Anxiety
Anxiety is an emotion characterized by feelings, thoughts, physical changes, and behaviors. This may include feeling overwhelmed, worry thoughts, feeling tense, or having increased blood pressure. Anxious responses/behaviors may include avoidance, irritability, and frequent reassurance seeking. Anxiety is a broad term for several specific conditions, some of which are very common for cancer patients.
Table 1. Most common anxiety disorders in cancer, ICD-10 codes, prevalence in cancer and the general population, and criteria for diagnosis
| Anxiety Diagnosis | Prevalence in Cancer1 | Prevalence in General Population | DSM-5 Criteria/Symptoms |
| Adjustment disorder with anxiety or with mixed anxiety and depressed mood (F43.22, F43.23) | 15.4%-19.4% | 2.94%-11.5% (varies substantially by population & stressors) |
· Emotional or behavioral symptoms within three months of a specific stressor · Experiencing more stress than would normally be expected or stress causes significant problems in relationships, work, or school · Symptoms are not the result of another disorder or part of normal grieving |
| Generalized anxiety disorder (F41.1) | 3.39% | 2.57% |
· Excessive worry about a variety of topics for a period of at least six months; may spend a lot of time each day worrying · Worry is difficult to control · Worry is accompanied by at least three of the following symptoms: § Restlessness or edginess § Tiring easily or more fatigued than usual § Impaired concentration § Irritability § Increased muscle tension or soreness § Sleep difficulties (often related to worry) |
| Panic disorder (F41.0) | 2.22% | 2.79% |
· Panic attacks can occur in the absence of panic disorder. To meet criteria for panic disorder, patients must have recurrent and unexpected attacks with attacks followed by persistent concern about future attacks, worry about the implications of the attack, and a significant change in behavior related to the attacks. The attacks are not due to medication or a medical condition and are not accounted for by another disorder. · Presence of four or more of the following symptoms: § Chest pain or discomfort, like an elephant sitting on patient’s chest § Sensations of shortness of breath or smothering § Trembling or shaking § Fear of dying § Feeling dizzy, unsteady, lightheaded, or faint § Chills or heat sensations § Sweating § Palpitations, pounding heart, or accelerated heart rate § Feeling of choking § Nausea or abdominal distress § Numbness or tingling sensations § Fear of losing control or going crazy § Feelings of unreality or being detached from oneself · Agoraphobia is a fear of entering open or crowded spaces, leaving home, using public transportation, or being somewhere where escape is difficult. Less than 1% of patients experience this as part of panic disorder and often describe this as a fear of having a panic attack in public. |
| Specific phobia (F40.9) | 10.97% | 9.08% |
· Unreasonable, excessive fear that is persistent and intense triggered by a specific object or situation · Immediate fear/anxiety when in presence of the object or situation · Person goes out of their way to avoid the object or situation or endures with extreme distress · Fear significantly impacts person’s school, work, or personal life · Duration must be for six months and not caused by another disorder |
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The prevalence of anxiety ranges from 10-30%1 depending on the cancer group being studied. Obsessive compulsive disorder (OCD) is less common (1-2%) but can present challenges with medical treatments (e.g., contamination phobias, obsessive information seeking). Other common but not diagnosable anxiety conditions include worry about cancer recurrence (for those in remission), cancer progression, fears of death and/or dying, and “scanxiety.” New treatments are being developed for each of these conditions. Some helpful strategies to manage scan anxiety include:
- Seek support from others who have had similar experiences
- Normalize scanxiety as part of the cancer experience
- Have a plan in place to receive results with supportive others in a reasonable timeframe
- Make a plan to engage in joyful or meaningful activities several days before your scans to keep your mind focused.
