Anxiety and cancer

DEFINITION: Anxiety encompasses a complex set of behavioral, cognitive, and physiological responses to a perceived threat. Symptoms of anxiety include apprehension, worry, or fearfulness toward a future event or outcome, physical signs (such as muscle tension, elevated heart rate, breathing changes, and sweating), and often concern about the meaning or implications of the anxious reaction itself.

Description of the problem: A key feature of anxiety is the perception of an imminent or future threat, regardless of the accuracy of the perception. Although in some cases, anxiety can be brought on by exaggerated or unrealistic appraisals of threat, in the case of cancer, anxiety is a normal and expected reaction to a serious and potentially life-threatening disease.

Excessive anxiety that interferes with an individual's daily life deserves further evaluation. Vital to the assessment of clinically-significant anxiety is the extent to which anxiety meaningfully impairs the ability to function. For example, extreme anxiety may prevent an otherwise able patient or loved one from continuing to work, or it may interfere with medical care when a patient’s fearful avoidance prevents or delays tests or treatments.

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (5th ed., text revision, 2022) recognizes several distinct types of anxiety disorders, including generalized anxiety disorder (GAD), panic disorder, panic attacks, specific phobias, social anxiety disorder, separation anxiety disorder, agoraphobia, and selective mutism, as well as substance- or medication-induced anxiety disorder, anxiety disorder due to another medical condition, other specified anxiety disorder, and unspecified anxiety disorder. Anxiety may also be a prominent feature of depression or an adjustment disorder (a short-term psychological reaction to a stressful event), both of which are common among cancer patients.

The experience of being a cancer patient can contribute to the development of anxiety disorders in several ways. For example, a patient may develop a phobia of particular objects or procedures such as needles or diagnostic tests that they associate with highly stressful experiences. After cancer care, some patients may experience symptoms of post-traumatic stress disorder (PTSD), a trauma- and stress-related disorder characterized by recurrent intrusive memories and flashbacks, avoidance of reminders of stressful events, and hyper-arousal symptoms such as sleep difficulties and irritability. Anxiety may also have origins in medical causes, such as certain types of tumors or physiological side effects from some treatments.

Prevalence: Not surprisingly, research suggests that the vast majority of cancer patients experience anxiety at some point during their illness. Far fewer develop clinical anxiety disorders. Although several studies have suggested an increased prevalence of anxiety disorders among cancer patients, others suggest little or no difference in this prevalence when cancer patients are compared with the general population. Reported rates of anxiety disorders are usually lower when patients are assessed using formal diagnostic criteria, and diagnoses range from 10 to 30 percent. A 2023 study published by the Multinational Association of Supportive Care in Cancer found that the percentage for people without a history of cancer was 46.9 percent and those with a history of cancer was 45.8 percent, demonstrating no marked difference.

Assessment: In the clinical setting, anxiety is most commonly assessed face to face by a primary care provider or by a provider with special expertise in mental health, such as a psychiatrist, psychotherapist, or a clinical psychologist. The assessment is usually in the form of an interview to establish the nature, duration, and severity of symptoms according to established criteria, whether according to the diagnostic standards set out by the American Psychiatric Association or some other diagnostic system.

Numerous standardized questionnaires are also available to measure anxiety in clinical and research settings. These questionnaires ask respondents to self-report the frequency or severity of various symptoms commonly associated with anxiety. Examples of anxiety assessment questionnaires that have been used with cancer patients include the Beck Anxiety Inventory, the State-Trait Anxiety Inventory, and the Hospital Anxiety and Depression Scale.

Treatment and therapy: Anxiety related to medication or disease is usually first treated by managing the underlying condition causing symptoms. However, in many cases, anxiety is treated as a condition in its own right. Effective interventions for anxiety include both medical and psychological treatment options.

Medical management of anxiety usually entails treatment with an anxiolytic (antianxiety) or antidepressant medication, the latter particularly when signs of a depressed mood are present. The class of drugs known as benzodiazepines, which includes clonazepam (Klonopin), alprazolam (Xanax), and diazepam (Valium), are sometimes used for short-term treatment. Longer-term treatment with benzodiazepines is controversial due to physical dependence and withdrawal symptoms patients can sometimes experience. Commonly prescribed antidepressants include selective serotonin reuptake inhibitors (SSRIs) such as paroxetine and sertraline (Zoloft) and fluoxetine (Prozac), serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine (Effexor) and duloxetine (Cymbalta), and to a lesser extent tricyclic antidepressants such as imipramine (Tofranil) and clomipramine (Anafranil).

Psychological treatments include individual psychotherapy (talk therapy), group therapy, family therapy, and certain mind-body interventions. Anxiety is highly responsive and often easily treated with appropriate therapy. In particular, research heavily supports the efficacy of cognitive-behavioral therapy, which encompasses a variety of therapeutic techniques. Broadly speaking, the goals of cognitive-behavioral therapy for anxiety are to guide patients toward a more balanced and rational appraisal of their concerns and to encourage behaviors that reduce or neutralize anxieties rather than exacerbate them. Other frequently used therapeutic approaches include training in relaxation techniques, mindfulness meditation, and hypnosis. Biofeedback may also be effective in helping patients recognize and manage physical symptoms of anxiety by, for example, reducing muscle tension and cardiovascular reactivity to stress.

Starting in the twenty-first century, researchers began studying the effects of psilocybin-assisted psychotherapy and other psychedelic drugs to treat palliative patients, such as those with cancer, who were experiencing anxiety and depression. Initial studies and pilot programs showed that the use of psilocybin demonstrated anxiolytic, antidepressant, anti-inflammatory, and entheogenic effects in patients.

Bibliography

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington: Author, 2013. Print.

Antony, Martin M., Susan M. Orsillo, and Lizabeth Roemer, eds. Practitioner’s Guide to Empirically Based Measures of Anxiety. New York: Kluwer Academic/Plenum, 2001. Print.

Baum, Andrew, and Barbara L. Andersen, eds. Psychosocial Interventions for Cancer. Washington: American Psychological Assoc., 2001. Print.

Cho, William C. S., ed. Evidence-Based Non-Pharmacological Therapies for Palliative Cancer Care. Dordrecht: Springer, 2013. Print.

Fardell, Joanna E., et al. “Anxiety, Depression, and Concentration in Cancer Survivors: National Health and Nutrition Examination Survey Results.” Supportive Care in Cancer: Official Journal of the Multinational Association of Supportive Care in Cancer 31, Article 272 (15 Apr. 2023). doi:10.1007/s00520-023-07710-w.

Ladas, Elena J., and Kara M. Kelly. Integrative Strategies for Cancer Patients: A Practical Resource for Managing the Side Effects of Cancer Therapy. Hackensack: World Scientific, 2012. Print.

Whinkin, Emily, et al. “Psilocybin in Palliative Care: An Update.” Current Geriatrics Reports 12.2 (2023): 50-59. doi:10.1007/s13670-023-00383-7