Cancer is one of the most common diseases in the world. Stress is a common experience among cancer patients. National Comprehensive Cancer Network (2017) defines cancer-related psychological distress as an: “ unpleasant emotional experience of a Mental, Physical, Social, or Spiritual nature. It can affect the way you think, feel, or act. Distress may make it harder to cope with having cancer, its symptoms, or its treatment. ”

1. Distress in Cancer Patients
Department of Psychology
Professor:
Reza Pourhosein, Ph.D.
By:
Negin Dorri
December 2019

2. What is Cancer?
• Cancer is one of the most common diseases in the developed world
• For a cancer to start, certain changes take place within the genes of a cell or a
group of cells.
• Cancer is when abnormal cells divide in an uncontrolled way.
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3. What is Cancer?
• The cancer burden continues to grow globally, exerting tremendous physical,
emotional and financial strain on individuals, families, communities and health
systems.
• Cancer is not just one disease. It is a large group of diseases that can start in almost
any organ or tissue of the body.
• 630,000 people are estimated to have died from cancer in 2020.
• 30-50% of cancers could be prevented.
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4. Common Types of Cancer
• There are more than 200 different types of cancer.
• The list of common cancer types includes cancers that are diagnosed with the greatest frequency in
the United Kingdom:
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5. • More than half of new cases
of cancer in males are:
- Prostate Cancer
- Lung Cancer
- Bowel Cancer
Cancer Research UK. 2014-2016.
• More than half of new cases
of cancer in females are:
-Breast Cancer
- Lung Cancer
- Bowel Cancer
Most common cancers in males: Most common cancers in females:
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6. Common Causes of Cancer
• known and possible causes of cancer:
- Gens and Mutations
- Lifestyle factors:
Smoking and Tobacco
Diet and Physical Activity
- Sun and Other Types of
Radiation
- Viruses and Other Infections
- Some forms of high-dose
chemotherapy and radiation

7. Physical Side Effects of Cancer
¯ Anaemia
¯ Bleeding and Bruising
¯ Bone Loss
¯ Diabetes
¯ Diarrhea
¯ Dry Mouth
¯ Eye Problems
¯ Lung Issues
¯ Nausea and Vomiting
¯ Organ Damage
¯ Pain
¯ Sexual Dysfunction
¯ Skin Problems
¯ Sleep Problems
¯ Fatigue
¯ Hair Loss
¯ Hearing Loss
¯ Heart Issues
¯ Hormonal Changes
¯ Infection
¯ Loss of Appetite
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8. Psycho social and Spiritual Impacts of Cancer
Psychological
Social
Spiritual
An investigation of the spiritual/existential needs of breast cancer patients from the
USA showed that these patients wanted help with:
• Overcoming fears (51%)
• Finding hope (42%)
• Finding meaning in life (40%)
• Finding spiritual resources (39%)
• Cancer and its treatment alter social roles and limit social activities of patients.
• Dealing with body symptoms (pain, fatigue).
• Psychological symptoms such as: Stress, Depression, Anxiety
Doi: 10.4103/2347-5625.189813

9. • Stress hormones have been shown to be important
mediator in driving malignant growth and reducing
treatment efficacy in Breast cancer.
• Stress hormones exposure can induce DNA damages
in breast cancer.
Doi: 10.1016/j.canlet.2019.o5.027
• The stress response is largely directed by HPA axis
Dysregulation.
• Stress is a feeling of emotional or physical tension. It
can come from any event or thought that makes you
feel frustrated, angry, or nervous (U.S. National Library of
Medicine, 2019).

10. The Body’s Response to Stress
• “Fight or Flight”, is a sympathetic nervous system response.
• “Rest and Digest”, is a response of parasympathetic nervous system.
• During “ Fight or Flight” several things happen:
¯ The heart rate increases
¯ Blood pressure rises
¯ Blood vessels constrict
¯ Glucose is released by the liver
¯ Digestion is inhibited

11. Psychological Distress
Doi: 10.1188/16.CJON.630-634
Psychological distress is a general term used to describe negative feelings or
emotions that affects ones level of functioning and interfere with activities of
daily living.
Psychological distress can result in distorted view of the self and circumstances
and is manifested by sadness, anxiety, distraction, and symptoms of mental
illness.

