Psychological Challenges of Surviving Cancer

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About 11 million Americans alive today—one in 30 people—are either currently undergoing treatment for cancer or have done so in the past. The National Cancer Institute considers all to be cancer survivors. Many would attest that cancer is not only life-threatening, but also life-altering.

Cancer and its treatment sometimes leave scars and other physical changes that can have long-lasting effects. Even so, many cancer survivors remain psychologically healthy. Some are happy simply to be alive. Others have developed greater self-esteem, confidence, and resilience, as well as a stronger appreciation for day-to-day life after having faced a formidable disease.

But some cancer survivors struggle with "subthreshold" symptoms of depression, anxiety, and post-traumatic stress disorder. Although these problems may not meet the criteria for a clinical diagnosis, they are often significant enough to cause suffering and disrupt lives, sometimes for years.

Adjusting to life after treatment

The psychological terrain of survivorship is dynamic, with the most difficult times occurring during transitions. Dr. William Pirl, a Massachusetts General Hospital (MGH) psychiatrist who works frequently with cancer survivors, believes that one transition in particular is likely to cause psychological distress: the period immediately following completion of intensive (primary) cancer treatment. For some patients, this transition may be as stressful, if not more so, as undergoing treatment itself.

This is counterintuitive. Patients, family, and friends understandably look forward to the completion of cancer treatment, especially when the prognosis is good. But when patients complete what may have been a grueling series of daily, weekly, or monthly medical visits, they also lose both the support system and structure provided by regular contact with an oncology team and other patients.

Furthermore, friends, co-workers, and even family members may not fully appreciate what cancer patients have gone through emotionally and physically, and so expect patients to return to "normal." But cancer survivors typically feel more vulnerable, anxious, and uncertain about the future after treatment ends.

How these challenges affect individual cancer survivors depends on a variety of factors, including age, overall psychological functioning, coping skills, social supports, and the type and severity of cancer.

Survivors of childhood cancer

About 270,000 Americans are survivors of cancer diagnosed during childhood. In 1993, the National Cancer Institute launched the Childhood Cancer Survivor Study, a long-term, retrospective study of 14,000 survivors and 3,700 siblings, to better understand the physical and psychological challenges encountered by these survivors.

Confirming earlier research, the study reported that most childhood cancer survivors who reached adulthood were psychologically healthy and just as emotionally well adjusted as siblings. But a separate report painted a less rosy picture of childhood cancer survivors still in adolescence, who were 1.5 times more likely than siblings to have symptoms of depression or anxiety, and 1.7 times more likely to act out at school and display other types of antisocial behavior.

Problems with cognitive abilities are also common in both adolescent and adult survivors of leukemia, lymphoma, or brain tumors—which account for about 60 percent of childhood cancers. Children with these cancers typically receive radiation or chemotherapy treatments that penetrate the brain, causing long-term problems with physical growth and with learning, short-term memory, and attention.

So far, interventions using drugs or psychotherapies to improve cognitive function in survivors of childhood cancer have produced limited success. For example, a randomized controlled trial involving 161 pediatric cancer survivors concluded that a cognitive remediation program that combined cognitive behavioral strategies with special education and brain injury rehabilitation techniques only modestly improved attention and academic achievement. The research continues, but for now the advice is to work with schools to develop accommodations and special education interventions to help the child learn as much as possible.

CONTINUED: Ongoing psychosocial issues

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