Psycho-oncology

It is a comprehensive overview of psycho-oncology.

1. PSYCHO-ONCOLOGY AN OVERVIEW Dr. Pawan Sharma [email protected]

2. Introduction Mental Health Consequences of Cancer at the time of diagnosis, active cancer and survivors Maladaptation Common mental disorders Impact of maladaptation Suicide Treatment of Cancer: Psychiatric sequelae Risk Factors for Cancer Initiation/ Maintenance Management of maladaptation Issues related to cancer in children and adolescents Indian research Conclusion and future directions

3. Areas not discussed Pharmacological Interactions Analgesic abuse Sexual issues Care giver burden Oncologist burnout Euthanasia

4. Introduction Mental Health Consequences of Cancer at the time of diagnosis, active cancer and survivors Maladaptation Common mental disorders Impact of maladaptation Suicide Treatment of Cancer: Psychiatric sequelae Risk Factors for Cancer Initiation/ Maintenance Management of maladaptation Issues related to cancer in children and adolescents Indian research Conclusion and future directions

5. Introduction 32.6 million people living with cancer (within 5 years of diagnosis) in 2012 worldwide Incidence rates of 205 and 165 per 100,000 in male and female respectively 48% (15.6 million) of the 5-year prevalent cancer cases occur in the less developed regions WHO, 2012

6. Introduction Subspecialty of cancer dealing with two psychological dimensions: P sychological reactions of patients with cancer and their families and health care providers P sychological , social and behavioral factors that contribute to cancer risk, detection and survival Slowly emerging as a subspecialty within oncology as well as psychiatry and psychosomatic medicine Its is the study of psychological aspects of cancer along the continuum from prevention to cure Meyer et al, 2009

7. Stress, Coping and Adaptation/ Maladaptation Screening: Some patients have long term negative psychological consequences: worry about cancer, intrusive thinking, perception of less healthy organs Brett et al, 2005 Diagnosis : A crisis requiring quick adaptation to catastrophic news 5 ‘D’- Death, Dependency, Disfigurement, Disability & abandonment, Disruptions in relationships, role functioning, and financial status Phase 1: shock and disbelief- depends on communication of diagnosis to patient (1 week) Phase 2: period of commotion of mixed anxiety, depression, insomnia, irritability (1-2 weeks) Phase 3: adaptation to diagnosis and treatment

8. Introduction Mental Health Consequences of Cancer at the time of diagnosis, active cancer and survivors Maladaptation Common mental disorders Impact of maladaptation Suicide Treatment of Cancer: Psychiatric sequelae Risk Factors for Cancer Initiation/ Maintenance Management of maladaptation Issues related to cancer in children and adolescents Indian research Conclusion and future directions

9. Stress, Coping and Adaptation/Maladaptation Four stages in the experience of cancer treatment: The recognition/exploratory stage: recognition of symptoms and diagnosis The crisis/climax stage : when the treatment is initiated (characterized by anxiety, depression, altered body image and concern about changing relationships) Adaptation / maladaptation stage: after initiation of treatment The resolution/disorganization stage: long term sequelae Survivors too face different psychological problems

10. Maladaptation Study Cancer N Test Results Love et al , 2008 Prostate Ca 211 New Dx Short-Form 36 Higher rate of anxiety Depression not significantly different from controls Akechi et al, 2006 Lung Ca 85 Immediate reaction: tension-anxiety 2 & 6 months: tension-anxiety significantly reduced 6 months: no change in other psychological distress (anger-hostility, fatigue, confusion)

11. Maladaptation 2004–2009: 2 centers ( n=10,153 consecutive patients ) Psychosocial Screen for Cancer questionnaire (anxiety, depression, perceived & desired social support, quality of life) Stage: First visit to a cancer center, prior to beginning treatment Anxiety 19% Sub-clinical anxiety 22.6% Depression 12.9% Sub-Clinical depression 16.5% > anxiety and depression score: lung , hematological and gynecological cancer < depression score: skin cancer > symptoms: y ounger patients Linden et al, 2010

12. Maladaptation N=160 ( breast, colorectal, lung and prostate cancer) Stage: baseline, 3months, 6months Measures: Mini Mental Adjustment to Cancer Scale (Mini MAC) Short Form General Health Survey Hospital Anxiety and Depression Scale Functional Assessment of Cancer Therapy (FACT) scale Life Orientation Test Revised(trait personality) NEO Five Factor Inventory ( neurotism , extroversion, introversion) Williams et al, 2011 Quality of life significantly predicted later anxiety and depression, the opposite effect was not observed > adjustment: older patients Other predictors for poor adjustment Neuroticism Negative emotion Mental health status

