A psychiatrist for more than 40 years, Jimmie C. Holland, MD, Attending Psychiatrist and Wayne E. Chapman Chair at Memorial Sloan-Kettering Cancer Center and Professor of Psychiatry, Weill Medical College of Cornell University in New York, is internationally recognized as the founder of the subspecialty of psycho-oncology. Dr. Holland conducted some of the first studies on the psychological impact of a cancer diagnosis on patients and proved that interventions to combat the anxiety and depression associated with cancer can work.
According to Dr. Holland’s research, one-third of patients with cancer experience clinically significant mental distress. To help oncologists evaluate their patients’ distress levels, Dr. Holland and her colleagues at the National Comprehensive Cancer Network developed a “distress thermometer,” a psychosocial distress-screening tool that measures a patient’s distress level on a 0-to-10 scale. If a patient scores 4 or higher on the distress thermometer, it is a signal that the individual should be further evaluated and referred to a mental health-care specialist and monitored closely.
Based on the Institute of Medicine (IOM) report, Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs, the Commission on Cancer, which accredits centers that treat patients with cancer, mandated that by 2015 providers must have a plan in place to evaluate patients for distress and refer them to programs for help.
The ASCO Post talked with Dr. Holland about integrating psychosocial care into routine cancer care, the progress being made in implementing methods to identify distress levels in patients, and advancements predicted over the next decade in the field of psycho-oncology.
Treating the Whole Patient
Please talk about the importance of caring for the whole patient and integrating psychosocial care into routine cancer care.
Cancer has had a particularly frightening stigma attached to it because for centuries we didn’t know the cause of it and we didn’t have a cure. The result was that people didn’t even say the word “cancer” because it was so frightening. Patients often were not even told of their diagnosis, and doctors gave up before they started treatment, because they thought there was nothing more to be done.
Those things really had an impact on people feeling that somehow cancer is different from heart disease or other life-threatening diseases. Cancer became more than just a disease, it was a metaphor for all bad things, so it had a fearsome meaning for a long while.
It wasn’t until Elisabeth Kübler Ross, MD, came around in the late 1950s and said that people with cancer want to talk about their disease, even when they have advancing disease, and doctors and nurses should be encouraging that communication, not avoiding the subject. That led to a change in the humanistic side of medicine. But the idea of treating the whole patient, both the physical and psychological ramifications of cancer, didn’t happen until more recently.
It has been an uphill battle to get across the idea that you must treat the whole person—that you must have a way to incorporate treatment of both the tumor and the emotional distress patients feel into your everyday care.
What was the turning point?
Things significantly changed in 2007, when the IOM report was published. The central message of the report was that there are evidence-based interventions—both psychological and pharmacologic—for patients with cancer, and that you cannot say you’re doing quality cancer care today unless you have integrated the psychosocial aspect into routine medical care. That was enormously helpful, and we took the report findings to the International Psycho-Oncology Society and the International Union Against Cancer, and about 60 countries have now endorsed the IOM’s recommendations.
In 2012, the Commission on Cancer (COC) mandated that in order to receive accreditation, cancer centers across the country must have a program in place by 2015 to identify distressed patients and refer them to the proper source.
Are you seeing evidence that cancer centers are starting to comply with the mandate?
Many centers still don’t have a distress program in place, but I think they are all concerned about meeting the deadline. We are working very hard with various organizations to provide staff education and help them implement programs.
Looking Ahead
What advancements do you see in psycho-oncology over the next 5 to 10 years, and how will those advancements benefit patients?
I often say we’ve always had a carrot to get people to pay attention to the psychosocial needs of patients. Now for the first time, we also have a stick—the mandate from the COC. So I think that within 5, and certainly 10 years, every center will have some type of psychosocial program.
The programs will vary from place to place, depending on the number of staff and resources they have, but at least some type of psychosocial program will be available for patients with cancer in every cancer center, whereas often there is nothing along those lines now. Once the ball starts rolling, people will see how important this program is, how grateful patients are, and that it is a big value added.
Over the next decade, there probably will be more ways to find out which patients meet the criteria for distress and need some type of therapy. For example, there might be a way patients can use their electronic health record to punch in whether they are feeling distressed, and we will be able to get help to more people in that way.
We would love to see a better way to diagnose and treat patients suffering from all forms of distress, including depression, anxiety, and insomnia. Part of the COC mandate is that you must triage patients to a mental health resource for monitoring or treatment. But right now it’s hard to find mental health counselors in many parts of the country, and that’s a big area we need to work on—how to triage patients to a proper resource. We need to come up with a national plan so people can find psychological help that has been vetted and that includes mental health professionals who know about cancer and its impact on patients and can offer counseling.
Currently, a wide array of evidence-based interventions are available to help patients cope with their level of distress, and that will grow wider. There are several forms of counseling, mindfulness meditation, yoga, relaxation techniques, music, and dance therapy, which qualify as complementary therapies. There are also medications for more serious types of distress. So the future looks good for providing patients with more helpful options.
The other area that needs attention is the shortage of mental health experts trained in the problems of having cancer. We need more opportunities to encourage and train young people in the fields of psychology and social work and then train them in the issues that affect patients with cancer. We also need to be sure that there are psychiatrists consulting with all the cancer centers, so every center has access to somebody who knows how to prescribe psychiatric medication and can diagnose the more formal psychiatric disorders.
Survivorship Issues
Will the need for psychosocial care for patients with cancer become even more important as the number of survivors grows?
Yes. There are over 13 million cancer survivors in the country, but the psychological issues do not end once treatment is over. There is anxiety about the cancer coming back and the long-term and late side effects of treatment.
All of the survivorship issues are new. When I started out, for example, there were not many Hodgkin lymphoma survivors, and now, almost 100% of those patients are cured, so we have a big survivorship population. We’re learning more about the psychosocial problems patients have, and it has opened a whole new era for us.
That said, our main issue is the implementation of a psychosocial program in every cancer center in the country by 2015. That’s where we are right now. We are trying to see how we can help all these cancer centers meet the new accreditation deadline. Once that happens, it will change the patient experience enormously, because oncologists will at least be paying attention to psychosocial issues in a way that hasn’t been true up to now. So things are changing. ■
Disclosure: Dr. Holland reported no potential conflicts of interest.
