CMLSupport: Coping With Cancer: A Psychosocial Approach

"Everywhere I go, I'm asked if I think the universities stifle writers. My opinion is that they don't stifle enough of them."
— Flannery O'Connor

Coping With Cancer: A Psychosocial Approach

European Cancer Conference, ECCO 11
Day 1 - October 21, 2001

Coping With Cancer: A Psychosocial Approach
Robert S. Mocharnuk, MD

Introduction

The events of September 11th at the World Trade Center and the Pentagon have affected every informed individual across the globe to some extent. Dr. David Spiegel,[1] Professor of Psychiatry at Stanford University in California, compared the degree and the diversity of responses to the September 11th attacks to those reactions experienced by cancer patients at any given point in their illness. Cancer is a compendium of stresses, which includes the fear and the diagnosis of cancer, the nature of treatment decisions, confronting one's mortality, physical limitations as well as physical and emotional pain, the arduous treatments to be endured, and the changes that one's social and family environments undergo.

Unlike other medical specialties in which the majority of physician interventions are designed to make patients feel better, the medical oncologist typically offers treatments that make the patient feel worse, no matter what the outcome. This places the medical oncologist at a great disadvantage, further complicating the physician/patient interaction. As a result, patients are conditioned to expect the worst from oncologists.

That being said, most cancer patients behave in ways reminiscent of posttraumatic stress disorder. Comparative data suggest that cancer patients react in the same fashion as sexual assault victims. The resulting depression is similar in nature, and is worse when faced alone. The ranks of the depressed grow from a general population baseline of 3%, to 6% among cancer outpatients, to 12% among cancer inpatients. Major depression characterized 1 of every 5 terminal ill patients, and 60% of individuals who requested assisted suicide are suffering from major clinical depression. The latter finding raises the provocative question of whether physicians ought to be treating the depression instead of supporting physician-assisted suicide.

Group Therapy

While numerous individual and group psychosocial treatment models exist, Dr. Spiegel focused on the group supportive expressive treatment model, which he employs almost exclusively in managing cancer patients. This model is predicated upon building social bonds, allowing for the discussion of common problems. Patients collectively view their reactions as normal and learn to find meaning in their own tragedies. Patients often choose to overcome the social isolation of illness by helping others to feel better through the sharing of their own experiences. This model encourages emotional expression, rather than attempting to suppress or channel it. The propriety of counting to 10 is replaced by Mark Twain's adage:

"When angry, count fair,
When very angry, swear!"

This environment supports facing feelings directly while restructuring those feelings in a supportive social context. Emotion is valued as a source of closeness, and not a cause of isolation. Patients are taught that cancer is not deserved and that it's acceptable not to put on a false happy face. While individuals are conditioned to treat crying as if they are bleeding — in other words, suppress with pressure — the group dynamic allows one, in the words of Shakespeare's Macbeth to "give sorrow words." Studies have shown that those who suppress suffer much higher rates of depression than those who express.

Group members are taught how to detoxify dying by restructuring their fears into components, including the process of dying, separation from loved ones, loss of control, and pain. Active coping strategies are taught and existential discussions are not uncommon. As a result, life's priorities are often reordered, particularly for those individuals whose treatments are not, nor have been, curative. Given limited and finite time frames, individuals sometimes develop a life project, a goal to be achieved, an event to be attended, a task to be completed.

Cancer's effect on the patient's family is acknowledged and methods for coping with this burden are explored. Participants are taught to appreciate the differences between male and female approaches to the same problem.

Patients are guided in terms of what to expect when dealing with doctors. Communication, control, and caring are essential components. Physicians should use plain language in speaking with patients and answer questions up front. The presence of family members and friends should be allowed during important discussions. It's okay to write down questions and treatment options, and one has the right to expect timely diagnostic and treatment schedules.

Physicians should identify areas of patient choice and encourage patients to make those choices. Alternative treatment approaches and patient-initiated explorations should be open to discussion. Physicians should use direct eye contact, acknowledge patient distress, express concern, and allow for interruptions during discussion.

Finally, patients learn ways to control symptoms of cancer or of treatment. Self-hypnosis has been shown in several studies to reduce the need for pain medication by up to 50%. Patients are also taught the difference between good and poor coping strategies.

Does Group Therapy Work? The Evidence

In an ongoing study that has enrolled 103 of 125 women for randomization to group supportive expression therapy vs no therapy, interim data show a greater decrease in the impact of events scale (ie, posttraumatic stress) index when compared with the control group. A multicenter study in which patients with primary breast cancer received 12 weeks of group therapy also showed a significant reduction in anxiety among patients with high baseline clinical anxiety. Earlier data from Spiegel translate this reduction in anxiety to survival improvement among women with metastatic breast cancer.[2] At 48 months, all control patients had died, while one third of those receiving group therapy were alive. With the advent of more modern therapies, the old survival data for both control and group therapy cohorts have been exceeded, but future data will likely show a continued benefit to group therapy.

Although some trials[3,4] support Spiegel's findings that group treatment improves survival in a number of cancer types, other studies[5,6] have shown no benefit.

Mediators of enhanced survival included improved patient self-care and health behavior, and increased adherence to treatment. There were also changes observed in biologic pathway; specifically, neurologic, immunoregulatory, and endocrine pathways. Indeed, McEwen has shown that a perpetual stressed state, termed an "allostatic load," does correlate with decreased immune status.[7] Similarly, Sephton and colleagues[8] noted reduced survival and flattened diurnal cortisol levels among breast cancer patients that correlated with an increase in anergy of the immune system and a decline in natural killer cell activity. Within the last year, additional studies have drawn a link between decreased cortisol levels and cancer progression.[9]

Clearly, there is more to psychosocial therapy in the overall scheme of cancer management than meets the eye. The data presented above suggest that, particularly for individuals with high levels of anxiety and poor coping skills, group therapy may be more than an ancillary component in the great treatment plan. Of course, this is not a new notion, as reflected in Shakespeare's King Lear:

"The mind much suffrance doth overtip
When grief hath mates and bearing fellowship."

References

Spiegel D. Psychological aspects of cancer care. Eur J Cancer. 2001;37(suppl 6):149. Abstract 546.

Spiegel D, Bloom JR, Kraemer HC, Gottheil E. Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet. 1989;2:888-891.

Fawzy FI, Fawzy NW, Hyun CS, et al. Malignant melanoma: effects of an early structured psychiatric intervention, coping, and affective state on recurrence and survival 6 years later. Arch Gen Psychiatry. 1993;50:681-689.

Kuchler T, Henne-Bruns D, Rappat S, et al. Impact of psychotherapeutic support on gastrointestinal cancer patients undergoing surgery: survival results of a trial. Hepatogastroenterology. 1999;46:322-335.

Linn MW, Linn BS, Harris R. Effects of counseling for late stage cancer patients. Cancer. 1982;49:1048-1055.

Cunningham AJ, Edmonds CV, Jenkins GP, Pollack H, Lockwood GA, Warr D. A randomized controlled trial of the effects of group psychological therapy on survival in women with metastatic breast cancer. Psychooncology. 1998;7:508-517.

McEwen BS. Protective and damaging effects of stress mediators. N Engl J Med. 1998;338:171-179. Sephton SE, Sapolsky RM, Kraemer HC, Spiegel D. Diurnal cortisol rhythm as a predictor of breast cancer survival. J Natl Cancer Inst. 2000;92:994-1000.

Spiegel D, Sephton SE. Psychoneuroimmune and endocrine pathways in cancer: effects of stress and support. Semin Clin Neuropsychiatry. 2001;6:252-265.

Source: Medscape

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