How to Support a Patient with a New Cancer Diagnosis

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Introduction   

Cancer, the second leading cause of death both in the United States and the world, is responsible for approximately 10 million deaths each year, including over 600,000 annual cancer deaths in the U.S. (1, 2). By the year 2040, conservative estimates are that there will be over 27 million new cancer cases and over 16 million deaths globally each year due to longer life expectancy and aging populations (1). With this inundation of cancer — 4 new cases and one death each minute in the U.S. alone — nurses need to be prepared to help their patients cope with a new cancer diagnosis (3).  

This course is designed to walk nurses through the basics of cancer, the impact of the diagnosis on a patient, and resources for the patient and for the nurse’s future reference. 

Cancer Today

What is cancer? Simply put, cancer is the growing and dividing of abnormal cells without control (6). These cells can infiltrate tissues and organs, even traveling throughout the body via the circulatory or lymphatic system; this process is called metastasis (2,6). Metastases are often the cause of death for cancer patients (2).  

What is your own experience with cancer?

How would you define cancer to a friend or a patient?

Epidemiology: The American Cancer Society estimates that there will be nearly 2 million new cases of cancer and over 600,000 cancer-related deaths in the US in the year 2021 (3). The projections of cases for several types of cancer expected to be diagnosed in 2021 are as follows: 

• Breast (284,200) 
• Prostate (nearly 250,000) 
• Lung and bronchus (over 235,000) 
• Colorectum (nearly 150,000) 
• Skin melanoma (106,110) 

Of the types listed above, the most deaths will likely be from lung and bronchus cancer, with about 132,000 deaths expected in 2021 in the US (3).  

Worldwide, this trend holds; the top five cancer killers, in order are as follows for women: breast, lung, colorectal, cervical, and stomach (4). For men, the top five types of cancer leading to death, respectively, are lung, liver, stomach, colorectal, and prostate (4).  In 2018, the highest combined total cases among men and women, in order of prevalence, were: lung, breast, colorectal, prostate, stomach (5).  Overall, it’s safe to say that the cancers most strongly affecting people are lung, breast, prostate, and colorectal.  

Approximately 80% of all cancer patients in the US are age 55 or older (1). In the average American’s lifetime, 39% of women and 40% of men will get a cancer diagnosis at some point (1).  

Do you know anyone impacted by cancer?  

What types of cancer, if any, have you come across in your own life?  

What are the main types of cancer responsible for the most deaths worldwide? 

In your opinion, what can be done to decrease the prevalence of cancer? 

Cultural considerations: While cancer can hit anytime, anywhere, and affect anyone, not all people have equal access to diagnostic methods and subsequent care needed. Outcomes may vary drastically by race, region, and socioeconomic status as well. For example, despite all advances in cancer research and treatment options, a Black American still has a 6% lower 5-year relative survival rate than a white American, though this rate varies greatly based on the type of cancer (1). Another figure states that the cancer death rate is 14% higher in Black Americans than white (11). Stunningly, nearly 70% of all cancer deaths worldwide occur in low- and middle-income countries (2).  

Since early diagnosis is key to a better outcome for those with cancer, it is essential that people have access to care. However, only about 20% of low-income countries have the resources to make this a possibility (2). Furthermore, poorer countries have nowhere near the diagnostic or treatment capabilities, leading to far worse patient outcomes than in wealthier nations (2).  

Being aware that cultural, racial, and socioeconomic statuses negatively affect cancer patients, how will this affect your practice as a nurse (or will it)?  

What can you say to a patient from a background different from your own when they say, “I don’t trust the doctors that I really have cancer, and I’m not too sure about the treatments, either”?   

Financial implications: Receiving a new cancer diagnosis can place a financial burden on patients. Worldwide, cancer care costs upwards of $1 trillion per year (7). This includes screening and detection, health care costs, prevention efforts, and more (7). In 2015, the US alone spent over $80 billion in direct medical costs related to cancer care (8). Furthermore, for under- or uninsured Americans, cancer patients cannot get or afford the care they so desperately need (8).  

How, if at all, can nurses help lighten the financial burden of cancer care?  

Is there a way to advocate for under- or uninsured cancer patients to help them get the services they need?  

Dealing with a New Cancer Diagnosis: A Case Study  

Bob is a 72-year-old white man living in a large U.S. city. He is a retired truck driver and smokes a pack a day, which he has been doing since he was 18. Bob lives with his wife, Betty, who is 68 and generally in good health. The couple has been married for 45 years. They have two children and three grandchildren, all who live in the same metropolitan area.  

Bob is even more sedentary now than he used to be when driving his semi-truck; he feels he put in his time on the road and should now be able to relax and enjoy the benefits of retirement. Since retirement, Bob has lost contact with many of his work buddies and now only sees family and an old high school friend. He rarely gets out of the house, except for church on the occasional Sunday, when Betty asks him to go with her. 

