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Imperial Journal of Interdisciplinary Research (IJIR)
Peer Reviewed – International Journal
Vol-5, Issue-2, 2019 (IJIR)
ISSN: 2454-1362, http://www.onlinejournal.in
Imperial Journal of Interdisciplinary Research (IJIR) Page 109
Psychological Issues related to patients with
Cancer: The role of Psychological, Cultural,
Social and Medical factors
Agathi Argyriadi1 & Alexandros Argyriadis2
1Collaborating Academic Staff, Cyprus University of Technology
2Assistant Professor, Frederick University
Abstract: The number of individuals living with a
history of cancer is estimated at 13.7 million in the
United States and is expected to rise with the aging
population (Stanton, Rowland & Ganz, 2015). The
purpose of this study is the analysis of the
psychological ramifications of cancer, a chronic and
painful disease, with severe effects on patients who
often feel a loss of control and strength (Stang &
Mittelmark, 2010). It includes a review of the
literature, databases and conventional libraries to
obtain scientific data. The results of the study
highlight the importance of the role of healthcare
professionals, with an emphasis on psychologists, to
effectively address and support difficult situations.
Patients are vulnerable and the state of their mental
health is a complex phenomenon requiring multiple
approaches to deal with it.
Key Words: Health Psychology, Health
Professionals, Support, Stress, Family.
Introduction
With regard to the psychological support of
patients with cancer, the interdisciplinary team is
instrumenting. Mental empowerment is accomplished
by the interdisciplinary collaboration of many
specialists, such as a psychologist, social worker and
mental health nurse. This group of experts informs
the patient about the disease and its treatment,
controlling adverse effects through hypnosis,
relaxation exercises and defense mechanisms, among
other stress reduction techniques to strengthen
incentives. The goal is for the patient to take an
active role in his / her healing by developing the
appropriate skills, trust and knowledge to respond to
the new circumstances. Through active listening and
the application of therapeutic communication, an
attempt is made to cultivate a climate of trust, mutual
understanding and respect between the health
professionals and the sufferer (Groen, Kuijpers,
Oldenburg, Wouter, Aaronson & Van Harten, 2015;
McCorkle, Ercolano, Lazenby, Schulman-Green,
Schilling, Lorig, 2011).
It is important that the health psychologist
provides counseling and psychotherapy so that
cancer patients express their feelings in a safe
context, overcoming anxiety, fears and depression
due to the disease. In particular, the goal of psycho-
educational programs is to reduce the discomfort of
severe negative emotions, while managing anxiety
and depressive symptoms, regaining a sense of life
and a positive attitude towards treatment. Patients
learn to manage feelings of loss, their fear of
complications and imminent metastasis. Moreover,
the therapeutic agenda includes the restriction of
social isolation, encourages participation in
psychosocial support groups for cancer patients and
ultimately improves quality of life (McCorkle,
Ercolano, Lazenby, Schulman-Green, Schilling,
Lorig, 2011). Related research has shown that
psychotherapy helps patients take on their daily
activities faster (European network on patient
empowerment, 2012; Johnson, 2011; Karadimas,
2005; McLallister, Dunn, Payne, Davies, Todd,
2012).
The psychological adjustment of patients with
cancer is as important as the type of cancer, disease
progression, side effects and frequency of
chemotherapy, the change in the patient's external
appearance and the presence of pain. Low- or
moderate-risk patients seem to manage the
psychological effects of cancer more easily.
Psychotherapy is greatly needed in high-risk
patients. Psychological interventions aim to improve
the patient quality of life, encouraging satisfaction
through personal evaluation. They also provide
psychological support to family members, preparing
the patient and relatives for the hospital stay and
relationships with health professionals. Interventions
help strengthen relations between family members,
facilitating decisions on treatment and preparing
them for the possibility of death (Groen, Kuijpers,
Oldenburg, Wouter, Aaronson & Van Harten, 2015;
Our K line, 2005; Wong-Rieger, 2012).
Imperial Journal of Interdisciplinary Research (IJIR)
Peer Reviewed – International Journal
Vol-5, Issue-2, 2019 (IJIR)
ISSN: 2454-1362, http://www.onlinejournal.in
Imperial Journal of Interdisciplinary Research (IJIR) Page 110
1. A common non-pathological psychological
reaction to the diagnosis of cancer
The diagnosis of cancer for most results in a
predictable sadness or depression lasting several
weeks. The diagnosis may engender the fear of pain
and death. In cases of potential deformation or
disability, the patient may experience a loss of
independence and self-esteem, as well as important
relationships due to the altered appearance or
disability. In addition, patients may experience pain,
uncertainty, frustration, anger, anxiety, depression,
fear of abandonment, fear of relapse, sexual
dysfunction, sleep disorders or cachexia. Alopecia
from chemotherapy is another powerful
psychological blow to the oncology patient, creating
a negative image of the self (low self-esteem)
(Singer, Kuhnt, Götze, Hauss, Hinz & Liebmann,
2009).
