PSYCHOSOCIAL ASPECTS OF CANCER

The diagnosis of cancer affects not only the individual but also the clients family.
Because cancer is not just a physical disease, it compels the clients- and health care
professionals- to face the meaning of their lives and their relationships. The cancer illness in
one member of a family will alter the emotional balance, finances, division of responsibility,
and social activities of the spouse or partner, as well as the rest of the family. How patients
and families become organized, and how they communicate and solve problems together to
cope with the threat often foretells their ability to recover. A support network of extended
family, friends, neighbours, spiritual counsellors, employers, and available community
resources will also contribute to the recovery process.
Many patients, even today, consider a cancer diagnosis as a sentence of impending
and painful death, with the result that it has great psychologic impact on their functioning
and that of their family. Initially, a psychologic crisis is created, which causes many
emotions ranging from anxiety, anger, fear, and depression caused by the often emotionally
paralyzing diagnosis and treatment options, to despair and hopelessness.
a. PROVIDING SUPPORT TO CLIENTS
The most valuable intervention you can offer a client with
cancer is your presence as a caring person. The dimensions of
your presence consist of verbal expressions of empathy, positive
regard, and availability of practical support.
Fear of pain, disfigurement, loss of function, loss of control,
and financial insecurity can be manifested by symptoms of
depression, anxiety, hopelessness, fear, and panic disorders. The incidence and severity of
these various negative sequelae have a considerable impact on the quality of a persons
life. How the patient adapts to the rigors of treatment, the requisite follow-up appointments,
and the impact of chronic illness depends on many factors, including his or her general
coping strategies, problem-solving abilities, communication skills, resiliency, flexibility,
hope, level of family support, ability to maintain a seminormal routine, and tolerance of
ambiguity.
Social isolation can be due not only to privacy factors, but also to the stigma of cancer,
to the anger of the family and friends because the patient developed the disease, and to
the fact that disability has risen and prevents participation in many social activities. Family
and friends want to help, but often it is by voicing cheery encouragement, rather than
allowing the patient to ask for what he or she needs and or feels would be helpful.
Sexual health and the sexual relationship are important aspects of the patients very
being; however, focus is usually centered on the physical well-being of the patient,
especially during diagnosis. As the patient traverses the treatment process and beyond,
sexual functioning can be threatened via numerous influences including fear of contagion,
disfiguring surgery, fertility issues, chemotherapy side effects like fatigue and malaise,
nausea and vomiting, and pain.
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There is a great variability in the distress, changes, and other effects of cancer in the
lives of clients and their families. Responses to cancer depend on the following:

The disease, the disabilities, and disfigurements it may cause

Any pre-existing medical conditions that limit treatment options
The clients psychological make-up and spiritual well-being
The clients family and social community
The availability of medical and financial resources

PSYCHOLOGIC DISORDERS: ANXIETY AND DEPRESSION

These feelings are normal, since cancer is an obvious threat to the persons very
well-being. However, many myths and assumptions exist which suggest that all cancer
patients must be depressed and require psychiatric intervention.
i.

ANXIETY

Behavioural techniques can offer stress reduction and teach patients coping skills if they
are exposed to an anxiety-producing thought or event. Relaxation or distraction using music
and techniques such as breathing exercises and yoga, guided imagery, biofeedback, and
meditation make up several behavioural components of nondrug therapy. A psychotherapy
consult may be appropriate to learn hypnosis and self-hypnosis, and in
cases of severe phobias or panic attacks, eye movement
desensitization and reprocessing (EMDR) procedures might be
considered.
Pharmacologic intervention for anxiety is usually accomplished with
drugs from the benzodiazepine family; however, stronger antipsychotic
medications like phenothiazine can be used if a patient is severely
anxious. There are several commonly prescribed benzodiazepines for
anxiety in cancer patients. They include the short-acting drugs such as lorazepam (Ativan)
and oxazepam (Serax); an intermediate-acting drug, alprazolam (Xanax); and several longacting drugs such as chlordiazepoxide (Librium), diazepam (Valium), and clorazepate
(Tranxene). Because the benzodiazepines can cause respiratory depression, antihistamines
can be used for patients with serious breathing impairment.
ii.

