Managing Anxiety in Patients with Advanced Cancer

Symptom Management, Web Exclusives

Anxiety is a common symptom in patients with advanced cancer, and is associated with reduced quality of life, increased symptom burden, poor medication adherence, and suboptimal treatment decisions at the end of life. Anxiety also tends to cluster with disease- and treatment-related side effects such as fatigue, pain, breathlessness, nausea, vomiting, and sleep disturbance.

According to Joseph Greer, PhD, Program Director, Center for Psychiatric Oncology and Behavioral Sciences, Massachusetts General Hospital Cancer Center, Boston, targeted intervention using cognitive behavioral therapy (CBT) can help to alleviate this anxiety and improve medical and psychosocial outcomes for patients with advanced cancer.

Cognitive Behavioral Therapy

CBT is an evidence-based first-line treatment for anxiety disorders in the general population, but historically, randomized controlled trials have not included patients with advanced cancer. In addition, this type of intervention generally targets unrealistic fears and worries in otherwise healthy individuals.

But in adapting this approach for patients with advanced cancer, Dr Greer found that traditional CBT fails to address the causes of anxiety in this specific patient population, such as negative thought patterns that are rational but are nonetheless intrusive and distressing.

“These are very real, very intrusive, very distressing worries that patients are coping with, particularly about their prognosis, the potential for death and dying, their loss of functioning and role transitions,” Dr Greer said in a webinar hosted by the American Psychosocial Oncology Society. “These are legitimate worries; these are not irrational thoughts.”

In addition, he noted a lack of tools and resources designed to help patients cope with medical and psychological stressors, such as changes in functional status, illness-related symptoms, burdensome medical treatments, and often the realization that they will eventually lose their autonomy.

To address these shortcomings, Dr Greer developed a pilot feasibility study of brief CBT for anxiety in ­patients with advanced cancer. The study included 40 adults with metastatic or incurable cancer and elevated anxiety who were randomized to CBT or to a wait-list control group. Crossover to the intervention group was allowed, and patients completed seven 60-minute sessions across 4 modules—psychoeducation and goal setting (1 session), relaxation training (1 session), coping with cancer fears (3 sessions), and activity planning and pacing (2 sessions).

The CBT Modules

Psychoeducation and goal setting involve identifying patient stressors to gain a better understanding of their cancer experience, including cognitive stressors (eg, my scans will show tumor growth), behavioral stressors (eg, avoiding family events), and physiological stressors (eg, breathlessness, palpitations).


Relaxation training can aid patients in the management of stress reduction and cancer-related side effects; breathing is a primary issue, and rates of dyspnea increase as cancer progresses. Diaphragmatic breathing can be practiced by leaning slightly forward to improve the mechanics of breathing while focusing on slowing the breath. It is a useful tool for reducing stress in the body when a patient is calm; however, it should not be used for acute breathlessness, because it can lead to rapid deep breaths, hyperventilation, and in turn, increased anxiety.

Pursed-lips breathing (in through the nose, out through the mouth) is a useful tool for acute breathlessness, especially for patients with breathing problems such as chronic obstructive pulmonary disease.

Autogenic training using repetitive words to guide the patient (ie, “my right arm is warm and heavy, my left arm is calm and relaxed”) is especially useful for patients with musculoskeletal pain.

Coping with Cancer-Related Fear

Coping with cancer fears involves working through worries and differentiating between realistic concerns and cognitive distortions. Many patients with high anxiety have selective attention to bodily sensations and often view benign somatic signals as dangerous because of their cancer diagnosis, in turn making them more anxious (ie, headache means the cancer has spread).

According to Dr Greer, many of these cognitive distortions are amenable to cognitive restructuring.

“This can give people perspective and help them recognize that they’re catastrophizing or underestimating their coping abilities,” he said. “It’s a hard cycle to break, but a common one for many.”

If a worry is realistic, and an action can be taken to resolve the worry, encourage patients to take that action—use problem-solving skills to explore treatment options, and practice activity pacing to conserve energy. If the worry is realistic but nothing can be done to solve it, encourage acceptance and tolerance by practicing mindfulness and engaging in self-­soothing and pleasurable activities.

Activity Planning

Activity planning and pacing is necessary when patients can no longer function physically the way they once had. Dr Greer suggests making planning and pacing logs with patients, by asking them to realistically assess their functional capacity (ie, determine “good” vs “bad” days).

Prioritization of activities is key, as is encouraging realistic expectations of time requirements and outcomes. Urge patients to be judicious about physically demanding tasks, and to plan to do those tasks on days when they know they will have more energy.

Tell patients to plan out responsibilities and pleasurable activities du­ring the week, and alternate between physically stressful and nonstressful activities to avoid overexertion.

On days when they know they will feel depleted, they should have self-care activities ready to go—Netflix, painting, online shopping—something that makes them feel slightly engaged, Dr Greer said.

Problem Solving

Finally, it is important to know when patients should give up an activity because they physically cannot do it.

“But before you go into problem solving or modifying, spend some time exploring what it means to them to lose that activity,” Dr Greer urged. “Let them experience that grief, so that they feel heard about why this loss of functioning is meaningful to them, and then move into problem solving (ie, can no longer play golf, try going to the driving range).”

Adopting Healthy Coping Strategies

At the completion of Dr Greer’s tailored CBT study, blinded post­assessment revealed that patients in the intervention group reported a significantly greater reduction of anxiety symptoms, with corresponding large positive effects for multiple clinician-rated and self-reported measures. “We were pretty pleased at the end of that trial,” he said.

Dr Greer compares these healthy coping strategies to patients taking a box off a shelf, looking inside at some of the scary things that need to be talked about, such as prognosis and future planning, then when they are ready, putting the lid back on, putting the box back on the shelf, and going on to live their lives.

“Adaptive coping with a diagnosis of terminal cancer doesn’t mean constantly thinking about dying. The person who takes the box off the shelf fares better than the person who lives inside the box and is depressed, or the person who never opens the box and doesn’t plan for the future,” Dr Greer said.

“Cognitively we need the ability to expose ourselves to these things, but also the ability to come back and take a break from it. These people are living, and I want them engaged in life for as long as possible.”

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