The typical physiological reaction is characterized
by three stages (Flannery, 2005).
1. Original denial
2. An acute phase of inconvenience
3. The adjustment phase
This similar to the reaction evoked when one
learns devastating news of any kind. In the
beginning a period of disbelief and denial occurs,
during which time the person contests the diagnosis
and wonders if there is a mistake. This is followed by
a period of one to two weeks of great disruption,
characterized by persistent disturbing thoughts of
death and illness, decreased concentration,
irritability, anxiety and depression, anorexia and
insomnia. Some show real weight loss that is
attributed to the progression of the cancer. The
patient may have clinical anxiety and an inability to
carry out day-to-day activities because of a concern
for the future.
The third phase of response includes acute
symptoms stemming from personal upheaval that
begin to subside as the reality of the disease becomes
more tolerable. Hope returns with the onset of a
healing plan and a clear course of action. The patient
returns to a previous ability to cope with the new
difficulties, characteristic of psychological resilience.
Any pre-existing psychiatric or personality
disorder will color the adjustment to a cancer
diagnosis based on certain factors (for example, the
presence of a generalized anxiety disorder or a
previous major depressive episode). A previous
disorder in a patient’s history creates caution about
the possibility of worsening the psychological
disorder within the framework of cancer treatment.
Kubler-Ross (1961) studied the mental reactions
of cancer patients and conducted interviews patients
who knew they were going to die. According to
Kubler-Ross, after a diagnosis of cancer, each person
goes through five stages:
The stage of denial and isolation: in this initial
phase, denial is a normal defense mechanism that
acts as a self-protective shield for the person
perceiving reality as threatening. Thus, he or she
denies the fact of the illness and its consequences.
There are several levels of denial. For example, in
the diagnostic phase, the individual denies his
symptoms and is late seeking medical help.
Sometimes he refuses to accept the diagnose. While
the patient recognizes the diagnosis, he refuses the
long-term effects that the disease and its treatment
may have in his life. On another level, denial
concerns the possibility of death. While the patient
realizes that he suffers from cancer, he denies that his
life is threatened and thinks he will reach old age. In
the early stages of the disease, denial is a normal
response. Sometimes denying the possibility of death
can have beneficial effects adjustment because it sets
long-term goals, schedules life and forms and
maintains interpersonal relationships. But when the
refusal is prolonged, it can have serious negative
consequences on the person's health, since he will
not likely follow medical advice.
The stage of anger: "Why? Why is this evil
happening to me?" This question is accompanied
anger and bitterness deriving from a sense of
injustice and weakness. It is a normal reaction, since
the person is obliged to suddenly accept a radically-
changing life. Anger is directed towards relatives,
friends and medical staff, and also against God.
When patients channel their anger inward, they
experience intense guilt on one hand because their
conduct and lifestyle have caused the illness. They
interpret their illness as a "punishment" for some
unethical action. They may also feel guilty about
lost opportunities in life. Although anger is a normal
emotion, it creates tensions in interpersonal
relationships, thereby alienating the patient when he
or she most needs support.
The stage of conciliation: negotiation or
bargaining creates the illusion that by avoiding
certain acts, the patient may delay or prevent the
disease or even death. Negotiation may have positive
and negative impacts. On the one hand, it can foster
behavior that promote health and patient compliance
in treatment. On the other hand, however, the
chances of experiencing feelings of betrayal,
disappointment and anger increase when the doctor
or God does not meet expectations and abandons the
Imperial Journal of Interdisciplinary Research (IJIR)
Peer Reviewed – International Journal
Vol-5, Issue-2, 2019 (IJIR)
ISSN: 2454-1362, http://www.onlinejournal.in
Imperial Journal of Interdisciplinary Research (IJIR) Page 111
patient, so he stops complying with instructions or
develops anxiety and depression.