DEPRESSION

Body language can also be significant as a communication too; effective eye contact,
active listening, and a caring touch demonstrate interest and sensibility. Although reflective
interaction can help patients admit and accept feelings, it can also frustrate patients if this
type of response is not used skilfully. If a patient simply hears her
statement repeated back to her, she may feel as if the
interviewer processes little if any understanding. Open-ended
questions encourage patients to express thoughts and feelings.
Because depression often accompanies anxiety, relaxation or
diversion methods (e.g., music, relaxation therapy, guied
imagery) are most useful.
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When considering the use of medication for depression, it is important to ascertain

whether the depression is severe, recurrent, or accompanied by psychotic symptoms. If any
are the case, medication is begun immediately with psychotherapy to follow. There are
many antidepressant drug families on the market that include the tricyclic antidepressants,
the selective serotonin reuptake inhibitors (SSRIs) and the monoamine oxidase inhibitors
(MAOIs). The most popular tricyclic antidepressants are amitriptyline (Elavil), doxepin
(Sinequan), and imipramine (Tofranil); the SSRIs include fluoxetine (Prozac), paroxetine
(Paxil), sertraline (Zoloft), escitalopram oxalate (Lexapro), and duloxetine (Cymbalta); the
MAOIs include phenelzie (Nardil) and tranylcypromine (Parnate).
b. PROVIDING SUPPORT FOR THE FAMILY
The impact of cancer diagnosis resonates within not only the patient but also the entire
family. Caregivers reflect the stressful events in the home. One has only to look at the
family caregiver at times to determine how well things are being managed at home.
Although the caregiver does not experience the physical symptoms of the patient, the
suffering the caregiver experiences is based on several other factors, such as prior pain
experiences, cultural milieu, relationship to the patient, and the meaning the caregiver
ascribes to the patients symptoms. The impact of the patients symptoms on the caregiver
and the latters interpretation of these symptoms can be manifested by the caregivers own
struggles with anger, depression, and existential suffering. The caregiver burden refers not
only to the physical demands placed on caregivers but also to emotional burdens. The
cancer experience is therefore a shared experience, the emotional and physical demands
being somewhat different for patient and the caregiver, but distressing all the same.

