The History of the Development of Psycho-Oncology Worldwide

Psycho-oncology is an interdisciplinary field that encompasses a wide range of tasks, from organizing medical and psychological care for patients and their families, providing psychoeducation and training for personnel who interact with patients, to conducting comprehensive research that includes studying the preventive role of behavioral factors in malignant disease, as well as treating mental disorders and addressing psychosocial problems throughout the entire course of cancer [14]. Given the significant importance of psychological problems that develop against the background of cancer, it seems strange that the official history of psycho-oncology in the world began only in the last quarter of the 20th century. However, it was precisely by this time that manifestations of a paternalistic attitude toward patients diminished, as a result of which physicians began to disclose accurate information about the diagnosis and prognosis, which made it possible to openly investigate and study the psychological reactions that arose.

The history of the development of psycho-oncology can be examined in the context of the following factors: first, the long-standing stigmatization of patients with both cancer and mental disorders; second, the difficulties in organizing the provision of psychological care to physically ill patients; third, the factors that led to the initial search for a psychological cause of malignant disease, thereby creating an interest in the psychosomatic nature of cancer; fourth, the absence of a theoretical model that could successfully integrate the approaches and contributions of the broad spectrum of disciplines involved in psycho-oncology (medicine, psychology, psychiatry, social work, religious counseling);

and fifth, the achievements of scientific research conducted from 1975 onward.

Despite the fact that the development of this discipline occurred primarily during the last quarter of the 20th century, it is extremely important to understand society's earlier attitude toward cancer and mental disorders, since it still influences the contemporary perception of illness, albeit in a less pronounced form. To this day, barriers still exist to providing optimal sociopsychological care to patients and to conducting scientific research.

As early as the beginning of the 19th century and in earlier times, a diagnosis of cancer was regarded as a death sentence. At that time, neither the causes nor the methods of treating malignant disease were known. Disclosing the diagnosis to a patient was considered cruel and inhumane, because the patient might lose all hope of recovery and coped with the painful condition better if unaware of its nature, causes, and prognosis. The fear of the disease was so great that the family was afraid to disclose the diagnosis to those around them because of the stigma associated with the patient and their family. Shame and guilt were the dominant emotions, combined with the fear that the disease might be contagious.

The gradual overcoming of the stigmatization of patients originates in the development of therapeutic methods and the experience of the first remissions of cancer. At the beginning of the 20th century, when high-quality anesthesia appeared and surgical skills improved, treatment of cancer became possible in cases where the tumor was detected in the early stages of the disease and could be removed before the stage of metastasis. From this moment, a need arose to inform society; educational programs were developed about the signs of cancer and the possibilities for its treatment in order to improve the rate at which the

population sought care, the timely establishment of a diagnosis, and the detection of symptoms of malignant disease. In order to counteract the ignoring of the disease, fatalism, and irrational fears, the symptoms of cancer were published in the mass media. Slogans such as «Fighting Cancer Through Information» were used to counter society's excessive fears. Despite efforts aimed at improving the public's awareness of the early manifestations of oncological pathology and at medical educational outreach, many people retained an anxious-anosognosic attitude toward the disease and came for consultation too late, when treatment was already ineffective.

In the first quarter of the 20th century, radiation therapy was added to surgical intervention as a means of treating cancer. It was proposed primarily as palliative treatment and was often applied after surgical failure, and for this reason people feared it, just as they feared surgery. Public concern and apprehension led to the funding of research devoted to the search for new ways of treating malignant disease. Thus, at the beginning of the 20th century in the United States, the first research center was organized on the basis of a cancer hospital, and in 1937 the National Cancer Institute was established. In 1948, Farber reported the first temporary remissions of acute leukemia in children using aminopterin therapy, which were followed by successes in treating Hodgkin's disease with chlormethine [25]. This marked the beginning of an active search for new antitumor drugs, and chemotherapy was added as a third method of treating cancer, in combination with increasingly effective surgery and radiation therapy.

