The best management of distress in a lung cancer patient involves aggressive physical symptom control, attention to concerns about death, and psychosocial support for the patient and his or her caregivers, as well as management of more typical psychiatric symptoms, such as generalized anxiety, panic attacks, or persistently depressed mood. In an ideal setting, the effort would include multidisciplinary support from palliative care and pain management specialists, physical therapists, nutritionists, social workers, psychiatrists, and psychologists. The patterns of physical and emotional distress seen in lung cancer patients respond well to several interventions available to the practicing oncologist; these patterns also suggest the appropriate direction for referral in more complex situations that require specialty care.
Lung cancer patients have a heavy burden of physical symptoms and increased rates of psychological distress when compared with patients with other cancers. Clinically significant distress in lung cancer patients has been measured in the range of 40%.[1] The relatively poor prognosis for lung cancer patients and the high frequency with which their disease is discovered at an advanced stage bring mortality concerns to the forefront, even in early-stage patients, as they may carry a significant risk of recurrence. Notably, an association between disease stage or treatment type and the level of distress has not been found.[2] The heavy symptom burden translates into increased debility, loss of functional capacity, and a need for more intense caregiving from those closest to the patient. As functional status declines, the incidence of depression reliably increases.[3,4]
Oncologists have been found to under-recognize depression and anxiety in their patients at rates varying from 30% to 80%, clearly indicating a need for standardized screening.[5,6] Recent recommendations suggest the Distress Thermometer or Patient Health Questionnaire (PHQ)-4, which are minimally burdensome, adequate screens that are available free of charge.[7]
Physical Symptom Management
The treatment of distress begins with assessment and aggressive treatment of physical symptoms. The most common physical symptoms reported in lung cancer patients are fatigue, pain, dyspnea, weakness, insomnia, nausea, poor concentration, and incoordination.[8] Fears about unmitigated physical suffering are common, and patients will benefit from education about the tools available for symptom control. The early introduction of palliative care is critical; it improves quality of life, decreases depression, reduces aggressive end-of-life care, and promotes longer survival.[9]
Mortality and Existential Concerns
Many lung cancer patients describe fears about death or dying, including fears about the process of death and unmitigated suffering, as well as the idea of crossing the threshold of death. These concerns are complex, and the distress around them can be decreased by simply offering an opportunity to discuss them. Patients fear loss of autonomy, pain, and loss of dignity, but may be reluctant to voice these things on their own. Inquiring about these concerns can be therapeutic and also offers a transition point for exploring end-of-life preferences.
Patients with advanced disease and distress around death can benefit from encouragement to be hopeful within realistic boundaries-specifically, to have hope that they will be able to maintain quality of life and connection to the meaningful elements in their life. Realistic prognostication allows patients to make reasonable plans to balance treatment goals with other important aspects of life.
Caregivers also undertake a journey with cancer patients and should be screened for distress. Individual or family therapy can be crucial in helping caregivers maintain a healthy, supportive connection through the course of treatment. For caregivers, education about the natural history of the disease and forecasting concerning the patient’s future needs can be useful for realistic planning and burnout prevention. An excellent resource for patients and families is the American Psychosocial Oncology Society (APOS), which maintains a website (www.apos-society.org) with resources and a helpline (1-866-APOS-4-HELP) that can facilitate connecting with mental health providers.
Dyspnea and Anxiety
Problematic anxiety is found in 25% or more of lung cancer patients.[10] Physiologically based anxiety related to breathing problems must be distinguished from psychologically based anxiety. Hypoxia/hypercarbia or increased work of breathing from pulmonary embolus, pneumonia, sepsis, anemia, lymphangitic carcinomatosis, airway obstruction, compressive ascites, or chronic obstructive pulmonary disease must be ruled out before considering other sources of anxiety.