The depression stage: depression ensues from all
the losses the patient feels upon hearing the diagnosis
of illness, such as the loss of work and resultant
financial burdens. According to Kubler-Ross,
depression is distinguished by a reactionary sadness
that the patient attributes to imminent losses, during
which time he prepares for death. In the stage of
depression, the patient should be encouraged to
express his feelings, as it facilitates acceptance.
The stage of acceptance: the patient understands
the impending end, gradually limits his interests to
the minimum, visits disturb him and he prefers to be
alone. Communicating with his or her environment is
usually done with suggestions and rarely with
speech.
It should be noted that the duration of each stage
is not the same for all patients. It is possible for a
patient to switch from one stage to the next or a
previous one several times during the same day or
stay for a long time in a particular stage (e.g. anger).
In the cancer patient, emotions can be strong
because he feels helpless and believes that the
diagnosis of cancer always results in death. To
address this feeling requires special attention on the
part of the treatment group. When the treating
physician only gives orders without explaining the
feasibility of the instructions, he does n’t help the
patient manage his feelings, perhaps he even
exacerbates them (Soldatos, 1981). Usually, the
cancer patient is easily treated for a variety of
reasons. The patient sees the treating physician as an
authority from whom he mainly expects help. Every
act and word from the doctor or nurse can have a
great positive or negative effect on his psyche
(Eaton, Meins, Mitchell, Voss & Doorenbos, 2015).
2. Mental disorders in cancer patients
The cancer patients often shows impaired adaptation
to a stressful depressed mood as well as a major
depressive disorder. Psychopathology increases
during progressive stages of the disease and
disability level (Singer, Kuhnt, Götze, Hauss, Hinz &
Liebmann, 2009). An anxiolytic or antidepressant
often significantly reduces symptoms and shortens
the phase of discomfort. It is important to bear in
mind that this pattern of sadness after diagnosis is
repeated in later transient stages of the disease with
more severe depressive symptoms. There may be a
relapse or further progression of the disease and
therapeutic failure with no further treatment possible
(Holland, 1996, 1997, Holland & Wiesel, 2016;
Kadan-Lottick, Vanderwerker, Block, Zhang & ,
2005; Miovic & Block, 2007) .
Depressive disorders
Sadness and sorrow about the loss of health and
well-being are normal responses in cancer patients.
Psychological reactions may progress, reaching the
level of hypochondrial symptoms, a depressed mood
disorder or a major depression. These are the most
common depressive disorders in oncology patients.
A diagnostic problem occurs because the symptoms
of depression are similar to many physical symptoms
seen in cancer patients, especially fatigue, decreased
psychomotor activity, insomnia, the absence of
libido, or anorexia and weight loss (Key & Breitbart,
2019; Massie & Holland, 1990). The specialist
should focus on the psychological symptoms of
depression in order to diagnose persistent depressive
and dysphoric feelings, a sense of worthlessness,
guilt, and fear of dealing with death.
Cancer patients are likely to report suicidal thoughts
from the very first stages of the disease. In fact, the
incidence of suicide in cancer patients far outweighs
that of the general population. However, many
patients with an advanced disease that commit
suicide may not be recorded. Suicide is a seen as a
way to regain absolute control. Regarding the
likelihood of end-stage suicide, research findings fall
into two categories: studies that conclude that the
prevalence of suicidal ideation in patients with end-
stage cancer is less than 10% (Latha & Lt; Bhat,
2005; Lee et al., 2013; Park, Chung, & Lee, 2016).
Such data contradict the clinical impression that
patients express thoughts of assisted suicide to
preserve the belief of a way out, giving them a sense
of control of the situation (Borg & Noble, 2010;
Breitbart, Rosenfeld, Pessin, Kaim, Funesti-
Esch, Galietta & Lt; Brescia, 2000).
According to Breitbart & Krivo (1998), patients in
recession with a good prognosis should be tested for
depression in the same way as physically healthy
people (Selmer, 2015): with a communication-
empathic approach to ensure the patient's
understanding of the disease and its symptoms, while
conducting an assessment of relative mental health
and variables in vulnerability and an evaluation of
the support system, taking a family history and
recording any previous suicide threats or attempts.
There should be an assessment of thoughts,
intentions and suicide plans with a need for close
monitoring and the creation of direct long-term
therapeutic treatment.
