Psychosocial Effects of Cancer 273PTSD (i.e., avoidant symptoms, intrusive symptoms), rather
than on the diagnosis of PTSD per se.
Suicide
Reports of suicide in cancer patients vary widely (Breitbart
& Krivo, 1998), ranging from estimates suggesting that it
is similar to the general population (Fox, Stanek, Boyd, &
Flannery, 1982) to estimates indicating that it is 2 to 10 times
greater (e.g., Whitlock, 1978). Holland (1982) suggests that
reports of suicide in cancer patients are probably greatly un-
derestimated because of the family•s reluctance to report
death by suicide.
The risk for suicide may be greater in the advanced stages
of the illness (Chochinov, Wilson, Enns, & Lander, 1998) and
with patients experiencing signi“cant fatigue (Breitbart,
1987). Some evidence indicates that suicide is also more
prevalent among patients with oral, pharyngeal, and lung can-
cers (e.g., Valente, Saunders, & Cohen, 1994). There are also
periods during the course of the disease when patients may
be at an increased risk for suicide. These include periods of
hospitalization, immediately after discharge, and at the time
of recurrence and/or treatment failure (Passik & Breitbart,
1996). However, it is important to recognize that suicide risk
in patients with cancer may be at its highest after successful
treatment or as a person•s depression lifts. As depression and
hopelessness have been found to be causally linked to suicide
(Beck, Kovacs, & Weissman, 1975), the degree to which
cancer patients experience such feelings may increase their
vulnerability to suicide. In fact, hopelessness has been found
to be a better predictor of completed suicide than depression
alone (Beck et al., 1975). In addition, the fear of death or of
recurrence of cancer may develop into suicidal ideation
(Valente et al., 1994).
Delirium
Delirium is a common psychiatric problem among cancer
patients because of the direct effects of cancer on the central
nervous system (CNS) and the indirect CNS complications of
the disease and medical treatment. Delirium can often go
unrecognized because it mimics depression (Massie &
Holland, 1987). Symptoms consist of agitation, impaired
cognitive function, altered attention span, and a ”uctuating
level of consciousness. Delirium can be attributed to medica-
tions, electrolyte imbalance, failure of a vital organ or system,
nutritional state, infections, vascular complications, or hor-
mone-producing tumors (Breitbart & Cohen, 1998). Esti-
mates of the prevalence of delirium in cancer patients range
from 8% to 40% (Derogatis et al., 1983). Those at an increased
risk for delirium are in-patients, elderly patients, and those
with an advanced or terminal disease (Massie, Holland, &
Glass, 1983).Body Image ProblemsBody image is one of the most profound psychological con-
sequences from cancer treatments affecting patients with a
variety of disease sites. The scars and physical dis“gurement
serve as reminders of the painful experience of cancer and its
treatment. The stress and depression that may be a result of
body image concerns can further impact other areas of the
patient•s and family•s life, such as sexual intimacy, psycho-
logical disorders, and self-esteem.
In women who have had breast surgery, concerns range
from distress over scars to feelings of decreased sexual
attractiveness and restrictions of use of certain items of cloth-
ing. In a study with women who had breast-conserving
surgery, 25% had serious body image problems (Sneeuw
et al., 1992). Even patients with cancer who have no outward
changes in appearance can experience dif“culty with body
image. For example, among a sample of Hodgkin•s survivors,
26% felt their physical attractiveness had decreased as a con-
sequence of cancer (Fobair et al., 1986). Moreover, these
perceived changes attenuated their level of energy and fre-
quency of sexual activities, and increased feelings of depres-
sion. A sample of leukemia patients was also found to have
poorer body image than those of a healthy control group
(Mumma, Mashberg, & Lesko, 1992).Sexual Functioning DifficultiesEstimates of sexual functioning problems vary depending on
the type of cancer, but appear to be common across cancer
sites. For example, approximately 18% to 25% of Hodgkin•s
disease patients experienced decreased sexual interest and
activity or poorer sexual functioning as a result of having
been treated for cancer (Fobair et al., 1986). In a study of can-
cer patients undergoing a BMT, 47% were found to have a
global sexual dysfunction and 60% had abnormalities of at
least one parameter of sexual dysfunction (Marks, Crilley,
Nezu, & Nezu, 1996). Common sexual functioning problems
among cancer patients include loss of sexual desire in both
men and women, erectile dysfunction in men, and dys-
pareunia (painful intercourse) in women. Studies suggest that
sexual dysfunctions continue 1 to 2 years posttreatment, indi-
cating a large impact on a patient•s quality of life (Ganz,
Rowland, Desmond, Meyerowitz, & Wyatt, 1998; Marks,
Friedman, DelliCarpini, Nezu, & Nezu, 1997). In addition,
research has shown that a positive self-schema among