During the past decade, provocative insights into the psyche and cancer have emerged.
For example, new studies refute earlier findings suggesting that stress can cause cancer, David Kissane, M.D., chair of psychiatry at Memorial Sloan-Kettering Cancer Center, reported during an interview. A prime example of one of these new studies, he said, was one conducted in Denmark. Using Denmark’s comprehensive national database, researchers assessed whether women who had a child die were more prone to cancer than matched controls. They found no such link. So it looks as if it may be “a myth that stress causes cancer,” Kissane said.
General emotional distress, maladaptive coping strategies, and psychiatric disorders such as anxiety and depression are common in cancer patients—in about 25 percent to 30 percent of them, Luigi Grassi, M.D., chair of psychiatry at the University of Ferrara in Italy and chair of the International Federation of Psycho-Oncology Societies, told Psychiatric News.
Depression can not only negatively impact cancer patients’ quality of life, but can reduce their chances of survival, just as it can in heart-disease patients, David Spiegel, M.D., said during an interview. Spiegel, an associate chair of psychiatry at Stanford University, is also a psycho-oncologist.
Yet effective treatment of depression may increase the chances of survival. A study conducted by Spiegel and his colleagues and published December 13, 2010, in the Journal of Clinical Oncology found that a decrease in depression symptoms was associated with longer survival in metastatic breast cancer patients.
Research during the past decade has also shown that various psychotherapies developed for cancer patients, such as supportive-expressive therapy, meaning-centered therapy, dignity therapy, cognitive-existential therapy, and cognitive-behavioral therapy (CBT) for reducing fear of cancer recurrence, can improve patients’ quality of life, Grassi stated.
Moreover, CBT can help women with breast cancer not only reduce negative emotions and levels of cortisol and increase positive emotions and levels of interferon, but reduce expression of genes likely to contribute to the cancer process, research by Michael Antoni, Ph.D., a professor of psychiatry at the University of Miami, and his team reported last November in Biological Psychiatry.
“Michael Antoni and his group have been doing elegant, groundbreaking work in psycho-oncology for a number of years,” Michelle Riba, M.D., director of the psycho-oncology program at the University of Michigan and a past APA president, told Psychiatric News. “Their current research is exciting. While the sample size was small, and this work will need to be replicated, it gives us important research directions that can help us determine more personalized types of treatment, impacting on morbidity and mortality of patients with cancer.”
Yet researchers need to learn more about how these psychotherapies for cancer work and whether they share common mechanisms of action, Spiegel noted. And there are other important unanswered questions about the psyche and cancer as well, he noted.
For instance, some SSRI antidepressants can interfere with the metabolism of the breast cancer drug tamoxifen. Thus more needs to be learned about potential interactions between psychotropic medications and cancer drugs. The cytokine interferon, which is used to treat certain cancers, can lead to depression and even suicide. How interferon triggers depression and how interferon-triggered depression can be prevented need to be determined. Some individuals who receive chemotherapy, as well as some who get androgens as a cancer treatment, complain that their brains no longer seem to function as well as they used to. More needs to be learned about the brain areas impacted by this disturbance—which some call “chemo-brain” or “chemo-fog.”
“Actually one of the big concerns resulting from cancer treatments during the last decade has been the impact that they can have on cognitive function,” Kissane noted. “And it is leading to some efforts to develop cognitive rehabilitation therapies [for individuals with so-called chemo-brain or chemo-fog].”
“I would say that one of the biggest unanswered questions about the psyche and cancer—and certainly the most controversial one—is whether psychological interventions can extend survival in cancer patients,” Fawzy Fawzy, M.D., vice-chair of psychiatry at the University of California, Los Angeles, and a scientist who has worked in this area, said during an interview. But even if such interventions don’t extend survival, “if we are able to improve patients’ psychological states, that is good enough,” Fawzy said.
Meanwhile, there is a lot that psychiatrists can do to aid cancer patients (see 3 and 2 ).
For example, cancer patients need to be evaluated for common comorbid conditions such as depression and anxiety and for less common ones such as delirium, psychosis, or dementia, Spiegel advised.
When cancer patients are afflicted with anxiety, depression, or other psychological problems, psychiatrists can help them not just with psychotropic drugs, but with psychotherapies designed expressly for them, Grassi suggested.
When smokers and drinkers develop head and neck cancers, their families sometimes blame them for getting cancer rather than supporting them. In such instances, the psychiatrist can work with the patient to alleviate guilt and with the family to have greater understanding, Riba advised. “It is hard to deal with this toward the end,” she admitted. “But it is important for everybody to heal.”
“With longer cancer-patient survival, the Elizabeth Kubler-Ross stages are no longer an adequate way to think about death and dying,” Randy Hillard, M.D., a Michigan State University psychiatrist battling stomach cancer (see below) emphasized. “Now, with effective treatments, new therapies on the horizon, and longer average survival, the process of dying is a lot more cyclical and complex for patients and their families. Thus, the most important thing that psychiatrists can do to help patients and their families is to transition from feeling ‘I’m dying of cancer’ to ‘I’m living with cancer.’ ”
Still another way psychiatrists can help cancer patients, Hillard suggested, is to point them toward the CaringBridge Web site— www.caringbridge.com. CaringBridge is a nonprofit charitable organization. Cancer patients can set up a blog through CaringBridge at no cost and stay in touch with family, friends, and interested strangers. Hillard maintained a CaringBridge blog during the months after he was diagnosed with cancer and found it incredibly supportive and healing, he said.
