Psychosocial Stress and Cancer - Essay Example

Psychosocial Introduction Psychological and social factors have been known to play important roles in initiation and progression of cancer. Depressive symptoms are common in the oncology setting. Evaluating their nature and intensity is important. Cancer patients are vulnerable to these symptoms at all stages of the illness, from appearance of the first symptoms of cancer to the time of diagnosis, during treatment, palliative care, and even after remission or cure. Sadness and worry for the future are normal responses, partly because of the meaning attached to cancer, such as the fear of disability or death. In many advanced cancer patients psychological symptoms such as apathy, dependency, irritability, and loss of sleep are very common irrespective of the cancer that the patient is suffering (Garssen, 2004). It has been stated that these may be manifestations of motivational disturbances due to advanced illness or longstanding suffering. It has also been suggested that physical changes associated with advanced and life-threatening illness associated with considerable suffering such as occurs in any patient with cancer may strongly influence the psychological adjustment of the patient in both positive and negative ways. This is an important factor in management of patients with cancer since the patient's perspective of cancer as a terminal illness strongly influences the care process. This also means that these responses indicate the psychological determinants of patient responses. Many cancer patients suffer from hopelessness, and this is regarded by the care professionals as conducive to illness, death, and suffering and the opposite psychological reaction may lead to a favourable outcome (Kunkel et al., 2000). Although investigated in other cancers, the role of psychological and social factors in cancer and in those who survive cancer has been well delineated. In some cancers psychological factors have been shown to be predictive of survival time. Most cancer patients have emotional distress, depression, and depressive coping, and all these have been correlated to shorter survival. On the contrary hope and active coping have been associated with longer survival. All cancers have specific somatic risk factors, and these associations have been indicated to be statistically independent of these somatic risk factors. Those patients who are coping actively have best outcomes. It is thus evident that if these psychological factors have influence on survival, then development of psychological interventions directed to enhance the use of positive coping styles leading to prolonged survival. Petticrew et al. (2002) in their literature review indicated several themes of psychological reactions in response to cancer. Knowledge regarding these would foster professional interventions in cancer patients leading to better outcome (Petticrew et al. 2002). A very prominent and significant psychological response is fighting spirit. Many studies have investigated the impact of fighting spirit on survival from established cancer. Fighting spirit is a coping style, and this has been reported to be associated with reduced risk. The next most common psychological manifestation is helpless and hopelessness. This is known to be a predictor of reduced survival and compromised quality of life. Some patients demonstrate denial or avoidance. There is no significant association between an avoidant coping and survival. In some cancers, denial may predict recurrence of disease. Some patients with cancer demonstrate stoic acceptance and fatalism (White and Verhoef, 2003). Some patients become anxious with cancer and may develop anxious preoccupation. Some patients may even be depressed. Those who are very anxious or have high anxious preoccupation demonstrate shorter survival. Those who employ a depressive coping style also have a shorter survival. Those who have active or problem focused coping demonstrated a longer survival. Suffering from cancer and going through the treatment have high impact on the patients' personal belief systems, and local and familial knowledge about outcomes of a cancer disease often leads to suppression of emotion or emotion focused coping. Studies have thus shown that the psychological attitude of a person who has been diagnosed with cancer may affect the probabilities of survival. Although it has been argued whether really these factors play any meaningful role in survival or coping with cancer, all these factors have implications on quality of life following diagnosis of cancer. While the biologic causalities of such psychological factors are yet not known, management strategies or care delivery with consideration of these factors may be associated with ease of suffering (Oliffe et al., 2009). As it has been indicated earlier, the cancer patients' psychological characteristics could be related to the length of survival of such patients. It has been more pronounced on the effect of the individual's psychological integrity in response to cancer. In practice it is often found that some patients quickly succumb to cancer. These individuals have been described as polite, cooperative, and unable to express negative affects and hostility. Those who survive longer have been noted to be expressive emotionally even to the extent of bizarreness. This has a social link too. Some population based studies have demonstrated direct link between emotional expression and survival. For any potentially serious disease, higher mortality rates have been noted in patients with scanty community ties. A loss of social support has been associated with increased risk of cancer death. It has been suggested that for any cancer, psychosocial factors influence the course of cancer disease, rather than causation (Clark and Talcott, 2006). A theoretical framework to ascertain the psychosocial variables associated with cancer. It is unfortunate to note that relevant literature does not use much of a theoretical framework which involves psychometrically sound measures grounded in theory. Such a theory is needed to discern the interactions between psychosocial factors and the