Understanding the Breadth and Depth of the Subspecialty: Psycho-Oncology

Among subspecialties of consultation-liaison psychiatry, psycho-oncology is one of the most well established. The field originated out of the Memorial Sloan-Kettering Cancer Center in New York in the 1950s, growing to its current state with professional organizations in 30 countries comprising the Federation of Psycho-Oncology Societies and establishing and leading Screening for Emotional Distress, the sixth vital sign in medical populations. Psycho-oncology is a multidisciplinary specialty, and cancer psychiatrists are core team members whose role includes assessing a patient’s psychiatric symptomatology; understanding how medical, psychological, and social factors affect the patients’ ability to cope with their illness; and helping the oncology teams develop patient-centered management.

Cancer psychiatrists have expertise in distinguishing between distress that is normative versus maladaptive. They use the etiological approach for psychiatric diagnosis in the context of the somatic consequence of cancer or its treatment; manage psychopharmacology and oncology drug interactions; and psychotherapeutically explore changes in identity and relationships, meaning and purpose, and fears, hope, and mortality.

Case Study

Ms. JS was a 42-year-old single woman with metastatic breast cancer, referred by her oncologist when she declined chemotherapy and requested medically assisted dying instead. She described her cancer as her “way out” of a difficult life filled with trauma, abusive relationships, and loss. Her mother died of advanced cancer when Ms. JS was 8 years old, and she was subsequently raised by an abusive uncle. She had a history of suicide attempts, the last one 15 years ago requiring psychiatric admission. She was lost to follow up after discharge. She described feeling chronically depressed since then, with a significant worsening since her cancer diagnosis two months ago.

After confirming there were no acute safety or capacity concerns, we began by conveying an understanding of how her mistrust had developed in the context of her abusive childhood and adolescence. We shared that our priority would be to develop a trusting relationship with her and to give her as much control over her care as possible. She preferred to avoid intravenous chemotherapy, which would feel intrusive to her and result in hair loss. This was communicated to her oncologist, and she was ultimately treated with tamoxifen, an oral endocrine therapy, and deferred her request for assisted dying. Due to the development of menopause symptoms, together with ongoing and worsening depressive symptoms, she was treated with venlafaxine after brain metastasis was ruled out. Venlafaxine was selected because it is known to alleviate hot flashes and does not interact with tamoxifen, which can occur with other antidepressants.

The scope of a psycho-oncologist includes helping patients with understanding their medical condition and supporting them in their capable treatment decision making. Since psychological suffering is the primary motivation behind assisted-dying requests, over 60 percent of which come from patients with cancer, psycho-oncologists can play a critical role in helping patients explore their options during discussions of care goals. Maintaining communication with the primary oncologist, nurse, social worker, and pharmacist is vital in providing this patient-centered care.

Ms. JS was also engaged in end-of-life psychotherapy. This helped her connect feelings about her past losses to her cancer in the present, which she perceived as another trauma. Over time, she experienced the medical care she received as reminiscent of how her mother had loved her, with compassion and respect. She could recognize her resilience and success in having a stable job and deriving a strong sense of meaning through her work, which she was able to continue throughout most of her two-year illness.

After progression of her disease, the need to control her physical appearance remained very important to her as a way of maintaining a valued aspect of her identity. She agreed to treatment with capecitabine, an oral chemotherapy that does not cause hair loss, and continued on this until a few months before she died. In hospice, she continued to be followed by the psycho-oncology team that she had grown to trust, allowing herself to receive care and dying peacefully.

In addition to the core C-L psychiatric management of medical patients, psycho-oncology provides a unique opportunity to work longitudinally with patients facing life-and-death issues, exploring and responding to existential distress. This in turn requires psychiatrists to be mindful of their own countertransference and well-being in working with this population. It necessitates exquisite professionalism, but at the same time can be a deeply personal experience, both rewarding and poignant. ■