Addressing the psychosocial needs of cancer patients is an essential component of healthcare systems. However, many gaps still exist in the provision of psychosocial care.¹ This article will explore the different psychosocial issues experienced by a female cancer patient, Olivia.* The aim of this article is to support nurses to recognise and manage the effects of cancer on the psychosocial needs of patients. 

Olivia, a 43-year-old woman, presented to the oncology day unit (ODU) for adjuvant treatment in a private hospital following a diagnosis of breast cancer in January 2021. She worked full time, was married with two primary school aged children and had a good prognosis. Having attended her sessions alone in the ODU due to Covid restrictions in the hospital, Olivia mentioned three psychosocial issues that had been affecting her, namely anxiety, sexuality and body image.

Body image

Addressing body image is a fundamental need for patients undergoing treatment for cancer. Hopwood and Hopwood² note that our perception of body image is both an internal and external learned representation of ourselves. Any interference or changes to the body through stress, trauma or surgery, eg. in cancer patients, can lead to a loss of sense of self in individuals. Price developed the body image care model whereby elements of body ideal, body reality and body presentation are represented.³ These three elements of body representation have the ability to react with the individual’s external environment, from which a self image is formed.   

As a young woman who had undergone a lumpectomy, Olivia expressed on her first visit to the ODU that she was unhappy with her appearance. She was emotional and noted that her clothes no longer fitted her. A cancer patient’s expression of dissatisfaction with their body is not an uncommon theme in the literature.⁴  Cash’s cognitive behavioural model of body image conveys two types of body image attitudes relating to cancer patients: body image evaluation and body image investment.⁵ In Olivia’s case, her body image evaluation was poor as she was dissatisfied with her appearance. In terms of body image investment, she stated that her body and appearance were of the utmost importance to her.

White notes the subjective nature of body image and states that it should be addressed regardless of whether or not physical changes are noticeable to others.⁶  However, this is not always adhered to in practice due to the tendency for patients’ needs to be treated at face value rather than in a manner that takes psychosocial concerns into consideration.

In order to address the psychological issue of body image, supportive behaviours in healthcare models should be used. Cohen and Mackay noted four categories of psychological support that are acknowledged in Price’s body image care model for cancer patients.⁷ These are: tangible support, appraisal support, self esteem support and belonging support. Although nothing was done to formally assess Olivia’s needs relating to body image, she did receive different elements of these supports throughout her cancer journey.

To implement strategies to help patients with psychosocial concerns, nurses must be given adequate training, time and resources to implement care plans. Improving patients’ quality of life through addressing psychological needs is one of the primary aims of the National Cancer Strategy.⁹

Anxiety and depression

Although the psychological effects of breast cancer, including anxiety and depression, are widely known, research proposes that clinicians are more likely to treat physical symptoms first. This could relate to lack of knowledge regarding psychosocial issues.¹⁰ In Olivia’s case, she expressed on her second visit that she had a lot of anticipatory nausea with her treatment and, although this was treated with medicinal interventions, little was done to assess her psychological needs.

A randomised trial of literature tells us that if left untreated, underlying psychological stresses such as anxiety can manifest physically.¹¹ In order to adequately assess Olivia’s psychosocial needs, a holistic needs assessment (HNA) could have been undertaken.

Fitch developed the supportive care pathway whereby patients’ needs are assessed using a tiered model of care.¹² This assessment involves early intervention to assess a patient’s physical and psychological needs, leading to signposting of appropriate psychosocial services, including counselling and group therapies.

The use of such a model would have been an excellent example of how to proactively identify Olivia’s psychosocial needs. However, time constraints were a factor in her case and little education was given regarding the importance of patients’ psychological needs. Furthermore, implementing a uniform HNA or model of care was not standard protocol within the hospital, therefore identifying a major gap in the provision of psychosocial services.

Should a HNA have been implemented at an early stage, Olivia’s needs regarding anxiety and body image could have been identified in a timely manner.^13,14 It would also have provided a more holistic service for all patients attending the ODU.¹⁵

Although a formal HNA had not been undertaken while Olivia was receiving treatment, she had a good rapport with nursing staff and was able to express her psychological needs verbally. However, a more dynamic approach to pinpoint Olivia’s psychosocial concerns could have been implemented, such as the use of Fingeret’s model of The Three Cs.¹⁶

This model involves reassuring the patient that their anxiety is common, asking if they have any specific concerns relating to cancer treatment and enquiring what they envisage the consequences of treatment to be. Nevertheless, Olivia latterly revealed that she was overwhelmed with anxiety while looking after her two young children, stating that she would like to avail of a counselling service. Unfortunately, a counsellor was only available for one day per week in the ODU. 

