Uncertainty In The Cancer Journey By Psychiatrist, Dr Arun Subramaniam

20 Aug 2021
Dr Arun Subramaniam, psychiatrist in private practice. My special interests include the treatment of anxiety, depression and post-traumatic stress disorder. I have considerable experience working with patients suffering from cancer as well as other medical illnesses. I also treat mothers with postnatal psychiatric illness.
One of the biggest issues for patients with an increased risk of cancer or for those undergoing cancer treatment is the extent of uncertainty involved.

Although uncertainty is a normal fact of life, this feeling is escalated when there is a family history of cancer or when one is determined to have an increased risk following genetic testing. As human beings, we all want certainty and control. It is therefore natural to feel overwhelmed by uncertainty. This uncertainty, in some instances, can contribute to clinical anxiety.

It is important to distinguish between normal anxiety and clinical anxiety. Everyone has some degree of anxiety, this is regarded as normal. Clinical anxiety is when the person is on edge almost all of the time and unable to focus on daily life in a meaningful way. The person may also suffer physical symptoms of anxiety, including a raised heart rate, feeling hot, gut issues or other psychosomatic concerns.

It is appropriate to note that many patients experiencing cancer may not necessarily develop a psychiatric illness. The risk of psychiatric illness is increased when the person has a previous history of a psychiatric condition. Other risk factors include a family history of psychiatric illness. Childhood adversity and trauma can also predispose one to mental illness.

Coming back to uncertainty, there are different aspects to this concern. The person may be concerned about a high risk of developing cancer because of BRCA 1 or 2 mutation. Genetic counselling will form an important part of this testing process, and patients will be assisted in processing the information and risk.

For patients in remission from cancer, the risk of recurrence is a concern. This of course depends on the stage and grade of illness. The treating oncologist will usually be able to provide a sense of the prognosis and some statistics.

From my point of view, as a psychiatrist, the discussion around uncertainty would involve embracing some degree of ‘not knowing’ while supporting the patient to continue in their regular life. There are some things under the patient’s control and some things beyond the patient’s control. It is important to focus on what can be done, this might include spending time with a loved one, watching a film, playing a board game or finishing a pet project. Travel is another important consideration, although this has been hampered by Covid.

A sense of agency can often help a person feel better about themselves.

If there is clinical anxiety, this can be treated with psychotherapy and medication if required.

Another major concern for patients undergoing cancer treatment is the side effects of treatment and its impact on quality of life. In this scenario, it is very important for clinicians to listen to the patient’s story and validate their narrative.

Side effects including nausea, hair loss and fatigue - these can majorly interfere with daily life. However, even in the midst of a storm, the patient can have moments when they feel free from side effects and psychological stress. It is generative to make the best use of these moments.