When anxiety is situational (i.e., produced by pain, another underlying medical condition, a hormone-secreting tumor, or a side effect of medication), the prompt treatment of the cause usually leads to immediate control of the symptoms.[1] Some effective coping strategies include encouraging fearful patients to confront the problem directly, to try to view the situation as a problem to be solved or as a challenge, to try to obtain complete information, to try to be flexible (taking things as they come), to think of major events as a series of step-by-step tasks, and to encourage the use of resources and support.[2]

Initial management of anxiety includes providing adequate information and support to the patient. Initial symptoms, which may warrant a psychiatric or psychological consultation, may first be reported to the primary oncologist or surgeon.[3] Psychologic approaches include combinations of cognitive-behavioral therapeutic techniques, insight-oriented psychotherapy, crisis intervention, couple and family therapy, group therapy, self-help groups,[4] and behavioral interventions. Behavioral approaches (hypnosis, meditation, progressive relaxation, guided imagery, and biofeedback) can be used to treat anxiety symptoms that are associated with painful procedures, pain syndromes, crisis situations, anticipatory fears, and depressive syndromes. Combining different approaches can be beneficial for some patients. One study examined the usefulness of a comprehensive intervention combining positive coping strategies based on cognitive behavioral therapy (e.g., calming self-talk or relaxation) with education about the disease, treatment, and potential side effects in 509 recurrence-free breast cancer survivors at 5 to 9 years posttreatment.[5] Findings from this study indicate that women in the intervention group (n = 244) regularly used the intervention components to deal with triggers of fears of breast cancer recurrence and long-term treatment side effects. Most women in the intervention group found the strategies very helpful.[5] Preliminary evidence suggests racial differences in the use and benefit of specific coping strategies (e.g., religious coping strategies such as prayer and hopefulness are used more by African American women and provide greater benefit for these women).[5,6]

An anxiolytic medication is often needed alone or in combination with psychologic approaches. The choice of a benzodiazepine depends on the duration of action that is best suited to the patient, the desired rapidity of onset needed, the route of administration available, the presence or absence of active metabolites, and metabolic problems. Dosing schedules depend on patient tolerance and require individual titration. The shorter-acting benzodiazepines (alprazolam and lorazepam) are given 3 to 4 times per day. Short-acting benzodiazepines, particularly those that can be administered by multiple routes (lorazepam and diazepam) are effective for high levels of distress. Benzodiazepines decrease daytime anxiety and reduce insomnia. (Refer to the PDQ summary on Sleep Disorders for more information.) The most common side effects of benzodiazepines are dose dependent and are controlled by titrating the dose to avoid drowsiness, confusion, motor incoordination, and sedation. Buspirone, a nonbenzodiazepine, is useful in patients who have not previously been treated with a benzodiazepine and in those who may abuse benzodiazepines (e.g., those with a history of illicit substance abuse or alcoholism). Buspirone is also useful in the geriatric population as an augment to fluoxetine for the treatment of anxiety and depression. The beginning dose is 5 mg 3 times a day and can be increased to 15 mg 3 times a day. Buspirone can also be given twice a day. Low-dose neuroleptics (e.g., thioridazine, 10 mg 3 times a day) are also used to treat severe anxiety when an adequate dose of a benzodiazepine is ineffective or if the patient might be expected to respond poorly to benzodiazepines (e.g., patients with brain metastases). Low-dose neuroleptics can also be used when benzodiazepines are not helpful or when there is the possibility of delirium, dementia, or other complications. For anxiety symptoms of another medical origin, reversal of the physical cause is the best treatment, if possible. Otherwise a benzodiazepine (e.g., lorazepam or clonazepam), a neuroleptic (e.g., thioridazine or haloperidol), or a combination of these classes of drugs can be used. Anecdotally, clinicians have prescribed atypical antipsychotics in low doses such as olanzapine, 2.5 mg twice a day or risperidone, 1 mg twice a day. Unstudied, these medications relieve anxiety and are associated with less akathisia.

