Anxiety

Anxiety during cancer care may be trigerred by the diagnosis itself or the
medical symptoms that led to diagnosis. Symptoms associated with anxiety
include pain, shortness of breath, diarrhea, and unanticipated physical symptoms,
with the highest correlation (unsurprisingly) to pain. This anxiety frequently
responds well to education and access to providers for normalization and
reassurance. However, responses to unpredictable but recurring physical
symptoms may require additional treatment with anxiolytics.
Persistent low-level anxiety and moderate to high levels of anxiety are
more common in patients with history of anxiety disorders or PTSD. If a patient
has a premorbid anxiety disorder of any type, the patient is predisposed to
developing worsenend anxiety in response to the new stressors. In a patient with a
premorbid history of anxiety, anxiety during cancer care is likely to take an
intensified form of the prior expression of anxiety. Thus, a patient with
generalized anxiety may experience familiar but worsened symptoms. While
low-level anxiety and adjusment disorder respond well to CBT, moderate to high
anxiety or more persistent anxiety symptoms may require SSRIs or SNRIs.
Altough most features of anxiety are similar in patients with cancer and
general population, patients may have increased somatic symptoms, including
nausea, pain, and neurological complaints such as headache and dizziness. These
can be difficult to tease apart from organic pain, and nausea, and neurogical
concerns arising from cancer and cancer treatment. Frequently, pain and nausea
symptoms go hand in hand with anxiety, and both show improvement with the
down regulation provided by benzodiazepines. In particular, chronic management
that includes the long-acting clonazepam can reduce symptoms and decrease
opiate dosing.
Patient experiencing spesific phobias and panic responses to cancer carerelated stimuli, including needles, recuring scans, and even approach to the clinic
or hospital itself, can also benefit from pre-medication with short-acting
benzodiazepines. For example, a patient who feels panic and nausea prior to
chemotherapy can be pre-medicated with lorazepam for symptom relief and re-

establishment of a sense of control. This enables her to comply with her

chemotheraupetic regimen until such time that behavioural strategies can be
implemented.
Post-Traumatic Stress Disorder
A patient with a prior history of PTSD may be trigerred by the proximal
awareness of his or her mortality that a cancer diagnosis or major medical episode
brings. Indeed, as we are coming to understand a patient with no history of PTSD
may report the full set of symptoms associated with that disorder as a result of the
acuteness of thoughts about death and the disruptive experience of treatment,
diagnosis, or an intense episode of medical illness and hospitalization,
remembered delirium episodes, and surgical procedures.
PTSD (both initial experience and reccurence) is responsive to education,
supportive theraphy, and psychopharmacological interventions. Therapy should
focus on appreciating te life-changing quality of diagnosis and treatment and
integrating the experience and information into the patients life.
One difference between PTSD in the cancer setting and PTSD resulting
from other causes is the chronic rather than acute nature of the stressor. Another is
the future-rather than pastorientation of intrusive thoughts. Thus, while a veteran
with PTSD may experience the intrusive thought of a moment of heightened risk
of death, a cancer patients intrusive thought may be characterized more by
thoughts of future suffering or death. Continuing with this example, a veteran with
a history of PTSD and subsequent threat to life via cancer may
experiencepowerful symptoms of PTSD, including intrusive thought of past and
future. (This circumtance is not uncommon in practice and will be expected to be
observed more as the veteran population ages and as a veterans of recent wars
present or cancer care.) Te same could be said for patients with other prior causes
of PTSD. Teymay need more aggressive management, and antidepressants and/or
benzodiazepines should be considered. Antipsychotics would only be appropriate
if psychotic symptoms are present or if dual purpose prescribingis warranted, as
described later in this chapter.

Cognitive Changes
Cognitive changes primarily exhibit as changesin levels of attention and
concentration, as well as sort-term memory dysfunction. This is patient-reported
as well as measurable by neuro-psychological testing (Ahles et al., 2012).
Unfortunately, the degree of loss is freuently subtel, and may not be observable by
bedside neuropsychological testing, instead requiringte use of long-term
instruments. These changes are commonly and casually describe by patient using
terms such as chemo-brain, and while there is some evidence that a subset of
patients who have been treated by chemotherapy are vulnerable to cognitive
effects that persist after treatment concludes, it is less clear how and under what
circumtances chemotherapeutic agents cause cognitive changes. The most
convincing studies have shown both anatomic and physiologic changes to the
brain after exposure to chemotherapy (McDonald Conroy, 2010; Deprez et al.,
2012). For patients experiencing this cognitive dysfunction, function can be
improved by psycho-stimulants (typically starting with metylphenidate 5mg at
morning and midday) and cognitive exercise (multilevel puzzles such as sudoku
or crosswords, as well as more structured brain-training programs).
Spesific cognitive changes can be anticipated with the direct effect of both
primary and secondary brain tumors, and intervention (surgical and radiological)
for brain tumors. These tumors can also lead to personality changes and increased
impulsivity, both of which may respond to antipsychotics. These symptoms are
particularly prominent when damage is in the frontal lobe or the parieto-frontal
region. In addition, neuro-endocrine tumors can effect personality changes and
cognitive changes.