Transcript Document

THE FOLLOWING LECTURE HAS BEEN APPROVED FOR
ALL STUDENTS
BY BIRMINGHAM CITY UNIVERSITY
This lecture may contain information, ideas,
concepts and discursive anecdotes that may be
thought provoking and challenging
Any issues raised in the lecture may require the
viewer to engage in further thought, insight,
reflection or critical evaluation
Behavioural aspects of
Cancer
Dr. Craig Jackson
Senior Lecturer in Health Psychology
School of Health and Policy Studies
Faculty of Health & Community Care
University of Central England
[email protected]
Cancer
Lottery of Life?
Pragmatic attitude to cancer
“No Cure for Cancer” - D.Leary
“Cancer lurks deep in the sweetest bud” – W.Shakespeare
Most funding directed at cure
Psychological & Behavioural considerations
Cancer
• Most feared of diseases
• 190+ Cancer types – NCI
• Distress in carers, patients, family, professionals
• Unpleasant and slow way to die
• Few develop psychiatric illness
• Psychological and Social problems more common
Pain
Nausea
Fatigue
Finances
Employment
Housing
Childcare
Family
Spiritual doubts
• Well-planned care can minimize this
Quality of Life
“There is surely a place for research into psychological interventions that
improve quality of life for patients after diagnosis or treatment.
Maybe happiness (or reduced unhappiness) has some effect on survival.”
Letter to BMJ, Nov 2002
Rene Descartes – division of body and mind
Biopsychosocial model reunified body & mind
Studies should incorporate the patient's perspective of outcome
Essential to provide evidence of impact on patient in terms of
(i) Health status
(ii) Health-related quality of life
Traditional model of Disease Development
Pathogen
Modifiers
Lifestyle
Individual susceptibility
Disease (pathology)
Biopsychosocial model of Illness
Hazard
Illness (well-being)
Psychosocial Factors
Attitudes
Behaviour
Quality of Life
Psychological Consequences
• Distress
• Reduced QoL
• Delay seeking help
Fear
Denial
• Depressed / Anxious
• Increased somatic complaints
Pain
Fatigue
• Adjustment Disorder – commonest psychiatric diagnosis
• Neuropsychiatric complications
• Increased risk of suicide in early stages
Breathlessness
Depression
• Response to perceived loss
• Awareness of losses to come = bereavement
• Loss of body, family, friends, role, life
• Severe depression X4 likely in cancer patients
• 10-20% of patients
Anxiety
• Response to perceived threat
• Apprehension, Worry, Restlessness, Panic attacks, Avoidance
• Over-estimate risk of treatment / likelihood of poor outcome
• Heighten perception of physical symptoms
• Specific cancers = Specific fears
Head and Neck cancers:
breathing
swallowing
• Develop phobias over treatments e.g. chemotherapy
Brain Structure
Neuropsychiatric syndromes
• Brain metastases = Delirium, Dementia
Orig. lung, breast, alimentary tract or melanomas
• Produce psych. symptoms before discovery
• Paraneoplastic Syndromes
Neuropsychiatric problems in absence of metastases
Orig. lung, ovary, breast, stomach, or Hodgkin’s
Neuropsychiatric syndromes
• 61 yr old female
• Frontal headaches for 3 months
• Lethargic and weak
• Difficulty walking
• Diffuse areas of nodular destructive
lesions
• Consistent with multiple myeloma or
metastatic disease
• Skeleton is common site for mets from carcinomas and occasionally sarcomas
• Lesions may be “silent” or symptomatic, such as pain, swelling, deformity,
compression of the spinal cord, nerve roots, or pathologic fractures.
Challenges to cancer patients
• Keep active
• Keep independence
• Coping with treatment side-effects
• Accept cancer
• Maintain positive outlook
• Seek / understanding medical info
• Regulate emotions
• Seek support
• Manage stress
Distress
Distress is an unpleasant emotional
experience of a psychological, social, or
spiritual nature that may interfere with a
patient's ability to cope with cancer and its
treatment.
Not always
Fear of cancer
e.g. Fallowfield 1986
Fear of treatment
Mastectomy patients no worse than “breast
Fear of treatment disfigurement
conserved” patients in post-op sex life
Vulnerable Sadness Fear Depression Anxiety Panic Isolation Crisis
Distress
Practical problems
housing
insurance
transport
child care
work / school
Family problems
dealing with partner
dealing with children
Emotional problems
worry
fears
sadness
guilt
Spiritual / religious concerns
relating to god loss of faith
depression
nervousness
Distress
Physical problems
Pain
Nausea
Fatigue
Sleep
Getting around
Bathing/dressing
Breathing
Mouth sores
Eating
Indigestion
Constipation
Diarrhoea
Changes in urination
Fevers
Skin dry / itchy
Nose dry/congested
Tingling in hands/feet
Feeling swollen
Sexual
Holland, JC: Update: NCCN Practice Guidelines for the Management of
Psychosocial Distress. Oncology 13:No 11A: 459-507, 1999.
