Psycho-oncology

PSYCHO-ONCOLOGY
AN OVERVIEW
Dr. Pawan Sharma
Pawan60@gmail.com

• Introduction
• Mental Health Consequences of Cancer at the time of diagnosis,
active cancer and survivors
– Maladaptation
– Common mental disorders
– Impact of maladaptation
– Suicide
• Treatment of Cancer: Psychiatric sequelae
• Risk Factors for Cancer Initiation/ Maintenance
• Management of maladaptation
• Issues related to cancer in children and adolescents
• Indian research
• Conclusion and future directions

Areas not discussed
• Pharmacological Interactions
• Analgesic abuse
• Sexual issues
• Care giver burden
• Oncologist burnout
• Euthanasia

Introduction
• 32.6 million people living with cancer (within 5 years of diagnosis)
in 2012 worldwide
• Incidence rates of 205 and 165 per 100,000 in male and female
respectively
• 48% (15.6 million) of the 5-year prevalent cancer cases occur in the
less developed regions
WHO, 2012

Introduction
• Subspecialty of cancer dealing with two psychological dimensions:
– Psychological reactions of patients with cancer and their families
and health care providers
– Psychological, social and behavioral factors that contribute to
cancer risk, detection and survival
• Slowly emerging as a subspecialty within oncology as well as
psychiatry and psychosomatic medicine
• Its is the study of psychological aspects of cancer along the
continuum from prevention to cure
Meyer et al, 2009

PSYCHO-
ONCOLOGY
ONCOLOGISTS
SOCIAL
WORKERS
PSYCHOLOGISTSPSYCHIATRIST
NURSES

Stress, Coping and Adaptation/ Maladaptation
Screening:
Some patients have long term negative psychological consequences: worry
about cancer, intrusive thinking, perception of less healthy organs
Brett et al, 2005
Diagnosis : A crisis requiring quick adaptation to catastrophic news
• 5 ‘D’- Death, Dependency, Disfigurement, Disability &
abandonment, Disruptions in relationships, role functioning, and
financial status
• Phase 1: shock and disbelief- depends on communication of
diagnosis to patient (1 week)
• Phase 2: period of commotion of mixed anxiety, depression,
insomnia, irritability (1-2 weeks)
• Phase 3: adaptation to diagnosis and treatment

Stress, Coping and Adaptation/Maladaptation
Four stages in the experience of cancer treatment:
• The recognition/exploratory stage: recognition of symptoms and
diagnosis
• The crisis/climax stage : when the treatment is initiated
(characterized by anxiety, depression, altered body image and
concern about changing relationships)
• Adaptation/ maladaptation stage: after initiation of treatment
• The resolution/disorganization stage: long term sequelae
• Survivors too face different psychological problems

Maladaptation
Study Cancer N Test Results
Love et al,
2008
Prostate
Ca
211
New
Dx
Short-
Form 36
•Higher rate of anxiety
•Depression not significantly
different from controls
Akechi et
al, 2006
Lung
Ca
85 • Immediate reaction: tension-
anxiety
• 2 & 6 months: tension-anxiety
significantly reduced
• 6 months: no change in other
psychological distress (anger-
hostility, fatigue, confusion)

Maladaptation
• 2004–2009: 2 centers (n=10,153 consecutive patients)
• Psychosocial Screen for Cancer questionnaire (anxiety, depression,
perceived & desired social support, quality of life)
• Stage: First visit to a cancer center, prior to beginning treatment
Anxiety 19%
Sub-clinical anxiety 22.6%
Depression 12.9%
Sub-Clinical depression 16.5%
> anxiety and depression score: lung , hematological and gynecological cancer
< depression score: skin cancer
> symptoms: younger patients
Linden et al, 2010

Maladaptation
• N=160 (breast, colorectal, lung and prostate cancer)
• Stage: baseline, 3months, 6months
• Measures:
– Mini Mental Adjustment to Cancer Scale (Mini MAC)
– Short Form General Health Survey
– Hospital Anxiety and Depression Scale
– Functional Assessment of Cancer Therapy (FACT) scale
– Life Orientation Test Revised(trait personality)
– NEO Five Factor Inventory (neurotism, extroversion,
introversion)
Williams et al, 2011
Quality of life significantly predicted later anxiety and depression, the
opposite effect was not observed
> adjustment: older patients
Other predictors for poor adjustment
Neuroticism
Negative emotion
Mental health status

Maladaptation
• Lack of clarification between actual clinical diagnosis vs only
symptoms
• Diagnostic cut-offs not empirically validated and diagnoses based
on different diagnostic systems
• Variation of quality of measurement tools
• Lack of homogeneity between the time when the prevalence rates
assessed

