History of Psycho-Oncology and Oncopsychology at the Oncology Institute

The middle of the last century and the beginning of the 21st century in Russia were marked by the active development of such a field of applied psychology as oncopsychology, which studies the psychological consequences of cancer. Also within the focus of oncopsychologists is psychological care for cancer patients and their relatives. Without in the least diminishing the significance of the psychological research being conducted

and the psychological care provided by specialists in the oncology institutions of our city and country, in the present work we wish to show how this took place at the N.N. Petrov Research Institute of Oncology.

The idea of the need to take into account the psyche of the cancer patient, which influences the outcome of treatment, was perhaps first formulated in the country back in 1945 by the founder of Russian oncology N.N. Petrov in his work «Questions of Surgical Deontology». He wrote: «For fully valuable surgical work, in addition to scientific knowledge, technical equipment, and the most brilliant surgical technique, the following are necessary: … full consideration of the significance of patients' psyche for the outcome of the treatment being performed, and the protection of this psyche while avoiding any trauma to it that can possibly be avoided»

and «Psychotherapy, on the other hand, is given completely insufficient attention; on the contrary, the gates are thrown wide open for the psychogenic traumatization of patients, and the notion of the great harm generated by psychogenic trauma is far too insufficiently instilled in the consciousness of surgeons» [11]. Already in those years N.N. Petrov pointed to the possibility of the psychological traumatization of the cancer patient. In his work he addressed oncologist physicians. Of course, in the 1940s it was impossible even to imagine psychologists working in oncology institutions.

Years passed, and the advancement of diagnostics and the application of modern, high-technology methods of treating cancer contributed to the gradual increase in the life expectancy of cancer patients. Thus, in the 1970s, in oncology, alongside questions of patients' life expectancy, questions of the quality of life of this category of patients became important. The aforementioned circumstances served as an impetus for the development of palliative oncology, on the one hand, and, on the other, the resolution of the rehabilitation problems of the individual cancer patient became relevant and practically necessary. Questions of the psychological rehabilitation of cancer patients began to attract particular attention.

At that time, experimental-psychological, psychiatric, and sociological studies in the field of oncology were already emerging abroad. These interdisciplinary studies led to the emergence of a new field of knowledge – psycho-oncology, which studies the psychological and social aspects of cancer [17]. The main focus in psycho-oncology is on the quality of life of cancer patients. In our country there had been no such studies as yet.

The impetus for the beginning of the systematic study of psycho-oncology at the N.N. Petrov Research Institute of Oncology was provided by a visit of a group of its leading specialists to the USA (the early 1970s), the program of which included visits to various oncology clinics. One of the members of the delegation was Professor D.P. Berezkin, to whom belongs the idea of involving psychologists in the study of cancer patients in our country. In 1974, for the first time in the USSR, in the laboratory for the study of the effectiveness of cancer treatment that he headed, a research group was organized to study the psychological characteristics of cancer patients. The research topics «Study of the personality characteristics of patients with rectal cancer» and «Development of the psychological foundations of early

clinical rehabilitation of patients with cancer of the gastrointestinal tract» were approved by the Committee on Science and Technology of the USSR. The choice of psychological research on patients with cancer of the aforementioned localizations was not accidental: among them, especially in patients with rectal cancer, despite the vital threat, there were observed refusals of operations caused by its mutilating nature, as well as high anxiety and depression, which created a suicidal risk. The first to begin working on these topics were Candidate of Psychological Sciences N.G. Zyryanova and psychiatrist A.V. Gnezdilov. In 1975 medical psychologists V.A. Chulkova and N.B. Shipovnikov joined the work (Fig. 1).

As a result of the studies conducted, A.V. Gnezdilov identified the psychogenic reactions of cancer patients at different stages of treatment depending on their premorbid characteristics, as well as ways of relieving these reactions, which formed the basis of his candidate's dissertation «Psychogenic Reactions in Cancer Patients». The psychologists V.A. Chulkova and N.B. Shipovnikov studied the personality characteristics of patients with rectal and gastric cancer, their reaction to the illness at different stages of treatment, their attitude toward the illness, toward the diagnosis, toward the operation, toward the future, which made it possible to adequately and successfully correct developing pathological states. These studies served as the basis of N.B. Shipovnikov's candidate's dissertation «Characteristics of the Personal Reaction to Illness in Gastric and Rectal Cancer».

From 1977, with the participation of physicians and research staff of various divisions of the Institute, large-scale research work began on the rehabilitation of patients with breast cancer (BC) [10]. BC carries within it the threat of psychological traumatization of patients. Its treatment is accompanied by excessive emotional strain, leading the patient to various psychological and neuropsychiatric disorders that sharply reduce quality of life even years after the completion of treatment.

