Psycho-oncology: Overview, obstacles and opportunities.

Worldwide, psychological and social issues in cancer were not the subject of scientific inquiry until the past two decades. Since then, a new subspecialty of oncology has evolved, psycho-oncology. It addresses two dimensions of cancer: the emotional responses of patients at all stages of disease, as well as their families and caretakers (psychosocial); and the pyschological, social and behavioral factors that may influence cancer morbidity and mortality (psychobiological). Obstacles to development have been the facts of small numbers of clinicians and investigators worldwide and the few valid assessment instruments and research methods available to the biomedical community. These obstacles are increasingly giving way to the louder demand of the public for maximal quality of life in cancer care. Psycho-oncology is attaining subspeciality status by presently bringing a set of clinical skills in counseling, behavioral and social interventions to oncology, by providing training curricula which teach basic knowledge and skills in the area, and through creating a body of research and scholarly information about clinically relevant issues in the care of patients with cancer. Since it is increasingly recognized that psychological, social and behavioral variables influence treatment outcome, attention will likely to continue to increase. The field must meet the challenges of the 1990's in psychosocial care and availability of services, support for training clinicians and investigators in psycho-oncology, and implementation of an exciting research agenda. The focus of new research will encourage collaborative investigations combining biological and psychosocial variables, quality of life research in clinical trials, controlled studies of psychotherapeutic, behavioral and psychopharmacologic research, and crosscultural studies that will examine differences in prevention and detection, health care systems, alternative therapies and meta analyses.

Prevalence and predictors of depression, pain, and fatigue in older- versus younger-adult cancer survivors.

BACKGROUND: As the number of older adults in the United States continues to grow, there will be increasing demands on health care providers to address the needs of this population. Cancer is of particular importance, with over half of all cancer survivors older than 65 years. In addition, depression, pain, and fatigue are concerns for older adults with cancer and have been linked to poorer physical outcomes. METHODS: For this retrospective chart review, 1012 eligible participants were identified via a query of the Electronic Medical Record for all patients referred to 1 of 4 Survivorship Clinics at Memorial Sloan Kettering Cancer Center. All patients were between the ages of 30 to 55 (younger adults) and >65 (older adults). Depression was measured using the Patient Health Questionnaire-9 (PHQ-9). RESULTS: The overall rate of depression in this sample of adult cancer survivors was 9.3%. There were no differences in the rates of clinically significant depression (defined as PHQ-9 score ≥10) between younger and older adult cohorts. However, there was a small trend toward higher mean PHQ-9 scores in the younger adult cohort (3.42 vs 2.95; t = 1.763, P = .10). Women reported greater rates of depression and higher pain and fatigue scores. Hispanic/Latino patients also reported significantly greater rates of depression. CONCLUSION: There were no observed differences in depression between older and younger adult cancer survivors. Gender and ethnic discrepancies in depression were observed. Future research should focus on understanding the nature of these differences and targeting interventions for the groups most vulnerable to depression after cancer treatment.

Setting the stage for universal financial distress screening in routine cancer care.

Financial burden from cancer treatment is increasingly being recognized as a threat to optimal access, quality, and outcomes of cancer care for patients. Although research in the area is moving at a fast pace, multiple questions remain unanswered, such as how to practically integrate the assessment and management of financial burden into routine health care delivery for patients with cancer. Although psychological distress screening for patients undergoing cancer treatment now is commonplace, the authors raise the provocative idea of universal screening for financial distress to identify and assist vulnerable groups of patients. Herein, the authors outline the arguments to support screening for financial burden in addition to psychological distress, examining it as an independent patient-reported outcome for all patients with cancer at various time points during their treatment. The authors describe the proximal and downstream impact of such a strategy and reflect on some challenges and potential solutions to help integrate this concept into routine cancer care delivery. Cancer 2017;123:4092-4096. © 2017 American Cancer Society.

The management of psychological issues in oncology.