Maladaptation
Authors Cancer N Scales Results
Fobair et al,
2006
Breast 546 Body image
questionnai
re
>50% subjects: >2 body image
problems
Fingeret et al,
2011
Oral cancer
(new Dx)
75 Self-report,
Structured
interviews
77% identified current /future
appearance-related concerns
Depression was the strongest and most consistent predictor of body image outcomes
(Brief Symptom Inventory 18 - BSI-18)

Common Mental Disorders
• Twelve-month prevalence rates of CMDs in cancers
• 13 high-income and 11 low-middle-income countries
• Data from World Mental Health Surveys (used CIDI)
– (N= 66,387; active cancer: 357, cancer survivors: 1373, cancer-free: 64,657)
Active Cancer Cancer survivor Cancer free
18.4% 14.6% 13.3%
59% sought services for mental health problems (similar in high & low
income countries )
Nakash et al, 2013

Active stage: Psychiatric Disorders
• Depression in palliative-care settings: prevalence between 1%-69%
• Actual rate of depression not clear: most publications have used
depression screens rather than diagnostic instruments
• Meta-analysis (Mitchell et al, 2011): Studies using psychiatric
interviews applied by trained researchers/health professionals
Setting: palliative care Setting: Oncology/
Hematology
Studies (patients) 24 from 7 countries
(N=4007)
70 from 14 countries
(N=10071)
Depression 14.3% 14.9%
Adjustment 15.4% 19.4%
Anxiety 9.8% 10.3%
Dysthymia 2.7%

Active Stage: Prevalence of Psychiatric Disorders
Community setting
• Nationally representative Canadian Community Health Survey Cycle
(n=36984)
• Major depression (OR=3.18; 95% CI: 1.69-5.96)
• Panic attacks (OR=2.15; 95% CI: 1.22-3.77)
Rasic et al, 2008
– Schizophrenia and BPAD: similar in cancer patients and general
population
Grassi et al, 2005

Active Stage: Determinants of Maladaptation

Depression: Diagnostic Issues
• Many symptoms of cancer and its treatment: fatigue, anorexia,
insomnia, and cognitive impairment overlap with depression
• Suicidality or the desire for hastened death may be a feature of
depression also found in states of demoralization in individuals
who are not clinically depressed
• Cancer related depression is not associated with core depressive
thoughts, such as sense of guilt and failure, dissatisfaction and self-
dislike, than primary depression
Le et al, 2012

Depression: Diagnostic Issues
4 conceptual approaches to evaluate depression in medically ill
Inclusive
• All symptoms
of depression
counted
regardless of
etiology
• High sensitivity
• Appropriate for
diagnosis in
clinical setting
Exclusive
• Eliminate
somatic
symptoms
from diagnostic
criteria
• High specificity
• Valuable for
research
Etiological
• Include a
symptom as a
part of
depression if it
is clearly not a
result of
medical illness
• Difficult to
apply due to
symptom
overlap
Substitutive
• Replace
somatic
symptoms of
depression
with
psychological
symptoms
• Little evidence
for superiority

Active Stage: Suicide
• Cohort study involving 6,073,240 Swedes
• Relative risk of suicide among patients receiving a cancer diagnosis
– 12.6 (95% CI: 8.6 - 17.8) during the first week
– Incidence: 2.50 per 1000 person-years
– 3.1 (95% CI: 2.7 - 3.5) during the first year
– Incidence: 0.60 per 1000 person years
Fang et al, 2012

• Systemic review: 24 articles (1999-2009)
• High rate of suicide
• Determinants:
– Male gender
– Age >65 years
– Specific cancers: prostate, lung, pancreatic, head and neck
– Specific period: 1st year after cancer diagnosis
Anguiano et al, 2012

• Maintain a supportive
relationship
• Control symptoms
( pain, nausea, depression)
• Strong correlation between
physical health and
suicidality
• Involve family or friends
• Allow patient to discuss
suicidal thoughts
• Given intense, ongoing
support, including open
discussions about
treatment optionHolland and Alici,2010

Active Stage: PTSD
• Publications (1994 – 2013): 25 studies
• Mean prevalence
– Current: 6.4%
– Lifetime: 12.6%
Abey et al, 2014

Cancer survivors: Maladaptation
• Cancer tumor registry of the Ireland Cancer Center (ICC)
• In-person interviews with 321 older (>60) adult long-term survivors
(5–34 years post-diagnosis)
• Cancer-related health worries scale (=0.84)
• Anxiety: The Profile of Mood States (POMS) (=0.86)
• Depression: Center for Epidemiologic Studies-Depression (=0.87)