Figure 1 – The establishment of the Service of Psychological Care for Cancer Patients and Their Relatives at the N.N. Petrov Research Institute of Oncology.

V.A. Chulkova conducted a psychological study of BC patients in different periods of the illness, investigated the personality characteristics of these women, and identified differences in their reaction to the illness, which are rooted in both the personality characteristics of the patient, the characteristics of accepting the illness, and the attitude of those around toward the ill woman [13]. The results of the study became the basis of V.A. Chulkova's candidate's dissertation «Psychological Study of Personal Reactions to Illness in Breast Cancer». It was shown that for adequate adaptation to the illness, which affects life after it, psychological care for BC patients is necessary, including care provided by professional psychologists.

The works of A.V. Gnezdilov, N.B. Shipovnikov, and V.A. Chulkova are characterized by the fact that they not only described the personality characteristics of patients, but also pointed to the dynamics of change in their psychological state and reactions depending on the stage and type of treatment. In these studies, criteria for the psychological compensation of cancer patients

were developed and psychological risk groups were determined. The results of the studies were reported at the All-Union Symposium «Improvement of Methods of Rehabilitation of Cancer Patients» on November 15–16, 1978, and were also published in the institute's collection «Rehabilitation of the Cancer Patient» in 1979 [1, 2].

A great influence on the formation of the views and approaches of our Institute's psychologists to the psychological problems of cancer patients was exerted by the collaboration with leading specialists in medical psychology and psychotherapy of the V.M. Bekhterev Saint Petersburg Research Psychoneurological Institute, and Professor E.F. Bazhin and Professor B.D. Karvasarsky became the scientific supervisors of the candidate's dissertations.

Thus, thanks to the very first psychological studies at the institute, the need for professional psychological care for cancer patients was demonstrated and the foundations for its implementation were developed. In addition, in the course of the research and numerous conversations with patients, the psychologists themselves acquired unique experience of psychological work with cancer

psychological counseling of cancer patients and their relatives began to be carried out for the first time in our country at the N.N. Petrov Research Institute of Oncology. Naturally, it is always difficult to do something for the first time. In this connection, the understanding and support on the part of the administration and staff of the Institute were very important.

In 1981, a department of rehabilitation of cancer patients was created at the Institute (headed by Professor L.V. Donskaya). Medical psychologists V.A. Chulkova and N.B. Shipovnikov became research staff of this department. The main direction of the scientific activity of the rehabilitation department was the study of the restoration

of the working capacity of patients with cancer of the breast, lung, ovaries, and uterine body after radical treatment. In addition to the psychologists, the research was carried out by oncologist and Candidate of Medical Sciences E.V. Demin and specialist in medical-labor expertise and Candidate of Medical Sciences N.I. Artemkina. Moreover, agreements were concluded between the Institute's department of rehabilitation of cancer patients and the territorial oncology departments of the Moskovsky, Vyborgsky, and Kirovsky districts, as well as, respectively, with general somatic city polyclinics Nos. 51, 99, and 43, according to which, for the first time in our city, real rehabilitation of BC patients after radical treatment began to be carried out. The jointly developed program for the restoration of women's health and working capacity included two-month sessions of therapeutic gymnastics, mechanotherapy and occupational therapy, and the prevention and treatment of lymphatic edema of the upper limb. A psychological study was conducted in all patients before and after undergoing the rehabilitation measures, while the women who were followed up in the Moskovsky district participated at the same time in individual and group psychotherapeutic work. The aim of the study was to examine the change in the psychological state of the patients and their self-esteem in the course of rehabilitation. It was shown that upon completion of the restorative treatment, patients' level of anxiety and depression decreased and self-esteem in the «health» category increased, while in patients who engaged in psychotherapy, self-esteem also increased in the «happiness» category; they could more freely express their feelings and discuss problems, and were more satisfied with life at the present moment. Using the example of BC patients, this work demonstrated the need to conduct rehabilitation programs with the mandatory inclusion of psychotherapy.

From 1987, the rehabilitation department became part of the department of dispensary follow-up and restorative treatment of cancer patients (headed by Professor N.N. Blinov). Further development was achieved by

the research studying the quality of life of cancer patients and the possibilities of improving it. Research staff and physicians of the department participated in carrying out the studies. Practically every work on the study of quality of life contained fragments of psychological research performed by the psychologists. The rehabilitation program in the city's oncology departments also continued. The psychological research under this program became part of E.V. Demin's doctoral dissertation «Ways of Improving the Postoperative Rehabilitation of Patients with Breast and Endometrial Cancer».

