e-book Treatment of Cancer Fifth Edition

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By McCready had acquired the practical skill of receiving direct tuition from guiding spirits in highly reliable and accurate way. In he ceased all building and maintenance operations and moved to London in order to start a new career in spiritual advancement. In this he was guided by one simple defining vision, he would, for the foreseeable future, have an Earthly occupation of connecting human beings to their higher spiritual faculties. He soon realized that when clients asked him. This best-selling self-help book for cancer patients and their families, by five practicing physicians and professors of medicine from Toronto and Vancouver, is the definitive authority on all aspects of breast cancer.

Patients with panic attacks often present with symptoms that can be difficult to differentiate from other medical disorders, though a known history of panic disorder can help clarify the diagnosis. Panic disorder in patients with cancer is most often managed with benzodiazepines and antidepressant medications [ 5 ] but also responds well to CBT. Generalized anxiety disorder is characterized by ongoing, unrealistic, and excessive anxiety and worry about two or more life circumstances, to a degree that is pervasive and does not respond to either reassurance or contrary evidence.

The following physical symptoms may be reported but do not have the sudden onset or intensity of panic attacks:. Obsessive-compulsive disorder OCD is characterized by persistent thoughts, ideas, or images obsessions and by repetitive, purposeful, and intentional behaviors compulsions that a person performs to manage his or her intense distress. Patients with cancer who have a history of OCD may engage in compulsive behaviors such as hand washing, checking, or counting to such an extent that they cannot comply with treatment. For such patients, normal worry about the cancer diagnosis and prognosis can develop into full obsessive-compulsive symptoms and be severely disabling.

Milder obsessive thoughts or use of rituals that are not interfering might be addressed with CBT, but medications are not indicated.

This disorder is rare in cancer patients who do not have a premorbid history of some type of anxiety disorder. Cancer survivors have been known to develop health anxiety disorder related to their fears of recurrence, including hypervigilance to potential physical symptoms; somatization; extreme focus on cancer status; identification with the patient role in care settings; and requesting frequent care, even after high-maintenance care needs have ended including, but not limited to, requests for additional office visits and premature maintenance scans.

Effective management of anxiety disorders begins with a thorough and comprehensive assessment and an accurate diagnosis. The normal fears and uncertainties associated with cancer are often intense. Frequently not clear is the distinction between normal fears and fears that are more severe and reach the criteria for an anxiety disorder refer to Table 3 for more information.

To assess the severity of the anxiety, it is important to understand how much the symptoms of anxiety are interfering with activities of daily living. Screening for anxiety could include a brief self-report questionnaire that, if a defined cutoff score is exceeded, could then be followed by a more-thorough clinical interview.

A variety of general screening questionnaires have been used to identify distress. Refer to the Self-Report Screening Instruments section of this summary for more information.

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Other anxiety-specific self-report questionnaires e. The following is a list of symptoms designed to distinguish common or normal worry from more-serious symptoms of anxiety.

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When patients are reporting the more-serious symptoms, referral to a qualified mental health professional may be warranted. When anxiety is situational i. 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.

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Psychological approaches include combinations of cognitive behavioral therapy CBT techniques, insight-oriented psychotherapy, crisis intervention, couple and family therapy, group therapy, self-help groups,[ 22 ] and relaxation-based interventions. These 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. Refer to the Psychosocial Interventions for Distress section of this summary for more information. Referring patients who may be struggling with anxiety disorders for full assessment and psychological treatment will enhance participation in care, improve quality of life, and reduce the pain experience. One study of recurrence-free breast cancer survivors at 5 to 9 years posttreatment examined the usefulness of a comprehensive intervention that combined positive coping strategies based on CBT e.

Most women in the intervention group found the strategies very helpful. Preliminary evidence suggests racial differences in the use and benefit of specific coping strategies e. Patients with cancer often have symptoms of both anxiety and depression that are caused by stressors related to cancer treatment. Such symptoms of distress often are resolved with psychologic support alone. However, in some cases, pharmacologic interventions are required to address these symptoms. Refer to Table 3 for descriptions of symptoms of anxiety disorders possibly requiring pharmacological treatment.

Following are brief descriptions of pharmacological treatment options and potential indications for their use. These descriptions are based on evidence derived from studies conducted in patients without cancer because of the lack of such studies in patients with cancer. However, clinicians have used some of these medications for several decades to treat anxiety symptoms in patients with cancer.

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The treatment options and their use in the situations described below are also based on clinical experience with these agents in patients with cancer. The use of medications to treat anxiety disorders is considered when patients are experiencing more-severe symptoms or when their responses to psychosocial interventions are inadequate. When counseling resources are not available or are declined by the patient, medication may be considered sooner rather than later. In certain cases, medications are started simultaneously with psychosocial interventions when it is likely that psychosocial support alone will be inadequate to provide relief or to provide it soon enough.

Pharmacological interventions can be used short-term or long-term, depending on individual patient and illness factors, including the following:. Specific anxiety medications—i. These medications are effective in the acute treatment of anxiety disorders because of their rapid onset of action. Following are some of the indications and safety considerations for the use of benzodiazepines in patients with cancer:[ 27 , 28 ].

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. 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. All benzodiazepines can cause some degree of respiratory depression, which is generally minimal in patients who have not used benzodiazepines in the past.

Benzodiazepines should be used cautiously or not at all in cases of respiratory impairment. Standard precautions should be considered when any sedative drug is used 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 kidneys e.

Another advantage of using lorazepam is its lack of active metabolites. Conversely, other benzodiazepines should be selected in cases of renal dysfunction. SSRIs e.

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Atypical antidepressants e. Older medications, such as tricyclic antidepressants e. The use of antidepressants in clinical practice is limited by their unfavorable side effects, poorer tolerability, and higher risks of toxicity. Refer to the Suicide Risk in Cancer Patients section in the PDQ summary on Depression for more information about the risk of suicidality and other neuropsychiatric side effects.


Buspirone, a nonbenzodiazepine, is useful in patients who have not previously been treated with a benzodiazepine and in those who may abuse benzodiazepines e. Buspirone is also useful in the geriatric population to augment 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.

The use of specific classes of medications is considered for managing treatment-refractory anxiety symptoms or in certain special clinical situations. Low-dose neuroleptics e. Low-dose neuroleptics can also be used when benzodiazepines are not helpful or when there is the possibility of delirium, dementia, or other complications. Low-dose anticonvulsants e. Consultation with a psychiatric clinician is strongly recommended before these medications are used.