Adjustment to Cancer: Anxiety and Distress (PDQ®)

References

1. Derogatis LR, Morrow GR, Fetting J, et al.: The prevalence of psychiatric disorders among cancer patients. JAMA 249 (6): 751-7, 1983. [PubMed: 6823028]
2. Massie MJ, Holland JC: Overview of normal reactions and prevalence of psychiatric disorders. In: Holland JC, Rowland JH, eds.: Handbook of Psychooncology: Psychological Care of the Patient With Cancer. New York, NY: Oxford University Press, 1989, pp 273-82.
3. Bisson JI, Chubb HL, Bennett S, et al.: The prevalence and predictors of psychological distress in patients with early localized prostate cancer. BJU Int 90 (1): 56-61, 2002. [PubMed: 12081771]
4. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th rev. ed. Washington, DC: American Psychiatric Association, 2000.
5. NCCN practice guidelines for the management of psychosocial distress. National Comprehensive Cancer Network. Oncology (Huntingt) 13 (5A): 113-47, 1999. [PubMed: 10370925]
6. Lauver D, Ho CH: Explaining delay in care seeking for breast cancer symptoms. J Appl Soc Psychol 23 (21): 1806-25, 1993.
7. MacFarlane ME, Sony SD: Women, breast lump discovery, and associated stress. Health Care Women Int 13 (1): 23-32, 1992 Jan-Mar. [PubMed: 1556029]
8. Gram IT, Slenker SE: Cancer anxiety and attitudes toward mammography among screening attenders, nonattenders, and women never invited. Am J Public Health 82 (2): 249-51, 1992. [PMC free article: PMC1694295] [PubMed: 1739156]
9. Lerman C, Kash K, Stefanek M: Younger women at increased risk for breast cancer: perceived risk, psychological well-being, and surveillance behavior. J Natl Cancer Inst Monogr (16): 171-6, 1994. [PubMed: 7999461]
10. Velikova G, Selby PJ, Snaith PR, et al.: The relationship of cancer pain to anxiety. Psychother Psychosom 63 (3-4): 181-4, 1995. [PubMed: 7624464]
11. Glover J, Dibble SL, Dodd MJ, et al.: Mood states of oncology outpatients: does pain make a difference? J Pain Symptom Manage 10 (2): 120-8, 1995. [PubMed: 7730684]
12. Ferrell-Torry AT, Glick OJ: The use of therapeutic massage as a nursing intervention to modify anxiety and the perception of cancer pain. Cancer Nurs 16 (2): 93-101, 1993. [PubMed: 8477405]
13. Davis-Ali SH, Chesler MA, Chesney BK: Recognizing cancer as a family disease: worries and support reported by patients and spouses. Soc Work Health Care 19 (2): 45-65, 1993. [PubMed: 8153845]
14. Dahlquist LM, Czyzewski DI, Copeland KG, et al.: Parents of children newly diagnosed with cancer: anxiety, coping, and marital distress. J Pediatr Psychol 18 (3): 365-76, 1993. [PubMed: 8340845]
15. Payne SA: A study of quality of life in cancer patients receiving palliative chemotherapy. Soc Sci Med 35 (12): 1505-9, 1992. [PubMed: 1283035]

References

1. Brennan J: Adjustment to cancer - coping or personal transition? Psychooncology 10 (1): 1-18, 2001 Jan-Feb. [PubMed: 11180573]
2. Folkman S, Greer S: Promoting psychological well-being in the face of serious illness: when theory, research and practice inform each other. Psychooncology 9 (1): 11-9, 2000 Jan-Feb. [PubMed: 10668055]
3. Kornblith AB: Psychosocial adaptation of cancer survivors. In: Holland JC, Breitbart W, Jacobsen PB, et al., eds.: Psycho-oncology. New York, NY: Oxford University Press, 1998, pp 223-41.
4. Nicholas DR, Veach TA: The psychosocial assessment of the adult cancer patient. Prof Psychol 31 (2): 206-15, 2000.
5. Spencer SM, Carver CS, Price AA: Psychological and social factors in adaptation. In: Holland JC, Breitbart W, Jacobsen PB, et al., eds.: Psycho-oncology. New York, NY: Oxford University Press, 1998, pp 211-22.
6. NCCN practice guidelines for the management of psychosocial distress. National Comprehensive Cancer Network. Oncology (Huntingt) 13 (5A): 113-47, 1999. [PubMed: 10370925]
7. Fashoyin-Aje LA, Martinez KA, Dy SM: New patient-centered care standards from the commission on cancer: opportunities and challenges. J Support Oncol 10 (3): 107-11, 2012 May-Jun. [PubMed: 22440532]
8. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th rev. ed. Washington, DC: American Psychiatric Association, 2000.

References

1. Hoffman BM, Zevon MA, D'Arrigo MC, et al.: Screening for distress in cancer patients: the NCCN rapid-screening measure. Psychooncology 13 (11): 792-9, 2004. [PubMed: 15386639]
2. Jacobsen PB, Donovan KA, Trask PC, et al.: Screening for psychologic distress in ambulatory cancer patients. Cancer 103 (7): 1494-502, 2005. [PubMed: 15726544]
3. Akizuki N, Akechi T, Nakanishi T, et al.: Development of a brief screening interview for adjustment disorders and major depression in patients with cancer. Cancer 97 (10): 2605-13, 2003. [PubMed: 12733160]
4. Roth AJ, Kornblith AB, Batel-Copel L, et al.: Rapid screening for psychologic distress in men with prostate carcinoma: a pilot study. Cancer 82 (10): 1904-8, 1998. [PubMed: 9587123]
5. Ibbotson T, Maguire P, Selby P, et al.: Screening for anxiety and depression in cancer patients: the effects of disease and treatment. Eur J Cancer 30A (1): 37-40, 1994. [PubMed: 8142161]
6. Trask PC, Paterson A, Riba M, et al.: Assessment of psychological distress in prospective bone marrow transplant patients. Bone Marrow Transplant 29 (11): 917-25, 2002. [PubMed: 12080358]
7. Carlson LE, Waller A, Mitchell AJ: Screening for distress and unmet needs in patients with cancer: review and recommendations. J Clin Oncol 30 (11): 1160-77, 2012. [PubMed: 22412146]
8. Hegel MT, Moore CP, Collins ED, et al.: Distress, psychiatric syndromes, and impairment of function in women with newly diagnosed breast cancer. Cancer 107 (12): 2924-31, 2006. [PubMed: 17103381]
9. Hegel MT, Collins ED, Kearing S, et al.: Sensitivity and specificity of the Distress Thermometer for depression in newly diagnosed breast cancer patients. Psychooncology 17 (6): 556-60, 2008. [PMC free article: PMC3806281] [PubMed: 17957755]
10. Jim HS, Andrykowski MA, Munster PN, et al.: Physical symptoms/side effects during breast cancer treatment predict posttreatment distress. Ann Behav Med 34 (2): 200-8, 2007 Sep-Oct. [PubMed: 17927558]

Model Screening Programs

Memorial Sloan-Kettering Cancer Center has experimented with a distress thermometer (DT) modeled after those used to measure pain.[9] The descriptive anchor points on the thermometer include the following:

• "No distress" at a rating of 0.
• “Moderate distress” at a rating of 5.
• “Extreme distress” at a rating of 10.

Patients are asked, “How would you rate your distress today, on a scale of 0 to 10?” Accompanying the thermometer is a problem list that helps identify relevant potential sources of stress. The patient is asked to check off the problems that are most relevant. Categories of problems include the following:

• Practical (e.g., housing, insurance, or transportation).
• Physical (e.g., pain, nausea, or fatigue).
• Family or support (e.g., partner, children, or friends).
• Emotional (e.g., worry, sadness, depression, or anger).
• Spiritual/religious (e.g., relating to God or loss of faith).

The primary oncology team (oncologist, nurse, palliative care specialist, and social worker) is responsible for administering and evaluating a patient’s response to this brief screening and arranging for a referral, when necessary. Preliminary testing of this procedure used a cutoff score of 5 or higher as requiring further evaluation. Initial needs assessments have shown that 20% to 35% of patients report significant levels of distress.

At Johns Hopkins Cancer Center, all new patients receive an 18-item version of the Brief Symptom Inventory (BSI),[10] which lists 18 problems people sometimes experience (e.g., feeling faint or dizzy, having no interest in things, loneliness, or nausea or upset stomach). They are asked, “How much were you distressed by” each of the 18 problems “during the past 7 days including today?” The procedure is automated and utilizes existing clerical and support staff to distribute and retrieve the inventory during the first or second visit.[2] After computerized scoring is completed, professional staff is involved when offers for services are being provided. Patients screened as having high distress are referred to a social worker for immediate follow-up; those screened as having low distress are referred to the psychosocial orientation program, which is a structured educational program designed to enhance the adaptation of patients by providing information about a range of psychosocial programs (e.g., disease-specific support groups or psychoeducational presentations).

The Oncology Symptom Control Research group at Community Cancer Care typically screens all incoming patients with the Zung Self-Rating Depression Scale (ZSDS).[11,12] The ZSDS is a 20-item self-report depression screen that has been used to detect depression and more general distress; single items are also used to screen for conditions such as fatigue.[13] Staff typically administer the screen while patients are in the waiting room. Scores are analyzed immediately after completion so that the medical oncologists can be briefed on any pertinent issues. In addition, patients scoring in the moderate range or higher are identified for further follow-up and more extensive interviews and assessment by the staff psychiatrist or psychologist. Also, patients who trigger single items of interest such as fatigue are interviewed and monitored for possible inclusion in a number of symptom-control research trials.

