Key learning points:
– Anxiety is very much a natural psychological response to the threat of cancer
– It is important to understand the specific nature of anxiety to understand how best to support it
– Although pharmacological treatments can be useful, psychological interventions may be more acceptable to patients, and more effective for longer-term anxiety management
Each year, the number of people affected by cancer increases; by 2030 there will be four million people living with or beyond cancer in the UK alone.1 A substantial proportion of cancer patients will experience anxiety. A survey carried out by Macmillan Cancer Support in 2006 found that 75% of all respondents had experienced problematic anxiety levels at some point during cancer treatment or survival, but there is no standard presentation. Some patients may experience anxiety for long periods of time, but for others it may be short-lived, or may come and go over time. Anxiety may occur during treatment, but for others it may be worse during follow-up care. Regardless of presentation, there is a general acknowledgement that anxiety is to be expected and is an entirely natural psychological response to the threat of cancer. As just one facet of psychological distress, anxiety management is imperative to good quality cancer care; high levels can impair quality of life,2 increase supportive care needs3 and impact treatment compliance.4
Anxiety in those with cancer will often manifest as a generalised worry or sense of fear. This may be related specifically to treatments and the side effects or functional limitations that may follow. It may present as worry about how one's illness is affecting other people, predominantly family members; it may be about the financial impact of cancer, and the transition in life roles that may follow; or, it could be related to the realisation that in some cases, diagnosis might mean that family members are at increased risk of cancer due to hereditary genetic factors. One of the most pervasive of all anxieties comes after the end of treatment, and that is the worry that the cancer will return, otherwise known as fear of cancer recurrence.5
The term anxiety can sometimes be confusing in the context of cancer. In a psychiatry context, the term describes a number of different types of disorders, ranging from phobias to obsessive compulsive disorders.6 Some patients may have an existing case history of one of these anxiety disorders, but for most cancer patients anxiety will be less specific and more diffuse. Those who have no previous history but have a more pronounced anxiety response may occasionally fit the profile for generalised anxiety disorder, due to another medical condition, or post-traumatic stress disorder. However the reality is that few patients will suffer the extent or duration of symptoms to warrant a specific diagnosis.7
Anxiety in this context is multifaceted and characterised by cognitive, emotional, and behavioural components. Some examples of the signs of anxiety include:
1.Cognitive: excessive worry, catastrophisation, or distrust/disbelief.
2.Emotional: panic, fear or nervousness.
3.Behavioural: avoidance, hyper-vigilance or seeking regular reassurance.
There will often be co-existing physiological (or involuntary behavioural) symptoms that are characteristic of anxiety, for example these range from muscle tension, chest tightness and breathlessness, to gastrointestinal symptoms.
Anxiety should be differentiated from depression, which is indicated instead by a significantly low mood or loss of interest or pleasure in daily activities, with impaired functioning in social, occupational or educational domains. Symptoms of depression include low mood, irritability, weight or appetite change, changed sleep patterns, fatigue and loss of energy, diminished concentration, excessive feelings of guilt and worthlessness, and/or suicidality.
A substantial challenge in cancer care is that many anxiety symptoms may also be present as a result of cancer or cancer treatments.8 Therefore, it is important not to rely entirely on the presence (or lack of) these physiological symptoms, and to probe underlying causes before deciding on appropriate treatment or supportive care responses.
Screening for anxiety
There are a number of validated anxiety screening tools but few are regularly used in routine cancer care: most healthcare professionals rely on their clinical judgement and detection via analysis of verbal and non-verbal cues,9 (for a thorough discussion of screening tools see Mitchell10). This reticence toward using screening tools is not entirely inappropriate given that few patients would score highly enough to be deemed ‘clinical’ or even ‘at risk’.
Whether working in a primary, secondary or community care setting, it is important that healthcare professionals create an environment in which any patient concerns and unmet needs can be discussed. Though lacking diagnostic specificity,11 a single question (eg, ‘How anxious are you feeling about your treatment?’), or the use of an anxiety thermometer can be easily integrated into routine care in any setting, and will open dialogue about concerns and potential treatments.
