Survivorship Issues for Patients With Lung Cancer

Christie L. Pratt Pozo, DHSc; Mary Ann A. Morgan, PhD; Jhanelle E. Gray, MD


Cancer Control. 2014;21(1):40-50. 

In This Article

Psychological Impact

The psychological effects and emotional impact of cancer have been well documented.[7,58,59] Although surviving a cancer diagnosis may evoke a new appreciation for life and a positive effect for some people,[36,52] many experience negative implications of their diagnosis that impact QOL, which may then manifest into psychological symptoms.


As many as 80% of survivors of cancer experience some degree of psychological distress, anxiety, and depression.[36] The overall psychological burden of cancer is referred to as distress. Cancer type was recognized as one of the best predictor of psychological distress. Patients with lung cancer were identified as having distress 3 times more commonly than patients with other cancer types.[58] Weisman and Worden[55] were among the first to identify risk factors for persistent vulnerability to emotional distress after treatment. These factors remain predictors of poor adjustment and include a history of depression and psychological issues, lack of social support, lack of economic resources, external stressors, treatmentrelated sequelae, comorbid conditions, and proximity from active treatment.[14,60]

The emotional and psychological distress common in patients with cancer may cause a decline in both cognitive and social functioning.[47,61] Distress can also affect QOL throughout the disease course.[36] Between 25% and 40% of cancer survivors continue to experience distress, often severe enough to require intervention. Although there are varied levels of distress, even mild symptoms can impact daily living functioning and QOL. Mild distress includes symptoms of fear, sadness, worry, uncertainty, poor sleep, and lack of concentration. Distress also encompasses a variety of psychological manifestations, including depression and anxiety, and is often thought to be acutely associated with diagnosis.[12,59] However, it is important to recognize that levels of distress change over the cancer trajectory and that coping capacity and social support play important roles in influencing emotional distress.[7,62] Two important factors positively associated with adaptation to distress include a patient's perceived social support and a positive coping style.[14,60] Depression among those with lung cancer has been identified as a serious, often underreported and undertreated problem.[36] Rates of reported depression among survivors of lung cancer vary from 11% to 44%.[14] Research utilizing both qualitative and quantitative methodology indicates that depression among survivors of lung cancer is highly correlated with a lower QOL.[7,36]


Stigma has a negative impact on health status. How those affected by the disease perceive themselves, as well as how they are treated by others and the health care system, can have adverse effects.[63] Based on its strong association with cigarette smoking, lung cancer is often seen as a preventable diagnosis. As a result, patients are often stigmatized for having caused their disease.[63] Stigma has been found to be highest among those with lung cancer when compared with other cancer diagnoses.[63]

The impact of lung cancer stigma is far-reaching, resulting in a lack of funding allocations for research, translating into stagnant low survival rates and poor prognoses.[1,64] Stigma, both perceived and real, has strong implications on a patient's well-being. Stigma can elevate levels of stress associated with the disease and contribute to social and psychological morbidity, access to care, and social support.[65] Perceived stigma can manifest into negative outcomes for patients with lung cancer, and it has been shown to increase depression and depressive symptoms among those with lung cancer.[66] Regardless of a positive or negative smoking history, a strong association exists with depression and decreased QOL as a result of perceived stigma. A notable lack of resources exists for those diagnosed with lung cancer compared with other cancers.[67] Lung cancer stigma can also affect social support. Stigma can prevent one from seeking social support, with lower social interactions, and affect access and availability to resources.[67] A recognition of the profound impact that stigma has on illness burden and distress level is also important when developing interventions and allocating resources throughout the continuum of cancer care for these patients.


Anxiety is a seen as a normal response to a cancer diagnosis, but it can have substantial negative effects on QOL and can manifest into physical and behavioral symptoms. Persistent anxiety can impede daily functioning. Heightened anxiety has been found to be correlated with an increase in physical symptoms and a decrease in functioning.[68] Fear of recurrence is prevalent across disease sites, ranging from 5% to 89% of survivors.[14] Anxiety, fear of recurrence, and uncertainty may be even more prevalent among survivors of lung cancer, as recurrence most often occurs within the first 2 years after diagnosis; however, the risk remains elevated for up to 10 years.[36] In addition, those with NSCLC are at risk for a second malignancy, including second lung, larynx, and bladder cancers, even 10 years after the initial diagnosis.[35] Although fear and anxiety tend to decrease over time, the degree of worry about recurrence varies and may be triggered by the onset of an unexplained symptom or anxiety related to follow-up.[69]