Distress Thermometer

Although many screening instruments have been tested with cancer patients (see Table 1), the National Comprehensive Cancer Network (NCCN) DT has been the most widely investigated. The psychometric properties of the DT (a 0–10 visual analog scale, in the form of a thermometer labeled with “No Distress” at 0, “Moderate Distress” at the midpoint, and “Extreme Distress” at 10) have been investigated.[14]

The measure was found to have reasonable convergent and divergent validity when compared with two well-established, multidimensional symptom inventories. This very brief rapid-screening procedure has a moderate ability to accurately detect distress as defined by scores indicative of “caseness” on the two-symptom inventories. When specific cutoff scores were tested to maximize sensitivity and specificity, no single cutoff that maximized accuracy of classification was discovered. Thus, it was recommended that varying cutoff scores result in different referral recommendations, such that low scores result in no referral, moderate scores result in an optional referral, and high scores result in a strong recommendation for further interventions.[14]

Self-Report Screening Instruments

The NCCN single-item, rapid-screening instrument asks patients to rate their distress on a scale of 0 (“no distress”) to 10 (“extreme distress”). On an accompanying problem list, patients are asked to indicate what has been a problem for them in the past week. Studies [14-18] have tested the ability of the single-item measure to accurately identify patients in distress. In general, these ultrashort screening methods have demonstrated only modest overall accuracy. They are best for ruling out, but performed poorly at confirming, distress, anxiety, and depression.

Many other self-report questionnaires have been used as screening instruments (see Table 1); in general, they also are better for ruling out distress and perform poorly at confirming distress. Thus, most screening instruments will yield a high number of false-positive results and need to be followed by a more extensive psychosocial assessment interview.

Table

Table 1. Examples of Self-Report Screening Instruments Used for Identification of Psychosocial Distress in Cancer Patients.

Self-report screening instruments must be scored, evaluated, and discussed with each patient. Triage—the process of communicating screening results, discussing each patient’s needs, and determining the best course of further action—is key to the successful use of screening. In fact, screening without availability of appropriate treatment resources is considered unethical. The primary oncology team (oncologist, nurse, palliative care specialist, social worker, and counselor) is responsible for successful triage. In some studies a significant percentage of patients who report moderate to high levels of distress refuse further assessment.[26-29] Thus, it is important to consider how the primary oncology team can introduce the need for further psychosocial assessment.

The NCCN standards of care [9] suggest distress rated as mild might result in a referral to a local self-help group or management by the primary oncology team only. Distress rated as moderate to severe warrants referral to other appropriate professionals (psychologists, psychiatrists, social workers, palliative care specialists, or pastoral counselors), depending on the nature of the distress.

Psychosocial Assessment

The assessment of psychosocial adaptation should follow screening when distress is identified. The psychosocial assessment is typically a semistructured interview during which the professional evaluates how well an individual patient, a patient’s family, and other significant people in a patient’s life are adapting to the current demands of the illness. In general, this assessment process considers a wide variety of factors relevant to overall adaptation.[1] (Refer to the General Factors Influencing Adjustment section of this summary for more information.)

A successful transition from screening to assessment involves clear communication between the oncology team and the patient. Although there is no single best way to talk to patients about psychosocial needs, clinical experience suggests some important concepts. First, most patients will respond to the recommendations of health care professionals who exhibit trust, expertise, warmth, care, and concern.

Choice of words is important. Words that suggest the stigma of serious mental illness, such as psychiatric, psychological, mental disorder, maladjustment, or mental illness, should be avoided—in favor of words such as distress, concerns, worries, uncertainties, or stressors from the illness or its treatment. Suggestions for word choice include the following:

• The questionnaire you filled out helps us to understand you as a whole person, and we want to provide the best care possible for you—physically, emotionally, socially, and spiritually.
• As you may realize, a serious illness can affect the quality of your life in many ways (emotionally, socially, work, relationships, finances, energy). There is much more to this illness than just the physical, and we want to be sure we are addressing these other dimensions of your life.
• Your concerns and worries are very understandable, given your illness and its treatment. We don’t want to ignore the (emotional, social, spiritual) aspects of your experience right now.
• We have found that many patients benefit greatly from a chance to talk further about their concerns with a (social worker, mental health professional, palliative care specialist, or pastoral counselor), and we would like to schedule that for you.
• For further explanation, we suggest an interview that lasts about 45 minutes with a professional who will:

  -

  Listen closely to you.

  -

  Want to know about your experiences with your illness.

  -

  Ask about you, your family and friends, and other support persons.

  -

  Ask about how you have been adjusting to your illness and may encourage you to continue (and give you feedback about) successful coping strategies you are already using.

  -

  Have suggestions about additional ways to address your concerns.

References

1. Nicholas DR, Veach TA: The psychosocial assessment of the adult cancer patient. Prof Psychol 31 (2): 206-15, 2000.
2. Zabora JR: Screening procedures for psychosocial distress. In: Holland JC, Breitbart W, Jacobsen PB, et al., eds.: Psycho-oncology. New York, NY: Oxford University Press, 1998, pp 653-61.
3. Zabora JR, Smith-Wilson R, Fetting JH, et al.: An efficient method for psychosocial screening of cancer patients. Psychosomatics 31 (2): 192-6, 1990 Spring. [PubMed: 2330401]
4. Kissane DW, McKenzie M, McKenzie DP, et al.: Psychosocial morbidity associated with patterns of family functioning in palliative care: baseline data from the Family Focused Grief Therapy controlled trial. Palliat Med 17 (6): 527-37, 2003. [PubMed: 14526887]
5. Maunsell E, Brisson J, Deschênes L, et al.: Randomized trial of a psychologic distress screening program after breast cancer: effects on quality of life. J Clin Oncol 14 (10): 2747-55, 1996. [PubMed: 8874336]
6. McLachlan SA, Allenby A, Matthews J, et al.: Randomized trial of coordinated psychosocial interventions based on patient self-assessments versus standard care to improve the psychosocial functioning of patients with cancer. J Clin Oncol 19 (21): 4117-25, 2001. [PubMed: 11689579]
7. Carlson LE, Groff SL, Maciejewski O, et al.: Screening for distress in lung and breast cancer outpatients: a randomized controlled trial. J Clin Oncol 28 (33): 4884-91, 2010. [PubMed: 20940193]
8. Carlson LE, Waller A, Groff SL, et al.: Online screening for distress, the 6th vital sign, in newly diagnosed oncology outpatients: randomised controlled trial of computerised vs personalised triage. Br J Cancer 107 (4): 617-25, 2012. [PMC free article: PMC3419958] [PubMed: 22828610]
9. NCCN practice guidelines for the management of psychosocial distress. National Comprehensive Cancer Network. Oncology (Huntingt) 13 (5A): 113-47, 1999. [PubMed: 10370925]
10. Derogatis LR, Melisaratos N: The Brief Symptom Inventory: an introductory report. Psychol Med 13 (3): 595-605, 1983. [PubMed: 6622612]
11. Zung WW: Depression in the normal aged. Psychosomatics 8 (5): 287-92, 1967 Sep-Oct. [PubMed: 6061160]
12. Zung WW: Factors influencing the self-rating depression scale. Arch Gen Psychiatry 16 (5): 543-7, 1967. [PubMed: 4381571]
13. Kirsh KL, Passik S, Holtsclaw E, et al.: I get tired for no reason: a single item screening for cancer-related fatigue. J Pain Symptom Manage 22 (5): 931-7, 2001. [PubMed: 11728796]
14. Hoffman BM, Zevon MA, D'Arrigo MC, et al.: Screening for distress in cancer patients: the NCCN rapid-screening measure. Psychooncology 13 (11): 792-9, 2004. [PubMed: 15386639]
15. Jacobsen PB, Donovan KA, Trask PC, et al.: Screening for psychologic distress in ambulatory cancer patients. Cancer 103 (7): 1494-502, 2005. [PubMed: 15726544]
16. Akizuki N, Akechi T, Nakanishi T, et al.: Development of a brief screening interview for adjustment disorders and major depression in patients with cancer. Cancer 97 (10): 2605-13, 2003. [PubMed: 12733160]
17. Dabrowski M, Boucher K, Ward JH, et al.: Clinical experience with the NCCN distress thermometer in breast cancer patients. J Natl Compr Canc Netw 5 (1): 104-11, 2007. [PubMed: 17239330]
18. Keir ST, Calhoun-Eagan RD, Swartz JJ, et al.: Screening for distress in patients with brain cancer using the NCCN's rapid screening measure. Psychooncology 17 (6): 621-5, 2008. [PubMed: 17973236]
19. Hegel MT, Collins ED, Kearing S, et al.: Sensitivity and specificity of the Distress Thermometer for depression in newly diagnosed breast cancer patients. Psychooncology 17 (6): 556-60, 2008. [PMC free article: PMC3806281] [PubMed: 17957755]
20. Kugaya A, Akechi T, Okuyama T, et al.: Prevalence, predictive factors, and screening for psychologic distress in patients with newly diagnosed head and neck cancer. Cancer 88 (12): 2817-23, 2000. [PubMed: 10870066]
21. Zigmond AS, Snaith RP: The hospital anxiety and depression scale. Acta Psychiatr Scand 67 (6): 361-70, 1983. [PubMed: 6880820]
22. Love AW, Kissane DW, Bloch S, et al.: Diagnostic efficiency of the Hospital Anxiety and Depression Scale in women with early stage breast cancer. Aust N Z J Psychiatry 36 (2): 246-50, 2002. [PubMed: 11982548]
23. Cella DF, Tulsky DS, Gray G, et al.: The Functional Assessment of Cancer Therapy scale: development and validation of the general measure. J Clin Oncol 11 (3): 570-9, 1993. [PubMed: 8445433]
24. McNair DM, Lorr M, Droppleman LF: Profile of Mood States Manual. San Diego, Calif: Educational and Industrial Testing Service, 1992.
25. Dugan W, McDonald MV, Passik SD, et al.: Use of the Zung Self-Rating Depression Scale in cancer patients: feasibility as a screening tool. Psychooncology 7 (6): 483-93, 1998 Nov-Dec. [PubMed: 9885089]
26. Roth AJ, Kornblith AB, Batel-Copel L, et al.: Rapid screening for psychologic distress in men with prostate carcinoma: a pilot study. Cancer 82 (10): 1904-8, 1998. [PubMed: 9587123]
27. Carroll BT, Kathol RG, Noyes R Jr, et al.: Screening for depression and anxiety in cancer patients using the Hospital Anxiety and Depression Scale. Gen Hosp Psychiatry 15 (2): 69-74, 1993. [PubMed: 8472942]
28. Ibbotson T, Maguire P, Selby P, et al.: Screening for anxiety and depression in cancer patients: the effects of disease and treatment. Eur J Cancer 30A (1): 37-40, 1994. [PubMed: 8142161]
29. Razavi D, Delvaux N, Farvacques C, et al.: Screening for adjustment disorders and major depressive disorders in cancer in-patients. Br J Psychiatry 156: 79-83, 1990. [PubMed: 2297623]

