Psycho-oncology: between psychological aspects in cancer patients and requests for support

Psycho-oncology: between psychological aspects in cancer patients and requests for support

The cancer event involves numerous aspects of the person’s life, starting from the diagnostic moment to subsequent follow-ups and there are numerous psychological repercussions on the cancer patient and his family.


Today, we are witnessing the increasing chronicity of fatal diseases thanks to the pharmacological innovations that allow the patient to live with the disease for many years (Taylor, 2014) and the concept of “quality of life” assumes increasing value. It becomes increasingly important to know and identify the impact and emotional repercussions of the disease to ensure psychological support and an emotional containment space for the cancer patient and family members (Moreno-Smith et al., 2010; Lim et al., 2013) , in an effective communication framework between the healthcare professional and the patient (Stamataki et al., 2015).

The cancer event involves numerous aspects of the person’s life, starting from the diagnostic moment to subsequent follow-ups and there are numerous psychological repercussions on the cancer patient and his family.

In a longitudinal study (Williams et al., 2016) the impact of the diagnosis of cancer on the psychological aspect of the patient was investigated, dividing the sample into three categories: two years before diagnosis, within two years of diagnosis and subsequent four. The research considered variables such as quality of life, daily difficulties, anxiety and depression. As you can imagine, the impact of the diagnosis resulted in a greater decline in perceived health, greater daily difficulties reported and scores of anxiety and depression considerably higher than the control group.

The key point of the study is to have shown that these scores do not return, although they diminish with time, at the pre-diagnosis levels, remaining significantly lower than in healthy subjects; suggesting that the pathology impacts long-term psycho-physical functioning and confirming the importance of psychological support that accompanies the patient along the disease event in its phases and in the follow-up.

In a 2014 research (Nikbakhsh et al.) A sample of 150 subjects with cancer was examined and it emerged that 40% showed subclinical levels of depression, while 32% arrived at indicative scores of clinical depression. Regarding the percentage of anxiety, the relative subclinical and clinical scores investigated with the HADS (Hospital Depression Anxiety Scale) were 44% and 22% respectively.

While in a 2012 study (Linden et al.) Involving 10153 cancer patients, a percentage of depression and subclinical anxiety of 17% and 23% respectively were also reported, reaching clinical levels in 13% and 19% of cases. We can therefore say that

These data seem to be confirmed also in qualitative studies, for example through hermeneutic interview (Stamataki et al., 2015) four areas have been investigated: emotional area, effects on relationships, functional effects and health system in patients with melanoma. Some themes that emerged are uncertainty for the future and the feeling of powerlessness, probably deriving from perceiving oneself as only passive in dealing with illness and not proactive in healing; the altered body image, given by the scar outcome of the surgical removal of melanoma, which would contribute to compromising the perception of physical and aesthetic integrity. There have been repercussions on family relationships, a desire not to burden the family, to maintain functional autonomy and to protect relatives from illness-related fears and negative feelings. Many functional problems have been reported such as pain, fatigue and exhaustion that affect getting work done, hobbies, daily activities and participating in social relationships. The feeling of reorganizing one’s life around the symptom has been reported as very frequent.

In summary, it is clear that the cancer event involves a succession of emotions that affect the subject himself, family, friends and health workers, leading to a mutual influence that affects both the patient and the environment close to him.

An important contribution given to the psycho-psychological field is represented by the pioneering work of Elizabeth Kluber-Ross (1969), the author has in fact described the five phases that the patient goes through in terminal illness. The five phases shown clearly represent the patient’s reactions to the pathology and constitute a pivotal point in clinical reality since, although it is not clear that they follow one another in a specific order, they allow the identification of the underlying needs of the patient and the promotion of an adequate support and intervention where required and appropriate. The steps reported by the author are:

1) Denial: this phase is frequent at the time of diagnosis and represents a defense mechanism through which people try to protect themselves from the effects of a disease. The person can behave as if the pathology was not serious or, in the most extreme cases, as if it had not happened; in fact, the patient can deny having a disease despite the diagnostic results. Denial represents a normal phase through which the subject initially takes a distance from the possible perspective of his own death, however if he persists and stiffens he may need psychological intervention.

2) Anger: this is the second reaction that the patient can have when faced with the prospect of his own death. Anger can be expressed directly towards the people around him such as health personnel, family and friends, because in health, for example, or indirectly by expressing bitterness. One can frequently be ironic about the fact that many things can no longer be done, about physical deterioration or make sharp jokes about the theme of death. It is not uncommon for the patient to ask himself why it happened to him and experience an envy towards people who are healthy or who have recovered from diseases. Anger can be directed towards family members and it is important that the clinician normalizes and contextualizes these emotions.

