Abstract
Introduction:
Head and neck cancer patients have high rates of psychological distress, which may be exacerbated by the treatments they receive. Many patients who undergo radiation therapy report significant anxiety associated with the thermoplastic mask required for immobilization during treatment.
Case Description:
This report presents two examples of head and neck cancer patients reporting high mask anxiety, along with a history of claustrophobia, who expressed concern about their abilities to initiate and adhere to treatment. Both were referred to supportive care psychology before radiation treatment initiation. With counseling and the use of systematic desensitization, they were successfully able to complete their treatments.
Discussion:
Results of these case reports highlight the value of integrating early supportive care in the treatment of head and neck cancer and support the need for further study in future randomized controlled trials.
Introduction
Psychological distress may impact a patient's approach to treatment, medical outcomes, and quality of life. 1 Cancer patients, specifically, face numerous stressful events and challenging treatments, including surgery, radiation, chemotherapy, or a combination of approaches. With these challenges come a range of emotional responses that might be exacerbated by the very treatments meant to help mitigate their disease. 2 Studies have consistently found that ∼1/3 of cancer patients meet criteria for at least one mental health disorder 1 with rates varying by cancer type. 3
Head and neck cancer patients have high rates of psychological distress, with a four-week prevalence of 41%. 4 These rates may be due to the high rate of pre-existing psychological comorbidities occurring in this population, 5 the diagnosis itself, and the distress associated with the often complex treatment required for curative intent. 6 If mood symptoms are left untreated, patients might elect to delay or avoid necessary treatment options. In fact, patient anxiety has been found to disrupt radiation treatment sessions for head and neck cancer, with a fear of having one's face covered or movement restricted being the most significant causes for treatment disruption. 7
Radiation therapy can be used before surgery or concurrently with chemotherapy for potentially curative head and neck cancer. 8 A prospective study of anxiety and depressive disorders in cancer patients receiving radiation found that anxiety significantly increased after initiating treatment. 2 Specifically, head and neck cancer patients report a high degree of anxiety associated with wearing the thermoplastic mask required for immobilization. 9 For some patients, this anxiety does not diminish through the course of radiation treatment. 10
While anxiolytics are used to manage anxiety associated with medical procedures, it has been recommended that alternative treatments also be considered for head and neck patients undergoing radiation therapy, 10 which may be especially important for those also prescribed opioids due to the harm of concurrent opioid and benzodiazepine use.11–13 In general, nonpharmacological methods, including cognitive-behavioral therapy (CBT) strategies, have demonstrated efficacy in managing anxiety. Exposure methods, such as systematic desensitization, are some of the most effective treatment strategies for anxiety disorders, particularly specific phobias. 14 Systematic desensitization is an empirically validated CBT intervention for claustrophobia and anxiety management that can reduce anxiety and distress. To date, it has had applications in treating distress in cancer patients, most of which has focused on treating nausea and vomiting associated with chemotherapy.
In brief, this therapy technique essentially helps patients reduce their anxiety/fear by “substituting” their fear response with an incompatible response, such as relaxation. Patients are first taught a relaxation technique such as guided imagery, diaphragmatic breathing, or progressive muscle relaxation. Next, a desensitization hierarchy is constructed starting with the least feared situation that creates the anxiety all the way up to the most feared situation. Then, patients work their way up the hierarchy, starting with the least feared situation, and slowly “exposing” themselves to the feared situation while engaging in relaxation practice. Exposure can be in vitro (imaginal exposure) or in vivo (direct exposure to the feared situation). Patients only move to the next step in the hierarchy when they have mastered the one before it.
In a systematic review of nonpharmacological strategies for managing common adverse effects of chemotherapy, systematic desensitization was found to yield a positive impact on the management of nausea and vomiting in >75% of the trials reviewed. 15 These strategies were also included in an updated review of recommendations for the prevention and treatment of anticipatory chemotherapy-induced nausea and vomiting in pediatric cancer patients. 16 With the exception of a recent case study utilizing a graded exposure approach to assist a patient who temporarily suspended radiation due to a fear of choking, 17 no research has been done on this approach to treat mask anxiety in patients receiving radiation therapy for head and neck cancer.
Herein, we present two case examples of patients reporting mask anxiety and claustrophobia, who were referred to supportive care psychology before radiation treatment initiation, and with counseling, successfully completed their treatments. We discuss the importance of early supportive and palliative care referrals for patients undergoing radiation for head and neck cancer, highlighting the necessity of early detection and screening for anxiety so that effective psychological interventions can be used before treatment initiation.