In 1990, medical psychologists V.A. Chulkova and N.B. Shipovnikov completed a course of training at the European School of Oncology in Poland. Instructors from Great Britain, France, Italy, and the USA, over the course of a week in Radziejowice near Warsaw, acquainted them with achievements in the field of psychosocial oncology and palliative treatment. At that time it was also possible to become acquainted with and discuss some problems of psycho-oncology with psychologists from Poland, Hungary, Bulgaria, and Spain. A strong impression was left by the visit to the rehabilitation department of the Institute of Oncology in Warsaw.

The events that took place in our country in the 1990s contributed to the fact that the exchange of scientific and practical knowledge between professional psychologists of different countries became accessible to our specialists as well. Psychological work with cancer patients has its own particularities and, at the same time, it is part of the general approach to helping people who are in an extreme and crisis situation. From 1991, V.A. Chulkova participated in a number of international seminars and training programs (USA, Great Britain, Norway, Holland, etc.) in the field of practical psychology and psychotherapy. In 1999, as part of a group of psychologists from the Saint Petersburg Institute of Psychotherapy and Counseling «Garmoniya», V.A. Chulkova visited the Netherlands. In Rotterdam they became acquainted with the work of the Institute of Biopsychosocial

Medicine (director – Professor M.J. de Vries). The uniqueness of the institute lies in the fact that its staff psychotherapists and psychologists conducted various types of psychotherapy for cancer patients, while independent researchers studied the influence of psychotherapy on the quality of life of cancer patients.

The experience of scientific and practical work with cancer patients in the field of psycho-oncology received further development at our institute.

Under the program for improving the quality of life of cancer patients, analgesic therapy began to be applied at the department of dispensary follow-up and restorative treatment (physician A.S. Priputin). Psychologist V.A. Chulkova participated in this work. Among others, psychological methods of analgesic therapy were also used. The study conducted in the process showed that the effect of analgesic therapy was higher in the group of patients with whom psychotherapy was carried out. The psychological study of the level of anxiety and depression also confirmed these results.

In the late 1990s, a research group for restorative treatment was created (headed by Prof. N.N. Blinov). Research work related to psychological care for BC patients and patients with lymphoproliferative diseases continued at an already higher level; this work, of course, drew on the accumulated experience and was of a more advanced nature. In addition, over the course of three years (1995–1998), in accordance with an agreement, psychological consultations and Balint groups were conducted with physicians and nurses of Hospice No. 2.

The results of all the psychological studies were reported at Russian and international conferences and published in domestic and foreign journals and in collections of scientific works. In the section of psycho-oncology, 10 sets of methodological recommendations and manuals for physicians were published.

The psychological studies conducted at the N.N. Petrov Research Institute of Oncology showed that cancer is associated with the patient's experiences, which affect the treatment and outcome of the illness, and therefore the problems of oncology cannot be successfully solved without taking into account the psychological component of the illness.

In 2008, the research group for restorative treatment was renamed the group for rehabilitation of cancer patients (headed by leading research fellow and Doctor of Medical Sciences I.P. Komyakov). At the same time, a psychological study of the burnout syndrome in oncologist physicians and nurses working in an oncology institution began. This study was dictated by the fact that in their activity oncologist physicians and mid-level medical personnel are forced to constantly encounter the negative emotional experiences of patients and to be involuntarily drawn into them, experiencing heightened emotional strain. All of this affects the well-being (physical and psychological) of oncologist physicians and nurses and reduces the effectiveness of their interaction

with patients, which indirectly affects rehabilitation and, thereby, the quality of life of cancer patients.

The aim of the study was to examine the severity of burnout syndrome and its connection with the personality characteristics and length of the physician's work experience. Based on the results of the work, a training manual for oncologist physicians was written [16].

At the same time, the psychologist of the group for rehabilitation of cancer patients V.A. Chulkova, together with the Department of Psychology of Crisis and Extreme Situations of Saint Petersburg State University and the laboratory of clinical psychology of the V.M. Bekhterev Research Psychoneurological Institute, developed a conceptual approach to the situation of cancer as an extreme situation and a psychological crisis. The essence of this approach is the notion that the situation of cancer for the patient and his family

is not merely stressful but super-stressful; it possesses the features of extreme and crisis situations and carries within it the threat of psychological traumatization [14].

