Facing Fear: How to Help Patients Navigate Cancer Anxiety

Fear is a powerful force --- and one that can cause a great deal of harm, it turns out. A recent survey found that 40% of patients said they would avoid seeing a doctor if they noticed a symptom they suspected was cancer. Another study found that roughly half of patients who had findings of lung cancer in screenings put off treatment for upwards of three months.

Fear may impede patients at crucial times, from preventing or delaying health screening to interfering with treatment compliance. For help understanding this phenomenon, we turned to Psychosocial Oncologist Shiyao Wang, MD, from Cleveland Clinic Cancer Institute’s Department of Palliative and Supportive Medicine.

Q: What advice can you share with healthcare providers about helping their patients with the very real fears of a cancer diagnosis?

Dr. Wang: Cancer and other chronic diseases can trigger a lot of fear and anxiety, which sometimes gets in the way of patients seeking help. Sometimes patients are too anxious to really listen to what their doctor is saying. It's hard to comprehend information when you're scared. Proactively talking with patients about anxiety and fear can be a helpful place to start.

Q: How can providers encourage patients to get regular cancer screenings despite their fears?

Dr. Wang: Fear can cut both ways. Fear of cancer can motivate some people to get screened regularly, but there is also the fear of undesired results, missing work and school and the potential pain or embarrassment of a screening procedure. Some surveys show roughly 30% of patients don't want to know if they have lung cancer because of fear of “a bad result” or being blamed for smoking.

Typically, a primary care physician is the first to notice when a patient has a lesion or other issue that necessitates a screening. Outreach between primary care physicians and specialists can boost screening participation, especially for breast, cervical and colorectal screening. Having someone in the doctor’s office who can streamline the scheduling process decreases the chance that a patient will put off screening out of fear. Nurse coordinators can also explain what to expect during the screening and what pain control regimens are available if they’re undergoing an invasive procedure.

Q: How can providers support patients and help them with the fear of facing a challenging diagnosis?

Dr. Wang: Part of the fear comes from the ambiguity of what they may face. They may meet with an oncologist and have an expectation that they're likely to have a serious diagnosis but there's also the potential that they may be ok.

Many patients also fear that if they do have cancer that the provider will blame them for lifestyle choices like smoking. Emphasize that a lot of disease is treatable and symptoms can be relieved. Discussing diagnosis in a very non-judgmental way can help counter the avoidance many patients have with seeing a doctor.

Q: How do you determine if a patient with cancer needs additional mental health support?

Dr. Wang: The goal is to have a social worker meet every patient with a recent cancer diagnosis and have social work be part of the care team from the start. Social workers perform distress screenings for early intervention. Cancer treatment is a continuum, though, and so even if a patient didn't have a need for emotional support early on, things may change. At a certain stage they may have a heightened level of distress where psychology, psychiatry and/or social work need to be reengaged to help the patient manage fear and anxiety.

Q: What are some other ways to help alleviate fear for patients during cancer treatment?

Dr. Wang: Use trauma-informed, culturally safe communication to help normalize fear and support patients in their journey. Make sure communication is individualized. Talk with patients about how much they want to know about their diagnosis and how much to share with their family. Some people want to know all the ins and outs of what's going to happen moving forward and others want to know the bare minimum. Meeting people where they want to be can reduce a lot of anxiety.

Q: I imagine some patients don’t want to share too much with family members to avoid worrying them. How can providers help patients in this situation?

Dr. Wang: People have better treatment outcomes when they have good social support.

From the get-go, explain to patients that treating cancer involves teamwork and that they'll need support. Part of this is helping patients learn to ask for help and be comfortable feeling vulnerable. That's a skill a lot of people never develop. Particularly men in our society are taught to “man up” and not to express fear. When facing cancer, this is the time to support patients in helping them learn how to reach out for that help.

Q: How can providers address fear of pain in patients with cancer?

Dr. Wang: It's been well established that being able to adequately manage symptoms from cancer and cancer treatment can enhance patients' quality of life as well as treatment outcomes. Pain is very common, especially in advanced cancer. For most people, we can achieve meaningful pain relief with a multi-factor approach.

Sleep and stress can also exacerbate pain, so being able to manage those factors is equally important. When we talk about pain, it's a two-way street. If you're in a lot of pain, you're likely to be more depressed, anxious and have trouble sleeping. And if you're depressed, having fear and anxiety or experiencing trouble sleeping, your pain will most likely feel worse, so managing those factors is important.

Many patients also have concerns about becoming addicted to pain medication like opioids. They need to know we’re not just going to go on autopilot if we put them on medication. We explain the benefits, how we’ll monitor side effects and that we’ll identify the lowest effective dose for pain control. And we address any underlying issues with the hope that we can decrease pain medication over time. That brings a sense of reassurance to help people accept effective pain management.

If patients are averse to pain medications or are not good candidates for pain medication, there are other options like nerve blocks, physical rehabilitation as well as pain psychology.

Q: How do you address pain management in patients with a history of substance abuse?

Dr. Wang: In the case of patients with substance abuse, their pain threshold may be higher, and their pain receptors may have altered over the years, so they may need a different level of pain management. Our goal is to help patients maintain function in the safest way. We educate them to address the stigma of pain management and talk openly about it.

Q: How can providers help patients with “scanxiety” and encourage them to continue regular monitoring of their disease?

Dr. Wang: The first step is to normalize the process of getting scans and to reach out to patients to reduce uncertainty. Explain to the patient that many people feel anxious before scans. Provide a clear timeline of what will happen and when the results will come back to make things more predictable. Bringing some structure can help people feel a bit more comfortable.

We can also walk patients through guided imagery or muscle relaxation to do in the days leading up to a scan. We review the underlying thoughts that perpetuate scanxiety and challenge some dysfunctional thoughts patients hold on to. Developing a stress-reducing regimen on scan day can also help. This may involve listening to music before their test or providing a short-acting anxiety medication.

Q: What guidance can you share with providers in helping patients and families with the understandable fears at end of life?

Dr. Wang: There are several evidence-based approaches such as psychotherapy to help patients and their families process the fear of death. This includes helping people reconnect with their values and sense of purpose they've received from life, and may involve talking with them about their personal life, ancestry, culture and heritage.

Another aspect of end-of-life care includes dignity therapy, where a member of the care team works with the patient to help them create a legacy document of what they want to leave behind. In addition, establishing structural goals such as advanced care planning is crucial. Helping families talk openly and make informed decisions can reduce existential distress and assist in spiritual well-being.

Q: I imagine many family members are understandably afraid to bring up the topic of dying. What are your thoughts on that?

Dr. Wang: Typically, when patients reach that stage, they are feeling very unwell and weak. Deep in their mind, whether or not they say it, the concept has come across their minds. People may suppress thoughts of death but that doesn't mean they're not thinking about it or that it's not causing them distress. Being able to provide that space where they can feel comfortable talking about it is essential. It's not an easy topic by any means but it's important and meaningful to address.

Sometimes people may fear bringing up the topic of death with their oncologist directly because they worry that they'll treat them differently or withhold further treatment. In that case, a third party like a social worker, psychologist or psychiatrist may be able to sit down with the patient to provide a safe place so they can truly share what's going through their mind.

Q: Would you like to share any final thoughts on helping patients cope with fear?

Dr. Wang: I should note that these practices we’ve discussed aren't unique to cancer. All of these practices are transferable to other disease groups.

Ultimately, fear is human, and our job is to name it, measure it and treat it with the same rigor we bring to other parts of cancer therapy. This means screening for distress, offering proven therapy and evidence-based medicine and making the path through cancer care clearer and kinder.