The risk factors for suicide in cancer patients are
diverse and revealed when taking a good history. The
Imperial Journal of Interdisciplinary Research (IJIR)
Peer Reviewed – International Journal
Vol-5, Issue-2, 2019 (IJIR)
ISSN: 2454-1362, http://www.onlinejournal.in
Imperial Journal of Interdisciplinary Research (IJIR) Page 112
most common reasons are uncontrolled pain,
delirium in which impulse control is reduced, and an
advanced disease with a poor prognosis. A review of
the patient’s medications is vital as some drugs cause
depressive symptoms. From a psychological point of
view, important prognostic indicators include a
history of previous depression or attempted suicide,
substance abuse, poor social support and current
depressive symptoms. In Scandinavia, a higher
suicide rate was found in patients who were told that
they had no further treatment options and who had
lost contact with their doctors, thus underlining the
need for continued support. Thus, physician
availability, continued support and symptom control
appear to be fundamentally necessary (Rosenfeld,
Breitbart, Galietta & Krivo, 1998).
When assessing depression and the risk of suicide,
where pain is not controlled, the first step is to
achieve it before reass es sing patient’s the mental
state. Pain management and psychiatric symptoms
are closely linked, especially for the advanced
cancer, where both are common. Factors associated
with an increased risk of suicide (Breitbart & Krivo
(1998): advanced disease and poor prognosis,
depression and despair, delirium, loss of control,
exhaustion and fatigue, pain, pre-existing
psychopathology and a previous history of suicide
(individual or family) (Mystakidou, K., Rosenfeld,
B., Parpa, E., Katsouda, E., Tsilika, E., Galanos, A.,
& Vlahos)
Some types of cancer are associated with depression
beyond expected reactive symptoms. Pancreatic
cancer has long been assumed to entail depression
(Brintzenhof-Szoc, Levin, Li, Kissane & Zabora,
2009; Musselman, Lawson, Gumnick, Manatunga,
Penna, Goodkin, Greiner, Nemeroff & Miller, 2001).
However, there is no clear evidence that depression
is often a symptom. Most patients are diagnosed
when the cancer has spread from and both pain and
other systemic symptoms have already developed
(Breitbart & Wein, 1998).
Surveys on breast cancer indicate that anxiety and
depression impair the smooth continuation of life and
even lead to a premature discontinuation of
treatment. The degree of anxiety appears to be a
determinant of a woman’s quality of life as well as
compliance with medical instructions. The anxiety
may be a permanent feature of the patient’s
personality or simply become exacerbated under
chemotherapy; but there is a case to be made for a
dependent anxiety reaction from repeated exposure
to the conditioned anxiety response (Jacobsen,
Bovbjerg & Redd, 1993).
3. Psychotherapeutic treatment of patients
with cancer
Prior to treatment, educational interventions are vital
(Zimmermann, Heinrichs, & Baucom, 2007). During
or after treatment, cognitive-behavioral approaches
to cancer-related problems are typically employed,
focusing on depression, stress, fatigue, pain, appetite
control and the side effects associated with
chemotherapy, radiation therapy, and other cancer
treatments (Antoni, Lehman, Kilbourne, Boyers,
Culver, Alferi & Carver, 2001; Curran, Beacham, &
Andrykowski, 2004; Montgomery, Kangas, David,
Hallquist, Green, Bovbjerg & Schnur, 2009; Phillips,
Antoni, Lechner, Llabre, Avisar & Carver, 2008;
Stagl, Antoni, Lechner, Bouchard, Blomberg, Gluck
& Charles, 2015). These interventions can
significantly improve quality of life. Mindfulness-
based stress reduction interventions hold promise as
well (Bränström, Kvillemo, Brandberg, &
Moskowitz, 2010). Painkillers remain the primary
method of treating cancer-related pain and behavioral
interventions that help include relaxation therapy,
hypnosis, cognitive reappraisal techniques, visual
imaging and self-hypnosis (Turk & Fernandez,
1990? Ward, Donovan, Gunnarsdottier, Serlin,
Shapiro & amp; Hughes, 2008).
Treatment of depression
The treatment of depression in cancer patients is
usually recommended in supportive cognitive
behavioral psychotherapy for mild cases. Support
groups are also helpful. Certain disorders of will
need medication (Akechi, Okuyama, Onishi, Morita
& Furukawa, 2018).
Treatment of anxiety
As mentioned, stress in many cancer patients
varies from the "normal" concerns and fears
associated with a life-threatening disease. This stress
can be a generalized anxiety disorder due to the
medical condition. The four main causes of anxiety
in cancer patients are:
1. The most common is the announcement of
the diagnosis, the emergence of a crisis in the disease
or its treatment, a conflict with staff or family, the
anticipation of a process or the fear of recurrence.