Opioids have the greatest proven benefit for palliation of air hunger in irreversible physiologic lung disease but must be used judiciously to avoid respiratory suppression. Supplemental oxygen may be helpful for desaturation, but evidence is mixed in nonhypoxic patients. It is important to note that benzodiazepines have not been found to improve the anxiety associated with air hunger and physiologic breathing problems, and therefore should not be used for that purpose. Referral to pulmonary rehabilitation specialists is helpful. Psychotherapeutic interventions, relaxation therapy, and counseling are ineffective for this type of anxiety.[11]
Key Points for the Psychiatric Management of Lung Cancer Patients
- Early referral to palliative care and aggressive symptom control are essential components of the psychiatric care of lung cancer patients. Collaboration with physical therapists, pain management specialists, counselors, and family support services reduces patient distress and improves quality of life.
- Ambulatory screening of lung cancer patients is feasible and high-yield, given the frequency with which their distress needs are undetected and unmet.
- Physiologic causes of anxiety secondary to lung dysfunction must be addressed before employing more psychologically oriented interventions.
- Side effects of some psychotropics can be used to improve sleep, appetite, nausea, concentration, diarrhea, and anergia.
When anxiety exists independently of respiratory deficits, both psychological and pharmacologic treatments can be employed. Evidence supports the efficacy of both breathing exercises and cognitive behavioral therapy, and referrals to providers with expertise in these areas should be pursued. For short-term, intermittent anxiety, benzodiazepines can be helpful, but these agents should be prescribed with care, avoided in patients with a history of misuse of alcohol or other substances, and used only minimally in elderly and frail patients. I prefer to use shorter-acting lorazepam in doses of 0.5 mg to 1 mg, taken up to twice daily. If the patient requires lorazepam more than once daily on a consistent basis for the treatment of anxiety, then standing medications like selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, or mirtazapine are indicated.
Debility and Depression
Screening for depression in cancer patients is confounded by the presence of neurovegetative symptoms that are a result of the cancer and treatment but are also suggestive of psychological distress. For example, lung cancer patients typically exhibit fatigue, insomnia, poor appetite, and decreased concentration. Thus, in the setting of cancer, it is useful to focus on psychologically based criteria-such as social withdrawal, tearfulness or sad affect, pessimism, hopelessness, or blunted and poorly reactive affect in conversation-for the detection of depression.[12]
Hypoactive delirium is not uncommon in this group of patients, particularly those with more advanced disease and those close to the end of life. Depression and delirium are easily confused, and care should be taken to assess for delirium and to treat reversible causes when it is found.
Insomnia and Fatigue
Insomnia is common in lung cancer patients and may be attributed to pain, nausea, dyspnea, anxiety, or depressed mood. Nonpharmacologic treatments should be attempted first, including daytime sleep restriction, increased daytime activity and exercise, and education on good sleep hygiene. The treatment of daytime fatigue will often improve nighttime sleep and day/night separation. Persistent sleep problems warrant referral to a sleep specialist. Insomnia and fatigue frequently exist in a mutually reinforcing pattern.
Moderate to severe fatigue is found in 40% of lung cancer patients at the time of initial presentation, and this rate may increase to 90% over the course of treatment.[13] Treatment of fatigue includes energy conservation strategies, physical therapy, and the use of stimulants like methylphenidate, amphetamine salts, and modafinil/armodafinil. Physical therapy has the strongest evidence supporting efficacy and also has collateral benefit to strength, mood/anxiety, appetite, sleep, cognition, and maintenance of muscle mass in cachectic patients. Published evidence for amphetamines indicates equivocal benefit; however, my clinical experience is that these agents can be useful not only for fatigue but also in improving appetite and cognition. Stimulants can also improve sleep through increased daytime activity and day/night separation.
Smoking Cessation
Smoking cessation should be pursued for all smokers. Smoking accounts for 30% of all cancer deaths and 80% of lung cancer deaths. “Light” or “low-tar” cigarettes do not reduce the risk of lung cancer. There is evidence that smoking cessation can offer a more than twofold improvement in long-term survival for early-stage lung cancer patients.[14] The benefits of smoking cessation in advanced disease are less clear, but increased time to progression and prolonged survival are suggested. Varenicline, bupropion, and nicotine replacement are all helpful, and evidence has shown that healthcare provider encouragement is pivotal in helping patients stop smoking.