In 2012–2014, research work was carried out, the aim of which was to study the psychological characteristics of cancer patients with various tumor localizations, their attitude toward the illness, and their adaptation to the illness at different stages of treatment. As a result of the study, the characteristics of patients with various localizations (breast cancer, gynecological cancer, prostate cancer, lung cancer), their attitude toward the illness, and the coping strategies they use in the process of adapting to the illness were identified. The results obtained made it possible to create a scientific foundation for a system of psychological care for cancer patients, the implementation of which meets the goals of rehabilitation of the cancer patient and contributes to improving his quality of life.

The consideration of cancer within the framework of the above-mentioned conceptual approach and the many years of experience in psychological counseling of cancer patients contributed to the creation of a three-phase model of professional psychological care for cancer patients, according to which the patient undergoes adaptation to the situation of illness [15]. A great part in understanding the meaning of psychological care for cancer patients was taken by medical psychologist E.V. Pestereva, who in 2011 defended the candidate's dissertation «Characteristics of Psychological Adaptation to Illness in Patients with Malignant Lymphomas at Various Stages of the Disease», and from 2014 began working at the Institute.

For many years, psychological counseling of cancer patients was conducted at the institute, but it did not have a systematic character. In 2015, the scientific department of innovative methods of therapeutic oncology and rehabilitation was created (headed by leading

research fellow and Doctor of Medical Sciences T.Yu. Semiglazova), which included medical psychologists. The research work «To study the characteristics of the psychological status of cancer patients depending on the method of systemic therapy», in which medical psychologists participated in 2015–2017, is part of a more general work carried out by the department.

From 2015, the active organization of the Service of Psychological Care for Cancer Patients and Their Relatives began, which makes it possible to carry out this type of care more effectively and in a more multifaceted way, and which meets the goal and objectives of the psychological rehabilitation of patients. A great role in the creation of the Service of Psychological Care was played by the Institute's chief physician, Candidate of Medical Sciences A.P. Karitsky, and the head of the scientific department of innovative methods of therapeutic oncology and rehabilitation, Doctor of Medical Sciences T.Yu. Semiglazova, as well as the head of the clinical-diagnostic department, now deputy chief physician for medical affairs, R.V. Donskikh. The number of specialists providing various types of psychological care to patients increased. At present it is provided by psychotherapist and Doctor of Medical Sciences T.A. Karavaeva, psychotherapist of the department of chemotherapy and combined treatment of malignant tumors in children O.A. Krylova, and medical psychologists: Candidate of Psychological Sciences V.A. Chulkova, Candidate of Psychological Sciences E.V. Pestereva, M.V. Vagaytseva, and K.O. Kondratyeva.

Beginning in 2016, at the Institute, in practically all patients who are at the stages of diagnosis and hospitalization in the inpatient facility, an assessment of the intensity of experiences is conducted for the purpose of identifying the groups of cancer patients most in need of psychological care. The basis of the study was the distress self-assessment methodology of the International Psycho-Oncology Society (IPOS) [12]. In the methodology as modified by us, patients are to assess the level of their experiences associated with the illness, treatment, and changes in life in

connection with them. At present, more than 4,000 forms filled out by patients have been processed. Psychological risk groups were identified; these included patients with a high level of experiences, acutely in need of psychological care, which was provided to them on an emergency basis.

The creation, in the distant 1970s, of a psychological group at the N.N. Petrov Research Institute of Oncology contributed to the development of N.N. Petrov's ideas about the role of the psyche in the treatment of cancer patients and, at the same time, observing continuity, became the basis for the organization, directly or indirectly, of other types of psychological care for cancer patients.

The understanding of the significance of psychological care for cancer patients led to the fact that in 1988 oncologist E.V. Demin and medical psychologist V.A. Chulkova organized the first volunteer group of social-psychological support for BC patients in our country, «Nadezhda» (Hope). The training of the volunteers was based on the international program «Reach to Recovery» – «The Path to Recovery». The volunteers of «Nadezhda», themselves former BC patients, underwent special selection and training and were able to help those who had fallen ill. Thereby a beginning was laid for a large movement in the field of non-medical care for cancer patients. At present «Nadezhda» has followers in various Russian cities: Kaliningrad, Kazan, Arkhangelsk, Yekaterinburg, Khanty-Mansiysk, Belgorod, Novosibirsk, and Khabarovsk. In 1992 the founders of «Nadezhda», E.V. Demin and V.A. Chulkova, were awarded personal medals of the international program «Reach to Recovery». Today, at the Institute, monthly, for 5 years now, the scientific department of innovative methods of therapeutic oncology and rehabilitation, with the active participation of the head of the department Doctor of Medical Sciences T.Yu. Semiglazova, together with the Saint Petersburg city public patient movement «Movement Against Cancer», conducts Schools for patients and their

relatives with the participation of oncologist physicians, lawyers, and psychologists. An important block of the Patient School is the participation of a psychologist, who advises patients on how not to break down, to hold out, and to fight the illness.