13. Maladaptation Lack of clarification between actual clinical diagnosis vs only symptoms D iagnostic cut-offs not empirically validated and diagnoses based on different diagnostic systems Variation of quality of measurement tools Lack of homogeneity between the time when the prevalence rates assessed

14. Maladaptation Authors Cancer N Scales Results Fobair et al, 2006 Breast 546 Body image questionnaire >50% subjects: >2 body image problems Fingeret et al, 2011 Oral cancer (new Dx ) 75 Self-report, Structured interviews 77% id entified current /future appearance-related concerns Depression was the strongest and most consistent predictor of body image outcomes (Brief Symptom Inventory 18 - BSI-18)

15. Common Mental Disorders Twelve-month prevalence rates of CMDs in cancers 13 high-income and 11 low-middle-income countries Data from World Mental Health Surveys (used CIDI) ( N= 66,387; active cancer: 357, cancer survivors: 1373, cancer-free: 64,657) Active Cancer Cancer survivor Cancer free 18.4% 14.6% 13.3% 59% sought services for mental health problems (similar in high & low income countries ) Nakash et al, 2013

16. Active stage: Psychiatric D isorders Depression in palliative-care settings: prevalence between 1%-69% Actual rate of depression not clear: most publications have used depression screens rather than diagnostic instruments Meta-analysis (Mitchell et al, 2011): Studies using psychiatric interviews applied by trained researchers/health professionals Setting: palliative care Setting: Oncology/ Hematology Studies (patients) 24 from 7 countries (N=4007) 70 from 14 countries (N=10071) Depression 14.3% 14.9% Adjustment 15.4% 19.4% Anxiety 9.8% 10.3% Dysthymia 2.7%

17. Active Stage: Prevalence of Psychiatric Disorders Community setting Nationally representative Canadian Community Health Survey Cycle (n=36984) Major depression (OR=3.18; 95% CI: 1.69-5.96) Panic attacks (OR=2.15; 95% CI: 1.22-3.77) Rasic et al, 2008 Schizophrenia and BPAD: similar in cancer patients and general population Grassi et al, 2005

18. Active Stage: Determinants of Maladaptation

19. Depression: Diagnostic Issues Many symptoms of cancer and its treatment : fatigue , anorexia, insomnia, and cognitive impairment overlap with depression S uicidality or the desire for hastened death may be a feature of depression also found in states of demoralization in individuals who are not clinically depressed Cancer related depression is not associated with core depressive thoughts, such as sense of guilt and failure, dissatisfaction and self-dislike, than primary depression Le et al, 2012

20. Depression: Diagnostic Issues 4 conceptual approaches to evaluate depression in medically ill

21. Active Stage: Suicide Cohort study involving 6,073,240 Swedes Relative risk of suicide among patients receiving a cancer diagnosis 12.6 (95% CI: 8.6 - 17.8) during the first week Incidence: 2.50 per 1000 person-years 3.1 (95% CI: 2.7 - 3.5) during the first year Incidence: 0.60 per 1000 person years Fang et al, 2012

22. Active Stage: Suicide Systemic review: 24 articles (1999-2009) High rate of suicide Determinants: Male gender Age >65 years Specific cancers: prostate , lung, pancreatic, head and neck Specific period: 1 st year after cancer diagnosis Anguiano et al, 2012

23. Active Stage: Suicide Maintain a supportive relationship Control symptoms ( pain, nausea, depression ) Strong correlation between physical health and suicidality Involve family or friends Allow patient to discuss suicidal thoughts Given intense, ongoing support, including open discussions about treatment option Holland and Alici,2010

24. Active Stage: PTSD Publications (1994 – 2013): 25 studies Mean prevalence Current: 6.4% Lifetime: 12.6 % Abey et al, 2014

25. Cancer survivors: Maladaptation C ancer tumor registry of the Ireland Cancer Center (ICC ) I n-person interviews with 321 older (>60) adult long-term survivors (5–34 years post-diagnosis ) Cancer-related health worries scale (  =0.84) Anxiety: The Profile of Mood States ( POMS) ( = 0.86) Depression: Center for Epidemiologic Studies-Depression (  =0.87)

26. Cancer Survivors: Maladaptation Cancer-related health worries: significant predictor of depression and anxiety

27. Cancer survivors: Maladaptation Meta-analysis: patients diagnosed with cancer for at least 2 years 43 studies N Depression Cancer Survivors 51381 11.6% Healthy controls 217630 10.2% N Anxiety Cancer Survivors 48964 17.9% Healthy controls 226467 13.9% Around 50% of studies: family members as controls No difference between the prevalence of depression and anxiety when patients compared to spouses Mitchell et al, 2013

