Health Link

Healthy living after treatment of childhood, adolescent, and young adult cancer

Mental Health after Cancer Treatment
The Cancer Experience
Diagnosis and Treatment
Diagnosis and treatment are difficult times for people with cancer and their families. During diagnosis, children or
teens have tests and procedures that are new, sometimes painful and often scary. For parents, the anxiety of waiting
for the results of these tests and procedures can be the worst part of this time. Learning the diagnosis can be a relief,
especially when effective treatments are available. These treatments, though, can be unpleasant for children to haveand upsetting for families to watch or give. Tests and procedures are repeated during treatment to find out if thetreatment plan is working or should change. Children and teens with cancer and their parents are frequently at thehospital, sometimes away from other family, friends, home, work, or school for long periods of time. Parents worry
about whether their child’s cancer will be cured, how to minimize their suffering, and how to make the most of life.
Brothers and sisters also worry about, and are sometimes jealous of the sibling with cancer. Childhood cancer survivors
and their siblings can be concerned about their parents, and keep worries and feelings to themselves to try to protect
their parents. As a result, people diagnosed with cancer, their parents, and their siblings can feel angry, lonely, sad, andafraid during treatment. Periods of anxiety and depression can occur.
After Treatment Ends
For survivors and their families, the end of treatment can bring new feelings as they come to know the good (andsometimes not so good) outcomes of successful treatment. During treatment, people tend to be concerned withgetting through the day-to-day. It is after treatment that people can begin to think about and come to terms with theirexperience. People can have a range of feelings after treatment ends, and the blend of feelings can be as unique as
each person. Survivors and their families often fear that the original cancer will return. Regular testing for recurrent
cancer or late effects, and even just talking about possible late effects can cause stress. The diagnosis of a late effectrelated to cancer treatment or a new health problem unrelated to childhood cancer can also be sources of distress.
Anniversaries of cancer events, such as the date of diagnosis or end of treatment, and life changes such as school
entry or the normalization of peer relationships can bring on feelings that include relief and happiness, sadness about
the loss of a regular childhood, and guilt over having survived when others did not. Some survivors may feel vulnerable
because of their cancer experience and can be concerned about their health and act with caution. Parents of childhood
cancer survivors very much want to protect all their children from harm. These protective feelings can increase usual
tensions between parents and teenagers over issues related to growing independence, especially in matters that canaffect health. Other individuals who have had cancer believe that having survived cancer, they can do anything—and
this makes them feel invincible. These feelings can lead some survivors to undertake difficult studies, work, or hobbies.
The same feelings can lead other survivors to take part in unhealthy or risky behaviors.
Some Reactions to the Stresses of Survivorship
For the most part, childhood cancer survivors and their family members respond well to the stresses of survivorship.
Sometimes though, physical problems or other stresses related to childhood cancer and everyday life can lead tointensely distressing emotions that need medical attention. Some survivors, and their family members, can experience
periods of high anxiety that may or may not be triggered by reminders of the upsetting aspects of treatment. They
may develop three types of symptoms typically seen in people with posttraumatic stress disorder (PTSD), including (1)unwanted recall of unpleasant memories of cancer, (2) physical or emotional overreactions, and (3) going out of the way
to avoid reminders of cancer. For the most part, childhood cancer survivors and their family members do not develop all
Copyright 2023 © Children’s Oncology Group. All rights reserved worldwide.