Coping Theory

One cognitive theory of coping [14] proposes that in response to significant life events, a person asks two important questions:

• Is this event personally significant to me?
• What resources do I have to manage/control this event?

When an event is perceived to be of personal significance (nearly all cancer-related life events would be), and when one’s personal resources are perceived to be inadequate to the demands of managing the event, distress can occur. One way to conceptualize the amount of distress experienced by patients is the balance or ratio between perception of the demands that a situation (e.g., chemotherapy) places upon them and perception of the resources they possess (e.g., effective antiemetics) to effectively manage these demands:

Distress = Perceived Demands/Perceived Resources

Individuals with the same diagnosis or treatment regimen may experience very different levels of distress. A high level of distress could result from an individual’s perceptions that either the demands of a situation are very high or his or her resources are very low (or both). Conversely, low distress is the result of a perception that either the demands of a situation are very low or the individual’s resources are high.[15] To lower distress, therefore, either the perceived demands of the situation should be lowered, or the perceived resources should be increased.

General Factors Influencing Adjustment

Although there are some commonalities in normal adjustment to the varying stressors of cancer, there are also many individual differences. It is difficult to predict how individuals will cope with cancer, so it is important to recognize factors that influence adjustment to cancer. One study of women with stage II or III breast cancer [16] reported that higher levels of stress measured postsurgically at the time of diagnosis predicted lower physical and psychological quality of life. The stress measures included the following:

• Number of stressful life events in the past year.
• Cancer-related traumatic stress symptoms.
• Perceived global stress.

All measures were predictive.[16]

Another study evaluated women with stage 0 breast cancer to stage III breast cancer (N = 89) at three time points: during treatment, at 3 weeks following end of treatment, and at 3 months posttreatment. Most survivors showed good adjustment on general distress indices. The factors predicting sustained distress included young age, history of depression or anxiety, and more extensive treatment. Younger age was the only factor that predicted greater distress across all evaluated measures.[17]

Psychosocial adjustment/adaptation has been determined to be influenced by three broad categories of factors: cancer derived, patient derived, and society derived.[4,18] Cancer-derived factors include the following:

• Type of cancer.
• Cancer stage.
• Prognosis.
• Where a patient falls in the cancer continuum of diagnosis, treatment, and recurrence.

Patient-derived factors include two types of resources:[19,20]

• Intrapersonal coping resources.
• Interpersonal social support (e.g., family support).[21]

Patient-derived factors also include consideration for stage of life [22] (i.e., developmental tasks—young adults may respond quite differently compared with older adults).

Society-derived factors include the general societal views of cancer (e.g., stigma), as well as the influence society has on issues such as availability of treatments, open versus closed discussion of the illness, and popular beliefs about cause.

The personality traits of optimism and pessimism might play a critical role in the psychological well-being of cancer patients. A German study investigated the impact of optimism and pessimism on psychological well-being in 161 newly diagnosed cancer patients with heterogeneous cancers.[23] Patients were assessed for optimism/pessimism and positive/negative emotions before the start of their first chemotherapy session and at 9 months' follow-up. Before the start of chemotherapy, psychological well-being was associated with higher optimism and lower pessimism. Only pessimism predicted negative change in psychological well-being at the 9-month follow-up. Additionally, only pessimism predicted heightened perception of chemotherapy-related side effects.

The availability of social support, as part of a social network, has been found to be related to mortality from breast cancer. In a longitudinal study of 2,835 female nurses with breast cancer, those who, before diagnosis, reported no close contacts (e.g., relatives, friends, or living children) had a twofold increased risk of mortality from breast cancer, compared with those who had more social contacts (e.g., ten or more close relatives). This increased mortality was only found when comparing these two extremes in social ties, suggesting that women with relatively few social contacts or an intermediate number of contacts may not be at increased risk. Overall, these results suggest the important role of close relatives willing to step in and provide needed care.[19]