Following the growing successes of pharmacotherapy for malignant disease came social debates about the advisability of informing patients about the disease and the proposed therapy, as well as about the need to introduce informed consent to treatment, which created the legal preconditions for an open dialogue between physician and

patient about the methods and results of diagnosis and treatment options. Patients' rights began to acquire ever greater significance. Evidence of certain experiments conducted in the United States on patients without their consent, including on those suffering from cancer, led to the adoption of a number of federal laws regulating the rules for clinical research on humans. The period of social upheaval in the United States (the 1960s–1970s) fostered movements for the rights of women, consumers, and, finally, patients, who began to demand recognition of their right to be informed about the methods of diagnosis, the nature of the prognosis, and the treatment options for the disease. Thus, in the 1960s, the first debates in the country began on the question of the advisability of concealing a cancer diagnosis from the patient. In these lively discussions, psychiatrists, citing the possible development of an excessively strong emotional reaction and the formation of mental disorders, took a position supporting keeping the patient's condition secret from them, whereas the majority of oncologists took the opposite position. In a study using the Oken questionnaire in 1961 [23], it was found that more than 90% of physicians in the United States usually did not disclose the diagnosis to the patient. However, the same questions asked in a survey in 1978 showed that 97% of physicians in the same geographical area of the United States had begun to tell patients accurate medical information about their condition [22]. Over these past 17 years, the volume of society's knowledge about oncology increased, and citizens meanwhile began to actively fight for their rights, advocating for a fairer and less paternalistic dialogue about diagnosis and treatment. In addition, the successes of oncology became more evident, more cases of recovery after cancer treatment became known, which encouraged optimism in patients' assessment of their prospects.

Considering the other pole of the interdisciplinarity of psycho-oncology, it should be noted that the centuries-old stigma of mental illness and

the unpopularity of its treatment significantly hindered the rapid development of this field in world science. In conceptions of mental illness, as of cancer, knowledge about etiology, pathogenesis, and effective methods of treatment was long absent. Since the Middle Ages, the main cause of mental disorders was defined as possession by evil spirits, and the patient became an outcast in most social communities [10]. In the United States and Europe in the 19th and early 20th centuries, the mentally ill were isolated from society in psychiatric hospitals that were in no way connected with medical therapeutic inpatient facilities.

By the end of the 19th century, an interest developed worldwide in treating mental illness within general medicine; psychiatric departments appeared in general hospitals, and the training of physicians and students in the diagnosis and treatment of mental disorders in physically ill patients began [19]. Nevertheless, attitudes toward the possible appearance of a psychiatrist in a medical department of a hospital ranged from hostile to indifferent. In 1929, the psychiatrist G. Henry [13] documented his professional experience. In this article, he reported 300 cases of detection and diagnosis of a psychiatric disorder in patients with somatic pathology. Despite changes in diagnostic terminology and differential criteria, the data obtained reveal similarities with contemporary scientific conceptions.

The experience of providing inpatient care in psychiatric institutions to patients with somatic diseases, as well as within the framework of psychiatric consultations for patients in general departments, marked the beginning of the field of consultation-liaison psychiatry, which was concerned with studying and correcting psychological changes in patients with somatic diseases.

Patients with cancer were traditionally treated by general practitioners. This pathology did not attract much

academic interest, since it was regarded by specialists as unpromising from the standpoint of studying it in scientific research. Patients felt largely rejected and hopeless, since physicians spent less time with them than with patients with other diseases, shunned them, avoided communication, did not discuss the diagnosis and prognosis, and evaded questions that might have led to such a conversation.

