After a person hears he or she is diagnosed with cancer, the first reaction frequently is a sort of shock: “It can not be me; they must have mixed up the test results with another person”. For many patients, receiving such a diagnosis is associated with the fear of intense pain, loss of control, stigmatisation and death (Holland et al. 1989). Getting such a diagnosis therefore feels like a nightmare. Complex processes of denial and subsequent realisation of the truth, often followed by denial again, are seen in those patients.

After a while, depending on the psychosocial resources a patient has, the truth can be faced more fully by the patient. In this phase of coping with disease, people often start fighting and arguing—with their doctors, their relatives, their fate. It is as if they try to overcome the disease by fighting. When they realise this is not possible, it often results in intense feelings of hope and helplessness which can turn into depression. Not everybody is able to finally accept the malignant disease as part of his or her life.

These phases of coping described above were conceptualised by Elisabeth Kübler-Ross after she had interviewed numerous dying patients (Kübler-Ross 2008). Her concept has been adapted by many authors, and at the same time criticised for not being empirically valid. Indeed, these “phases” can be seen in many patients (and their relatives), however, there is no certain order of the “phases” which is why we prefer to call them emotional reactions, that can occur consecutively or simultaneously.

Denial allows the patient to keep reality away from the consciousness until he or she is able to deal with it. Clinicians should be aware of the fact that this is a natural process of our psyche to keep our psychological structure alive. At least in the beginning of the cancer trajectory, patients and relatives should get enough time from the medical team until they can refrain from denial. It is not advisable to push them into the truth too fast.

However, continuing denial can be a challenge in oncology, as patients often need to be treated within a short period of time. One should avoid “breaking the denial” by aggressive instructions about the disease and its treatment. This will only result in aggression and anger, be it openly expressed or more silent.

A better way of supporting the patient in getting over his denial is to (a) strengthen his psychosocial resources and (b) avoiding denial in ones own perspective. Health care providers should try to be neutral and not joining the patient in his or her denial. It is often challenging to not do this because it is seductive, especially when treating young patients, to just avoid the idea of pain and potential death. However, if the patient feels that his carers deny his situation he will be even more convinced that his fate is horrible and that he can not deal with it (if not even the “professionals” can deal with it!). This can also make the patient feel totally alone with his fears. So, if the health care provider can accept the patient in his denial and at the same time be prepared to also talk about distressing topics such as the danger of functional impairment, losses and death, it will support the patient to overcome his denial.

Example:

My patient was a 40 year old single mother. She received the diagnose ovarial carcinoma 5 years ago and I had been seeing her since then. While she first wanted to see a psychologist to identify psychological causes of her disease with the aim of then changing her life accordingly to be cured from cancer, she was faced with multiple metastases in her entire body. Still, she thought that psychotherapy can cure her and she asked me to help her visualise her blood and cancer cells because she read in a book that this would cure her.

I saw her emotional suffering and wanted to support her, at the same time I knew that she had a tumour with a poor prognosis, she had multiple metastases, and she was admitted to the palliative medicine ward at our hospital. Her daughter was 15 years old, the patient described her ex-husband as being alcohol dependent, so she did not want her daughter to live with him.

The patient seemed torn between the hope of cure and the realisation of nearby death, but the truth was too hard to bear so she denied it and seemed to force all others to share this denial with her. Her physician told me about her refusal to find a solution for her daughter, which needed to be resolved since she was facing death.

During our next session, the patient told me in tears that her parents said to her: “Girl, make sure you get better soon”. When she wanted to talk with them about her fears, they both said: “Forget it, you will be better”. This obviously did not help her, as she felt utterly alone. In this situation, I decided to openly ask the patient about her feelings regarding death and dying. No one from the team had done this before feeling sorry for the patient and because she seemed to refuse any conversation about it. However, the patient now reacted relieved. We talked about dying, her experiences with death, her ideas about what happens thereafter, and finally about her daughter living without her.

The patient deceased two weeks later.

This example shows that, although patients often deny, they can at the same time talk about distressing topics if they experience a supporting relationship with someone they trust and who is not in denial himself.

At times, psychological distress can be severe for cancer patients, resulting in clinically relevant mental health conditions. Numerous studies have investigated the frequency of these conditions in cancer patients over the past years.

Several meta-analyses and large multi-centre studies have shown that, during the time of cancer diagnosis, about 30 % of the patients suffer from a mental health condition (Mitchell et al. 2011; Singer et al. 2010, 2013a; Vehling et al. 2012). Less is known however about the course of those conditions during the cancer trajectory. Available evidence suggests that their frequency does not decrease considerably over time (Bringmann et al. 2008).

Known risk factors for mental disorders in cancer patients are pain, high symptom burden, fatigue, mental health problems in the past and disability (Akechi et al. 2004; Rooney et al. 2011; Banks et al. 2010; Agarwal et al. 2010). There are no consistent correlates of depression in cancer patients (Mitchell et al. 2011).

In some studies alcohol dependence was more common in men (Matheson et al. 2012; Dawson 1996; Kessler et al. 1994; Bronisch et al. 1992; Krauß et al. 2007) and in patients with malignancies in the head and neck, oesophagus and liver (Shimazu et al. 2012; Freedman et al. 2007; Hashibe et al. 2007; Kugaya et al. 2000).