Treating and managing anxiety
Before deciding on the most appropriate intervention, a multidisciplinary team should make evidence-based decisions appropriate to the extent of disruption caused to each patient specifically. Decisions should take into account patient preference, and it is important to note that of cancer patients screening positive for distress (including anxiety), only 36% indicate a desire for help or support to deal with it.12 Many patients simply want psychosocial aspects of cancer to be recognised, acknowledged and discussed.
Pharmacological treatments, including benzodiazepines, selective serotonin reuptake inhibitors (SSRIs), or serotonin norepinephrine reuptake inhibitors (SNRIs) have an emotional dampening effect that can be useful in the management of highly problematic anxiety,8 but caution should be used before prescribing. Pharmacological treatments may not be suitable for, or acceptable to, some patients; side effects are often undesirable, and some treatments may interact with specific cancer treatment regimes.13
The evidence base for psychosocial interventions is variable. Simply providing information is rarely sufficient for cancer-related anxiety and may worsen symptoms if information is unexpected or misinterpreted. Support-groups, and more theoretically-informed, group-delivered and expressive group therapy is reportedly beneficial for some patients and can provide a forum for the sharing of information and experiences, and needed social support. However, evidence for effectiveness on anxiety outcomes has not been reliably demonstrated.
Cognitive behavioural therapy (CBT) is considered a gold-standard, first-line treatment for anxiety. CBT assumes that the emotional, behavioural and physiological symptoms of anxiety are the result of faulty, distorted, or otherwise problematic cognitions. The therapy works by helping patients to identify and reframe these cognitions to reduce the problematic consequences. CBT is often a costly and intensive therapeutic intervention involving a number of intervention sessions, and a reliance on patients completing homework tasks.15 Though there have been trials of CBT for anxiety in cancer patients, these are not always well-designed. Indications from this literature suggest that while it is more effective than education or support approaches, this is typically only the case where patients are more highly symptomatic (ie, in only a small proportion of patients), and only with short-term effects.15
Third-wave psychological intervention approaches such as acceptance and commitment therapy (ACT), and mindfulness-based interventions have more promise17,18 and a recently published review encourages the use of these newer types of intervention as more suitable for the specific and frequently changing needs of cancer patients.19
There is growing acknowledgement of the benefits of healthy lifestyle change for not only physical rehabilitation following cancer, but also for psychosocial wellbeing. Exercise, in particular, has a rapidly growing evidence base and demonstrates efficacy for anxiety reduction both in patients undergoing treatment20 and post-treatment survivors.21 While there is literature exploring the effectiveness of complementary and alternative approaches (eg, hypnosis, massage, creative art therapies), the evidence is weak and any effects on anxiety reduction tend to be short-lived, if present at all. Though increasingly popular, the use of acupuncture for anxiety is not supported by evidence.22
Supporting cancer patients with anxiety
The nursing workforce remains one of the most important sources of support and care for the cancer patient.
Research demonstrates that nurse-led psychosocial care can lead to effective distress reduction,23 and there are some basic steps that all nurses can take to ease the burden of anxiety on their patients, these include:
1.Be vigilant for signs of anxiety; the appropriate use of needs assessments and brief screening questions can be easily and effectively implemented into routine care.
2.Ensure open communication and an environment where patients can discuss psychosocial concerns.
3.Prepare yourself with information and have systems in place to refer patients on to other specialists or support services for most effective management of their anxiety.
4.Know the evidence base; while patient preference for treatment is important, patients will look to healthcare teams for advice and/or endorsement and so it is important to keep knowledgeable about current evidence-based principles.
5.Support further research into the management of psychological concerns in cancer patients; the nurse role in cancer care is pivotal and so support, involvement and advocacy is vital if we are to create cancer care systems that best meet patient needs.
Macmillan. Worried sick: The emotional impact of cancer–
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