Cancer can take an enormous emotional toll on older people’s mental health. Kathy Oxtoby reports on what practitioners – whatever their specialty - can do to support them.
Phil Morris can clearly recall the moment he was diagnosed with testicular cancer. “It’s like suddenly being told that you’re mortal – and you’re not really in control of your life.
“Putting on a ‘brave face’ is physically draining. You get really depressed, tired, wound up and stressed. And you get to a point where you think ‘I can’t do this anymore’.”
A supportive practitioner encouraged him to seek counselling. And recognising there were many men like him ‘silently’ trying to cope with this condition, he founded Testicular Cancer UK so that others had somewhere they could seek support too.
This June, the charity is running a mental health and cancer campaign to raise awareness about these issues, and remind people with cancer that it’s good to talk, and that they’re not alone.
According to the Mental Health Foundation one in three people with cancer will experience a mental health problem such as depression or anxiety disorders before, during or after treatment.
But Mr Morris believes most patients with cancer can expect it to have some impact on their mental health at some point. “Large or small, these problems hit them eventually,” he says.
Cancer has enormous emotional impact on patients
As many people understand only too well, cancer, and the associated symptoms, treatment and aftermath, can have an enormous emotional impact on patients, their families, and carers. The Mental Health Foundation says: “The experience of being diagnosed, feelings of hopelessness and uncertainty around survival and death, can all have a detrimental impact on patients' wellbeing.
“The stigma surrounding both mental and physical health conditions, such as lung cancer, can exacerbate feelings of guilt and shame. The physical symptoms of specific cancers can also impact mental health (such as incontinence and sexual dysfunction). These are some of the factors that together place people living with cancer at heightened risk of developing common mental health conditions.
“Despite this, the combination of cancer and poor mental health has generally received little research attention.”
The Mental Health Foundation’s own research has found that mental health problems often arise at the very end of cancer treatment, when patients normally expect to recover, with little or no emotional support at hand.
“Once treatment stops, and people leave strictly managed clinical environments, survivors describe feeling as though they had 'fallen off a cliff edge'. The sudden loss of support often leaves people feeling isolated and abandoned at a time when support is needed the most,” the Mental Health Foundation says.
Of the people the charity interviewed for its report ‘Supporting the emotional and mental health needs of people with cancer’, 49% said they received no support or advice from health services about managing their mental health through cancer. More than half (66%) said they were not informed at all about potential mental health problems that could arise at the end of treatment.
Mr Morris and members of his support charity know only too well that the trigger for anxiety and stress can be when the treatment has finished and they must wait weeks and months for their scan results - and even years to potentially get the ‘all clear’.
“You’ve been in a whirlwind of treatment Then you leave hospital and wait to have a scan - that’s when anxiety kicks in. You’re expected to crack on with life while you’re wondering if the chemo has worked,” says Mr Morris.
Jessica Mitchell, a psychotherapist at The Goldfinch Practice, London, and a BACP member, has worked with people with cancer for a decade. She says a diagnosis of cancer “changes people’s worlds”, and leads to “a rollercoaster of emotions”, from enduring the pain of treatment and dealing with their own and family members’ anxieties, to facing the long term effects of cancer, and fear of dying.
Older people, cancer and mental health
Older people are particularly vulnerable when it comes to cancer and mental health issues. According to Cancer Research UK the highest incidence rates of cancer are in older people. In the UK in 2015-2017, on average each year more than a third (36%) of new cases were in people aged 75 and over.
Dr Cassandra Ng, co-chair of the BGS Geriatric Oncology Special Interest Group, says that “older people are more likely to live alone, and loneliness is common. Some are also already caregivers to others so may have a significant carer burden in addition to one’s own cancer diagnosis”.
She says lack of social support is a risk factor for mental health problems. Older people are also “less likely to recognise it as a problem early on, and often present late – usually when their mental health has already negatively impacted on their physical health, which adds complexity to treatment”, she says.
She adds that the shielding policy during the Covid 19 pandemic also meant that older adults were getting less social support.
