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Addressing Psychological Challenges After Cancer: A Guide for Clinical Practice

Addressing Psychological Challenges After Cancer: A Guide for Clinical Practice

The person diagnosed with cancer typically is confronted with a variety of difficult challenges. Treatment for cancer can be physically arduous, it generally disrupts patients’ social and work life, and it may even limit their ability to care for themselves or live independently for some period of time. In addition to these physical and functional burdens, cancer patients often face fears of death or disability, and may be prone to feelings of isolation or depression.

Not surprisingly, many patients show signs of depressed mood or acute stress reactions at some point during their diagnosis and treatment.[1,2] Given the physical, economic, and psychological burdens experienced by cancer patients during treatment, it is perhaps a testament to human resilience and the quality of care and social support that patients receive that most adapt to these challenges and have a positive psychological outcome. Studies of long-term cancer survivors indicate that the majority do not suffer from significant psychological distress, though they may be at higher risk for depression than people never affected by cancer.[1]

While most long-term survivors will not have significant psychological distress related to their cancer, there is a sizable minority of cancer survivors who will. This article focuses on understanding the psychological challenges cancer survivors may face, and how nurses and other medical providers can recognize and respond to these issues. With more than 12 million cancer survivors in the US,[3] the enormous variety of survivor experiences and associated psychological issues must be acknowledged.

The “cancer survivors” we write about may have been treated for dozens of different types of cancer, at many different points in their lives, and with any of hundreds of different treatments. After completion of therapy they may be left healthy and disease-free, or with any of a variety of ongoing medical issues. Here we will address the most common psychological challenges cancer survivors face following completion of active therapy. We choose this focus not because other issues or phases of care are less important, but because patients who have completed active treatment have fewer visits with their medical providers, making it more difficult for providers to monitor psychological adjustment even as new issues of “life after cancer” emerge. After considering how psychological challenges may emerge following cancer treatment, we briefly discuss anxiety, depression, fatigue, and sexual function. Finally, we review methods for addressing these issues in the context of a medical visit and provide information on appropriate follow-up resources.

Psychological Complications After Cancer

Table 1Psychological challenges are part of life. As Erikson wisely demonstrated in tracing the “crises of development” from infancy to adulthood, the specific challenges change and change us as individuals, but they are ongoing as long as we are.[4] Challenges provide opportunities for reworking past unresolved issues as well as the risk that an unresolved challenge may end in maladaptation. Cancer, though not an expected challenge, may similarly result in psychological growth as well as maladjustment. Understanding why some survivors develop ongoing emotional problems while others do not is important in identifying survivors in need of additional support and treatment. Generalizing across cancers can be difficult, but research and clinical experience suggest that several factors may predispose a cancer survivor to ongoing psychological problems[1,2] (also see Table 1). Perhaps most important are health and functional status after completion of treatment. Physical and mental health are typically strongly associated, and survivors who have chronic conditions (eg, heart disease, diabetes), and especially those with multiple chronic conditions or chronic pain, may be particularly vulnerable to problems in psychological adaptation. Similarly, those who cannot return to work or are limited in their ability to care for themselves independently may be at risk.

The list of psychological challenges potentially facing cancer survivors is extensive, but among the most common are fatigue, depression, anxiety, and sexual problems. As with all patients, emotional concerns or sexual difficulties should be evaluated in the context of any medical conditions or medications that may be contributing to the development of symptoms. This is particularly important in working with cancer survivors because cancer treatments may have medical late effects on pulmonary, cardiac, hormonal, and other physiological systems that can contribute to a variety of psychological symptoms.[5,6] Similarly, many commonly prescribed medications may cause psychological symptoms or interfere with sexual functioning.

Common Psychological Challenges Experienced by Survivors

Fatigue

One of the most commonly reported effects that persist after cancer treatment is fatigue.[7] This fatigue is characterized by the subjective feeling of tiredness and anergia that does not subside with rest, and may be severe enough to impair life functioning.[5] As many as 34% of breast cancer survivors report fatigue even many years after the end of treatment.[7]

Answering Survivors’ Questions About Mental Health Services

Why would I need a Mental Health Professional?

Many people who experience problems in their lives seek a mental health professional for some kind of therapy or counseling. They may look for treatment of a specific symptom such as panic attacks, or they may want to learn a new way to manage problems in a relationship or at work. Cancer survivors may look for a mental health provider for these same reasons, as well as for issues related to their cancer.

What can I expect if I see a Mental Health Professional?

There are several kinds of mental health providers and many kinds of treatments. Your experience will depend on the provider you see and the problem for which you want help. You can expect the provider to listen to your experiences and ask questions about your personal history. You will need to talk about your difficulties and your goals for treatment. Most therapists see patients once a week for 45–50 minutes. Some types of therapy will last only a few sessions, while other therapy may continue for months or longer.

Finding the right Mental Health Professional

1. Mental health services can be expensive, often $90–$200 a visit, so most people use insurance to help pay for therapy. Contact your insurance provider for information about mental health services. Find out:

• What services are covered, if you have a co-pay, and how many sessions are covered.

• If you can use your insurance with any mental health provider, or instead need to see a provider who is part of the insurance network.

• If the insurance plan has a list of providers in your area. Some insurers will fax you a list or let you search a web site of affiliated providers.

2. Talk with your primary care provider (PCP) about your concerns and ask about mental health professionals in your area. If your insurer provides a list, ask if your PCP recommends any of the listed professionals. You may want to ask your PCP about possible medical causes of your current symptoms.

3. You may get helpful recommendations from trusted sources in your community. Friends and family, clergy, and
local hospitals or community centers may be able to recommend a mental health professional.

4. When you find the names of two or three providers, contact them by telephone. When you call:

• You will typically need to leave a message and ask the provider to return your call.

• Tell them about your concerns and ask about their experience helping people with similar issues.

• Ask about availability, fees, insurance, and if they are licensed. You may want to ask about their education, expertise, and years in practice.

• If you are satisfied with the answers, make an appointment.

5. During your first visit, plan to describe the reasons that led you to seek help. The provider may ask you detailed questions about your personal and medical history. Ask the provider what kind of treatment s/he recommends, and what other kinds of treatment might be available. Ask about expected benefits, length of treatment, and any side effects you might expect.

6. It is important to find someone with whom you have rapport, and feel you can trust. It may take a few visits to be sure you have a good “fit” with the provider and for him/her to get to know you. Talk to the provider about your questions or concerns. If you don’t feel you have a good fit with the provider talk to her/him about that, too.
Be honest—it is your treatment and the provider’s job is to help you. The provider may be able to change the approach to your therapy, or help you find a therapist who is a better match for you. Recontact your insurer or PCP if you need further assistance.

Fatigue may be particularly likely in survivors who are younger; have lower income; and experience pain, menopausal symptoms, and certain medical conditions such as arthritis and high blood pressure.[8] Reduced levels of physical activity during cancer treatment may be one source of fatigue after treatment completion, and chemotherapy treatments have been associated with lingering fatigue.[5]

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