Adjustment to Illness - Cancer

Question 1

What are the key issues at the pre-diagnosis stage of illness?

Answer 1

The process of screening and tests can be distressing:

Genetic testing for breast cancer - 25% of women undergoing testing report:

• high levels of intrusive thoughts about the potential negative consequences of testing
• ‘constant/frequent’ worrying about their risk
• high levels of anxiety
• Elevated levels of distress even among those given apparently ʻgood news’

Question 2

What are the key issues at the diagnosis stage of illness?

Answer 2

Common reactions to cancer diagnosis include
- Shock, Numbness, Disbelief
- Acute distress, Anxiety, Anger, depression, grief
- Bargaining, Protest
- Gradual adjustment, Acceptance
However wide variations may occur, (Can be calm acceptance, denial may continue)

Health professional-patient-family communication can
influence the impact of the diagnosis & long term adjustment
- Guidelines for ‘breaking bad news’ and discussing prognosis, Communication skills training, Audio-taping consultations
- Empathy is crucial

Question 3

What are the key issues at the time of Treatment decision making?

Answer 3

There is great variability in the degree to which patients prefer to be involved in decision-making, ranging from paternalistic, to shared, to patient led decisions.

Shared-decision making (SDM)

• 3 stages; information, deliberation, decision
• improves; overall satisfaction, doctor/patient relationship, knowledge, treatment adherence

Strategies:

• coaching patients/family to ask questions, question prompt sheets,
• psycho-educational resources
• facilitate involvement and avoid coercion

Question 4

How can family be involved in coping with illness?

Answer 4

Family caregivers:
- regularly attend medical consultations
- may have a considerable impact on the dynamics and
outcomes of medical consultations

Roles: emotional, informational, decisional and logistical support, advocate, interpreter, memory aid in consultations

Question 5

What are the key issues around the treatment phase of illness?

Answer 5

Cancer treatment can be highly traumatic

• surgery; high pre-operative anxiety
• chemo; side effects can cause depression, often seen as more frightening than surgery
• radiotherapy; most feared treatment (images), anticipatory nausea and vomiting is common

Adequate preparation and post-treatment support
is critical:
- patient and staff attitudes to side effects/pain
- education (procedural and sensory information)
- anxiety management;
- managing side-effects;
- continuous support (nurse care coordinators)
- complementary therapy (Used to help alleviate symptoms and side effects, commonly used - 65%)

Question 6

What are the key issues between end of treatment and 5 year follow up?

Answer 6

For the majority, psychological adjustment returns to normal

• for some, cessation of treatment can cause heightened anxiety
• fear of cancer recurrence is very common
• 2 years after treatment; 30% patients are clinically anxious, 10-20% patients remain clinically depressed

Question 7

What are the key issues around end of life care?

Answer 7

Terminal patients and their families will experience many issues such as:

• Uncertainty – what will happen to me?
• Fear of pain and suffering, anticipatory grief
• Fear of the process of dying
• Decision-making: advanced directives
• Carer: feelings of inadequacy
• Practical issues (care type, legal issues, funerals)

Question 8

What are the key issues around survivorship?

Answer 8

Life after cancer diagnosis and treatment may be vastly different to the life before cancer:

• not only physiologically but also in terms of identity, relationships and quality of life
• may be more difficult and more painful than that of the treatment phase

Common challenges:

• expectation to return to normal
• existential tension
• identity disruption
• fear and distrust of own body
• mental health (only direct impact as a cancer survivor)

Question 9

What are some strategies for dealing with post cancer survivorship?

Answer 9

Dispell pressure to keep a “positive attitude/fighting spirit” at all times:

• Unrealistic => feelings of sadness, fear, anxiety post-cancer diagnosis are normal
• Adds to the patient’s emotional burden

Other major strategies:

• Normalising and validating the experience
• Tailoring psychosocial care to the needs of the survivor and their family
• Overcoming poorly coordinated follow-up care with SURVIVORSHIP CARE PLANS (formal, written documents that provide details of a person’s history and recommended future treatment)