There is “complexity in diagnosing depression in older adults with cancer”, says Dr Kirsty Colquhoun, secretary of the BGS Geriatric Oncology Special Interest Group.
“They often do not present with the same typical features as younger patients. There is an overlap between symptoms of cancer or treatment and depression making it more difficult to diagnose.
“Typical screening tools for detecting depression in older adults such as the Geriatric Depression Score are therefore less sensitive. These complexities mean that older adults with cancer are less likely to be referred to specialist services,” she says.
Older patients with cancer may also have pre-existing health issues, such as dementia – a recent study found that 7.5% of cancer patients aged 75 and over had this condition.
The prevalence of delirium in older adults with cancer will also be higher than the younger population. Delirium can complicate cancer treatments such as surgery and chemotherapy.
“Both dementia and delirium add challenges to accessing cancer treatments and they will need to be tailored to meet those patients’ specific needs,” says Dr Colquhoun.
She explains that other consequences of cancer and depression are increased mortality from cancer, reduced quality of life, increased utilisation of health resources, and for older adults in particular, a negative impact on rehabilitation. And in cancer patients with depression, older adults are at higher risk of suicide, she says.
Mental health support for cancer patients
Support for cancer patients to safeguard their mental health is available from their oncologist, cancer nurse specialist and GP. Dr Colquhoun advises that in some cancer centres there may be specialist oncogeriatric services – with geriatricians or nurse specialists for older adults, and allied health professionals who can support older adults with cancer.
Occupational therapists can do anxiety management, while some cancer centres will have psychologists attached to them. There are also older adults psychiatrists for complex cases. And charities such as Macmillan Cancer Support and Maggies offer psychological support.
Macmillan Cancer Support is one of a number of cancer charities that offers useful information to support people’s emotional wellbeing, such as talking therapies, which practitioners can signpost to patients.
The charity also funds Macmillan nurses to sit within surgical teams, as well as support workers within nurse specialist teams based in the community to help people with non-clinical needs. Dany Bell, strategic advisor for treatment medicines and genomics for Macmillan, says it’s important to recognise that for cancer patients “emotional needs are also a priority”.
‘Need for greater awareness by service providers’
But while support is on offer, “there needs to be a greater awareness by all service providers of the mental health impacts of cancer and the need to support emotional wellbeing and mental health needs”, the Mental Health Foundation says.
In its report ‘Supporting the emotional and mental health needs of people with cancer’ the charity’s recommendations include tailored, person centred support offered at all stages of the cancer journey, greater collaboration and communication between service providers, and improved signposting for mental wellbeing services.
It also calls for clearer and co-ordinated support pathways after treatment, and further research into how best to tackle social deprivation and co-morbid health inequalities.
Ms Bell says health professionals working in cancer care need to be aware of the impact cancer can have on people’s mental health, to identify if they are struggling with, say, anxiety, and to signpost them to support. GPs and geriatricians also need to know where to signpost cancer patients for help, such as the Macmillan support line, and where to access information and advice. She also urges practitioners to “know what’s in your local trust and area and signpost people in need of this support rather than just letting them walk out of your clinic”.
Mr Morris would like to see more support groups at trusts and more support for people who may have survived cancer but who are still living with the impact it has had on their mental and physical health.
It is also important, he says, for doctors to simply ask people with cancer “‘how are you feeling?’, and let them know help is available”.
Ms Mitchell recognises that health professionals are “often in a rush and have so much to do”. “But people say that they always notice if a practitioner takes care to see them as a person”, rather than “being treated as a body stuck with needles”, she says.
Asking for support with mental health issues and counselling needs to be “normalised”, she believes. And signposting support needs to happen not just at the time of diagnosis when people may be in shock and unable to process detailed information.
Not all patients and practitioners may believe in the value of counselling for cancer patients she says. “But in my experience it can make a big difference to people to have that space.
“The mental health aspects of cancer are no less than the physical aspects. Cancer is not just a physical illness. It also brings out a lot of feelings. So it’s really important for people to have the chance to express those feelings, and have support around them to help them deal with difficult emotions, if they choose.”