Situation-Specific Influences on Adjustment

References

1. Brennan J: Adjustment to cancer - coping or personal transition? Psychooncology 10 (1): 1-18, 2001 Jan-Feb. [PubMed: 11180573]
2. Folkman S, Greer S: Promoting psychological well-being in the face of serious illness: when theory, research and practice inform each other. Psychooncology 9 (1): 11-9, 2000 Jan-Feb. [PubMed: 10668055]
3. Kornblith AB: Psychosocial adaptation of cancer survivors. In: Holland JC, Breitbart W, Jacobsen PB, et al., eds.: Psycho-oncology. New York, NY: Oxford University Press, 1998, pp 223-41.
4. Nicholas DR, Veach TA: The psychosocial assessment of the adult cancer patient. Prof Psychol 31 (2): 206-15, 2000.
5. Spencer SM, Carver CS, Price AA: Psychological and social factors in adaptation. In: Holland JC, Breitbart W, Jacobsen PB, et al., eds.: Psycho-oncology. New York, NY: Oxford University Press, 1998, pp 211-22.
6. Loscalzo M, Brintzenhofeszoc K: Brief crisis counseling. In: Holland JC, Breitbart W, Jacobsen PB, et al., eds.: Psycho-oncology. New York, NY: Oxford University Press, 1998, pp 662-75.
7. Schou I, Ekeberg Ø, Ruland CM, et al.: Pessimism as a predictor of emotional morbidity one year following breast cancer surgery. Psychooncology 13 (5): 309-20, 2004. [PubMed: 15133772]
8. Pearlin LI, Schooler C: The structure of coping. J Health Soc Behav 19 (1): 2-21, 1978. [PubMed: 649936]
9. Rowland JH: Intrapersonal resources: coping. In: Holland JC, Rowland JH, eds.: Handbook of Psychooncology: Psychological Care of the Patient With Cancer. New York, NY: Oxford University Press, 1989, pp 44-57.
10. Ahmad MM, Musil CM, Zauszniewski JA, et al.: Prostate cancer: appraisal, coping, and health status. J Gerontol Nurs 31 (10): 34-43, 2005. [PubMed: 16262089]
11. Trask PC, Paterson AG, Trask CL, et al.: Parent and adolescent adjustment to pediatric cancer: associations with coping, social support, and family function. J Pediatr Oncol Nurs 20 (1): 36-47, 2003 Jan-Feb. [PubMed: 12569433]
12. Ransom S, Jacobsen PB, Schmidt JE, et al.: Relationship of problem-focused coping strategies to changes in quality of life following treatment for early stage breast cancer. J Pain Symptom Manage 30 (3): 243-53, 2005. [PubMed: 16183008]
13. De Faye BJ, Wilson KG, Chater S, et al.: Stress and coping with advanced cancer. Palliat Support Care 4 (3): 239-49, 2006. [PubMed: 17066965]
14. Lazarus RS, Folkman S: Stress, Appraisal, and Coping. New York, NY: Springer Publishing Co, 1984.
15. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th rev. ed. Washington, DC: American Psychiatric Association, 2000.
16. Golden-Kreutz DM, Thornton LM, Wells-Di Gregorio S, et al.: Traumatic stress, perceived global stress, and life events: prospectively predicting quality of life in breast cancer patients. Health Psychol 24 (3): 288-96, 2005. [PMC free article: PMC2151211] [PubMed: 15898865]
17. Costanzo ES, Lutgendorf SK, Mattes ML, et al.: Adjusting to life after treatment: distress and quality of life following treatment for breast cancer. Br J Cancer 97 (12): 1625-31, 2007. [PMC free article: PMC2360272] [PubMed: 18000503]
18. Holland JC: Clinical course of cancer. In: Holland JC, Rowland JH, eds.: Handbook of Psychooncology: Psychological Care of the Patient With Cancer. New York, NY: Oxford University Press, 1989, pp 75-100.
19. Kroenke CH, Kubzansky LD, Schernhammer ES, et al.: Social networks, social support, and survival after breast cancer diagnosis. J Clin Oncol 24 (7): 1105-11, 2006. [PubMed: 16505430]
20. Arora NK, Finney Rutten LJ, Gustafson DH, et al.: Perceived helpfulness and impact of social support provided by family, friends, and health care providers to women newly diagnosed with breast cancer. Psychooncology 16 (5): 474-86, 2007. [PubMed: 16986172]
21. Baider L, Ever-Hadani P, Goldzweig G, et al.: Is perceived family support a relevant variable in psychological distress?. A sample of prostate and breast cancer couples. J Psychosom Res 55 (5): 453-60, 2003. [PubMed: 14581100]
22. Ganz PA, Guadagnoli E, Landrum MB, et al.: Breast cancer in older women: quality of life and psychosocial adjustment in the 15 months after diagnosis. J Clin Oncol 21 (21): 4027-33, 2003. [PubMed: 14581426]
23. Pinquart M, Fröhlich C, Silbereisen RK: Optimism, pessimism, and change of psychological well-being in cancer patients. Psychol Health Med 12 (4): 421-32, 2007. [PubMed: 17620206]
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25. Holland JC, Gooen-Piels J: Principles of psycho-oncology. In: Holland JC, Frei E, eds.: Cancer Medicine e.5. 5th ed. Hamilton, Ontario: B.C. Decker Inc, 2000, pp 943-58.
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29. Deshields T, Tibbs T, Fan MY, et al.: Ending treatment: the course of emotional adjustment and quality of life among breast cancer survivors immediately following radiation therapy. Support Care Cancer 13 (12): 1018-26, 2005. [PubMed: 15800768]
30. Cherny NI, Coyle N, Foley KM: Suffering in the advanced cancer patient: a definition and taxonomy. J Palliat Care 10 (2): 57-70, 1994 Summer. [PubMed: 8089819]
31. Dienstfrey H: Training for cancer: an interview with Michael Lerner. Advances: The Journal of Mind-Body Health 10 (2): 27-37, 1994.
32. Beck AT, Weissman A, Lester D, et al.: The measurement of pessimism: the hopelessness scale. J Consult Clin Psychol 42 (6): 861-5, 1974. [PubMed: 4436473]
33. Ray A, Block SD, Friedlander RJ, et al.: Peaceful awareness in patients with advanced cancer. J Palliat Med 9 (6): 1359-68, 2006. [PubMed: 17187544]
34. Northouse LL, Mood D, Kershaw T, et al.: Quality of life of women with recurrent breast cancer and their family members. J Clin Oncol 20 (19): 4050-64, 2002. [PubMed: 12351603]
35. Polinsky ML: Functional status of long-term breast cancer survivors: demonstrating chronicity. Health Soc Work 19 (3): 165-73, 1994. [PubMed: 7959398]
36. Curbow B, Somerfield MR, Baker F, et al.: Personal changes, dispositional optimism, and psychological adjustment to bone marrow transplantation. J Behav Med 16 (5): 423-43, 1993. [PubMed: 8254649]
37. Belec RH: Quality of life: perceptions of long-term survivors of bone marrow transplantation. Oncol Nurs Forum 19 (1): 31-7, 1992 Jan-Feb. [PubMed: 1538986]
38. Tartaro J, Roberts J, Nosarti C, et al.: Who benefits?: distress, adjustment and benefit-finding among breast cancer survivors. J Psychosoc Oncol 23 (2-3): 45-64, 2005. [PubMed: 16492651]
39. Smith MY, Redd WH, Peyser C, et al.: Post-traumatic stress disorder in cancer: a review. Psychooncology 8 (6): 521-37, 1999 Nov-Dec. [PubMed: 10607985]
40. Baker F, Denniston M, Smith T, et al.: Adult cancer survivors: how are they faring? Cancer 104 (11 Suppl): 2565-76, 2005. [PubMed: 16258929]
41. Clough-Gorr KM, Ganz PA, Silliman RA: Older breast cancer survivors: factors associated with change in emotional well-being. J Clin Oncol 25 (11): 1334-40, 2007. [PubMed: 17312327]

Psychosocial Interventions for Distress

The efficacy of psychosocial interventions in adult cancer patients is supported by an extensive literature.[3][Level of evidence: IV];[4-6][Level of evidence: I] Reviews have concluded that, in general, psychosocial interventions for cancer patients have shown positive benefits.

Psychosocial interventions have generally been defined as nonpharmacologic interventions that include a variety of psychological and educational components. Typical components include the following:

• Relaxation training.
• Cognitive and behavioral coping strategies.
• Cancer education/information sessions.
• Group social support.

Interventions have included various combinations of these components, have varied in length (single session to multiple weekly sessions), and have been administered in both individual and group formats. The most common patient population has been U.S. white women of middle to higher socioeconomic status who have breast cancer; however, some studies include mixed cancer diagnoses, and studies from European countries have appeared.[3] Outcome measures have varied and have included the following:[3,4]

• Emotional adjustment (e.g., depression, anxiety).
• Functional impairment (e.g., return to work, social roles).
• Disease-related symptoms (e.g., nausea/vomiting, fatigue, pain).
• Health behaviors (e.g., diet, smoking, exercise).
• Immune system functioning.

A biobehavioral model [3] hypothesizing psychological, behavioral, and biologic pathways from cancer stressors to disease outcome has guided much of this research; however, the most common outcome measured has been emotional adjustment.

Although positive benefits have been found, their clinical significance has been questioned. Reviewers have offered varying conclusions regarding the size of these positive effects,[4][Level of evidence: I] ranging from negligible for depression, to small for overall emotional outcomes, to moderate for anxiety.[5][Level of evidence: I]

Effect sizes may be related to the timing of the intervention and patient selection procedures. For most patients, levels of psychosocial distress are highest during the earliest days of their cancer experience and, for many, dissipate quickly. Thus, if interventions are offered later in the cancer experience (weeks or months after diagnosis and treatment), patients may be experiencing less distress than they would have experienced if interventions had been offered earlier, making large effects more difficult to detect.[7][Level of evidence: II]

In one study,[8] 249 breast cancer patient-partner dyads were randomly assigned to one of four groups:

• A control group that received standard disease management.
• A standardized psychoeducation group.
• A group that received telephone counseling.
• A group that received psychoeducation plus telephone counseling.

Patients and partners who received the study interventions had less side-effect distress and severity as well as higher levels of psychological well-being than those who received standard care. In addition, the study results support the efficacy of low-cost, replicable interventions by video and telephone to achieve these physical and psychological benefits.[8]

Two meta-analyses [4,5][Level of evidence: I] report the following effect sizes:

• 0.19 for depression [5] and functional adjustment.[4]
• 0.24 for emotional adjustment.[4]
• 0.26 for treatment- or disease-related symptoms.[4]
• 0.28 for global measures of outcome.[4]
• 0.36 for anxiety.[5]

These positive effect sizes indicate that the average patient receiving the intervention is better off than between 57% and 65% of those not receiving the intervention.

In summary, it appears that when psychosocial interventions are offered to patients who are found to be experiencing distress (e.g., anxiety, depression), the efficacy of the intervention is very strong. Thus, the overall positive benefit for psychosocial interventions seems to be greater with those who seem to need it most.[4,5]