Cancer Survivors: Maladaptation
Cancer-related health worries: significant predictor of depression and anxiety

Cancer survivors: Maladaptation
• Meta-analysis: patients diagnosed with cancer for at least 2 years
• 43 studies
N Depression
Cancer Survivors 51381 11.6%
Healthy controls 217630 10.2%
N Anxiety
Cancer Survivors 48964 17.9%
Healthy controls 226467 13.9%
• Around 50% of studies: family members as controls
• No difference between the prevalence of depression
and anxiety when patients compared to spouses
Mitchell et al, 2013

Depression & Anxiety: Impact on Non
Compliance
Meta-analysis: depression (12 articles), anxiety (13 articles)
• Depression was associated with non compliance (OR: 3.03 (95% CI:
1.96 - 4.89)
• Anxiety: no significant association with non compliance
DiMatteo et al, 2000
• Few studies have suggested anxiety or depression might improve
adherence
– Optimism (positive attitude toward medication) improved
adherence
Theofilou et al, 2012

Depression: Impact on Cancer Survival
Depression as predictor of progression of cancer (Satin et al, 2009)
• Meta-analysis: 3 studies
• Depression: not a significant predictor of progression
Depression as predictor for mortality
• Meta-analysis: 24 studies (Satin et al, 2009)
– Depression (major/minor): 39% > mortality (RR=1.39; 95% CI:
1.10-1.89; P= .03)
• Meta-analysis: 76 prospective studies (Pinquart & Duberstein, 2010)
– Depression (diagnosis/ symptoms):  mortality (RR  19%)
– Shorter survival in: leukemia/lymphoma, breast cancer, lung and
brain cancer
– > association in older age group

Depression: Impact on Cancer Survival
Davis et al, 2011
• Random assignment: Supportive expressive group therapy Vs.
control group (educational materials)
• 125 women with metastatic breast cancer
• Center for Epidemiologic Studies–Depression Scale (CES-D) at
baseline, 4, 8 and 12 months follow-up
• CES-D change score (1st year): predicted survival over 14 years
• No significant interaction between treatment condition and CES-D
change score on survival

Depression: Impact on QOL of Survivors
• Breast cancer: 240 patients (6–13 years since treatment)
• Scales:
– Patient Health Questionnaire (PHQ-8)
– European Organization for Research and Treatment of Cancer Quality
of Life Questionnaire Core 30
• Depression: inversely associated with HRQOL subscales for
functioning, financial and global health
• Depression: positively associated with cancer symptom
Reyes-Gibby et al, 2012

Depression and Cancer:
Some Take Home Messages
• The psychiatric issue most studied in cancer is depression
• Depression acts as a predictor of non- compliance to treatment
• Depression acts as a predictor of mortality in cancer
• Depression lowers the quality of life in the cancer patients
• Lowering of the depressive symptoms increases survival

Other Psychological Factors Impacting
Compliance
• Social support:
– Married women were more likely to adhere to chemotherapy
than unmarried women
– 51.7% of clinicians reported that the patient’s social support
was an important factor in their decision to give palliative
chemotherapy to women with metastatic breast cancer
– Grunfeld et al, 2002
• Quality of life:
– Favorable quality of life enhances adherence and survival
– Coates et al,2000

Delirium
STUDY PREVALENCE SAMPLE
(N)
STUDY TYPE SCALE SETTING
Kim et al, 2010 30.2% 108 Prospective CAM Palliative care
Gagnon et al, 2009 6.2% 2515 Prospective(3
year follow-
up, day time
setting
CRS Palliative care
Hun-Kai et al, 2008 46.9% 228 Prospective DRS Hospice and
palliative care
Gaudreau et al, 2005 30.0% 107 Prospective Nu-
DESC
Oncology unit
Lawlor P et al, 2000 68.3% 104 Prospective MDAS Palliative care
Gagnon P et al, 2000 32.8% 64 Prospective CAM Hospice

Psychiatric side-effects of Cancer Medication
Depression Suicide Hallucinations Delusions
Dacarbazine Dacarbazine Vincristine Tamoxifen
Vinblastine Interferon Hydroxyurea
Vincristine Steroids Steroids
L- Asparaginase
Procarbazine
Interferon
Steroids
Tamoxifen
Additional Issues
• Delirium
• Behavioral manifestation of CNS toxicity
• Cognitive deterioration
• Discrepancy between self report (> dysfunction)
and objective assessment (? inability of battery
to test real life situations)
• Long term post treatment cognitive changes in
17-34 % patients