28. Depression & Anxiety: Impact on Non Compliance Meta-analysis: depression (12 articles), anxiety (13 articles) Depression was associated with non compliance (OR: 3.03 (95% CI: 1.96 - 4.89) Anxiety: no significant association with non compliance DiMatteo et al, 2000 Few studies have suggested anxiety or depression might improve adherence Optimism (positive attitude toward medication) improved adherence Theofilou et al, 2012

29. Depression: Impact on Cancer Survival Depression as predictor of progression of cancer (Satin et al, 2009) Meta-analysis: 3 studies Depression: not a significant predictor of progression Depression as predictor for mortality Meta-analysis: 24 studies (Satin et al, 2009) Depression (major/minor): 39% > mortality (RR=1.39; 95% CI: 1.10-1.89; P= .03) Meta-analysis: 76 prospective studies ( Pinquart & Duberstein, 2010) Depression (diagnosis/ symptoms):  mortality (RR  19%) Shorter survival in: leukemia/lymphoma, breast cancer, lung and brain cancer > association in older age group

30. Depression: Impact on Cancer Survival Davis et al, 2011 Random assignment: Supportive expressive group therapy Vs. control group (educational materials) 125 women with metastatic breast cancer Center for Epidemiologic Studies–Depression Scale ( CES-D) at baseline, 4, 8 and 12 months follow-up CES-D change score (1 st year): predicted survival over 14 years No significant interaction between treatment condition and CES-D change score on survival

31. Depression: Impact on QOL of Survivors Breast cancer: 240 patients (6–13 years since treatment) Scales: Patient Health Questionnaire (PHQ-8) European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 Depression: inversely associated with HRQOL subscales for functioning, financial and global health Depression: positively associated with cancer symptom Reyes- Gibby et al, 2012

32. Depression and Cancer: Some Take Home Messages The psychiatric issue most studied in cancer is depression Depression acts as a predictor of non- compliance to treatment Depression acts as a predictor of mortality in cancer Depression lowers the quality of life in the cancer patients Lowering of the depressive symptoms increases survival

33. Other Psychological Factors Impacting Compliance Social support: Married women were more likely to adhere to chemotherapy than unmarried women 51.7 % of clinicians reported that the patient’s social support was an important factor in their decision to give palliative chemotherapy to women with metastatic breast cancer Grunfeld et al, 2002 Quality of life: Favorable quality of life enhances adherence and survival Coates et al,2000

34. Delirium STUDY PREVALENCE SAMPLE (N) STUDY TYPE SCALE SETTING Kim et al, 2010 30.2 % 108 Prospective CAM Palliative care Gagnon et al, 2009 6.2 % 2515 Prospective(3 year follow-up, day time setting CRS Palliative care Hun-Kai et al, 2008 46.9 % 228 Prospective DRS Hospice and palliative care Gaudreau et al, 2005 30.0 % 107 Prospective Nu-DESC Oncology unit Lawlor P et al, 2000 68.3 % 104 Prospective MDAS Palliative care Gagnon P et al, 2000 32.8 % 64 Prospective CAM Hospice

35. Introduction Mental Health Consequences of Cancer at the time of diagnosis, active cancer and survivors Maladaptation Common mental disorders Impact of maladaptation Suicide Treatment of Cancer: Psychiatric sequelae Risk Factors for Cancer Initiation/ Maintenance Management of maladaptation Issues related to cancer in children and adolescents Indian research Conclusion and future directions

36. Psychiatric side-effects of Cancer Medication Depression Suicide Hallucinations Delusions Dacarbazine Dacarbazine Vincristine Tamoxifen Vinblastine Interferon Hydroxyurea Vincristine Steroids Steroids L- Asparaginase Procarbazine Interferon Steroids Tamoxifen Additional Issues Delirium Behavioral manifestation of CNS toxicity Cognitive deterioration Discrepancy between self report (> dysfunction) and objective assessment (? inability of battery to test real life situations) Long term post treatment cognitive changes in 17-34 % patients