References

1. NCCN practice guidelines for the management of psychosocial distress. National Comprehensive Cancer Network. Oncology (Huntingt) 13 (5A): 113-47, 1999. [PubMed: 10370925]
2. Fashoyin-Aje LA, Martinez KA, Dy SM: New patient-centered care standards from the commission on cancer: opportunities and challenges. J Support Oncol 10 (3): 107-11, 2012 May-Jun. [PubMed: 22440532]
3. Andersen BL: Biobehavioral outcomes following psychological interventions for cancer patients. J Consult Clin Psychol 70 (3): 590-610, 2002. [PMC free article: PMC2151208] [PubMed: 12090371]
4. Meyer TJ, Mark MM: Effects of psychosocial interventions with adult cancer patients: a meta-analysis of randomized experiments. Health Psychol 14 (2): 101-8, 1995. [PubMed: 7789344]
5. Sheard T, Maguire P: The effect of psychological interventions on anxiety and depression in cancer patients: results of two meta-analyses. Br J Cancer 80 (11): 1770-80, 1999. [PMC free article: PMC2363129] [PubMed: 10468295]
6. Barsevick AM, Sweeney C, Haney E, et al.: A systematic qualitative analysis of psychoeducational interventions for depression in patients with cancer. Oncol Nurs Forum 29 (1): 73-84; quiz 85-7, 2002 Jan-Feb. [PubMed: 11817494]
7. Antoni MH, Lehman JM, Kilbourn KM, et al.: Cognitive-behavioral stress management intervention decreases the prevalence of depression and enhances benefit finding among women under treatment for early-stage breast cancer. Health Psychol 20 (1): 20-32, 2001. [PubMed: 11199062]
8. Budin WC, Hoskins CN, Haber J, et al.: Breast cancer: education, counseling, and adjustment among patients and partners: a randomized clinical trial. Nurs Res 57 (3): 199-213, 2008 May-Jun. [PubMed: 18496106]
9. Scheier MF, Helgeson VS, Schulz R, et al.: Interventions to enhance physical and psychological functioning among younger women who are ending nonhormonal adjuvant treatment for early-stage breast cancer. J Clin Oncol 23 (19): 4298-311, 2005. [PubMed: 15994143]
10. Antoni MH, Wimberly SR, Lechner SC, et al.: Reduction of cancer-specific thought intrusions and anxiety symptoms with a stress management intervention among women undergoing treatment for breast cancer. Am J Psychiatry 163 (10): 1791-7, 2006. [PMC free article: PMC5756627] [PubMed: 17012691]
11. Andersen BL, Farrar WB, Golden-Kreutz DM, et al.: Psychological, behavioral, and immune changes after a psychological intervention: a clinical trial. J Clin Oncol 22 (17): 3570-80, 2004. [PMC free article: PMC2168591] [PubMed: 15337807]
12. Andersen BL, Farrar WB, Golden-Kreutz D, et al.: Distress reduction from a psychological intervention contributes to improved health for cancer patients. Brain Behav Immun 21 (7): 953-61, 2007. [PMC free article: PMC2039896] [PubMed: 17467230]
13. Nezu AM, Nezu CM, Felgoise SH, et al.: Project Genesis: assessing the efficacy of problem-solving therapy for distressed adult cancer patients. J Consult Clin Psychol 71 (6): 1036-48, 2003. [PubMed: 14622079]
14. Jacobsen PB, Meade CD, Stein KD, et al.: Efficacy and costs of two forms of stress management training for cancer patients undergoing chemotherapy. J Clin Oncol 20 (12): 2851-62, 2002. [PubMed: 12065562]
15. McQuellon RP, Wells M, Hoffman S, et al.: Reducing distress in cancer patients with an orientation program. Psychooncology 7 (3): 207-17, 1998 May-Jun. [PubMed: 9638782]
16. Lengacher CA, Johnson-Mallard V, Post-White J, et al.: Randomized controlled trial of mindfulness-based stress reduction (MBSR) for survivors of breast cancer. Psychooncology 18 (12): 1261-72, 2009. [PubMed: 19235193]
17. Schnur JB, Bovbjerg DH, David D, et al.: Hypnosis decreases presurgical distress in excisional breast biopsy patients. Anesth Analg 106 (2): 440-4, table of contents, 2008. [PubMed: 18227298]
18. Cohen L, Parker PA, Vence L, et al.: Presurgical stress management improves postoperative immune function in men with prostate cancer undergoing radical prostatectomy. Psychosom Med 73 (3): 218-25, 2011. [PubMed: 21257977]
19. Wise M, Han JY, Shaw B, et al.: Effects of using online narrative and didactic information on healthcare participation for breast cancer patients. Patient Educ Couns 70 (3): 348-56, 2008. [PMC free article: PMC2367096] [PubMed: 18201859]
20. Spiegel D, Bloom JR, Kraemer HC, et al.: Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet 2 (8668): 888-91, 1989. [PubMed: 2571815]
21. Fawzy FI, Fawzy NW, Hyun CS, et al.: Malignant melanoma. Effects of an early structured psychiatric intervention, coping, and affective state on recurrence and survival 6 years later. Arch Gen Psychiatry 50 (9): 681-9, 1993. [PubMed: 8357293]
22. Fox BH: A hypothesis about Spiegel et al.'s 1989 paper on Psychosocial intervention and breast cancer survival. Psychooncology 7 (5): 361-70, 1998 Sep-Oct. [PubMed: 9809327]
23. Goodwin PJ, Leszcz M, Quirt G, et al.: Lessons learned from enrollment in the BEST study--a multicenter, randomized trial of group psychosocial support in metastatic breast cancer. J Clin Epidemiol 53 (1): 47-55, 2000. [PubMed: 10693903]
24. Classen C, Butler LD, Koopman C, et al.: Supportive-expressive group therapy and distress in patients with metastatic breast cancer: a randomized clinical intervention trial. Arch Gen Psychiatry 58 (5): 494-501, 2001. [PubMed: 11343530]
25. Kissane DW, Love A, Hatton A, et al.: Effect of cognitive-existential group therapy on survival in early-stage breast cancer. J Clin Oncol 22 (21): 4255-60, 2004. [PubMed: 15452189]
26. Newell SA, Sanson-Fisher RW, Savolainen NJ: Systematic review of psychological therapies for cancer patients: overview and recommendations for future research. J Natl Cancer Inst 94 (8): 558-84, 2002. [PubMed: 11959890]
27. Chow E, Tsao MN, Harth T: Does psychosocial intervention improve survival in cancer? A meta-analysis. Palliat Med 18 (1): 25-31, 2004. [PubMed: 14982204]
28. Smedslund G, Ringdal GI: Meta-analysis of the effects of psychosocial interventions on survival time in cancer patients. J Psychosom Res 57 (2): 123-31; discussion 133-5, 2004. [PubMed: 15465065]
29. Edwards AG, Hailey S, Maxwell M: Psychological interventions for women with metastatic breast cancer. Cochrane Database Syst Rev (2): CD004253, 2004. [PubMed: 15106244]
30. Kissane DW: Survival following psychotherapy interventions. In: Holland JC, Breitbart WS, Jacobsen PB, et al., eds.: Psycho-oncology. 2nd ed. New York, NY: Oxford University Press, Inc., 2010, pp 479-82.
31. Andersen BL, Yang HC, Farrar WB, et al.: Psychologic intervention improves survival for breast cancer patients: a randomized clinical trial. Cancer 113 (12): 3450-8, 2008. [PMC free article: PMC2661422] [PubMed: 19016270]
32. Coyne JC, Stefanek M, Palmer SC: Psychotherapy and survival in cancer: the conflict between hope and evidence. Psychol Bull 133 (3): 367-94, 2007. [PubMed: 17469983]

Prevalence

In the general population, adjustment disorders are thought to be common, although prevalence rates vary by population studied. In studies of community samples of children, adolescents, and the elderly, prevalence estimates have ranged from 2% to 8%. In outpatient mental health settings, prevalence rates have been as high as 10% to 30%; while in general hospital inpatients, prevalence rates have been as high as 12% of those referred for a mental health consultation.[1]

Nearly every cancer patient experiences what could be considered an identifiable stressor, whether that is diagnosis, treatment, recurrence, or side effects. The presence of an adjustment disorder is determined more by the patient’s response to the identifiable stressor, and whether that response is considered in excess of what would be expected or results in significant impairment, typically in social or occupational functioning.

One study [2] evaluated 215 randomly selected hospitalized and ambulatory cancer patients in three different cancer centers and found that of this group, slightly fewer than half (47% or 101 patients) met the diagnostic criteria for any mental disorder (DSM-III criteria). From this group of 101, 68% (69 patients) met the diagnostic criteria for an adjustment disorder. Of the entire 215 patients evaluated, approximately 32% were identified as meeting the diagnostic criteria for an adjustment disorder—the highest prevalence of any diagnostic category.

Additional reviews [3] have continued to find adjustment disorders to be the most common mental disorder. In patients with advanced cancer, prevalence ranges from 14% to 34.7%; in terminally ill patients, rates range from 10.6% to 16.3%. These variable prevalence rates are influenced by stage of disease, type of cancer, diagnostic procedures used, and other patient variables. In a study of women with breast cancer undergoing adjuvant chemotherapy, a 36.1% prevalence rate was found.[4]

In another study of terminally ill Japanese cancer patients referred to a palliative care unit, 16.3% were diagnosed with an adjustment disorder at the time of their initial referral, and 10.6% were diagnosed with an adjustment disorder at the time of their admission to the palliative care unit. Of patients diagnosed with adjustment disorder at initial referral, 42% had progressed to major depression at admission to the unit, and 42% had no diagnosis.[5]

Adjustment disorders are the most commonly diagnosed mental disorder in the oncology setting.

Course

As defined in the diagnostic criteria, an adjustment disorder begins within 3 months of the onset of an identifiable stressor and lasts no longer than 6 months after the stressor or its consequences have ceased. Two specifiers exist to discriminate between an acute adjustment disorder (≤6 months) and a chronic adjustment disorder (>6 months). The cancer patient may experience a sequence of multiple, sequential stressors such as the diagnosis, the start of treatment, side effects of treatment, conclusion of treatment, and return to work.

It is often difficult to determine when a stressor has ceased. It is not unusual to see a chronic adjustment disorder that persists because of the presence of multiple, sequential stressors. The persistent adjustment disorder may also progress to become a more serious mental disorder (e.g., major depressive disorder). Chronic adjustment disorders that persist and progress to more severe mental disorders appear more common in children and adolescents than in adults.[1] (Refer to the PDQ summary on Pediatric Supportive Care for more information.)

Problems in Diagnosing Adjustment Disorders

The adjustment disorders are an intermediate category between normal adjustment and a specific diagnosable mental disorder. In terms of their location within a hierarchy of increasingly severe mental disorders, the adjustment disorders are an intermediate category as follows:

• Major mental disorders (e.g., major depressive disorder, panic disorder, posttraumatic stress disorder, generalized anxiety disorder).
• Disorders not otherwise specified.
• Adjustment disorders.
• Problem-level diagnoses (e.g., partner relational problems, bereavement, physical abuse of child).
• Fluctuations in mood that represent normal adaptation.[6]

Screening instruments for the identification of adjustment disorder have been difficult to identify.[7,8] This intermediate status and the lack of any specific list of symptoms raise a number of problems with the adjustment disorder’s diagnostic category.[6] Most of the problems stem from lack of specificity and resulting subjectivity. This lack of specificity applies to both the identifiable stressor and the marked distress/significant impairment.