Bob’s diet still consists of a great deal of fast food; he loves hamburgers and fries. He is overweight, carrying most of the excess weight in his abdomen. He drinks a few beers now and then, particularly when watching sports. One day while watching TV at home alone, Bob feels tightness in his chest. Worried he might be having a heart attack; he calls 9-1-1 and reports his acute chest pain.  

Upon arrival to the local emergency department, Bob immediately gets a full cardiac workup. His troponins are negative. His EKG shows normal sinus tachycardia with occasional premature ventricular contractions (PVCs). His chest X-ray shows a normal cardiac silhouette and no signs of acute cardiac problems. However, the radiologist notes, there are some spots on Bob’s left lung that are concerning. The attending physician orders a CT scan, which shows two large lung infiltrates that are for concerning malignancy. Eventually, Bob is discharged with a follow-up appointment for sputum cytology and a lung biopsy.  

When Bob gets home, he doesn’t tell Betty at first. She got back from a day of being with the grandchildren, and he didn’t want to bring her down. Instead, he stays quiet throughout dinner and can’t fall asleep later that night.  

Weeks later, Bob decides to tell Betty about his day in the emergency department. Betty is shocked and saddened that he didn’t tell her but accompanies him to his follow-up appointment. The biopsy of his lung nodules both come back malignant. Upon another appointment, this time with an oncologist, Bob receives the diagnosis of stage IIIB non-small cell lung cancer (NSCLC).  

Supporting a Patient with a New Cancer Diagnosis 

Bob, like so many other patients, may feel any of a variety of emotions. These often range from anger to fear, regret, shame, despair, or denial (9).  

As a nurse, it can be quite disheartening to hear of a patient’s cancer diagnosis, especially if the person is well-known among staff or in the community. For most nurses, cancer will be an ongoing presence, if only in professional life, and may seem like background noise after a point. However, it is of the utmost importance that you be aware of your own feelings about cancer when striving to support a patient with a new cancer diagnosis. You will want to have an outlet for your own grief, as well as a way to deal with the constant exposure to cancer diagnoses.  

When taking care of the patient, you should keep in mind the following: 

Don’t assume the patient feels one particular way. Depending on the type and stage of cancer and the patient’s age and comorbidities, there can be a large spectrum of emotions experienced, even minute-by-minute, for the individual. Cancer is often akin to a death sentence for baby boomers, whereas younger generations may find the word less alarming due to recent advances in medicine.  

The patient has likely already started looking up his or her prognosis. In the Information Age, you’ll be hard-pressed to find patients who haven’t started turning to “Doctor Google” for answers. Unfortunately, some patients tend to fall down the proverbial rabbit hole and become discouraged, angered, or despondent when learning about outcomes for those with their type of cancer.  

There is a whole new vocabulary for the patient (and maybe the nurse) to learn. Though the patient’s oncologist and other advanced-practice providers should be able to answer most (if not all) of the patient’s questions, you should be prepared as well. Especially if the patient is not at all familiar with the dastardly world of cancer, you’ll want to brush up on words like the following: metastasis, standard of care, chemotherapy, radiation, palliation, adjuvant (and neoadjuvant) therapy, immunotherapy (or biotherapy), remission, relapse, and so forth (10). 

Avoid cliches, if possible. Sometimes, the worst thing a nurse can say is, “Everything will be all right,” or “You’ll be fine! Plenty of people deal with cancer every day.” Not only can these phrases invalidate the patient’s experience, but they also provide false hope or reassurance. This might be the patient’s first-ever time dealing with cancer, so they may rely on the nurse’s medical knowledge and be falsely reassured. This can horribly backfire later if things do not turn out to be okay.  

Sometimes presence is the best gift. Many patients, when faced with a new cancer diagnosis, may simply prefer silence from those in their hospital room. Listening might be all the person wants from you, the nurse. It’s best to let the patient take the lead on any discussion of his outcome.  

How do you cope with death, dying, and loss?  

If a patient wants to talk to you about her new cancer diagnosis, how will you prepare yourself? 

Are you comfortable talking to people about cancer, death, and dying?  

What would you say to the patient’s family member who wants to know more about the diagnosis?

Assessing the patient’s situation: When trying to help your patient cope with the new cancer diagnosis, it is probably best to determine immediate and long-term needs by doing a quick nursing assessment.  

What’s most important to your patient? Is it the thought of death? How to keep going through a daily routine? 

Other concerns that might not seem as obvious are: finances, health insurance (particularly what will and will not be covered as they navigate their cancer care), transportation, job loss, family role change, or additional aspects of their life you may not have initially considered (12).  

What are some potential concerns your patient may have in this situation?   

Personal support system: In Bob’s case, his wife Betty is likely his primary support person. Hopefully, his children and grandchildren will help in his situation, as well as his high school friend.  