Psychiatric sequelae of Cancer Treatment
STUDY N CANCER MODALITY SCALES RESULT
Kawase et
al, 2010
172 Breast Radio Rx HADS
Radiotherapy
Categorical
Anxiety Scale
Anxiety & depression
decreased after
completion of
radiotherapy sessions
Mackenzie
et al, 2013
454 NA Radio Rx HADS Anxiety: 15%
Depression: 5.7%
Torres et
al, 2013
64 Breast Radio Rx
Chemo Rx
Inventory of
Depressive
Symptomatology
-Self Report
No difference post
treatment. Higher
depressive score reported
throughout the study in
chemo group
Reece et
al, 2013
32
(follow
up)
Breast Chemo Rx PHQ-9
GAD-7
Depression: 32.7%
Severity peaked after 12-
14 week of chemo Rx
Depression severity was
correlated with anxiety

Psychological Factors as Risk Factors for
Cancer Initiation/ Maintenance
• Behavioral Risk Factors
• Stressful life events
• Locus of control and personality factors
• Coping and adjustment to illness
• Psychiatric diagnoses
• Repression of negative emotions

Risk Factors for Cancer Initiation/
Maintenance: Behavioral
• Tobacco:
– 30% of total cancer deaths in the developed world and 90% of
all lung cancer deaths
– Increased risk for other types of cancer
– 10 years of cessation the risk for lung cancer mortality
decreases between 30 and 50%. And 5 years of cessation of
smoking causes 50% reduction in cancer risk of the esophagus
and oral cavity
• Alcohol
– meta-analysis of 235 studies (n over 117,000 ) showed strong
trend in increased risk for cancers of the oral cavity and pharynx,
esophagus and larynx
Nezu et al, 201

Maintenance: Behavioral
• Diet and Obesity
– Approximately one third of the cancer deaths that occur in the
United States each year are a function of poor nutrition, limited
physical activity, and obesity
– Losing weight appears to reduce the risk of breast cancer and to
reduce cancer mortality
American Cancer Society, 2010

Maintenance: Stress
• 3 long term follow-up studies(15 to 26 years)
– Jacobs & Bovasso, 2000 (n= 1213 women)
– Kvikstad et al, 1994(n= 4491 cases 44910 controls)
– Ewertz, 1986(1792 cases, 1739 controls)
• After adjusting for the covariates like age, parity, family history,
depression odds ratio for the developing of breast cancer after
adverse life events
– One study found significant risk of developing breast cancer
(OR=2.56) after death of parents in childhood
– One study equivocal for death of spouse
– No association for divorce

Maintenance: Stress
• Random effects meta-analysis of the higher quality studies found
no significant relationship
– Breast cancer and bereavement OR=0. 9 (95% CI: 0.57 – 1.45)
– Other adverse life-events OR=0. 8 (95% CI: 0.61 - 1.06)
Petticrew et al, 1999

Study N Follow-up Measure of
depression
Adjusted risk Covariates
Penninx et
al, 1998
4825 4 years CES-D Baseline depression
1.03
Chronic depression
1.88
Age, gender,
smoking, alcohol,
race, disability,
hospital admissions
Gross et al,
2000
3177 24 years DIS Any cancer
(HR: 1.9, 95%
CI: 1.2-3.0)
Breast Ca
(HR: 4.4, 95% CI:
1.08-17.6)
Age, gender,
smoking, alcohol
Jacob &
Bovasso,
2000
1213 15 years DIS Ca Breast
Major depression/
dysthymia: 1.4
Age, gender,
smoking, family
history, race, socio-
demographic
factors, other
psychiatric
diagnoses, life
events, somatization
Risk Factors for Cancer Initiation/ Maintenance: Depression

Maintenance: Depression
• No significant association between depression and subsequent
breast cancer risk (RR: 1.12: 95% CI: 0.99–1.26)
• No significant associations between depression and subsequent
lung, colon or prostate cancer
• Sensitivity analysis (Studies with follow-up of 10 years)
– Significant relative risk for breast cancer: 2.50 (1.06–5.91)
Oerlemans et al, 2007
Increased risk of Ca breast but no causal association with other cancers
Findings may be a chance finding

Psychosocial Factors as Causal/ Maintenance Factors
for Cancer Initiation and Progression
• One possible connection between stress and cancer development is
the reactivation of latent tumor promoting viruses (stress and EBV-
associated tumors)
• Stress is associated with a reduction in the activity of natural killer
(NK) cells and cytotoxic T cells that can target abnormally growing
cells for destruction
• Stress-induced shift in the balance from Th1 towards Th2 cytokine
profile may be permissive to virus replication, and thereby
increases the frequency of tumor promotion
Godbout & Ronald Glaser, 2006

