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Review Article
Psychological Distress among Cancer Patients on Chemotherapy
Abstract
Distress has been defined as a multifactorial unpleasant emotional experience of
a psychological, social, and/or spiritual nature that may interfere with the ability
to cope effectively with cancer, its physical symptoms, and its treatment. It can
be a normal reaction, but when the reaction is out of proportion or a somatic
consequence of cancer or its treatment, an individual may develop a
psychological disorder, more commonly, anxiety and depression. Cancer
patients undergoing chemotherapy are more likely to experience psychological
distress because of the negative effects of chemotherapy agents, the uncertainty
of post-treatment, and the occurrence of psychosocial problems.
Key words: psychological distress, anxiety, depression, cancer, chemotherapy
Introduction
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Psychological distress can be a normal response to a catastrophic event such as upon
receiving a diagnosis of cancer or any other life-threatening medical disease (1). In
2003, the National Comprehensive Cancer Network (NCCN) preferred to use the
word “distress” because it is more readily accepted and less embarrassing than a
psychological or psychiatric term (2). In the context of cancer, distress has been
defined as “a multifactorial unpleasant emotional experience of a psychological
(cognitive, behavioral, emotional), social, and/or spiritual nature that may interfere
with the ability to cope effectively with cancer, its physical symptoms, and its
treatment” (3).
A lot of work has been done in determining psychological distress in cancer patients
(4-6). The prevalence of long-term psychological distress in cancer patients ranges
from 20% to 60% (7,8). Anxiety is common at crisis points such as the start of a new
treatment or upon receiving the diagnosis of recurrence or illness progression (9).
Depression has been given much attention in cancer patients because depressive
symptoms can be a normal reaction, a psychological disorder, or a somatic
consequence of cancer or its treatment. The rate of depression in cancer patients is
higher than that in the general population and at least as high as the rate associated
with other serious medical illnesses (10).
Most cancer patients who undergo chemotherapy experience psychological distress as
a result of the negative effects of chemotherapy agents (11). Nausea and vomiting,
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tiredness or fatigue, sore mouth, reduced fertility, peripheral neuropathy, and skin
problems are common side effects of chemotherapy agents (12)
As people live longer after treatment for cancer, attention turned to the survivor’s
quality of life and the distress that they may experience (13). Consensus-based
guidelines developed by the Distress Management Panel of the NCCN recommend
screening all patients regularly for psychological distress as part of routine cancer
care, including follow-up care (2). These guidelines are based on evidence that
oncologists and oncology nurses do not recognize psychological distress, despite its
prevalence in the cancer population and its association with greater non-adherence to
treatment recommendations, poor satisfaction with care, and poorer quality of life
across many domains (5). Maintaining a good quality of life is extremely important.
Psychological distress in cancer patients who are on treatment, particularly
chemotherapy, need to be determined and understood (14). This is the primary focus
of this article.
Factors Related to Psychological Distress in Cancer Patients
Before we discuss the psychological issues that arise in patients receiving
chemotherapy, we need to understand the factors related to psychological distress in
these patients. Almost one-third of newly diagnosed breast cancer patients experience
considerable psychological morbidity in the first 2 years after initial chemotherapy
(15-18). Various patient and disease characteristics have been found to be potential
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risk factors related to psychological distress in cancer patients. Although most
findings were inconclusive (19-22), understanding the risk factors might help
improve the identification and management of patients with cancer who are likely to
have psychological distress (23, 24).
The number of stressful life events, previous history of depression (25), the patient’s
preoperative psychiatric status, marital status, social class, and menopausal status
were all predictors of high psychological distress after an operation (18). A study on
patients who underwent chemotherapy in Malaysia suggested that the prevalence of
psychological distress determined by a “distress thermometer” was 51%. Distress was
significantly associated with psychosocial problems (14). The effects of age on
emotional distress after a mastectomy revealed that younger women apparently have
resources that protect them against depression, although they are more likely to fear
the recurrence of the disease and they worry more about disfigurement resulting from
surgery. This finding is interesting and conflicts with other studies that generally
believe that being married is a buffer against stressful life events (26).