12. Stress and Cancer
Doi: 10.1002/cncr.32477
• Stress is a common experience among cancer survivors.
• Chronic stress can lead to persistent and more severe
anxiety, depression and pain.
Can Psychological Stress cause Cancer
• Although stress can cause a number of physical health problems, the evidence
that it can cause cancer is weak.
• Apparent links between psychological stress and cancer
could arise in several ways. For example, people under
stress may develop certain behaviors, such as smoking,
overeating, or drinking alcohol, which increase a person’s
risk for cancer
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13. Distress and Cancer
National Comprehensive Cancer Network (2017) defines cancer-related psychological distress as an:
“ unpleasant emotional experience of a Mental, Physical, Social, or Spiritual nature. It
can affect the way you think, feel, or act. Distress may make it harder to cope with
having cancer, its symptoms, or its treatment. ”

14. Distress and Cancer
• The term distress is commonly used in oncology context to signify negative feelings,
such as:
¯ Fear
¯ Sadness
¯ Sleep Disorder
¯ The inability to cope with cancer
• Distress is generally associated with:
¯ Gender
¯ Younger Age
¯ Lower Education
¯ Poor Socio-economic Advantage
¯ Late Diagnosed Stage
¯ Poor Social Support
Doi: 10.1097/NCC.0000000000000388

15. Risk factors for higher distress
• Have uncontrolled symptoms
• Have a severe illness other than cancer
• Have cognitive impairment
• Have limited access to health care
• Are younger in age
• Are a woman
• Have barriers to communicating
• Have money problems
• Have spiritual or religious concerns
• Have family conflicts
• Have a lack of social support
• Live alone
• Have young children
• Have been physically or sexually abused
• Have had a substance use disorder (ie, alcohol, drugs)
• Have had a mental disorder (eg, anxiety, depression)

16. Parenting, Stress and Cancer
Doi:10.1007/s00520-018-4611-5
• About 24% of cancer patients are also parents of an under age child.
• These parents must deal with their cancer and its treatment as well as
with their duties as parents.
Methods:
¯ A sample of mothers with cancer (clinical group; n=64)
¯ A sample of healthy mothers ( control group; n=80)
¯ Self-reported Questionnaires:
 The Parenting Stress Index
 Depression Symptoms
 Emotional Regulation Strategies
• When a mother has cancer, the diagnoses upsets the entire family system.
• Its physical and emotional burden, its treatment, hospitalisations and uncertainty
about the prognosis may affect ill individuals’ availability to participate in
parenting.

17. The Parenting Stress Index
Doi:10.1007/s00520-018-4611-5
• In order to prevent these negative consequences, it is crucial to identify antecedents of PS
(depression and cognitive reappraisal) as early as possible in order to promote healthy mother–
child relationships and child development.
• The PSI/SF, one of the most worldwide used questionnaire to assess parenting stress,
encompasses 36 items rated on a 5-point Likert scale ranging from 1 to 5.
• The PSI/SF includes a total stress score and three subscale scores:
¯ Parental Distress
¯ Parent–child Dysfunctional Interaction
¯ Difficult Child Characteristics

18. Stressful Life Events and Cancer
Bahri, N., Fathi Najafi, T., Homaei Shandiz, F. et al. The relation between stressful life events and breast cancer: a systematic review and meta-analysis of cohort studies. Breast Cancer Res Treat 176, 53–61
(2019) doi:10.1007/s10549-019-05231-x
• Breast cancer is the most common type of cancer among women that involves 1.5 million
women annually.
• Breast cancer has different risk factors such as age, family history, early menarche, late
menopause, use of contraceptives, environmental factors, and lifestyle.
• Some studies have investigated the role of stress or other psychological distress in cancer
occurrence.
• The overall results of this systematic review and meta analysis elucidated that stressful life
events slightly increases the risk of breast cancer.

