Anxiety and distress can affect the quality of life of patients with cancer and their families.

Patients living with cancer feel many different emotions, including anxiety and distress.

• Anxiety is fear, dread, and uneasiness caused by stress.
• Distress is emotional, mental, social, or spiritual suffering. Patients who are distressed may have a range of feelings from vulnerability and sadness to depression, anxiety, panic, and isolation.

Patients may have feelings of anxiety and distress while being screened for a cancer, waiting for the results of tests, receiving a cancer diagnosis, being treated for cancer, or worrying that cancer will recur (come back).

Anxiety and distress may affect a patient's ability to cope with a cancer diagnosis or treatment. It may cause patients to miss check-ups or delay treatment. Anxiety may increase pain, affect sleep, and cause nausea and vomiting. Even mild anxiety can affect the quality of life for cancer patients and their families and may need to be treated.

Patients living with cancer can feel different levels of distress.

Some patients living with cancer have a low level of distress and others have higher levels of distress. The level of distress ranges from being able to adjust to living with cancer to having a serious mental health problem, such as major depression. However, most patients with cancer do not have signs or symptoms of any specific mental health problem. This summary describes the less severe levels of distress in patients living with cancer, including:

• Normal adjustment—A condition in which a person makes changes in his or her life to manage a stressful event such as a cancer diagnosis. In normal adjustment, a person learns to cope well with emotional distress and solve problems related to cancer.
• Psychological and social distress—A condition in which a person has some trouble making changes in their life to manage a stressful event such as a cancer diagnosis. Help from a professional to learn new coping skills may be needed.
• Adjustment disorder—A condition in which a person has a lot of trouble making changes in his or her life to manage a stressful event such as a cancer diagnosis. Symptoms such as depression, anxiety, or other emotional, social, or behavioral problems occur and worsen the person's quality of life. Medicine and help from a professional to make these changes may be needed.
• Anxiety disorder—A condition in which a person has extreme anxiety. It may be because of a stressful event like a cancer diagnosis or for no known reason. Symptoms of anxiety disorder include worry, fear, and dread. When the symptoms are severe, it affects a person's ability to lead a normal life. There are many types of anxiety disorders:

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  Generalized anxiety disorder.

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  Panic disorder (a condition that causes sudden feelings of panic).

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  Agoraphobia (fear of open places or situations in which it might be hard to get help if needed).

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  Social anxiety disorder (fear of social situations).

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  Specific phobia (fear of a specific object or situation).

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  Obsessive-compulsive disorder.

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  Post-traumatic stress disorder.

There are certain risk factors for serious distress in people with cancer.

Nearly half of cancer patients report having a lot of distress. Patients with lung, pancreatic, and brain cancers may be more likely to report distress, but in general, the type of cancer does not make a difference. Factors that increase the risk of anxiety and distress are not always related to the cancer. The following may be risk factors for high levels of distress in patients with cancer:

• Trouble doing the usual activities of daily living.
• Physical symptoms and side effects (such as fatigue, nausea, or pain).
• Problems at home.
• Depression or other mental or emotional problems.
• Being younger, nonwhite, or female.
• Having a lower level of education.

Screening is done to find out if the patient needs help adjusting to cancer.

Screening is usually done by asking the patient questions, either in an interview or on paper. Patients who show a high level of distress usually find it helpful to talk about their concerns with a social worker, mental health professional, palliative care specialist, or pastoral counselor.

See the following PDQ summaries for information on depression and post-traumatic stress disorder:

• Depression
• Cancer-Related Post-traumatic Stress

Patients living with cancer need to make adjustments in their lives to cope with the disease and changes in treatment.

Living with a diagnosis of cancer involves many life adjustments. Normal adjustment involves learning to cope with emotional distress and solve problems caused by having cancer. Patients with cancer do not make these adjustments all at once, but over a period of time as their disease and treatment change. Patients may need to make adjustments when they:

• Learn the diagnosis.
• Are being treated for cancer.
• Finish treatment.
• Learn that the cancer is in remission.
• Learn that the cancer has come back.
• Become a cancer survivor.

Coping methods help patients adjust.

Patients find it easier to adjust if they can carry on with their usual routines and work, keep doing activities that matter to them, and cope with the stress in their lives.

Coping is the use of thoughts and behaviors to adjust to life situations. The way people cope is usually linked to their personality traits (such as whether they usually expect the best or worst, or are shy or outgoing).

Coping methods include the use of thoughts and behaviors in special situations. For example, changing a daily routine or work schedule to manage the side effects of cancer treatment is a coping method. Using coping methods can help a patient deal with certain problems, emotional distress, and cancer in his or her daily life.

Patients who adjust well are usually very involved in coping with cancer. They also continue to find meaning and importance in their lives. Patients who do not adjust well may withdraw from relationships or situations and feel hopeless. Studies are being done to find out how different types of coping methods affect the quality of life for cancer survivors.

Patients who are adjusting to the changes caused by cancer may have distress.