37. Psychiatric sequelae of Cancer Treatment STUDY N CANCER MODALITY SCALES RESULT Kawase et al , 2010 172 Breast Radio Rx HADS Radiotherapy Categorical Anxiety Scale Anxiety & depression decreased after completion of radiotherapy sessions Mackenzie et al, 2013 454 NA Radio Rx HADS Anxiety: 15% Depression: 5.7% Torres et al, 2013 64 Breast Radio Rx Chemo Rx Inventory of Depressive Symptomatology-Self Report  No difference post treatment. Higher depressive score reported throughout the study in chemo group Reece et al, 2013 32 (follow up) Breast Chemo Rx PHQ-9 GAD-7 Depression: 32.7% Severity peaked after 12-14 week of chemo Rx Depression severity was correlated with anxiety

38. Introduction Mental Health Consequences of Cancer at the time of diagnosis, active cancer and survivors Maladaptation Common mental disorders Impact of maladaptation Suicide Treatment of Cancer: Psychiatric sequelae Risk Factors for Cancer Initiation/ Maintenance Management of maladaptation Issues related to cancer in children and adolescents Indian research Conclusion and future directions

39. Psychological Factors as Risk Factors for Cancer Initiation/ Maintenance Behavioral Risk Factors Stressful life events Locus of control and personality factors Coping and adjustment to illness Psychiatric diagnoses Repression of negative emotions

40. Risk Factors for Cancer Initiation/ Maintenance: Behavioral Tobacco: 30% of total cancer deaths in the developed world and 90% of all lung cancer deaths Increased risk for other types of cancer 10 years of cessation the risk for lung cancer mortality decreases between 30 and 50%. And 5 years of cessation of smoking causes 50% reduction in cancer risk of the esophagus and oral cavity Alcohol meta-analysis of 235 studies (n over 117,000 ) showed strong trend in increased risk for cancers of the oral cavity and pharynx , esophagus and larynx Nezu et al, 201

41. Risk Factors for Cancer Initiation/ Maintenance: Behavioral Diet and Obesity A pproximately one third of the cancer deaths that occur in the United States each year are a function of poor nutrition, limited physical activity, and obesity Losing weight appears to reduce the risk of breast cancer and to reduce cancer mortality American Cancer Society, 2010

42. Risk Factors for Cancer Initiation/ Maintenance: Stress 3 long term follow-up studies(15 to 26 years) Jacobs & Bovasso , 2000 (n= 1213 women) Kvikstad et al, 1994(n= 4491 cases 44910 controls) Ewertz , 1986( 1792 cases, 1739 controls) After adjusting for the covariates like age, parity, family history, depression odds ratio for the developing of breast cancer after adverse life events One study found significant risk of developing breast cancer (OR=2.56) after death of parents in childhood One study equivocal for death of spouse No association for divorce

43. Risk Factors for Cancer Initiation/ Maintenance: Stress Meta-analysis: 29 studies Random effects meta-analysis of the higher quality studies found no significant relationship Breast cancer and bereavement OR=0 . 9 (95% CI: 0.57 – 1.45) O ther adverse life-events OR=0. 8 (95 % CI: 0.61 - 1.06) Petticrew et al, 1999

44. Study N Follow-up Measure of depression Adjusted risk Covariates Penninx et al, 1998 4825 4 years CES-D Baseline depression 1.03 Chronic depression 1.88 Age, gender, smoking, alcohol, race, disability, hospital admissions Gross et al, 2000 3177 24 years DIS Any cancer (HR: 1.9, 95% CI: 1.2-3.0) Breast Ca (HR: 4.4 , 95% CI: 1.08-17.6) Age, gender, smoking, alcohol Jacob & Bovasso , 2000 1213 15 years DIS Ca Breast Major depression/ dysthymia : 1.4 Age, gender, smoking, family history, race, socio-demographic factors, other psychiatric diagnoses, life events, somatization Risk Factors for Cancer Initiation/ Maintenance: Depression

45. Risk Factors for Cancer Initiation/ Maintenance: Depression Meta-analysis: 8 studies No significant association between depression and subsequent breast cancer risk (RR: 1.12: 95% CI: 0.99–1.26) No significant associations between depression and subsequent lung , colon or prostate cancer Sensitivity analysis (Studies with follow-up of 10 years) Significant relative risk for breast cancer: 2.50 (1.06–5.91 ) Oerlemans et al, 2007 Increased risk of Ca breast but no causal association with other cancers Findings may be a chance finding

46. Psychosocial Factors as Causal/ Maintenance Factors for Cancer Initiation and Progression One possible connection between stress and cancer development is the reactivation of latent tumor promoting viruses (stress and EBV-associated tumors) Stress is associated with a reduction in the activity of natural killer (NK) cells and cytotoxic T cells that can target abnormally growing cells for destruction Stress-induced shift in the balance from Th1 towards Th2 cytokine profile may be permissive to virus replication, and thereby increases the frequency of tumor promotion Godbout & Ronald Glaser, 2006

