Damian Sendler Oncologic disease is on the rise as a result of advancements in medicine, better living conditions, and longer life spans. The fact that more and more patients are surviving cancer or living with the disease for an extended period of time is also extremely encouraging. While the fight for survival continues, the importance of improving patients’ quality of life has come to the fore. However, patients’ physical and mental health and well-being are profoundly affected by psychosocial issues, even if these issues don’t directly affect the course of the disease. There has been a recent rise in the field of psycho-oncology, which aims to address these issues and provide support for cancer patients as they face a variety of challenges throughout the disease. Here, we provide a summary of current knowledge on the body-mind interactions in cancer and an overview of the wide range of psycho-oncologic care, paying particular attention to treatment of pain, fatigue, sexual problems and fear of progression.
Damian Jacob Sendler There are a wide range of physical and psychological issues that arise from cancer and its treatments. Physical discomfort, exhaustion, and a diminished sense of self-determination are just a few of the symptoms that can have a significant impact on one’s overall well-being. This has resulted in a dramatic increase in the demand for psychosocial interventions to treat and support patients with cancer and cancer survivors. The development of psycho-oncology as a new interdisciplinary discipline has also been aided by other historical developments. The de-stigmatization of cancer and mental illness, the evolution of the doctor-patient relationship, a shift away from survival rates and life expectancy in favor of quality of life, and the growth of palliative care are a few examples.
Dr. Sendler Oncology’s use of psycho-oncology has grown steadily since the 1970s. Numerous organizations have been formed to coordinate supportive care networks and conduct systematic research, including IPOS (International Psycho-Oncology Society, founded in 1984), national societies in the majority of the world’s industrialized countries, and a slew of guidelines has been developed. In addition, the scope of psychooncologic treatment has been steadily expanding in line with the evolving concept of health-related quality of life.
Psychosocial factors play a role in both the onset and progression of cancer, and the disease itself brings with it a slew of new psychological burdens and changes to one’s life.
In contrast to health behavior and socioeconomic status, the role of stress and personality factors in cancer development and prognosis is less clear1, 2. A variety of cancer-related processes, such as DNA damage and repair, apoptosis, migration and invasion, and angiogenesis, may be affected by the major stress pathways of the hypothalamic-hypopituitary axis and the release of adrenal hormones. Stress has been shown to have a significant impact on tumor genesis and progression in a variety of experimental designs in animal models of disease. 3-7 Such findings have yet to be applied to the treatment of patients. Even though there is a statistically significant correlation between major life events and cancer incidence,8-9, recall bias may distort the results in a retrospective design. Studies in the future have shown that depression, personality traits, life events, and the development of cancer have little or no connection. 10
There is some evidence to suggest that cancer patients who suffer from mental illness, particularly depression, have a worse prognosis.
11,12 However, this correlation has not been proven to have a causal effect. If depression-related processes directly impact cancer progression, or if other, interdependent factors like health behavior mediate this effect is still up in the air.
The question of whether or not psychosocial interventions can help cancer patients live longer has been hotly debated.
13-15 For example, a recent study on nonmetastatic breast cancer found that those who received psychosocial interventions were more likely to live longer than those who did not.16,18 In parallel studies of the same cohort, downregulation of proinflammatory and metastasis-related genes and upregulation of type I interferon response genes were found. 19-21 Psychosocial interventions have yet to be shown to have a significant impact on cancer progression or survival. As research gathers momentum, it’s becoming increasingly clear that stress — and the social support it fosters — both influence the progression of cancer. Figure 2 depicts the role of psychosocial factors in cancer progression and development. Interrelations should not be overemphasized in light of inconsistent evidence and small effect sizes. Medical professionals and the general public tend to underestimate the impact of psychological factors in the development of cancer. In the past, ideas like the “cancer personality” have harmed cancer patients by causing them to attribute guilt to themselves in ways that aren’t true. 22 In light of the current data, it is unjustifiable to force cancer patients to undergo psychotherapy in order to extend their lives.
Psychooncological interventions may not be desired, required, or beneficial for all patients. There is a problem, however, in that many caretakers fail to recognize the need for support and thus fail to meet it. As a result, all cancer patients should be routinely screened for psychooncologic distress to monitor their progress. Distress has been used instead of “psychiatric,” “psychosocial,” or “emotional” because it is more acceptable and less stigmatizing to patients. 24 The National Comprehensive Cancer Network (NCCN) guidelines recommend the use of an easy-to-use distress thermometer and a short list screening for practical, physical, emotional, and family issues, as well as spiritual and religious concerns. 25 Various short screening tools have been analyzed in a comprehensive study. 26 In addition to the screening, the patient should be informed about the variety of psychooncological services available and their desire for psychosocial support should be assessed. Following the discovery of pathological findings, a more thorough clinical evaluation of mental health issues should be conducted, along with recommendations for appropriate treatment options. When patients agree to and utilize appropriate psychosocial services, screening for distress is feasible and leads to better outcomes. 27 However, this is not a universally held opinion. In spite of the fact that most guidelines recommend screening, a systematic review found that the evidence did not support a positive impact on distress symptoms.
Damian Sendler
In cancer patients, pain is one of the most common sources of physical distress. 29 The tumor’s invasive growth is the primary cause of the pain, but it can also be caused by other factors, such as surgery, chemotherapy, or radiation, as well as immobility. The World Health Organization (WHO) cancer pain ladder is used as a guide for medical treatment. 30 Aside from that, mental health care should also be provided. A strong body of evidence shows that pain and emotional distress are interconnected. Multiple meta-analyses and high-quality randomized controlled trials have shown that psychological and cognitive behavioral treatments can reduce pain severity and interfere with function (RCTs). CBT, psychoeducation, hypnosis, relaxation, yoga and exercise have all been shown to be effective in different stages of the disease. 31-34 The goal of these treatments is to help patients better cope with and accept pain, as well as increase their sense of self-efficacy, reframe negative thoughts, modify their behavior, and change their attentional focus. The use of treatment options and communication with health care providers are also supported by educational interventions.
Even though cancer-related fatigue is at least as common and important a cause of distress and reduced function in patients at various stages of the disease as pain, it is less often addressed and recognized by health care providers.
35,36 At the end, 84% of the patients reported fatigue, and even among long-term survivors, between 17% and 56% reported fatigue as a major symptom that negatively affected their quality of life. 37 Frustration is a common symptom of cancer, but its underlying causes are still a mystery. Proinflammatory cytokines, anemia, electrolyte disturbances, weight loss, metabolic disorders, infection, or the effects of chemotherapy and radiotherapy, as well as the use of sedative drugs, are all possible physical causes of cancer-related symptoms. 38,39 Excessive sleep deprivation, stress, and physical discomfort can all contribute to tiredness. 40 The NCCN guidelines and the consensus group recommendations of the European Association for Palliative Care provide practical treatment guidelines and algorithms (EAPC). 41 Education, energy expenditure planning, and physical exercise are part of symptomatic treatment. A stimulant-based pharmacological treatment is also available, but it’s not without its risks. 42 A number of clinical trials have shown that aerobic training and, in some cases, resistance or strength training, can help alleviate fatigue. 43-45 The goal of energy expenditure interventions is to tailor a patient’s level of activity to his or her unique capabilities and requirements. Prioritizing and delegating are among the most important aspects of daily life, as they allow people to focus on the things that are most important to them. Rest, stress reduction, learning relaxation techniques, and engaging in enjoyable activities can all help restore energy levels. Acceptance strategies and attentional processes can also be the focus of psychotherapeutic efforts to combat negative or catastrophizing thinking.
Damian Jacob Markiewicz Sendler There are numerous ways in which cancer can impact one’s sexuality, both directly and indirectly. Sexual dysfunction can be harmed by both the cancer itself, as well as surgical treatment, such as chemotherapy, radiation therapy, or surgery for gynecological tumors. Sexual function can be negatively impacted by changes in hormones caused by a disease or by treatments such as chemotherapy, hormone therapy, or surgery. In addition to the physical effects of cancer, such as fatigue, pain and emotional distress, or strains on a relationship with a mate, there are also psychological effects. 46,47 An individual’s overall well-being suffers greatly when they experience sexual dysfunction.
A person’s method of dealing with life’s difficulties varies greatly. In the face of a life-threatening illness, sexuality may lose significance for some patients, but for others, it takes on new significance as a means of preserving pleasure, vitality, and emotional connection.
