Psychological impact of a diagnosis of skin cancer and the role of the CNS

A diagnosis of cancer can be one of the most devastating events of a person’s life (Buckman, 1996). An individual’s emotional response to hearing that they have cancer may be complex and include an array of emotions such as anxiety, shock, anger, denial, fear and uncertainty (Van der Molen, 1999). Until recently, little has been known about the specific impact of the diagnosis of skin cancer and the specific needs of this client group, but an audit undertaken through the use of focus groups of patients with melanoma found that many patients reported feelings of shock and blankness when learning of the diagnosis (Wright et al., 2004). The way in which the diagnosis is communicated can affect the individual’s adjustment to the disease and his or her attitude to treatment (Buckman, 1996). It is therefore recommended that health professionals, including the CNS who should be present during this consultation, who inform patients that they have skin cancer have attended a communication skills course (National Institute for Health and Clinical Excellence, 2006a).

The CNS plays a vital role in supporting patients with skin cancer; a role recognised by NICE (National Institute for Health and Clinical Excellence, 2006a) in the Manual for Improving Outcomes for People with Skin Tumours including Melanoma. Often the CNS will be designated the patient’s ‘key worker’ who co-ordinates their care across many disciplines and thus acts as a permanent fixture in their journey. To help the CNS identify the most ‘at risk’ patients and provide the appropriate intervention, Perkins (1993) describes four psychosocial phases. The first two are important at the time of diagnosis. During psychosocial Phase 1, known as the existential crisis, acute anxiety is often experienced due to a poor knowledge of melanoma and ‘anticipatory grief due to the fear of dying’. During this phase, the CNS may reduce the patient’s anxiety by providing information. The need for information appears greatest at the time of diagnosis. Whilst the type of information required varies according to the stage of the patient (Bonevski et al., 1999), information pertaining to diagnosis, test results and treatment, risk of recurrence, life expectancy, effect of the disease on work and family life is most desired (Bonevski et al., 1999; Schofield et al., 2001).

Nationally produced written materials by ‘Cancerbacup’ (Macmillan Cancer Support, 2009), Cancer Research UK (Cancer Help; Cancer Research UK, 2009e), ‘Marc’s Line’ (Melanoma and Related Cancers of the Skin) (Wessex Cancer Trust, 2004) and the British Association of Dermatologists (2009) provide generic information. However, information outlining local services, including names of key personnel and contact details, and relevant and local and national support groups should be provided (National Institute for Health and Clinical Excellence, 2006a). The offer and acceptance of written information should always be recorded in the patient’s notes. In addition, a permanent record of the consultation at which treatment options were discussed should be offered (NICE, 2006a). Whilst it is recommended that patients should receive targeted information throughout their cancer journey (SIGN, 2003), this can be difficult to achieve since patients with skin cancer make few visits for diagnosis and treatment, many of which are brief outpatient visits. An alternative means of providing information may be via structured information programmes whereby patients diagnosed with melanoma are invited to participate in a group meeting such as that described by Brandberg et al. (1996). To help patients to deal with ‘anticipatory grief due to the fear of dying’ suggested by Perkins (1993), the CNS may help by offering simple interventions such as signposting patients to relevant self-help groups, facilitate emotional disclosure, listening and responding to their worries and concerns and helping them to normalise their experiences (Thompson, 2009). The CNS should ascertain individual patient’s coping styles and teach appropriate coping strategies if appropriately trained to do so. A randomized control trial of patients with melanoma found that a 6-week structured, psychiatric group intervention improved outcomes in terms of affective states and coping style at 6 weeks follow-up and at 6 months follow-up (Fawzy et al., 1990). A later study by Fawzy et al. (2003) found that a 6-week structured, psychiatric group intervention which included health education was associated with a survival advantage, after adjusting for gender and Breslow thickness.

In the second psychosocial phase (Phase 2), referred to as accommodation and mitigation, ‘patients feel physically healthy, yet are constantly living with the fear that the disease may return’ (Perkins, 1993, p. 162). Nationally organised support, specific to patients with a diagnosis of melanoma, is limited to a telephone support, ‘Marc’s Line’ and therefore many patients rely on the CNS whom they are likely to have established a good report with. Those who are identified as struggling to come to terms with their diagnosis should be referred to an appropriate individual within the extended skin cancer team such as the clinical psychologist.