Although attempts were made to ensure Olivia’s appointment was on this specific day, this was not possible due to resource demand and patient availability. There are a few reasons that private hospitals do not provide adequate psychosocial services, potentially due to financial constraints or ineffective distribution of services.

Olivia’s treatment took place during the Covid-19 pandemic and she noted the effects of quarantine had left her isolated from her family. It was recommended that she join a local cancer support network where she could avail of social activities and a confidential counselling service. 

Many psychological interventions and therapeutic models of care have been noted as beneficial in improving the quality of life in cancer patients, including cognitive behavioural therapy (CBT), patient diaries and support groups, none of which were available in this clinical setting. CBT is recognised as a gold standard of psychological treatment in cancer patients.¹⁷ Content relating to CBT including core belief work and cognitive restructuring are proven to help with body image and fatigue in cancer patients.¹⁸

As healthcare moves towards combating psychosocial issues, online resources and models of care that implement interventions such as CBT provide a promising approach to delivering health-based interventions.¹⁹ Although this was not used in the clinical setting, research suggests that online services may be useful where barriers exist, including patient health stigma, distance and travel constraints that prevent patients from utilising psychosocial services.²⁰

Online psychosocial interventions could also be beneficial for private hospitals that may not have the financial capacity to provide face-to-face psychosocial care. Price³ noted that a support network of friends, family and external resources provide the milieu whereby a person with an altered body image or medical condition is re-integrated into society.

Olivia said she wanted to return to her ‘normal life’ of teaching and socialising with others. She communicated verbally to nursing staff that she was happy to avail of online CBT and group networking sessions through her local cancer support network. 

The benefits of online programmes in cancer care have been widely published.²¹ A randomised trial of social networking for cancer-related distress found that patients with high levels of distress and anxiety who engaged with online CBT had more pronounced reduction in symptoms when compared to a control group.²² However, it has been argued that online psychosocial interventions can have varying levels of intensity, success and quality.²³

In order to provide a more evidence-based psychological service for patients, future trials are needed and could to be adopted into an official model of care. Nevertheless, online psychosocial interventions provide a promising approach to combating gaps in healthcare services across the world.

Another fruitful option that could have been used to address Olivia’s psychosocial needs is supportive expressive group therapy for cancer patients. Cadet et al recognised group therapy as an important component of the Basal Cell Carcinoma Integrated Cancer Care Model in order to normalise illness when patients are living with cancer.²⁴

Research has also shown the benefits of group therapy in metastatic breast patients, with a decline in traumatic stress syndromes and an improvement in relationships and symptom control.²⁵ Although group therapy was not available in the hospital, it might have been useful for Olivia, who suffered from a complex interplay of psychosocial concerns.

In the weeks that followed, Olivia availed of online counselling via her local cancer support network. She reported that being able to attend CBT gave her a “new lease of life” and that she was not burdening her children or her husband with her concerns regarding body image and sexual activity. However, she told staff she wished these issues had been addressed sooner. 

Sexual health

Addressing patient’s needs relating to sexuality, although recognised as important, is often a missed opportunity in healthcare. Hordern et al suggest that clinicians are often too focused on clinical priorities to address patients’ needs regarding sexual function and changes due to cancer treatment.²⁶ Studies have further suggested that clinicians do not address sexual matters due to avoiding embarrassment, lack of experience or time constraints.²⁷ However, these barriers are assumptions; if no intervention exists to address a patient’s sexual health, it has the potential to forever go unaddressed.

There are, however, models of care to assist healthcare professionals in addressing the topic of sexuality in the acute and community setting. Mick et al used the BETTER model to address sexuality in the clinical environment in a sensitive, appropriate and constructive manner.²⁸ Andersen also used the ALARM model to directly question patients regarding sexual activity, libido, arousal and medical history.²⁹ Perhaps it could have been a helpful approach to adapt these models of care into Olivia’s assessment in order to identify her needs relating to sexual health.

Furthermore, in order to tackle this gap in the service, resources such as leaflets could support professionals in addressing sex and intimacy issues in patients with cancer.³⁰ Although nurses and healthcare professionals may be embarrassed to address issues relating to body image, anxiety and sexual health, the use of such tools may allow for appropriate acknowledgment of patients’ physical, emotional and psychological needs.

Although some of Olivia’s psychosocial needs were addressed, this case study highlights the many barriers to psychosocial care in the private sector. In challenging times it is essential for healthcare workers to be dynamic and to provide more practical and tangible means of psychosocial support to patients, moving towards a more patient-centred care system.