Psychological Responses and Coping Strategies in Skin Cancer Patients

Introduction

Despite continued progress in the clinical management of malignant skin diseases, the diagnosis of skin cancer, including melanoma and non-melanoma skin cancer (NMSC), remains a difficult time in the lives of many patients and their families. The psychosocial care of a person with skin cancer begins from the time of initial diagnosis, through treatment, recovery and survival, or through the transition from curative to non-curative aims of treatment, initiation of palliative care, death and bereavement. Each patient and their family and friends will experience a range of practical, emotional, physical, and social challenges as a result of their cancer diagnosis and treatment, and these challenges may continue to have an impact on some people long after their initial diagnosis. A diagnosis of skin cancer has the potential to change many aspects of an individual's life, from self-identity, body image, self-esteem, and perceived well-being, to family roles and relationships, sexuality, career opportunities, friendships, and finances. These changes are likely to manifest differently depending on the type of skin cancer diagnosed, as well as a range of other clinical, demographic, and psychosocial factors. Patients experience shock, fear, sadness, and/or anger at the time of diagnosis, and some will also have to face progressive illness and approaching death. Psychological distress has been associated with: patient delay in seeking medical advice; decreased adherence to treatment regimens; increased rates of cancer recurrence, morbidity and mortality; lower quality of life; greater medical costs; and reduced engagement in post-treatment screening and preventive behaviors. Understanding the range of emotional, physical and behavioral responses to skin cancer diagnosis (see Table 62.1 ), as well as effective and sustainable interventions to reduce distress, remain important clinical and research endeavors.

Psychological challenges associated with early-stage skin cancers

The fact that most skin cancers are detected early and are associated with good prognosis, coupled with the often healthy outward appearance of NMSC and early-stage melanoma patients, may contribute to the prevailing belief that such patients have ‘little or nothing to worry about’. Despite a good prognosis, however, early-stage melanoma patients deal with both the immediate stress of being diagnosed with a possibly life-threatening disease, as well as the threat of recurrence or systemic spread, which is greatest during the first 2 years after diagnosis but may occur within 10 years of diagnosis. Throughout the diagnostic process, patients with melanoma report significant reductions in emotional functioning and quality of life, as well as greater fatigue and sleep problems. Research suggests that many patients experience the period between detection of a suspicious lesion and skin biopsy as the most stressful time in the diagnostic process, possibly indicating anxiety about the prospect of surgery. Some patients experience an underlying fear of disfigurement caused by surgery, and the visibility of treatment-related scarring may form a constant reminder of the individual's cancer experience. The degree of tissue loss with loss of contour as a consequence of skin grafting rather than primary closure, and the discrepancy between the actual size of a scar and pre-surgery expectations may all contribute to emotional distress. With approximately 20% of melanomas and 80% of NMSCs occurring on the head and neck, disfiguration and change in bodily appearance may threaten patients' self-esteem and self-confidence, especially in younger adults. Family, friends, and clinicians may not recognize the need for social and psychological support of seemingly high-functioning NMSC and early-stage melanoma patients ( Table 62.2 ).

Prevalence of psychological distress in patients with skin cancer

Approximately 30% of all patients diagnosed with melanoma report levels of psychological distress indicative of the need for clinical intervention, most commonly in the form of anxiety and/or depression with significant interference in daily life. While anxiety and depression commonly coexist, anxiety is uniquely characterized by symptoms of excessive, pervasive and uncontrollable worry or fear, whereas depression is typified by symptoms of low mood, intense and prolonged sadness, increased irritability, social withdrawal, and diminished interest or pleasure in most activities. Gibertini et al. reported that approximately one in five newly diagnosed, non-metastatic melanoma patients have some form of depression. Approximately one in four melanoma patients beginning chemotherapy report clinically relevant levels of anxiety. Overall, anxiety appears to be more prevalent than depression at both the diagnostic and treatment phases, with the proportion of participants within the clinical range for anxiety and depression found to be around 23% and 11%, respectively.

The proportion of patients with melanoma who report clinically significant levels of distress is equivalent to that identified in breast and colon cancer patients, and demonstrably higher than that reported by patients with gynecological or prostate cancer. There is, however, substantial variability between studies in regard to the prevalence of reported anxiety and depression. Such variation may reflect important differences between study samples in terms of disease stage, time since diagnosis or treatment, involvement in clinical trials, environmental conditions (e.g. areas of high versus low exposure to ultraviolet radiation), or cultural attitudes and beliefs.