Anxiety in cancer patients may be a normal response or a pathology. Anxiety symptoms may occur occasionally or persist, and may manifest primarily psychologically or somatically. Patients may have very specific fears, such as fear of needles, or other fears that are not specific, but rather generalized concerns. Anxiety may appear earlier than a cancer diagnosis, or as a consequence of a cancer diagnosis, disease experience, or fear of treatment. These differences do not significantly define categories of anxiety, but rather indicate a continuum from normal reactions to pathology.
Physicians and other health care professionals often attribute anxiety to the patient’s fear of dying or moving toward death. However, it should be recognized that anxiety may reflect a number of other worries. These concerns exist in patients who have difficulty tolerating contemporary “invasive” oncology treatments and include fear of cancer recurrence or disease metastasis; fear of pain, loss of control, and side effects associated with cancer treatment, dependence on others, and abandonment by family, friends, and even doctors; fear of physical damage and no longer having an intact body; and fear of intimacy and strangers. words and actions and strangers.
Anxiety is common among cancer patients. The reported rate of anxious patients varies depending on the heterogeneity of patients being evaluated. Using the Hospital Anxiety and Depression Scale (HADS), the incidence is 18% to 31% with anxiety scale scores of 8 or higher. A more conservative estimate of the incidence is 9% to 19% with anxiety scale scores of 11 or higher. Although in the general population, younger women are usually more likely to be anxious, in cancer patients, age, gender, marital status, social class, and education are usually not associated with anxiety.
Patients with acute anxiety may present with a variety of somatic symptoms. Such as palpitations, tachycardia, increased systolic blood pressure and chest pain. There may also be shortness of breath and a feeling as if one is suffocating. Anxiety can also affect the autonomic nervous system, with symptoms such as sweating, chills, hot flashes, dizziness and lightheadedness. A variety of neurological symptoms may also occur, including tremors, abdominal pain, heartburn, diarrhea, overeating, and gas gulping. The various fear manifestations described above may also be present during an acute anxiety attack. In addition, patients may experience wandering away from themselves or their surroundings.
Chronic anxiety is characterized by a number of long-term symptoms, such as excessive or unreliable worry, irritability, muscle tension, sleep difficulties, irritability, fatigue, difficulty concentrating, and difficulty making decisions.
Primary anxiety disorders may appear earlier than cancer and include: compliance response to anxiety, generalized anxiety disorder, panic disorder, and post-traumatic stress syndrome, phobias, and obsessive-compulsive disorder. This may be exacerbated by cancer, especially when the course of cancer or cancer treatment coincides with some of the patient’s specific fears. The different anxieties need to be identified from each other and include the following.
1. Anxiety secondary to cancer diagnosis
Normal anxiety reactions are extremely common in cancer patients at all points in the disease course, from pre-cancerous screening to the end stage of cancer. Anxiety can be anticipatory or reactive.
Any anxiety disorder may develop after a cancer diagnosis, and phobias about needles, biopsies, chemotherapy-related side effects, and blood transfusions are common. Post-traumatic stress syndrome can occur after a highly traumatic event such as experiencing or witnessing the death of another cancer patient on the same ward. Panic and/or generalized anxiety often occurs when anxiety symptoms become overpowering and exceed the patient’s ability to cope.
2. Anxiety due to mental disorders
Anxiety symptoms are usually seen in patients with other psychiatric disorders. Some patients with depression may also have significant anxiety symptoms, such as insomnia. When depression-specific symptoms occur, such as excessive guilt or suicidal ideation, depression should be considered as the primary diagnosis. Substance abuse may also contribute to anxiety, which may manifest as nicotine, alcohol, benzodiazepine, or barbiturate withdrawal symptoms, or signs of addiction to stimulants (e.g., cocaine or amphetamines). The possibility of withdrawal should be considered in the case of anxiety that develops shortly after hospitalization.
