Cancer survivors are known to be at risk of developing post-traumatic stress disorder (PTSD) related to their illness. Although the prevalence varies across studies and cancer types, PTSD appears to be more common in cancer survivors than in the general population.1
“Trauma can be experienced at multiple points during the cancer journey, from receiving the initial diagnosis, undergoing burdensome treatment that can have distressing side effects, and, for some, having the continued worry about cancer recurrence,” explained Bo Fu, MD, a clinical assistant professor of psychiatry and behavioral sciences atthe Keck School of Medicine of the University of Southern California in Los Angeles.
“It is understandable that these frightening experiences can then lead some patients to develop PTSD symptoms,” Dr Fu said.
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PTSD is characterized fear of re-experiencing a traumatic event, and PTSD symptoms include intrusive thoughts and nightmares or flashbacks of the event.1
Impact of PTSD on Cancer Outcomes
“It is critical for hem/onc providers to have an awareness of how tremendously impacted patients may be due to the trauma of having a cancer diagnosis,” said Sheila Lahijani, MD, clinical associate professor of psychiatry and behavioral sciences at Stanford University School of Medicine in California.
“If left untreated, cancer-related PTSD can contribute to treatment nonadherence, pain, disability, and desire to die,” Dr Fu noted.
In a 2020 study of veterans with oral-digestive cancers, for example, the odds of chronic pain were 4.24 times higher in patients with combat- or cancer-related PTSD symptoms, when compared with patients who did not have PTSD symptoms.2 The odds of chronic pain were 8.49 times higher in those with PTSD symptoms related to both combat and cancer.
These findings underscore the need to recognize and address these symptoms as early as possible and at regular intervals throughout the course of cancer, Dr Fu said.
Risk Factors and Assessment
According to Dr Fu, factors associated with an elevated risk of cancer-related trauma symptoms include a history of previous PTSD or other psychiatric conditions, advanced disease, more invasive treatment, low socioeconomic status, and limited social support.
“Female patients, those of younger ages, and patients with lung cancer or head and neck cancer are also at high risk of PTSD,” said Yu Dong, MD, PhD, an assistant professor of psychiatry at the University of Maryland School of Medicine in Baltimore.
Dr Dong said that acute PTSD, which may be characterized by intense anxiety and avoidant behaviors, is relatively easy to identify and more likely to prompt supportive care during active treatment.
However, both “chronic PTSD and PTSD with delayed onset can be easily missed, especially when cancer is in remission and follow-up with the cancer center has dropped significantly to every 6 months or longer,” Dr Dong said.
Due to the heterogeneity of cancer diagnoses and treatments, assessments for PTSD vary across clinical and research settings,3 and instruments like the Primary Care PTSD Screen (PC-PTSD)4 and the PTSD Checklist (PCL)5 have not been validated specifically in the cancer population.
“Perhaps more important is having regular dialogues with patients to check in on how they are emotionally coping with their cancer diagnosis and treatment and whether they are experiencing intrusive thoughts or nightmares, feeling on edge, or maladaptive avoidance behavior,” Dr Fu said. “If there are concerns, there should be a low threshold to consider referral to mental health therapists or psychiatrists.”
Treatment and Support
Effective evidence-based therapies for PTSD, such as cognitive behavioral therapy, may be used and combined with pharmacological treatment as needed, Dr Lahijani said. In addition, clinicians should explore the potential presence of associated disorders such as depression and the risk for suicidal ideation.
“Referring to mental health specialists can be done at any time, but that should not delay an assessment or the offering of resources that can help in the meantime, including collaborations with social workers,” Dr Lahijani said.
In the long term, clinicians can deepen their understanding of cancer-related trauma symptoms by collaborating with oncology social workers, she added. On a broader level, adopting non-traditional approaches such as the collaborative care model can improve mental health care access and assure systematic strategies to evaluate and treat PTSD.
References
- Leano A, Korman MB, Goldberg L, Ellis J. Are we missing PTSD in our patients with cancer? Part I. Can Oncol Nurs J. 2019; 29(2): 141–146.
- Sager ZS, Wachen JS, Naik AD, Moye J. Post-traumatic stress disorder symptoms from multiple stressors predict chronic pain in cancer survivors. J Palliat Med. 2020;23(9):1191-1197. doi:10.1089/jpm.2019.0458
- Cordova MJ, Riba MB, Spiegel D. Post-traumatic stress disorder and cancer. Lancet Psychiatry. 2017;4(4):330-338. doi:10.1016/S2215-0366(17)30014-7
- US Department of Veterans Affairs. Primary Care PTSD Screen for DSM-5 (PC-PTSD-5). Accessed October 25, 2021. https://www.ptsd.va.gov/professional/assessment/screens/pc-ptsd.asp
- US Department of Veterans Affairs. PTSD Checklist for DSM-5 (PCL-5). Accessed October 25, 2021. https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp
