Cancer immunotherapy has expanded the range of treatment options for patients with advanced or metastasizing tumors. While the large number of publications dealing with cancer immunotherapy focus on aspects like clinical efficacy, safety, biomarkers and survival of patients, increased attention is being paid to the psychological effects of these treatments on patients.
These considerations need to be incorporated in the holistic assessment and treatment of patients with cancer who are on immunotherapy. With growing number of patients on these therapies, it is also becoming increasingly important for all health care providers dealing with such patients to have some basic understanding of issues and considerations relevant for them.
Modern cancer immunotherapy affects the patient and his relatives during the long treatment period. Here, we review the psychological implications of modern cancer immunotherapy for patients. In addition, factors that influence the patient’s experiences with immunotherapy are described. Importantly, we discuss the need for multidisciplinary support during cancer treatment with the increasing number of cancer therapies, such as the PD-1 inhibitor.
The Changing Psychological Landscape of Cancer Care
In the past, patients with an advanced cancer were often offered limited treatment options, within a curative or a palliative setting. Introduction of immunotherapy has provided such patients with another treatment option to consider.
Therefore, patients who are treated with cancer immunotherapy may experience a spectrum of emotions including hope, anxiety, optimism and uncertainty, and some may report a positive emotional outlook as a result of potential long-term disease control, while others experience psychological distress in anticipation of treatment outcome. Healthcare professionals should be aware that the emotional responses of patients during their treatment can change and may need to be assessed on an ongoing basis as opposed to solely at diagnosis.
Psychological Responses During Immunotherapy
Immunotherapy has different types of effects on patients than cytotoxic agents. While effects of cytotoxic agents are often immediate, with either positive or negative effects, immunotherapy can have a delayed effect, sometimes even in an unexpected manner. This makes it more difficult for patients to understand, which in turn can create problems in terms of their expectations and coping strategies. Common psychological experiences include:
- Hope associated with emerging treatment options
- Anxiety while awaiting imaging or biomarker results
- Fear of disease progression despite ongoing treatment
- Uncertainty regarding treatment effectiveness
- Emotional distress related to immune-related adverse events
- Difficulty balancing optimism with realistic expectations
- Concerns regarding long-term treatment planning
Each person can react differently, and many factors influence their experiences. These include the stage of the disease, the previous treatments a person has received, their level of resilience, the support they receive from family and friends, and their overall physical health.
The Role of Communication in Psychological Well-Being
Healthcare professionals who provide balanced, evidence-based information regarding treatment goals, expected timelines, possible adverse events, and monitoring strategies may help reduce uncertainty while supporting informed decision-making. Effective communication may include:
- Explaining treatment objectives using understandable language
- Discussing realistic expectations for response
- Clarifying the possibility of delayed clinical benefit
- Reviewing monitoring schedules and follow-up evaluations
- Encouraging questions throughout treatment
- Addressing misconceptions regarding immunotherapy
Consistent information from all members of the multidisciplinary team is also crucial to reducing patients’ confusion and promoting confidence in the cancer treatment process.
Managing Expectations in the Era of Immunotherapy
Awareness of immunotherapy has grown greatly through many scientific articles, media reports, and through advocacy groups of patients with cancer. Rising awareness of immunotherapy has led to more informed conversations between patients and their healthcare providers, as well as among patients themselves. However, there is also the risk of increasing the already high expectations of treatment that patients and their families have.
When communicating with patients about immunotherapy it is also important to remember that the treatment is not suitable for every patient with every type of cancer. There are many clinical factors that need to be considered prior to selecting treatment. Individualized treatment decisions are important to note during any discussions of potential benefits and corresponding limitations of immunotherapy for a patient’s specific cancer.
Psychological Considerations Related to Biomarker Testing
Potential psychological considerations include:
- Anxiety during the testing process
- Uncertainty while awaiting laboratory results
- Disappointment when anticipated treatments are not appropriate
- Relief when additional treatment options become available
- Questions regarding personalized treatment strategies
Healthcare professionals should recognize that biomarker discussions can be of a scientific and emotional nature and need to be communicated appropriately.
The Impact of Immune-Related Adverse Events
There are important differences between immune-related adverse events (IRAEs) and the toxicities that occur with chemotherapy, because they are caused by the activated immune system affecting normal tissues.
Even though most immune-related adverse events can be managed with the appropriate recognition and intervention, they can also create great amounts of anxiety as patients and families are uncertain about the cause of new symptoms and whether treatment will have to be held. Psychological effects may include:
- Fear associated with unexpected symptoms
- Reduced confidence in continuing treatment
- Anxiety regarding long-term health consequences
- Concerns about quality of life
- Emotional fatigue resulting from prolonged monitoring
Educating the patients about recognition and management of symptoms will help them and their families face uncertainties.
The Role of Multidisciplinary Support
Psychological support can play an important role in comprehensive cancer care and may be provided at all stages of a patient’s care journey, including diagnosis, treatment, and follow-up. Multidisciplinary teams may include:
- Medical oncologists
- Radiation oncologists
- Oncology nurses
- Clinical psychologists
- Psychiatrists
- Social workers
- Nutrition specialists
- Rehabilitation professionals
- Palliative care specialists
All aspects of care are integrated in a holistic way: emotional, physical, nutritional and supportive aspects of care in addition to medical treatment.
Supporting Shared Decision-Making
Shared decision-making has become increasingly important as treatment options continue to expand. Healthcare professionals can support informed decisions by discussing:
- Available treatment options
- Expected therapeutic goals
- Potential benefits and limitations
- Possible adverse events
- Patient preferences and values
- Quality-of-life considerations
- Follow-up requirements
Some patients may want to have more involvement in their treatment decisions than others in order to feel more confident in and satisfied with their treatment and care.
Emerging Research in Psycho-Oncology
As with cancer treatment in general, there is ongoing research on psychological outcomes of immunotherapy patients. Current areas of investigation include:
- Anxiety associated with biomarker-driven treatment selection
- Psychological adaptation during long-term immunotherapy
- Patient-reported quality-of-life outcomes
- Emotional responses to durable remission
- Mental health interventions integrated into oncology care
- Digital approaches to psychosocial support
- Longitudinal survivorship studies
Future studies are likely to identify additional ways in which psychological interventions can be used in conjunction with treatments given within the conventional cancer care continuum.
Key Takeaways
Immunotherapy has not only changed the clinical treatment of cancer but also the psychological process of patients. They and their families experience high expectations and uncertainty. The goal of cancer treatment is a long-term remission of cancer. Patients are subjected to biomarker-driven treatments. They experience anxieties and fears before each treatment.
For the healthcare professional treating cancer patients, there are psychological elements involved with immunotherapy that need to be recognized to be able to give comprehensive care to patients and their families. Patients and families are best served when evidence-based communication, a multidisciplinary approach to patient care, routine psychosocial assessment, and individualized supportive care are provided throughout the cancer care continuum.
The information provided in this article is intended for educational purposes only and should not be interpreted as medical advice, a clinical guideline, or a recommendation for any specific treatment. Consult Healthcare professionals for full prescribing information, peer-reviewed literature, and current national and international clinical guidelines before making treatment decisions. Patients should seek advice from their haematologist, oncologist, or other qualified healthcare professional regarding diagnosis and treatment options.