No criteria or guidelines exist in DSM-IV-TR to quantify the nature of the psychosocial stressor(s). Given individual differences in coping abilities, certain stressors are likely to be very stressful for one patient and not stressful at all for another patient. With no quantifiable guidelines for measuring stressors, a diagnosis is often determined by the nature of an individual’s response. If a person responds with marked distress or significant impairment in functioning, it is often assumed that the life event was an identifiable stressor. However, the identification of a response that evidences marked distress or significant impairment also lacks specificity and is thus very subjective. Many of these diagnostic terms are too vague to be valid or reliable; thus, there is considerable variation in the use of the adjustment disorder category.

Despite these problems, the adjustment disorder category does provide a means of identifying an emotional or behavioral response in need of further treatment. Cancer patients are regularly confronted with a variety of stressors and thus face the potential of experiencing an adjustment disorder.

Treatment

Current Clinical Trials

Check the list of NCI-supported cancer clinical trials for supportive and palliative care trials about adjustment disorder that are now accepting participants. The list of trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI website.

References

1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th rev. ed. Washington, DC: American Psychiatric Association, 2000.
2. Derogatis LR, Morrow GR, Fetting J, et al.: The prevalence of psychiatric disorders among cancer patients. JAMA 249 (6): 751-7, 1983. [PubMed: 6823028]
3. Miovic M, Block S: Psychiatric disorders in advanced cancer. Cancer 110 (8): 1665-76, 2007. [PubMed: 17847017]
4. Morasso G: Screening adjustment disorders related to mastectomy and its treatment. New Trends in Experimental and Clinical Psychiatry 13 (1): 90-3, 1997.
5. Akechi T, Okuyama T, Sugawara Y, et al.: Major depression, adjustment disorders, and post-traumatic stress disorder in terminally ill cancer patients: associated and predictive factors. J Clin Oncol 22 (10): 1957-65, 2004. [PubMed: 15143090]
6. Strain JJ: Adjustment disorders. In: Holland JC, Breitbart W, Jacobsen PB, et al., eds.: Psycho-oncology. New York, NY: Oxford University Press, 1998, pp 509-17.
7. Kirsh KL, McGrew JH, Dugan M, et al.: Difficulties in screening for adjustment disorder, Part I: Use of existing screening instruments in cancer patients undergoing bone marrow transplantation. Palliat Support Care 2 (1): 23-31, 2004. [PubMed: 16594232]
8. Kirsh KL, McGrew JH, Passik SD: Difficulties in screening for adjustment disorder, Part II: An attempt to develop a novel self-report screening instrument in cancer patients undergoing bone marrow transplantation. Palliat Support Care 2 (1): 33-41, 2004. [PubMed: 16594233]
9. Meyer TJ, Mark MM: Effects of psychosocial interventions with adult cancer patients: a meta-analysis of randomized experiments. Health Psychol 14 (2): 101-8, 1995. [PubMed: 7789344]
10. Greer S, Moorey S, Baruch JD, et al.: Adjuvant psychological therapy for patients with cancer: a prospective randomised trial. BMJ 304 (6828): 675-80, 1992. [PMC free article: PMC1881503] [PubMed: 1472184]
11. Telch CF, Telch MJ: Group coping skills instruction and supportive group therapy for cancer patients: a comparison of strategies. J Consult Clin Psychol 54 (6): 802-8, 1986. [PubMed: 3794024]
12. Penedo FJ, Dahn JR, Molton I, et al.: Cognitive-behavioral stress management improves stress-management skills and quality of life in men recovering from treatment of prostate carcinoma. Cancer 100 (1): 192-200, 2004. [PubMed: 14692040]
13. Goodwin PJ, Leszcz M, Ennis M, et al.: The effect of group psychosocial support on survival in metastatic breast cancer. N Engl J Med 345 (24): 1719-26, 2001. [PubMed: 11742045]
14. Moorey S, Greer S, Bliss J, et al.: A comparison of adjuvant psychological therapy and supportive counselling in patients with cancer. Psychooncology 7 (3): 218-28, 1998 May-Jun. [PubMed: 9638783]
15. Jacobsen PB, Hann DM: Cognitive-behavioral interventions. In: Holland JC, Breitbart W, Jacobsen PB, et al., eds.: Psycho-oncology. New York, NY: Oxford University Press, 1998, pp 717-29.
16. Allen SM, Shah AC, Nezu AM, et al.: A problem-solving approach to stress reduction among younger women with breast carcinoma: a randomized controlled trial. Cancer 94 (12): 3089-100, 2002. [PubMed: 12115339]
17. Jacobsen PB, Meade CD, Stein KD, et al.: Efficacy and costs of two forms of stress management training for cancer patients undergoing chemotherapy. J Clin Oncol 20 (12): 2851-62, 2002. [PubMed: 12065562]
18. Fawzy FI, Cousins N, Fawzy NW, et al.: A structured psychiatric intervention for cancer patients. I. Changes over time in methods of coping and affective disturbance. Arch Gen Psychiatry 47 (8): 720-5, 1990. [PubMed: 2378543]
19. Heiney SP, McWayne J, Hurley TG, et al.: Efficacy of therapeutic group by telephone for women with breast cancer. Cancer Nurs 26 (6): 439-47, 2003. [PubMed: 15022975]
20. Sherwood P, Given BA, Given CW, et al.: A cognitive behavioral intervention for symptom management in patients with advanced cancer. Oncol Nurs Forum 32 (6): 1190-8, 2005. [PMC free article: PMC1805479] [PubMed: 16270114]

Anxiety Disorder Caused by Other General Medical Conditions

The following table highlights possible causes of anxiety in cancer patients.

Table

Table 2. Possible Causes of Anxiety^a.

Patients in severe pain are anxious and agitated, and anxiety can potentiate pain. To adequately manage pain, the patient’s anxiety must be treated.[12,13]

Acute onset of anxiety may be a precursor of a change in metabolic state or of another impending medical event such as myocardial infarction, infection, or pneumonia. Sepsis and electrolyte abnormalities can also cause anxiety symptoms. Sudden anxiety with chest pain or respiratory distress may suggest a pulmonary embolism. Patients who are hypoxic can experience anxiety; they may fear that they are suffocating.

Many drugs can precipitate anxiety in persons who are ill. For example, corticosteroids can produce motor restlessness, agitation, and mania as well as depression and thoughts of suicide. Bronchodilators and B-adrenergic receptor stimulants used for chronic respiratory conditions can cause anxiety, irritability, and tremulousness. Akathisia, motor restlessness accompanied by subjective feelings of distress, is a side effect of neuroleptic drugs, which are commonly used for control of emesis. Withdrawal from opioids, benzodiazepines, barbiturates, nicotine, and alcohol can result in anxiety, agitation, and behaviors that may be problematic for the patient who is in active treatment.

Certain tumor sites can produce symptoms that resemble anxiety disorders. Pheochromocytomas and pituitary microadenomas can present as episodes of panic and anxiety.[14] Non–hormone-secreting pancreatic cancers can cause anxiety symptoms. Primary lung tumors and lung metastases can often cause shortness of breath, which can lead to anxiety.

Primary Anxiety Disorders

Patients who have the following symptoms may be experiencing a specific anxiety disorder that was present before they became ill with cancer and that recurs because of the stress of the diagnosis and treatment:

• Intense fear.
• Inability to absorb information.
• Inability to cooperate with medical procedures.

Somatic symptoms include the following:

• Shortness of breath.
• Sweating.
• Lightheadedness.
• Palpitations.

Patients with cancer can present with the following anxiety disorders:

• Phobias.
• Panic disorder.
• Generalized anxiety disorder.
• Obsessive-compulsive disorder.
• Adjustment disorder.
• Post-traumatic stress disorder.
• Anxiety disorder that is caused by other general medical conditions.

Patients with these anxiety disorders are generally distressed about their symptoms and are usually compliant with behavioral and psychopharmacologic intervention.[4]

Screening and Assessment

Effective management of anxiety disorders begins with a thorough and comprehensive assessment and an accurate diagnosis. The normal fears and uncertainties associated with cancer are often intense. Frequently not clear is the distinction between normal fears and fears that are more severe and reach the criteria for an anxiety disorder (see Table 3 for more information).[11]

Treatment should consider the patient’s quality of life, not be based solely on the disorder. To assess the severity of the anxiety, it is important to understand to what extent the symptoms of anxiety are interfering with activities of daily living. Screening for anxiety could include a brief self-report questionnaire that, if a defined cutoff score is exceeded, could then be followed by a more thorough clinical interview. A variety of general screening questionnaires have been used for identification of distress. (Refer to the section on Self-report screening instruments in this summary for more information.) Other anxiety-specific self-report questionnaires (e.g., State-Trait Anxiety Inventory) have also been used, and a questionnaire for the assessment of prostate cancer–related anxiety has been developed and validated.[2,15,16]

The following is a list of symptoms designed to distinguish common or normal worry from more serious symptoms of anxiety. When patients are reporting the more serious symptoms, referral to a qualified mental health professional may be warranted.

Table

Table 3. Common Worry versus Anxiety Disorders^a.