Most patients with delirium will also exhibit significant signs and symptoms of anxiety. In the early stages of delirium, there is a risk of misdiagnosis as anxiety. However, delirium can be distinguished from other causes of anxiety by a brief mental status examination. Patients with delirium usually have disorders of orientation, attention, and memory, perceptual disturbances (e.g., hallucinations), and altered levels of consciousness.
3. Medical causes of anxiety
Anxiety symptoms may have an underlying medical etiology. In cancer patients, uncontrolled or poorly controlled pain is probably the most common “medical” cause of anxiety. Respiratory distress with or without hypoxia is also a common cause. Anxiety symptoms may be the result of acute sympathetic autonomic discharge from medical conditions such as pulmonary embolism, cardiac arrhythmias, angina pectoris, or gastroesophageal reflux, or from metabolic disorders. Other medical causes include infections, central nervous system metastases, and hormone-secreting tumors.
4.Anxiety caused by side effects of drug therapy
Anxiety symptoms may also be the result of drug side effects. The most common drug-induced anxiety-like reaction in cancer patients is inability to sit still, characterized by acute objective and subjective manifestations of restlessness or inability to sit still. Sedentary inability usually progresses from a few hours to several days after drug administration. Sedation inability is a side effect of most antipsychotic medications such as haloperidol and chlorpromazine, as well as antiemetics such as gastroflucan, haloperidol, promethazine, and chlorpromazine. Notably, sedation cannot occur with newer antiemetics, such as ondansetron and granisetron. Sedation inability is particularly common in patients receiving high-dose intravenous antiemetic therapy. Sedation inability usually resolves rapidly after treatment with a starting dose of diphenhydramine 25-50 mg (orally or intravenously), benzodiazepines (e.g., lorazepam 2 mg orally twice or three times daily), or beta-blockers (e.g., propranolol 10 mg orally three times daily as a starting dose). Anxiety, irritability and/or shakiness may be a side effect of sympathomimetic, i.e., beta-adrenoceptor agonist over-the-counter medications, theophylline, caffeine and other methylxanthine derivatives, and antidepressants.
The symptoms produced by excessive caffeine intake are indistinguishable from generalized anxiety disorder and can also exacerbate anxiety disorders. Physical or mental fatigue resulting from cancer or its treatment may be self-regulated by patients through increased intake of coffee or other methylxanthine-containing products. Patients with anxiety should be asked to chemicalize their consumption of coffee, tea, caffeinated sodas, and over-the-counter medications containing caffeine and other stimulants. It should be realized that many herbal products, just some of the teas and other infusions marketed as modulators, contain large amounts of caffeine or related methylxanthine derivatives or sympathomimetic drugs. Some of these agents are potent, and even very small amounts can cause anxiety in some patients.
Treatment of anxiety includes supportive therapy, medication and psychological intervention therapy.
5.Supportive treatment
Supportive therapy should be used at the beginning of anxiety treatment. Because cancer patients often have predictable or reactive anxiety symptoms, patients should be allowed to express their feelings. The physician or health facility should provide realistic reassurance, correct any misunderstandings, and deal with any unrealistic expectations about the future. Patients should be prepared for specific as well as potentially anxiety-inducible diagnoses and treatments.
Each intervention should be carefully evaluated to avoid being too much or not enough. For example, without reassurance and assurance, many patients will think of the worst possible outcome and abandon treatment. Conversely, unrealistic reassurance can undermine physician trust and can lead to a loss of patient confidence in treatment.
Any factors that may exacerbate anxiety, such as sleep deprivation, inadequate pain management, excessive caffeine intake, and nicotine withdrawal, should be eliminated.
Simple relaxation techniques such as deep breathing, progressive muscle relaxation, and/or intentional therapy are useful for the management of mild anxiety and may be helpful when used in combination with other psychological or pharmacological interventions. More sophisticated relaxation techniques include hypnosis, biofeedback, contemplation, and yoga. Patients with severe anxiety are often too tense to fully engage in relaxation therapies; however, this group of patients may benefit from relaxation therapy when symptoms are relieved with medication.
