A growing number of people with cancer are being treated on an outpatient basis. At the Herbert Irving Comprehensive Cancer Center of New York-Presbyterian Hospital/Columbia University Medical Center in New York, to ensure that the psychosocial and psychiatric needs of these patients were being met, Jon Levenson, MD, Associate Clinical Professor of Psychiatry and Attending Physician, and colleagues helped launch the hospital’s Cancer Support and Counseling Outpatient Service in 2007.
A specialist in a subfield of psychiatry known as consultation-liaison psychiatry, or psychosomatic medicine, Dr. Levenson is part of the interdisciplinary oncology team at the Herbert Irving Comprehensive Cancer Center. He addresses the psychiatric disorders, such as depression and anxiety, patients may experience following a cancer diagnosis and through long-term survivorship. Prior to 2007, the consultation-liaison psychiatry service at the cancer center was primarily an inpatient-provided program.
“Cancer care has dramatically changed over the past few years and is now nearly all conducted on an outpatient basis. We had to adjust to the development of cancer as an outpatient disease,” said Dr. Levenson. He is also a past President of both the American Psychosocial Oncology Society and the Society for Liaison Psychiatry.
The ASCO Post talked with Dr. Levenson about how a cancer diagnosis, cancer pain syndromes, and even long-term survivorship are contributing to the psychological distress felt by many people.
Multidisciplinary Collaboration
Is there a greater recognition now in oncology about the importance of working collaboratively with mental health specialists to treat both the disease and psychological symptoms patients may experience?
Absolutely. In addition to the three programs I’m programmatically involved with—for breast cancer, gynecologic oncology, and neuro-oncology—I also often attend tumor board meetings and provide input when the oncology team is discussing treatment for patients. For example, if the patient is a woman newly diagnosed with breast cancer and there is a family history of a psychiatric illness or if she has a past psychiatric history, I’ll be able to immediately work with the oncology team to develop an individualized treatment plan, which will usually include direct consultation between the patient and me.
The American Psychosocial Oncology Society (APOS) is an interdisciplinary organization consisting of psychiatrists, psychologists, social workers, nurses, chaplains, patients, and oncologists. So it really represents the multidisciplinary nature of providing comprehensive care for patients with cancer and families. APOS has a toll-free helpline from which patients and caregivers can obtain psycho-oncology referrals in their home communities (1 866 APOS 4 HELP).
Psychological Symptoms
What are some common psychological symptoms patients with cancer may experience?
Many newly diagnosed patients develop acute emotional symptoms that abate within 2 weeks. Most of the time, that is a normal reaction to learning about having a serious medical condition. Commonly, people may experience transient sleep disturbance or some anxiety symptoms, and have intermittent trouble concentrating because they are preoccupied with the medical news and predicament they now find themselves in.
It is important for oncology teams to engage with patients to see if their symptoms develop into a formal type of depression or anxiety disorder. Not all patients experience these psychiatric complications, but a significant minority will develop them, and we need to prescribe formalized treatment when they do.
Many patients will have sub-threshold symptoms of depression and anxiety. While they may not meet the diagnostic criteria for major depression or an anxiety disorder, these patients will benefit from some kind of ongoing psychosocial support, which might include support that the oncologist and the nurse practitioner provide. This support might include an ongoing psychoeducational approach to reviewing the patient’s diagnosis and treatment plans. It could also entail strategies to minimize the distress of the initial staging, such as frequent contact to combat demoralization, and the judicious use of benzodiazepines (such as lorazepam) to help with insomnia and imaging-related claustrophobia (MRI scanning).
Newly diagnosed patients often benefit from joining cancer support groups, which is true for family members, too. Cancer advocacy organizations with support group programs include CancerCare, Gilda’s Club, and the American Cancer Society, as well as site-specific groups such as PanCan (pancreatic cancer), Lung Cancer Alliance, and SHARE (for women with breast or ovarian cancer).
An outstanding resource for adult patients with school-age children is the website Parenting at a Challenging Time (mghpact.org). The program, which was developed at the Massachusetts General Hospital Cancer Center, provides specialized support for patients with cancer, partners or spouses, and their children, and can be very helpful to families dealing with the stress of cancer and treatment.