All benzodiazepines can cause some degree of respiratory depression, though generally it is minimal in patients who have not used benzodiazepines in the past. They should be used cautiously (or not at all) for respiratory impairment. Standard precautions should be considered when using any sedative drug in patients who have borderline respiratory function. Ongoing assessment of this population is important. Low doses of the antihistamine, hydroxyzine (25 mg 2–3 times a day), can be used safely in such situations. In patients with hepatic dysfunction, it is best to use short-acting benzodiazepines that are metabolized primarily by conjugation and excreted by the kidney (e.g., oxazepam, temazepam, or lorazepam). Another advantage of using lorazepam is its lack of active metabolites. Conversely, other benzodiazepines should be selected for renal dysfunction.

Patients with cancer often have symptoms of both anxiety and depression that are caused by cancer-treatment stressors. These symptoms of distress often are resolved with psychologic support alone. If the symptoms are manifestations of a depressive disorder, however, pharmacologic management is best achieved with antidepressant medication that has sedative properties (e.g., amitriptyline or doxepin) or with a serotonin reuptake inhibitor.[7] One meta-analysis of pediatric antidepressant clinical trials [8] found antidepressants efficacious relative to placebo in the treatment of anxiety disorders, with strongest effects in non–obsessive-compulsive disorder (OCD) anxiety disorders (e.g., generalized anxiety disorder or social anxiety disorder) and intermediate effects in OCD. (Refer to the PDQ summary on Depression for a discussion of the risk of suicidal ideation/suicide attempt associated with antidepressant use.)

Akathisia usually can be quickly controlled by stopping or changing the offending drug (if possible) or by the addition of a benzodiazepine, or a beta blocker such as propranolol. Treatment of withdrawal depends on the particular agent. Sometimes the goal is to stabilize the patient on the agent (e.g., a benzodiazepine), and sometimes a suitable substitute can be given (e.g., a benzodiazepine for ethanol).

In general, patients with cancer need to be encouraged to take sufficient amounts of medication to relieve anxiety. Medications are readily tapered and discontinued when symptoms subside. Concerns about addiction are exaggerated in patients with cancer and often interfere with adequate symptom relief.

References

1. Breitbart W: Identifying patients at risk for, and treatment of major psychiatric complications of cancer. Support Care Cancer 3 (1): 45-60, 1995.  [PUBMED Abstract]
   
   
2. Johnson J: I Can Cope: Staying Healthy with Cancer. 2nd ed. Minneapolis, Minn: Chronimed Pub., 1994. 
   
   
3. Hinshaw DB, Carnahan JM, Johnson DL: Depression, anxiety, and asthenia in advanced illness. J Am Coll Surg 195 (2): 271-7; discussion 277-8, 2002.  [PUBMED Abstract]
   
   
4. Montazeri A, Jarvandi S, Haghighat S, et al.: Anxiety and depression in breast cancer patients before and after participation in a cancer support group. Patient Educ Couns 45 (3): 195-8, 2001.  [PUBMED Abstract]
   
   
5. Gil KM, Mishel MH, Germino B, et al.: Uncertainty management intervention for older African American and Caucasian long-term breast cancer survivors. J Psychosoc Oncol 23 (2-3): 3-21, 2005.  [PUBMED Abstract]
   
   
6. Reddick BK, Nanda JP, Campbell L, et al.: Examining the influence of coping with pain on depression, anxiety, and fatigue among women with breast cancer. J Psychosoc Oncol 23 (2-3): 137-57, 2005.  [PUBMED Abstract]
   
   
7. Massie MJ: Anxiety, panic, and phobias. In: Holland JC, Rowland JH, eds.: Handbook of Psychooncology: Psychological Care of the Patient With Cancer. New York, NY: Oxford University Press, 1989, pp 300-9. 
   
   
8. Bridge JA, Iyengar S, Salary CB, et al.: Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials. JAMA 297 (15): 1683-96, 2007.  [PUBMED Abstract]
   
   

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