Psychological issues in the cancer setting are highly prevalent and well documented, and can lead to adverse outcomes. Several series of guidelines have been put forth to ensure that both psychological and psychiatric issues are addressed. The management of psychological issues in cancer is relevant for clinicians whose patients are identified clinically or via screening mechanisms with psychological or psychiatric sequelae from cancer. This review describes the psychological impact of cancer, distress screening as a triage mechanism, and the presentation and management of several specific comorbid psychological/psychiatric diagnoses in the oncology setting.

The role of posttraumatic growth and timing of quitting smoking as moderators of the relationship between stigma and psychological distress among lung cancer survivors who are former smokers.

OBJECTIVE: Patients diagnosed with lung cancer report high levels of stigma and psychological distress. This study examined posttraumatic growth among lung cancer survivors as a potential buffer against this relationship between stigma and psychological distress and examined how these relationships differed by the timing of quitting smoking (pre versus post-diagnosis). METHODS: Stages IA and IB non-small-cell lung cancer survivors (N = 141) who were former smokers, 1-6 years post-treatment, and had no evidence of disease completed standardized questionnaires assessing stigma, posttraumatic growth, timing of quitting smoking history, and psychological distress. RESULTS: Hierarchical linear regression and simple slope analyses indicated that among those who quit smoking prior to diagnosis (pre-diagnosis quitters), stigma had a positive association with psychological distress at high levels of posttraumatic growth (p = 0.003) and had a positive (but non-significant) association with psychological distress among those with low levels of posttraumatic growth (p = 0.167). Among those who quit smoking after diagnosis (post-diagnosis quitters), stigma had a positive association with psychological distress among those with low levels of posttraumatic growth (p = 0.004) but had no relationship among those with high levels of posttraumatic growth (p = 0.880). CONCLUSIONS: Findings indicate that posttraumatic growth buffers against the negative effects of stigma on psychological distress but only among post-diagnosis quitters. Future interventions could focus on fostering posttraumatic growth as a way to decrease the negative effects of stigma.

The Roots of Psychosomatic Medicine II: George L. Engel.

OBJECTIVE: The purpose of this article is to examine and appreciate the contributions of George Libman Engel, MD, to psychosomatic medicine. CONCLUSION: Engel was a prolific researcher, medical educator, and writer who championed the biopsychosocial model, which has been widely embraced and practiced in psychiatry and medicine to this day. In the late 1970s, when Engel published his seminal article on the biopsychosocial model, the dominant model of medicine was still the biomedical model. This model considered the most important and scientifically sound aspects of patient history to be those that could be easily quantified, such as laboratory values. The biomedical model left no room for the psychosocial aspects, such as the patient's relationships and social status, to be integrated into patient care. Though many had expressed dissatisfaction with the biomedical model and suspected that it was too 1 dimensional to provide adequate patient care, Engel was among the first to propose a replacement model. Furthermore, he stipulated that there is a scientific necessity to consider psychosocial aspects of patient history to provide the most complete diagnoses and treatment plan. Along with his biopsychosocial approach to the patient, Engel also contributed heavily to research and to education of medical students. His legacy is one of compassionate, scientific doctoring.

The validity of the distress thermometer in prostate cancer populations.