Mental Health | Version 6.0 | October 2023 | Page 1 of 4

Health Link

Healthy living after treatment of childhood, adolescent, and young adult cancer

three types of symptoms and PTSD. Yet one or two of these symptoms can nonetheless get in the way of relationships,
school, work, and other key areas of daily life after cancer.
Personal growth can be another reaction to the stresses of life after cancer. After years of living with childhood cancer,
some survivors and their family members may find that they have undergone meaningful and beneficial changes inthemselves, their relationships with other people, and their values as a result of their experiences. Furthermore, they may
have been able to find some positive changes in their lives as a result of surviving the cancer experience. Experiencing
these positive changes is sometimes referred to as posttraumatic growth.
Risk Factors
Several factors can affect the development of depression and anxiety with symptoms of posttraumatic stress after
diagnosis and treatment of childhood cancer, including:• Female gender• Adolescent or young adult age• Prior trauma• Mental health or learning difficulties before childhood cancer• Developing health problems or physical limitations due to cancer treatment• Low levels of social support• Parental history of depression, anxiety, or PTSD
• Central nervous system (CNS) cancers (brain or spine) or treatment (radiation to the head/spine or intrathecalchemotherapy)• Treatment with hematopoietic cell transplant (bone marrow or stem cell transplant)
When to Seek Help
People with distress that (1) lasts two weeks or more, and/or (2) interferes with their ability to do daily home, schoolor work tasks, should call their healthcare provider to discuss the need for a referral to a mental health professional.
Because physical health problems can cause these same symptoms, a thorough check-up by your primary healthcare
professional is recommended if they occur. Some possible signs that help is needed can include:• Changes in appetite and weight• Crying easily or being unable to cry• Constant tiredness and low energy level• Sleeping more than usual or being unable to sleep• Feeling hopeless• Thoughts of hurting yourself or others• Engaging in self-harm behaviors (ie. cutting)• Alcohol or drug use to avoid unpleasant feelings• Increased irritability• Decreased interest in activities that had been pleasurable in the past• Unwanted recall of painful aspects of cancer• Feeling extremely fearful, upset, or angry when thinking about cancer• Physical reactions (rapid heart rate, shortness of breath, nausea) when thinking about cancer• Avoiding health care visits•

Refusing to talk about cancer

Copyright 2023 © Children’s Oncology Group. All rights reserved worldwide.

Mental Health | Version 6.0 | October 2023 | Page 2 of 4

Health Link

Healthy living after treatment of childhood, adolescent, and young adult cancer

Share Your Concerns with Your Healthcare Provider
If you experience distress, discuss it with your primary health care provider or childhood cancer specialist. Your
distress may be related to your cancer experience, worries about late effects, or other events in your life. In anycase, there is treatment. Talking with others about your fears and worries is a first step in gaining control over them.
In addition to receiving help from a health care provider, some people also find support through support groups,
participation in activities at their place of worship, or their faith.
Treatment Options
Treatments for depression, anxiety and posttraumatic stress symptoms include counseling in group or individual
sessions and, sometimes, medication. Medication usually works in combination with some form of counseling. Mental
health professionals (including mental health nurse practitioners, psychiatrists, psychologists, and social workers)
provide treatment for depression and anxiety in a variety of community settings. Your primary healthcare provider canhelp you find a suitable mental health professional in your community.
Resources
Support is available to childhood cancer survivors and their families who have anxiety and depression after treatment.
These are just a few of the many resources available:
American Cancer Society www.cancer.org
This site provides web-based support network, other programs and services, and stories of hope for cancer survivors
and their families.
American Psychiatric Association www.psychiatry.org
This site provides guidelines for choosing a psychiatrist.
The Anxiety and Depression Association of America www.adaa.org
This site provides information that can help people with anxiety disorders and depression find treatment and develop
self-help skills.
American Childhood Cancer Organization www.acco.org
This site offers education, support, service, and advocacy for childhood cancer survivors, their families and theprofessionals who care for them.
Childhood Cancer Guides www.childhoodcancerguides.org
This site provides articles related to psychosocial aspects of survivorship.
Children’s Oncology Group www.childrensoncologygroup.org
This site provides parents and families with information related to specific cancer type, treatment stage and age groupas well as tips on navigating the health care system, getting and giving support, and maintaining a healthy lifestyle.
National Institute of Mental Health www.nimh.nih.gov
This site provides general information about anxiety or depression, available treatments, finding a mental healthprovider, and access to research reports and other relevant information. See these specific areas of the web site:www.nimh.nih.gov/health/topics/anxiety-disorders
www.nimh.nih.gov/health/topics/depression

Copyright 2023 © Children’s Oncology Group. All rights reserved worldwide.