47. Tumor promotion or progression Godbout & Ronald Glaser, 2006

48. Cancer as Causal/ Maintenance Factor for Psychiatric Conditions C ompromises immune system function or inhibits DNA repair mechanism Can inhibit DNA repair enzymes that are critical for apoptosis and defense against malignant tumor growth D ecreased natural killer ( NK) cell function Gross et al, 2010

49. Risk Factors for Cancer Initiation/ Maintenance: Coping Style Breast cancer (Coping assessment: Mental Adjustment to Cancer Interview) Longer survival: initially reacted with fighting spirit or denial Shorter survival: initially reacted with helplessness/hopelessness or stoic acceptance Greer et al,1990 There is no good evidence that coping style or the way one adjusts to the disease is related to cancer progression The role of repression is questionable with respect to the initiation of cancer but m ore expression and less suppression of emotions predicted longer survival in few studies Garseen, 2002

50. Risk Factors for Cancer Initiation/ Maintenance: Personality Cancer prone personality- Described as cooperative, unassertive, patient, suppressing negative emotions and accepting external authority (Greer & Watson, 1985; Temoshok , 1987 ) ‘‘ Type C’’ constellation including stoicism, perfectionism, and over-agreeableness are risk factors for the initiation and progression of cancer (Greer, 1991; Gross, 1989; Temoshok , 1987 ) Large study (N=30,000) in Japan ( Nakaya et al., 2003) No associations between Eysenck Personality Questionnaire–Revised scales & cancer risk Personality factors and locus of control, do not seem to play an important role.(B. Garssen 2002)

51. Risk Factors for Cancer Initiation/ Maintenance: Social Support N= 224 women with newly diagnosed breast cancer Confidant with whom they had discussed personal problems Prospective follow-up: 7 years Survival rate without a confidant: 56 % Survival rate with confidant ( 1 ): 72% Maunsell et al, 1995

52. Risk Factors for Cancer Initiation/ Maintenance: Schizophrenia Review: 11 studies Reduced incidence of several cancers unrelated to smoking Reduced incidence of breast cancer in female patients Reduced overall incidence of cancer in siblings and parents Lower susceptibility to cancer may be a genetic advantage Catts et al, 2008

53. Introduction Mental Health Consequences of Cancer at the time of diagnosis, active cancer and survivors Maladaptation Common mental disorders Impact of maladaptation Suicide Treatment of Cancer: Psychiatric sequelae Risk Factors for Cancer Initiation/ Maintenance Management of maladaptation Issues related to cancer in children and adolescents Indian research Conclusion and future directions

54. How to communicate- Bad News Rabow and McPhee (1999) used the mnemonic ABCDE based on the summary of review of sixty seven articles published after 1985. A= Advance Preparation Read the medical notes Practice the conversation Brace yourself for an emotional task Assess patient understanding Arrange for a family meeting B= Build a Therapeutic Environment/Relationship Find a quiet place Ensure enough time Use open body language Address the patient’s fears

55. How..... C= Communicate Well Be direct Avoid euphemisms and medical jargon Use the words like “cancer” and “death” Ensure patient understanding Allow silence for questions of patient/family D= Deal with Patient and Family Members Assess the patient’s reaction and coping strategies Listen actively and show empathy E= Encourage and Validate Emotions (reflect back emotions) Ensure accurate interpretation of the news Address further needs including support Provide written information (patient information leaflets) Arrange follow up (within a few days) Process your own feelings

56. Collaborative Care Fann et al, 2012

57. Collaborative Care: Models DCPC: (Depression Care for People With Cancer) Specially trained nurse provide brief psychological treatment (problem solving therapy) C-L Psychiatrist supervises the nurse and communicates with the patient’s oncologist and primary care provider about the use of antidepressant medication Progress monitored using telephone-administered rating scale ADAPt -C ( Alleviating Depression among Patients with Cancer) P roblem-solving therapy as well as patient navigation of the care system by social worker Psychiatrist supervise the social worker and prescribed antidepressant medications Fann et al, 2012

58. Collaborative Care: Models IMPACT (Improving Mood—Promoting Access to Collaborative Treatment) S tepped-care management program for depression in older primary care patients P atients have access to a depression care manager (nurse or clinical psychologist) for up to 12 months Supervised by a psychiatrist and primary care provider INCPAD Indiana Cancer Pain and Depression trial: Centralized tele-care management by a nurse-physician specialist team A utomated home-based symptom monitoring by interactive voice recording or Internet Fann et al, 2012