Tumor promotion or progression
Godbout & Ronald Glaser, 2006

Cancer as Causal/ Maintenance Factor for
Psychiatric Conditions
• Compromises immune system function or inhibits DNA repair
mechanism
• Can inhibit DNA repair enzymes that are critical for apoptosis and
defense against malignant tumor growth
• Decreased natural killer (NK) cell function
Dysrugulated
proto-
oncogenes
(Ras)
Inhibit
dopamine
and
serotonin
synthesis
DEPRESSION
Certain
cancers,
specificall
y of the
pancreas,
lung,
colon, and
skin
Gross et al, 2010

Risk Factors for Cancer Initiation/ Maintenance:
Coping Style
Breast cancer (Coping assessment: Mental Adjustment to Cancer Interview)
• Longer survival: initially reacted with fighting spirit or denial
• Shorter survival: initially reacted with helplessness/hopelessness or stoic
acceptance
Greer et al,1990
• There is no good evidence that coping style or the way one adjusts to the
disease is related to cancer progression
• The role of repression is questionable with respect to the initiation of
cancer but more expression and less suppression of emotions predicted
longer survival in few studies
Garseen, 2002

Personality
• Cancer prone personality- Described as cooperative, unassertive,
patient, suppressing negative emotions and accepting external
authority (Greer & Watson, 1985; Temoshok, 1987)
• ‘‘Type C’’ constellation including stoicism, perfectionism, and over-
agreeableness are risk factors for the initiation and progression of
cancer (Greer, 1991; Gross, 1989; Temoshok, 1987)
• Large study (N=30,000) in Japan (Nakaya et al., 2003)
– No associations between Eysenck Personality Questionnaire–
Revised scales & cancer risk
• Personality factors and locus of control, do not seem to play an
important role.(B. Garssen 2002)

Social Support
• N= 224 women with newly diagnosed breast cancer
• Confidant with whom they had discussed personal problems
• Prospective follow-up: 7 years
– Survival rate without a confidant: 56 %
– Survival rate with confidant (1): 72%
Maunsell et al, 1995

Schizophrenia
• Review: 11 studies
• Reduced incidence of several cancers unrelated to smoking
• Reduced incidence of breast cancer in female patients
• Reduced overall incidence of cancer in siblings and parents
• Lower susceptibility to cancer may be a genetic advantage
Catts et al, 2008

How to communicate- Bad News
Rabow and McPhee (1999) used the mnemonic ABCDE based on the
summary of review of sixty seven articles published after 1985.
A= Advance Preparation
1. Read the medical notes
2. Practice the conversation
3. Brace yourself for an emotional task
4. Assess patient understanding
5. Arrange for a family meeting
B= Build a Therapeutic Environment/Relationship
1. Find a quiet place
2. Ensure enough time
3. Use open body language
4. Address the patient’s fears

How.....
C= Communicate Well
1. Be direct
2. Avoid euphemisms and medical jargon
3. Use the words like “cancer” and “death”
4. Ensure patient understanding
5. Allow silence for questions of patient/family
D= Deal with Patient and Family Members
1. Assess the patient’s reaction and coping strategies
2. Listen actively and show empathy
E= Encourage and Validate Emotions (reflect back emotions)
1. Ensure accurate interpretation of the news
2. Address further needs including support
3. Provide written information (patient information leaflets)
4. Arrange follow up (within a few days)
5. Process your own feelings

Collaborative Care
Fann et al, 2012

Collaborative Care: Models
DCPC: (Depression Care for People With Cancer)
• Specially trained nurse provide brief psychological treatment
(problem solving therapy)
• C-L Psychiatrist supervises the nurse and communicates with the
patient’s oncologist and primary care provider about the use of
antidepressant medication
• Progress monitored using telephone-administered rating scale
ADAPt-C (Alleviating Depression among Patients with Cancer)
• Problem-solving therapy as well as patient navigation of the
care system by social worker
• Psychiatrist supervise the social worker and prescribed
antidepressant medications
Fann et al, 2012

Collaborative Care: Models
IMPACT (Improving Mood—Promoting Access to Collaborative
Treatment)
• Stepped-care management program for depression in older primary
care patients
• Patients have access to a depression care manager (nurse or clinical
psychologist) for up to 12 months
• Supervised by a psychiatrist and primary care provider
INCPAD Indiana Cancer Pain and Depression trial:
• Centralized tele-care management by a nurse-physician specialist
team
• Automated home-based symptom monitoring by interactive voice
recording or Internet
Fann et al, 2012