Post-traumatic Stress Disorder
Researchers at your institution found that 23% of newly diagnosed patients with breast cancer have post-traumatic stress disorder (PTSD),1 and other studies have shown PTSD onset in other cancer types. Is PTSD becoming a more common problem among patients with cancer?
I don’t think post-traumatic stress disorder is becoming more common, but we are getting better at recognizing its signs and symptoms, which can develop with aggressive treatment regimens.
PTSD appears to be particularly common in the setting of breast cancer treatment. For example, over the course of a year, many women will have a significant surgery—and often more than one procedure—as well as radiation therapy, systemic chemotherapy, and hormonal therapy if the tumor is estrogen receptor–positive, so the potential for side effects from these multimodal treatments is significant. Patients with breast cancer are especially vulnerable to being traumatized by the type of surgery they have (mastectomy vs lumpectomy, for example) or by complications from reconstructive surgery that delay healing.
Contributing factors for PTSD also include the patient’s prior psychiatric history of anxiety or depression.
What are some of the symptoms of post-traumatic stress disorder?
Patients may relive the cancer experience in nightmares during sleep or in flashbacks during waking hours, and they may be in a continuous state of fearfulness and irritability. Other symptoms can include an altered startle response and emotional numbing. The symptoms are different for each person. PTSD can be effectively treated with a combination approach of psychotherapy and psychopharmacology.
Distress in Survivors
Do long-term survivors encounter psychological distress from their diagnosis?
Increasingly, cancers are being caught at an early stage, which for some people may lead to a cure of their disease. Even for people whose cancer is incurable, it is now possible for them to live a long time with cancer as a chronic illness. However, living longer is not always associated with improved quality of life. Many people living with cancer as a chronic disease need continuous cancer treatment and may have ongoing side effects from their cancer and treatment, and that can negatively impact quality of life and raise the likelihood of feeling distressed and anxious.
Once patients are identified as having a significant level of distress, we can further determine whether they have a depressive disorder like major depression or an anxiety disorder, like generalized anxiety disorder or post-traumatic stress disorder, or whether they are suffering from psychiatric complications related to a poorly controlled cancer pain syndrome and its management. For example, patients may have neuropsychiatric side effects from pain medications like opioids. Opioids are effective at relieving pain, but their side effects might be intolerable and can include confusion, which we also call delirium.
That said, we can provide these patients with effective support, which may include individual psychotherapy, cancer support group involvement, and pharmacologic therapy. And long-term cancer survivors who have achieved cure often have good quality of life with minimal distress. Conversely, we know that some of these long-term survivors are quietly symptomatic with fatigue states, sexual dysfunction, and a condition called Damocles’ syndrome, which refers to survivors feeling like a sword is always hanging over their head. Thus, it is critical for oncology teams to serially evaluate how long-term survivors are coping because they may benefit from psychosocial oncology services.
Evaluating Distress
How can oncologists evaluate a patient’s level of mental distress?
Jimmie C. Holland, MD [Wayne E. Chapman Chair in Psychiatric Oncology at Memorial Sloan-Kettering Cancer Center] developed a “distress thermometer,” which measures a patient’s level of distress on a 0-to-10 scale. If a patient scores 4 or higher, her level of distress is considered significant and she should be further evaluated by a mental health specialist to see if psychotherapy is warranted.
Also, some cancer treatments, such as high-dose interferon and the corticosteroid dexamethasone, are associated with causing depression or anxiety. We have new evidence showing that some patients on interferon may benefit from being ‘pretreated’ with antidepressants like selective serotonin-reuptake inhibitors. Studies have shown that pretreatment with one of these agents before a patient receives high-dose cytokine treatment can greatly reduce the incidence of depression.
One caveat I’ll mention is that some commonly prescribed antidepressants such as fluoxetine and paroxetine may interfere with the effectiveness of certain chemotherapies like tamoxifen, so it is important for physicians and patients to understand that some antidepressants may not be advisable.■
Disclosure: Dr. Levenson reported no potential conflicts of interest.
Reference
1. Vin-Raviv N, Hillyer GC, Hershman DL, et al: Racial disparities in posttraumatic stress after diagnosis of localized breast cancer: The BQUAL study. J Natl Cancer Inst 105:563-572, 2013.