BACKGROUND: The Distress Thermometer (DT) is widely recommended for screening for distress after cancer. However, the validity of the DT in men with prostate cancer and over differing time points from diagnosis has not been well examined. METHOD: Receiver operating characteristics analyses were used to evaluate the diagnostic accuracy of the DT compared with three commonly used standardised scales in two prospective and one cross-sectional survey of men with prostate cancer (n = 740, 189 and 463, respectively). Comparison scales included the Impact of Event Scale - Revised (IES-R, Study 1), the Hospital Anxiety and Depression Scale (HADS, Study 2) and the Brief Symptom Inventory-18 (BSI-18, Study 3). RESULTS: Study 1: the DT showed good accuracy against the IES-R at all time points (area under curves (AUCs) ranging from 0.84 to 0.88) and sensitivity was high (>85%). Study 2: the DT performed well against both the anxiety and depression subscales for HADS at baseline (AUC = 0.84 and 0.82, respectively), but sensitivity decreased substantially after 12 months. Study 3: validity was high for the anxiety (AUC = 0.90, sensitivity = 90%) and depression (AUC = 0.85, sensitivity = 74%) subscales of the BSI-18 but was poorer for somatization (AUC = 0.67, sensitivity = 52%). A DT cut-off between ≥3 and ≥6 maximised sensitivity and specificity across analyses. CONCLUSIONS: The DT is a valid tool to detect cancer-specific distress, anxiety and depression among prostate cancer patients, particularly close to diagnosis. A cut-off of ≥4 may be optimal soon after diagnosis, and for longer-term assessments, ≥3 was supported. © 2013 The Authors. Psycho-Oncology published by John Wiley & Sons, Ltd.

Review of the history and development in the field of psychosocial oncology.

Psychosocial oncology is a multi-disciplinary field of practice and, as a recently developed speciality, covers the psychological, social and behavioural dimensions of cancer. We describe the historical background and changing ethos in medical practice in order to understand factors that contributed to the emergence of this new discipline. Modern psychosocial oncology covers a number of topics; the diagnosis and management of psychological morbidity and distress across the cancer continuum from diagnosis through survivorship and, for some patients, terminal illness, the recognition that behaviour and lifestyle contribute to cancer risk and prognosis, the need to include families and carers alongside patients in a comprehensive model of supportive cancer care. Best practice, based on evidence and nationally and internationally accepted guidelines, is being integrated into national cancer plans, and services are briefly described. Future challenges include the need to recognize that the behavioural and mental health sciences have a role to play in comprehensive cancer care and that multi-disciplinary care, which includes psychosocial care, is the best model for ensuring patients needs are comprehensively and adequately met. The return of modern medicine to a more holistic person-focused ethos is needed in order to put the patient back into patient-centred cancer care.

Distress screening and the integration of psychosocial care into routine oncologic care.

Many patients being treated for cancer have significant distress and often do not receive the attention they require. The psychosocial concerns of these patients are now better recognized and treated through psycho-oncology, which has become a multidisciplinary subspecialty of oncology concerned with the emotional responses of patients at all stages of disease, their families, and staff. In her presentation at the NCCN 18th Annual Conference, Dr. Jimmie C. Holland briefly reviewed the early role played by the NCCN as well as other national and international organizations in improving the psychosocial care of patients with cancer.

Distress management.

The integration of psychosocial care into the routine care of all patients with cancer is increasingly being recognized as the new standard of care. These NCCN Clinical Practice Guidelines in Oncology for Distress Management discuss the identification and treatment of psychosocial problems in patients with cancer. They are intended to assist oncology teams identify patients who require referral to psychosocial resources and to give oncology teams guidance on interventions for patients with mild distress to ensure that all patients with distress are recognized and treated.

Effect of socioeconomic status as measured by education level on survival in breast cancer clinical trials.

OBJECTIVES: This paper aims to investigate the effect of socioeconomic status, as measured by education, on the survival of breast cancer patients treated on 10 studies conducted by the Cancer and Leukemia Group B. METHODS: Sociodemographic data, including education, were reported by the patient at trial enrollment. Cox proportional hazards model stratified by treatment arm/study was used to examine the effect of education on survival among patients with early stage and metastatic breast cancer, after adjustment for known prognostic factors. RESULTS: The patient population included 1020 patients with metastatic disease and 5146 patients with early stage disease. Among metastatic patients, factors associated with poorer survival in the final multivariable model included African American race, never married, negative estrogen receptor status, prior hormonal therapy, visceral involvement, and bone involvement. Among early stage patients, significant factors associated with poorer survival included African American race, separated/widowed, post/perimenopausal, negative/unknown estrogen receptor status, negative progesterone receptor status, >4 positive nodes, tumor diameter >2 cm, and education. Having not completed high school was associated with poorer survival among early stage patients. Among metastatic patients, non-African American women who lacked a high school degree had poorer survival than other non-African American women, and African American women who lacked a high school education had better survival than educated African American women. CONCLUSIONS: Having less than a high school education is a risk factor for death among patients with early stage breast cancer who participated in a clinical trial, with its impact among metastatic patients being less clear. Post-trial survivorship plans need to focus on women with low social status, as measured by education.