The home may be the setting for cancer care, even if the caregiver is physically,
emotionally, or financially challenged to do so. Family caregiving requires adjustment in
daily schedules, imposes financial burdens, and causes the individual members to reevaluate their relationships. With advances in cancer treatment, extended survival times
have led to caregiving demands that may continue for years. These changes can profoundly
affect roles and relationships, ranging from financial responsibilities to matters of intimacy.
Daily life is changed. Other family members may need to assume the role or
responsibilities of the client or serve as a caregiver. Nursing often views the family as the
context of caring for the client with cancer; the family needs to be the unit of care. A
familys resources, perceptions of the cancer, functioning patterns, coping strategies, and
stressors are factors affecting their ability to respond to the crisis of cancer. Much of the
distress for the client and the family can be lessened with minimal assistance from the
health care team. Without these services, even highly functioning families struggle.
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The Family Life History Model, which was designed to be broadly applicable to situations
where families are having to cope with physical illness, suggest that a process unfolds in
many families with chronic illness in which family life is increasingly organized around
illness-generated needs and demands.
Support can be provided to family caregivers by helping
them make decisions about the role that the illness should be
allowed to have in the family. Families can be advised to take
a closer look at current resources available and to consider
reallocation of resources in a way that meets the needs of the
patient but also the needs of the caregivers and other family
members.
10 Tips for Family Caregivers
1. Caregiving is a job and respite is youre earned right. Reward yourself with respite
breaks often.
2. Watch out for signs of depression, and dont delays in getting professional help
when you need it.
3. When people offer to help, accept the offer and suggest specific things that they
can do.
4. Educate yourself about your loved ones condition and how to communicate
effectively with doctors.
5. Theres a difference between caring and doing. Be open to technologies and
ideas that promote your loved ones independence.
6. Trust your instincts. Most of the time theyll lead you in the right direction.
7. Grieve for your losses, and then allow yourself to dream new dreams.
8. Stand up for your rights as a caregiver and a citizen.
9. Seek support from other caregivers. There is great strength in knowing you are
not alone.
10.Caregivers often do a lot of heavy lifting, pushing, and pulling. Be good to your
back.
c. PROMOTING POSITIVE SELF-CONCEPT
Cancer affects all levels of functioning. Physical and psychological distress, medications,
or the disease, medications, or the disease itself can cloud the clients intellectual function.
The clients self-concept is affected by physical, role, or function changes. A breadwinner
may become dependent on others and become a consumer of family savings and
resources. The young adult, striving for independence, may need to revert to an earlier
level of dependency.
Body image also changes for most clients. Weight loss, hair loss, and skin changes can
result from treatment. Radical surgical procedures can make devastating and permanent
changes in appearance and function. Procedures such as laryngectomy, glossectomy,
mastectomy, and prostatectomy may result in physical changes that humiliate and
overwhelm the client.
d. PROMOTING COPING THROUGH THE CANCER CONTINUUM
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Although each cancer experience is unique, people with cancer have some common
problems. Strategies for outcome management to help clients cope with the disease and its
treatment are addressed for each phase of the cancer continuum: diagnosis and treatment,
survivorship, recurrent disease and progression, and terminal illness.
DIAGNOSIS AND TREATMNET
Clients reach the point of cancer diagnosis in many ways. A client may have had vague
manifestations, such as weight loss and fatigue, that may have been ignored or a cause of
some anxiety for weeks or months. Another client may have manifestations, such as pain or
abdominal bloating, which evaded diagnosis. Many times, cancer is found incidentally
during a routine examination. Often the client suspect cancer, but many people are shocked
when the diagnosis is made. The diagnostic period may be long and extremely stressful.
This period is filled with anxiety about each test result, especially when staging procedures
are performed. More than 70% of clients consider the time of diagnosis and treatment as
the most stressful in the cancer experience.
Most clients fear death during the first few months of the cancer experience; whether
clients can express their fears or not, it is an underlying cause of distress. During diagnosis
the magnitude of the clients problems become apparent. The client may speculate on the
following questions: Is my disease curable? Will my disabilities be temporary or permanent?
What types of physical impairment will occur? What would be the side effects of treatment?
Will my manifestations be relieved? Will I be able to return to work? What adjustments have
to be made in family life or work? Will finances be adequate? Which changes in lifestyle will
be temporary and which permanent?
Clients must deal with health-related problems and with the emotional distress that
occurs at this time. They may feel angry and frustrated because their lives have been
changed; they may feel isolated or may worry about being abandoned by family and
friends. They may be shocked and unbelieving that they are the ones with cancer. They
may also feel guilty if they believe they have contributed to their disease through
behaviour, such as by smoking, drinking, or putting themselves at risk for sexually
transmitted diseases.
Clients reactions vary greatly. The initial response to the diagnosis of cancer may be
profoundly influenced by previous life experiences with the disease. When the disease is
advanced at the time of diagnosis, the client and family are likely to experience more
psychological distress as they are confronted with the dual stressors of a cancer diagnosis
and a terminal illness. Some have minimal distress, whereas others may be overwhelmed
and devastated. You may sometimes feel, on the basis of your own personality and
experience that a client is responding inappropriately to a cancer diagnosis. It is crucial,
however, to acknowledge every clients response as acceptable and unique for that client.
Weisman identified coping styles used by many clients with cancer. Denial, which is a
part of coping, allows a client to repudiate what cannot be avoided, by substituting a more
favourable or agreeable idea. Denial can be useful as healthy coping mechanism in
diagnostic phase, when the number of problems may be overwhelming. Denial is harmful
when it prevents the client from seeking appropriate treatment.
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GENERAL COPING STRATEGIES

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Seek more information (rational inquiry).

Share concern and talk with others (mutuality).
Laugh it off; make light of the situation (affect reversal).
Try to forget; put it out of your mind (suppression).
Do other things for distraction (displacement, redirection).
Take firm action on the basis of present understanding (confrontation).
Accept but find something favourable (redefinition, revision).
Submit to the inevitable (fatalism, passive acceptance).
Do something- anything- however reckless or impractical (impulsivity).
Consider or negotiate a feasible alternative (if x, then y).
Reduce tension with excessive drink, drugs, danger (life threats).
Withdraw into isolation; get away (disengagement).
Blame someone or something externalization, projection).
Seek direction; do what you are told (cooperative compliance).
Blame yourself; sacrifice or atone (moral masochism).