Vulnerability to Distress
Closely related to pre-existing vulnerability
Not related to cancer type
Occurs at specific points of cancer experience
• Diagnosis
• Treatment
• End of treatment
• Post treatment
• Recurrence
• Terminal disease
Stress of Diagnosis
Stressful
Uncertainty
Shock, anger, disbelief, distress
May resolve spontaneously
High distress may predict later larger emotional problems
Stress of Treatment
Stressful
Hospital attendance
Hospital admission
Unpleasant therapy
surgery, radiotherapy, chemotherapy
Side effects
Disfigurement
Apparent treatment failure / Treatment lag
Stress of Systemic Therapy
(chemotherapy and endocrine therapy)
Decrease sexual desire (Silerfarab et al1980)
Effects body image (Falllowfield & Clark 1990)
Ovarian ablation induces early menopause (see young women)
Endocrine therapies induce menopausal symptoms
Stress of Radiotherapy
Fear of radiation
Effects on partners and family (Schover and Jenson)
Cycle of treatments, anticipation and side effects
Depression and anxiety makes side-effects worse
Selecting a QoL Assessment
Generic or specific test
Index or profile
Single instrument or battery?
Is it suitable for target population
Is it psychometrically sound?
Which response format is used?
What is the time frame?
Method of administration?
Who will complete assessment?
QoL Assessments for Cancer Patients
Generic
Nottingham Health Profile (NHP)
Sickness Impact Profile (SIP)
Medical Outcomes Survey (MOS SF36)
Specific
Functional
QoL – State Trait Anxiety Inventory (STAI)
Population
Paediatric Functional Independence measure (PFIM)
Disease
Arthritis Impact Measurement Scale (AIMS)
Why Physicians Ignore QoL
Feel that clinical judgement is sufficient
Do not know which tests to use
“Takes too much time”
Think that the patient will get upset
Do not know how to analyse tests
Do not know how to interpret data
e.g.
Charing Cross Hospital Study
Prietman and Baum (1978)
QoL is BEST predictor of prognosis
Better predictor than tumour size!
Stress at End of Treatment
Rebound distress - fear of spread or recurrence
Ending prolonged relationship with treatment centre
Loss
Vulnerability
Delayed reaction to enormity of it all
Stress After Treatment
Survivors re-order their life
Psychological benefits / Greater appreciation of life
Continuing preoccupation with loss, illness and avoidance
Health anxiety
Fear of reoccurrence
Misinterpretation of physical sensations
Reassurance seeking
Stress of Recurrence
Cured patients more devastated by any recurrence
Greater risk of severe distress
Worse than initial diagnosis
Stress of Terminal Disease
40% cancer patients die
Fear of uncontrolled pain, dying, death, and fate of loved ones
Depression common
Worse in those with poorly controlled physical symptoms
Risk Factors for Psychiatric Disorder
Patient sources
History of psychiatric disorder
Social isolation
Dissatisfaction with medical care
Poor coping style
Cancer sources
Limitation of activity
Disfigurement
Poor prognosis
Treatment sources
Disfigurement
Isolation
Side effects
Issues for Planning Care
• Patient / Family understand illness & treatment
• Patient / Family understand help available
• Explain symptomatic relief provision
• Patient involvement in care
• Management of treatment plan
• Routine & emergency contact arrangements
• Practical everyday help
• Home support
• Involve / Support family and friends
Psychological Care for Cancer Patients
• PRIMARY CARE
• Multidisciplinary skills
• Individually agreed collaborative care
• Regular liaison with units / agencies
• Local training
• SPECIALIST UNITS
• Training in psychological aspects
• Regular review of treatment plans
• Understand “at risk” stages
• Specialist nurses, psychiatrists and psychologists
• Self-help methods and specialist agencies
Psychological Care for Cancer Patients
• Benefits QoL
• Improve survival (time)
• Psych care delivered in Primary Care
• Staff need skills
• Psychological care overlooked by medical focus on treatment
• Good case managers needed
• Active screening for Depression and Anxiety
• Patients can be distressed due to non-cancer reasons
Treatment
• Information
• Social Support
• Addressing worries
• Managing Anxiety
Accurate info Symptom details
Practical help
Short-term prescription of anxiolytics
• Managing Depression
Non-differential management from non-cancer patients
Empathy
Reassurance
Practical help
Discussion
CBT for persistent Dep
Specialist Treatment
• Antidepressant Drugs
• Effective drug treatment of Pain, Nausea, & Other symptoms
• Problem solving discussions
• Cognitive Behavioural Therapy of psych. Complications
• Joint / Family interviews
• Group support / treatment
• CBT to cope with unpleasant treatments
• Persistent / severe distress referred onto Psychiatry / Psychology
• Check quality of any non-NHS agency used
Anxiety & Depression Screening
How are you feeling in yourself?
