A 42-Year-Old Woman with a Recent Diagnosis of Metastatic Breast

A 42-year-old woman with a recent diagnosis of metastatic breast cancer comes to the office for a follow-up visit.  Although the patient is currently stable, she decided to stop working due to the stress of managing her illness and caring for her 7-year-old son, who has multiple behavioral issues and special needs.  The patient has a history of depression in her 20s and late 30s.  She was previously treated with weekly psychotherapy that she found helpful.  She tries to exercise 2 or 3 times per week but often feels too weak.  The patient describes her husband as extremely supportive.  Her son attends a special school for children with autism.  As the physician reviews the chemotherapy regimen, recent imaging, and laboratory results, the patient becomes tearful.  She says, "I think I was doing much better when I was distracted by work.  Now, I'm so afraid of dying and what's going to happen after I'm gone that it's hard to think of anything else.  I know I have to be brave for my son."  Which of the following is the most appropriate initial response to the patient's concerns?

A) I am concerned that your depression may be returning; a trial of antidepressant medication might help.
B) I can only imagine how hard this must be.  Have you told your husband how much you are struggling?
C) I can only imagine how hard this must be.  What has it been like for you?
D) I can see how stressful this is for you; would you be open to speaking with a therapist again?
E) This must be so difficult for you, but fears of dying are a normal and understandable reaction to a cancer diagnosis.