For many patients, particularly those who are widowed and/or have no children or close family, it can be an isolating experience to go through a new cancer diagnosis. For people over the age of 60, it is likely that they will either rely on their family or the healthcare system for their support.   

Regardless of who is in the patient’s support system, these people should be able to provide ongoing support, transportation, and general assistance. If possible, it would be helpful for support members to clarify their roles with each other, perhaps even creating a schedule for the day-to-day necessities as they relate to the patient.  

Who would you identify as your own personal support system? 

In what ways should personal support systems help a loved one?  

What duties, if any, do Bob’s family and friend have to him during this phase of his life? 

Community support: Fortunately for Bob and others like him, there are many resources available for cancer patients and those who care about them. Particularly in the time of COVID-19, online resources are available now more than ever. There are plenty of online support groups, even divided by type of cancer, caregiver role, and location. In Bob’s example, there are several support groups through the American Lung Association that can help him connect with people from across the country who are also dealing with lung cancer (13, 14).  

More and more resources are coming out all the time to support cancer patients. The Cancer Support Community, American Cancer Society, and National Cancer Institute all have fantastic information and outreach programs for those afflicted with this diagnosis (15, 16, 17).  

Do you know of any local resources in your area that can help provide support to cancer patients? If not, would you know how to find some in order to refer your patient?  

Financial and insurance support: In the United States, roughly 29 million nonelderly people still live without reliable health insurance, which is over 10% of the US nonelderly population (18). After a new cancer diagnosis, treatment can be particularly daunting if the patient doesn’t have insurance or if they might lose their job – and thus their health insurance – due to the diagnosis. It is a tragedy that many cancer patients now have two enormous burdens placed on them: a harrowing new health problem and the means to finance its treatment.  

Fortunately, there are some ways to help get treatment to these vulnerable patients.  The American Cancer Society (ACS) can help provide rides, housing, and financial assistance to cancer patients and their families (16). Additionally, ACS provides a comprehensive guide for patients on dealing with health insurance, getting pre-approval, dealing with denied claims, and much more (20).  

Hospitals are another fantastic resource for insurance and financial assistance. Hospital social workers and patient navigators can help patients get their costs covered as much as possible. It’s always a good idea for a nurse to know which social workers are affiliated with their healthcare institution or company.  

If your patient asks you, “How much of this hospital visit will my insurance cover?,” what would your response be?  

Who can you direct patients to in your own practice, so they can get help with insurance or payment issues? 

“Why isn’t there a cure for cancer yet?”

If you’re helping a patient navigate a new cancer diagnosis, they might ask (perhaps tongue-in-cheek, perhaps earnestly), “Why haven’t we cured this yet?” The simple answer is: There are many different types of cancer that work in many ways (19). 

• Five main types of cancer: In brief, the different kinds of cancer are:  
• Carcinoma: affects epithelial cells found in the skin, linings of internal organs, and mucous membranes 
• Sarcoma: found in connective tissue, such as: bone, fat, muscle, blood vessels, and cartilage  
• Leukemia: cancer that starts in the blood-forming tissue, as in the bone marrow 
• Lymphoma & multiple myeloma: originate in the immune (lymphatic) system 
• Central nervous system: cancers that begin in the spinal cord and brain  

Contributing factors for cancer

Since there isn’t just one cause for cancer, there isn’t just one cure. As much as 30-50% of cancer deaths are preventable, so nurses need to be prepared to explain risk factors and ways to reduce them- to their patients (2).  Here are some risk factors that can be prevented:  

• Tobacco: responsible for 22% of global cancer deaths each year, the single most important risk factor when it comes to cancer

• Obesity/high body mass index (BMI)

• Cancer-causing infections (which can be prevented by vaccines):

– Human Immunodeficiency Virus (HIV) à Kaposi’s sarcoma

– Hepatitis B (HBV) à hepatoma (cancer of the liver)

– Human Papilloma Virus (HPV) à Cervical, rectal, and oral cancer

• Unhealthy diet

• Alcohol use

• Ultraviolet and ionizing radiation

• Urban air pollution

• Environmental exposure to toxins like asbestos, arsenic, and radon

Cancer Treatment 

While the type of cancer usually dictates the course of treatment, these are some generalizations that might be helpful to your patient with a new cancer diagnosis:  

What to expect from radiation: Radiation is a localized approach used to shrink tumors and kill cancer cells (20). There are two types of this treatment: 

• External beam, which uses a large machine to target radiation directly at the tumor site 
• Internal (also called brachytherapy), which is implanted in the body at the site of the tumor 

Radiation can be used to cure cancer, shrinking tumors until they are gone (20). It can also be used as palliation to reduce pain and symptoms caused by the tumor(s). Finally, it can be used to shrink tumors before a course of chemotherapy; in this case, radiation would be referred to as adjuvant therapy, which occurs before a primary treatment.  

