When Carly Flumer was a teenager, she was diagnosed with anxiety and depression. She saw a psychiatrist and a therapist regularly, and got medication and counseling. She managed her mental health well for over a decade. But in January 2017, she was diagnosed with an aggressive form of thyroid cancer that had spread to her lymph nodes by the time it was diagnosed.

That’s when things got complicated again.

Flumer, then 27, underwent surgery to remove her thyroid. She also received intensive radiation. To all observers, she got a clean bill of health — at least with regard to her cancer. But, she says, her mental health had suffered.

“People absolutely do not understand the panic a cancer diagnosis can cause,” Flumer says. “My depression and anxiety got worse when I got diagnosed. I also have had more suicidal thoughts because of the cancer,” she says. “The side effects of treatment are real. So is the stress of waiting to see if the cancer comes back again.”

Flumer, who is still receiving medication and counseling for her anxiety and depression, is not alone in struggling with mental health issues brought on or worsened by cancer. Research has found a higher risk of depression and suicidal thoughts among cancer patients.

The Evidence for the Mental Health Toll Wrought by Cancer

There's no shortage of evidence that cancer takes a toll on mental health. A study published in March 2022 in Nature Medicine examined patients with 26 different cancers and concluded that depression was the most common mental illness in people diagnosed with cancer.

People who were treated with chemotherapy, radiotherapy, and surgery were more likely to experience mental health issues, according to the study, and a link between depression and the immune system’s inflammatory reaction to tumors was found, indicating that the body’s fight against tumors can come with a mental health cost. Researchers for this study also found an increased risk of self-harm in this population, which was highest in the first year following a mental illness diagnosis.

Another study, also published in March 2022 in Nature Medicine, found that patients with cancer had an 85 percent higher death rate from suicide than the general population. The suicide death rate was higher in patients with difficult-to-treat cancers, such as liver, stomach, head and neck, and pancreas, according to the study.

Mental Health Screening and Follow-Up

In 2014, the American Society of Clinical Oncology (ASCO) recommended that all cancer patients and survivors be screened for symptoms of depression and anxiety throughout their care with a short screening questionnaire, such as the nine-item Patient Health Questionnaire (PHQ-9).

Getting any traction on this has been difficult, says Patricia Ganz, MD, a medical oncologist and the director of cancer prevention and control research at the Jonsson Comprehensive Cancer Center at the University of California in Los Angeles. “It is still not being done routinely, and, if it is done, it is often done early, but not subsequent to treatment,” she says.

Dr. Ganz warns that it’s not enough to screen cancer patients for depression if doctors and facilities aren’t equipped to follow up with appropriate care. And not all are. In a study published in March 2022 in JAMA Network Open, researchers found out that of patients screened, 77 percent met criteria for follow-up care, but only 32 percent received care within three months of screening.

Trevor’s Story

Trevor Maxwell says he became depressed after he was diagnosed with stage 4 colon cancer, which had spread to his liver, in April 2018. Maxwell had multiple surgeries and more than 50 rounds of chemotherapy and immunotherapy to try and control his disease. But with a stage 4 diagnosis, his disease will be one he has to manage for the rest of his life.

That has been hard to accept, Maxwell says. “I felt like a failure and was ashamed,” he says. “I felt I was going to die and leave my family at a relatively young age. That was just crushing.”

While he did fill out mental health questionnaires, he says the coordination of care for mental health was disorganized. “It wasn’t that no one made any efforts,” Maxwell says. “It wasn’t really coordinated, and there was not enough attention to follow-up.”

As a result, Maxwell’s depression worsened over the course of a year, getting to a point where he hardly left his bedroom except to receive treatment. “My medical providers were so focused on treating cancer, the thing that was killing me, that the mental health piece had to come second,” he says.

Some healthcare providers understand the importance of prioritizing mental health, but many focus on cancer first. “Cancer treatment gets priority because we have more measurable points to address a cancer diagnosis,” says Liudmila Schafer, MD, a medical oncologist and the author of The Other Side of Oncology.

Cancer gives providers a clear and measurable adversary, unlike depression, which can be extremely individual and hard to quantify, Dr. Schafer explains. Oncologists can look at a tumor on an MRI, or see a number from a lab test, and know exactly what’s going on. Depression and anxiety are harder to follow up with. However, providers are starting to talk about how they can better treat mental health and cancer together.

Healthcare Providers Are Learning How to Manage Mental Illness

Erin E. Hahn, PhD, MPH, led a key depression screening study published in January 2022 in JAMA. She found that training and supporting clinicians with tailored strategies on how to conduct depression screenings and referrals led to more behavioral health referrals for patients.

In the study, nearly 8 percent of the 744 patients with breast cancer in the group treated by trained and supported clinicians were referred for mental health services. Of those patients, 75 percent completed a visit with a mental health provider; in the control group of 692 patients, just 1 patient was referred for follow-up.

“The emotional burden of cancer should never be sidelined,” says Dr. Hahn, who is a research scientist with the Kaiser Permanente Southern California department of research and evaluation.

Some centers screen and refer more effectively than others. Fred Hutchinson Cancer Center, for example, already screens cancer patients routinely every two months for mental distress, but Jesse Fann, MD, MPH, medical director of psychiatry and psychology at Fred Hutch, says any positive screening should always be followed up with a more detailed clinical assessment to hone in on exactly what services a patient needs.

This requires a frank discussion with the patient to determine how much their symptoms are affecting their daily lives, how long they have experienced these symptoms, and how their ability to complete their cancer treatment may be compromised, Dr. Fann notes.

Sometimes, all a patient needs is basic coping strategies, like making time for exercise or spending time with friends and family, Fann says. Finding a cancer support group can be helpful for sharing coping strategies, feelings, and personal experiences.

When and Where to Seek Help

Feeling sad or stressed about a cancer diagnosis is normal. But it can be difficult to pinpoint how you feel, and even more challenging to explain it to a health professional.

The National Comprehensive Cancer Network provides a handy tool called a “distress thermometer,” Schafer says. Using this assessment, you can figure out how you’re feeling, and express it to your provider or a trusted friend. Whether you feel ready to talk or not, it’s important to tell someone if you are in emotional distress.

The first step is to tell your oncologist about your mental health symptoms. Don’t wait until it feels comfortable. If you have already been coping with depression or anxiety before your diagnosis, that’s important information for your provider to know. If you feel too embarrassed or just can’t face the conversation yet, Schafer suggests asking a friend or family member to communicate that to your provider. It’s okay to let someone be the middleman to start.

Ideally, you or your loved one would receive screening and a referral for treatment, if necessary, experts say, preferably with a professional familiar with cancer. “It is helpful to have a therapist who has treated people with cancer so they have some awareness of the consequences of treatment,” Ganz says.

Your provider isn’t your only option. “Any type of provider can refer you for mental health services,” Schafer says. If your oncologist doesn’t refer you to a mental health professional, you can always talk to your primary care doctor. If you don’t have a provider yet, the American Cancer Society can help you find an oncologist.

You can also choose family members and friends you trust to talk about your mental health with. And if someone you care about has cancer and they’re isolating themselves, not responding to phone calls or text messages, having trouble sleeping, or not engaging in activities that used to give them pleasure, alert their healthcare team.

“I would advise any patient to be ‘your own guide,’” Schafer says, “Bring it up to the doctor or ask family members to talk about [your] depressive symptoms.”

Other Resources

You can always call the Suicide and Crisis Lifeline by dialing 988 in the United States. If you have any thoughts of harming yourself, know you are not alone in this.

There are also several cancer resource organizations you can turn to for some extra support, including:

More and more healthcare providers understand that recognizing and addressing depression, anxiety, and other mental health issues during cancer treatment is very important. By prioritizing mental healthcare alongside physical treatment, patients can better navigate the challenges of their illness with greater resilience and optimism.

Additional reporting by Abby McCoy.

Depression Is Often Overlooked in Cancer Patients