Pharmacotherapy Choices
Pharmacotherapy can be guided by the intent of using side effects to benefit the patient. The following medications are particularly useful in the management of lung cancer patients. Notes on particular risks are also included.
Mirtazapine, 7.5 mg to 30 mg daily at bedtime: Indicated for depression but also helpful for anxiety. Collateral benefit to sleep and appetite/nausea; may slow bowel transit. Anticholinergic side effects require caution in elderly patients.
Escitalopram, 5 mg to 20 mg daily: Indicated for anxiety and depression. This agent is my preference because of limited side effects and minimal interaction with other drugs via CYP3A4 metabolism. May require QTc interval monitoring; risk of arrhythmia is particularly increased with the concurrent use of ondansetron. May exacerbate nausea.
Olanzapine, 2.5 mg to 10 mg daily at bedtime or twice daily: Indicated for psychosis, bipolar disorder, and depression. It is helpful for anxiety, with collateral benefit to sleep, nausea, and appetite. It causes QTc prolongation and metabolic side effects, including hyperglycemia and hypercholesterolemia, which require monitoring in long-term use.
Bupropion extended-release, 150 mg to 300 mg daily: Indicated for depression and attention-deficit/hyperactivity disorder; also useful to support smoking cessation. It can offer benefit to concentration and anergia. It does not typically cause sexual side effects. It may increase anxiety and should be used cautiously in anxious patients.
Financial Disclosure:The author has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.
References:
1. Zabora J, BrintzenhofeSzoc K, Curbow B, et al. The prevalence of psychological distress by cancer site. Psychooncology. 2001;10:19-28.
2. Graves KD, Arnold SM, Love CL, et al. Distress screening in a multidisciplinary lung cancer clinic: prevalence and predictors of clinically significant distress. Lung Cancer. 2007;55:215-24.
3. Hopwood P, Stephens RJ. Depression in patients with lung cancer: prevalence and risk factors derived from quality-of-life data. J Clin Oncol. 2000;18:893-903.
4. Kurtz ME, Kurtz JC, Stommel M, et al. Predictors of depressive symptomatology of geriatric patients with lung cancer-a longitudinal analysis. Psychooncology. 2002;11:12-22.
5. Werner A, Stenner C, Schüz J. Patient versus clinician symptom reporting: how accurate is the detection of distress in the oncologic after-care? Psychooncology. 2012;21:818-26.
6. Fallowfield L, Ratcliffe D, Jenkins V, Saul J. Psychiatric morbidity and its recognition by doctors in patients with cancer. Br J Cancer. 2001;84:1011-5.
7. Pirl WF, Fann JR, Greer JA, et al. Recommendations for the implementation of distress screening programs in cancer centers: report from the American Psychosocial Oncology Society (APOS), Association of Oncology Social Work (AOSW), and Oncology Nursing Society (ONS) joint task force. Cancer. 2014;120:2946-54.
8. Gift AG, Jablonski A, Stommel M, Given CW. Symptom clusters in elderly patients with lung cancer. Oncol Nurs Forum. 2004;31:202-12.
9. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363:733-42.
10. Brintzenhofe-Szoc KM, Levin TT, Li Y, et al. Mixed anxiety/depression symptoms in a large cancer cohort: prevalence by cancer type. Psychosomatics. 2009;50:383-91.
11. Bausewein C, Booth S, Gysels M, Higginson I. Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database Syst Rev. 2008;(2):CD005623.
12. Endicott J. Measurement of depression in patients with cancer. Cancer. 1984;53:2243-9.
13. Hui D, Bruera E. Palliative care for patients with lung cancer. In: Stewart DJ, ed. Lung cancer: prevention, management, and emerging therapies. New York, NY: Humana Press; 2010. p. 483-502.
14. Parsons A, Daley A, Begh R, Aveyard P. Influence of smoking cessation after diagnosis of early stage lung cancer on prognosis: systematic review of observational studies with meta-analysis. BMJ. 2010;340:b5569.
