Dr. Anand Shankar S: I was drawn to psycho-oncology because it stands at the very human-crossroad of illness, identity, fear, and hope. Early in my training, I noticed how a cancer diagnosis affects not just the body. Patients were not only dealing with treatment plans, but also anxiety, grief, changes in relationships, and difficult questions about life and death, all while trying to make important medical decisions.

Research in psycho-neuroimmunology and behavioral medicine research provide evidence that stress, poor sleep, and unhealthy coping patterns can affect the body’s natural defence systems and overall strength during cancer treatment. These insights highlight why psychological care should be a core part of oncology, not something separate or secondary. Supporting a patient’s mental and emotional well-being is closely connected to their overall health and recovery.

Dr. Anand Shankar S: From a psycho-oncology perspective, cancer is not a single emotional event. It is a journey of distress that often begins at diagnosis and can continue long after treatment ends. Emotional suffering is shaped by many factors, including the nature of the disease, the intensity of the treatment, personal coping styles, family dynamics, cultural beliefs, and the way the patient's system responds.

In my experience, some deeper and long-term aspects of distress often go unnoticed:

• Existential distress and loss of meaning: Cancer can shake a person’s basic sense of control, identity and fairness. Patients may struggle with hopelessness, spiritual conflict, or a sense that life no longer feels the same. This is different from clinical depression and is often overlooked.

• Difficulty living with uncertainty: Ongoing questions about prognosis, scan results, or remission can create constant worry and tension, even when the patient is medically stable.

• Changes in identity and roles: Many patients find it hard to adjust to becoming dependent on others or stepping away from professional and family responsibilities. They may feel like they are no longer the person they once were.

• Emotional suppression: Some patients hide their distress to avoid worrying loved ones or to appear strong and positive. This often leads to silent suffering.

• Strain in relationships: Illness can affect intimacy, communication, and family roles. These changes are common but are rarely addressed unless serious conflict arises.

• Distress after treatment ends: Emotional difficulties may actually increase once active treatment is over, as medical supervision reduces but fear of recurrence remains.

• Financial stress and social instability: The cost of treatment and loss of income can deeply affect mental well-being, yet these pressures are often treated as separate from psychological care.

• Cultural beliefs and stigma: In many communities, including low- and middle-income countries, stigma, fatalistic attitudes, or moral judgments about illness can add another layer of emotional burden.

• Emotional needs at the end of life: Concerns about dignity, abandonment, and unfinished life stories are deeply human needs that may be overshadowed when care focuses only on physical symptoms.

Dr. Anand Shankar S: When anxiety, depression, or a sense of demoralisation go unnoticed, they can affect a patient’s ability to make clear decisions. A distressed patient may find it hard to process complex medical information, which can lead to regret later, delays in giving consent, or even avoidance of treatments that could be life-saving. Fear and hopelessness may also reduce trust in the medical team and make patients more vulnerable to misinformation.

Emotional distress is closely linked to poor treatment adherence. Patients may miss appointments, stop chemotherapy or radiotherapy early, take medications inconsistently, or disengage from supportive care. From a psycho-oncology perspective, this happens because distress reduces both mental clarity and the emotional energy required to continue long and demanding treatment plans.

Impact on recovery and clinical outcomes

Ongoing psychological distress keeps the body in a prolonged stress state. This is often associated with increased pain, greater fatigue, sleep problems, and difficulties with concentration and memory, sometimes referred to as “chemo brain.” These symptoms can slow recovery and make treatment side effects feel more intense.

Patients may also withdraw socially or struggle with changes in identity, which can make returning to work, relationships, and daily life more difficult. Even when someone is medically disease-free, these emotional challenges can significantly reduce their sense of well-being.

Impact on overall quality of life

Quality of life in cancer care includes physical, emotional, social, functional, and spiritual well-being. When emotional distress is not addressed, it can affect all of these areas at once. It may:

• Increase the burden of physical symptoms

• Strain family and caregiver relationships

• Reduce independence and sense of meaning

• Deepen feelings of helplessness or loss of dignity

Dr. Anand Shankar S: That is an important and often overlooked question. From a psycho-oncology perspective, family members and caregivers are not just support systems. They are often carrying their own emotional burden alongside the patient. Supporting these “co-patients” is not optional. It is essential for steady and sustainable care. 

How to support families and caregivers

1. Recognize caregiver distress as real and valid: Caregivers frequently experience anxiety, low mood, guilt, frustration, anticipatory grief, and burnout. Many feel they must remain strong and do not allow themselves to struggle. Clinicians can help by openly acknowledging this strain during consultations. Even a simple statement such as, “This is difficult for you as well,” can reduce feelings of isolation and silence.