In the postwar years, the only formal psychological support for cancer patients was provided through the American Cancer Society's «Visitor» programs. Patients who had already undergone difficult surgical treatment—laryngectomy or colostomy–were asked to talk with patients who were afraid to undergo these treatment procedures. In this way, the first patient self-help groups were formed. They were followed by the creation of an organization called «Reach to Recovery», which began its activity in the 1950s on the basis of the American Cancer Society. In this program, women with successful experience of undergoing mastectomy visited patients in the postoperative period. However, despite broad approval from society and interest on the part of patients, physicians and medical personnel were in no hurry to recognize the useful role of self-help groups of patients with the same diagnosis and treatment. Strong prejudice against them continued until the last quarter of the 20th century. A change in attitude toward self-help groups of women after mastectomy occurred when it became evident that the benefits of their sociopsychological support far outweighed the risks.

The first works studying the psychological burden of patients with neoplasms were carried out by K.R. Eissler and J. Norton [21], who set out detailed and confidential observations of patients who developed malignant disease during psychoanalytic therapy. The data obtained served as rich material for

beginning researchers in the 1960s, since they described for the first time how patients coped with the progressive stages of the disease and approaching death.

In the early 1950s, the first scientific studies appeared reflecting the formation of closer cooperation between specialists from the fields of psychiatry and clinical medicine and devoted to studying the psychological reactions of patients hospitalized in connection with malignant disease. Key works described the experience of feelings of guilt and shame as the main psychological reaction associated with the stigma of cancer. Researchers also studied how patterns of patients' interaction with those around them changed depending on the stage of the disease, noting an increase in the restriction of communication as the tumor process progressed [24]. Works appeared reflecting the psychological reactions of patients associated with the performance of radical surgical procedures in gynecological cancer, breast cancer, and malignant tumors of the colon. Two original works by M. Bard et al. and A.M. Sutherland et al., which are still relevant today, described the psychological experiences of patients when a colostomy was brought out onto the anterior abdominal wall and when a radical mastectomy was performed [5,27]. Professional psychiatric communities began to form clinical and scientific ties with groups of surgeons, radiotherapists, and oncologists.

Another factor that generated heightened interest in the psychological problems of cancer patients in the 1960s was the work of the psychiatrist E. Kübler-Ross. She spoke out against the prohibition on discussing the predicted fatal outcome with cancer patients and recommended that physicians and nurses not avoid communication with these patients, but pay attention to their emotional experiences and difficulties. Her contribution was of decisive importance for the beginning of the development of

thanatology, the strengthening of the concept of hospice care, and the humanization of palliative medicine [18].

Nevertheless, resistance to «everything psychological» did not disappear either among medical workers or among patients, and this became one of the reasons for the slow development of psycho-oncology and the limited involvement of psychological and psychiatric services in providing care to persons with cancer. A patient suffering from malignant disease experiences the fear that those around them may perceive them not only as a person with an incurable physical ailment, but also as a person who is mentally unwell and in need of specialized psychological or psychiatric care. To overcome the stigmatization of cancer patients, professional psychological care and social rehabilitation must be harmoniously and comprehensively integrated into the cancer service as part of a systemic approach in the treatment of cancer patients.

The official recognition of psycho-oncology in the world began in 1975, when the barrier associated with concealing a cancer diagnosis from patients collapsed and the possibility arose of an open dialogue with patients about their disease and its consequences for their future life. This coincided with several social changes. First, the public in various countries felt greater confidence in the possibility of curing cancer, driven mainly by the increase in the number of survivors, which testified to the successful results of scientific research and the development of effective methods of therapy. Second, the mass media around the world began to cover information about cancer, diagnosis, and successful cases of cancer treatment substantially more widely. As a result of all these factors, malignant disease ceased to be concealed, and opportunities opened up for investigating the psychological aspect of the malignant process.

Thus, in 1975, a small group of clinical researchers gathered in San Antonio (Texas, USA) for the first national scientific-practical conference on psycho-oncology. During the conference, the question was raised about the absence of instruments for the quantitative assessment of the severity of psychopathological symptoms in cancer patients, since methods designed for studying physically healthy individuals are not adapted for measuring the types of disorders in somatic patients. At subsequent conferences, instruments were developed for the quantitative measurement of the subjective symptoms of pain, anxiety, nausea, depression, and delirium.

