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Cancer diagnosis and treatment heightens people’s fears and anxieties, but nurses can help ease patients’ concerns and improve their experience
Fear, shock, anger, loneliness and grief for a life hoped for – there are many emotions people will experience when diagnosed with cancer, as well as during and after treatment.
Cancer Nursing Practice. 22, 5, 7-9. doi: 10.7748/cnp.22.5.7.s3
Published: 04 September 2023
People living with cancer may feel sadness, guilt and blame, a loss of control and confidence, and also worry about their finances, such as the cost of travelling to treatment, their work, and their future.
Even if a person is in recovery, the fear and anxiety can remain because of the potential for cancer to return.
Counselling psychologist Cordelia Galgut, writing about her own experience in Private Practice journal, says: ‘One unrecognised, ongoing and pronounced issue is the fear of cancer coming back, or getting worse if it’s still present. It’s a big deal for most of us living on after cancer, and an unavoidable stress.’
Macmillan Cancer Support strategic adviser for treatment, medicines and genomics Dany Bell says worries, fears and concerns about the consequences of cancer and its treatment are natural, but that does not mean they are easy to cope with.
She says people living with cancer will often need support for their emotional needs. ‘Occasionally, emotional needs will become prolonged or intense, and require medication or specialist mental health support,’ says Ms Bell.
‘Even a short but meaningful conversation can make a huge difference’
Ceinwen Giles, co-chief executive, Shine Cancer Support
‘People living with cancer may be diagnosed with mental health conditions such as clinical anxiety or depression – at this stage, they become classified as psychological needs.’
Cancer Research UK asked 1,015 people who had ever been diagnosed with cancer about their mental health experiences through a YouGov survey in 2018.
It found that almost three in ten (29%) had experienced mental health issues, such as anxiety and depression, while one in ten (11%) respondents had sought advice from a mental health professional.
Ms Bell says younger, poorer people and those from ethnic minority backgrounds are more likely to report severe psychosocial needs, but the age profile of cancer means there are more older people with these needs.
While cancer nurses have a professional role in the symptom management of people living with cancer, including symptom screening and assessment, nurses are also the healthcare professionals who spend the most time with patients and their families, she says.
‘They will have an empathetic and calming approach, as well as providing information, supporting difficult decisions and listening to their fears, anxieties, and hopes for the future.’
Trinity College Dublin associate professor in mental health nursing Michael Nash says referral to a GP or specialist will depend on a number of factors. These might include whether a patient’s symptoms are persistent and lowering quality of life, or if they are actively suicidal due to a cancer diagnosis.
Not all patients will display how they are feeling. Mr Nash says signs of depression or anxiety – which may also stem from the side effects of cancer or cancer treatment – include severe low mood, disrupted sleep, cognitive impairment, hopelessness and helplessness.
People living with cancer may face a dual stigma of having cancer and how others may react to it as well as the stigma of mental illness, which can prevent them from speaking about it and getting help, says Mr Nash.
‘Don’t be afraid to talk about depression and anxiety. Not talking can be a barrier to holistic care. But talking about it can normalise the experience and show the person they are not alone,’ he says.
Ms Bell says nurses can create a supportive relationship with people living with cancer by listening to them and using language that is meaningful to them.
‘People living with cancer need to feel safe by knowing what is happening, so they need to be kept informed at every point,’ she says.
‘People need to understand what the general plan is for their treatment and how it might affect them’
Ceinwen Giles, co-chief executive, Shine Cancer Support
She also recommends using active listening skills, taking cues from patients, not being afraid of silences and paying attention to non-verbal clues such as facial expression, gestures and eye contact.
1. Take time to get to know patients and to understand their feelings and experiences, and what is important to them
2. Encourage patients to talk about their fears and worries in a calm, private and safe environment – listening actively and without judgement is important for the patient to feel safe and heard
3. Acknowledge how they are feeling and find out how they prefer to be supported emotionally – some patients prefer an upbeat approach while others may want you to just be there and listen
4. Do not try to fix emotional problems – asking open questions and allowing patients to talk about how they are feeling is likely to be more helpful
5. Make yourself aware of what is available to support patients between appointments and signpost it – if you are unclear what is available in your area signpost to a support line where someone can help them
6. You do not need all the answers or expertise, just to listen and signpost or refer
7. Be aware of assessment tools such as the Hospital Anxiety and Depression Scale
Source: Dany Bell, Macmillan Cancer Support
Prostate Cancer UK specialist nurse Deidre Vlotman says it is important when supporting patients to reassure them that there is no right or wrong way to feel, and that their feelings may change daily, hourly or even minute to minute. ‘It can often help to normalise feelings,’ she explains.
Backing up information with easy-to-understand written material, ideally with information specific to the patient such as test results, can enable patients to feel more in control, says Ms Vlotman.
Jane Murphy, senior clinical nurse specialist at the charity Breast Cancer Now, says that some conversations with patients may be particularly challenging. Clinical supervision can help nurses reflect on such conversations and give them the tools and skills to draw on in the future, she says.