Normal Response to the Stress of Cancer
A life-threatening disease such as cancer interrupts a forward life trajectory,
interrupting an individual’s assumptive world (27-29). Individuals who are diagnosed
with cancer, or who learn that relapse has occurred, or that treatment has failed, often
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show a characteristic emotional response
a period of initial shock and disbelief,
followed by a period of turmoil with mixed symptoms of anxiety and depression,
irritability, and disruption of appetite and sleep. These symptoms usually resolve over
a few days or weeks with support from family, friends, and physicians who opt to
have a treatment plan that offers hope (1).
Patients whose distress interferes with their normal functions or is prolonged or
intolerable may consult a psychiatrist as they adjust their assumptions, find adaptive
and maladaptive coping strategies, and move on (30). Some patients continue to have
a high level of distress, persisting for weeks or even months. This persistent reactive
distress is not adaptive, often impairs social or occupational functioning, and
frequently requires psychiatric treatment (1).
One of the early efforts in psycho-oncology was to obtain objective data on the type
and frequency of psychological problems among cancer patients. A study done in the
ion’s Diagnostic and Statistical
Manual of Mental Disorders to determine psychiatric disorders in 215 randomly
assessed cancer patients, found that 53% of these patients were adjusting normally to
stress; the remaining 47% had clinically apparently psychiatric disorders. Of the 47%
with psychiatric disorders, 68% had adjustment disorders with depressed or anxious
mood, 13% had a major depression, and 4% had a preexisting anxiety disorder (26).
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Anxiety
Anxiety is often a response to the existential plight and the threat of deformity,
abandonment, loss of control, and loss of dignity that may come with the diagnosis of
cancer (30). It is also attributed to fear of recurrence (31-34), additional treatment,
and the potential for adverse effects (35). There are specific anxiety syndromes that
are likely to occur in the course of treatment that significantly disrupt patient
functioning (30).
Nausea and vomiting are the common side effects of chemotherapy. It is a vivid
visceral memory that may result in classical conditioning or anticipatory nausea and
vomiting in up to 75% of all patients (36). It is revealed that state anxiety can play a
causal role in the development of anticipatory nausea and vomiting. It is hypothesized
that state anxiety exacerbates post-treatment nausea and vomiting and thus increases
the risk for anticipatory nausea and vomiting (37-41). Prior occurrence of posttreatment nervousness also predicts anxiety before subsequent infusions, even after
accounting for trait anxiety and other post-treatment side effects (42). In addition, a
study on the mediating mechanism for anticipatory reaction in cancer chemotherapy
reported a positive correlation between degree of autonomic reactivity and
conditionability. Autonomic reactivity was recorded in a habituation paradigm before
chemotherapy was initiated. The patients in the anticipatory nausea and vomiting
group showed significantly increased sympathetic reactivity as compared with the
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control group, implying that autonomic reactivity is a mediator of the development of
anticipatory nausea and vomiting symptoms (43).
Patients who were at high risk of developing anticipatory nausea and vomiting were
younger than 50, had experienced nausea and vomiting in their last chemotherapy,
were susceptible to motion sickness, and have had other side effects in their last
chemotherapy (44).
The treatment of cancer may involve intense stressors capable of traumatizing
patients and inducing symptoms of acute and post-traumatic stress disorder (PTSD).
This might occur in both adults and children who survived cancer (45). It can also be
a consequence of their cancer diagnosis, treatment, or post-treatment episode. PTSD
was associated with the coping style of suppression. It showed that chemotherapy,
disease stage, and the interaction between chemotherapy and disease stage were
significant predictors of hyper-arousal (35). PTSD may interfere with the patients’
ability to tolerate and return for follow-up care (46).
Functional modification at the hypothalamic-pituitary-adrenal axis and volumetric
alteration of the amygdala are suggested as major participants in triggering emotional
and fear response in PTSD (47-50). However, our understanding of the cancer
patients’ experience at the emotional and cognitive levels remains insufficient.