In Europe, the 1970s are considered the time of the establishment of psycho-oncology as an independent discipline. Thus, for example, in 1974 a society for helping cancer patients was founded in Germany, and international conferences and studies began to be conducted devoted to examining the influence of stress and the coping strategies used by patients on the course of the disease and adaptation to it, as well as to analyzing the quality of life of patients with neoplasms. Then, in 1975, an interdisciplinary working group on psychosocial oncology was created, and in 1983 a professional society of psycho-oncologists was organized.

By the mid-1970s, the first wave of studies devoted to the epidemiology of comorbid mental disorders in patients with cancer arose. One of the most advanced and significant works was a multicenter, cross-sectional study of the frequency and type of diagnosis according to the DSM-III classification in cancer patients, conducted by Derogatis et al., which showed that the prevalence of mental disorders in the studied category of patients exceeded 47%. In a number of countries, scientific works produced data on the relationship between the frequency and character of the development of depression and the localization and stages of malignant disease. They also

described the difficulties of differentiating physical and psychopathological symptoms, made attempts to determine the causes of delusional disorders, and studied the relationships of psychopathological symptoms with pain manifestations and cognitive impairment. Clinical trials began with sociopsychological and psychopharmacological interventions. In 1979, a manual on psychosomatic medicine edited by T. Uexküll was published in Germany. This manual contained a section devoted to the psychosomatic aspects of cancer. The results of international research and clinical experience were set out in the first textbook on psycho-oncology, published in 1989 [15].

Another link of world psycho-oncology that developed in its early stages was psychoneuroimmunology, the beginning of which is associated with the work of R. Ader and H. Cohen on the conditioned immune response in rats. It was of important significance in the development of research in the field of cancer, since it contributed to an understanding of the conditioned nausea and vomiting in patients undergoing a course of chemotherapy. Studies showed that years after the end of chemotherapy, patients remained sensitive to visual and olfactory stimuli that reminded them of chemotherapy. Associative visual images and smells could, after a long time, evoke brief nausea accompanied by anxiety. The appearance of symptoms could be provoked by a visit to a medical institution, the sight of a nurse or physician, or the smell of antiseptic [17]. Psychoneuroimmunology used new methods that made it possible to track biological events and measure the associated psychological phenomena in a much more precise way. Scientists in various countries also investigated the impact of stress and ways of coping with it on immune function over the course of treatment of malignant disease. Determining the significance of changes in psychoimmune mechanisms as risk factors for the development of cancer and for reduced

survival remains, to this day, a relevant scientific problem, and psychoneuroimmunology is a generally recognized independent field.

The introduction in most countries of the results of scientific research into curricula and the organization of national and international conferences created the opportunity for training the personnel of cancer clinics on the questions of psycho-oncology. In Europe and the USA, group sessions began to be held more frequently for the staff of cancer hospitals, where physicians and nurses studied such phenomena as resistance, countertransference, emotional burnout, and the influence of stress on hospital staff, physicians, and caregivers.

The development of the cognitive-behavioral direction of psychotherapy and its introduction into world medicine at the end of the 1970s contributed to the emergence of a new wave of studies of the sociopsychological aspects of cancer. Works appeared describing theoretical models of coping with stress and coping mechanisms, among which the most effective were identified; cognitive-behavioral strategies of psychological interventions were developed that became widely adopted and confirmed their effectiveness. Psychologists' research on the connection between a healthy lifestyle and the risk of developing tumor pathology contributed to the prevention of cancer. In addition, the assessment of the efficacy and safety of new drugs for treating cancer today is conducted not only on the basis of their influence on the duration of remission, but also takes into account indicators reflecting the dynamics of patients' quality of life in the form of a quantitative assessment of the result according to specially developed methods.