19. A Case Study of a Veteran with End-Stage Colon Cancer
• This individual case was selected from a larger study in order to explore the depths of psychosocial
distress among a male, older African American veteran who was suddenly diagnosed with end-
stage, metastatic cancer that completely impacted his life.
• Charles was a 65-year-old Vietnam veteran who was born in Alabama, U.S. and lived on the road,
working as a truck driver most of his life, sleeping in his truck, and moving from place to place.
• Psychosocial distress in end of life (EOL) cancer care is recognized as an unpleasant or negative
emotional experience involving physical, psychological, social, and/or spiritual issues, leading to
impaired physical and emotional functioning and limitations in patients ability to cope with the
course of illness.
• Since beginning cancer treatment in a VA Medical Center, Charles had been staying in one of the VA
Nursing Home Care buildings in order to access cancer treatment while maintaining stability. At the
time of the first interview, Charles had lived in the nursing home for six months.

20. Factors Triggering Psychosocial Distress
Psychosocial Distress: A Case Study of a Male African American Veteran with End-Stage Colon Cancer
*
* Veterans Affairs Supportive Housing

21. “Trying to get me a place to stay at so I can get out of here. So I can be getting on out of here to do my own thing.”
• The Table shown on the previous slide presents a summary of key issues Charles
raised about the cause of his distress. When asked about his immediate concerns,
he replied:
• While Charles knew that he had been diagnosed with a life-limiting disease, he
was more concerned about the loss of independence and control over the way he
chose to live. The themes provide a description of significant factors that
triggered his psychosocial distress:
2. Navigating complicated veteran services
1. The emotional impact of being diagnosed
5. Experiencing inescapable loss of independence
3. Adjusting to nursing home placement
4. Lacking social support

22. Melatonin
doi: 10.18632/oncotarget.16379
• Melatonin could also be utilized as adjuvant of cancer therapies, through reinforcing the therapeutic effects
and reducing the side effects of chemotherapies or radiation.
• Melatonin could be an excellent candidate for the prevention and treatment of several cancers, such as breast
cancer, prostate cancer, gastric cancer and colorectal cancer.
• Melatonin (40 mg/day orally) significantly increased 1 year survival rate of patients with metastatic
colorectal cancer, compared with supportive care alone .
• Patients receiving concomitant melatonin showed higher overall tumor regression rate and 5-year survival,
with a better tolerance to chemotherapy.
“Melatonin for the prevention and treatment of cancer”

23. • Bedtime melatonin was associated is a significant improvement in objective sleep quality, subjective
sleep, sleep fragmentation and quantity, fatigue severity, global quality of life, and social and
cognitive functioning scales.
• The risk of developing depressive symptoms in subjects who received 6 mg oral melatonin was
significantly lower than that of subjects who took placebo.
• Several studies reported that melatonin might be able to improve the sleep and quality of life in
patients with breast cancer.
doi: 10.18632/oncotarget.16379
Oncotarget. 2017 Jun .Published online 2017 Mar 18. PMCID: PMC5503661

24. Outcomes of Distress
By definition, being distressed isn’t pleasant. Feeling lousy doesn’t make coping with cancer any easier.
• Distress may affect how well you function
It can interfere with sleep. You might sleep less or more than normal.
Distress may affect how well you can focus. You may need to ask people to
repeat what they said because you lost track.
Distress may affect how well you relate to people. You may pull away from
others. If you have children, you may have trouble taking care of them.
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25. Outcomes of Distress
• Distress may worsen your health
• Distress may interfere with your health decisions or actions.
Research found that people who are distressed are less likely to take their
medicines as their doctor prescribed. Likewise, distressed people are less
likely to attend their follow-up visits. As a result, you may make extra
visits to the doctor’s office and emergency room. If you’re distressed, you
may also have trouble making treatment decisions and be less likely to
exercise and quit smoking.
Distress leads to poorer quality of life. It may even have a harmful impact
on your length of life (survival)
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26. Doi: 10.1038/sj.bjc.6601887
• All patients should be screened for distress at their initial visit.
• In a study the most frequent problem endorses was:
Fatigue 48.5%
Pain 26.4%
Managing emotions/stress 24.8%
Depression 24.0%
Anxiety 24.0%
Fatigue
Pain
Managing/stress
• Cancer-related psychological distress is prevalent in about one third of patients
with a cancer diagnosis and highest in patients with advanced disease and poor
prognosis.

