The diagnosis and treatment of cancer brings many stresses and burdens to the lives of patients, as well as to the lives of their family members and friends. It also brings opportunities for personal growth, for clarifying what matters in life, and for strengthening convictions about living with purpose. The resilience and resources available to people touched by cancer vary greatly, and provision of psychosocial care is best when it is tailored to the particular vulnerabilities and strengths of patients and their support systems. This is consistent with a growing approach to precision and personalized medicine.

Cancer does not occur in a vacuum, but within a life context that can be placid or fraught with non-cancer stressors. A married woman in her 40s with early-stage colon cancer whose adolescent children are well adjusted and whose spouse is employed in a high-paying and flexible job has a much different set of challenges than a woman of the same age with the same cancer who is a single mother working at a low-paying job and going to school at night. The availability of resources for coping with the demands of cancer, in the life context of the person and family compared to the demands on these resources, will shape the need for professional help during the cancer journey.

Stress is a common and familiar part of life. Selye’s definition remains useful to this day: “Stress is a process in which environmental demands tax or exceed the adaptive capacity of an organism, resulting in psychological or biological change that may place the person at risk of disease” [1]. Cancer puts extensive demands on the lives of patients and family members. The severity of cancer and its associated stressors vary with the degree of threat to the life course of patients and their family members. The life course of the patient and family is manifest in its continuity over time [2]. It arises from their particular history and is guided toward the future by shared values and goals. Our concept of threat is informed by the work of Brown and Harris (1989) who designated the magnitude of threat based on the meaning of life events in the context of close relationships, personal history, and social circumstances. They showed that the risk of depressive disorder was increased in proportion to the threat from stressful life events and difficulties defined in this way [3]. Measurement of the threat to the life course, therefore, is the best assessment of the stress in the cancer context because it is based on the effects of the specific experience of patients and their family members over time.

Emotional distress in response to disruptions of one’s life course, such as receiving a cancer diagnosis, is normal. Resilient patients use this emotional reaction to focus their attention on the implications of this new situation for their life goals and to begin to adapt to them. Rather than avoid the initial emotional pain, they accept it as an important signal, providing information about a change to which they need to adapt. These resilient individuals call on their past experience of coping with life challenges, and they turn to trusted family and friends to help them process or “metabolize” the news, in preparation for adjusting their perspectives on their bodies, their sense of self, their roles in life, and their spiritual orientation. This is an active, effortful process and occurs over time, with the end result of a “new normal” being established for the patient and their close others. The new normal evolves over time as treatment unfolds and comes to an end or when the cancer progresses and the individual enters the chronic or palliative phase of cancer care.

Vulnerability to prolonged episodes of distress and less optimal adaptation occurs in individuals with preexisting patterns of emotional responding that either perpetuate the distress or bury it before it is processed. Rather than appraising the threat as circumscribed and specific, they generalize their sense of helplessness to all aspects of their new situation [4]. They are more likely to be younger and to have fewer close relationships that are secure and reliable [5]. Limited economic resources and less flexibility in their work and community environments increase the likelihood of non-metabolized emotional distress, which compromises their ability to think clearly and adapt their lives to the new demands of the stressful cancer context. When emotional and social resources are not available to mitigate the stressors of cancer patients, there is increased risk of adverse outcomes such as noncompliance with care, as well as the new onset of mental health problems.

Stress generation occurs when depression and anxiety resulting from overwhelming stress create the context for a cascade of new stressors. Maunsell et al. [6] found that women with stressful life events in addition to breast cancer have greater distress, depending on stressor magnitude. Burgess et al. [5] conducted a 5-year study of stressors in 170 breast cancer patients. Severely stressful difficulties predicted higher risk for major/minor depressive disorders or anxiety from 4 months to 2 years (RR: 1.36) and from 2 to 5 years (RR: 1.54), but not in the initial 4 months post-diagnosis. Low et al. [7] found that higher magnitude non-cancer-related events in the past year predicted more depressive symptoms concurrently and 6–12 months later.

The time course and style of adaptation to cancer vary with each patient’s preexisting emotional, cognitive, and social resources. Oncology professionals and the patient’s close others are well advised to accept differences in coping, such as a long initial phase of denial of distress and very limited disclosure of the cancer diagnosis to others in the patient’s social network, in order to maintain empathy for the patient experience. Compassionate relationships provide the holding environment for patients to adjust their lives to the need for cancer treatment and offer an important opportunity for support and psychosocial interventions to be offered and accepted over time [8].

Post-traumatic growth occurs when patients and family members use adaptive coping strategies such as problem solving, positive reappraisal, active seeking of emotional support from others, and acceptance of aspects of the cancer situation over which they have limited control [9]. Resilient individuals pay attention to their emotions and share them with people they trust. Activation of attachment and caregiving drives within patients and their family members brings them together, promoting new awareness of their values and their ability to prioritize their efforts to maximize life satisfaction [2].

The developmental stage of patients and their families influences the nature and the extent to which cancer threatens their life goals [10]. For example, cancer in early childhood occurs in the context of acquiring skills of movement, cognition and communication, and learning to socialize with peers. Young families of children with cancer are establishing their identity, and the need to rely on grandparents interferes with the autonomous functioning and sense of control for the parents. Family disruption when a parent or sibling has cancer puts children at risk for regression from developmental milestones, increasing fears of being different from others and separation anxiety.