course of a malignant disease. One such clinical determinant may be the quality of daily life in patients diagnosed with cancer. These were termed by some researchers to be key psychosocial variables. As expected these might show the individual coping mechanisms to a life-threatening illness. This is based on theoretical premise of dysregulation related to progression of cancer. Jensen (1987) has termed this as dysregulation theory where cancer is a dysregulatory event to both quality of life and other psychosocial parameters as the disease progresses (Jensen, 1987). Although this theory is sufficient to describe the psychosocial changes associated with cancer disease this framework does not explain the causal theories which have been incorporated in the Levy model (1988) where emotional and behavioural factors have been linked with hormonal and immunological determinants of cancer leading to modification of biological pathways associated with cancer through which tumor response may be a manifestation of higher cortical pathway responses (Levy et al., 1988). The most significant psychosocial factors associated with cancer progressions would be manifestations of individual coping with cancer as a disease and cancer as a social concept. These are of paramount importance while planning a care of such a patient. The patient in this assignment is a patient with prostatic cancer. Literature describing psychological and social effects with prostatic cancer is rare. Therefore, these concepts are elaborated here drawing upon research based on other cancers. The manifestation of coping with cancer is underpinned by the theoretical model of coping with cancer proposed by van den Borne and Pruyn (1983). This model assumes and proposes that cancer is condition with immense suffering with some psychological parameters with social implications. Cancer is a condition with considerable uncertainty. Consequently most patients suffer from negative feelings which comprise of depression, loneliness, psychosocial and physical complaints. They suddenly feel that they are extremely dependent and can no longer drive their own lives. These lead to loss of control and threatened self-esteem. These four indicators are so important that measures to reduce the influence of these four indices often produce better psychosocial outcomes even in patients with advanced disease of cancer of any origin (Pruyn, 1983). Although this is a generalist approach, most patients have a conscious effort to prevent or reduce these problems. As mentioned earlier these are called coping strategies. These have an individual pattern, and while formulating these, many social parameters are incorporated into the coping strategies, and they have their own share of influences. These are essentially person related, and sociodemograhic variables such as income, education, marital status, smoking and drinking, age, and daily activities. Taking into account an average patient with prostate cancer, there are many drugs for prostate cancer which can be very effective but costly. The patients may not be able to afford it. Radiotherapy or brachytherapy may cause loss of income. Radiation or chemotherapy may lead to loss of libido which may affect the marital status. Daily activities may be compromised to a great extent due to any cancer or its treatment. These psychosocial factors may also be closely related to illness related factors such as stage of the disease and the type of the treatment. It is evident that coping with a cancer disease is the sum total of psychological affects in response to the physical and psychosocial problems, which may determine the responsiveness of the patient to treatment and the outcome leading to factors, which may influence the course of the disease (Ellison et al., 2001). Again from the perspective of a prostate cancer, if a patient with pelvic bony metastasis is receiving a radiation therapy, he may feel hopeless since radiation might have caused diarrhea which leads to frequent visit to the toilet, while visiting toilet frequently may be extremely cumbersome for a patient who is socially alienated without a support system. This may reinforce the depression, hopelessness, and despair in such patients. On the contrary in a patient with a social support system which can offer help in such activities the same scenario may not be seemingly that out of control and would not generate similar or identical negative feelings. If negative feelings determine outcomes of prostate cancer, thus the outcome in the case of the second patient may be more favourable (Eton et al., 2001). Intrapersonal factors such as trait anxiety and locus of control are important factors in manifestation of psychological affects. However, interpersonal concepts which primarily comprise of social factors are nothing less important. Information about the disease, its course, available treatments are very important since they tend to reduce the uncertainty associated with the disease. A service design which accommodates information transmission tend to reduce the worries and anxieties since the patients come to know and anticipate what is coming and they can accordingly design their own coping strategies. Health care providers may play important roles in disseminating information regarding the disease and the treatment to the prospective patients. Support received from others also play important roles. Many studies have indicated a close relationship between social support measures and disease progression (Northouse et al., 2007). The patients who experience support, who have confidants, and have sufficient social support network comprising of relatives and friends demonstrate longer survival and a prolonged remission phases. It has been found that scope of discussion about personal problems relieves stress and anxiety. This creates the mainstay of cancer care professionals who need to master art of communication to engage patients in conversation in order to be able to offload the burden of thoughts. Studies in this relation have identified different forms of confidants such as spouses, children, colleagues, friends, physicians, and nurses. These social