Interventions

When anxiety is situational (i.e., produced by pain, another underlying medical condition, a hormone-secreting tumor, or a side effect of medication), the prompt treatment of the cause usually leads to immediate control of the symptoms.[1] Some effective coping strategies include encouraging fearful patients to:[18]

• Confront the problem directly.
• Try to view the situation as a problem to be solved or as a challenge.
• Try to obtain complete information.
• Try to be flexible (taking things as they come).
• Think of major events as a series of step-by-step tasks.
• Use resources and support.

Initial management of anxiety includes providing adequate information and support to the patient. Initial symptoms, which may warrant a psychiatric or psychological consultation, may first be reported to the primary oncologist or surgeon.[19][Level of evidence: IV]

Pharmacologic interventions

Patients with cancer often have symptoms of both anxiety and depression that are caused by stressors related to cancer treatment. Such symptoms of distress often are resolved with psychologic support alone. However, in some cases, pharmacologic interventions are required to address these symptoms. (Refer to Table 3 for descriptions of symptoms of anxiety disorders possibly requiring pharmacological treatment.)

Following are brief descriptions of pharmacological treatment options and potential indications for their use. These descriptions are based on evidence derived from studies conducted in patients without cancer because of the lack of such studies in patients with cancer. However, it is important to note that clinicians have used some of these medications for several decades to treat anxiety symptoms in patients with cancer. The treatment options and their use in the situations described below are also based on clinical experience with these agents in patients with cancer.

The use of medications to treat anxiety disorders is considered when patients are experiencing more severe symptoms or when their responses to psychosocial interventions are inadequate. When counseling resources are not available or are declined by the patient, medication may be considered sooner rather than later. In certain cases, medications are started simultaneously with psychosocial interventions when it is likely that psychosocial support alone will be inadequate to provide relief or to provide it soon enough.

Pharmacological interventions can be used short-term or long-term, depending on individual patient and illness factors, including the following:

• Severity of anxiety symptoms.
• Level of functional/social impairment.
• Psychiatric history.
• Continued presence of cancer.
• Cancer treatment–related factors contributing to anxiety directly or indirectly (e.g., high-intensity or long-term cancer treatments or treatment with agents known to cause to psychiatric symptoms [e.g., cytokines]).

Specific anxiety medications—i.e., medications from the benzodiazepine class, as listed in Table 4—are frequently used alone or in combination with psychological approaches to provide relief from anxiety symptoms. These medications are effective in the acute treatment of anxiety disorders because of their rapid onset of action. They are frequently used as monotherapy or as adjunctive agents in the short-term management (<4 months) of anxiety disorders. Their long-term use (>4 months) is limited by the potential for abuse and dependence and by their lack of antidepressant effects, as depression is often comorbid with anxiety disorders. Following are some of the indications and safety considerations for the use of benzodiazepines in patients with cancer:[23,24]

• Short-acting benzodiazepines such as alprazolam and lorazepam can be effectively used to provide short-term relief at specific points in the cancer continuum of diagnosis, treatment, and recurrence. Examples of such short-term use include the treatment of anxiety during diagnostic procedures (e.g., certain radioimaging procedures) and the treatment of patient anxiety about pending test results (e.g., for yearly mammograms in patients with histories of breast cancer).
• Cancer treatments such as intensive chemotherapeutic regimens can cause significant physical and emotional distress and thus exacerbate anxiety. Short-acting or intermediate-acting agents (e.g.,clonazepam) can provide significant relief of anxiety and other symptoms (e.g., insomnia secondary to anxiety) during active cancer treatments.
• Longer-acting medications (e.g., diazepam and clorazepate) should generally be avoided because of their long half-lives. These medications can cause or exacerbate cognitive impairment, disorientation, and drowsiness because of their potential for accumulation.
• Patients with medical conditions such as delirium can present with anxiety and agitation. Benzodiazepine use in patients with such conditions is counterindicated because these agents can cause or exacerbate confusion and disorientation.
• All patients, especially elderly patients, receiving benzodiazepines should be closely monitored for cognitive impairment, daytime sedation, and fall risks. Use of these agents should be optimized in elderly patients, patients with multiple comorbidities, patients with liver disease, and patients receiving multiple medications.
• Use of these agents should be closely monitored and optimized in patients receiving other sedating medications, central nervous system depressants, and agents with potential for causing respiratory depression (e.g., opiates).
• It is important to continuously monitor and reevaluate anxiety symptoms in all patients receiving benzodiazepines. Use of these medications can be tapered off if anxiety symptoms resolve with the conclusion of cancer treatments.
• In some patients, the use of benzodiazepines is continued (as monotherapy or as adjunctive treatment) over a longer period (>4 months) because of persistent and debilitating anxiety symptoms. It is important to monitor the development of tolerance, abuse, and dependence issues as well as comorbid depressive symptoms in such patients. Long-term and sometimes chronic use of these agents might be indicated in a subpopulation of patients, with close monitoring and frequent risk-benefit assessments. Persistent (after 3 or 4 months) anxiety symptoms frequently lead to depression. Patients with persistent anxiety symptoms with or without depression might benefit from alternative treatments (e.g., paroxetine, sertraline).

Table

Table 4. Commonly Prescribed Benzodiazepines in Cancer Patients^a.

The choice of a benzodiazepine depends on the following:

• Duration of action that is best suited to the patient.
• Desired rapidity of onset needed.
• Route of administration available.
• Presence or absence of active metabolites.
• Metabolic problems.

Dosing schedules depend on patient tolerance and require individual titration. The shorter-acting benzodiazepines (alprazolam and lorazepam) are given 3 to 4 times per day. Short-acting benzodiazepines, particularly those that can be administered by multiple routes (lorazepam and diazepam), are effective for high levels of distress. Benzodiazepines decrease daytime anxiety and reduce insomnia. (Refer to the PDQ summary on Sleep Disorders for more information.) The most common side effects of benzodiazepines are dose dependent and are controlled by titrating the dose to avoid drowsiness, confusion, motor incoordination, and sedation.

All benzodiazepines can cause some degree of respiratory depression, which is generally minimal in patients who have not used benzodiazepines in the past. Benzodiazepines should be used cautiously (or not at all) in cases of respiratory impairment.

Standard precautions should be considered when any sedative drug is used in patients who have borderline respiratory function. Ongoing assessment of this population is important. Low doses of the antihistamine hydroxyzine (25 mg, 2–3 times a day) can be used safely in such situations. In patients with hepatic dysfunction, it is best to use short-acting benzodiazepines that are metabolized primarily by conjugation and excreted by the kidneys (e.g., oxazepam, temazepam, or lorazepam). Another advantage of using lorazepam is its lack of active metabolites. Conversely, other benzodiazepines should be selected in cases of renal dysfunction.

SSRIs (e.g., fluoxetine and sertraline) and serotonin-norepinephrine reuptake inhibitors (SNRIs) (e.g., venlafaxine) are considered first-line pharmacotherapy for long-term management of anxiety disorders. SSRIs and SNRIs are also effective in the treatment of depressive symptoms frequently comorbid with persistent anxiety disorders. SSRIs and SNRIs can take approximately 4 to 6 weeks to take effect because of their slow onset of action. Benzodiazepines are frequently used as adjunctive agents to stabilize symptoms in the initial period of treatment with SSRIs and SNRIs.

Atypical antidepressants (e.g., mirtazapine) are sometimes used to treat anxiety disorders because of their added effects on comorbid symptoms such as insomnia. Older medications such as tricyclic antidepressants (e.g., imipramine and clomipramine) and monoamine oxidase inhibitors (e.g., phenelzine) are also effective in treating anxiety disorders. The use of antidepressants in clinical practice is limited by their unfavorable side effects, poorer tolerability, and higher risks of toxicity.[26]

(Refer to Table 2 in the PDQ summary on Depression for antidepressant dosing. Refer to the Suicide Risk in Cancer Patients section in the PDQ summary on Depression for risk of suicidality and other neuropsychiatric side effects.)

Buspirone, a nonbenzodiazepine, is useful in patients who have not previously been treated with a benzodiazepine and in those who may abuse benzodiazepines (e.g., those with a history of illicit substance abuse or alcoholism). Buspirone is also useful in the geriatric population to augment fluoxetine for the treatment of anxiety and depression. The beginning dose is 5 mg 3 times a day and can be increased to 15 mg 3 times a day. Buspirone can also be given twice a day.

The use of specific classes of medications is considered for managing treatment-refractory anxiety symptoms or in certain special clinical situations. Low-dose neuroleptics (e.g., thioridazine, 10 mg 3 times a day; and risperidone, 1 mg twice a day) are used to treat severe anxiety when an adequate dose of a benzodiazepine is ineffective or if the patient might be expected to respond poorly to benzodiazepines (e.g., patients with brain metastases). Low-dose neuroleptics can also be used when benzodiazepines are not helpful or when there is the possibility of delirium, dementia, or other complications. Low-dose anticonvulsants (e.g., pregabalin, 200 mg per day) are sometimes used to treat severe treatment-resistant anxiety when other medications are ineffective or contraindicated because of certain associated risks.[26] Generally, the use of neuroleptics or anticonvulsants is considered after adequate trials with several first-line agents (e.g., SSRIs, SNRIs, and benzodiazepines) because of the significant side effect burden and potential for drug-drug interactions with these agents. Consultation with a psychiatric clinician is strongly recommended before these medications are used. Direct involvement of a psychiatric clinician is imperative for the management of patients receiving these medications.

