“Cancer doesn’t just affect you physically…It can affect every aspect of your life including your role in your family, your relationships, your work life, and even your identity.”

Mental Health and Cancer

Sometimes life can be a precarious balancing act. This balance can be disrupted in any number of ways – including the loss of a job or a divorce or a cancer diagnosis. Traumas like this can lead to mental health challenges during times when balance is difficult to maintain.  According to the World Health Organization mental health is defined as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community”.

“Cancer doesn’t just affect you physically,” says Elissa Kolva, PhD, University of Colorado Cancer Center researcher. “It can affect every aspect of your life including your role in your family, your relationships, your work life, and even your identity.”

Combine emotional distress with other elements of a cancer diagnosis such as treatment and tough side effects and you have a recipe for any number of mental health challenges.

“Although there are many mental health problems a patient with cancer may experience, anxiety and depression are the two biggest challenges,” says Kristin Kilbourn, PhD, psychologist and CU Cancer Center investigator. “These can affect nearly all aspects in their quality of life from the ability to sleep to the motivation to go and do things they once enjoyed. It can be very debilitating.”

It is estimated that 22 percent to 29 percent of patients with cancer will experience depression. Symptoms may include feelings of hopelessness and losing interest or pleasure in the things you normally enjoy. Typically, prevalence of depression increases with the severity of disease or side-effects from treatment.

“It is important to point out that having feelings of sadness, anger, and hopelessness after a cancer diagnosis is not abnormal,” says Kolva, who also is an assistant professor in the Division of Medical Oncology at CU Anschutz Medical Campus and clinical psychologist at UCHealth University of Colorado Hospital.  “If you get down and stay down or have trouble getting yourself out it becomes more of a problem. In those cases, it may be helpful to speak with your medical team about possibly trying an antidepressant or meeting with a mental health provider for psychotherapy.”

In addition to depression, anxiety affects many patients, especially when they are first diagnosed. According to the American Cancer Society, symptoms of anxiety include uncontrolled worry, trembling or shaking, restlessness, dry mouth, and angry outbursts or irritability. For more information about helping with anxiety and depression visit this website from the American Cancer Society.

Patients with cancer may also experience post-traumatic stress syndrome (PTSD), chemo-brain, and prolonged grieving.    

Mental Health Problems and Prognosis

Mental health problems, namely depression, have been linked to higher mortality rates in cancer patients. According to a study from the Journal of the National Cancer Institute cancer survivors who are depressed are twice as likely to die prematurely as those who are not depressed. While the reasons for this are unclear, studies have found mechanisms that may explain the phenomenon.

One mechanism may be found in how your body reacts to stress. Times of stress lead to increased level of the hormone cortisol. It is responsible for many mechanisms in the body including regulating the metabolism and inducing the “flight or fight” response. Typically, cortisol levels are higher in the morning and lower in the middle of the night. However, in patients with depression cortisol is released at elevated levels. In animal models, tumors with increased cortisol levels grew much more rapidly compared to the animals with normal cortisol levels.

Furthermore, some behaviors of patients with mental health problems may explain higher mortality rates.

“Depression can have a negative impact on self-care behaviors such that those with depressed mood are less likely to get enough sleep, avoid or limit alcohol or substance use, may not adhere to a healthy diet and/or regular exercise,” explains Kilbourn. “Additionally, depression is typically associated with social isolation and social withdrawal and there is quite a bit of research within the area of health psychology that suggests a strong link between social support and overall health as well as recovery from major illnesses or diseases.”

According to a study from Psychological Medicine, patients with depression are also less likely to adhere to preventive screening procedures, prescribed medication regimens and miss treatments.

Finally, many times symptoms of depression and side-effects from cancer treatment are very similar and can feed off one another.

“Cancer can affect depression and depression can affect cancer,” says Kolva. “Symptoms such as fatigue or lack of appetite can become more severe based on the combination of mental health symptoms and cancer treatment.”

More research is needed to fully understand the link between higher mortality rates and mental health problems in patients with cancer.

Cancer and Suicide

Patients going through cancer treatment are at a two to four times greater risk of suicide than the general population.

“In Colorado this is significant because suicide rates are already higher than the national general population,” explains Kolva. “It’s important for care providers to take this in account and assess psychological distress in their patients with cancer.”

Although depression is commonly associated with an increased risk of suicide a study in the Journal of National Cancer Institute found other explanations include feelings of hopelessness, functional limitations, anxiety, loneliness and a lack of social support. The study also found that there is a higher risk of suicide among patients who are white, male, unmarried, and are diagnosed with advanced disease. “Patients may express a wish for a hastened death or find comfort in the thought of dying or disease progression, this may be more prevent in patient with advanced stage disease,”says Kolva. “They can feel like going though treatment is not worth it. It is not uncommon for patients to have these thoughts. Once we help them recognize that they are not alone they can often move forward to engage meaningfully in their lives.”

However, there are times when patients have more persistent thoughts of hurting themselves or hastened death.

“In these cases we look to identify the factors contributing to these persistent thoughts.  If it is depression we focus on treating the depression, if it is uncontrolled pain we will work to collaborate with the medical team,”says Kolva. “The patient’s safety is most important, we often work with patients to establish a safety plan.  In some cases we may end up recommending inpatient treatment.”

A safety plan usually includes providing a suicide hotline number (1-800-273-TALK (8255), designating trusted people to talk to if a patient has thoughts of harming him or herself, and having the nearest emergency room information.