3) The negotiation: the patient can abandon anger in favor of the negotiation, or the belief that if he performs morally just and ethical acts he will have health in return. Events such as charity gifts or unusually pleasant behaviors can be an indication of this phase, therefore there is a negotiation between good conduct in exchange for good health.

4) Depression: in this phase the patient recognizes that he can do little to keep the disease under control. This realization coincides with a sharp drop in mood, worsening of symptoms, increased tiredness, fatigue and pain. It is difficult to distinguish between symptoms resulting from depression and those resulting from drug treatment or disease, therefore an adequate clinical distinction between the two is important. Kluber-Ross (1969) identifies this phase as the “anticipatory mourning” phase, where patients “mourn” the prospect of their death, anticipate the loss of future relationships and activities.

5) Acceptance: the last phase of the stages reported by Kluber-Ross, represents a global awareness of one’s own death, where the patient may be too tired to be angry and too accustomed to the disease to be depressed.

Acceptance is not said to be peaceful and includes a state of calm, but some patients use this time to make preparations, decide how to divide their assets and how to spend time with family members.

The reactions and mutual influences that can occur within the family are manifold: for example, it may happen that with the progress of the disease and the consequent physical and psychological decline the patient decides to move away from the family and social interactions (Taylor, 2014); it may happen that the patient chooses not to talk about the disease with family and friends in order not to burden them (Stamataki, 2015). The family in turn may face a reorganization of roles according to the patient, with repercussions on work or other family relationships.

In a 2010 review (Stenberg et al.) On a sample of nearly 20,000 family caregivers, the main problems reported by them were: depression, tiredness, anxiety, uncertainty, fear, difficulty sleeping, weight loss and appetite.

As the authors suggest, a person’s illness disrupts family roles, which can become overprotective and impose high standards in patient care, assuming a high responsibility towards him; if the job is not flexible they can take days off or sick, reorganizing themselves according to the patient. Identifying the “assisting” family members who are in difficulty and integrating them into the psycho-psychological support path represents a fundamental point of the patient’s overall care, as supporting the family members is of considerable importance for the patient and for a more effective care path / efficient and less painful.

Despite the evidence in favor of social support in reducing stress and increasing perceived psychological well-being (Kiecolt-Glaser et al., 2002), the percentage of cancer patients seeking psychological support is low and there is a large number of operators health that underestimate the emotional difficulties reported by this target. The percentage of cancer patients seeking support was examined (Merckaert et al., 2009): of 381 patients, only 25% of women expressed a desire for psychological support, while high levels of anxiety and depression they were tested by 70% of the female sample; as regards the male sample, 10% sought help on a percentage of 50% who reported significant scores of anxiety and depression. The greater demand from women can be explained by their tendency to adopt more active coping, aimed at seeking support. According to the authors, the low percentage of patients asking for help can be explained by their underestimation of the benefits of psychological support and by considering anxiety and depression as normal consequences of the impact of cancer and treatment.

In this regard, Butow et al. (2002) examined the response patterns of doctors and the information requested in the oncology department and it was reported that doctors respond more to requests for information on prognosis, treatment etc., rather than requests for emotional support. On the other hand, patients are more likely to request medical information, as they perceive doctors and operators as “busy” and do not consider it appropriate to involve them in their fears and anxieties. As the authors report

It can therefore be argued that giving information cut out on the person with sensitivity, involving the patient in the treatment and in the decisions so that it has an active role and recognizing the emotional discomfort, are factors that contribute to the reduction of psychopathological morbidity in cancer patients ( Butow et al., 2002).

However, it is necessary to specify that the presence of emotional responses also depends on the ability of the team to bring out the “psychological needs” and to respond congruently to them, underlining the need to sensitize the health personnel towards the distress experienced by the cancer patient; therefore the importance of paying attention to these signals and interpreting the underlying needs of the emotional reactions elicited by the oncological disease in its different phases, as well as in the treatment phases. Working in a biopsychosocial perspective includes giving due weight to the psychological, social and biological variables which, interacting with each other, can contribute to the success of a treatment; being in close interaction these variables it is necessary both to inform the patient about the medical aspects of the disease, both to inform about common feelings, fears and anxieties in the oncological process, ensuring the opportunity to be followed in a psychological path. The emotional aspect of the disease, especially if it is fatal, is increasingly important and worthy of being monitored in order to guarantee an acceptable and satisfactory quality of life experienced by the patient, reiterating the fact that nowadays there is always an more frequent chronicity of the disease (Matarazzo, 1980) and a growing need for coexistence with it.