1. Psycho-Oncology and Palliative Care: Potential Contributions*
07/16/96
Psycho-Oncology and Palliative Care: Potential Contributions
Jimmie C. Holland, M.D.
Founding President,
International Psycho-Oncology Society
Attending Psychiatrist, Psychiatry& Behavioral Sciences
Memorial Sloan-Kettering Cancer Center *

2. PSYCHO-ONCOLOGY Definition
Multidisciplinary subspecialty of oncology concerned with the emotional responses of patients at all stages of disease, their families and staff (psychosocial)
The psychological, social and behavioral variables that influence cancer prevention, risk and survival (cancer control)

3. HISTORICAL BARRIERS – 1 Double Stigma
Patients not told their diagnosis and psychological responses could not be explored
Mental disorders/illness long feared and stigmatized

4. HISTORICAL BARRIERS – 2
Belief that subjective phenomena (pain, feelings) could not be quantitatively measured
Patient’s self-report was considered unreliable (only observer ratings reliable)
Social science methods were not understood by basic scientists

5. Basic to Psycho-Oncology Research*
07/16/96
Basic to Psycho-Oncology Research
Developed and validated quantitative measures of subjective symptoms
QOL
Core and disease specific modules
Pain
Fatigue
Distress
Anxiety
Depression
Delirium *

6. Barriers to Psych-Oncology Issues in Palliative Care
Attitudes of medical staff that assume the “nonphysical” psychological domain as less
important
Attitudes of patients and family: “Think I’m crazy”: embarrassed, angry by mental health consultation
Attitudes may discourage integration of mental health member of palliative care team

7. Barriers to Psych-Oncology Issues in Palliative Care
Absence of training of palliative care team in recognition, diagnosis and management of distress and absence of an algorithm when to refer to mental health
Inadequate funding for mental health counselors as compared to medical
Absence of minimum standards and accountability for psychological, social care and for meeting existential, spiritual needs

8. Barriers to Psych-Oncology Issues in Palliative Care
Inadequate numbers of well-trained mental health professionals in psychosocial care
Too few training programs
Absence of oversight of staff in management of psychosocial/ psychiatric problems

9. Advanced Cancer Requires Coping With
Physical symptoms (pain, fatigue)
Psychological (fears, sadness)
Social (family, future)
Spiritual – seeking a comforting philosophical, religious, or spiritual beliefs
Existential – seeking meaning of life in the face of death

10. EXISTENTIAL CRISES IN CANCER
DIAGNOSIS OF CANCER
ADVANCING
DISEASE;
DNR; HOSPICE
RECURRENCE OF
DISEASE
COMPLETION
TREATMENT
DEATH
INITIAL
N.E.D.
TERMINAL
PALLIATIVE
“I could
die from
this.”
“I have
survived --
will it
Return?”
“I will
likely die” --
depressed;
anxious
“I am
dying.”
Adapted from McCormick & Conley, 1995

11. “We are not ourselves when nature, being oppressed, commands the mind to suffer with the body”
King Lear, Act II, Sc. IV, L

12. What to call this constellation of non physical aspects of severe illness?
“Suffering of the mind”
“Existential crisis”
“Human side”
Overlapping psychological and spiritual domains: psychospiritual crisis

13. Psychospiritual Crisis of ILLNESS
Loss of meaning
Loss of control (helpless)
Need for connection to some larger whole, greater than self
J. Kass, 1996

14. Spiritual and Religious Beliefs Provide
A way of coping and feeling in control despite the uncertainty, treat of death, the unknown, and loss
A set of moral values
Comforting rituals (prayer, mediation)
An existential perspective (meaning of life, death, connection to greater whole)
Support (emotional and tangible) of those who share similar beliefs

15. DISTRESS in Cancer
An unpleasant emotional experience of a psychological, social and/or spiritual nature which extends on a continuum from normal feelings of vulnerability, sadness and fears to disabling problems such as depression, anxiety, panic, social isolation and spiritual crisis.
Adapted, NCCN

16. Contributions to Care - 1
Psychological interventions unique for palliative care
Meaning-centered therapies
 Frankl Meaning-Based
Breitbart
 Dignity-Conserving
Chochinov
 Meaning-Folkman
Holland

17. Folkman-based Psychotherapy
Help patient reconcile life goals and plans with constraints of illness and loss
Use beliefs, values, prior strengths, to find a new and tolerable meaning of life in the face of death

18. Contributions to Care - 2
Concern for family members
 Identifying their concerns Conflict, needs (distress levels are as high as patients)
 Evaluation of minor children-guidance in how to talk to them
 Grief counseling for family

19. Contributions to Care - 3
Education of staff and patients that seeking treatment for psychological problems is not a sign of weakness
Advocate as a team member to psychosocial and “human” side of care

20. Treatment Guidelines for Mental Health Professionals
DSM-IV Diagnoses
Dementia
Delirium
Mood disorder (depression)
Adjustment disorder
(reactive anxiety/depression)
Anxiety disorder
Substance abuse
Personality disorder

21. Treatment Guidelines for Social Work
Practical Problems
housing, assistance
Psychosocial Problems
family conflict
communication
culture/language

22. Treatment Guidelines for Pastoral Counseling
Death/afterlife
Loss of faith/meaning
Grief
Isolation from religious community
Guilt
Hopelessness

23. NCCN Clinical Practice Guidelines for
NCCN Clinical Practice Guidelines for distress have been modified for end-of- life care – they should be tested in a clinical setting
Holland & Chertkov, 2001
IOM Improving Palliative-Care

24. Contributions to Care – Burnout
Mental health of Staff
Physicians’ acknowledged feelings
(anger, frustration, depression)
Affect
Clinical decisions
Behavior with patients
Quality of care
Risk of burnout
Meier et al, 2002

25. Common Burnout Symptoms
PSYCHOLOGICAL
Frustration
Irritability
Tense, sad feeling
Anger
Withdrawn; “Numb”
Detached emotionally
Cynical about work
PHYSICAL
Fatigue
Insomnia
Headaches
Back aches
Appetite change
GI disturbance

26. UK Study 476 Oncologists Burnout Emotional exhaustion 31%
Low personal Accomplish 33%
Diminished Empathy 23%
Psychiatric Disorder (GHI) 28%
Ramirez et al, BMJ, 1995

28. Research Directions - 1
Pro inflammatory cytokines as cause for fatigue, poor concentration, depression, anxiety
(↑ in pancreatic patients)

29. Research Directions - 2 Cytokine-induced Sickness behavior in animals
Several cancer-related symptoms
Fatigue
Pain
Anxiety
Depression
Cognitive loss
Weakness

30. C. Cleeland, et al, Cancer, 2003, Working Group
Research Directions - 3
C. Cleeland, et al, Cancer, 2003, Working Group

31. Research Directions - 4
Genetic contributions to chemo- related cognitive deficit
APOE4 allele
Fatigue (DYPD over expression)

32. “…. the secret of the care of the. patient is in caring for the
“….the secret of the care of the patient is in caring for the patient.”
Peabody, JAMA
1926

33. IPOS Liaison to National Psycho-Oncology Societies

34. 8th WORLD CONGRESS PSYCHO-ONCOLOGY
"Multidisciplinary Psychosocial Oncology:
Dialogue and Interaction"
October 2006
Palazzo del Cinema Venice, Italy
Details will continue to be posted on the conference website at