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.

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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.
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 wellbeing. 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 selfhypnosis, 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 long-acting
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.

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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.
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.
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Family

caregiving

requires

adjustment

in

daily

schedules,

imposes financial burdens, and causes the individual members to re-evaluate 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.
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 illnessgenerated 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.

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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
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?
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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.
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.
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.

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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. Accept the person unconditionally.
2. Make plans for the future.
3. Keep communication open, but let the person with cancer set the pace.
4. Be sincere when providing support and reassurance.
5. Assist and encourage referrals to community services.
6. Be a good listener, and try to feel comfortable with silence.
7. Visit; if words fail, a loving look or touch can say a lot.
8. Ask the patient with cancer what you can do to help, and then follow-through.
9. Do not share privileged communication with others without permission.
SURVIVORSHIP
Clients who have completed successful treatment enter an indeterminate period of longterm 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
dominate their lives. Plans may be suspended. Decisions about changing jobs, buying a

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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
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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.
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:
o

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. 8th edition, 2004

Langhorne, Martha E., et.al. Oncology Nursing, 5thedition, Elsevier, 2011

Prepared By:
Mannylyn Echavaria, RN

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