits to minimize sleep interruptions.
Increasing consumption of fluids and fiber during the day.
Taking medication for incontinence before bedtime.
Eating a high-protein snack 2 hours before bedtime.
Avoiding heavy, spicy, or sugary foods 4 to 6 hours before bedtime.
Avoiding drinking alcohol or smoking 4 to 6 hours before bedtime.
Avoiding drinks with caffeine within 12 hours of bedtime
Exercising (which should be completed at least 2 hours before bedtime).
Keeping regular sleeping hours.
Stretching before bed
Journaling to get closure on the day and “vent” stressors
Setting a regular routine so your body is “cued” to get sleepy
Medications may also be used to help relieve sleep problems.
As a clinician working with a cancer patient, there are many things you can do to aid him/her in leading the highest quality of life. It is important to remember that patients with cancer who are seeking counseling are often in crisis, so write down suggestions or interventions they are to try at home.
About the Author: Dr. Snipes received her PhD in Counseling and Education from the University of Florida. She has worked for 10 years in community mental health and is an ordained Christian minister. Currently she runs an online private practice Doctor Is In and an online continuing education site . Both sites are managed by her husband at Data Recovery and Computer Analysis.