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Depression
Depression in cancer patients may be a response to the psychosocial stress of cancer,
a medical symptom of cancer or its treatment, or may be unrelated to cancer and just
coincidental (30). Between 10% and 50% of cancer patients have been found to have
depression, depending on the stage of the disease and the methods used to assess
depression (51).
Many research groups have assessed depression in cancer patients, and the reported
prevalence varies significantly because of varying conceptualizations of depression,
the different criteria used to define depression, the differences in methodological
approaches used to measure depression, and the different populations studied.
Depression is highly associated with oropharyngeal (22-57%), pancreatic (33-50%),
breast (1.5-46%), and lung (11-44%) cancers. A lower prevalence of depression is
reported in patients with other cancers, such as colorectal (13-25%), gynecological
(12-23%), and lymphoid cancers (8-19%) (9).
A group of researchers from India evaluated 117 patients undergoing chemotherapy
using distress inventory for cancer (DIC2) and Hospital Anxiety and Depression
Scale (HADS). Of all the patients, 15% were found to have anxiety, whereas 16% had
depression. In the study, high social class was the only factor found to influence
distress, whereas female gender was the only one that influenced depression (52).
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Depression in cancer patients is common and may affect treatment outcome either
directly (by lowering defenses) or indirectly (by lowering compliance). It was
reported that cancer patients who responded to chemotherapy were less depressed at
the end of the treatment (53). In addition, it was found that two dimensions of
emotion (i.e., arousal and valence) significantly predicted changes in fatigue and
depressive symptoms in cancer patients undergoing chemotherapy. Changes in
fatigue depended more on the valence dimension, whereas changes in depressive
symptoms depended on both valence and arousal dimensions (54).
Based on the theory of unpleasant symptoms (55), it was found that women who were
receiving chemotherapy had more anxiety and fatigue and poorer quality of life than
men. Older age was associated with better quality of life and less insomnia, fatigue,
anxiety, and depression. It was suggested that insomnia and fatigue are related to
depression and that depression is more closely associated with quality of life (56).
An interaction between psychological attitude and outcome in early-stage cancer has
been postulated, with a possible explanation related to the presumed tendency of
patients with depression to be less proactive in obtaining health care. A study on the
degree of acceptance of adjuvant chemotherapy in patients with breast cancer who
have concomitant depression found that only 51.3% of the study group accepted and
received the proposed chemotherapy compared with 92.2% of the control group. This
suggests that treatment of depression might be essential for tailoring adjuvant
treatment with chemotherapy (57).
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A suggested guideline for diagnosis, correcting myths, and detecting major
depression revealed that fewer than half of the patients with cancer-related depressive
symptoms were offered treatment. The guideline suggests that alleviation of major
depression will improve the quality of life of these cancer patients. Clinicians
proficient in psychosocial assessment should be able to detect subtle signs, monitor
risk factors, reduce major depression with cognitive strategies, and prevent
complications. Untreated major depression lowers life expectancy and treatment
compliance and therefore increases the risks of suicide and contracting cardiac
disease (58).
Depression is a progressive condition that is most responsive to treatment in its
earliest stages because of the progressive nature of alterations in neurological circuits
and neurotransmitters. It is suggested that aggressive screening and management
using cognitive-behavioral therapy or adequate psychopharmacological intervention
can promote recovery from cancer-related depression and improve the patients’
quality of life (59, 60). Adequate psychopharmacological management of depression
requires consistent and informed involvement of health care professionals, patients,
and caregivers. Patients and caregivers need to be prepared to assess responses to
therapy, recognize adverse effects, and manage minor side effects and threats to
treatment adherence (60).
Conclusions
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The significant experience of psychological distress among cancer patients
undergoing chemotherapy should not be left unrecognized and untreated. Factors that
concern the patients should be addressed accordingly, and in doing so, there may be a
need for a multidisciplinary approach. Therefore, the role of the mental health team in
managing cancer patients is very important.
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