The presence or absence of specific psychiatric or medical comorbidities is frequently a critical factor in the selection of pharmacological treatments. Pharmacokinetic and pharmacodynamic interactions with other medications are also important factors to be considered in the selection of agents. Following are some examples of such factors and clinical situations driving the selection of pharmacological treatments:

• When depressive symptoms are comorbid with anxiety, treatment with SSRIs, SNRIs, or other antidepressants is strongly considered.
• When neuropathic pain is comorbid with anxiety symptoms, specific antidepressants with known efficacy in treating neuropathic pain (e.g., duloxetine and venlafaxine) are considered.
• When hot flashes are comorbid with anxiety symptoms, specific agents with known efficacy in treating hot flashes (e.g., venlafaxine) are considered.
• Specific medications with known side effects (e.g., nausea with duloxetine or risk of sedation with mirtazapine) are avoided when patients are already experiencing these side effects from their cancer treatments and because of the possible exacerbation of these side effects.
• Patients who are treated with CYP2D6 inhibitors (e.g., paroxetine) and tamoxifen may be at risk of significant drug-drug interactions. (Refer to the PDQ summary on Hot Flashes and Night Sweats for more information.)

No pharmacological treatment studies have been conducted in children and adolescents with cancer. Furthermore, evidence on pharmacological treatment of anxiety disorders in pediatric patients without cancer is also limited. One meta-analysis of pediatric antidepressant clinical trials [27][Level of evidence: I] found antidepressants efficacious relative to placebo in the treatment of anxiety disorders, with strongest effects in non-OCD anxiety disorders (e.g., generalized anxiety disorder or social anxiety disorder) and intermediate effects in OCD. (Refer to the PDQ summary on Depression for a discussion of the risk of suicidal ideation/suicide attempt associated with antidepressant use.)

In general, patients with cancer need to be encouraged to take enough medication to relieve anxiety. Medications are readily tapered and discontinued when symptoms subside. Concerns about addiction are exaggerated in patients with cancer and often interfere with adequate symptom relief.

Current Clinical Trials

Check the list of NCI-supported cancer clinical trials for supportive and palliative care trials about anxiety disorder that are now accepting participants. The list of trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI website.

References

1. Breitbart W: Identifying patients at risk for, and treatment of major psychiatric complications of cancer. Support Care Cancer 3 (1): 45-60, 1995. [PubMed: 7697303]
2. Stark D, Kiely M, Smith A, et al.: Anxiety disorders in cancer patients: their nature, associations, and relation to quality of life. J Clin Oncol 20 (14): 3137-48, 2002. [PubMed: 12118028]
3. Schag CA, Heinrich RL: Anxiety in medical situations: adult cancer patients. J Clin Psychol 45 (1): 20-7, 1989. [PubMed: 2925881]
4. Razavi D, Stiefel F: Common psychiatric disorders in cancer patients. I. Adjustment disorders and depressive disorders. Support Care Cancer 2 (4): 223-32, 1994. [PubMed: 8087440]
5. Maguire P, Faulkner A, Regnard C: Managing the anxious patient with advancing disease--a flow diagram. Palliat Med 7 (3): 239-44, 1993. [PubMed: 8261191]
6. Nordin K, Glimelius B: Predicting delayed anxiety and depression in patients with gastrointestinal cancer. Br J Cancer 79 (3-4): 525-9, 1999. [PMC free article: PMC2362410] [PubMed: 10027324]
7. Green BL, Krupnick JL, Rowland JH, et al.: Trauma history as a predictor of psychologic symptoms in women with breast cancer. J Clin Oncol 18 (5): 1084-93, 2000. [PubMed: 10694561]
8. Friedman LC, Lehane D, Webb JA, et al.: Anxiety in medical situations and chemotherapy-related problems among cancer patients. J Cancer Educ 9 (1): 37-41, 1994. [PubMed: 8204456]
9. Partridge A, Adloff K, Blood E, et al.: Risk perceptions and psychosocial outcomes of women with ductal carcinoma in situ: longitudinal results from a cohort study. J Natl Cancer Inst 100 (4): 243-51, 2008. [PubMed: 18270338]
10. Hackett TP, Cassem NH: Massachusetts General Hospital Handbook of General Hospital Psychiatry. 2nd ed. Littleton, Mass: PSG, 1987.
11. Massie MJ: Anxiety, panic, and phobias. In: Holland JC, Rowland JH, eds.: Handbook of Psychooncology: Psychological Care of the Patient With Cancer. New York, NY: Oxford University Press, 1989, pp 300-9.
12. Velikova G, Selby PJ, Snaith PR, et al.: The relationship of cancer pain to anxiety. Psychother Psychosom 63 (3-4): 181-4, 1995. [PubMed: 7624464]
13. Glover J, Dibble SL, Dodd MJ, et al.: Mood states of oncology outpatients: does pain make a difference? J Pain Symptom Manage 10 (2): 120-8, 1995. [PubMed: 7730684]
14. Wilcox JA: Pituitary microadenoma presenting as panic attacks. Br J Psychiatry 158: 426-7, 1991. [PubMed: 1645208]
15. Roth AJ, Rosenfeld B, Kornblith AB, et al.: The memorial anxiety scale for prostate cancer: validation of a new scale to measure anxiety in men with prostate cancer. Cancer 97 (11): 2910-8, 2003. [PubMed: 12767107]
16. Roth A, Nelson CJ, Rosenfeld B, et al.: Assessing anxiety in men with prostate cancer: further data on the reliability and validity of the Memorial Anxiety Scale for Prostate Cancer (MAX-PC). Psychosomatics 47 (4): 340-7, 2006 Jul-Aug. [PubMed: 16844894]
17. Nicholas DR: Emotional Side Effects of Cancer: Distinguishing Normal Distress from Mental Disorders [brochure]. Muncie, Ind: Ball Memorial Hospital and Ball State University, 2008.
18. Johnson J: I Can Cope: Staying Healthy with Cancer. 2nd ed. Minneapolis, Minn: Chronimed Pub., 1994.
19. Hinshaw DB, Carnahan JM, Johnson DL: Depression, anxiety, and asthenia in advanced illness. J Am Coll Surg 195 (2): 271-7; discussion 277-8, 2002. [PubMed: 12168975]
20. Montazeri A, Jarvandi S, Haghighat S, et al.: Anxiety and depression in breast cancer patients before and after participation in a cancer support group. Patient Educ Couns 45 (3): 195-8, 2001. [PubMed: 11722855]
21. Gil KM, Mishel MH, Germino B, et al.: Uncertainty management intervention for older African American and Caucasian long-term breast cancer survivors. J Psychosoc Oncol 23 (2-3): 3-21, 2005. [PubMed: 16492649]
22. Reddick BK, Nanda JP, Campbell L, et al.: Examining the influence of coping with pain on depression, anxiety, and fatigue among women with breast cancer. J Psychosoc Oncol 23 (2-3): 137-57, 2005. [PubMed: 16492656]
23. Stiefel F, Berney A, Mazzocato C: Psychopharmacology in supportive care in cancer: a review for the clinician. I. Benzodiazepines. Support Care Cancer 7 (6): 379-85, 1999. [PubMed: 10541978]
24. Michael Kaplan E, DuPont RL: Benzodiazepines and anxiety disorders: a review for the practicing physician. Curr Med Res Opin 21 (6): 941-50, 2005. [PubMed: 15969894]
25. Breitbart W, Jaramillo JR, Chochinov HM: Palliative and terminal care. In: Holland JC, Breitbart W, Jacobsen PB, et al., eds.: Psycho-oncology. New York, NY: Oxford University Press, 1998, pp 437-49.
26. Hoffman EJ, Mathew SJ: Anxiety disorders: a comprehensive review of pharmacotherapies. Mt Sinai J Med 75 (3): 248-62, 2008 May-Jun. [PubMed: 18704983]
27. Bridge JA, Iyengar S, Salary CB, et al.: Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials. JAMA 297 (15): 1683-96, 2007. [PubMed: 17440145]

Purpose of This Summary

This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about normal adjustment issues, and the pathophysiology and treatment of psychosocial distress and the adjustment disorders. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.

Reviewers and Updates

This summary is reviewed regularly and updated as necessary by the PDQ Supportive and Palliative Care Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).

Board members review recently published articles each month to determine whether an article should:

• be discussed at a meeting,
• be cited with text, or
• replace or update an existing article that is already cited.

Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.

The lead reviewers for Adjustment to Cancer are:

• Andrea Barsevick, PhD (Thomas Jefferson University)
• Jayesh Kamath, MD, PhD (University of Connecticut Health Center)
• Jean Kristeller, PhD (Indiana State University)
• Lillian M. Nail, PhD, RN, FAAN, CNS (Oregon Health & Science University Cancer Institute)
• Amy Wachholtz, PhD, MDiv, MS (University of Colorado)

Any comments or questions about the summary content should be submitted to Cancer.gov through the NCI website's Email Us. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.

Levels of Evidence

Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Supportive and Palliative Care Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.

Permission to Use This Summary

PDQ is a registered trademark. Although the content of PDQ documents can be used freely as text, it cannot be identified as an NCI PDQ cancer information summary unless it is presented in its entirety and is regularly updated. However, an author would be permitted to write a sentence such as “NCI’s PDQ cancer information summary about breast cancer prevention states the risks succinctly: [include excerpt from the summary].”

The preferred citation for this PDQ summary is:

PDQ® Supportive and Palliative Care Editorial Board. PDQ Adjustment to Cancer. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: http://www.cancer.gov/about-cancer/coping/feelings/anxiety-distress-hp-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389397]

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