Perhaps the most intriguing and interesting findings of this report come from the analysis of the effect of anxiety disorders on aspects of the doctor-patient relationship. We were unable to locate other studies addressing how psychological disorders in cancer patients affect trust, patient understanding, comfort, and how they feel their physicians view them and their care. In this study we found that advanced cancer patients with anxiety disorders have less trust in their physicians, are less comfortable asking questions about their health, and also feel less able to understand the medical information that their physicians share with them. These patients were also more likely to believe that their physicians would provide futile care, and less likely to believe that their physicians did an adequate job controlling their pain. Finally, they were also less likely to feel as if their physicians treated them as a whole person.
The trust that a patient places in his/her physician is the foundation of the therapeutic relationship and it is what makes the patient an effective partner and participant in health care delivery22
. Trust has been shown to be one of the attributes valued most by patients and is taught from the first day of medical school23,24
. The relationship between anxiety disorders and decreased trust is vitally important as diminished trust can be a factor in communication breakdown, missing appointments, decreased adherence to therapeutic regimens and recommendations, and an overall sense of dissatisfaction with care16,22,25
Additionally, advanced cancer patients with anxiety disorders were more likely to report a decreased understanding of doctors’ explanations of their health and care. This is a concern since patients that feel knowledgeable and informed are more likely to adhere to prescribed medication regimens and health-related behavioral modifications26
. Health care providers should be aware that patients who are not adherent to recommendations or those not comfortable in discussing and asking questions about their health status and care may be suffering from an anxiety disorder and merit further evaluation.
Another finding that could have significant clinical implications is that advanced cancer patients with anxiety disorders feel like their physicians do a poorer job at making them comfortable – including poorer pain control. The importance of this finding is that the primary treatment strategy for many patients with advanced cancer (i.e. those with distant metastases) is pain control and comfort given that cure is not the therapeutic goal. This finding suggests that the efforts of the oncologist, primary care physician, or palliative care specialist to alleviate pain and provide comfort for these patients could be subverted, and further suggests the importance of screening patients for psychiatric disorders in order to treat patients appropriately.
Interestingly, while advanced cancer patients with anxiety disorders reported increased difficulties with their doctor-patient relationships, this did not lead to an increase in aggressive care measures utilized at the EOL. This may seem contrary to what we would expect or have experienced in caring for advanced cancer patients, anxious patients, and those with diagnosed/diagnosable anxiety disorders. One explanation is that only 7.6% of the studied advanced cancer patients met diagnostic criteria for an anxiety disorder. A much larger percentage may have sub-syndromal levels of anxiety. Statistical power limitations associated with the relative rarity of anxiety disorders may have inhibited our ability to detect more subtle associations between anxious symptoms and care.
As mentioned above, we found the prevalence of anxiety disorders (i.e., Generalized Anxiety Disorder, Panic Disorder, Posttraumatic Stress Disorder) among advanced cancer patients to be 7.6%. Several studies have previously reported a wide range of estimates for the incidence of anxiety in cancer patients—from 6–34%1–7
. In this study we used the SCID to diagnose anxiety disorders. Although this method requires intensive interviews, it is the gold standard for diagnosing psychiatric disorders, unlike other survey instruments that estimate cases using cut-off scores based upon symptoms; e.g. the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), Hospital Anxiety and Depression Scale (HADS), Composite International Diagnostic Interview (CIDI), Monash Interview for Liaison Psychiatry (MILP), Memorial Anxiety Scale for Prostate Cancer (MAX-PC), or the Generalized Anxiety Disorder Questionnaire (GAD-Q).
We also report here that advanced cancer patients who are younger and female are more likely to meet diagnostic criteria for an anxiety disorder. These findings differ from Stark’s and House’s27
earlier findings which showed that traditional risk factors for anxiety—age, marital status, social class and education—did not apply to cancer patients. Our results, while novel within the cancer literature, are consistent with studies in outpatient and inpatient settings, which have shown that younger, female patients are at higher, risk for anxiety disorders28,29
. It is likely that a confluence of factors explain why these individuals are at risk for anxiety, including contributions from genetic and heritable traits, perceived external trauma, stress, and distinct neural pathways30,31
. With the exception of PTSD, which occurs after a traumatic event, anxiety disorders usually present earlier in life with peak ages of onset years before the mostly mid- to late-life diagnoses of cancer.