Treatment of Depression in Cancer
• 10 randomized controlled trials (6 psychotherapeutic and four
pharmacologic studies)
• N=1362 (mixed cancer type and stage)
• Cognitive Behavioral Therapy (CBT) & Problem Solving Therapy
(PST)
• Interventions more effective than control conditions up to 12–18
months
• CBT more effective than PST
• CBT and pharmacotherapy: similar efficacy
Hart et al, 2012

Treatment of Depression in Cancer
• Cochrane review (2010): TCAs and SSRIs more effective than placebo
• Same finding replicated in another meta-analysis
Rayner et al, 2010
• Head to head trials (Meta-analysis)
– Paroxetine vs Desipramine
– Paroxetine vs Amitriptyline
– Mirtazapine vs Imipramine
• No significant difference in groups
• Mirtazapine led to greater improvement than Imipramine
in one study
Laoutidis and Mathiak, 2013

Other Psychotherapeutic Approaches
No psychotherapeutic approach increase the survival among patients
• Crisis intervention
– Assistance in sudden, surprising and disintegrating life events
– Adequate and prompt assessment as immediate reaction may bring
tragic consequences
• Psychological counseling
– Support offered to individuals experiencing developmental crisis or
adaptive difficulties
– Involves several interviews aimed to identify a problem and find a
solution
• Support for the patient and their
family
• Help in making the patient
understand the situation
• Suggesting specific measures (e.g.
additional doctor consultation,
calling a voluntary social worker,
reconsidering the decision to quit
treatment)
• Building the patient’s hope by
showing perspectives for the nearest
future (week, month)
Katarzyna Cieslak, 2013

• Self-support groups (clinical psychologist as a group expert)
– Post-mastectomy women, post stoma surgery
– Emotional support, help one another in obtaining important
information, equipment, medicines
• Psychological rehabilitation
– To address direct/ indirect consequences of cancer/ treatment
– Individual psychological therapy, e.g. as part of comprehensive
care provided by oncology centers to women with diagnosed
breast cancer

• Rational psychotherapy:
– Preparing the patient for a physically or mentally burdening
experience
– Clear and understandable presentation of the treatment
methods
– Discussion of possible immediate and delayed side effects
• Behavioral method of gradual desensitization
– To prevent anticipatory vomiting or anxiety
– To manage distress regarding smell of medicines, aprons for
children

Other Psychotherapeutic Approaches: Existential
Psychotherapy
• The capacity for self-awareness ( we are finite, yet we have the potential to
continually grow until we die)
• Freedom and responsibility (we can make the commitment to authentically choose
a life for ourselves)
• The need for center and the need for others (we can have the courage to
experience aloneness and relatedness)
• The search for meaning ( we have the capacity to discard old values, to freely
choose new ones, and to continually question and challenge the meaning of life)
• Anxiety as a condition of living (experience anxiety as a source of growth and
experience the escape from anxiety)
• Awareness of death and nonbeing (very realization of eventual nonbeing gives
meaning to existence)

Palliative Care
Author
(Year)
No. of
studies
Type of
intervention
Outcome
measures
Results
Brietbart
et al 2010
N= 90 Group MCT vs.
supportive
psychotherapy
Stage III
and IV
cancer
Measures of
anxiety,
depression,
hopelessness,
spiritual well
being
•Significantly higher spiritual
wellbeing, decrease in anxiety,
desire for death
•No significant diff. in
depression, optimism,
hopelessness at 2 m f/u
Brietbart
et al 2012
N=120 Individual MCT
Vs. control
Stage III
and IV
cancer
Measures of
anxiety,
depression,
hopelessness,
spiritual well
being, QoL
•Higher spiritual well-being,
QoL, decrease in physical
symptom distress
•No significant difference on
levels of anxiety, depression, or
hopelessness at 2 m f/u

Other Psychotherapeutic Approaches:
Cancer Pain
• Cancer pain education
• Hypnosis and imagery based methods
– Acute procedural pain prior to breast biopsy
– Less evidence in chronic pain
• Coping skills training
• Paying attention to spiritual needs and existential concerns often
associated with pain
Paice et al, 2011

Other Psychotherapeutic Approaches:
Anticipatory Nausea and Vomiting
• Conditioned response
• 25% of patients develop by the fourth treatment cycle
• Psychological Interventions:
– Hypnosis
– Biofeedback
– Relaxation methods like Yoga
– Systemic desensitization
Roscoe et al, 2011