Ms Bell says trusting, open communication is key to reducing anxiety and supporting people to be in control. Always putting the patient first, competence in knowledge, honesty, caring and showing respect are some of the ways nurses can gain trust from their patients, she says.
Maggie’s counsellor support specialist Lizzie Morgan advises nurses to ensure that patients ‘feel safe and in a comfortable space’.
Remembering the small details that are of significance to the patient – such as how many children they have – helps to gain their trust, she says.
Mr Nash says that to provide person-centred care for people with cancer, nurses should involve them in their care plans and support. ‘Ask for their opinions and discuss options. This interaction will be a chance to reassure people,’ he says.
Ceinwen Giles, co-chief executive of Shine Cancer Support, says educating people on their diagnosis can help to empower them at a time when they may be feeling powerless, fearful and helpless.
‘People need to understand what the general plan is for their treatment and how it might affect them. It’s also important to remember that for most people all of this will be completely new to them.’
Mr Nash advises against using lots of jargon, and says to explain things in simple terms. And Ms Morgan suggests having follow-up conversations with people to check if they have any further questions.
Peer support groups can normalise what people are feeling and show those living with cancer that they are not alone.
Ms Bell says: ‘Peer support groups can help reduce isolation, allow people to gain a sense of hope, facilitate sharing – which can be therapeutic – and can be a source of emotional support to reduce distress.’
When signposting patients to peer support they need to be aware of the options, which include face-to-face, and online communities, as they may have a preference, she says.
Maggie’s runs a variety of peer support groups facilitated by cancer support specialists.
Ms Morgan says: ‘Peer support groups can often normalise what people are feeling, reducing feelings of isolation, stress and anxiety.’
Ms Giles says Shine’s support groups are run by young adults, and activities are peer-led.
‘Peer support is powerful and can provide people with a community at a time when friends and family, as much as they want to support them, won’t fully understand what they are going through,’ she says.
If people feel overwhelmed, Mr Nash says nurses can advise them to talk to their health team – or to peers if they have developed peer support networks.
‘Bottling things up can make it worse. The person may feel like a burden or guilty, but we need to reassure them that they are still important.’
Ms Bell calls ‘prehabilitation’ – making yourself ready for treatment to help reduce side effects and improve chances of recovery – ‘a good start in terms of prevention and giving people the tools to support themselves, particularly because it promotes healthy behaviours, which also maintain emotional well-being’.
People living with cancer are at increased risk of taking their own lives compared with the general population, according to a study by Public Health England.
The 2018 study found they have a 20% increased risk, which is at its greatest within the first six months of diagnosis.
Trinity College Dublin associate professor in mental health nursing Michael Nash (pictured) says: ‘Thoughts of suicide are common in people diagnosed with cancer, but in the majority of cases they are not acted on. However, thoughts can change into ideas and behaviours indicative of suicide risk.’
He says there may be a similarity in signs of suicidal thoughts between those with and without cancer. This might include feelings of hopelessness, worthlessness or guilt, such as blaming yourself for a cancer diagnosis, as well as sleep disruption, poor appetite, isolation and an increase in alcohol or drug intake as a form of self-medication.
Warning signs Specific warning signs include an increase in the frequency, intensity or duration of symptoms of mental illness, an increase in the frequency, intensity and duration of suicidal thoughts, a preoccupation with dying and using self-harm as a way to cope with emotional stress.
Mr Nash says that when suicidal thoughts are present there is a need for specialist mental healthcare, as cancer nurses may not have the skills to manage.
‘Shared care with specialist mental health services should be considered for people with clinical depression or anxiety, a past history of severe mental illness, or if assessed as at high risk of suicide.’
Patients can also be signposted to sources of self-help approaches such as talking therapy and mindfulness. And nurses can help patients to focus on the present and set goals to focus on, she says.
Cancer nurses can help to ease some of the practical concerns that could be affecting a patient’s mental health.
Patients may have to take time off work and travel long distances to receive treatment, incurring costs and adding to their worries. However, nurses may be able to adjust the timing of appointments to minimise costs.
Ms Bell says: ‘There are support services and funds that people can access to help with the financial impact of cancer. Cancer nurses should be familiar with these and be able to signpost, and can ensure patients are not charged for parking and are offered virtual appointments.’
Sometimes emotional upset and mental health issues may prevent patients from attending appointments and receiving treatment. They may fear a diagnosis and avoid treatment, or the treatment may make them feel physically ill and affect their mental health to the extent that they stop attending.
And sometimes, says Ms Giles, it is the simple things that can help, like just asking people how they are feeling. ‘Even a short but meaningful conversation can make a huge difference.’
Breast Cancer Now www.breastcancernow.org
Cancer Research UK www.cancerresearchuk.org
Galgut C (2023) Living with the fallout of cancer. Private Practice. www.focrap.co.uk/living.pdf
Maggie’s (2023) How the Hidden Cost of Cancer is Damaging Mental Health.
Shine Cancer Support shinecancersupport.org