Anxiety is common in patients with cancer and can develop as a result of cancer and its treatments.  Symptoms of anxiety are seen in up to 48% of all cancer patients, often in the form of a “situational anxiety”—these symptoms include worry as well as physical symptoms like muscle tension, restlessness, palpitations, sweating, and shortness of breath.  A smaller percentage of patients actually develop a formal anxiety disorder such as panic disorder, post-traumatic stress disorder, phobias, or generalized anxiety disorder.  Typical anxiety symptoms include severe worry, feeling “on edge,” irritability as well as physical symptoms such as nausea/vomiting, diarrhea, shortness of breath, and palpitations.  You can see that similar to depression, the physical symptoms of anxiety are similar to those of cancer and treatment side effects.  Shortness of breath in particular gives me pause, as it is intimately linked with anxiety—the two can often trigger each other and cause a vicious cycle, making both the anxiety and the shortness of breath much worse.

What causes anxiety in cancer?
As mentioned, the diagnosis of cancer itself can act as a stressor to induce symptoms of anxiety, as well as uncontrolled symptoms such as pain or nausea.  Other medical conditions unrelated to the cancer can cause symptoms of anxiety, including heart disease, thyroid disease, emphysema and asthma, neurologic disorders, as well as metabolic imbalances (hypercalcemia, for example).  Certain medications used in cancer treatment can cause side
anxiety as a side effect—medication like antipsychotics, anti-emetics (reglan or compazine, for example), and steroids.  The withdrawal of certain medications like benzodiazepines or opioids can also precipitate anxiety.

Treatment strategies
Similar to depression, the most effective treatment strategies for anxiety include a psychotherapy component and a medication component.  Psychotherapy in anxiety, similar to depression, focuses on supportive strategies and coping.

Behavioral interventions have also demonstrated efficacy in controlling symptoms of anxiety, including relaxation techniques and guided imagery.  One study compared the use of a relaxation technique (muscle relaxation) to xanax (alprazolam) and found that both were effective in reducing cancer-related anxiety, though xanax had a faster onset of action than the use of muscle relaxation.

There are two major classes of medications used in the treatment of anxiety: benzodiazepines and anti-depressants.  Benzodiazepines are anti-anxiety medications such as ativan (lorazepam), valium (diazepam), or klonopin (clonazepam).  They act on GABA-receptors in the brain which are responsible for modulating mood, sleep, anxiety, and seizures.  They are used as first-line medication therapy for intermittent anxiety or mild chronic anxiety.

Ativan is most commonly used in this class: it is short-acting and effective for controlling intermittent anxiety.  The challenge with the short-acting benzodiazepines, like ativan or xanax, is that patients can experience breakthrough anxiety with frequent use; these patients may benefit form the use of longer-acting benzodiazepines such as valium or klonopin.  Several of the benzodiazepines come in rapid-dissolve forms, such as ativan tablets, which can be taken sublingually or klonopin wafers (rapid-dissolving), which are useful in achieving quick control
of anxiety symptoms and also when patients are nauseous or having trouble swallowing.

The major class of anti-depressants used for anxiety is the selective serotonin reuptake inhibitor (SSRI) class — this includes medications like paxil (paroxetine) or celexa (citalopram).  They are the drug of choice in patients with anxiety and depression together.  Their disadvantage is their slow onset of action (usually 3-6 weeks) so the benzodiazepines are preferred for immediate symptom management.  Buspirone is another medication (also works on serotonin receptors as well as dopamine receptors in the brain) used for chronic anxiety—its onset of action is 5-10 days (still not immediate).

Other medications
While antipsychotic medications are primarily used in cancer for symptoms of delirium, they can be helpful in cases of anxiety that are accompanied by hallucinations or other psychotic symptoms or when benzodiazepines are not adequate to control severe anxiety symptoms.  These include haldol, olanzapine, and mellaril (thioridazine).  For patients with anxiety and pain, the antihistamine atarax (hydroxyzine) has been used for the anxiety symptoms.

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