Few phrases strike fear in the hearts of people more than hearing their doctor say, “You have cancer.” For many patients, perhaps most, those words can sound an awful lot like, “This is the end.” But the diagnosis is only the beginning, of course.
From how a person handles the initial shock of being told they have cancer, to their treatments, recovery and beyond, patients with cancer face a myriad of emotional issues and sometimes functional changes as a result of their journey. Studies have long shown psychological distress, such as depression and anxiety, leads to poorer prognosis in patients with cancer.
In the U.S., one in four patients with cancer is depressed, 45 percent deal with anxiety, and among cancer survivors, the rate of suicide is twice the average rate, according to the National Cancer Institute.
While in the U.K., results from a study of more than 160,000 adults recently showed patients with higher levels of depression and anxiety had a 32 percent higher risk of total cancer mortality (BMJ 2018;361:k1415).
Investigators also are researching genetic factors behind the spiraling relationship between mental health and patients with cancer.
In one recent study of nonmetastatic breast cancer survivors, for example, women who participated in psychosocial intervention groups had reduced cortisol levels and altered leukocyte expression, including downregulation of proinflammatory and metastasis-related genes and upregulation of type 1 interferon response genes (Dialogues Clin Neurosci 2018;20(1):13-22).
Historically, the emotional well-being of patients with cancer wasn't always seen as a major factor in achieving positive outcomes, resulting in underfunded research and treatment programs for decades. But that's all been slowly changing, experts say. Today, major cancer centers in the U.S. and abroad have psycho-oncology specialists on staff dedicated to treating the emotional challenges of patients with cancer.
Shanthi Gowrinathan, MD, a psychiatrist specializing in both Women's Psychiatry and Psycho-oncology at John Wayne Cancer Institute at Providence Saint John's Health Center in Santa Monica, Calif., shares insight into the mental health challenges of patients with cancer and the services many require to optimize quality of life during all phases of their cancer journey.
What are some of the common mental health issues patients experience associated with a cancer diagnosis, treatment, and recovery?
The most common mental health issues directly associated with cancer diagnosis and treatment, similar to the general population, are anxiety and depression, with anywhere from 30 to 60 percent of patients reporting significant levels of either one or the other. People can also experience mood swings, low frustration tolerance, fatigue, and insomnia, all of which can be debilitating.
What types of counseling and psychiatric services are needed most by patients with cancer as they progress from diagnosis through recovery? Do you also offer services to families/caregivers?
The psychiatric and counseling needs can vary greatly, from patient to patient, based on the cancer and treatment and even in the same patient at different stages of the cancer journey. The most important part of any intervention is to meet the patients where they are at in their journey. We use a variety of techniques including cognitive behavioral therapy, supportive psychotherapy, psycho-education, behavioral interventions, and psychopharmacology to not only treat patients symptoms but also to give them the tools to cope going forward.
Treating the family unit and caregivers is of course ideal, but is difficult to accomplish due to both time constraints and the lack of coverage for families/caregivers to get psychiatric care or therapy without incurring prohibitive out-of-pocket costs. Whenever possible, family members are included in discussions and psychosocial issues that may be impacting the patient's treatment or recovery are addressed.
What therapeutic techniques do you utilize, and how do you decide which would be the best for each individual patient?
Psycho-oncology is as much about human connection as it is about therapeutic techniques. There is a unique privilege in walking into a patient's life at such a pivotal moment, and a tremendous responsibility to do no harm to a patient who may already be in crisis. I try to make sure that I understand a great deal about the patient's past history and where they are now physically and emotionally. I tailor the therapeutic approach to alleviate as many facets of suffering as possible (physical, emotional, psychosocial, behavioral, spiritual).
What are some of the specialized psycho-oncology services provided to your patients?
Cognitive behavioral therapy, marital/relational therapy, and grief and trauma counseling are the most utilized psychotherapy interventions we offer.
I also spend a great deal of time communicating with oncology teams and primary care teams to help patients address issues with side effects to treatment, difficulty understanding medical information, and concerns about prognosis or treatment plans. I collaborate directly with palliative care, nutrition, pain management, chaplaincy, and rehabilitation providers.
As part of the Pacific Neuroscience Institute, I can also offer cognitive interventions, neuropsychiatric testing, TMS, and cutting-edge psychedelic treatments.
Does the medical community view the emotional needs of patients with cancer as being more important to positive outcomes than perhaps it did in the past? How has it evolved in general and/or at your facility?
Over the past 30 years, as cancer treatment has advanced and survival rates have improved, it has become evident that it is no longer enough to help people survive cancer, it is now widely recognized that psycho-oncology and cancer support services should be a standard of cancer care. The Commission on Cancer and ASCO now both include requirements regarding support services in recognition of their impact on clinical outcomes and quality.
How big of a role has clinical research played in improving how medicine approaches treating the emotional needs of patients with cancer? What further research needs to be done?
Clinical research has been instrumental in the development of the guidelines for psycho-oncology and supportive care. For example, the implementation and effectiveness of distress screening was driven by research showing improved clinical outcomes when distress was monitored in oncology clinics.
There is a tremendous amount of research yet to be done. We still know too little about the long-term effects of the relatively new immunotherapies on mental and cognitive health. Another exciting new frontier, which has become a particular focus of mine, is the exploration of previously maligned psychedelic therapies for the treatment of psychiatric and end-of-life issues in cancer patients.
Is there anything you would like to add about the services you offer patients and/or the importance of addressing the mental health needs of patients with cancer?
Brain health (both cognitive and mental/emotional health), nutritional needs, pain and debilitation, and existential issues (spirituality or life-meaning/purpose) can all become barriers to successfully navigating cancer and its treatment. As a psycho-oncologist, my role is to identify and remove these barriers through medication, psychotherapy, direct communication with the oncologist, or collaboration with our larger Cancer Support Services team. Addressing these barriers makes it so much easier for patients to find pockets of joy, even in the worst of circumstances. They are able to rise up and take back their lives. It is impossible to overstate how fulfilling it is for patients and providers alike when patients find peace or joy in the midst of cancer. It uplifts us all.
Chuck Holt is a contributing writer.