“How are my scans coming along, doctor?” enquired the 42-year-old mother during her breast cancer follow-up visit. Three years ago, she was diagnosed with late-stage breast cancer. This was her tenth follow-up visit, yet she looked just as worried as the first one. Her understanding of breast cancer grew dramatically over time, but there was one concern that always bothered her - "Will my cancer ever return?"
The estimated number of cancer patients in India in 2020 was 27 lakh, with nearly 14 lakh newly diagnosed cancer patients. Medicine has advanced significantly, especially in the treatment of cancer. Cancer outcomes have significantly improved as a result of advanced diagnostic tools and therapy alternatives. Because of increased survival rates, modern therapeutics have reduced cancer from a death sentence to a lifelong debilitating condition.
Managing cancer entails multiple visits to the doctor to monitor the disease's course. But in the customary quick follow-up consultations, the emphasis is more on the patient's physical symptoms. As a result, unless the patient looks anxious or visibly depressed, the subject of a person's mental health requirements is rarely broached. The process of battling cancer is undeniably stressful and approximately one-fourth of cancer survivors experience long-term issues such as anxiety, depression, and other psychological and social distress (Fig 1). Cancer survivors generally report a poor quality of life which can be attributed to psychological and physical factors.
Fig 1:
People with cancer and other chronic illnesses are roughly seven times more likely to experience mental health illnesses like depression, and anxiety, than individuals without cancer. Those who have both cancer and other chronic illnesses are at an even higher risk. In the year 2019, 1174 cancer patients committed suicide, accounting for 0.8% of all suicides that year. Mental illness is at an all-time high in India (the economic loss is estimated to be over USD 1.03 trillion between 2012-30). As cancer detection rates are increasing alongside, existing mental diseases in individuals may get exacerbated by cancer.
Monitoring cancer survivors' mental well-being is critical in the initial three years post therapy. Cancer diagnosis and treatment can cause significant physical, emotional, social, vocational, and financial stress. The dread of their cancer relapsing, the return to their life roles and the perceived loss of functional and emotional support from family and friends are all significant challenges during the early post-treatment period.
Generalized anxiety caused by cancer exacerbates feelings of grief, disrupts sleep patterns, provokes nausea and vomiting, and has a negative impact on patients' standard of living. Anxiety symptoms mainly occur during the preliminary stages of the disease and are triggered by healthcare decisions, and concerns about relapse. Doctors play a significant role in a patient’s anxiety. It was observed that patients who had doctors who spent more time discussing the diagnosis and outcome with them had lesser anxiety.
Cancer and depression are closely associated. In an Indian study, depression was shown to be present in nearly 1 out of every 6 cancer patients. Common signs of depression reported in cancer patients are having difficulty performing basic daily chores, feeling as if life isn't worth living, continuous unhappiness, and loss of interest in activities that a person previously enjoyed. Depression is associated with a higher risk of death in cancer patients, passive suicidal thoughts, poorer pain control, reduced adherence to treatment, and refusal of long-term therapy. This makes screening for depression in cancer patients an important part of the treatment in order to give holistic care.
Being a fatal disease, cancer can result in the development of Post Traumatic Stress Disorder (PTSD). PTSD is a mental health illness that gets triggered by past experiences and memories and is associated with intense emotional and physical reactions. Having flashbacks, nightmares, and uncontrollable thoughts are common symptoms of PTSD seen among cancer patients undergoing therapy. Past experience with stressful life events, a history of psychological disorders, poor social support, and a significant level of emotional turmoil prior to cancer diagnosis are all risk factors for developing PTSD during or after cancer treatment.
One of the most essential but little-discussed issues is how cancer impacts sexual health which further impacts mental health. An increase in cancer rates among adolescents adds to the problem as they are most vulnerable to these issues. Males typically have reduced sex drive, erectile problems, and low sexual satisfaction. All types of cancer treatment have the potential to negatively impair the physical components of female sexual function, such as arousal, orgasm, and desire. Chemotherapy has been linked to female infertility, and therefore informing young patients regarding this possible side effect and offering fertility-preserving solutions is important. Furthermore, sexual dysfunction can negatively impact body image, particularly after mastectomies, resulting in low self-esteem, psychological discomfort, and a lower quality of life. Regardless of the fact that sexual dysfunction associated with cancer therapy is prevalent with more than half of them experiencing the above, the majority of cancer patients are not always provided with the support, medication, or information they require for these disorders.
We often overlook that cancer carries a second struggle that must also be fought by the caretakers. A cancer diagnosis can cause stress and anxiety for the companion, and even after treatment is over, partners may experience more suffering and concern about a recurrence than the patient. In addition to managing their own stress, spouses or close family members frequently serve as the patient's principal support system with little regard for or acknowledgment of their own needs. As a result, they may endure a lower quality of life and significant unmet needs.
As India battles rising cancer numbers along with the hidden epidemic of mental health diseases, many non-government organizations have taken the responsibility to address these issues. One such organization, CanSupport, offers psychological support not just to cancer patients but also to their caretakers. The digitalization of health has made mental healthcare more accessible than ever before. However, more work remains to be done. Similar to cancer, mental health illnesses can be treated too. All we need to do is carefully listen to cues that could point toward a mental health disease. It is time, with the help of family and professional support, to address concerns other than physical health in order to improve the lives of cancer patients.
About the Author:
Dr. Gaurav Urs is a Registered Medical Practitioner who recently graduated from Adichunchanagiri Institute of Medical Sciences, Karnataka, and a researcher at the nonprofit think tank - Association for Socially Applicable Research (ASAR), Pune, Maharashtra, India. In addition to his interests in cancer care and research, he is an avid swimmer and Formula 1 aficionado.