Clients who are good problem-solvers or who cope effectively tend to confront reality,
avoid excessive denial, remain flexible, accept support, and stay hopeful and optimistic.
Clients who cope poorly use avoidance and excessive denial; they are pessimistic and feel
hopeless. Every client uses a variety of strategies.
Families also should be assessed for their coping abilities. Use of a specific family
assessment tool may not be possible, but you may be able to identify high-risk families
from your interaction. Unresolved past problems may affect a familys ability to cope.
Families who use excessive denial, exhibit strong anger and guilt, or are unreasonably
demanding may be at increased risk for dysfunction. When the client is the pivotal person in
the family or when the family has had a previous experience of cancer with a negative
outcome, their need for ongoing psychosocial support systems may be increased.
Actively listen for remarks that describe the meaning and effect of cancer as
experienced by the client. Often, time limitations do not permit you to provide support
separate from physical caregiving. Consequently, while giving care, take the opportunity to
initiate social interactions, such as chatting about family, sharing stories, or greeting
visitors. Consider these actions a professional intervention. What did you learn about the
clients perceptions of cancer? What coping mechanisms did the client or significant others
use with past lifestyle changes? How will the clients and the familys lives be affected?
What needs for teaching or community resources did you note? Would referrals to other
members of the health care team, such as the chaplain and social worker, be helpful?
Providing social support and improving the clients sense of control help to reduce
anxiety. Stress reduction or relaxation techniques can be taught. Speaking with cancer
survivors encourages many clients. Support groups and one-to-one visitation programs such
as Reach to Recovery or CanSurmount (ACS) provide this opportunity. Internet support
groups offer the same opportunity for clients who are uncomfortable with the face-to-face
interactions of a traditional support group.

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Informational needs for the client and family are great during the diagnostic and
treatment periods. Tests, procedures, and treatments, which are often technical and
complicated, must be explained. Present consistent, accurate information in as much detail
as the client wants. Be sure that all health care providers are telling the client the same
thing. When clients from a cancer clinic were surveyed, information and support from
family, friends, and caregivers were identified as high priority needs.

NEEDS FOR CLIENTS WITH CANCER

The following are needs identified by those with cancer. While nurses should always
treat clients as they wish to be treated, the following suggestions may make this difficult
time easier.
1.
2.
3.
4.
5.
6.
7.
8.
9.

Accept the person unconditionally.

Make plans for the future.
Keep communication open, but let the person with cancer set the pace.
Be sincere when providing support and reassurance.
Assist and encourage referrals to community services.
Be a good listener, and try to feel comfortable with silence.
Visit; if words fail, a loving look or touch can say a lot.
Ask the patient with cancer what you can do to help, and then follow-through.
Do not share privileged communication with others without permission.

