Cancer Patients Have Much to Gain From Psychiatric Treatment

During the past decade, provocative insights into the psyche and cancer have emerged.

For example, new studies refute earlier findings suggesting that stress can cause cancer, David Kissane, M.D., chair of psychiatry at Memorial Sloan-Kettering Cancer Center, reported during an interview. A prime example of one of these new studies, he said, was one conducted in Denmark. Using Denmark’s comprehensive national database, researchers assessed whether women who had a child die were more prone to cancer than matched controls. They found no such link. So it looks as if it may be “a myth that stress causes cancer,” Kissane said.

General emotional distress, maladaptive coping strategies, and psychiatric disorders such as anxiety and depression are common in cancer patients—in about 25 percent to 30 percent of them, Luigi Grassi, M.D., chair of psychiatry at the University of Ferrara in Italy and chair of the International Federation of Psycho-Oncology Societies, told Psychiatric News.

Depression can not only negatively impact cancer patients’ quality of life, but can reduce their chances of survival, just as it can in heart-disease patients, David Spiegel, M.D., said during an interview. Spiegel, an associate chair of psychiatry at Stanford University, is also a psycho-oncologist.

Yet effective treatment of depression may increase the chances of survival. A study conducted by Spiegel and his colleagues and published December 13, 2010, in the Journal of Clinical Oncology found that a decrease in depression symptoms was associated with longer survival in metastatic breast cancer patients.

Research during the past decade has also shown that various psychotherapies developed for cancer patients, such as supportive-expressive therapy, meaning-centered therapy, dignity therapy, cognitive-existential therapy, and cognitive-behavioral therapy (CBT) for reducing fear of cancer recurrence, can improve patients’ quality of life, Grassi stated.

Moreover, CBT can help women with breast cancer not only reduce negative emotions and levels of cortisol and increase positive emotions and levels of interferon, but reduce expression of genes likely to contribute to the cancer process, research by Michael Antoni, Ph.D., a professor of psychiatry at the University of Miami, and his team reported last November in Biological Psychiatry.

“Michael Antoni and his group have been doing elegant, groundbreaking work in psycho-oncology for a number of years,” Michelle Riba, M.D., director of the psycho-oncology program at the University of Michigan and a past APA president, told Psychiatric News. “Their current research is exciting. While the sample size was small, and this work will need to be replicated, it gives us important research directions that can help us determine more personalized types of treatment, impacting on morbidity and mortality of patients with cancer.”

Yet researchers need to learn more about how these psychotherapies for cancer work and whether they share common mechanisms of action, Spiegel noted. And there are other important unanswered questions about the psyche and cancer as well, he noted.

For instance, some SSRI antidepressants can interfere with the metabolism of the breast cancer drug tamoxifen. Thus more needs to be learned about potential interactions between psychotropic medications and cancer drugs. The cytokine interferon, which is used to treat certain cancers, can lead to depression and even suicide. How interferon triggers depression and how interferon-triggered depression can be prevented need to be determined. Some individuals who receive chemotherapy, as well as some who get androgens as a cancer treatment, complain that their brains no longer seem to function as well as they used to. More needs to be learned about the brain areas impacted by this disturbance—which some call “chemo-brain” or “chemo-fog.”

“Actually one of the big concerns resulting from cancer treatments during the last decade has been the impact that they can have on cognitive function,” Kissane noted. “And it is leading to some efforts to develop cognitive rehabilitation therapies [for individuals with so-called chemo-brain or chemo-fog].”

“I would say that one of the biggest unanswered questions about the psyche and cancer—and certainly the most controversial one—is whether psychological interventions can extend survival in cancer patients,” Fawzy Fawzy, M.D., vice-chair of psychiatry at the University of California, Los Angeles, and a scientist who has worked in this area, said during an interview. But even if such interventions don’t extend survival, “if we are able to improve patients’ psychological states, that is good enough,” Fawzy said.

Meanwhile, there is a lot that psychiatrists can do to aid cancer patients (see More Psychiatrists Needed and What Drew Psychiatrist to Cancer Patients?).

For example, cancer patients need to be evaluated for common comorbid conditions such as depression and anxiety and for less common ones such as delirium, psychosis, or dementia, Spiegel advised.

When cancer patients are afflicted with anxiety, depression, or other psychological problems, psychiatrists can help them not just with psychotropic drugs, but with psychotherapies designed expressly for them, Grassi suggested.

When smokers and drinkers develop head and neck cancers, their families sometimes blame them for getting cancer rather than supporting them. In such instances, the psychiatrist can work with the patient to alleviate guilt and with the family to have greater understanding, Riba advised. “It is hard to deal with this toward the end,” she admitted. “But it is important for everybody to heal.”

“With longer cancer-patient survival, the Elizabeth Kubler-Ross stages are no longer an adequate way to think about death and dying,” Randy Hillard, M.D., a Michigan State University psychiatrist battling stomach cancer (see below) emphasized. “Now, with effective treatments, new therapies on the horizon, and longer average survival, the process of dying is a lot more cyclical and complex for patients and their families. Thus, the most important thing that psychiatrists can do to help patients and their families is to transition from feeling ‘I’m dying of cancer’ to ‘I’m living with cancer.’ ”

Still another way psychiatrists can help cancer patients, Hillard suggested, is to point them toward the CaringBridge Web site— www.caringbridge.com. CaringBridge is a nonprofit charitable organization. Cancer patients can set up a blog through CaringBridge at no cost and stay in touch with family, friends, and interested strangers. Hillard maintained a CaringBridge blog during the months after he was diagnosed with cancer and found it incredibly supportive and healing, he said.