Distress can occur when patients feel they are unable to manage or control changes caused by cancer. Patients with the same diagnosis or treatment can have very different levels of distress. Patients have less distress when they feel the demands of the diagnosis and treatment are low or the amount of support they get is high. For example, a health care professional can help the patient adjust to the side effects of chemotherapy by giving medicine for nausea.

The way each patient copes with cancer depends on many physical and emotional factors.

The following factors affect how a patient copes with the stress of cancer:

• The type of cancer, cancer stage, and chance of recovery.
• Whether the patient is newly diagnosed, being treated, in remission, or having a recurrence.
• The patient's age.
• Whether the patient is able to get treatment.
• How well the patient usually copes with stress.
• The number of stressful life events the patient has had in the last year, such as starting a new job or moving.
• Whether the patient gets support from friends and family.
• Social pressures caused by other people's beliefs and fears about cancer.

Cancer patients need different coping skills at different points in time.

The coping skills needed will change at important points in time. These include the following:

Feelings of emotional, social, or spiritual distress can make it hard to cope with cancer treatment.

Almost all patients living with cancer have feelings of distress. Feelings of distress range from sadness and fears to more serious problems such as depression, panic, feeling uncertain about spiritual beliefs, or feeling alone or separate from friends and family.

Patients who are in distress during any phase of cancer need treatment and support for their distress. Patients are more likely to need to be checked and treated for distress during the following periods:

• Soon after diagnosis.
• At the start of treatment.
• At the end of treatment.
• From time to time after finishing treatment and during remission.
• If the cancer comes back.
• If the goal of treatment changes from curing or controlling cancer to palliative therapy to relieve symptoms and improve quality of life.

Patients who are having trouble coping with cancer may find it helpful to talk with a professional about their concerns and worries. These specialists include:

• Mental health professionals, including psychologists and psychiatrists.
• Social workers.
• Palliative care specialists.
• Religious counselors.

Patients who are in distress can be helped by different kinds of emotional and social support.

Studies have shown that patients who are having trouble adjusting to cancer are helped by treatments that give them emotional and social support, including:

• Relaxation training.
• Counseling or talk therapy.
• Cancer education sessions.
• Social support in a group setting.

These types of treatment may be combined in different ways for one or more sessions. Studies have shown that patients with cancer who receive such therapies receive benefits compared to those who do not receive these therapies. Benefits include having lower levels of depression, anxiety, and disease- and treatment-related symptoms, as well as feeling more optimistic. Patients who have the most distress seem to get the most help from these therapies. However, patients who received these therapies did not live longer than those who did not receive them.

Adjustment disorders may cause serious problems in daily life.

An adjustment disorder occurs when the patient's reaction to a stressful event:

• Is more severe than the expected amount of distress.
• Affects relationships or causes problems at home or work.
• Includes symptoms of depression and anxiety or other emotional, social, or behavioral problems.

Causes of adjustment disorders in cancer patients include the following:

• Diagnosis.
• Treatment.
• Recurrence.
• Side effects of treatment.

An adjustment disorder usually begins within three months of a stressful event and lasts no longer than six months after the event is over. Some patients may have a chronic adjustment disorder because they have many causes of distress, one right after another.

An adjustment disorder may become a more serious mental disorder such as major depression. This is more common in children and adolescents than in adults. (See the PDQ summary on Pediatric Supportive Care for more information.)

Counseling can help patients with adjustment disorders.

Individual (one-to-one) and group counseling have been shown to help cancer patients with adjustment disorders. Counseling may include treatment that focuses on the patient's thoughts, feelings, and behaviors. The following may help patients cope:

• Relaxation training.
• Biofeedback.
• Mental imagery exercises.
• Problem-solving.
• Plan for events that may happen in the future.
• Change beliefs that are not true.
• Distraction.
• Thought stopping.
• Positive thoughts.

Counseling may be combined with antianxiety medicine or antidepressants.

Counseling should be tried before medicine. Some patients are not helped by counseling or have a more severe mental health problem, such as severe anxiety or depression. These patients may be helped by an antianxiety or antidepressant medicine along with counseling. (See the PDQ summary on Depression for more information.)

Current Clinical Trials

Use our clinical trial search to find NCI-supported cancer clinical trials that are accepting patients. You can search for trials based on the type of cancer, the age of the patient, and where the trials are being done. General information about clinical trials is also available.

Anxiety disorders are very strong fears that may be caused by physical or psychological stress.

Studies show that almost half of all patients with cancer say they feel some anxiety and about one-fourth of all patients with cancer say they feel a great deal of anxiety. Patients living with cancer find that they feel more or less anxiety at different times. A patient may become more anxious as cancer spreads or treatment becomes more intense.

For some patients feelings of anxiety may become overwhelming and affect cancer treatment. This is especially true for patients who had periods of intense anxiety before their cancer diagnosis. Most patients who did not have an anxiety condition before their cancer diagnosis will not have an anxiety disorder related to the cancer.