6. Medication
Medications used for anxiety treatment include benzodiazepines, non-benzodiazepine anxiolytics, antidepressants, anti-neuroleptics and antihistamines.
(1) Benzodiazepines
Benzodiazepines are the first-line treatment for patients with mild to moderate anxiety. This class of drugs takes effect in a few hours to a few days, thus making them suitable for the basic treatment of acute anxiety. In this case, short-acting drugs such as clorazepam, alprazolam, and norethindrone are preferable for minimizing sedation. However, when continuous dosing is required, mid-college benzodiazepines such as clonazepam are more appropriate for reducing the rebound of anxiety symptoms between doses.
Most benzodiazepines are metabolized in the liver by oxidation. Therefore, these drugs rarely accumulate in patients with reduced oxidative metabolism. This includes elderly patients as well as those with liver dysfunction and various medical conditions. Typically, short-acting benzodiazepines are metabolized to pharmacologically inactive metabolites, whereas intermediate-acting and long-acting benzodiazepines are metabolized to pharmacologically active metabolites.
The continued use of long-acting benzodiazepines in elderly patients should be avoided because this group is more sensitive to the sedation, confusion, and loss produced by the accumulation of the parent drug and its active metabolites. In palliative care, rectal or sublingual administration of benzodiazepines often helps to control anxiety, irritability, and agitation associated with the last stages of life.
The most common adverse effects associated with benzodiazepines are sedation, nonspecific CNS depression-related symptoms such as fatigue, poor concentration, and incoordination. Psychological adverse effects such as significant confusion can be observed in some patients, especially those with advanced disease and elderly patients with prior brain disease. The incidence of fantasy and depression also increases with the use of benzodiazepines. Paradoxical state arousal phenomena such as torpor and insomnia may also occur during regular drug use.
Withdrawal symptoms are usually caused by discontinuation of regular benzodiazepine use. Drug withdrawal may be associated with new, severe and potentially crisis symptoms such as psychosis, seizure-like epilepsy and coma. Withdrawal symptoms after regular drug use can be reduced by slowly decreasing the drug dose at a rate of 25% or less per week.
(2) Antidepressants
Many antidepressants also have anxiolytic activity, and some can also be used to treat insomnia and chronic pain. Several classes of antidepressants are available, including 5-hydroxytryptamine reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and others.
The biggest disadvantage of antidepressants used to treat anxiety is the slow onset of drug action, requiring 1 to 4 weeks to reduce symptoms. The anxiolytic activity of all antidepressants is comparable. Most were administered once daily and tolerance and dependence did not occur. Among antidepressants SSRIs are usually preferred because they are usually the most well tolerated. The use of TCAs is usually limited due to significant adverse effects.
Trazodone is usually useful for cancer patients because it improves sleep and appetite. The drug can cause sedation and static balance. It should be noted that although promethazine can be administered by intramuscular injection, it is rarely used because of the severe pain that can result from administration by this route.
(3) Antipsychotics
Antipsychotics can be used for anxiety in the context of psychosis (e.g., delusions or fantasies), anxiety accompanying delirium, or very severe acute anxiety. They are usually used when benzodiazepines do not control the symptoms of anxiety well.
In patients with respiratory distress or impairment, antipsychotics are perhaps the safest class of anxiolytic drugs. They are usually administered by starting a low-level dose and can be given by titration if needed.
Haloperidol is the most widely used antipsychotic. It is administered at a starting dose of 0.5 mg, slowly administered intravenously every 30 to 45 minutes until symptoms are controlled. Therefore, if possible, oral administration is preferred.
Despite being administered at low doses, older antipsychotics (especially haloperidol) can bring about some extravertebral fascicular symptoms (EPS) and, in rare cases, neuroblocker malignant syndrome.