Hormonal therapy, erection aids, reconstructive surgery, and educational and counseling interventions may be used to help patients. Sexual or couple therapy may be necessary from time to time. There has been some success with multimodal treatment programs, but evidence is still lacking. 48
Some types of cancer can impair reproductive function, but chemo- and radiotherapy are the most common causes of infertility. For men, freezing sperm is a simple way to preserve fertility, but for women, it can be a challenge. Ovarian transposition prior to pelvic radiation and the cry opreserva Lion of fertilized ovum are well-established methods, but they may be helpful only in certain situations. Cryopreservation of unfertilized ova or ovary tissue are other, less well-researched options. All of these techniques, however, are quite invasive. This can be a stressful time, and fertility preservation decisions must be made while dealing with other treatment decisions that already have a significant emotional toll.
Damian Jacob Sendler
Patients who are faced with these decisions, fears about reproduction, or the loss of reproductive function due to treatment are in need of assistance. Cancer heritability, chemo- or radiotherapy-induced genetic damage, or the pregnancy’s impact on recurrence risk are all common concerns for prospective parents (eg, in hormonereceptor-positive breast carcinoma). In these situations, it’s critical to get all the facts and work with the reproductive medicine team.
Many cancer patients suffer from mental health issues such as depression, anxiety, and difficulty adjusting. There are approximately if percent of depression and dysthymia, 10.2 percent of an anxiety disorder, and 12.5 percent of adjustment disorder point prevalences in the general population. 50 Cancer patients who have psychiatric comorbidities have a lower quality of life and a lower prognosis. 51 Depressive episodes in cancer patients are treated in much the same way as depressive episodes in non-cancer patients, and this has been specified in numerous guidelines. 50,52,53 In the diagnosis process, however, special attention is needed because of the overlap between cancer symptoms and depression. It’s also important to keep in mind the potential side effects and interactions of antidepressant medications (eg, the interactions between some antidepressants and tamoxifen). Psychotherapeutic interventions have been shown to improve depressive symptoms in cancer patients at various stages of the disease, according to a large body of research. 54,55 There has been research into traditional therapeutic approaches like cognitive behavioral therapy, and more recently, the development of specialized treatment programs. The specific treatment setting, the stage of disease, physical distress symptoms, and the existential threat must all be taken into account in psychotherapeutic treatment. ‘ It is not uncommon for psychotherapy and medication to be used in the treatment of anxiety disorders in a similar manner to that used in non-cancer patients. 56,57
A distinct entity in cancer treatment is the fear of recurrence (also the fear of progression). One of the most common concerns of cancer survivors is the “fear, worry, or concern that cancer will return or progress. DSM 5 and ICD-10 do not define it, and it must be understood as an adaptive reaction rather than an unrealistic or neurotic fear. Fear of recurrence, on the other hand, can cause severe emotional distress. Specific questionnaires have been developed and validated for fear of recurrence in the evaluation of anxiety disorders. 58 As many as 70% of patients fear a recurrence of their illness, and they report feeling isolated in dealing with this issue. 59 Progression anxiety can be treated using a variety of approaches. Using cognitive behavioral principles, a group therapy in a rehabilitation inpatient setting was shown to reduce anxiety about progressing, and it has also shown some promising effects in an outpatient pilot phase, with a few modifications. Self-observation, exposure-based techniques, refraining techniques, and the implementation of behavioral changes are the most important aspects of the process. 60,61
It has recently been shown in an RCT that patients who have survived breast, prostate, and colorectal cancer benefit greatly from another program based on Leventhal’s Self-Regulation Model of Illness that employs a combination of psychoeducation, cognitive restructuring, and behavioral modification in an individual therapeutic setting.
Over the past year, 62 pilot studies have shown promising results or are currently in progress.
On the whole, psycho-oncology research advances our knowledge of the mind-body connection, and it has challenged long-held assumptions about cancer’s mechanism of action. Using a psycho-oncological therapeutic approach, cancer patients can experience better physical and mental well-being, as well as improved quality of life. Psychotherapy must be tailored to the unique needs of people facing life-threatening conditions as well as those grappling with existential questions and spiritual longings, as standard psychiatric treatment falls short in this case. The future of therapy is bright, but it necessitates more scrutiny and differentiation.
