Lecture
Psycho-oncology is an interdisciplinary field situated at the intersection of the physical, psychological, social, and behavioral aspects of the experience of coping with cancer, both for patients and for caregivers. Also known as psychiatric oncology or psychosocial oncology, this field is concerned with studying the aspects of the experience of people facing cancer beyond medical treatment, and throughout the entire course of the disease, including diagnosis, treatment, transition to the period of recovery, and approaching the end of life. Founded by Jimmie Holland in 1977 through the creation of a psychiatric service at Memorial Sloan Kettering Cancer Center in New York, this field has since expanded considerably and is now universally recognized as an integral part of quality cancer care. [ 1 ] Cancer centers at major academic medical centers throughout the country now universally incorporate a psycho-oncology service into their clinical practice and provide the infrastructure to support research efforts to advance knowledge in this field.
Psycho-oncology studies psychological responses to the experience of cancer, the behavioral component of coping with difficulties associated with cancer, as well as changes in health behavior, including preventive medicine, and the social factors associated with the diagnosis and treatment of cancer, including communication with physicians and loved ones, as well as social support. In addition, over the past two decades, research devoted to the influence of psychosocial factors on the biological processes associated with the disease has intensified considerably. Many studies use a biopsychosocial approach to account for the interaction of biological, psychological, and social factors in coping with difficulties associated with cancer. The integration of psycho-oncology into routine cancer care represents an important step forward in the comprehensive approach to patient treatment.
The diagnosis and treatment of cancer are known to significantly affect psychological well-being. The level of psychological distress in most people diagnosed with cancer is higher compared with population norms. [ 2 ] [ 3 ] Common psychological responses to cancer include problems related to mood and anxiety. Elevated levels of depression and anxiety in response to a cancer diagnosis are often attributed to uncertainty regarding mortality, as well as to burdensome treatment and concerns related to functional impairments and problems associated with body image or other aspects of self-esteem. Understanding how people respond psychologically to cancer is important for maintaining their overall well-being and maximizing quality of life during treatment and afterward. Although the prevalence of psychological disorders in response to cancer is relatively high compared with population norms, many people report fairly stable psychological well-being throughout the course of cancer treatment, and some even report improved psychological well-being.
Common psychological responses to the diagnosis and treatment of cancer include depressive symptoms and anxiety. [ 4 ] Factors that may contribute to clinically significant anxiety and depression in the context of cancer include the threat to life, uncertainty regarding prognosis and treatment outcomes, concern about toxic treatments, functional impairments resulting from toxic treatments, and the physical symptoms themselves, commonly including fatigue, pain, nausea, neuropathy, and «chemo brain». [ 5 ] These themes have been incorporated into psychotherapeutic treatments adapted to the experience of living with cancer. Although most people diagnosed with cancer do not exhibit clinically significant symptoms of depression or anxiety, their prevalence after a cancer diagnosis is significantly higher than in population norms. [ 6 ] Psychological well-being is associated not only with overall quality of life but has also been shown to be associated with a shorter lifespan. [ 7 ]
People's psychological and behavioral responses to the diagnosis and treatment of cancer, aimed at coping with significant stress and a threat to health, represent a primary area of interest in the field of psycho-oncology. These responses can be referred to as strategies for coping with a threat to health. Cognitive adaptation to cancer is particularly complex because of the many domains affected by cancer treatment. There are two broad categories of coping strategies: approach-oriented and avoidance-oriented. [ 8 ]
The approach-oriented coping strategy includes the cognitive, behavioral, and emotional aspects of adaptation to cancer, including expressing emotions, actively participating in one's own treatment, maintaining activity, and discussing difficulties with loved ones. Overall, research supports the idea that the use of an approach-oriented coping strategy promotes more positive adaptation and psychological well-being than an avoidance-oriented coping strategy.
Avoidant behavior is a person's maladaptive attempt to mitigate the psychological harm from a stressful event. Suppression of emotions and avoidance of discussing the topic of cancer, as well as passive behavior, impede the direct management of the problems that cause psychological distress. Many psychological treatments are aimed at enhancing people's ability to apply more adaptive coping strategies and reducing maladaptive ones.