“As research advances our goal is to better understand the factors that increase risk for suicide in patients with cancer,” says Kolva. “Until we can better define that it is important for patients to know that support is available if they are struggling.”

Importance of Mental Health Screening After Cancer Treatment

Often times mental health problems arise after treatment is completed and patients are returning to their “normal” lives. This transition often is accompanied with feelings of anxiety about recurrence or other side-effects from treatment.

“The time after treatment is finished is often perceived to be a time to celebrate and get back into the routine you had before the cancer diagnosis,” says Linda Overholser, MD, MPH, CU Cancer Center investigator and primary care physician. “However, many times I find patients are more anxious because they are not being seen as often and may bewondering ‘what happens next?’ Sometimes treatment itself can lead to symptoms that contribute to poorer mental health, including fatigue and cognitive dysfunction.”

Concerns may include “will my cancer come back?” “Will I ever be able to have children?” or “Will I develop another cancer in the future because of my treatment?” These concerns lead to an increased rate of mental health problems in this population. According to an article from North Carolina Medical Journal, 10.1 percent of cancer survivors reported poor mental health as compared to 5.9 percent of adults without cancer.

“As a primary care physician, this statistic is a red flag for me,” says Overholser. “Because patients often return to seeing their PCP after treatment is completed it is important that we open up conversations and check in with them about more than their physical health.”

Transitioning to regular visits with a PCP can cause anxiety as visits with the oncologist become less frequent.  Patients may worry that their usual doctor will not catch signs of recurrence or may not be familiar with their cancer. However, reconnecting with your primary caredoctor for follow up care is important in cancer survivorship as this can ensure that individuals receive more comprehensive care. These check-ups may include bloodwork and other tests to monitor any changes in your health. They are also an opportunity to talk about how you are doing emotionally in the months and years after treatment. Mental health problems are not uncommon after completing cancer treatment, that is not to say that all patients will experience them. Many patients do well after cancer.

“I have seen patients who come out with a new perspective on life and have developed a resilience they never thought they had,” says Overholser. “A cancer diagnosis does not necessarily mean that you will develop a mental health problem, but it is important that it is treated if you do.”

Mental health screenings during and after cancer treatment are increasingly becoming the standard when it comes to cancer survivorship.  If you are struggling be sure to talk to your doctor and get the support you need.

Ways to Cope

Having reliable and effective coping strategies is very important to maintaining and improving quality of life while going through a time of trauma. There are many universal techniques that can help to lower stress and anxiety during the cancer experience.

“Engaging in hobbies and interests that bring about joy and happiness, asking for and accepting social support, getting enough sleep, maintaining a healthy diet, limiting alcohol and other substances, engaging in regular activities and pacing and prioritizing are some things that patients do can do reduce stress, “says Kilbourn. “Recognizing that the experience of cancer does not have to be all negative and can lead to many positive changes such a greater appreciation for life can be very empowering.”

Individualized coping strategies are another effective way to deal with stressors on a personal level. In order to do this a patient must first recognize which stressors they can control and determine which coping response will be most beneficial to them.

“There are two coping strategies that we recommend to patients, problem-focused and emotion-focused,” explains Kilbourn. “Problem-focused coping strategies include

seeking information, decision-making, setting goals, and asking for help. These strategies work best when the stressor is controllable.”

Examples of controllable stressors may include choosing where to get cancer treatment or whether to get a second opinion.

“Emotion-focused coping strategies include reframing your thoughts, exercising, journaling, and acceptance,” says Kilbourn. “These strategies work best with the stressor is out of your control.”

Uncontrollable stressors may include the cancer diagnosis itself or the stage of disease.

If a patient is finding that coping strategies are not effective professional assistance via counseling or “talk” therapy, group therapy and/or considering medical intervention such as an antidepressant medication may be beneficial.

The Future of Mental Health in Cancer Care

The importance of maintaining good mental health while going through cancer was once not considered a priority as it was assumed depression was a normal response to diagnosis. However, there has recently been a push by researchers to increase the funding of mental health research in cancer survivors as more studies show that mental health problems are not only common but also can affect the quality and quantity of life of those survivors.

In 2014 the American Society of Clinical Oncology (ASCO) adapted guidelines for the screening, assessment, and treatment of anxiety and depressive symptoms in adults with cancer. These guidelines include having patients screened for depressive symptoms at the initial visit and at appropriate intervals throughout and after treatment is completed and referring at-risk patients to a professional immediately if there is indication of self-harm or harm to others.

Additionally the National Comprehensive Cancer Institute (NCCN) as well as the Children’s Oncology Group (COG) have guidelines for screening and management of psychosocial concerns in individuals with cancer.

“Recognizing and treating mental health problems in all patients with cancer at all stages of diagnosis is increasingly proving to be fundamental to maintain and improve quality of life during and after treatment,” says Overholser, who is on the Survivorship Guidelines Panel of the NCCN.

As the significance of supporting good mental health during and after cancer treatment increases, psychologists are working to find ways to help as many patients as possible through technology such as mindfulness apps on their phones.

“We typically only see patients for one hour a week,” says Kolva. “Using these apps can be a great way to continue to practice mental health exercises even when they cannot be with a psychologist.”

The philosopher Plato once said “the part can never be well unless the whole is well”. By focusing on not only the physical health but also the mental health of patients with cancer, there is hope that survivors will have increased access to the support they need in the years ahead.