Anxiety

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Anxiety is a common psychological effect among cancer survivors regardless of their cancer stage, primary cancer site, and phase of treatment.  Death anxiety is a form of anxiety in which the individual has an extreme fear of death and is anxious when experiencing thoughts about dying or posthumous events. ​

 

Physical and psychological symptoms of anxiety include insomnia, hypervigilance to symptoms or events, shortness of breath, jitteriness, distractibility, worrying thoughts, apprehensive, low concentration, emotional numbness and fatigue. If these symptoms interfere with your quality of life and the ability to carry out daily activities, further evaluation and treatment may be required. Speak to your doctor if you are experiencing these symptoms. Treatments include, talk therapies, either individually or in a group, and anti-depressants. You may try relaxation exercises that can help improve your mood, such as, yoga, meditation, or massage.

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Risk factors include:

1. Timing and Disease Factors:

• Occurs more often in the acute phase following diagnosis of a life-threatening cancer

• More common with advanced or longer duration of disease

2. Personal and Social Factors:

• Unemployment

• Younger age

• Less satisfactory communication with healthcare providers

• Insecure attachment style

• Impaired social and cognitive functioning

3. Treatment-related Factors:

• Chemotherapy

• Radiotherapy

4. Pre-existing Conditions

• Though a history of anxiety before cancer may increase risk, two-thirds of anxious cancer patients have no prior anxiety history

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Risk Factors for death anxiety:

• Female gender

• Unemployment

• Lower income

• Less preparation for end-of-life

• Lower resilience 

• Lower self-esteem

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Treatment options

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Non-Pharmacological Options:

1. Psychoeducation 

• The effects of psychoeducation (behavioural, counselling, and education techniques) intervention for anxiety have observed be shown within 6 months 

• It was found that face-to-face psychoeducation was effective in reducing anxiety and improving overall quality of life 

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2. Supportive therapy (counselling, supportive–expressive)

• A form of psychotherapy that aims to stabilize individuals, who are not suited for other forms of therapies 

• Supportive therapy is shown to be effective for anxiety

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3. Cognitive and behavioural interventions

• Cognitive behavioural aims to use techniques to modify dysfunctional beliefs and correct the individual’s thinking by eliminating negative thoughts, this is found to be effective for anxiety 

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4. Mindfulness-based therapy (MBT) (MBSR and MBCT)

• MBSR focuses on mindfulness meditations to alleviate stress, stress, and anxiety 

• MBSR has shown significant improvements in anxiety 

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5. Other relaxation training

• The Benson relaxation technique encourage creative visualization and relaxation of all the senses  and has been found to improve anxiety among cancer patients 

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6. Meaning-centred therapy

• This has been found to be effective for individuals with advanced stages of the disease

 

Pharmacological Options:

1. Anxiolytics 

• Data supporting the use of anxiolytics are absent within this setting

• E.g., 

  •  Alprazolam

  • Lorazepam

2. Antidepressants (AD)

• Evidence for AD is limited 

• E.g.,

• Fluoxetine

• Paroxetine

• Sertraline

• Bupropion

• Mirtazapine

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Depression

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Survivorship can pose a risk to clinical depression and it was found that there is a 5-to10-year risk of late onset depression among different cancers; 14.7% in breast cancer, 9.9% in prostate cancer, 13.2% in colorectal cancer survivors. The role of stressors related to aging, such as other health conditions and the loss of a partner, in increasing the risk or severity of depression is not fully understood. Symptoms of depression are typically more severe in individuals with advanced illness or a high symptom burden. Furthermore, depression at diagnosis and throughout the cancer journey is linked to lower treatment adherence, increased inflammation, weakened immune function, and poorer survival outcomes
 

Risk factors include:

1. Medical: 

• Advanced disease

• Multiple treatments

• Higher symptom effect

• Comorbidities

• Less rehabilitative options

• Poor patient-physician relationship

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2. Personal:

• Prior psychiatric history

• Past trauma

• helplessness/hopelessness

• Low education

• Low income

• Relationship issues

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3. Social: 

• Single

• Limited social connections

• Stigma

• Socio-environmental stressors

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Treatment Options:

 

Non-pharmacologic

1. Psychotherapy

• Psychotherapeutic interventions such as cognitive behavioral therapy (CBT) focus on changing maladaptive behaviors are frequently used among cancer survivors but the results are inconsistent

2. Alternative treatments

• Examples include yoga, tai chi, mindfulness 

• Studies have found that Qigong and mindfulness can reduce depressive symptoms among cancer survivors

 

Pharmacologic 

1. Antidepressants 

Antidepressants drugs have been shown to be beneficial for depression among cancer patients, how evidence is limited among survivors 

2. Selective serotonin reuptake inhibitors (SSRIs)/serotonin norepinephrine reuptake inhibitors (SNRIs)

SSRIs and SNRIs can be used in survivors with moderate to severe intensity major depression 

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Screening tools:

These validated measures can be used to screen for depression:

• PHQ-9 for Depression

• GAD-7

• PROMIS

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It is important to get help immediately if you are experiencing thoughts of suicide.

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