- Focus on what is under your control (i.e., eating healthy, physical activity, helpful thoughts)
- Practice relaxation strategies such as diaphragmatic breathing, progressive muscle relaxation, or guided imagery or make an appointment with a mental health specialist to learn these techniques
Cultural Considerations
There are notable cultural differences in anxiety presentation. For example, Caucasians are more likely than other groups to receive an anxiety disorder diagnosis, while Black individuals are more likely to receive a diagnosis of trauma-related distress (e.g., PTSD). In Latinx communities, those experiencing intense life stressors may present with ataque de nervios, a cultural syndrome characterized with both anxious and depressive features, including fears of losing control, trembling, and intense episodes of crying or tearfulness.3 Also, studies have found higher fear of recurrence rates among Latinx cancer survivors than among their white or African-American counterparts.4 More research is needed, however, regarding cultural differences in the presentation of cancer-related anxiety.
Significance. Patients with anxiety are more likely to experience greater distress related to cancer, have poorer sleep, and reduced quality of life. Anxiety is associated with higher levels of cancer symptoms, including fatigue, nausea, vomiting, pain, and other treatment side effects – although the causal direction of this association is unclear. Patients with significant anxiety have a higher risk of substance use disorder. Unaddressed, anxiety disorders are associated with higher rates of suicidal ideation and attempts.1,2 Patients with anxiety are also more likely to attend to threatening communication and information. They may have greater resource utilization, as well as more difficulty with timely hospital discharge.5
Anxiety Management Guidelines
- NCCN Guidelines Distress Management GuidelinesV2.20246 https://www.nccn.org/home
- American Society of Clinical Oncology Guideline Adaption of a Pan-Canadian Practice Guideline: Screening, Assessment and Care of Psychosocial Distress (Depression, Anxiety) in Adults with Cancer (2014)7 https://www.asco.org/sites/new-www.asco.org/files/content-files/practice-and-guidelines/documents/depression-anxiety-summary-of-recs-table.pdf
- Reviews a stepped care approach to treatment of anxiety and depression for cancer patients: Butow P, Price MA, Shaw JM, Turner J, Clayton JM, Grimison P, Rankin N, Kirsten L. Clinical pathway for the screening, assessment and management of anxiety and depression in adult cancer patients: Australian guidelines. Psycho‐Oncology. 2015 Sep;24(9):987-1001. https://onlinelibrary.wiley.com/doi/10.1002/pon.3920
Screening Tools
All screening should be followed by clinical assessment including an interview for diagnosis, determination of contributing factors, and treatment planning.
- Hospital Anxiety and Depression Scale
- Generalized Anxiety Disorder – 2
- Edmonton Symptom Assessment System
- Distress Thermometer with Problem List 6
- James Supportive Care Screening (more comprehensive screening)
Table 2. Risk factors for cancer-related anxiety
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Evaluation and Diagnosis
Diagnosis of anxiety disorders in oncology populations typically occurs in the context of a clinical interview. Formal diagnostic tools, such as the Structured Clinical Interview for DSM-5 or the Anxiety and Related Disorders Interview Schedule for DSM-5, may be used.8,9 These structured approaches, which systematically review the diagnostic criteria for anxiety-related problems specified in the DSM-5, assist with diagnostic accuracy, particularly for research purposes, but they are time-consuming (45-120 mins) to administer.
