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Psycho-Oncology

Introduction

Psycho-oncology is an interdisciplinary field at the intersection of physical, psychological, social, and behavioral aspects of the cancer experience for both patients and caregivers. Also known as Psychiatric Oncology or Psychosocial Oncology, researchers and practitioners in the field are concerned with aspects of individuals' experience with cancer beyond traditional medical treatments, and across the cancer trajectory, including at diagnosis, during treatment, transitioning to and throughout survivorship, and approaching the end-of-life. Founded by Jimmie Holland in 1997 via the incorporation of a psychiatric service within the Memorial Sloan Kettering Cancer Center in New York, the field has expanded drastically since and is now universally recognized as an integral component of quality cancer care.Cancer centers in major academic medical centers across the country now uniformly incorporate a psycho-oncology service into their clinical care, and provide infrastructure to support research efforts to advance knowledge in the field.

Psycho-oncology broadly deals with the psychological reactions to the experience of cancer, the behavioral component of coping with cancer as well as health behavior change including preventative medicine, and social factors that are associated with diagnosis and treatment of cancer, including communication with providers and loved ones and social support. In addition, research related to the influence of psychosocial factors on biological disease-related processes has burgeoned over the past two decades. Much research takes a biopsychosocial approach to account for the interplay between biological, psychological, and social factors in coping with cancer. The integration of psycho-oncology into routine oncologic care represents a major step forward in terms of care for the whole patient.

Psychological

Diagnosis and treatment of cancer is known to influence psychological well-being to a significant degree. Rates of psychological distress are elevated for most individuals who have been diagnosed with cancer when compared to population normsChief among psychological reactions to cancer are mood and anxiety-related concerns. Elevated rates of depression and anxiety in response to a cancer diagnosis is often attributable to uncertainty regarding mortality and well as going through arduous treatments and concerns related to functional interference and body-image or other self-concept related distress. Understanding how individuals react psychologically to cancer is important to support their overall well-being and maximize quality of life during treatment and beyond.

While the prevalence of psychological disturbance in reaction to cancer is relatively high when compared to population norms, many individuals report fairly stable psychological well-being through the cancer trajectory and some even report improved psychological well-being.

Depression and Anxiety

Common psychological reactions to cancer diagnosis and treatment include depressive symptoms and anxiety. Factors that may contribute to clinically significant anxiety and depression in the context of cancer include threat to life, uncertainty regarding prognosis and treatment outcome, worry regarding toxic treatments, functional impairment as a result of toxic treatments, and physical symptoms themselves, commonly including fatigue, pain, nausea, hair loss, neuropathy, and chemo brain. While the majority of inidivuals diagnosed with cancer do not exhibit clinically significant symptoms of depression or anxiety, prevalence after cancer diagnosis is substantially higher than population norms.

Coping

Psychological and behavioral responses by individuals to diagnosis and treatment of cancer in an effort to manage the substantial stress and threat to health are of primary interest in the field of psycho-oncology. These responses constitute what can be referred to as one's coping response to a health threat and is closely associated with individuals' illness perceptions.

Approach

Avoidance

Emotional Approach

Positive Psychological Reactions

Benefit Finding

Benefit finding is a cognitive process whereby individuals identify positive contributions that have been made by their diagnosis of cancer. It is an example of a positively oriented coping strategy or approach oriented coping strategy. Research on benefit finding and

Meaning Making

as part of interventions for individuals who do not naturally or spontaneously engage in these processes

illness perceptions/representations

Behavioral

Health Promoting Behaviors/preventative medicine

Smoking Cessation, skin protection, screening (e.g., melanoma, breast cancer, lung cancer)

physical activity (e.g., fatigue, inflammation associations)

Treatment Adherence

Adherence to medical treatment is of crucial importance to managing cancer effectively and is a topic that largely falls under the purview of psycho-oncology for the cognitive-behavioral causes for lack of treatment adherence. A number of factors can contribute to lack of treatment adherence including toxic side effects, misinformation or lack of understanding of treatment regimen, lack of communication with medical providers, and lack of medical support (e.g., treatment self-management). Treatment adherence has become an increasingly important topic of study in psycho-oncology due to the increasing popularity of oral antineoplastics. Individuals on oral chemotherapy must manage sometimes complex treatment regimens at home, on their own, and be able to communication effectively with treatment providers to manage toxic side effects that may influence ability or willingness to take the prescribed drug without the assistance of nursing as in traditional intravenous chemotherapy.

Social

Social Support and Isolation

During a stressful experience such as cancer diagnosis, social connections can provide valuable emotional and practical support. Research in the broader field of Health Psychology has revealed significant influences of social support on the psychological well-being of individuals as well as associations with disease processes, particularly in cardiovascular disease. Patients undergoing treatment for cancer often rely on a social support network of varying size, including spouses, children, friends and other family, to support them through difficult treatments and functional impairment. These types of social support refer to instrumental social support and are related to task-based support. Additionally, the emotional toll that cancer diagnosis can take on a person necessitates a degree of emotional support from the support network. Both instrumental and emotional social support have been shown in research to improve quality of life in patients being treated for cancer.

On the other hand, a diagnosis of cancer can be significantly socially isolating for individuals. Life changes including functional impairment may separate people from their friends and family, and a shift from "healthy" to "ill" in terms of self-identity can lead to a sense of social isolation as well. Research has shown that social isolation and perceptions of loneliness have significant negative impact on physical and psychological quality of life in individuals with cancer.

Biological

Stress Pathways to Disease

Antoni review

Lutgendorf Review

Psychosocial Treatment Models

Adaptations of CBT, ACT, other effective interventions

Multiple evidence based treatments for mood and anxiety disorders in the general population have been adapted to deal with stressors directly related to cancer. Common maladaptive cognitions that are associated with cancer include misinterpreting pain or other physical sensations as cancer progression, or struggling to adapt to the uncertainty of treatment and life after treatment. Cognitive Behavioral Therapy and related psychotherapies are particularly well suited to manage these cognitive concerns that emerge throughout the cancer process and serve to interfere with individuals' quality of life.

Mindfulness

Mindfulness is a burgeoning area of interest as a common element across multiple modalities in mental health treatment, having shown effectiveness in ameliorating depressive symptoms and anxiety. Particular to cancer, mindfulness has been applied to general stress reduction through mindfulness-based stress reduction (MBSR), with evidence growing for not only decreased levels of cancer-related distress in response to mindfulness-baed treatments, but impact on biomarkers of disease and enhanced survival

Technology-Assisted Interventions

Online social support

mobile symptom tracking for medication adherence and communication with providers

Overall Impact on Standard Oncology Care

Routine Distress Screening

As awareness of the prevalence of psychological distress that accompanies a cancer diagnosis and increased efforts to integrate evidence based psychosocial treatments into overall oncologic care, screening for adjustment to diagnosis and treatment became important Routine distress screening throughout the cancer process (e.g., diagnosis, treatment, survivorship) is crucial to identifying individuals who are already struggling with symptoms of depression or anxiety or for identifying those at risk for psychological issues related to cancer. Historically, communication about psychological adjustment was lacking between patients and providers regarding topics related to adjustment to diagnosis, living with cancer, living cancer-free in survivorship, or transitioning to end of life care. The stigmatized nature of psychological concerns made it difficult to identify those patients who could benefit from early intervention to prevent or attenuate symptoms of depression or anxiety that may emerge.