Rowland et al. outlined the developmental stages and their effects on adaptation to cancer, along with interventions to maximize childhood coping when a parent has cancer (Tables 10.4 and 10.7 from Holland in Blumenfield and Strain) [8]. Psycho-oncology interventions to preserve achievement of developmental milestones and to acknowledge their delay or loss when necessary can reduce the threat of overwhelming stress from cancer.

Major depressive disorder is twice as prevalent in cancer patients attending outpatient oncology office visits as compared to the general population (6 % vs. 2 %), based on data from a recent screening study of over 20,000 oncology patients at all stages of cancer care [11]. Adjustment disorders, with persistent anxiety and depressive symptoms that do not reach the threshold for major depression, nevertheless compromise functioning in up to 50 % of cancer patients. Fear of recurrence is reported by 70 % of cancer patients up to 5 years after diagnosis and probably longer [12]. Intrusive thoughts of cancer recurrence interfere with daily functioning in occupational, family, and community roles, although full-blown post-traumatic stress disorder is uncommon. Adjustment disorders with compromised emotional, cognitive, and social functioning are at least twice as prevalent in cancer patients as in people without a cancer diagnosis in the general population.

Depression heightens risk for morbidity and mortality in several chronic diseases, including AIDS and heart disease [13]. Although findings are not completely consistent, depression may confer risk for mortality in cancer [14], a relationship for which plausible biological mediators have been advanced [15]. Onitilo et al. [16] compared effects of depression on mortality in people with and without cancer in 10,025 participants in the National Health and Nutrition Examination Survey. After adjustment for confounders, people with both cancer and depression had a 19 % increased risk of death compared to people with cancer only. Mykletun [17] found a 33 % increased risk of death from cancer associated with disorder-level depressive symptoms in a prospective study of 61,349 adults in Norway followed for 4.4 years after depression assessment. Evidence that unremitting depressive symptoms are more pernicious for health outcomes than an acute depressive episode [18] underscores the importance of examining depression trajectories over time. A meta-analysis [19] revealed that depression, but not anxiety, triples the risk for nonadherence to a variety of medical regimens. Elevated depressive symptoms predict lower arm mobility [20] and lower satisfaction with medical care [21] over time in breast cancer patients. Medicare beneficiaries diagnosed with cancer are at least twice as likely to use emergency departments and medical inpatient services if they have significant depressive symptoms than if they do not [22]. In other chronic diseases, comorbid depression increases healthcare use, functional disability, and work absence [23].

Many interventions to optimize psychosocial adaptation to cancer have been tested and found to be effective in high-quality randomized clinical trials over the past 40 years. A recent meta-analysis of interventions to reduce emotional distress and improve quality of life in cancer patients and survivors reported on 198 RCTs involving 22,238 patients [24]. This meta-analysis included only interventions delivered in person and included a range of psychological techniques, such as education, coping skills training, psychotherapy, and relaxation, alone and in combination, provided by professional therapists to patients with cancer. Significant small-to-medium effects were observed for individual and group psychotherapy and psychoeducation, and these effects were sustained for 6 months. Longer interventions were more likely to be sustained beyond 6 months.

Mindfulness-based therapy for symptoms of anxiety and depression has been studied over the past 10 years. A meta-analysis of 22 independent studies, including nine RCTs, found medium effect sizes (Hedges’ g) of 0.60 and 0.42 in non-randomized pre-post design studies for anxiety and depression, respectively [25]. There was great heterogeneity of effect sizes between studies, likely due to differences in cancer type and severity, comorbid anxiety and/or depressive disorders, use of antidepressant medications, as well as level of motivation to practice between sessions, which is known to be associated with effects on symptom outcomes.

Most of these intervention studies targeted all patients with cancer, and because many cancer patients do not have high levels of distress, the pre-post changes across the interventions for the groups as a whole were modest. Larger reductions in distress were achieved when interventions targeted patients with elevated emotional distress or at significant risk for distress. Given the limited number of professionals trained to deliver psychosocial interventions to cancer patients, focusing resources on those with elevated psychosocial distress may need to be considered.

Identification of clinically significant social and emotional disorders and their treatment by professionals with mental health training is crucial for restoring quality of life and facilitating full participation in lifesaving cancer treatments, yet professional oncology teams have commonly overlooked this area of patient care. Screening for psychosocial distress as a criterion for accreditation by the American College of Surgeons Commission on Cancer (COC) is required by the end of 2015. This requirement arose because the detection and treatment of emotional disorders is inadequate for cancer patients, resulting in suffering and worse outcomes [26, 27]. Only 27 % of those with documented major depression disorder (MDD) in a large screening study in outpatient oncology clinics in Scotland were receiving potentially effective treatment [11]. Pirl et al. [28] published recommendations for the implementation of distress screening, and the choice of which of several screening instruments to use is left to the judgment of the local cancer committee and the particular systems and personnel available to perform this task. These recommendations were developed by authors representing the American Psychosocial Oncology Society (APOS), the Association of Oncology Social Work (AOSW), and the Oncology Nursing Society (ONS) in which over 36,000 oncology social workers, psychologists, nurses, chaplains, psychiatrists, and other physicians who provide psychosocial care to patients with cancer in the United States are members. They emphasize that a plan for assessment and treatment of the detected distress must be in place prior to the initiation of screening. Oncology treatment providers who begin screening for distress must employ professionals who can intervene or who can effectively refer patients in need of mental health intervention to available providers of care.