What Every Mental Health Provider Should Know About Cancer Survivorship

“What Every Mental Health Provider Should Know About Cancer Survivorship” was presented at the Minnesota Psychological Association Friday Forum series on March 6, 2015. Drs. Morrison, Ehlers, and Staab focused on three key questions for treating cancer patients and survivors: What do we know?; How can we identify?; and  How can we treat?

Beginning in 2015, the American College of Surgeons (ACoS) Commission on Cancer requires that all comprehensive cancer centers, in order to maintain accreditation, screen for depression and anxiety symptoms, provide mental health referral when needed, and monitor psychosocial symptoms until remission and beyond. As the number of cancer survivors continues to increase in our state, mental health professionals in Minnesota will undoubtedly encounter cancer patients and survivors, regardless of the professional context of their practice or whether cancer is the primary presenting problem.

What do we know?

The number of cancer survivors in the United States continues to grow. In recent reports by the American Cancer Society (ACS) and National Cancer Institute (NCI),(1,2) nearly 14.5 million Americans with a history of cancer were alive on January 1, 2014. This figure is estimated to grow to 19 million by January 1, 2024. Research shows that cancer diagnosis and survivorship are associated with long-term physical and psychological effects impacting the cancer survivor’s quality of life.(3) While there is no universal definition of cancer survivorship, the overall conceptualization recognizes phases defined by diagnosis, active treatment, and post-treatment. This is an overarching definition that includes family members and friends as “survivors.”

Lung, prostate (male), breast (female), and colorectal cancers have both the highest incidence rates and mortality rates in the U.S. Despite improved medical screening approaches for early cancer detection, patients may underuse these resources due to lack of knowledge, psychological distress (e.g., fear, anxiety), and/or poor access to quality health care. Cancer health disparities threaten the patient’s chance for optimal survivorship after a cancer diagnosis, to include racial/ethnic, lower socioeconomic status, rural, and LGBTQ patient groups. Behavioral factors in cancer may also place patients at greater risk for onset and/or recurrence of cancer, and worse cancer outcomes. Tobacco use, alcohol and other substance use, poor nutrition, obesity, and sedentary lifestyle all place patients at greater risk for worse physical, functional, and psychological outcomes.

Patients often present with physical, functional, and psychological symptoms.  Physical symptoms may be the result of cancer disease (e.g., tumor growth) or treatment (e.g., surgery, chemotherapy, radiation side effects), and may be acute, chronic, or late-emerging. Assessing the severity, persistence, and concurrence of cancer symptoms (e.g., the well-studied Pain-Depression-Fatigue symptom cluster(4)) is critical. While certain symptoms are widely assessed, such as pain, weight change, or gastrointestinal symptoms, others also require attention (e.g., infertility, sexual morbidity, cognitive changes or “chemobrain”). Risk factors for psychological distress include, but are not limited to, younger age, cancer type, advanced disease, poor prognosis, and personal or familial psychiatric history. Adjustment disorder is the most common mental health diagnosis in the cancer context, typically reflecting distress-related functional impairment in social, occupational, or other important areas of functioning.  Due to distress, patients may experience reduced ability to organize and adhere to their cancer care regimen or maintain a typical level of performance in life roles.  Differential diagnosis is complicated by physical symptoms such as fatigue.

How can we identify?

Cancer-related developmental disruption is a necessary consideration, as children, adolescents/young adults, middle-age adults, and older adults each have unique life phase experiences that are impacted by cancer. In the adult population, widely used measures have been identified to determine clinically relevant distress in cancer. The Patient Health Questionnaire(5) (PHQ-9) has a traditional cut-off score of 10 to determine clinically relevant depressive symptoms; however a score of 8 has been identified to be more appropriate in the cancer context.(6) The Generalized Anxiety Disorder questionnaire (7) (GAD-7) has yet to be standardized in cancer populations; though it is suggested that the traditional cut-off score of 10 remains suitable for identifying significant anxiety in cancer.(6) Differential diagnosis relies on the careful assessment of affective and psychological symptoms, above and beyond neurovegetative symptoms.

How can we treat?

