Over 15.5 million cancer survivors are alive today in the US, which is similar to the populations of New York City, Los Angeles, and Chicago combined. The number of survivors continues to grow, not just because of earlier detection and treatment, but because of revolutionary new therapies that have been emerging over the past decade. Now, patients with poor-prognosis metastatic cancers such as lung cancer and melanoma can live many years with good quality of life while on active treatment. For many individuals, this changes the landscape from a terminal illness to more of a chronic illness.
Concurrent with advances in cancer treatment, the importance of psychosocial care of individuals with cancer is being increasingly recognized. In 2008, the Institute of Medicine published Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs, which documented under-detection and failure to optimally manage psychiatric disorders and psychosocial needs in patients with cancer and their families.1 Unmet needs can have negative consequences for quality of life, treatment adherence, and survival. Subsequently, the American College of Surgeons Commission on Cancer started requiring cancer centers to screen patients for psychosocial distress as part of accreditation, and the American Society of Clinical Oncology developed practice guidelines for managing depression and anxiety.
Although most cancer centers provide some psychosocial services, increased attention to the psychosocial needs of patients with cancer may result in increased referrals to mental health professionals in other settings. Some basic knowledge about a patient’s cancer and treatment are essential for psychiatric management.
Studies have documented that a cancer diagnosis results in high levels of emotional distress.2,3 Patients go through an adjustment period for about 4 to 6 weeks after diagnosis. Cancer for many patients is synonymous with death and debilitating treatments, with images of a prolonged painful dying process. Patients often say they feel overwhelmed trying to assimilate medical information and make treatment decisions—all while continuing to manage family, work, and other responsibilities. However, for the majority of patients, once they receive a plan of action and begin treatment, their emotions tend to level out. Yet, cancer should not be considered as one discrete crisis, but rather as a series of crises that may occur at any time in the disease trajectory from diagnosis, treatment, cycles of recurrences and remissions, post-treatment, and sometimes palliative care.
In terms of psychiatric disorders among cancer patients, there is significant variability in the prevalence rates reported due to different assessment methods (clinical interview versus standardized measures), diagnostic criteria, type of cancer, and stage of disease among other variables. Recently, Mehnert and colleagues4 reported a 31% prevalence rate for any psychiatric disorder in cancer patients. Adjustment disorders tend to be the most commonly diagnosed, with the rates ranging from 11% to 35%.5 Rates for depression vary from 11% to 37%, and anxiety disorders show rates from 2.6% to 19.4%.5-7 The rate for depression in the general population is 7%—and thus lower than among cancer patients—but the rates for overall anxiety disorders seem to be comparable.
Assessment and treatment
The Case Vignette presents specific issues important for psychiatrists to consider when treating patients with cancer.
Mrs. T is a 53-year-old postmenopausal married woman with 2 teenage daughters who recently received a diagnosis of stage IV breast cancer metastatic to pelvic bone. Up until 2 months ago, she had been working full-time as an attorney but had to stop because of severe pain that progressively worsened. A medical workup showed an estrogen and progesterone receptor–positive, human epidermal growth factor receptor 2 (HER2)-negative tumor. She was treated with local pelvic bone radiation to help manage the pain, tamoxifen, and zoledronic acid. She was reluctant to take pain medications because of fear of addiction.
She does not have a psychiatric history or comorbid illnesses. Soon after starting tamoxifen, she began to feel very sad, anxious, irritable, and fatigued; cried easily; and had trouble sleeping because of hot flashes. She ruminates on dying and leaving her daughters. She denies hopelessness and suicidal ideation, and quite the contrary she very much wants to live.
Dr. Pozo-Kaderman is Director of Cancer Support Services at the Sylvester Comprehensive Cancer Center in Miami, FL. Dr. Pirl is Associate Director, Sylvester Comprehensive Cancer Center, and Associate Professor of Psychiatry, Miller School of Medicine, University of Miami, Miami, FL.
The authors report no conflicts of interest concerning the subject matter of this article.
1. Institute of Medicine (US) Committee on Psychosocial Services to Cancer Patients/Families in a Community Setting. In: Adler NE, Page AEK, eds. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: National Academies Press; 2008.
2. Zabora J, BrintzenhofeSzoc K, Curbow B, et al. The prevalence of psychological distress by cancer site. Psycho-Oncol. 2001;10:19-28.
3. Carlson LE, Angen M, Cullem J, et al. High levels of untreated distress and fatigue in cancer patients. Br J Cancer. 2004;90:2297-2304.
4. Mehnert A, Brahler E, Faller H, et al. Four-week prevalence of mental disorders in patients with cancer across major tumor entities. J Clin Oncol. 2014; 32:3540-3546.
5. Mitchell AJ, Chan B, Bhatti H, et al. Prevalence of depression, anxiety, and adjustment disorder in oncological, hematological, and palliative care setting: a meta-analysis of 94 interview based studies. Lancet Oncol. 2011;12:160-174.
6. Li M, Fitzgerald P, Rodin G. Evidence-based treatment of depression in patients with cancer. J Clin Oncol. 2012;30:1187-1196.
7. Traeger L, Greer JA, Fernandez-Robles C, et al. Evidence-based treatment of anxiety in patients with cancer. J Clin Oncol. 2012;30:1197-1205.
8. Sanjida S, Janda M, Kissane D, et al. A systematic review and meta-analysis of prescribing practices of antidepressants in cancer patients. Psycho-Oncol. 2016;25:1002-1016.