General Factors Influencing Adjustment
Specific Influences on Adjustment
        Hearing the Diagnosis
        Cancer Treatments
        Post-Treatment
        The Return of Cancer
        Survivorship

Adjusting to cancer is an ongoing process in which the patient learns to cope with emotional distress, solve cancer-related problems, and gain control over cancer-related life events. Patients are faced with many challenges that change as the disease and its treatment change. Common periods of crisis and significant challenge include hearing the diagnosis, receiving treatment (for example, surgery, radiation therapy, and chemotherapy), completing treatment, hearing that the cancer is in remission, hearing that the cancer has come back, and becoming a cancer survivor. Each of these events involves specific coping tasks, questions about life and death, and common emotional problems.

Patients are better able to adjust to a cancer diagnosis if they are able to continue fulfilling normal responsibilities, cope with emotional distress, and stay actively involved in activities that are meaningful and important to them.

Coping is the use of thoughts and behaviors to adjust to life situations. A person's coping style is usually related to his or her personality (for example, always expecting the best, always expecting the worst, being shy or reserved, or being outgoing).

Coping strategies are thoughts and behaviors that are used in rare situations, for example, when one must change his or her daily routine or work schedule to adjust to the side effects of cancer treatment. Developing coping strategies can help a patient learn how to change problem situations, manage emotional distress, and understand why cancer has happened and what impact cancer may have on his or her life. Patients who adjust well are usually committed and actively involved in coping with cancer. They are still able to find meaning and importance in their lives. Patients who do not adjust well become less involved with coping, withdraw, and feel hopeless. Studies are looking at how different types of coping strategies affect the quality of life for cancer survivors.

Distress can occur when a person feels that he or she does not have the resources to manage or control the cancer. Distress experienced by patients who have the same diagnosis and are undergoing the same treatment may be very different. A doctor or health care professional can help the patient adjust to the treatment schedule and/or help the patient cope with treatment by, for example, providing medication for nausea.

Many individual differences affect how a patient adjusts to cancer. It is difficult to predict how a person will cope with cancer. The following factors influence how a patient adjusts to cancer:

• The type of cancer, cancer stage, and chance of recovery.



• The phase of cancer such as newly diagnosed, being treated, in remission, or recurrent cancer.



• Individual coping abilities.



• Whether or not the patient tends to focus on the most hopeful side of situations.



• Friends and family available to support the patient.



• The patient's age.



• The availability of treatment.



• Beliefs about the cause of cancer.

The process of adjusting to cancer can begin even before hearing the diagnosis. Patients may experience normal levels of fear, worry, and concern when they have unexplained symptoms or are undergoing testing to determine if they have cancer. When a patient hears the diagnosis of cancer, many patients wonder, "Could I die from this?"

Receiving a diagnosis of cancer can cause expected and normal emotional distress. Some patients may feel disbelief and ask, "Are you sure you have the right test results?" Most patients feel they are unable to think clearly. They may feel numb or in shock, or as if "This can't be happening to me." Many patients may not understand or remember important information that the doctor gave them about the diagnosis and treatment options. Patients should have a way to review this information by having someone with them at appointments, requesting that the session be taped, or by requesting a second appointment to ask the doctor questions and go over the treatment plan. As the patient gradually accepts the reality of the diagnosis, he or she may begin to experience depression, anxiety, lack of appetite, inability to sleep, poor concentration, and varying degrees of inability to function in daily activities. There can be high levels of stress for newly diagnosed patients awaiting surgery. Extra professional support to help deal with problems such as fatigue, insomnia, and depressed mood can be helpful during this time. When the patient receives and understands information about treatment options, he or she may gradually feel more hopeful and optimistic. Eventually, patients develop ways to cope and to adjust to the cancer diagnosis.

When cancer treatment begins, patients may experience fears about painful procedures, unwanted side effects (for example hair loss, nausea and vomiting, fatigue, pain), and interruptions to normal activities and responsibilities (for example being unable to work). Patients who can weigh the discomforts of short-term loss against the benefits of long-term gain (for example living longer) and decide, "It's worth it" usually adjust well. Questions that patients may ask during treatment include, "Will I survive this?"; "Will they get it all?"; or "What side effects will I experience?" As these questions arise, patients will learn to adjust with them. Developing ways to cope with specific problems (for example fatigue, transportation to treatment, and work schedule changes) is helpful.

Completing cancer treatment can cause mixed feelings. It may be a time of celebration and relief or a time of increased anxiety with awareness that the cancer could return once the treatment is stopped. Patients who can balance their positive expectations with the realities of ongoing fears adjust well. Many patients experience increased anxiety and fear of the cancer returning as they have less frequent contact with their physician. Other adjustment concerns include living with uncertainty, resuming previous responsibilities, and being overly concerned about health. During remission, patients often experience normal anxiety and worry as the dates of regular follow-up appointments with their oncologist approach with the possibility that the cancer has returned.

A study of women with early-stage breast cancer suggests that patients who have more physical symptoms and side effects during treatment are more likely to have distress following treatment.

Normal adjustment to post-treatment and remission may involve using the following coping strategies to help control normal emotional distress:

• Being honest with one's emotions.
• Being aware of one's feelings and able to express them to others.
• Having a nonjudgmental acceptance of one's feelings and a willingness to work through these emotions.
• Having support from others who are willing to listen and accept.

Patients who can express a wide range of both positive and negative emotions usually adjust well.

Changing from a treatment plan that focuses on curing the cancer to one that provides comfort and relief of symptoms can cause extreme anxiety. Patients may experience shock, disbelief, and denial followed by a period of significant distress (for example, depressed moods, difficulty concentrating, and frequent thoughts of death). Normal adjustment may include periods of sadness and crying, feelings of anger at God or a higher power, periods of withdrawal and isolation, and thoughts of giving up. Patients gradually adjust to the return of cancer over a period of weeks by changing expectations from curing to healing. Healing is a process of "becoming whole again" by transforming one's life in many ways in the face of death. It is very important that the patient maintain hope throughout this process. Patients who believe that pain and suffering can be controlled will have hope for future quality of life. Those who believe they are loved and cared for will have hope in future relationships. Religion and spirituality are very important in helping patients maintain hope.

The adjustment from completing cancer treatment to a long-term survivorship is a gradual process that extends over many years. Some common problems reported by cancer survivors as they face the future include fear of the cancer coming back, lasting physical effects such as tiredness, problems sleeping, and concerns about sexual function. Most patients adjust well and some even report benefits of having cancer such as a greater appreciation of life, changes in life values, and stronger spiritual or religious beliefs. Patients who do not adjust well usually have more medical problems, fewer friends and family who provide support, fewer financial resources, and problems with psychological adjustment unrelated to the cancer.

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