The etiology of psychiatric illness in cancer is unclear, but is likely multifactorial, involving biological, psychological, and social factors.  Use of psychotropic medications is higher in U.S. cancer survivors than the general population. Some cancer medications impact mood (e.g., steroids) and drug-drug interactions can impact cancer treatment effectiveness (e.g., certain antidepressants and cancer preventives). The side effects of some antidepressants may be beneficial, for example by stimulating appetite or counteracting fatigue. Careful and informed prescription of antidepressants, benzodiazepines, and antipsychotics are useful in treating physical effects of disease, distress, and psychiatric disorder in cancer.

Psychological interventions have been shown to reduce anxiety, stress, and depressive symptoms;(8-11) improve physical functioning and reduce symptom burden; (8,11,13) improve social functioning;(8) improve health behaviors such as tobacco use and physical activity,(8) and improve quality of life.(9,10) These interventions also demonstrate improved endocrine, immune functioning, and survival.(8,9,11,12,13) Trained  with specific knowledge about the psychosocial implications across the phases of cancer survivorship, mental health providers are well-positioned to tailor psychotherapeutic approaches to the unique cancer experience. Targets for therapy are overarching, from depression and anxiety, to medication and appointment adherence, stress management, optimizing communication and other social skills, addressing sexual health concerns, physical symptom management, and health behavior change to optimize cancer treatment outcomes. This includes providing intervention for caregivers, who may experience as much distress as the patients for whom they provide care.

There are various local and national resources available to providers and patients. Refer to the American Cancer Society and National Cancer Institute websites for more information. Evidence-based trainings for providers who treat cancer are also available (Cancer to Health Training Institute, http://cancertohealth.osu.edu/).

Footnotes

(1) DeSantis et al.2014. Cancer treatment and survivorship statistics, 2014. CA Cancer J Clin.

(2) American Cancer Society. Cancer Facts & Figures 2014. Atlanta: American Cancer Society; 2014.

(3) Stein et al., 2008. Cancer 2008;112(11 suppl):2577–92.

(4) National Institutes of Health State-of-the-Science Conference Statement. 2002. J Natl Cancer Inst 95;15:1110–7.

(5) Kroenke, Spitzer, & Williams. 2001. J Gen Intern Med. 2001 Sep; 16(9):606-13.

(6) Andersen et al., 2014. J Clin Onc, 32, 15, 1605-1620.

(7) Spitzer, Kroenke, Williams, & Löwe. 2006. Arch Intern Med. 166(10):1092-7.

(8) Andersen et al. 2004. J Clin Onc, 22(17), 3570-3580

(9) Carlson et al. 2013. J Clin Onc, 31 (25), 3119-3127.

(10) Clark et al. 2013. Cancer, 119, 880-887.

(11) Antoni et al. 2001. Health Psychology, 20(1), 20-32.

(12) Antoni. 2013. Brain Behav Immun. 2013 March; 30 (Suppl): S88–S98.

(13) Fawzy et al. 2003. Archives of General Psychiatry, 60(1), 100-103.

Eleshia Morrison, Ph.D., L.P., is a licensed psychologist and postdoctoral fellow in medical psychology at Mayo Clinic, Rochester, MN, in the Department of Psychiatry and Psychology. She completed her doctorate in clinical psychology at The Ohio State University with an emphasis in health psychology. Her clinical work and research are specialized in psychosocial oncology and blood and marrow transplantation. Her research is focused on psychological responses, physical symptom burden, and quality of life in cancer patients and survivors.

Shawna L. Ehlers, Ph.D., L.P., ABPP, is diplomate of the American Board of Professional Psychology in the specialty of Clinical Health Psychology (ABPP-CHP).  She maintains expertise in treating psychological and behavioral factors to optimize oncology outcomes.  She is an Associate Professor, and faculty member of the Mayo Clinic Clinical Health Psychology Fellowship (Department of Psychiatry and Psychology) and Mayo Clinic Graduate School (Rochester, MN).  Her research program focuses on psychological and behavioral factors in outcomes for oncology, blood and marrow transplantation, and other medical populations. 

Jeffrey P. Staab, M.D., M.S., is an Associate Professor of Psychiatry in the Department of Psychiatry and Psychology at Mayo Clinic, Rochester, MN, where he and his team in the Behavioral Medicine Program evaluate and treat more than 1200 patients with functional, somatic symptom, and medical-psychiatric disorders each year.  His research covers a range of problems at the interface of psychiatry and medicine, including illness anxiety and functional neurologic disorders.  Dr. Staab completed his medical education at the University of Pittsburgh and his internal medicine internship and psychiatry residency at the National Naval Medical Center in Bethesda, MD.

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