|CANCER & TREATMENTS FOR CANCER CENTER PATIENTS PREVENTION & RISK ASSESSMENT CLINICAL TRIALS & RESEARCH LIVING WITH CANCER|
Progress, Fall 2004
Frequently Asked Questions
The Emotional Dimensions of Cancer
Cancer breeds questions. At the U-M Comprehensive Cancer Center, we face tough questions every day -- in our clinics, our laboratories, our classrooms and our community -- and we know we're only as good as our latest answer. In this installment of Frequently Asked Questions, we take on the emotional aspects of cancer. To help, we've asked Michelle Riba, M.D., clinical professor of psychiatry, who directs the Cancer Center's newest multidisciplinary area to care for cancer patients and families, the PsychOncology Clinic. Dr. Riba also serves as the current president of the American Psychiatric Association.
First, tell us about your new clinic. What exactly is PsychOncology?
The term PsychOncology is a rather new one, referring to a field of psychiatry that integrates the emotinoal issues associated with cancer. It's important to consider that before someone is diagnosed with cancer, they already have a history -- a medical, psychological and psychosocial history. That history may include major or minor episodes of psychological distress, substance abuse or other issues. With the trauma of cancer, there may be other issues to deal with, from depression or anxiety to the myriad of concerns impacting the family -- remember, cancer rarely affects just one person. So PsychOncology looks at the entire context -- before, during and after cancer -- and provides the most appropriate care at each stage.
Although we've been providing psychological support to patients and families for some time, what's new is that we now have dedicated space to see those patients who need immediate care without requiring an appointment.
Since cancer is, as you say, a trauma, it's hard to imagine anyone going through it without some emotional impact.How can a patient or family member determine whether their situation has reached a point where they should seek professional help?
Your question raises a few important points. First -- patients needn't feel alone in determining whether to ask questions or seek help for their emotional health. Part of our mission is to train Cancer Center clinicians to better anticipate and monitor the emotional needs of our patients -- that's part of comprehensive care. Second -- things don't have to escalate to a crisis before they receive attention. Our goal is to create an environment where patients feel comfortable telling a nurse or doctor about all of their symptoms, including emotional symptoms. Our staff, too, needs to ask questions and leave the door open to talk about issues. That includes both past problems and current worries -- both can impact the patient's health. There's a stigma surrounding psychiatric illness, yet conditions like depression, anxiety and panic affect 30-40 percent of the population. We need to open the door and get the conversation going.
For both patients and clinicians, do you have any suggestions for starting that conversation?
Although every situation is unique, we do know that along the road from diagnosis through recovery, there are some common points that present problems for many people, as well as opportunities for conversations. It's a good idea for both patients and caregivers to anticipate these "bumps" in the road: When the diagnosis is received, patients can be overwhelmed by technical information, and afraid and anxious about making choices. They may feel out of control, and feel too exhausted to consider seeking additional opinions. During initial treatment, some patients may feel somewhat relieved to have a treatment plan to follow. But although the uncertainty may abate, it may be replaced with pain, and difficulty dealing with changes in appearance, energy, sex drives and other physical adjustments. After their initial recovery, although the acute phase is over, they may face another emotional danger point -- returning to their "normal" routine -- no longer seeing their physician regularly, and returning to work, school and daily responsibilities.
Finally, we also know that longterm survivors may experience anxiety when facing their regular check-ups, anticipating the possibility of recurrence. So the possibility of distress is heightened at any one of a number of points along the path.We're trying to train our doctors, nurses and social workers to be ready to listen and learn at these and other points.
Do you find that cancer patients are reluctant to raise emotional issues because they fear they will distract from their treatment?
Yes. Several reasons may keep these issues hidden. For example, many patients don't want to discuss their past -- they worry their doctor will think ill of them, and perhaps conclude they're not strong enough to endure the proper dose of medication or chemotherapy. Also, if they have a history of substance abuse, they may fear they won't be prescribed pain medication.
Patients may also have difficulty describing their emotional symptoms, or may fear their issues will not be taken seriously. A good example is what's commonly referred to as "ChemoBrain," a fuzzy-headed feeling sometimes experienced during treatment. Some assume that the problem is due to chemotherapy drugs, but it may not be that simple. Although some drugs – notably cisplatin— have been shown to affect concentration, other factors, including the cancer itself, along with anemia, fatigue, sleep problems, depression and anxiety can all contribute as well. It’s a complicated puzzle. That’s why many in our field are conducting research to try and understand how these different variables interact.
A related challenge is that many cancer patients receive chemotherapy “cocktails” – mixtures of powerful medications. One medication may be administered to counteract the adverse reaction of another. For example, to compensate for inflammation, a medication may be added that may cause sleep disruption or jitteriness, sometimes leading to anxiety.The drug intended to fight the cancer isn’t necessarily causing the anxiety.
It’s important for patients experiencing distress to receive a proper assessment to determine the best course of action. Emotional distress during treatment is very real, but unfortunately, in many cases there may be no better medical alternative to attack their cancer. It doesn’t mean their care team doesn’t appreciate the gravity of their symptoms, and won’t look for ways to minimize their distress if possible.That’s why patients need to be empowered to keep track of their symptoms and express themselves – to help identify those opportunities.
It’s vital that caregivers know the patient’s history, as well as what worries the patient today. It’s our responsibility to provide a safe and open place for people to tell their story and ask for help – it doesn’t detract from treatment – it enhances treatment.
What tools are you giving the staff to help them open an emotional dialogue while they're delivering treatment?
That is one of our biggest challenges. One of the most important tools we're using is a screening questionnaire to help determine the level of distress in patients and families.Through a series of questions, they can assess whether distress is mild, moderate or severe.When distress is mild, it may be related to issues like finance, transportation, employment or family dynamics -- issues that can often be addressed by providing more education or information. So the next step for these patients is a referral to a social worker or the Patient Education Resource Center (PERC). One of the most common questions patients need resolved is how to tell their children about their cancer.The PERC has a wealth of materials to prepare parents for that discussion. If the screening tool indicates moderate or severe distress, we may move next to a psychiatric evaluation, perhaps followed by individual or group therapy. But the initial tool is relatively easy to administer, for both the clinician and the patient, and can open the door to a better discussion of the underlying issues, before things become critical. The bottom line: Patients deserve world class care that addresses both their medical and their emotional needs.
To learn more about the Multidisciplinary PsychOncology Clinic at the U-M Cancer Center, please call the Cancer AnswerLine™ toll free at 800-865-1125.