Benefit finding is a cognitive process in which people identify positive changes that a cancer diagnosis has brought to their lives. This is an example of a positive- or approach-oriented coping strategy. For example, a person may determine that a cancer diagnosis prompted them to reflect on what truly matters in life, which subsequently led to an improved quality of life. Research, conducted primarily with women who have survived breast cancer, has shown that interventions aimed at enhancing the ability to identify the benefits of a stressful event such as a cancer diagnosis can improve quality of life. [ 9 ]
Post-traumatic growth is of important significance for a cancer diagnosis because of the potentially life-threatening nature of the disease. People may be compelled to reflect on their own mortality and to adapt by changing their approach to others, to the world, and even to themselves. [ 10 ] Some patients refer to cancer as a «gift» because it inspires them to take a close look at their life or death and to make changes to improve both. [ 11 ]
Cancer represents a serious threat to health that often calls into question the sense of self-worth of a person trying to adapt to the changes in their life brought about by the diagnosis and treatment. Meaning-making is an attempt to restore order and purpose in the lives of people that have been so profoundly altered by the illness. [ 12 ] Meaning-making can be part of the positive process of growth that occurs following a cancer diagnosis and is associated with improved quality of life and well-being. [ 13 ]
In addition to behavioral responses to the cognitive responses to diagnosis and treatment, the field of psycho-oncology studies behavior associated with the risk of developing cancer, as well as behavior that puts people at risk of adverse disease outcomes. This area of interest includes preventive medical practices, such as smoking cessation and the use of skin protection, as well as adherence to the treatment regimen.
Changing behavior in order to reduce the risk of developing cancer is a major public health concern because of the health care costs associated with the treatment of oncological diseases. [ 14 ] Behavior change falls entirely within the scope of interest of psycho-oncology because of the psychological factors involved in implementing behavior changes. The main behaviors targeted to reduce people's risk of developing cancer include: smoking and alcohol consumption, diet and exercise, and sun exposure. These behaviors are known to increase (or decrease, in the case of exercise and diet) the likelihood of developing cancer, as well as a multitude of other diseases.
Participation in screening procedures is also of important significance for cancer prevention, and in the case of some types of cancer it is an underutilized resource. Fear and anxiety are barriers for some people wishing to undergo screening for cancer. [ 15 ] However, cancer screening provides the opportunity to detect tumors at very early stages and to avoid intensive systemic treatment in favor of more acute and localized treatment methods with a greater likelihood of curing the cancer (for example, surgical resection).
Behavior change is also relevant to improving the quality of life of people living with cancer. For example, a common and debilitating symptom of cancer is fatigue. However, one method of treating fatigue is increasing the level of physical activity, despite the difficulties. Low-intensity and mindfulness-based forms of exercise have emerged, including yoga and tai chi [ 16 ], which have been shown to help manage fatigue and pain and to improve overall physical and psychological quality of life.
Historically, the terminology associated with a patient's acceptance of treatment was referred to as «compliance», which implied a more passive role for the patient and a more clearly defined hierarchy between physician and patient. However, modern models of ethical treatment call for greater equality between patient and physician, and the discussion related to treatment has shifted toward treatment adherence. Adherence to medical treatment is critically important for the effective treatment of cancer and is a topic that largely falls within the scope of psycho-oncology because of the cognitive-behavioral reasons for non-adherence to treatment. [ 17 ] A number of factors may contribute to non-adherence to treatment, including toxic side effects, misinformation or misunderstanding of the treatment regimen, lack of communication with health care providers and lack of medical support (for example, self-monitoring of treatment), as well as psychological factors such as depression and anxiety. Treatment adherence has become an increasingly important topic of research in psycho-oncology in connection with the emergence and spread of oral antineoplastic drugs. [ 18 ] Patients receiving oral chemotherapy must independently, sometimes under complex conditions, adhere to the treatment regimen at home and be able to communicate effectively with treating physicians in order to manage toxic side effects that may affect their ability or willingness to take the prescribed drug without the assistance of medical personnel, as occurs with traditional intravenous chemotherapy.