SURVIVORSHIP
Clients who have completed successful treatment enter an indeterminate period of
long-term survivorship. Survivorship has been divided into a time of acute survival
followed by a period of extended survival. Transition between these periods is not
precise but evolves as time passes and the cancer does not recur.
Depending on the extent of treatment, this period of extended survival may still be
one of physical fatigue and limitation. Physical rehabilitation to improve functioning may
dominate the clients energy in this early period. Efforts focus on restoring the clients
previous level of functioning.
The long-term physical effects of cancer treatment are now becoming apparent as
data accumulate, especially from clients with pediatric cancer. The physical effects may
range from minimal restriction to life-threatening complications. The effects can be
organ-specific, such as cardiomyopathy or pulmonary fibrosis, or general, such as
fatigue.
The potential for development of second malignancy as a result of primary treatment
is always a possibility. Although this possibility is usually rare, some studies have
reported up to 20% occurrence of another cancer after treatment of Hodgkins disease
and other cancers with alkylating agents.
Psychologically, the period of extended survival is one in which clients must assume
previous roles or adjust and recognize their lives. The possibility of recurrence may
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dominate their lives. Plans may be suspended. Decisions about changing jobs, buying a
house, starting a family, or beginning retirement may be difficult in the face of the
uncertainty of recurrence or concerns about insurance coverage.
Making sure the client adheres to routine follow-up and long-term health care with
attention to prevention and early detection (health promotion) will provide early
detection of recurrent cancer and second primary sites as well as early intervention for
late effects of treatment. Follow-up appointments and events such as National Cancer
Survivors Day celebrations (which are held in many communities each June) are
opportunities to obtain emotional support, alleviate fears of recurrence, and let clients
know that they are not alone in their feelings and concerns.
Employment discrimination has been problematic for cancer survivors. Despite the
fact that clients with a a cancer history are dependable and productive, studies show
that as many as 84% of blue-collar workers and 38% of white-collar workers with cancer
experience some type of discrimination employment. Over the years, these issues have
been partially rectified by state laws protecting the rights of the disabled.
Obtaining insurance coverage with a history of cancer has also been difficult,
ruinously expensive, and sometimes impossible. Legislative efforts have corrected some
of these problems. Insurance discrimination can be legally appealed. Federal programs
such as the Consolidated Omnibus Budget Reconciliation Act (COBRA) protect the
insurance coverage of an employee for 18 months after termination of employment but
an increased monthly premium. A client, spouse, or parent may be trapped in an
unrewarding job to maintain the employer-funded group insurance; direct clients who
have difficulty with insurance coverage to contact the National Coalition for Cancer
Survivorship, the ACS, their state department of human rights, or their state of insurance
department.
With time, these problems usually recede and clients move into a period of extended
survival. The experience of cancer is nonetheless indelibly imprinted on their lives.
Amazingly, most clients cope well and face the difficulties in their lives with courage. For
many clients the experience triggers a reappraisal of goals and values, making life richer
and more meaningful.
RECURRENT DISEASE AND PROGRESSION
Most clients with cancer live with the threat or reality of recurrent disease. Weisman
describes the effect that this phase has on the client as the hope for a cure becoming the
struggle for existence. With recurrent cancer, therapy may once again be used to
eradicate or stabilize the disease process.
Although subsequent recurrent disease may occur, it is usually the first recurrence
that causes surprise, shock, and disbelief in client. Physical impairment may be greater, and
quality of life may be limited because of disease or treatment. The client who previously
projected an optimistic outlook may now express a more guarded attitude. Maintain open
communication and be sensitive to the informational and support needs of the client and
family.
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Clients at this stage in the cancer continuum are usually not in imminent danger of
dying. They are generally awake of the likely eventuality of death. Often they still want to
continue treatment. Surgery, XRT, or chemotherapy may still be of value for palliation of
manifestations regardless of whether the treatment extends life. Surgery, XRT, or
chemotherapy may be used to palliate complications used by persistent tumor growth. For
example, surgery may be used to manage a malignant obstruction, or XRT may be used to
prevent paralysis from spinal cord compression. Palliative treatment is not curative but is
aimed at improving the quality o0f the remainder of the clients life, however long or short.
Although clients at this stage may not qualify for traditional hospice care, they could
benefit from the supportive services and management of manifestations offered by hospice
programs. Increasingly, hospitals are developing supportive care programs or palliative care
teams to meet these needs. Palliative care is the provision of management of
manifestations and psychosocial support, best offered by a multidisciplinary health care
team. Palliative care can be added gradually as the cancer and its manifestation progress.
Clients can be participating in evaluating when the side effects of treatment modalities such
as chemotherapy outweigh the benefits of palliating cancer manifestations. Increasingly
today, professionals are recognizing the value of incorporating quality-of-life outcomes for
clients throughout the course of their illness. Palliative care programs combine the medical
models goal to prolong life with hospice goals to relieve manifestations and improve the
quality of clients remaining time.
TERMINAL ILLNESS
About 50% of clients with cancer will die of their disease. The time from diagnosis to
death ranges from weeks to years. Not all clients with cancer become terminally ill. Some
clients die during the initial treatment; others die of complications of treatment. Many,
however, reach an end-point at which their cancer no longer responds to treatment and
progression of the disease cannot be controlled. Then the goal of treatment is directed
toward providing supportive care and minimizing distress until death occurs.

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REFERENCES:
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Black, Joyce M. & Hawks; Jane, Hokanson. Medical-Surgical Nursing, Clinical

Management for Positive Outcomes. 7th edition, Elsevier Saunders, 2005
Varrichio, Claudette. A Cancer Source Book for Nurses. 8 th edition, 2004
Langhorne, Martha E., et.al. Oncology Nursing, 5 thedition, Elsevier, 2011

Prepared By:
Mannylyn Echavaria, RN

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