In 1990, A.V. Gnezdilov, who worked at the N.N. Petrov Research Institute of Oncology for more than 10 years, organized in Lakhta Hospice No. 1 – the first hospice not only in our city but in our country. In large part thanks precisely to A.V. Gnezdilov, palliative care for cancer patients in our country received its development. On the basis of the work of this hospice, programs of palliative care for cancer patients, including analgesic therapy, were created and developed. Now, probably, in all regions of our country there are hospices, and so it is difficult to imagine that at one time such care for patients did not exist.

From 2002, at the Department of Oncology of the I.I. Mechnikov North-Western State Medical University (head of the department Professor A.M. Belyaev), for the first time in our country, a course in psycho-oncology and oncopsychology has been conducted for oncologist physician trainees within the section of rehabilitation of cancer patients and the section of medical ethics and deontology and legal issues of the oncology service. The instructor of the course is associate professor of the Department of Oncology and Candidate of Psychological Sciences V.A. Chulkova. Within the framework of the course

questions are considered about psychological problems in oncology, the psychological reactions of cancer patients to the illness, the psychological aspects of medical practice, and others. A program for a seminar-training «Psycho-Oncology: What Does the Practicing Physician Need to Know to Work with the Cancer Patient?» has been created. To the 10 manuals for oncologist physicians published earlier, another 5 have been added in recent years.

The Institute's medical psychologists actively conduct scientific-methodological and educational activity in other educational institutions of Saint Petersburg as well. Thus, beginning in 2003, at Saint Petersburg State University in the Faculty of Psychology

(Department of Psychology of Crisis and Extreme Situations), associate professor V.A. Chulkova conducts classes with students – clinical psychologists on the topic «Psychological Care for Cancer Patients». At present, in the Faculty of Psychology, for the «clinical psychology» specialization, a course «Psychological Problems in Oncology» is taught. At the Department of Psychology of Crisis and Extreme Situations (Faculty of Psychology of Saint Petersburg State University), at the end of 2010 a permanently operating scientific-practical seminar on oncopsychology was organized. The aim of organizing the scientific-practical seminar is to unite and support psychologists working in various oncology institutions of Saint Petersburg, to raise their professional competence, as well as to form an adequate conception of cancer patients and of work with them and their relatives among psychologists who do not work in oncology. The leader of the seminar is the associate professor of the aforementioned department and senior research fellow of the N.N. Petrov Research Institute of Oncology V.A. Chulkova.

In the year of the celebration of the 90th anniversary of the N.N. Petrov Research Institute of Oncology, one can note with pride that under the leadership of the Institute's director Prof., Doctor of Medical Sciences A.M. Belyaev, and with the participation of chief physician Candidate of Medical Sciences and associate professor A.P. Karitsky and the head of the scientific department of innovative methods of therapeutic oncology and rehabilitation Doctor of Medical Sciences T.Yu. Semiglazova, the Service of Psychological Care for Cancer Patients and Their Relatives has been created and is actively developing, being a mandatory component of the multidisciplinary approach to the treatment and rehabilitation of patients with various malignant neoplasms. At the Institute today 2 psychotherapists and 4 medical psychologists work, which makes it possible to carry out psychological care more effectively and in a more multifaceted way, which fully meets the goals and objectives of

the psychological rehabilitation of cancer patients at all three main stages. Monthly, at the Institute, together with the Saint

Petersburg city public patient movement «Movement Against Cancer», Schools for patients and their relatives are conducted with the participation of oncologist physicians, lawyers, and psychologists, who advise patients on how not to break down, to hold out, and to fight the illness. With the active participation of medical psychologist, associate professor, Candidate of Psychological Sciences V.A. Chulkova, with the trainees and attendees of the cycles of the educational-methodological department (head of department associate professor M.V. Rogachev), current questions of the psychological reactions of cancer patients to the illness, the psychological aspects of medical practice, and so on are actively discussed. The results of the research work on the study of various aspects of attitude toward treatment, which includes the characteristics of the psychological response of cancer patients to it, carried out both within the framework of the state assignment and the clinical trial of the Ministry of Health of Russia, are actively used in practical healthcare and in the planning of further scientific research.

Thus, this historical overview shows how, beginning with the works of N.N. Petrov, the development of psycho-oncology and oncopsychology at the Institute took place and continues to take place gradually and steadily, and that some of the approaches and studies in this field developed at the Institute are pioneering for our country.