27. Identifying Patients
• Identifying patients who are at risk of emotional distress may raise awareness in
cancer healthcare professionals of the need for careful assessment and early
investigation.
• To detect early signs of distress and the emotional status of cancer patients
throughout their treatment, it is strongly recommended to measure anxiety and
depression at multiple time-points.
• Cancer type might be an important factor to consider because different types involve
different clinical treatment strategies.
“The prevalence and predictors of emotional distress and social difficulties among surviving cancer patients in Jordan.”

28. Early Signs of Distress
• Sadness, fear, and helplessness
• Questioning your faith, your purpose, the meaning of life
• Pulling away from too many people
• Concerns about illness
• Concerns about your social role (ie, asmother, father, caregiver)
• Poor sleep, appetite, or concentration
• Anger, feeling out of control
• Depression, anxiety, panic
• Frequent thoughts of illness and death
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29. Cancer-Related Psychological Distress.2015.
Cancer Related Psychological Distress
• Four attributes are described in the literature that encompass the concept of cancer-related psychological
distress:
Depression, Anxiety, Fear, and feeling Discouraged.
• Depression can be difficult to detect because symptoms of depression, such as lack of appetite and
fatigue, mimic the symptoms of cancer itself or the common effects of its treatment.
Model Case:
“I cannot sleep at night [anxiety]. I am constantly thinking the
chemotherapy will make me so sick [fear]. I do not feel like
eating, and I cry constantly [depression]. I cannot even think
about planning for the holidays, let alone going to work. My
family wants to help, but nothing can help me now [feeling
discouraged].”

30. doi: 10.1188/16.CJON.630-634
Cancer Related Psychological Distress
Contrary Case:
“In this contrary case, the patient was able to voice her feelings of
comfort to the nurse. The four attributes of cancer-related
psychological distress were explored and assessed during the
appointment. The patient did not have depression, anxiety, fear, or
feelings of being discouraged and left the unit feeling positive about
the visit with her needs met.”
Borderline Case:
“I am relieved that chemotherapy was not as hard as I thought it
would be. I feel as good as can be expected, and I am glad we
worked everything out with my boss by turning in the Family and
Medical Leave Act paperwork. I am scared about the cancer coming
back, though. What do I do now?”

31. Cancer Type
Doi: 10.1038/sj.bjc.6601887
Methods
Instruments
• A total number of 3095 patients were
assessed over a 4-week period.
• Full data was available on 2776 patients.
• Types of cancer were varied :
¯ Breast Cancer 23.5%
¯ Prostate Cancer16.9%
¯ Colorectal Cancer 7.5%
¯ Lung Cancer 5.8%
• Demographic and Cancer History Questionnaire
• Psychosocial Questionnaire
• Problem checklist
• Brief Symptom Inventory – 18 (BSI–18)
Cancer type might be an important factor to consider because different types involve
different clinical treatment strategies.

32. Doi: 10.1038/sj.bjc.6601887
Percentage of distress ‘cases’ by cancer diagnosis
The Johns Hopkins Hospital (JHH) is the teaching hospital
and biomedical research, located in Maryland, U.S.
Tom Baker Cancer Centre (TBCC) is a tertiary care facility,
located in Alberta, Canada.

33. Screening Tool
The Distress Thermometer and Problem List
The Distress Thermometer is a well-known screening
tool among cancer care providers. It has been shown
in many studies to work well. It measures distress on a
0 to 10 scale.
Instructions:
Please circle the number (0–10) that best describes
how much distress you have been experiencing in the
past week including today.
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34. coping with stress
Emotional and social support can help patients learn to cope with psychological stress. Such support can
reduce levels of depression, anxiety, and disease- and treatment-related symptoms among patients.
Approaches can include the following:
• Training in relaxation, meditation, or stress management
• Counseling or talk therapy
• Cancer education sessions
• Social support in a group setting
• Medications for depression or anxiety
• Exercise
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35. December 17th 2019
Local Time 22:15
Key Words

36. “It is much more important to know what sort of patient has a disease than what sort of disease a patient has.”
Sir William Osler, M.D.
Thank you