Psychosocial Dimensions of Cancer in
Children
• Family factors:
– Flexibility of the family attempts to bring normalcy to the
adolescent or young adult’s life
– Presence of family cohesion and family adaptability
– Most adolescent cancer survivors diagnosed with PTSD also had
mothers with PTSD
• Psychological/emotional factors:
– Higher intensity of symptoms experienced by older children
– Adolescents with cancer demonstrate more coping strategies
than typical peers(Older adolescent show greater coping
strategies)
Evan and Zeltzer, 2005

Children
– Increased risk of reporting psychological symptoms than sibling
– Longer the adolescents were off treatment, the more they
perceived problems related to self-worth, social anxiety, and
greater negative perceptions of body image
– Intense chemotherapy increased the risk of reporting somatic
distress and depression
– Most survivors reported that symptoms of depression, anxiety,
or somatic distress did not pose problems in their daily life
(Childhood Cancer Survivor Study)
Evan and Zeltzer, 2005

Children
• Social factors
– Active treatment: frequently miss school, cognitive deficits
appear more and contribute to difficulties with social skills
– Survivors were less likely to graduate from high school
– Survivors demonstrate greater impairments in friendships and
romantic relationships than controls
Special issues in intervention
– Emphasis on the age and developmental level of the child
– School re-integration, social skill training
– Adaptive coping skills at an early age
– Parents as a major source of information
– May be wise to refrain from disclosure of excessive medical
information Evan and Zeltzer, 2005

Indian Research
• A review by Mehrotra : Identified 120 studies (1977-2006)
• Studies have focused on psychosocial issues like apprehensions about
screening, pre-occupation with family problems, practical difficulties &
lack of approval from spouse to be responsible for poor utilization of
prevention and early detection programs for Ca cervix
• Self examination for Ca breast: poor compliance due to forgetfulness
and being too busy
• Psychiatric morbidity: 40-80%, MC- depressive disorders
• Studies suggest low referral rates to psychiatric services

Indian Research
• Awareness about ∆: 54-66% aware of their ∆, inconsistent association
between awareness of ∆ and psychiatric morbidity
• Studies have examined the preference of the patient about diagnosis:
patients want to know the diagnosis contrary to the expectations of
the caregivers
• Studies have also evaluated QOL in cancer patients
• Some studies suggests higher frequency of life events in early life in
cancer patients compared to controls
• Neuroticism, incommunicativeness, emotional de-surgency: some of
the personality features that have been implicated to be
differentiating between cancer patients and healthy controls
(Mehrotra, 2008)

Indian Research
• Most frequently reported distressing thoughts of pts: burden on
family, illness worsening and illness as a punishment from God
• MC coping mechanism: turning to religion (leaving the responsibility of
cure to God) was the among 80% of pts
• Distress and issues in palliative care: concerns about physical pain,
anxiety and depression (related to unfulfilled dreams and concerns
about the welfare of the family), body- image issues, social
withdrawal, disease viewed as bad karma, desire for hastened death
and hope
• Transcendental meditation, yoga and group counseling modules in a
group of ambulatory cancer patients: leads to positive effect on QOL
(Mehrotra, 2008)

ONCOLOGIST BURNOUT
• Burnout is a “syndrome of emotional exhaustion, depersonalization
and a sense of low personal accomplishment that leads to
decreased effectiveness at work”
Tait Shanafelt,2008
• Depression, cynicism, a sense of futility, and nihilism
• Point prevalence of 25% to 35% (medical oncologists) 38%
(radiation oncologists) and 28% to 36% (surgical oncologists)
• No specific interventions ?Mindfulness based meditation,
technique to increase self awareness might be useful (further
research warranted)

CARE GIVERS
Effects
• Psychological Impairment and Mood Disturbance
– Anxiety 39% and Depression 40%
– Family caregiver’s mental health burden exceeded that of the
patient with cancer
– responses to cancer interdependent- each person (patient and
caregiver)affected the other’s level of emotional well-being
• Symptoms Related to Sleep Disturbances
– More than 90% have some disturbance (subscales that assessed
sleep quality, duration, efficiency, disturbance and daytime
function)
Northouse et al, 2012

CARE GIVERS
• Physical Health Changes
– High care giving burden independent risk factor for coronary
heart disease(4 year follow-up study)
– 53% report fatigue
• Neuro-hormonal and Inflammatory Changes
– Studies in small sample size
– Changes noted
• Perceived Burden and Positive Aspects of Caregiving
– lack of confidence, inadequate preparation to perform skills
expected of them, disruptions in lifestyle, and restrictions in
activities
• Changes in Financial Well-Being

