Cancer has discrete stages with specific characteristics, existential issues, needs, and interventions. The ways in which people move through each stage prepare them for each subsequent stage.

The potential stages of the cancer journey include the following. All cancer patients do not deal with all of these stages.

• Before the Cancer Diagnosis
• Cancer Diagnosis
• Cancer Treatments
• End of Cancer Treatment
• Cancer Recurrence
• Cancer as a Chronic Disease
• End of Life

Before the Cancer Diagnosis

Several key factors that are present before the cancer diagnosis play important roles and contribute to trust versus mistrust, trauma, shock, treatment decision-making, beliefs about prognosis, and recovery.

• Circumstances of a person’s cancer diagnosis
• Prior experience in the medical system
• Belief systems about health and illness
• Belief systems about life and death, living and dying
• Previous experiences with adversity
• Pre-existing support systems
• Other social factors such as race, gender, ethnicity, religion, education, employment, finances, and the patient’s role in their family
• Psychological strengths and weaknesses
• Coping mechanisms
• Self-esteem
• Personality traits such as independence and motivation
• Prior history of depression, anxiety, and other mental health issues
• Previous traumas

Cancer Diagnosis

Everyone deals with a cancer diagnosis differently. Physical factors that influence the diagnosis are age, gender, and type and stage of disease. For many people affected by cancer, some or many of the following reactions and issues surface around the cancer diagnosis.

• Anxiety, confusion, guilt, panic, disorientation, despair, grief, frozen feelings such as numbing and cognitive overwhelm
• Search for mastery
• Difficulty or inability making decisions
• Difficulty controlling overwhelming feelings
• Self doubts about ability to cope
• “We’ll just fight it” mentality with a stiff upper lip
• Families may begin to be dishonest with each other to “protect”the other and thereby create feelings of isolation and loneliness
• Varying degrees and episodes of existential plight
• Cursory or more comprehensive life review
• Thoughts about mortality

Cancer Treatments

Preparation for and the experience of having cancer treatments involve many stages within itself. There is tremendous variability with how people cope.

• Traumatic or empowering or both
• Preparation through avoidance, deep contemplation, tending to unfinished business, and/or spiritual engagement
• Recognition that cancer is a teachable moment
• Inquiring into the meaning of illness and lessons to extract from the experience
• Utilization of mind-body skills such as meditation, deep breathing, writing, and others
• Approaching cancer treatments as a ritual

Preparation Anxiety Around Firsts

• Surgery, radiation, chemotherapy and other treatments
• Hair loss
• Other side effects
• Communicating with loved ones about illness, fears, other feelings, and the spectrum of life issues triggered by cancer

Temporary Stability

• Education through research and reading
• Creating a healing plan
• Creating a healing team

-OR-

• F—frustrated, fatigued, frozen
• I—ill, isolated, indirect
• N—nervous, nice, neglected, neurotic
• E—edgy, envious, elevated

Continuous Assessment of Attitude and Coping

• Perceived harm from and complex attitudes about treatments such as toxicity from chemotherapy
• Healing images
• Time of temporary lull and alternating emotional terrain with some distress
• Coasting
• Treatment highs
• “If I just get rid of this, I’ll be okay”
• “Fighting spirit”
• Attitude of embracing, learning, and growing

End of Cancer Treatments

The end of treatment may involve a wide range of feelings, attitudes, coping styles, and other reactions that may contain mixed emotional extremes. This period is a major transition in the cancer journey.

• Anxiety due to end of cancer treatments
• Intensified existential anxiety
• Relief
• Fear
• Grief
• Learning to live with uncertainty and ambiguity
• Post-treatment issues, grief, depression, and anxiety around follow-up appointments, including perhaps feeling “neurotic”and trying to hide it
• Dealing with long term and late physical and psychological effects from cancer and its treatments

Cancer Recurrence

A cancer recurrence is often a major shock accompanied by a foundation of experience with knowledge, coping skills, and resilience.

• Reactions influenced by coping strategies used for the initial diagnosis and degree of psycho-spiritual growth
• Existential plight may be bigger
• Seeking multiple opinions
• Casting the net further searching far and wide
• Assessing where previous treatments may have fallen short
• Overwhelm with thoughts such as “I cannot do this again”
• Empowerment recognizing “I can do this again”
• Reassessing priorities
• Opportunity and invitation to go deeper

Cancer as a Chronic Disease

This stage occurs when some form of the disease is present for a long period of time and managed. Difficulties may stem from dealing with illness for many years and those can co-exist with profound life lessons learned along the way.

• Fatigue around dealing with cancer for a long period of time
• Cultivation of coping skills and self-care tools to negotiate the challenge
• Periods of normalcy contrasted by episodes with more recognition of the disease due to doctor’s appointments, tests, treatments, and not feeling well
• Duality and/or perceived contradiction of being healthy while dealing with cancer
• Ongoing learning about health, wellness, and disease
• Deepened relationship with life and death, living and dying
• Potential to have deeper connections with one’s self, other people, and all of life
• Challenges with family and friends who cannot understand
• Willingness to take more risks and make life changes
• Deeper engagement with meaning, purpose, and spirituality

End of Life

End of life in some people with cancer is the final stage in the continuum of life transitioning into death. In On Death and Dying, Elisabeth Kubler-Ross, MD describes five stages of death that she observed in the psychology of many people with cancer. The stages may last for different periods of time and will replace each other or may exist simultaneously. All of these stages are necessary for the dying to work through their anguishes and anxieties to arrive at the fifth stage of acceptance and peace. Hope is described as the quality that persists throughout every stage.

1. Denial and Isolation

◦                     Initial coping strategy to deal with an uncomfortable and painful situation

◦                     Temporary defense

◦                     Denial functions as a buffer after unexpected shocking news

◦                     Allows people to collect themselves and mobilize other less radical defenses over time

2. Anger

◦                     Expressions of anger, rage, envy, and resentment

◦                     “Why me?”

◦                     Anger can be displaced and projected in many directions

◦                     Frustrations due to a lack of control

3. Bargaining

◦                     Offering to give something in return for a reward

◦                     Sometimes includes a prize for good behavior with a self-imposed deadline and an implicit promise of not asking for more

◦                     People with cancer most often wish for an extension of life followed by time without pain and physical discomfort

◦                     Bargaining is an attempt to postpone

4. Depression

◦                     Rooted in a sense of great loss that has already occurred or is forthcoming

◦                     Depression is associated with hopelessness

◦                     Loss can be associated with the physical, sensual, psychological, family, employment, finances, luxuries, and many other areas

5. Acceptance

◦                     Contemplating the end with a certain degree of quiet expectation

◦                     Almost void of feeling

◦                     Circle of interest diminishes

◦                     Deepened connection with silence and stillness

◦                     Potentially desiring less time with other people

Supportive Strategies

Many strategies exist to navigate the stages of the journey. The most helpful approaches may vary depending on the person and their circumstances. Explore other topics in Mind and the Spirit section for information about strategies that support navigating stages of the journey. A qualified trained professional can also provide assistance to help people affected by cancer develop understanding and identify strategies that work best for them.

Jeannine Walston would like to thank Lora Matz, MS, LICSW for her input related to Stages of the Cancer Journey. The content was created in large part through presentations by Lora at CancerGuides conferences hosted by the Center for Mind-Body Medicine (CMBM).