It is estimated that nearly a quarter of adults diagnosed with cancer have dependent children. [ 19 ] Parenting children can significantly increase stress for these individuals and is often cited as one of the most difficult aspects of coping with difficulties associated with a cancer diagnosis. [ 20 ]
In stressful situations, such as a cancer diagnosis, social connections can provide valuable emotional and practical support. Research in the broader field of health psychology has identified a significant influence of social support on people's psychological well-being, as well as a connection with pathological processes, particularly cardiovascular disease. [ 21 ] Patients undergoing cancer treatment often rely on a social support network of varying size, including spouses, children, friends, and other family members, to support them during difficult periods of treatment and functional impairment. These types of social support pertain to instrumental social support and are associated with task-oriented support. In addition, the emotional burden that a cancer diagnosis can place on a person requires a certain degree of emotional support from the support network. Both instrumental and emotional social support have been shown by research to improve the quality of life of patients undergoing cancer treatment. [ 22 ]
Conversely, a cancer diagnosis can significantly isolate people from society. Changes in life, including functional impairments, can distance people from friends and family, and the transition from «healthy» to «sick» in terms of self-identity can also lead to feelings of social isolation. Research has shown that social isolation and feelings of loneliness have a significant negative impact on the physical and psychological quality of life of people with cancer. [ 23 ]
Communication with health care providers and loved ones has been identified as an important social factor throughout the entire course of oncological disease. Communication has been shown to be associated with improved adherence to medication regimens and treatment satisfaction. [ 24 ] Interventions based on cognitive-behavioral therapy include strategies for communicating with health care providers on topics such as symptom management and understanding prognosis. [ 25 ] In addition, open communication between patients and caregivers is associated with improved quality of life for patients and caregivers. [ 26 ] Open communication within the family of a cancer patient is also important for the well-being of the entire family. [ 27 ]
Knowledge from other fields of health psychology, in particular the psychosocial risk factors and outcomes of cardiovascular disease, has led to the study of the influence of psychological factors on the biological processes associated with cancer. As knowledge of the biological processes associated with the development and progression of cancer has advanced [ 28 ], so too has knowledge of the relationship between biological processes, namely inflammation, and psychological processes. Research has identified biobehavioral pathways to disease [ 29 ], which points to the importance of treating the psychological problems arising from a cancer diagnosis in efforts to reduce the likelihood of cancer progression. In addition, knowledge continues to advance regarding the intractable symptoms of cancer, including pain and fatigue, which may be driven by biobehavioral factors, which has led to the development of new approaches to treatment [ 30 ].
Numerous evidence-based treatments for mood disorders and anxiety disorders in the general population have been adapted to address stressors directly associated with cancer. Common maladaptive cognitions associated with cancer include the misinterpretation of pain or other physical sensations as cancer progression, or difficulty adapting to the uncertainty of treatment and life after treatment. Cognitive-behavioral therapy and related psychotherapies are particularly well suited to managing these cognitive problems that arise throughout the process of cancer treatment and interfere with patients' quality of life. [ 31 ] CBT and related therapies have also been used to support the management of chronic pain and fatigue that patients undergoing chemotherapy frequently experience, helping to improve both their interpretation of symptoms and the management of their lives at the behavioral level in the context of functional impairments. [ 32 ] [ 33 ] In this context, the influence of improved self-regulation on the survival of people with breast cancer and colon cancer has also been investigated. [ 34 ]
Mindfulness is a rapidly developing area of interest as a common element in various treatments for mental disorders [ 35 ], having shown its effectiveness in relieving symptoms of depression and anxiety [ 36 ] [ 37 ]. Mindfulness-based stress reduction, specifically developed to help patients with cancer, has proven effective in reducing the level of cancer-related stress [ 38 ]. Recently, the possibility of applying digital psychotherapy as a low-cost and readily accessible treatment method has been studied [ 39 ].
Given the awareness of the prevalence of psychological distress accompanying a cancer diagnosis, and the intensified efforts to integrate evidence-based psychosocial treatments into general cancer care, screening for adaptation to diagnosis and treatment has become more common. [ 40 ] Regular screening for distress throughout the process of cancer treatment (for example, diagnosis, treatment, recovery) is critically important for identifying individuals already experiencing symptoms of depression or anxiety, or for identifying those who are at risk of developing psychological problems associated with cancer. Historically, there has been a lack of communication between patients and physicians on matters of psychological adaptation concerning adaptation to the diagnosis, living with cancer, living without cancer during the period of recovery, or the transition to palliative care. The stigmatized nature of psychological problems has made it difficult to identify those patients who could benefit from early intervention to prevent or attenuate symptoms of depression or anxiety that may arise.
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