Mental Health | Version 6.0 | October 2023 | Page 3 of 4

Health Link

Healthy living after treatment of childhood, adolescent, and young adult cancer

Revised by Sheila J. Santacroce, PhD, APRN, CPNP, UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC. Originallyadapted by Debra A. Kent, RN, MSN, CPNP, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, from “Dealing withEmotions after Childhood Illness” by Melissa Hudson, MD, After Completion of therapy (ACT) Clinic, St. Jude Children’s Research
Hospital, Memphis, TN.
Reviewed by by Leeann Carmichael, DNP, APN, FNP-BC; Christine S. Yun, MSN, PNP, CPON; and Kayla L. Foster, MD, MPH.

Additional health information for childhood cancer survivors is available atwww.survivorshipguidelines.org
Note: Throughout this Health Links series, the term “childhood cancer” is used to designate pediatric cancers that may occur during childhood, adolescence, or young adulthood.
Health Links are designed to provide health information for survivors of pediatric cancer, regardless of whether the cancer occurred during childhood, adolescence, or young
adulthood.
Disclaimer and Notice of Proprietary Rights
Introduction to Late Effects Guidelines and Health Links: The Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers and accompanying HealthLinks were developed by the Children’s Oncology Group as a collaborative effort of the Late Effects Committee and Nursing Discipline and are maintained and updated by the Children’sOncology Group’s Long-Term Follow-Up Guidelines Core Committee and its associated Task Forces.
To cancer patients (if children, their parents or legal guardians): Please seek the advice of a physician or other qualified health provider with any questions you may have regarding a
medical condition and do not rely on the Informational Content. The Children’s Oncology Group is a research organization and does not provide individualized medical care or treatment.
To physicians and other healthcare providers: The Informational Content is not intended to replace your independent clinical judgment, medical advice, or to exclude other legitimate
criteria for screening, health counseling, or intervention for specific complications of childhood cancer treatment. Neither is the Informational Content intended to exclude other reasonable
alternative follow-up procedures. The Informational Content is provided as a courtesy, but not intended as a sole source of guidance in the evaluation of childhood cancer survivors. The
Children’s Oncology Group recognizes that specific patient care decisions are the prerogative of the patient, family, and healthcare provider.
No endorsement of any specific tests, products, or procedures is made by Informational Content, the Children’s Oncology Group, or affiliated party or member of the Children’s Oncology Group.
No Claim to Accuracy or Completeness: While the Children’s Oncology Group has made every attempt to assure that the Informational Content is accurate and complete as of the date of publication, nowarranty or representation, express or implied, is made as to the accuracy, reliability, completeness, relevance, or timeliness of such Informational Content.
No Liability on Part of Children’s Oncology Group and Related Parties/Agreement to Indemnify and Hold Harmless the Children’s Oncology Group and Related Parties: No liability is assumed
by the Children’s Oncology Group or any affiliated party or member thereof for damage resulting from the use, review, or access of the Informational Content. You agree to the following terms ofindemnification: (i) “Indemnified Parties” include authors and contributors to the Informational Content, all officers, directors, representatives, employees, agents, and members of the Children’s Oncology
Group and affiliated organizations; (ii) by using, reviewing, or accessing the Informational Content, you agree, at your own expense, to indemnify, defend and hold harmless Indemnified Parties from any
and all losses, liabilities, or damages (including attorneys’ fees and costs) resulting from any and all claims, causes of action, suits, proceedings, or demands related to or arising out of use, review oraccess of the Informational Content.
Proprietary Rights: The Informational Content is subject to protection under the copyright law and other intellectual property law in the United States and worldwide. The Children’s Oncology Groupretains excursive copyright and other right, title, and interest to the Informational Content and claims all intellectual property rights available under law. You hereby agree to help the Children’s Oncology
Group secure all copyright and intellectual property rights for the benefit of the Children’s Oncology Group by taking additional action at a later time, action which could include signing consents and legal
documents and limiting dissemination or reproduction of Informational Content.

Copyright 2023 © Children’s Oncology Group. All rights reserved worldwide.

Mental Health | Version 6.0 | October 2023 | Page 4 of 4