CARE GIVERS
• Psycho-education :Information about management of symptoms,
physical aspects of patient care and attention to emotional aspects
of care
• Skill training: development of caregivers’ coping, communication
and problem-solving skills
• Therapeutic counseling :strengthening patient-caregiver
relationships, managing conflict, and dealing with loss
• Relationship focused interventions that address patient-caregiver
communication and joint problem-solving)have more positive
outcome
• Patient-caregiver dyad should be treated as the unit of care

Author N Adjusted risk Covariate
Jacobs &
Bovasso,
2000
1213 women,
Initiation of Ca
breast,
F/U: 15 years
Death of parent in
childhood
OR: 2.56
Age, Family H/O breast cancer,
dysthymia, depression,
household income
Kvikstad et
al, 1994
4491 cases
44910 controls,
Initiation of Ca
breast,
F/U: 15 years
after life event
Death of spouse:
OR: 1.13
Divorce:
OR: 0.83
Age, Residence, Parity, Age at
birth of first child
Ewertz, 1986 1792 cases,
1739 controls;
Initiation of Ca
breast,
F/U: 26 years
after life event
Death of spouse
OR: 0.8
Divorce
OR: 0.9
Age
Risk Factors for Cancer Initiation/ Maintenance: Stress

MEANING CENTRED THERAPY
• New therapeutic approaches to enhance meaning, spiritual
wellbeing, quality of life among terminally ill cancer patients
• Brings awareness to their choice of attitudes, ability to connect and
engage with life, legacy they have lived or want to create in future
• Has been tested in both group and individual therapy formats
among patients with advanced cancer
• 8 weekly sessions in group, and 7 sessions with individuals
• Facilitated by psychiatrists, psychologists, contains both didactic and
experiential activities
(Brietbart et al, 2004)

MINDFULNESS-BASED THERAPY
• Originate from ancient Buddhist meditation techniques,secularised,
manualized, and appropriated for use in a range of clinical settings
• Original research focussed on chronic pain, became increasingly
popular in chronic disease management over last 30 years
• Group-oriented, Mindfulness Based Stress Reduction (MBSR) most
well researched approach
• 3 meditation techniques: breath awareness, body awareness,
dynamic yoga postures taught in groups over 8 weeks
• MBCT: derivative of MBSR, emphasis on cognitive techniques
• Majority research on efficacy in cancer, pain conditions,
cardiovascular disease, DM, HIV/AIDS, IBS
(Simpson et al, 2014)

Guidelines
Recommendations Evidence
(quality)
Strength
Communicate with palliative care patients in an open,
non- judgmental, patient- centered manner and
actively enquire about their concerns and feelings
Moderate Strong
In accordance with patients’ wishes, provide
information on the nature, course and treatment of
illness and appropriate sources of support
Moderate Strong
Consider referral to specialist palliative care for
improved symptom control and psychosocial support
High Strong
Prioritize cognitive/ affective symptoms in detecting
depression as physical symptoms (e.g. weight loss,
fatigue) may be caused by physical disease or medical
treatment
Moderate Strong
Rayner et al, 2011

Guidelines
Recommendations Evidence
(quality)
Strength
Consider screening for depression in palliative
care patients. Screening tools may help clinicians
detect depression (evidence that they improve
depression outcomes is lacking)
Very low Weak
The psychological state of patients in palliative
care unstable, regularly review depressive
symptoms to capture changes in mood
Moderate Strong
Refer patients with depression to specialist
palliative care for improved symptom control and
psychosocial support
High Strong
Consider antidepressants for treatment of
depression in palliative care
High Strong
Consider psychological therapy for treatment of
depression in palliative care
High Strong
Rayner et al, 2011

Transactional model by Lazarus,1999

Conclusion and Future Directions
• Psycho-oncology though a new field but is broad
• Cancer patients can have negative psychological consequences at
every stage of disease (screening to palliative care)
• Psychiatric morbidity: high and has grave consequences
• Role of psychological factors in development of cancer: not
established but behavioral issues have significant role
• Psychological interventions are helpful in cancer related physical
symptoms
• Further research is needed for better understanding of relationships
between psychiatry and cancer

Psycho-oncology

Recomendados

Recomendados

Mais conteúdo relacionado

Mais procurados

Mais procurados (20)

Destaque

Destaque (20)

Semelhante a Psycho-oncology

Semelhante a Psycho-oncology (20)

Último

Último (20)

Psycho-oncology

Notas do Editor