59. Treatment of Depression in Cancer 10 randomized controlled trials (6 psychotherapeutic and four pharmacologic studies) N=1362 (mixed cancer type and stage) Cognitive Behavioral Therapy (CBT) & Problem Solving Therapy (PST) Interventions more effective than control conditions up to 12–18 months CBT more effective than PST CBT and pharmacotherapy: similar efficacy Hart et al, 2012

60. Treatment of Depression in Cancer Cochrane review (2010): TCAs and SSRIs more effective than placebo Same finding replicated in another meta-analysis Rayner et al, 2010 Head to head trials (Meta-analysis) Paroxetine vs Desipramine Paroxetine vs Amitriptyline Mirtazapine vs Imipramine No significant difference in groups Mirtazapine led to greater improvement than Imipramine in one study Laoutidis and Mathiak , 2013

61. Other Psychotherapeutic Approaches No psychotherapeutic approach increase the survival among patients Crisis intervention Assistance in sudden, surprising and disintegrating life events Adequate and prompt assessment as immediate reaction may bring tragic consequences Psychological counseling Support offered to individuals experiencing developmental crisis or adaptive difficulties Involves several interviews aimed to identify a problem and find a solution Support for the patient and their family H elp in making the patient understand the situation S uggesting specific measures (e.g. additional doctor consultation, calling a voluntary social worker, reconsidering the decision to quit treatment ) Building the patient’s hope by showing perspectives for the nearest future (week, month) Katarzyna Cieslak , 2013

62. Other Psychotherapeutic Approaches Self-support groups (clinical psychologist as a group expert) P ost-mastectomy women, post stoma surgery E motional support, help one another in obtaining important information, equipment, medicines Psychological rehabilitation To address direct/ indirect consequences of cancer/ treatment Individual psychological therapy, e.g. as part of comprehensive care provided by oncology centers to women with diagnosed breast cancer Katarzyna Cieslak , 2013

63. Other Psychotherapeutic Approaches Rational psychotherapy: P reparing the patient for a physically or mentally burdening experience Clear and understandable presentation of the treatment methods D iscussion of possible immediate and delayed side effects Behavioral method of gradual desensitization To prevent anticipatory vomiting or anxiety To manage distress regarding smell of medicines, aprons for children Katarzyna Cieslak , 2013

64. Other Psychotherapeutic Approaches: Existential Psychotherapy The capacity for self-awareness ( we are finite, yet we have the potential to continually grow until we die ) Freedom and responsibility (we can make the commitment to authentically choose a life for ourselves ) The need for center and the need for others (we can have the courage to experience aloneness and relatedness) The search for meaning ( we have the capacity to discard old values, to freely choose new ones, and to continually question and challenge the meaning of life) Anxiety as a condition of living (experience anxiety as a source of growth and experience the escape from anxiety) Awareness of death and nonbeing (very realization of eventual nonbeing gives meaning to existence) Breitbart et al, 2004

65. Palliative Care Author (Year) No. of studies Type of intervention Outcome measures Results Brietbart et al 2010 N= 90 Group MCT vs. supportive psychotherapy Stage III and IV cancer  Measures of anxiety, depression, hopelessness, spiritual well being Significantly higher spiritual wellbeing, decrease in anxiety, desire for death No significant diff. in depression, optimism, hopelessness at 2 m f/u Brietbart et al 2012 N=120 Individual MCT Vs. control Stage III and IV cancer Measures of anxiety, depression, hopelessness, spiritual well being, QoL Higher spiritual well-being, QoL , decrease in physical symptom distress No significant difference on levels of anxiety, depression, or hopelessness at 2 m f/u

66. Other Psychotherapeutic Approaches: Cancer Pain Cancer pain education Hypnosis and imagery based methods Acute procedural pain prior to breast biopsy Less evidence in chronic pain Coping skills training Paying attention to spiritual needs and existential concerns often associated with pain Paice et al, 2011

67. Other Psychotherapeutic Approaches: Anticipatory Nausea and Vomiting Conditioned response 25% of patients develop by the fourth treatment cycle Psychological Interventions: Hypnosis B iofeedback Relaxation methods like Yoga Systemic desensitization Roscoe et al, 2011

68. Introduction Mental Health Consequences of Cancer at the time of diagnosis, active cancer and survivors Maladaptation Common mental disorders Impact of maladaptation Suicide Treatment of Cancer: Psychiatric sequelae Risk Factors for Cancer Initiation/ Maintenance Management of maladaptation Issues related to cancer in children and adolescents Indian research Conclusion and future directions