2. Stress associated with the disease is more
common in poorly-controlled pain.
3. Causes associated with treatment such
anxiety-inducing medications, in particular some
anti-emetic drugs, and depression and pathological
reactions associated with chemotherapy.
Imperial Journal of Interdisciplinary Research (IJIR)
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ISSN: 2454-1362, http://www.onlinejournal.in
Imperial Journal of Interdisciplinary Research (IJIR) Page 113
4. Anxiety that is a worsening of a pre-existing
disorder: phobia, panic or generalized anxiety, and
post-traumatic anxiety disorder in response to a
previous trauma or as a result of traumatic cancer
therapy (Holland, 1996).
Addressing anxiety in cancer patients
The guideline is to ensure that the patient is
adequately informed about the disease and its
treatment. Minimizing scary procedures before they
happen can reduce stress without requiring additional
intervention. Individual and group treatments are
helpful. Cognitive behavioral psychotherapy serves
to help patients reposition their perceptions and train
them in relaxation techniques (Gillanders, Sinclair,
MacLean & Jardine, 2015; Stagl et al., 2015).
With Tomiki psychotherapy, the aim is for the
patient learn to feel energetic, have more confidence
and express his feelings. The need to maintain hope
to fight for his life is paramount (A Kechie. al.,
2008). The patient needs:
1. To learn to replace the need to be always
good and liked by others. Trying to be constantly
likeable to others means giving little priority to his
own needs, desires, feelings and perceptions.
2. To develop new ways of expressing,
promoting and making decisions, regardless of what
others are saying and thinking.
To learn to establish deep and honest human
relationships. With individual psychotherapy, the
patient is given the opportunity to evolve into what
he wants and not to what others want. Patients must
understand that they are not always victims of the
disease but that they, themselves, may have
contributed to its development. They are obliged to
revise goals and priorities in their lives and ask
themselves about the meaning of existence
(Breitbart, Rosenfeld, Pessin, Applebaum,
Kulikowski & Lichtenthal, (2015)).
4. Prevention of cancer
According to Eysenck (1985), certain
personality traits can contribute to the prevention of
cancer. Assertive extroverted and conscientious
individuals with great self-discipline and a sense of
duty have the ability to achieve their goals. Low
levels of depression and increased anxiety about
health effect early diagnosis and treatment. On the
contrary, people with despair and sense of
helplessness are considered more susceptible to
cancer. In addition, it has been found that people
with a lower survival rate managed their negative
feelings. They got on with the nursing staff and were
docile when returning home. They felt that they did
not need to make major changes in their lives to deal
with their condition (Gillanders, et al., 2015). In
addition, they were given a better prognosis after
diagnosis (Gillanders, et al., 2015). Finally, it has
been hypothesized that the development of cancer is
associated with a decreased expression of emotions.
That is, cancer patients have an increased ability to
hold back and repel emotional conflicts without
expressing them externally (Kissen, 1963). On the
basis of this data, the specific focus of therapy should
be on strengthening mental resilience (Min, Yoon,
Lee, Chae, Lee, Song & Kim, 2013) .
5. Conclusions
Cancer is an illness which, in addition to the
profound physical impact on humans, causes intense
psychological, emotional and cultural shocks that the
individual are not always able to cope with. For this
reason, the role of psychologists with a special focus
on health psychology is significant in supporting and
responding to the needs arising in each case. The role
of the family and health professionals should be
cooperative and based on the principles of scientific
handling, disease management strategies and
techniques in order to make an effort to cope with the
situation in an evidence-based way.
Health and illness are two dynamic concepts, which
are often volatile and both situations are part of the
everyday life that shape the individual's inner
psychosynthesis as well as its identity. However, this
reflects in the wider society as cancer becomes a
transformation symbol of the conventional human
being who becomes a different Other and placed in
the context of diversity. This condition is often
accompanied by social stigma which characterizes
the person suddenly and forms a new identity.
Finally, since cancer diagnosis affects family
dynamics by altering relationships and roles among
members, immediate and long-term psychological
support is needed to address the reported effects of
cancer and achieve holistic empowerment
(Deshields, Rihanek, Potter, Zhang, Kuhrik, 2012;
Dimatteo & Martini, 2011; Duberstein, Masling,
2007; Govina, Vlachou, Kavga-Paltoglou,
Kalemikerakis, Papageorgiou, Fasoi, 2014; Ohman,
Soderberg & Lundman, 2003 ).
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Imperial Journal of Interdisciplinary Research (IJIR) Page 114
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