The Psychosocial Aspect of Cancer Care

In addition to grappling with the physical challenges associated with treatment, recovery and survivorship, cancer patients often battle anxiety, depression and stress. A 2008 report published by the Institute of Medicine (IOM) notes that these mental health issues can affect health outcomes by decreasing patients’ motivation to complete treatment and reducing their ability to cope with the demands of a rigorous treatment process. “The failure to address the very real psychosocial health needs of patients and their caregivers is a failure to effectively treat that patient’s cancer,” the IOM report concludes.

Cleveland Clinic’s Taussig Cancer Institute has offered an array of support services to cancer patients and families for several years, says staff clinical psychologist Beth Gardini Dixon, PsyD. But in recent years, the Cancer Institute has devoted additional resources to psychosocial needs.

Dr. Dixon points to a cultural shift dating to the 1970s, when breakthroughs in cancer treatment gradually led to greater numbers of long-term survivors, and stigmatization of mental disorders began to diminish. Caregivers started to discuss the psychological aspects of cancer. More recently, “we began to realize how greatly the quality of life for these survivors was impacted by post-treatment distress, ” Dr. Dixon says. “We have directed attention to interventions for those undergoing active treatment, as well as for those in survivorship.”

A focused approach

Taussig Caner Institute Chairman Brian Bolwell, MD, and Isabel Schuermeyer, MD, Director of the Psycho-Oncology Program, viewed the lack of a dedicated psychologist as a “service gap” and brought Dr. Dixon in two years ago to run the Cancer Institute’s first psychology clinic, complementing other services such as psychiatry, peer support, social work, and music and art therapy.

“Depression, in particular, has been a major focus because it’s the most common mental disorder that we see among people with cancer,” Dr. Dixon notes. “Depressed patients tend to have more treatment complications. There tend to be delays in treatment as a result of the depression in comparison with non-depressed patients, and they tend to have more difficulty getting through their treatment. Fortunately, we have a growing body of research supporting the effectiveness of treatment for depression and anxiety, and of fatigue management.”

For example, the authors of a comprehensive 2008 article in CA: A Cancer Journal for Physicians summarized the findings of previous systematic reviews and meta-analyses of the effects of psychosocial interventions on anxiety and depression in adults with cancer. Among the 14 publications they reviewed that reached a conclusion about efficacy, six reached positive conclusions about interventions for anxiety, and nine for depression (some publications addressed both conditions). Nonpharmacological interventions showing benefits in randomized controlled studies included cognitive-behavioral therapy, relaxation training, education and couples therapy, among others.

Dr. Dixon says she has adapted evidence-based interventions from her general mental health background to the needs of individual cancer patients. One example is behavior activation therapy, intended for depressed cancer patients who have lost the motivation to pursue activities that previously brought them joy and fulfillment. “For example, maybe athletics was an important part of their life, and they’ve experienced neuropathy as a result of chemotherapy,” she explains. “I use this intervention to help them rethink what was important to them about exercise and modify that. So maybe they can’t run a marathon any more, but they can perform other activities that help them re-establish ties to their former self.”

Additional efficacy research needed

The authors of the CA review also interpret psychosocial interventions broadly to include guided imagery, music therapy, stress management and support groups. Dr. Dixon says that while all these approaches to care have enthusiastic supporters, not all are supported by evidence derived from randomized controlled trials — a gap that researchers may be able to address in the future.

“We don’t have good studies on treatment of post-traumatic stress disorder in this population, and some people do develop trauma symptoms in response to the diagnosis and treatment of cancer,” she says. “Certainly support groups offer another area where we need more research on efficacy.”

Stacey Carabin, RN, OCN, Program Coordinator of the Cancer Institute’s 4th Angel Mentoring Program, expresses the need for further research addressing the effectiveness of peer mentoring among cancer patients and their lay caregivers.

Meanwhile, she emphasizes the 4th Angel Mentoring Program’s value to its current participants, who hail from all 50 states. “In oncology, we as clinicians can explain drugs and procedures very well, and we can give patients an idea of what to expect,” she says. “But we can’t tell you how you’re going to feel. You get a completely different perspective when you can talk to someone who gets what you’re feeling, what your questions are, your thoughts and fears.”