We also found that anxiety disorders were associated with lower Karnofsky scores among advanced cancer patients. Patients with anxiety disorders had nearly a 10 point difference in their performance status, which is roughly equivalent to the difference between being able to care for oneself (KPS score of 70) and having to depend upon others for assistance in activities of daily living (KPS score of 60). This distinction is not trivial. It marks a difference between a patient who has total independence and one who has began to lose a portion of that independence. The initiation of a loss of independence can be itself psychologically detrimental to both patient and family as well as economically challenging as increased care either inside or outside of the home is often required.
Although cancer-care providers often use giving information and reassurance to these patients as first line “treatment,” we know that does not effectively combat the anxiety that advanced cancer patients experience -- especially as they approach death. Stark et al32
showed that reassurance may not reduce cancer patients’ anxiety; and may actually serve to increase anxiety in the most severely afflicted patients.
Those who care for advanced cancer patients at the EOL must be attuned to the fact that an anxiety disorder may be undermining the physical, emotional and psychological well-being of their patients. Reports continue to show that physicians are notoriously poor at recognizing patients with psychiatric morbidity33–36
, referring them for the appropriate services, or adequately treating the disorder9
. Our study supports this assertion by demonstrating that advanced cancer patients with anxiety disorders are no more likely than advanced cancer patients without anxiety disorders to receive anxiolytic therapy (). This suggests a need for clinicians to become better versed in screening for anxiety disorders and making referrals to mental health professionals in order to provide appropriate treatment.
The development of a screening system for anxiety disorders in cancer patients would be a valuable step forward in helping affected patients while ideally not requiring a burdensome amount of already scarce clinician time and effort. We advocate screening for advanced cancer patients to not only aid in the diagnosis and treatment of those with anxiety disorders, but also to distinguish them from patients who have adjustment disorders with anxious features—a more prevalent diagnosis that is often given to patients with poorly defined distress related to their cancer diagnosis. Effective treatments for anxiety disorders exist whereas those for adjustment disorders are not well established. The comparisons and intricacies of these two distinct diagnoses still need to be investigated within a population of advanced cancer patients and is an important area of focus for future research.
We are unaware of any published, randomized clinical trials for the treatment of anxiety among advanced cancer patients. Nevertheless, we can extrapolate from other work that has suggested that prompt diagnosis and appropriate treatment of anxiety disorders alleviates patients’ suffering along with its associated physical and psychological sequelae4,5,36
These results were generated from a prospective cohort study of advanced cancer patients assessed at baseline and followed through death after which a postmortem assessment was conducted. Future research that examines the effects of the treatment of anxiety in advanced cancer patients is needed to show that anxiety can be effectively reduced in this population--and that appropriately treated anxiety is associated with improvements in physician-patient relationships, advanced cancer patients’ quality of life and quality of death.
While this study shows how anxiety disorders can be detrimental to the physical, interpersonal, medical, and emotional well-being of advanced cancer patients, it is possible that some additional effects are not able to be seen because of the relatively low prevalence of anxiety disorders in this population (i.e. possible effects on EOL outcomes or EOL care decisions). This sample may also underestimate the rates of anxiety disorders because all of the participants were required to have an informal caregiver, which may have excluded patients who had less social support, perhaps because of their anxiety. Our hope is that this work will continue to bring to the forefront the necessity of careful assessment of anxiety disorders in advanced cancer patients.
To our knowledge this is the first study to show that anxiety disorders have a detrimental effect on the doctor-patient relationship and by extension may lead to poorer outcomes for these patients. Oncologists, palliative care specialists, and primary care physicians alike have the opportunity to alleviate at least some of the anxiety and subsequent suffering of the advanced cancer patients for whom they provide care. In order to further develop a comprehensive understanding of the effects of anxiety disorders on advanced-cancer patients, the focus of future research includes determining the best approaches to screening, referral and treatment of anxiety disorders in this population. Additionally, future work should explore if, and how patients with anxiety disorders have been treated prior to their cancer diagnosis, with particular reference to treatment failures, successes, and relapses.