Patients are more likely to have anxiety disorders during cancer treatment if they have any of the following:

• A history of an anxiety disorder.
• A history of physical or emotional trauma.
• Anxiety at the time of diagnosis.
• Few family members or friends to give them emotional support.
• Pain that is not controlled well.
• Cancer that is not getting better with treatment.
• Trouble taking care of their personal needs such as bathing or eating.

Anxiety disorders may be hard to diagnose.

It may be hard to tell the difference between normal fears related to cancer and abnormally severe fears that can be described as an anxiety disorder. The diagnosis is based on how symptoms of anxiety affect the patient's quality of life, what kinds of symptoms began since the cancer diagnosis or treatment, when the symptoms occur, and how long they last.

Anxiety disorders cause serious symptoms that affect day-to-day life, including:

• Feeling worried all the time.
• Not being able to focus.
• Not being able to "turn off thoughts" most of the time.
• Trouble sleeping most nights.
• Frequent crying spells.
• Feeling afraid most of the time.
• Having symptoms such as fast heart beat, dry mouth, shaky hands, restlessness, or feeling on edge.
• Anxiety that is not relieved by the usual ways to lessen anxiety such as distraction by staying busy.

There are different causes of anxiety disorders in cancer patients.

In addition to anxiety caused by a cancer diagnosis, the following may cause anxiety in patients with cancer:

• Pain: Patients whose pain is not well controlled with medicine feel anxious, and anxiety can increase pain.
• Other medical problems: Anxiety may be a warning sign of a change in metabolism (such as low blood sugar), a heart attack, severe infection, pneumonia, or a blood clot in the lung. Sepsis and electrolyte imbalances can also cause anxiety.
• Certain types of tumors: Certain hormone-releasing tumors can cause symptoms of anxiety and panic attacks. Tumors that have spread to the brain and spinal cord and tumors in the lungs can cause other health problems with symptoms of anxiety.
• Taking certain drugs: Certain types of drugs, including corticosteroids, thyroxine, bronchodilators, and antihistamines, can cause restlessness, agitation, or anxiety.
• Withdrawing from habit-forming drugs: Withdrawal from alcohol, nicotine, opioids, or antidepressant medicine can cause agitation or anxiety.

Anxiety from these causes is usually managed by treating the cause itself.

A cancer diagnosis may cause anxiety disorders to come back in patients with a history of them.

When patients who had an anxiety disorder in the past are diagnosed with cancer, then the anxiety disorder may come back. These patients may feel extreme fear, be unable to remember information given to them by caregivers, or be unable to follow through with medical tests and procedures. They may have symptoms including:

• Shortness of breath.
• Sweating.
• Feeling faint.
• Fast heart beat.

Patients with cancer may have the following types of anxiety disorders:

Medicine may be used alone or combined with other types of treatment for anxiety disorders.

Antianxiety medicines may be used if the patient doesn’t want counseling or if it’s not available. These medicines relieve symptoms of anxiety, such as feelings of fear, dread, uneasiness, and muscle tightness. They may relieve daytime distress and reduce insomnia. These medicines may be used alone or combined with other therapies.

Although some patients are afraid they may become addicted to antianxiety medicines, this is not a common problem in cancer patients. Enough medicine is given to relieve symptoms and then the dose is slowly lowered as symptoms begin to get better.

Studies show that antidepressants are useful in treating anxiety disorders. Children and teenagers being treated with antidepressants have an increased risk of suicidal thinking and behavior and must be watched closely. (See the Treatment section of the PDQ summary on Depression for more information.)

Current Clinical Trials

Use our clinical trial search to find NCI-supported cancer clinical trials that are accepting patients. You can search for trials based on the type of cancer, the age of the patient, and where the trials are being done. General information about clinical trials is also available.

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Purpose of This Summary

This PDQ cancer information summary has current information about normal adjustment issues, and the pathophysiology and treatment of psychosocial distress and the adjustment disorders. It is meant to inform and help patients, families, and caregivers. It does not give formal guidelines or recommendations for making decisions about health care.

Reviewers and Updates

Editorial Boards write the PDQ cancer information summaries and keep them up to date. These Boards are made up of experts in cancer treatment and other specialties related to cancer. The summaries are reviewed regularly and changes are made when there is new information. The date on each summary ("Updated") is the date of the most recent change.

The information in this patient summary was taken from the health professional version, which is reviewed regularly and updated as needed, by the PDQ Supportive and Palliative Care Editorial Board.

Clinical Trial Information

A clinical trial is a study to answer a scientific question, such as whether one treatment is better than another. Trials are based on past studies and what has been learned in the laboratory. Each trial answers certain scientific questions in order to find new and better ways to help cancer patients. During treatment clinical trials, information is collected about the effects of a new treatment and how well it works. If a clinical trial shows that a new treatment is better than one currently being used, the new treatment may become "standard." Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Clinical trials are listed in PDQ and can be found online at NCI's website. For more information, call the Cancer Information Service 1-800-4-CANCER (1-800-422-6237).

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PDQ® Supportive and Palliative Care Editorial Board. PDQ Adjustment to Cancer. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: https://www.cancer.gov/about-cancer/coping/feelings/anxiety-distress-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389325]

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