Table 3. Self-report measures to assess and monitor anxiety symptoms in oncology populations
| Problem | Measure | Items/Subscales | Scoring |
| Anxiety | Beck Anxiety Inventory (BAI) | · 21 items |
0-7 minimal 8-15 mild 16-25 moderate 26-63 severe Scores > 7 identify 89% of individuals with panic disorder |
| Depression, Anxiety, Stress Scale-21 (DASS-21) |
21 items; 3 subscales: · Depression (DASS-D) · Anxiety (DASS-A) Stress (DASS-S) |
4-5 minimal 6-7 moderate 8-9 severe 10+ extremely severe |
|
| Hospital Anxiety and Depression Scale (HADS) |
14 items; 2 subscales: · Anxiety (HADS-A) · Depression (HADS-D) |
HADS-A scores > 6 may warrant clinical attention Scores > 8 associated with GAD |
|
| GAD | Generalized Anxiety Disorder Assessment (GAD-7) | · 7 items |
5-9 mild 10-14 moderate 15+ severe Scores > 7 associated with GAD |
| Penn State Worry Questionnaire (PSWQ) | 16 items | Scores > 62 associated with GAD | |
| Intolerance of Uncertainty Scale (IUS) | 12 items | Scores > 28 associated with GAD | |
| Panic Disorder | Panic Disorder Severity Scale (PDSS) | 7 items | Scores > 10 associated with panic disorder |
| Agoraphobic Cognitions Questionnaire (ACQ) | 14 items | Item mean > 3 associated with panic disorder/agoraphobia | |
| Specific Phobias | Blood–Injection Symptom Scale (BISS) | 14 items | |
| Medical Fear Survey (MFS) | 25 items | ||
| Claustrophobia General Cognitions Questionnaire (CGCQ) | 26 items | ||
| Cancer-Related Distress | Assessment of Survivor Concerns Scale (ASC) | 5 items | |
| Fear of Progression Questionnaire-Short Form (FoP-Q-SF) | 12 items | Scores > 34 may warrant clinical attention | |
| Fear of Relapse/Recurrence Scale (FRRS) | 5 items |
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Several substance-related and medical factors mimic anxiety disorders. When diagnosing anxiety disorders, it is essential to rule out:
- Withdrawal effects of nicotine and alcohol
- Amphetamine and cocaine use
- Excessive caffeine use
- Coronary symptoms (e.g., palpitations, pulmonary embolism, angina, dysrhythmia)
- Hyperthyroidism
- Medication effects (e.g., antidepressants, albuterol, steroids, stimulants)
- Respiratory disease (e.g., asthma, COPD, pneumonia, lung cancer), which can contribute to anxiety related to dyspnea
Treatment
Cognitive-behavioral treatment (CBT) for anxiety disorders has been a primary focus of evidence-based treatment. The American Psychological Association Division 12, Society of Clinical Psychology, identifies numerous cognitive-behavioral interventions with strong empirical support on its Research Supported Psychological Treatment website (https://div12.org/psychological-treatments/). Many of these treatments have been tailored for use in oncology populations. CBT has demonstrated strong outcomes in treating GAD, health anxiety (including fear of recurrence or progression), specific phobias, panic disorder, PTSD, and OCD. Exposure-based forms of CBT are the “gold standard” for treating phobias, panic disorder, PTSD, and OCD. Mindfulness- and acceptance-based approaches, including acceptance and commitment therapy (ACT) and mindfulness-based cognitive therapy (MBCT), also have research support for the treatment of anxiety. Elements of these treatments include patient education, mindfulness, and acceptance of experience.
Medication options for anxiety include antidepressant and anxiolytic medications. Note that many anxiolytics, such as benzodiazepines, are intended only for short-term use and may lead to dependence or rebound anxiety. For chronic anxiety, antidepressants (e.g., SSRIs, SNRIs) are recommended.