Case Descriptions
Case 1: Mr. K
Mr. K is a man in his 60s with a diagnosis of stage II HPV-positive squamous cell carcinoma of the tongue. His oncologist referred him to supportive care for anxiety management noting he was quite anxious about the process of radiation, especially having to wear a mask. As such, his supportive care physician referred him to supportive care psychology for an evaluation of and counseling for his anxiety.
During the initial psychological consultation, Mr. K reported experiencing significant anxiety secondary to his upcoming radiation treatments. He reported a history of panic attacks for the past 5 years, stating he occasionally takes alprazolam when he feels a panic attack coming on. He reported that panic attacks occur infrequently, but when they do, he feels the need to escape and has feelings of uncontrollability. He also acknowledged a history of claustrophobia as well as a “need to be in control.” He anticipated difficulty with future radiation due to having to wear a mask and having his head secured to the table, noting it would be difficult for him to escape. He denied any significant depressive symptomatology.
Given that he was most concerned about his upcoming treatment, a systematic desensitization approach was provided to address his claustrophobia. He was taught guided imagery for relaxation and encouraged to practice it daily; guided imagery was chosen over other relaxation techniques since his radiation treatment required he be still, and other techniques may involve some movement. He was then provided a mask similar to the one he would use for his radiation treatments. He was instructed to wear the mask during daily relaxation practice, beginning with 10 minutes/day, and after 3 to 4 days of being able to practice with low levels of anxiety, progress to 15-minute practices followed by 20-minute practices. He was instructed not to increase the time until he could master each step with tolerable anxiety.
Approximately 3 weeks following the initial session, he presented to a psychology follow-up appointment reporting he had worked up to 30-minute practices using guided imagery and wearing the radiation mask. He even creatively had his wife securely hold the mask in place while he engaged in relaxation practice, noting it would be similar to having his head secured during his radiation. He arrived to his psychology appointment after successfully completing his simulation exclaiming “I did it!” when he walked into the room.
Notably, both his mood and anxiety improved during this time frame, as indicated by changes in ratings on the Edmonton Symptom Assessment Scale 18 from depression 3 and anxiety 4 at the initial psychology visit to depression 2 and anxiety 1 by his third counseling session occurring on the same day as his simulation. He reported no longer dreading his upcoming radiation treatments and increased confidence in his ability to cope. He combined this technique with 2 mg of lorazepam before every treatment to assist with anxiety management. He went on to successfully complete 33 fractions of radiation therapy.
Case 2: Mr. R
Mr. R is a man in his 50's with a diagnosis of stage III squamous cell carcinoma of the right base of the tongue. He was referred to supportive care by his radiation team for evaluation of and treatment for fatigue, insomnia, and emotional distress. During that visit, he reported significant distress when thinking about his upcoming radiation treatment, a history of claustrophobia, anxiety interfering with his sleep, and worry about dying. As such, the supportive care physician referred him to supportive care psychology to assist with mood/anxiety management before treatment initiation.
During the initial psychological consultation, Mr. R reported adjustment related symptoms of intermittent sadness and anxiety secondary to his health and concerns about radiation treatment. He reported a history of claustrophobia but denied any other significant history of anxiety. He expressed concern about having to wear a mouthguard/stent during his treatment noting that it will prevent him from swallowing. He also reported concern about wearing the radiation mask and expressed anxiety just thinking about it. He acknowledged mild anhedonia (loss of interest in previously enjoyed activities) and denied any current or past suicidal ideation, intent, or plan. He reported good support from his immediate family.
Given that he was most concerned about his upcoming treatment, a CBT approach utilizing systematic desensitization was provided. First, he was taught guided imagery for relaxation and was encouraged to practice twice a day, beginning with 1 minute and gradually increasing to 15 minutes. Following skills mastery, he was encouraged to practice while wearing a mouthguard purchased from a local sporting goods store, beginning with doing relaxation for 1 minute and gradually increasing to 20 minutes.
At the second psychology visit, he was progressing well through the desensitization hierarchy. He reported starting with doing relaxation for one minute, wearing top and bottom mouth guards, while also biting down on a self-made stent to mimic the one he would wear during his actual radiation treatment. He also creatively engaged in relaxation while lying under his coffee table and wearing a self-made mask. He reported taking alprazolam 5 mg before starting the relaxation noting that he would use this medication during his upcoming radiation treatments. By this session, he was successfully able to work his way up to 17 minutes with tolerable anxiety.