Looking at the roots of psychosomatic medicine: Adolf Meyer.

BACKGROUND: Adolf Meyer, the first Professor of Psychiatry at Johns Hopkins, and Chief of the Phipps Clinic, brought a bevy of new ideas to clinical practice and to medical education. He used the word "psychobiology," which helped to establish psychosomatic medicine and formed the basis for Engel's "biopsychosocial" concept. OBJECTIVE: This paper aims to review the contributions of Adolf Meyer, who proposed that in studying patients, it was impossible to consider the mind and body separately. RESULTS: Adolf Meyer, through his insight and tenacity, promoted the integration of psychiatry and medicine in medical education and practice. CONCLUSION: By taking a closer look at the role of Meyer's work in relation to today's psychosomatic medicine, current challenges do not appear to be dramatically different from the issues faced a century ago.

Management of distress in cancer patients.

Psychosocial distress is highly prevalent and diverse at all stages of cancer care. In the early 21st century, screening, assessment, and management of psychological distress in cancer patients are supported by a growing body of literature. Psychosocial care of cancer patients snow considered an essential component of quality cancer care by the Institute of Medicine. Increasing numbers of professionals from different disciplines are being trained in the United States and internationally to provide consultative services in support of the psychological care of cancer patients. This review article highlights the psychosocial distress experienced by cancer patients, featuring an overview of the assessment and management of psychological distress in the context of cancer as well as the common psychiatric disorders experienced by cancer patients at all stages of disease.

Psychosocial Distress Screening: An Educational Program's Impact on Participants' Goals for Screening Implementation in Routine Cancer Care.

BACKGROUND: Psychosocial distress screening is a quality care standard in cancer care. Screening implementation may be facilitated by an educational program that uses goals to evaluate progress over time. OBJECTIVES: This article describes the content and design of the Screening for Psychosocial Distress Program (SPDP), reports on its delivery to 36 paired participants, and evaluates its effects on distress screening activities and goals. METHODS: The SPDP used a one-group pre-/post-test design. It was delivered at 2 workshops and 10 conference calls during a two-year period. Data on screening and goal achievement were collected at 6, 12, and 24 months. Data on the quality of dyads' relationships were collected at 24 months. FINDINGS: At 24 months, all 18 dyads had begun screening. Dyads reported working effectively together and being supportive of the other member of the dyad while achieving their goals for implementing psychosocial distress screening.

Single-agent versus combination chemotherapy in advanced non-small-cell lung cancer: the cancer and leukemia group B (study 9730).