The psychological consequences of the disease and its treatment became an important direction of scientific research throughout the world. Treatment of cancer, including the application of new, modern technologies of cancer therapy, on the one hand, makes it possible for

cancer patients to have a longer life, but, on the other hand, creates the preconditions for the development of a number of psychiatric and psychoneurological disorders that appear some time after treatment. In 1981, American scientists described for the first time the psychological consequences of cancer as a stress factor in patients in remission. From 10% to 20% of survivors after bone marrow transplantation noted the presence of all the symptoms characteristic of post-traumatic stress disorder (PTSD), but in an even greater number of those studied, only symptoms of PTSD were partially identified, which also determined clinically significant psychopathological disturbances. Those who went through the most traumatic stage of treatment, such as high doses of chemotherapy or stem cell transplantation, turn out to be the most vulnerable in terms of the likelihood of developing borderline mental disorders. In patients with cancer, the predominant manifestations are anxiety, depressive, and asthenic manifestations, disturbances of the sexual sphere, and of self-esteem.

Mental complications developing in the provision of palliative care also came within the sphere of specialists' attention. The study of the features of the development and course of depressive disorders in cancer patients was extremely important in connection with the widespread problem of suicides in patients. A number of studies examined the clinical assessment of the severity of delirium developing against the background of the late stages of cancer, and the possibilities of pharmacological management of patients' mental state.

In most countries, psychotherapy groups became widely available for patients with cancer. The main impetus for their introduction was the studies of Spiegel et al. in 1989 [26], and then of Fawzy et al. in 1990 [11], which reported that group psychotherapy sessions for patients with breast cancer and

malignant melanoma had a positive effect on the duration of remission.

Social workers were among the first who, along with nurses, began to participate in addressing the psychological and social problems of cancer patients and their family members. They continued to develop the principles of completeness and comprehensiveness in the provision of medical care and joined psycho-oncology as important partners. Research on children's and parents' reactions, the management of distress, the experiences of caregivers, and especially aspects of palliative care were within their competence [20, 28]. In 1983, the first journal of psychosocial oncology was published in the United States, devoted to informing readers about the results of current research.

The 21st century determined the official recognition of psycho-oncology and the inclusion of psychosocial interventions in European standards for the provision of medical care to patients with cancer. Thus, for example, in 2008, a national cancer plan was adopted in Germany, in accordance with which support was to be provided to comprehensive projects aimed at supporting psycho-oncological care in the realization of its main goals and objectives. In 2014, the priority directions for the development of health care emphasized the need to ensure that all patients with cancer who require it receive high-quality psychosocial care at both the inpatient and outpatient stages of treatment.

Only in recent years has the role of religious counseling in psychological care for patients been recognized in many countries, and spiritual and religious services have been included in psychosocial models for overcoming existential crisis, reflecting patients' need to find possible meaning in the situation of illness. Psychological instruments were developed for measuring the spiritual and existential beliefs of cancer patients [16].

The participation of specialists in the fields of psychiatry, medical psychology, and social work, the introduction into medicine of the achievements of representatives of the cognitive-behavioral and existential directions, the involvement of religious counseling, as well as the efforts of oncologists, ethics specialists, and the patients themselves, created a wealth and diversity of information. All this made it possible to develop theoretical and practical models and strategies used both in scientific research and in the clinical treatment of patients with cancer throughout the world. The most successful are those units that effectively use the entire arsenal of known methods and approaches, function as multidisciplinary organizations, drawing on the knowledge of each specialist, while remaining fully integrated into the structure of general medical care for patients.

Psycho-oncology is a little more than 40 years old, and in this short period significant progress has been achieved in the world in the direction of its development. It occupies a recognized place within the oncological community, both in clinical practice and in scientific research. The realization of the knowledge obtained can significantly improve the psychological well-being and quality of life of patients. As was justly noted in 1994 by S. Greer: «The most important task of psycho-oncology is to close the yawning chasm between current knowledge and actual clinical care of patients» [12].