After this session, he was provided an actual radiation mask, since it was next in the hierarchy, and instructed to practice relaxation while wearing the mask and the mouthguards, again starting at 1 minute and gradually increasing to 30 minutes. He was instructed not to increase the time until he could master each step with tolerable anxiety. By the third counseling session, he had progressed to wearing the mouth guards, self-made stent, and radiation mask while lying under his coffee table for seven minutes. Approximately one month following the first psychology visit, he successfully completed his radiation simulation. He subsequently completed 33 fractions of radiation therapy using the coping skills learning in session and taking alprazolam before each treatment.
Notably, both his mood and anxiety improved through the course of treatment, as indicated by changes in ratings on the Edmonton Symptom Assessment Scale (ESAS) 18 from depression 7 and anxiety 8 at the initial psychology visit to depression 0 and anxiety 1 by his seventh counseling session. He noted that the skills he learned provided him a sense of preparedness for radiation and strategies to utilize through the course of radiation. Midway through his treatment, he shared that he no longer felt anxiety or dread about wearing the mask.
Discussion
A cancer diagnosis is stressful and typically elicits distress, which may be exacerbated by challenges associated with treatment. These two cases suggest that integrating psychological services with cancer treatment can help reduce cancer-related distress and improve treatment adherence. 1 Although emotional distress may manifest in different ways and stem from different stressors, claustrophobia is one potential impediment to successful treatment completion. Claustrophobia has been found across studies to cause ∼2% of patients receiving MRIs to require sedation or early termination of the scan. 19 Head and neck imaging has been ranked highest among claustrophobia-related MRI-scan termination, compared to those undergoing extremity, breast, or pelvic MRI, likely due to the claustrophobic affects of the head coil.
A study assessing adherence of patients with head and neck squamous cell carcinoma, found a high drop-out frequency, primarily patient-related, including such factors as dysphagia and claustrophobia. 19 Minimizing such occurrences during diagnostic imaging and treatment may facilitate successful completion, as well as greatly improve patient comfort and overall satisfacation, 20 similar to what was experienced by our two patients.
These cases highlight the usefulness of systematic desensitization to assist patients before and during radiation treatment. Although both patients were receiving anxiolytics before radiation, they still lacked confidence that they could initiate and complete the treatment process. Our first case had used medication in the past for panic as an abortive, not preventive, strategy. Now, with the need to lie still and in a claustrophobic environment, a proactive approach was necessary. Despite having tried medication in the past, he did not feel confident going into treatment with medication alone. Our second case had been prescribed alprazolam before starting radiation therapy. Even with that medication, he had to gradually desensitize himself to the situation and was initially only able to tolerate the exposure for brief periods of time. Had medication alone been sufficient, he should have been able to tolerate 30 minutes of exposure from the onset.
Providing cognitive and behavioral coping skills to utilize during the treatment itself, in addition to pharmacological assistance, helped these patients to manage their anxiety, build confidence, and successfully complete their treatment process. It is important to note that both patients were able to receive this psychological intervention three to four weeks before radiation simulation. Unfortunately, behavioral strategies alone can take time to create change. In an acute setting, there is often not enough time for the patient to practice and become completely effective using behavioral strategies alone, so medication may be warranted.
More research is needed to establish the ideal timeliness and “dose” of this CBT strategy, and the potential for this intervention to reduce or prevent the need for anxiolytic medications, especially patients receiving opioids who might present with more serious side effects. Research also should examine the efficacy of desensitization compared to other psychological and attention control interventions, and also with and without anxiolytic medications. Studies in healthy individuals are inconclusive with regard to the effect of combined therapy versus monotherapy in the treatment of anxiety disorders. 21 Certainly, this requires further study in cancer patients. The encouraging response in our patients suggests that such studies are justified.
Indeed, our findings are limited in these case reports, and there is potential for placebo or obsequiousness bias (patient trying to please the treating psychologist by reporting the expected outcome). Another limitation of this intervention is the need for three to four weeks before initiation of radiation, which may not be possible for patients who need to start treatment immediately or for those whose distress is not recognized early enough. Universal assessment of physical and psychosocial distress of all patients who will undergo radiation therapy using simple, self- completed, free tools such as ESAS 18 will help identify patients who might benefit from an early referral to supportive care. Further study is needed to identify screening tools with appropriate sensitivity and specificity to predict which patients may have a disruption in their radiation therapy due to anxiety. 7
Footnotes
Authors' Contributions
C.L.C. (co-first author): conceptualization, writing—original draft, and reviewing and editing; M.T.A. (co-first author): conceptualization, writing—original draft, and reviewing and editing; S.A.-Y.: conceptualization and reviewing and editing; E.B.: writing—original draft and reviewing and editing.
Funding Information
No funding was received for this article.
Author Disclosure Statement
No competing financial interests exist.