69. Psychosocial Dimensions of Cancer in Children Family factors: F lexibility of the family attempts to bring normalcy to the adolescent or young adult’s life P resence of family cohesion and family adaptability M ost adolescent cancer survivors diagnosed with PTSD also had mothers with PTSD Psychological/emotional factors: Higher intensity of symptoms experienced by older children A dolescents with cancer demonstrate more coping strategies than typical peers( Older adolescent show greater coping strategies) Evan and Zeltzer , 2005

70. Psychosocial Dimensions of Cancer in Children Increased risk of reporting psychological symptoms than sibling Longer the adolescents were off treatment , the more they perceived problems related to self-worth, social anxiety, and greater negative perceptions of body image Intense chemotherapy increased the risk of reporting somatic distress and depression Most survivors reported that symptoms of depression, anxiety, or somatic distress did not pose problems in their daily life (Childhood Cancer Survivor Study) Evan and Zeltzer , 2005

71. Psychosocial Dimensions of Cancer in Children Social factors Active treatment: frequently miss school, cognitive deficits appear more and contribute to difficulties with social skills S urvivors were less likely to graduate from high school S urvivors demonstrate greater impairments in friendships and romantic relationships than controls Special issues in intervention Emphasis on the age and developmental level of the child School re-integration, social skill training A daptive coping skills at an early age Parents as a major source of information M ay be wise to refrain from disclosure of excessive medical information Evan and Zeltzer , 2005

72. Introduction Mental Health Consequences of Cancer at the time of diagnosis, active cancer and survivors Maladaptation Common mental disorders Impact of maladaptation Suicide Treatment of Cancer: Psychiatric sequelae Risk Factors for Cancer Initiation/ Maintenance Management of maladaptation Issues related to cancer in children and adolescents Indian research Conclusion and future directions

73. Indian Research A review by Mehrotra : I dentified 120 studies (1977-2006) Studies have focused on psychosocial issues like apprehensions about screening, pre-occupation with family problems, practical difficulties & lack of approval from spouse to be responsible for poor utilization of prevention and early detection programs for Ca cervix Self examination for Ca breast : poor compliance due to forgetfulness and being too busy Psychiatric morbidity : 40-80%, MC- depressive disorders Studies suggest low referral rates to psychiatric services

74. Indian Research Awareness about ∆ : 54-66% aware of their ∆ , inconsistent association between awareness of ∆ and psychiatric morbidity Studies have examined the preference of the patient about diagnosis: patients want to know the diagnosis contrary to the expectations of the caregivers Studies have also evaluated QOL in cancer patients Some studies suggests higher frequency of life events in early life in cancer patients compared to controls Neuroticism, incommunicativeness, emotional de- surgency : some of the personality features that have been implicated to be differentiating between cancer patients and healthy controls (Mehrotra, 2008)

75. Indian Research Most frequently reported distressing thoughts of pts: burden on family, illness worsening and illness as a punishment from God MC coping mechanism: turning to religion (leaving the responsibility of cure to God) was the among 80% of pts Distress and issues in palliative care: concerns about physical pain, anxiety and depression (related to unfulfilled dreams and concerns about the welfare of the family), body- image issues, social withdrawal, disease viewed as bad karma, desire for hastened death and hope Transcendental meditation, yoga and group counseling modules in a group of ambulatory cancer patients: leads to positive effect on QOL (Mehrotra, 2008)

76. Other Aspects

77. ONCOLOGIST BURNOUT Burnout is a “syndrome of emotional exhaustion, depersonalization and a sense of low personal accomplishment that leads to decreased effectiveness at work” Tait Shanafelt,2008 Depression , cynicism, a sense of futility, and nihilism P oint prevalence of 25% to 35% (medical oncologists) 38% (radiation oncologists) and 28% to 36% (surgical oncologists) No specific interventions ?Mindfulness based meditation, technique to increase self awareness might be useful (further research warranted)

78. ONCOLOGIST BURNOUT

79. CARE GIVERS Effects Psychological Impairment and Mood Disturbance Anxiety 39% and Depression 40% F amily caregiver’s mental health burden exceeded that of the patient with cancer responses to cancer interdependent- each person (patient and caregiver)affected the other’s level of emotional well-being Symptoms Related to Sleep Disturbances More than 90% have some disturbance ( subscales that assessed sleep quality, duration, efficiency, disturbance and daytime function) Northouse et al, 2012