relationships are important in modifying the prognosis of cancer disease. However, it has been demonstrated that these social support mechanisms work only in primary disease, and the intensity of its influence is blunted in patients with recurrent disease. The choice of the social support system is a patient preference based on his perceptions. This means if a patient thinks that a friend of colleague who has survived prostate cancer to be a better support system than the treating doctor, more favourable benefits can be accomplished through inclusion of that colleague in the support system (Kiss and Meryn, 2001). The question remains how these factors influence care. It is well-known that prostate specific antigen test a reliable screening test of prostatic cancer. Presenting self for screening in itself is a psychologic manifestation. Family history is a known risk factor for prostate cancer. This promotes men to present more for screening. It may spring from the belief that prostate cancer is inherited, and little can be done to prevent it. Personal worry is an important determining factor, and in conventional medical screening, the people who are worried present themselves in increased numbers. Across countries fear for prostate cancer is main driving factors for motivating men to present for PSA screening. In prostate cancer literature, it has been demonstrated that distress, social support, and coping styles may influence the course of cancer. It has also been demonstrated that these psychosocial factors may influence the health related quality of life in patients affected with prostate cancer (Wallner et al., 2008). The most important associated biological factor for this may be the progressively increased incidence of this disease with increasing age. Those who have locally advanced disease or metastasis to the bones or pelvic lymph nodes are considered to be very advanced disease and they cannot be offered treatments such as surgery and radiotherapy but palliative therapy of some sort. The effect on quality of life with some offered treatment may really be devastating for some patients. For example radical prostatectomy may have permanent or total erectile dysfunction or permanent incontinence of urine. Radiotherapy may lead to erectile dysfunction in the long run and other urinary or gastrointestinal disturbances may be perennial. Hormonal palliative treatment may add to the burden of progressive cancer disease with problems of decreased libido, erectile dysfunction, and hot-flushes (Van Andel et al., 2003). As evident these conditions will be associated with negative feelings as a derivative of high state anxiety, high depression, and guilt. Quite frequently these are increased with high overall survival. These will eventually lead to greater hopelessness and helplessness without an appropriate support system eventually leading to high dependency and low self-esteem. These may also lead to phobic anxiety and anger eventually culminating into hostility. Pain management is very important from the point of views of care provision even if it is palliative, since increased pain has been correlated to shorter overall survival. Since prostate cancer is a disease of advanced age, loss of control is one important psychological manifestation that needs a management. These patients on baseline have high cognitive disturbance, and increased forgetfulness and difficulty concentrating may lead to their shortened survival with this disease. The compromise with the functional status, role limitation would threaten the self-esteem in a more acute manner affecting the coping strategies (Penedo and Dahn, 2004). The prostate cancer treatment outcome thus is related heavily to these factors and other biological treatment related factors such as control of symptoms, response to treatment, relapse, and survival. Now it is recognised that health related quality of life also influences the outcome. Although emotionally significant, the two major form of definitive therapy for prostate cancer such as radical prostatectomy and radiation therapy do not affect the quality of life. However, when the gastrointestinal, urinary, and erectile dysfunction problems set in, these psychosocial problems start taking their course. The problem becomes more acute in palliative treatment with hormones. It has been demonstrated that treatment with hormonal agents lead to more fatigue, loss of energy, more emotional distress, and lower overall health related quality of life (Visser et al., 2003). Conclusion Based on the discussion above, it is evident that due consideration must be given to the psychological and social factors in individuals with advanced cancer. Prostate cancer is also not an exception of this. Although there is deficit of rigorously designed study in this area, based on the theoretical framework of psychosocial determinants of cancer, caner is associated with distinct negative affects that base on intrapersonal, interpersonal, social, and demographic parameters. Added to those high age, social support systems, information, and the biological effects of treatment or progressive disease may implicate further the psychosocial determinants. Therefore, it could be the right approach to strengthen the self-esteem of these people through information and communication to modify the psychological and social factors which may have a bearing on the treatment outcomes of such patients. Reduction of anxiety and creating an environment of support, pain relief, symptom control, and helping the patients to build a positive attitude may change the normally grim outcome of compromised health related quality of life. References Clark, JA. and Talcott, JA., (2006). Confidence and Uncertainty Long After Initial Treatment for Early Prostate Cancer: Survivors' Views of Cancer Control and the Treatment Decisions They Made. J. Clin. Oncol.; 24: 4457 - 4463. Ellison, GL., Coker, AL., Hebert, JR., Sanderson, SM., Royal, CD., and Weinrich, SP., (2001). Psychosocial stress and prostate cancer: a theoretical model. Ethn Dis; 11(3): 484-95. Eton, DT., Lepore, SJ., and Helgeson, VS., (2001). 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