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The 6 Feared “D’s” y y y y y y y
PSYCHOSOCIAL ONCOLOGY THE NEARLY FORGOTEN
SUBSPECIALITY IN CANCER CARE
1) Discomfort 2) Dependency 3) Disfigurement 4) Disability 5) Disruption 6) Disengagement 7) Death
(Holland et al, 2001)
IPOS International Psycho-Oncology Society (IPOS) was created to foster international multidisciplinary communication about : clinical, educational and research issues that relate to the subspecialty of psycho psycho-oncology oncology and two primary psychosocial dimensions of cancer:
1) Response of patients, families and staff to cancer and its treatment at all stages; 2) Psychological, social and behavioral factors that influence tumor progression and survival.
A Historical Perspective on Psychosocial Cancer Care: United States of America First psychosocial research in oncology published by psychiatrists and social worker team
Psychosocial Oncology
APOSW Is formed
1950s Introduction of chemotherapy in Rx of Cancer
1960s Combined Therapeutic Modalities Increase Survival in Childhood leukemia
Factors contributing to greater emphasis on psychological and social Issues in cancer
1971
1972
“War on Cancer,”” Cancer, P.L. 9292-218, Nixon admin
National Cancer Plan includes rehabilitation, cancer control, and psychosocial research
y Societal Attitudes shifting away from fatalism
The Psychosocial Oncology Group is formed
1976--1981 1976
about cancer
IPOS Is formed APOS Is formed
1984
1990s First decrease in cancer mortalities in US
y Trend toward revealing diagnosis in many countries
y Patient participation in treatment decisions (autonomy, informed consent)
Oncology
y Increased doctor-patient dialogue
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Cont. y Development of valid instruments for measuring subjective symptoms and quality of life
y Recognition that effective cancer prevention and screening is dependent on changing behaviors
Complexity of Cancer “ The complexity and variability of psychosocial issues associated with cancer has created the demand for highly skilled practitioners who are trained to provide multilevel assessment and g the illness continuum.” intervention throughout
y [Increased awareness of psychosocial sequelae of cancer and cancer treatment accompanying increased survival] Smith, Walsh-Burke and Cruzan, 1998 Holland, Jimmie (Ed.). (1998). Societal view of cancer and the emergence of psycho-oncology. Chapter 1 in Holland and Jacobson, Psycho-oncology. New York: Oxford University Press; p.9
Domain of psychosocial oncology “ Formal Study, understanding and treatment of social , psychological, emotional, spiritual, quality of life and functional aspects of cancer as applied across the cancer trajectory from pprevention to bereavement”
Psychological oncology y Study of psychological reaction of patients of all diseases.
y Exploring psychological, social and behavioral factors that impact cancer and survival.
y Scientific inquiry by developing and evaluating efficacy of psychosocial interventions to improve quality of life Canadian Association of Psychosocial oncology, 1999.
Psychosocial oncology y Behavioral research in lifestyle changes. y Information on reduction of cancer risk( Genetic counseling)
y Symptom S mptom control( Anxiety, An iet depression, depression pain, pain fatique)
y
Baum, A.,& Andersen, B.L.(2001)psychosocial intervention for cancer : Washington DC: APA
Models of care in psychosocial oncology y Equitable care- Right to care( IPOS 2014, Lisbon).
y Patient centered. y IntegratedIntegrated Screening, Screening diagnosis, diagnosis treatment, treatment reccurent or transition to palliative care.
y Psychological sequelae in cancer survivors.
y Culturally appropriate
y Psychological aspects of palliative and end of
y Multidisciplinary
life care.
y Evidence based assesment and intervention.
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Models of care Cont. y Inclusion of Supportive care as integral
Components of psychosocial care
component care.
y Up-skilling of psychosocial cancer workforce. y Screening for psychosocial ps chosocial distress. distress y Survivorship- Significant psychological, physical, financial , occupational and social burden of survivorship.
1.Psychological sequlae ( distress)
DISTRESS LADDER: MANAGEMENT BY STANDARDS & PRACTICE GUIDELINES
y A multifactorial unpleasant emotional experience of a psychological (cognitive, behavioural, emotional), social, and/or spiritual nature that may interfere with the ability to cope effectivelyy with cancer.
≥5 DISTRESS Scale (0–10)
y Distress extends along a continuum, ranging from common normal feelings of vulnerability, sadness, and fears to problems that can become disabling , such as depression, anxiety, panic, social isolation, and existential and spiritual crisis.
<5
Adapted from WHO Analgesic Ladder
2.Depression y Response to perceived loss y Diagnosis of cancer may precipitate feelings similar to bereavement.
y About 47% cancer patients experience depression
at some point during their illness (Derogatis et al, 1983).
y Of these, most fit criteria for Adjustment
Disorder, smaller number for Major Depressive Disorder.
.Derogatis LR, Abeloff MD, Melisartos N: Psychological coping mechanism and survival time in metastatic breast cancer. JAMA 1979; 242:1504ﾐ15086.Greer S, Morris J, Pettingage KW: Psychological response to breast cancer: effect on outcome. Lancet 1979; 2:785ﾐ787
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4.Psychoeducational interventions
3.Anxiety • Response to a perceived threat • Apprehension, uncontrollable worry, restlessness, panic attacks, and avoidance
• Overestimate risks • Heighten perceptions of physical symptoms (such ( as breathlessness in lung cancer)
Structured psycho-educational intervention increase psychological well being( Fawzy,1999). “ The more knowledgeable the care recipients and informal caregivers are, the more positive health related outcomes will be for all” Information provided helps to comprehend and digest complex information in a proactive fashion.
Ellen. P.Lukens, William Mc Farlane, Psychoeducation as evidence based parictice: Considerations for practice, research and ploicy
5.Pediatric psycho-oncology
6.Delirium
y High % with Post Traumatic Stress Symptoms
y Neuropsychiatric syndrome also called acute confusional
y 99% of mothers and 100% of fathers showed some
y Disturbance of consciousness with inattention that
percentage of PTSS
y 99% of families with ith a child who ho is a survivor sur i or had at least 1 parent meet PTSD symptom of reexperiencing
state or acute brain failure. develops over short time.
y Acute confusional state. y 32 % -66 % of the cases are unrecognized by medical staff.
y Less likely to seek social support, report less personal stability and lower quality of life Yale- New Haven Study( Inouye S.Ann Intern Med 1993:119-474
7.Spiritual care Spirituality gives meaning to cancer experience(meaning based therapies)
Research into spirituality and health y Mortality: People who have regular spiritual practices tend to live longer.
y Coping: Patients who are spiritual utilize their
beliefs in coping with illness , pain and life’s stresses.
Man is not destroyed by suffering; he is destroyed by suffering without meaning( Victor Frankl).
y Recovery: spiritual commitment tends to enhance recovery.
Christina Puchalski
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8. Palliative Care
Existential crises in cancer • COMPLETION OF TREATMENT
DIAGNOSIS OF CANCER
RECURRENCE OF DISEASE
INITIAL TREATMENT
“I could die from this.”
ADVANCING DISEASE; DNR; HOSPICE
PALLIATIVE TREATMENT
“I will likely die” -depressed; anxious
“I have survived -will it Return?”
• DEATH
Pain is often the primary focus Psychological issues are often not identified and treated as an equally i important aspect off end-of-life d f lif care
TERMINAL
“I am dying.”
• Need for more participation of psychooncologists in end-of-life for clinical and research collaboration
Adapted from McCormick & Conley, 1995
9.Interdisciplinary Team Collaboration
Any questions?????
MD
Social Work
Psychologist
Patient/Family
Nursing
Spiritual Counselor
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