On Thanksgiving day 2010, Randy Hillard, M.D., had much to be thankful for. The 61-year-old psychiatrist had a loving wife, fine adult children, and work at Michigan State University that he enjoyed. He was also feeling perfectly healthy.
He was getting short of breath climbing stairs and felt light-headed when he stood up. So he visited his internist, who scheduled tests to determine the cause of his symptoms.
On December 1, 2010, Hillard read the pathology test results in his electronic medical record: “Moderately differentiated adenocarcinoma of the stomach, ulcerated.” On January 5, 2011, a gross tumor was surgically removed from his stomach and found to be stage 4. After that, he endured months of chemotherapy and radiation, with the attendant nausea.
Recently he shared his thoughts and emotions about his ordeal with Psychiatric News.
Q. When you learned that you had stage-4 stomach cancer, what were your thoughts and emotions?
A. I was not as in touch with my feelings initially as with my thoughts, which were pretty much “I’m dead. My death will be ugly and painful, and nothing in my life has mattered.” I remembered the horrifying chemotherapy reactions and abdominal deaths that I had seen during medical school. I looked up my prognosis in the National Cancer Institute SEER database and found that I had a 30 percent chance of surviving three years and a 10 percent chance of surviving five years. I started looking into how to establish residency in Oregon so that I could take advantage of its assisted-suicide law and even contacted an assisted-suicide organization in Switzerland called Dignitatis.
Q. Did being a psychiatrist influence how you reacted to the news, and if so, how?
A. My psychiatric training helped me realize soon after all of this that I was, well, temporarily insane—or at least suffering from an acute stress reaction with mixed emotional features. I realized that I was not in touch with my emotions. I started getting psychotherapy. I allowed myself to reach out to my wife, my parents, my children, and my coworkers.
Q. Did being a psychiatrist sustain you in any way during the months you were enduring harsh side effects from chemotherapy and radiation and wondering whether you were going to survive?
A. Being a psychiatrist and getting psychotherapy did help me move from shock and horror to the feelings that were behind them, which were mostly feelings of fear and helplessness.
Q. What is your prognosis at this point?
A. Currently I have no symptoms and no evidence of disease. My doctors say that I am doing well and have even said that they regard me as “cancer free” at present. They are, of course, careful in their use of words, as we psychiatrists are when we talk with patients who have serious psychiatric illness. I suppose that I could revisit the SEER database and try to calculate my one-, three-, and five-year survival probabilities, but I have not bothered to. I have been through all the Kubler-Ross stages of denial, anger, bargaining, depression, and acceptance (although not in any orderly sequence). Now I am mostly back to denial. I recently bought a new car rather than a used one because I believe that I might outlive a used one.
Q. Are you working currently, and if so, in what capacity?
A. Actually I started back to work in September. I have been working with student mental health two days a week. I am doing some teaching and supervision and am working on several interesting research projects. One is a pharmacoeconomic study about implementing new guidelines for the diagnosis of heliocobacter infection (which I had) in patients with a first- or second-degree relative with stomach cancer (which I had). I am going to help a hospital start a new residency program, and I’m going to consult at a hospice two days a week.
Q. Can you cite one or two of the most important lessons that you learned from your cancer ordeal?
A. That productivity as a religion and being a career robot were never that good an idea and that relationships and kindness are what really matter.
Why did David Spiegel, M.D., an associate chair of psychiatry at Stanford University and a psycho-oncologist, choose to work with cancer patients?
“It started a long time ago,” he said in an interview. “I was a philosophy major in college and got interested in existential philosophy. One of the key concepts in existential philosophy is that you really don’t live authentically until you face the prospect of non-being and that facing death can be an opportunity for personal growth, not just decline.
“Then I went to medical school and found myself drawn to situations where people faced life-threatening situations—that is, where they were being challenged existentially. And, as a young psychiatrist during the 1970s, I started to help run group psychotherapy sessions for women with advanced breast cancer—again, people facing the prospect of non-being. At the time, such psychotherapy was a radical idea. Most oncologists feared that it would make cancer patients feel worse, not better. But I found myself tremendously engaged in trying to help them. There was something so compelling and honest about the way that they faced their own mortality and grieved one another’s losses.
“We also started doing studies to see how such frank, open, and supportive discussion affected them,” Spiegel continued, “and we found out that it was not harmful, but actually helpful—that it not only reduced their anxiety, depression, and physical pain, but even added to survival time. And I’m happy to say that over the decades we’ve been doing this work, psychological support groups for cancer patients have become increasingly accepted, so that today most major cancer centers offer them.”
“There are far more psychologists working in psycho-oncology than psychiatrists,” David Spiegel, M.D., associate chair of psychiatry at Stanford University and a psycho-oncologist, told Psychiatric News. “Yet among health care professionals, psychiatrists are the ones with both medical and psychological training. It’s not that I don’t welcome my psychology colleagues. It’s just that I wonder why there aren’t more of us psychiatrists involved because we are so perfectly trained to work in this area.”
Spiegel urges not just his colleagues, but APA to reach out to oncology groups such as the American Society for Clinical Oncology to see how they and oncologists might collaborate in the acute and chronic care of cancer patients. “Actually I think that psycho-oncology is one of the few potential growth areas for psychiatry,” he ventured.