Radiation side effects can range from irritating to debilitating, depending on where the therapy is targeted. In the case of external beam radiation, hair loss (alopecia) at the site is common, as are skin changes like a sunburn (20). Radiation can also cause fatigue, nausea, vomiting, weight loss, headaches, and other changes related to the system(s) it is targeting (20). 

If your patient is about to undergo external beam radiation of the head, what side effects might you anticipate for them?  

What to expect from chemotherapy: Nowadays, there are many dozens of types of chemotherapy, which is a toxic medication used to kill fast-growing cancer cells. Chemotherapy is often combined with other treatments, like immunotherapy, to help the medication target cancer cells more directly and effectively (19). This topic warrants its own entire course, and nurses who administer chemotherapy need to receive specialized training to handle these cytotoxic agents.  

In general, though, there are many common side effects that chemotherapy can cause. Of course, this depends on the dose, the type of drug(s) used, and the cells it targets. Common side effects include: 

• Fatigue 
• Nausea 
• Vomiting 
• Diarrhea 
• Anorexia 
• Alopecia 
• Anemia 
• Cardiotoxicity 
• Renal toxicity 
• Peripheral neuropathy 
• Hypersensitivity reactions (19) 

Suppose you are taking care of a patient receiving chemotherapy. In that case, it is generally best to consult with the oncologist, nurse practitioner, or oncology certified nurse (OCN) when learning about the treatment regimen. There are many variables involved with chemotherapy, but the more you know, the more information you can give to anxious patients.  

Where would you go to find out reliable information about the patient’s upcoming chemotherapy regimen? 

What side effects would you warn your patient about if they were about to undergo chemotherapy? 

Clinical trials

These are an option for many patients whose first (or subsequent) line of treatment failed to effectively treat their cancer (21). There are always new clinical trials being developed, particularly in the realm of oncology. It is worth mentioning this to patients, so they at least know it’s another avenue they can pursue. There are four phases of clinical trials (19): 

• Phase I: This is the first time a human is treated with an investigational drug (after animal studies). The goals here are to determine maximum tolerated dose (MTD), drug-drug interactions, and how the body processes and excretes the drug. Usually, these studies enroll 15-60 patients.  
• Phase II: This phase, enrolling more patients, determines the activity and effectiveness of the drug against one specific type of cancer and helps find side effects. Phase II trials usually have 100-300 subjects.  
• Phase III: Even larger studies that compare the active drug versus a placebo. The study is randomized and usually double-blinded, meaning neither the physician nor the patient knows if the drug is real or placebo. There are typically more than 300 people on Phase III trials.  
• Phase IV: These trials seek to find “off-label” uses of drugs already approved by the Food and Drug Administration (FDA). Other uses for drugs are found here, as well as long-term side effects and benefits.  

What are the goals of the four phases of clinical trials? 

If your patient stated, “I don’t think clinical trials are very safe. We’re just guinea pigs,” how would you respond? 

Mental health for patients with a new cancer diagnosis

When treating the whole patient, psychosocial and mental health is also of paramount importance. For nurses practicing in hospitals or health centers, it is always good to know some resources for patients, regardless of their diagnoses. Social workers, case managers, nursing supervisors, nutritionists, chaplains, and patient advocates are great starting points for connecting patients with services they may need, either now or in the present.  

Your Patient Received a New Cancer Diagnosis… Now What? 

If your patient with a new cancer diagnosis is about to be discharged, perhaps some other topics that warrant discussion are that of long-term care. Palliative care, Hospice, and other community resources can be useful to patients and their families when coping with the new cancer diagnosis.  

• Palliative care: Contrary to popular belief, palliative care isn’t only for the dying. The goal of palliation is to alleviate symptoms and pain as much as can be reasonably expected (22). Anyone with a chronic health problem can receive palliative care, and many healthcare centers now have palliative care teams of their own.  
• Hospice: While palliative care is certainly a part of Hospice, it is not the only piece. To qualify for hospice care, a patient needs a prognosis of 6 months or less to live, should the disease take its natural course (22). However, many people don’t know that one can “graduate” from Hospice and return to normal life. Hospice may sound like giving up to an oncology patient, but it is really just one more resource they can utilize while enduring their diagnosis. Patients may come on and off Hospice, and it’s not just for the very end of life.  

Conclusion 

Cancer remains the number-two killer in the world and wreaks havoc on all those effects. Patients who are newly diagnosed with this disease have unique needs of which the nurse should be aware. By understanding the main types of cancer and some of their risk factors, you will be a great asset to your patient and their loved ones. Though cancer and its treatments are complex, there are advances all the time and many resources available, both online and in individual communities. There are always opportunities for nurses and their patients to learn more information and serve as sources of support.  

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