Have you ever been troubled by feeling anxious, nervous or depressed?
What are your main concerns or worries at the moment?
What have you been doing to cope with these? Has it worked?
What effects do you feel cancer and treatment will have on your life?
Is there anything that would help you cope with this?
Who is helping you at the moment?
Standardised Metrics
GHQ
HAD
BDI
Cancer-Related Fatigue
Can occur in upto 96% of cancer cases
Functional syndrome
Can be Acute or Chronic
NOT Chronic Fatigue Syndrome
Causes varied: extreme stress, central nervous system may be affected by
the cancer or therapy, medication (eg tumor necrosis factor decreases
protein stores).
Managing Cancer-Related Fatigue
- Educate on difference between fatigue and depression
- Possible medical causes of fatigue
- Observe rest and activity patterns during the day and over time
- Engage in attention-restoring activities
- Recognise fatigue that is a side effect of certain therapies
- Participate in exercise programs that are realistic
- Avoid activities which cause fatigue
- Identify environmental or activity changes that may help decrease fatigue
- Importance of eating enough food and drinking enough fluids
- Physical therapy may help with nerve or muscle weakness
- Respiratory therapy may help with breathing problems
- Schedule important daily activities during times of less fatigue
- Cancel unimportant activities that cause stress
- To avoid or change a situation that causes stress
- To observe whether treatments being used to help fatigue are working
Stressful Life Events and Breast Cancer
Widespread belief stress causes cancer
Especially Breast Cancer
1701
40% Australian women believe stress causes cancer
Some studies found link between stress and....
Relapse (Ramirez et al. 1989)
Onset of breast cancer (Chen et al. 1995)
Evidence is contradictory
Stressful Life experiences common:
66% of females with lump experienced difficulty in last 5 years
Women diagnosed with breast cancer no more likely to have stressful
experiences before diagnosis (Protheroe et al. 1999)
Gulf War #1 and Cancer Legacy
Liberation of Kuwait, 1991
US used 945,000 rounds of depleted uranium shells
Incidence of cancer and congenital defects in Iraq increased significantly
Rates have doubled since 1991
5 times higher in heavily bombed areas
Misan and Thi-Qar
Risk Factors for Breast Cancer
Female sex
Advanced age
Previous history of breast cancer
Family history
Nulliparity *
Benign breast disease ( Multiple papillomatosis )
Early menarche
Late menopause
Irradiation
Obesity *
Alcohol *
Contraceptive pill & hormone replacement therapy *
* Behavioural
Risk Factors for Colonic Carcenoma
Familial adenomatous polyposis syndrome
Hereditary factors
Ulcerative colitis
Crohn's colitis
Schistosomal colitis
Exposure to radiation *
Villous polyps
Previous surgery
Ureterocolostomy
Diet rich in fat & meats *
High calorie intake *
Low dietary calcium intake *
Low intake of fermentable fibre *
Immunosuppression *
* Behavioural
Risk Factors for Oral Cancer
Cigarette smoking *
Alcohol abuse *
Chewing tobacco *
Chewing of betal nuts *
Industrial chemical agents *
Leukoplakia
Erythroplakia
* Behavioural
The Future.....
Prognostic Markers & Predictive Markers
Behavioural Markers???
Mobile Phone use
Responsibility on sufferer e.g. Lung cancer
Genetic susceptibility
Genetic screening
Individual vulnerability to cancer
Less of a “lottery” – more of a “lifestyle choice” ?
Summary
Indirect behavioural causes of cancer
Direct behavioural causes of cancer
Stress may be an indirect cause of stress
Cancer diagnosis - treatment - afterlife very distressing
Anxiety & Depression are natural responses
Neuropsychiatric syndromes from metastases
Fatigue one of biggest side effects of cancer and treatment
Understand reasons for distress
Some distressed more than others
Management and care is multidisciplinary
Survival rates affected by personality ?
Further Reading
Barraclough J. Cancer and emotion : a practical guide to psycho-oncology.
3rd ed. Chichester: John Wiley, 1998
Burton M, Watson M. Counselling patients with cancer. Chichester: John
Wiley, 1998
Faulkener A, Maguire P. Talking to cancer patients and their relatives. Oxford:
Oxford Medical Publications, 1994
Holland JC. Psycho-oncology. Oxford: Oxford University Press, 1998
Lewis S, Holland JC. The human side of cancer: living with hope, coping with
uncertainty. London: Harper Collins, 2000
Scott JT, Entwistle V, Sowden AJ, Watt I. Recordings or summaries of
consultations for people with cancer. Cochrane Database of Systematic
Reviews. 2001