Not only does psychiatric co-morbidity represent enhanced distress of the patients calling for specific support from the medical team it also increases the length of hospital stay (Wancata et al. 2001) and negatively affects survival, if not treated adequately (Kissane 2009; Pinquart et al. 2010). It is therefore highly important to identify patients suffering from mental health disorders as soon as possible. Unfortunately, health care providers often fail in identifying these patients (Singer et al. 2011a; Absolom et al. 2011; Fallowfield et al. 2001; Söllner et al. 2001), resulting in severe under-treatment (Singer et al. 2005; Schwarz et al. 2006; Singer et al. 2011b; Oliffe et al. 2008; Stoppe et al. 1999; Werrbach et al. 1987; Wilhelm 2009).

In a large prospective study with cancer patients we found that of those with mental health conditions, 9 % saw a psychotherapist within 3 months of the diagnosis, 19 % after 9 months and 11 % after 15 months. Mental health care use was higher in patients with children ≤ 18 years (odds ratio 3.3) and somatic co-morbidity (odds ratio 2.6) (Singer et al. 2013a). Interestingly, in this study, uptake of mental health care was equal between men and women, in contrast to findings from studies in the general population (Oliffe et al. 2008; Stoppe et al. 1999; Werrbach et al. 1987; Wilhelm 2009). The admission to mental health care did not differ in patients with different educational attainments.

During the past decade, increasing interest has been given to potential benefits of the experience of cancer despite it being challenging and often highly distressing, i.e. whether traumatic experiences can lead to emotional growth in patients and relatives (Hungerbuehler et al. 2011; Kahana et al. 2011; Kim et al. 2011; Love et al. 2011; Demirtepe-Saygili et al. 2011; Fromm et al. 1996). Such posttraumatic growth has been defined as positive psychological change experienced as a result of the struggle with highly challenging life circumstances (Calhoun et al. 2000, 2001). It describes the experience of individuals whose development has surpassed what was present before the struggle with the crises occurred, i.e. people feel that they did not simply “go back to life as usual” but that they feel enriched, wiser, grown, etc. after the crisis.

According to Tedeschi and Calhoun (2004), positive changes can be found in five dimensions, representing different types of posttraumatic growth: greater appreciation of life and changed sense of priorities; warmer, more intimate relationships with others; a greater sense of personal strength; recognition of new possibilities of paths for one’s life and spiritual development (Tedeschi et al. 2004).

Individuals’ experience of posttraumatic growth depends on several predictors. Many facilitating factors have been reported: younger age, female gender, low consumption of alcohol, low levels of pessimism and depression, high life satisfaction, high levels of extraversion, having an active sexual life and receiving counseling (Cormio et al. 2010; Milam 2004; Mols et al. 2009; Paul et al. 2010; Sheikh 2004; Jansen et al. 2011; Barskova et al. 2009). Benefit finding, a concept similar to posttraumatic growth, depends on the amount of time that has passed since stressor onset, the instrument used and the racial composition of the sample (Helgeson et al. 2006).

To date only a few studies have investigated whether or not psychosocial interventions can help to increase posttraumatic growth after traumatic events or serious illness. Especially in cancer patients, evidence is scare. Own research has shown that art therapy once weekly over a period of 22 weeks in the outpatient setting did not increase posttraumatic growth (Singer et al. 2013b). This finding is in accordance with scepticism towards the concept of growth in the context of adversity, including serious illness and towards positive psychology in general (Coyne et al. 2010).

Low socioeconomic position is known to be associated with poor health on the one hand and with less access to healthcare on the other (Williams 2012; Garrido-Cumbrera et al. 2010; Korda et al. 2009; Habicht et al. 2005; Celik et al. 2000; Jenkins et al. 2008; Lorant et al. 2007; Weich et al. 1998, 2001; Singer et al. 2012). The socioeconomic position may even decrease after a cancer diagnosis, especially in younger patients if they lose their jobs due to cancer-caused disability (Banks et al. 2010). On the other hand, it is also possible that social problems may decrease or even disappear after a cancer diagnosis, for example if a previously unemployed person receives a pension due to disability.

Vocational rehabilitation of cancer patients differs remarkably between countries. For example, while in Scandinavia about 63 % of all patients returned to work after a total laryngectomy (Natvig 1983) and 50 % did so in France (Schraub et al. 1995) only 11 % could return in Spain (Herranz et al. 1999). Predictors of successful return to work are flexible working arrangements, counseling, training and rehabilitation services, younger age, educational attainment, male gender, less physical symptoms and continuity of care (Mehnert 2011).

Similarly, patients’ financial burden depends largely on the country’s social system and health care insurances. Specific problems are the so-called “out-of-Pocket-health payments”. These are expenses the patient has because of the disease and/or its treatment that are not reimbursed by insurance. In the US, breast cancer patients (n = 156) who were insured (either by Medicare, Medicaid, or privately) reported that they spent 597 dollars per month for direct medical costs (e.g. stay at a hospital) without reimbursement, 131 dollars for direct non-medical costs (e.g. transport to the hospital, salary for baby sitters etc.) and 727 dollars for indirect costs (e.g. loss of money to do reduced income) (Arozullah et al. 2004). In contrast, we found that, in a group of German cancer patients (n = 502), the average amount spent “out-of-pocket” over 3 months was 98 Euros at the time of diagnosis and 30 Euros 15 months after diagnosis (data unpublished). This study however did not tackle indirect costs.

Regarding the course of financial problems, findings are mixed. In a group of German cancer patients at the time of cancer diagnosis (n = 799), 41 % reported having financial difficulties due to the disease while this was increased to 52 % half a year after diagnosis (Schwarz et al. 2008). Similar trends were seen in the US (Arozullah et al. 2004) while others found decreasing (Tsunoda et al. 2007; Arndt et al. 2005) or persisting problems (Sullivan et al. 2007).