80. CARE GIVERS Physical Health Changes High care giving burden independent risk factor for coronary heart disease(4 year follow-up study) 53% report fatigue Neuro-hormonal and Inflammatory Changes Studies in small sample size Changes noted Perceived Burden and Positive Aspects of Caregiving lack of confidence, inadequate preparation to perform skills expected of them, disruptions in lifestyle, and restrictions in activities Changes in Financial Well-Being Northouse et al, 2012

81. CARE GIVERS Psycho-education :Information about management of symptoms, physical aspects of patient care and attention to emotional aspects of care Skill training: development of caregivers’ coping, communication and problem-solving skills Therapeutic counseling : strengthening patient-caregiver relationships, managing conflict, and dealing with loss Relationship focused interventions that address patient-caregiver communication and joint problem-solving)have more positive outcome Patient-caregiver dyad should be treated as the unit of care Northouse et al, 2012

82. Author N Adjusted risk Covariate Jacobs & Bovasso , 2000 1213 women, Initiation of Ca breast, F/U: 15 years Death of parent in childhood OR: 2.56 Age, Family H/O breast cancer, dysthymia, depression, household income Kvikstad et al, 1994 4491 cases 44910 controls, Initiation of Ca breast, F/U: 15 years after life event Death of spouse: OR: 1.13 Divorce: OR: 0.83 Age, Residence, Parity, Age at birth of first child Ewertz , 1986 1792 cases, 1739 controls; Initiation of Ca breast, F/U: 26 years after life event Death of spouse OR: 0.8 Divorce OR: 0.9 Age Risk Factors for Cancer Initiation/ Maintenance: Stress

83. MEANING CENTRED THERAPY New therapeutic approaches to enhance meaning, spiritual wellbeing, quality of life among terminally ill cancer patients Brings awareness to their choice of attitudes, ability to connect and engage with life, legacy they have lived or want to create in future Has been tested in both group and individual therapy formats among patients with advanced cancer 8 weekly sessions in group, and 7 sessions with individuals Facilitated by psychiatrists, psychologists, contains both didactic and experiential activities ( Brietbart et al, 2004)

84. MINDFULNESS-BASED THERAPY Originate from ancient Buddhist meditation techniques,secularised , manualized , and appropriated for use in a range of clinical settings Original research focussed on chronic pain, became increasingly popular in chronic disease management over last 30 years Group-oriented, Mindfulness Based Stress Reduction (MBSR) most well researched approach 3 meditation techniques: breath awareness, body awareness, dynamic yoga postures taught in groups over 8 weeks MBCT: derivative of MBSR, emphasis on cognitive techniques Majority research on efficacy in cancer, pain conditions, cardiovascular disease, DM, HIV/AIDS, IBS (Simpson et al, 2014)

85. Guidelines Recommendations Evidence (quality) Strength Communicate with palliative care patients in an open, non- judgmental, patient- centered manner and actively enquire about their concerns and feelings Moderate Strong In accordance with patients’ wishes, provide information on the nature, course and treatment of illness and appropriate sources of support Moderate Strong Consider referral to specialist palliative care for improved symptom control and psychosocial support High Strong Prioritize cognitive/ affective symptoms in detecting depression as physical symptoms (e.g. weight loss, fatigue) may be caused by physical disease or medical treatment Moderate Strong Rayner et al, 2011

86. Guidelines Recommendations Evidence (quality) Strength Consider screening for depression in palliative care patients. Screening tools may help clinicians detect depression (evidence that they improve depression outcomes is lacking) Very low Weak The psychological state of patients in palliative care unstable, regularly review depressive symptoms to capture changes in mood Moderate Strong Refer patients with depression to specialist palliative care for improved symptom control and psychosocial support High Strong Consider antidepressants for treatment of depression in palliative care High Strong Consider psychological therapy for treatment of depression in palliative care High Strong Rayner et al, 2011

87. Transactional model by Lazarus,1999

88. Introduction Mental Health Consequences of Cancer at the time of diagnosis, active cancer and survivors Maladaptation Common mental disorders Impact of maladaptation Suicide Treatment of Cancer : Psychiatric sequelae Risk Factors for Cancer Initiation/ Maintenance Management of maladaptation Issues related to cancer in children and adolescents Indian research Conclusion and future directions

89. Conclusion and Future Directions Psycho-oncology though a new field but is broad Cancer patients can have negative psychological consequences at every stage of disease (screening to palliative care) Psychiatric morbidity: high and has grave consequences Role of psychological factors in development of cancer: not established but behavioral issues have significant role Psychological interventions are helpful in cancer related physical symptoms Further research is needed for better understanding of relationships between psychiatry and cancer

90. Thank you