2. Involve caregivers meaningfully in the care journey: Caregivers are often present at appointments, but only for practical reasons. They should also be included in emotional and decision-related discussions when appropriate. Asking about their understanding, fears, and expectations helps prevent miscommunication and reduces tension within the family.

3. Screen for distress and burnout early: Support should not begin only when a crisis occurs. Simple check-ins or short screening tools can help identify early signs of strain. Warning signs may include sleep problems, irritability, withdrawal, physical complaints, or becoming overly controlling. Early recognition can prevent emotional exhaustion later.

4. Normalize mixed emotions: Caregivers may feel love and frustration, hope and exhaustion, commitment and a desire for escape at the same time. These reactions are human. Naming and normalizing them reduces guilt, which is often one of the heaviest burdens caregivers carry.

5. Offer structured emotional support: Support should be active and organized, not just offered “if needed.” This may include - 

   • individual or family counseling, 

   • caregiver support groups, and 

   • brief guidance on coping with uncertainty and anticipatory grief

Dr. Anand Shankar S: That is a very relevant question. Anxiety is common in cancer care, but it is also manageable. From a psycho-oncology perspective, the most helpful support combines emotional understanding, practical coping skills, and steady follow-up throughout the illness journey.

1. Clear and compassionate communication - Uncertainty often creates more anxiety than difficult news itself

   • Honest, simple explanations without medical jargon

   • Clear information about side effects, timelines, and next steps

   • Consistent messaging from the entire care team

   • Even brief and empathetic communication can significantly reduce anxiety

2. Preparing patients for emotional reactions

   • Helping patients understand what to expect before scans, procedures, and waiting periods

   • Normalizing emotional ups and downs at different stages of treatment

   • When patients know their reactions are normal, they regain a sense of control

3. Supportive counseling - Often the first step in psycho-oncology support. Even short sessions can reduce distress meaningfully.

   • Providing space to express fear, anger, grief, and uncertainty without judgment

   • Offering validation instead of forced positivity

   • Focusing on coping and emotional support rather than trying to “fix” feelings

4. Practical coping strategies - Structured techniques can help patients manage anxious thoughts. These tools are practical and give patients a sense of control, especially during scan-related anxiety or medical procedures.

   • Addressing worst-case thinking such as assuming every symptom means relapse

   • Teaching grounding techniques and simple reframing methods

   • Supporting patients through scan-related anxiety and procedural fear

5. Peer and group support - Connecting with others who are going through similar experiences reduces isolation. This helps normalise emotions and reduce fear of the unknown.

   • Support groups, either in person or online

   • Peer mentors or survivor support programs

6. Complementary supportive approaches - These approaches support emotional balance and help patients feel more connected to their bodies.

   • Yoga and gentle movement

   • Acupressure or acupuncture for symptom-related anxiety

   • Creative therapies such as art, music, or writing

Dr. Anand: From a psycho-oncology perspective, survivorship is a period of psychological vulnerability rather than relief.

Why distress often peaks after treatment ends?

During active treatment, patients are held within a structured system of frequent visits, clear goals, constant monitoring. 

However, treatment ends:

• External support drops off abruptly

• The body feels unfamiliar and untrustworthy

• The patient is expected to “be grateful and move on”

Dr. Anand: End-of-life care is not only about managing physical symptoms, it is about how a person lives until death. From a psycho-oncology and palliative care perspective, psychological support is central to preserving dignity, comfort, and meaning during this phase.

1. Reduces fear and emotional suffering: Fear of death, pain, abandonment, and loss of control is common, yet often unspoken. Psychological support provides a safe space to:

• Express fears openly without being corrected or rushed

• Separate realistic concerns from overwhelming worst-case thoughts

• Reduce panic, agitation, and emotional distress

2. Preserves dignity and personhood: As illness progresses, patients may feel defined only by their diagnosis or physical decline. Psychological care:

• Affirms the person beyond the illness

• Respects individual values, preferences, and identity

• Supports decision-making wherever possible

3. Helps process grief, loss, and unfinished matters: The end of life often involves multiple losses, including independence, roles, and future plans. Psychological support helps patients:

• Grieve these losses

• Express regret, forgiveness, gratitude, or love

• Address unresolved relationships or life stories

4. Supports meaning, purpose, and peace: Questions about meaning and life’s purpose often become more intense at this stage. Therapeutic conversations can help patients:

• Reflect on what has mattered most in their lives

• Affirm their values and legacy

• Feel a sense of completion rather than despair

5. Improves the experience of physical symptoms: Emotional distress can intensify pain, breathlessness, and fatigue. When anxiety and emotional tension are reduced, psychological support:

• Lowers the perceived burden of symptoms

• Enhances the benefits of medical care

• Promotes better rest and emotional calm

What dignified end-of-life care looks like 

• Being listened to without feeling rushed

• Having both physical pain and emotional distress taken seriously

• Having personal choices respected

• Being free to express fear, hope, faith, or doubt

• Feeling supported and not alone

Dr. Anand: Cancer-related psychological symptoms may appear similar on the surface, but their causes, course, and treatment needs are different. Labeling all emotional distress as “depression” can lead to both over-treatment and under-treatment.

1. Depression in the context of cancer

• Nature

  • A clinical mental health condition

  • May exist before cancer, be triggered by it, or occur separately

  • Marked by persistent low mood, loss of interest or pleasure, deep hopelessness, guilt, thoughts of self-harm, and clear decline in daily functioning beyond what would be expected

• Psychological care approach

  • Careful assessment and possible use of antidepressant medication

  • Structured psychotherapy

  • Ongoing monitoring for suicide risk and functional decline

• Goal

  • To treat a clinical condition, restore functioning, and reduce the risk of serious harm.

2. Stress, anxiety, and cancer-related distress

• Nature

  • A natural response to diagnosis, treatment, uncertainty, and threat to life

  • May include fear of recurrence, anxiety before procedures, adjustment difficulties, loss of meaning, or demoralization

  • Often rises and falls with major illness milestones such as diagnosis, scans, relapse, or end of treatment

• Psychological care approach

  • Supportive counseling and clear information

  • Normalizing emotional reactions

  • Teaching coping skills such as relaxation, grounding, and mindfulness

  • Meaning-focused conversations and reflective approaches

  • Involving family when appropriate

  • Often brief and time-limited support is enough

  • Medication is usually not the first step unless symptoms become severe or long-lasting

• Goal

  • To help patients adjust, strengthen coping, and reduce suffering without labeling normal reactions as illness.

Dr. Anand: Tele-counselling has become a quiet but meaningful support in psycho-oncology, especially where access, stigma, distance, or physical weakness make in-person visits difficult. When thoughtfully integrated, it helps more patients receive timely psychological care, including in areas such as palliative dentistry.

Role of tele-counselling in psycho-oncology

1. Expanding access despite distance or physical limits : Many cancer patients, particularly those with advanced illness, cannot travel easily because of fatigue, pain, low immunity, or financial strain. This is especially important in settings where specialist services are available only in larger cities. Tele-counselling:

• Brings psychological support directly into the patient’s home

• Reaches rural and underserved communities

• Reduces missed appointments and drop-outs from care

2. Reducing stigma and making help easier to seek: Speaking from home often feels safer and more private. Tele-counselling:

• Lowers the hesitation to seek mental health support

• Reduces fear of being labeled or judged

• Encourages patients to seek help earlier rather than waiting for a crisis

3. Providing continuity throughout the illness journey: Cancer-related distress changes over time. A steady connection helps patients feel supported as their needs evolve. Tele-counselling allows ongoing support:

• During diagnosis and active treatment

• During survivorship and fear of recurrence

• During palliative and end-of-life care

4. Supporting caregivers and families: Caregivers often struggle to leave the patient to seek help for themselves. Tele-counselling:

• Allows joint patient and caregiver sessions

• Offers private sessions for caregivers to share their emotions

• Helps reduce burnout and indirectly improves patient care

Dr. Anand: That is a meaningful area to feel curious about. Psycho-oncology truly needs thoughtful and grounded professionals. It brings together mental health, cancer care, and palliative care to address the emotional, social, and deeper personal impact of a cancer diagnosis. Before specializing, it is important to build strong clinical foundations in assessment, therapy skills, and risk management. A clear understanding of how cancer progresses, how treatments affect patients, and how uncertainty shapes decision-making helps ensure that psychological support remains practical, relevant, and closely aligned with medical care.

A final thought

If you choose psycho-oncology, do so with clear intention. This field will change the way you understand illness, suffering, resilience, and even your own inner world. At times, that awareness can feel heavy. Yet it is also deeply meaningful and enriching, offering the privilege of walking alongside patients and families during some of the most vulnerable moments of their lives.