Delayed-onset movement disorders are rarely considered due to their usual short-term use in this population. Newer drugs such as olanzapine, lipitorone, quetiapine, and ziprasidone have a lower risk of producing dyskinesia compared to older antipsychotics. In addition, the newer antipsychotics rarely cause nerve blocker malignant syndrome. The newer drugs are not intended for extragastric use, but may be used in patients with contraindications to team benzodiazepines or when extravertebral fascicular symptoms limit the use of traditional antineuroleptics.
(4) Antihistamines
Antihistamines such as hydroxyzine and diphenhydramine have mild anxiolytic, sedative, and analgesic activity. These drugs are most effective when used as adjunctive analgesics in combination with opioid analgesics. 100 mg of hydroxyzine administered parenterally can enhance the analgesic activity of morphine.
It is important to note that antihistamines have only mild anxiolytic activity, and in fact they can exacerbate or even promote confusion or confusion in debilitated patients. These drugs are not recommended for the treatment of anxiety.
7. Psychological intervention therapy
Studies have shown that individual and group psychotherapy can reduce anxiety in cancer patients. It is worth mentioning that the effectiveness of psychological intervention therapy is also evident in patients with metastatic disease. This therapy helps patients take control of their fear of death, enhances their emotional control, and improves their coping skills, including phobias, post-traumatic stress disorder, and panic attacks.
8. Other interventions
Religious interventions can reduce patients’ emotional trauma. Although doctors cannot prescribe religion as a prescription, many patients are isolated from seeking support from their faith, chaplains, and Congregational churches. Dedicated teachers in hospitals are another avenue to seek help. Social support can also be sought through educational support organizations as well as national and local cancer organizations.
9. Treatment Summary
General support measures such as giving patients the opportunity to discuss their feelings and various relaxation exercises can be effective in managing mild anxiety. Short-acting benzodiazepines can be prescribed by the doctor if needed.
If the anxiety interferes with the patient’s daily activities, then other pharmacological interventions are needed. If the patient’s mobility is moderately impaired, then short-acting benzodiazepines should be considered for up to 2 weeks. However, if the intensity of anxiety remains severe, antipsychotic medications should be considered. Once symptoms are effectively controlled and the patient is active, then benzodiazepines may be used as appropriate.
If somatic symptoms, particularly palpitations and tremors, are predominant, then a beta blocker such as a beta-transport blocker should be considered. The risk of hypotension in patients treated with benzodiazepines should also be considered.
If phobias and panic are still present, then antidepressant therapy such as a suspension 5-hydroxytryptamine inhibitor or tricyclic antidepressant should be used. Identification of triggers for this phenomenon is useful as well as consideration of coping strategies for dealing with panic and behavioral interventions for phobias.
Once anxiety has been adequately controlled, it is necessary to return to the top of the flow chart and emphasize supportive strategies and relaxation training. However, if standard pharmacological measures are not effective in controlling anxiety, then the patient should seek specialist treatment.
Anxiety is common in patients with cancer. Symptoms may be episodic or persistent, primarily psychological or somatic in nature, and focused or undefined. Anxiety may appear earlier than the cancer or occur after the diagnosis. It may represent a new-onset primary anxiety disorder or a reaction to cancer. Anxiety may be associated with a variety of psychiatric disorders, such as depression, substance abuse, or delirium, and it is possible that anxiety is caused by other disorders or is an adverse reaction to medication.
Initially supportive strategies and relaxation training should be used to manage anxiety. If medication is required, benzodiazepines should be used as first-line treatment, preferably as appropriate. Antihistamines should be avoided.
Depending on the clinical presentation, other medical interventions may be useful in managing anxiety in patients with cancer. The non-benzodiazepine buspirone is useful for chronic anxiety or for those who cannot tolerate benzodiazepines. Antidepressant therapy is also effective for patients with depressive manifestations and panic and phobic disorders. Antipsychotic medications are useful for anxious patients who are confused or delirious and for those whose severe anxiety interferes with daily life.
In conclusion, effective management of anxiety assessment is an important part of the overall treatment of cancer patients.