Table 4. Evidence-based psychological treatments for anxiety disorders
| Problem | Intervention | Techniques | Resources |
| Adjustment to cancer |
Supportive psychotherapy CBT |
· Reflective listening · Normalizing cancer-related fear thoughts and beliefs and challenging/reframing unhelpful thoughts · Identifying values/goals and re-establishing meaning/purpose · Enhancing support systems · Establishing healthy boundaries and self-care |
American Cancer Society https://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects/emotional-mood-changes.html
National Cancer Institute https://www.cancer.gov/about-cancer/coping |
| GAD (worry) |
CBT ACT MBCT |
· Psychoeducation · Worry awareness and monitoring · Decentering/defusing from worry thoughts · Challenging positive (e.g., “If I worry about it, it won’t happen.”) and negative (e.g., “This worry is making me sick.”) beliefs about worry · Worry postponement (i.e., creation of a “designated worry period”) · Mindfulness practices · Relaxation techniques (e.g., diaphragmatic breathing; progressive muscle relaxation) |
Society of Clinical Psychology
|
| Panic/ agoraphobia |
CBT ACT |
· Psychoeducation · Interoceptive exposure (e.g., experiencing increased heart rate) · Graduated exposure to feared situations · Challenging/disconfirming fears, thoughts, and beliefs · Decentering/defusing from fear thoughts · Identifying values/goals |
Oxford Series: Treatments That Work
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| Blood-injection-injury phobia; Claustrophobia |
Behavior therapy CBT |
· Psychoeducation · Identifying values and goals (i.e., motivation for facing feared stimulus) · Applied muscle tension (blood-injection-injury) · Graduated exposure to feared stimulus · Relaxation techniques · Challenging/disconfirming fear thoughts and beliefs · Decentering/defusing from fear thoughts |
Society of Clinical Psychology
Centre for Clinical Interventions
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Many individuals experiencing anxiety in the context of a cancer diagnosis appreciate non-directive supportive psychotherapy in both individual and group formats. Some well-intentioned anxiety interventions, however, may do more harm than good. These include offering repeated reassurance (potentially reinforcing worry), advising patients to “stay positive” in the face of distressing medical news (may induce feelings of shame or guilt), and instructing patients to “stop thinking” about a given worry or problem (perhaps useful in the moment, and thought suppression can lead to the opposite effect). Finally, patient buy-in is critical for any exposure-based anxiety treatment. Exploring values may help patients recognize reasons for facing fears. Ask permission before broaching painful or anxiety-provoking topics, though, and always respect the patient’s “no.”
Conclusions
Anxious distress is common among oncology patients. Among those endorsing anxiety symptoms, worry is the most widespread form of distress, though specific phobias pertaining to illness and treatment are also prevalent. Screening measures are useful to identify patients in need of further evaluation and treatment. Evidence-based interventions include CBT, relaxation techniques, and exposure-based treatments, as well as mindfulness- and acceptance-based approaches.
References
- Greer JA, Solis JM, Temel JS, Lennes IT, Prigerson HG, Maciejewski PK, Pirl WF. Anxiety disorders in long-term survivors of adult cancers. Psychosomatics. 2011 Sep 1;52(5):417-23.
- Bolton JM, Cox BJ, Afifi TO, Enns MW, Bienvenu OJ, Sareen J. Anxiety disorders and risk for suicide attempts: findings from the Baltimore Epidemiologic Catchment area follow‐up study. Depression and anxiety. 2008 Jun 1;25(6):477-81.
- Hofmann SG, Hinton DE. Cross-cultural aspects of anxiety disorders. Current psychiatry reports. 2014 Jun;16(6):1-5.
- Samuel CA, Mbah OM, Elkins W, Pinheiro LC, Szymeczek MA, Padilla N, Walker JS, Corbie-Smith G. Calidad de Vida: a systematic review of quality of life in Latino cancer survivors in the USA. Quality of Life Research. 2020 Oct;29(10):2615-30.
- Glynne-Jones R, Chait I, Thomas SF. When and how to discharge cancer survivors in long term remission from follow-up: the effectiveness of a contract. Clinical Oncology. 1997 Jan 1;9(1):25-9.
- Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelinesâ) for Distress Management V.2.2024. ã National Comprehensive Cancer Network, Inc. 2024. All rights reserved. Accessed April 3,2024. To view most recent and complete version of the guideline, go online to NCCN.org.
- Andersen BL, DeRubeis RJ, Berman BS, et al. Screening, assessment, and care of anxiety and depressive symptoms in adults with cancer: an American Society of Clinical Oncology guideline adaptation. J Clin Oncol. 2014;32(15):1605-1619. doi:10.1200/JCO.2013.52.4611 https://dx.doi.org/10.1200%2FJCO.2013.52.4611
- Brown TA, Barlow DH. Anxiety and related disorders interview schedule for DSM-5 (ADIS-5)-adult and lifetime version: Clinician manual. Oxford University Press; 2014.
- First MB, Williams JB, Karg RS, Spitzer RL. Structured clinical interview for DSM-5—Research version. Arlington, VA: American Psychiatric Association. 2015.