PURPOSE: We compared the efficacy of combination chemotherapy versus single-agent therapy in patients with advanced non-small-cell lung cancer. PATIENTS AND METHODS: A total of 561 eligible patients were randomly assigned to receive paclitaxel alone or in combination with carboplatin. RESULTS: The response rate was 17% in the paclitaxel arm and 30% in the carboplatin-paclitaxel arm (P < .0001). Median failure-free survival was 2.5 months in the paclitaxel arm and 4.6 months in the carboplatin-paclitaxel arm (P = .0002). Median survival times were 6.7 months (95% CI, 5.8 to 7.8) and 8.8 months (95% CI, 8.0 to 9.9), and 1-year survival rates were 32% (95% CI, 27% to 38%), and 37% (95% CI, 32% to 43%), respectively. The overall survival distributions were not statistically different: hazard ratio = 0.91 (95% CI, 0.77 to 1.17; P = .25). Hematological toxicity and nausea were more frequent in the combination arm, but febrile neutropenia and toxic deaths were equally low in both arms. There was no significant survival difference in elderly patients. Performance status 2 patients treated with combination chemotherapy had a better survival rate than those treated with single-agent therapy (P = .019). CONCLUSION: Combination chemotherapy improves response rate and failure-free survival compared with single-agent therapy, but there was no statistically significant difference in the primary end point of overall survival. The results in elderly patients were similar to younger patients. Performance status 2 patients had a superior outcome when treated with combination chemotherapy.

American Cancer Society Award lecture. Psychological care of patients: psycho-oncology's contribution.

The centuries-old stigma attached to cancer precluded patients' being told their diagnoses, and thus, delayed any exploration of how they dealt with their illness. This situation changed in the United States in the 1970s when patients began to be told their cancer diagnosis, permitting the first formal study of the psychological impact of cancer. However, a second and equally long-held stigma attached to mental illness has been another barrier and this has kept patients from being willing to acknowledge their psychological problems and to seek counseling. This "double stigma" has slowed the development of psycho-oncology. However, we began to see rapid changes occurring in the last quarter of the 20th century. Valid assessment instruments were developed which were used in well-designed studies. Data from these studies and clinical observations led to increased recognition that psychosocial services are needed by many patients and provide significant assistance in coping with illness. Psycho-oncology has two dimensions: first, the study of the psychological reaction of patients at all stages of the disease, as well as of the family and oncology staff; second, exploring the psychological, social, and behavioral factors that impact on cancer risk and survival. Psycho-oncology now has a recognized role within the oncologic community through clinical care, research, and training as it relates to prevention of cancer through lifestyle changes, evaluation of quality of life, symptom control, palliative care and survivorship. Presently, there are sufficient research studies from which standards of care have been established. Both evidence and consensus-based clinical practice guidelines have been promulgated. It now possible to monitor the quality of existing psychosocial services by using these benchmarks of quality that have evolved in recent years.

Impact of azacytidine on the quality of life of patients with myelodysplastic syndrome treated in a randomized phase III trial: a Cancer and Leukemia Group B study.

PURPOSE: The impact of azacytidine (Aza C) on the quality of life of 191 patients with myelodysplastic syndrome was assessed in a phase III Cancer and Leukemia Group B trial (9221). PATIENTS AND METHODS: One hundred ninety-one patients (mean age, 67.5 years; 69% male) were randomized to receive either Aza C (75 mg/m(2) subcutaneous for 7 days every 4 weeks) or supportive care, with supportive care patients crossing over to Aza C upon disease progression. Quality of life was assessed by centrally conducted telephone interviews at baseline and days 50, 106, and 182. Overall quality of life, psychological state, and social functioning were assessed by the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire C30 and the Mental Health Inventory (MHI). RESULTS: Patients on the Aza C arm experienced significantly greater improvement in fatigue (EORTC, P =.001), dyspnea (EORTC, P =.0014), physical functioning (EORTC, P =.0002), positive affect (MHI, P =.0077), and psychological distress (MHI, P =.015) over the course of the study period than those in the supportive care arm. Particularly striking were improvements in fatigue and psychological state (MHI) in patients treated with Aza C compared with those receiving supportive care for patients who remained on study through at least day 106, corresponding to four cycles of Aza C. Significant differences between the two groups in quality of life were maintained even after controlling for the number of RBC transfusions. CONCLUSION: Improved quality of life for patients treated with Aza C coupled with significantly greater treatment response and delayed time to transformation to acute myeloid leukemia or death compared with patients on supportive care (P <.001) establishes Aza C as an important treatment option for myelodysplastic syndrome.