Table Of ContentRecent Results in Cancer Research
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Ute Goerling Editor
Psycho-Oncology
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Recent Results in Cancer Research
Volume 197
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Ute Goerling
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Psycho-Oncology
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Editor
Ute Goerling
Department of Psychooncology
Charité ComprehensiveCancerCenter
Berlin
Germany
ISSN 0080-0015 ISSN2197-6767 (electronic)
ISBN 978-3-642-40186-2 ISBN 978-3-642-40187-9 (eBook)
DOI 10.1007/978-3-642-40187-9
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Contents
Psychosocial Impact of Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Susanne Singer
Fear of Progression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Peter Herschbach and Andreas Dinkel
Gender Opportunities in Psychosocial Oncology. . . . . . . . . . . . . . . . . 31
Matthew Loscalzo and Karen Clark
Psycho-Oncology: A Patient’s View . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Patricia Garcia-Prieto
The Oncological Patient in the Palliative Situation. . . . . . . . . . . . . . . 59
Steffen Eychmueller, Diana Zwahlen and Monica Fliedner
Psychosocial Burden of Family Caregivers to Adults with Cancer. . . . 73
Anna-leila Williams
Rehabilitation for Cancer Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Joachim Weis and Jürgen M. Giesler
Cancer Survivorship in Adults. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Cecilie E. Kiserud, Alv A. Dahl, Jon Håvard Loge
and Sophie D. Fosså
Psycho-Oncological Interventions and Psychotherapy
in the Oncology Setting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Mirjam de Vries and Friedrich Stiefel
Quality of Life in Oncology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Ute Goerling and Anna Stickel
v
Psychosocial Impact of Cancer
Susanne Singer
Abstract
Diagnosisandtreatmentofmalignantdiseasesaffectinmanywaysthelivesof
patients, relatives and friends. In this chapter, we summarise the current
knowledge concerning the psychosocial consequences of cancer.
Contents
1 PsychologicalImpact............................................................................................................ 2
1.1 PsychologicalReactiontotheCancerDiagnosis....................................................... 2
1.2 Denial........................................................................................................................... 2
1.3 Co-morbidMentalHealthConditions........................................................................ 3
1.4 PotentialPositiveImpact............................................................................................ 4
2 SocialImpact........................................................................................................................ 5
2.1 SocioeconomicPosition.............................................................................................. 5
2.2 SocialRelations........................................................................................................... 6
References................................................................................................................................... 7
S.Singer(&)
EpidemiologyandHealthServicesResearch,UniversityMedicalCentreMainz,Obere
ZahlbacherStraße69,55131,Mainz,Germany
e-mail:[email protected]
U.Goerling(ed.),Psycho-Oncology,RecentResultsinCancerResearch197, 1
DOI:10.1007/978-3-642-40187-9_1,(cid:2)Springer-VerlagBerlinHeidelberg2014
2 S.Singer
1 Psychological Impact
1.1 Psychological Reaction to the Cancer Diagnosis
After a person hears he or she is diagnosed with cancer, the first reaction fre-
quently is a sort of shock: ‘‘It can not be me; they must have mixed up the test
results with another person’’. For many patients, receiving such a diagnosis is
associated with the fear of intense pain, loss of control, stigmatisation and death
(Holland et al. 1989). Getting such a diagnosis therefore feels like a nightmare.
Complex processes of denial and subsequent realisation of the truth, often
followed by denial again, are seen in those patients.
After a while, depending on the psychosocial resources a patient has, the truth
canbefacedmorefullybythepatient.Inthisphaseofcopingwithdisease,people
often start fightingand arguing—with their doctors, their relatives,their fate. It is
as if they try to overcome the disease by fighting. When they realise this is not
possible, it often results in intense feelings of hope and helplessness which can
turnintodepression.Noteverybodyisabletofinallyacceptthemalignantdisease
as part of his or her life.
These phases of coping described above were conceptualised by Elisabeth
Kübler-Ross after she had interviewed numerous dying patients (Kübler-Ross
2008). Her concept has been adapted by many authors, and at the same time
criticised for not being empirically valid. Indeed, these ‘‘phases’’ can be seen in
many patients (and their relatives), however, there is no certain order of the
‘‘phases’’whichiswhyweprefertocallthememotionalreactions, thatcanoccur
consecutively or simultaneously.
1.2 Denial
Denial allows the patient to keep reality away from the consciousness until he or
she is able to deal with it. Clinicians should be aware of the fact that this is a
naturalprocessofourpsychetokeepourpsychologicalstructurealive.Atleastin
the beginning of the cancer trajectory, patients and relatives should get enough
timefromthemedicalteamuntiltheycanrefrainfromdenial.Itisnotadvisableto
push them into the truth too fast.
However, continuing denial can be a challenge in oncology, as patients often
need to be treated within a short period of time. One should avoid ‘‘breaking the
denial’’ by aggressive instructions about the disease and its treatment. This will
only result in aggression and anger, be it openly expressed or more silent.
A better way of supporting the patient in getting over his denial is to
(a) strengthen his psychosocial resources and (b) avoiding denial in ones own
perspective. Health care providers should try to be neutral and not joining the
patient in his or her denial. It is often challenging to not do this because it is
seductive, especially when treating young patients, to just avoid the idea of pain
PsychosocialImpactofCancer 3
andpotentialdeath.However,ifthepatient feelsthathiscarersdenyhissituation
he will be even more convinced that his fate is horrible and that he can not deal
with it (if not even the ‘‘professionals’’ can deal with it!). This can also make the
patient feel totally alone with his fears. So, if the health care provider can accept
the patient in his denial and at the same time be prepared to also talk about
distressingtopicssuchasthedangeroffunctionalimpairment,lossesanddeath,it
will support the patient to overcome his denial.
Example:
My patient was a 40year oldsingle mother. She receivedthe diagnose ovarial carci-
noma5yearsagoandIhadbeen seeinghersincethen.While shefirstwantedtosee a
psychologisttoidentifypsychologicalcausesofherdiseasewiththeaimofthenchanging
herlifeaccordinglytobecuredfromcancer,shewasfacedwithmultiplemetastasesinher
entirebody.Still,shethoughtthatpsychotherapycancureherandsheaskedmetohelp
hervisualiseherbloodandcancercellsbecauseshereadinabookthatthiswouldcure
her.
Isawheremotionalsufferingandwantedtosupporther,atthesametimeIknewthat
she had a tumour with a poor prognosis, she had multiple metastases, and she was
admittedtothepalliativemedicinewardatourhospital.Herdaughterwas15yearsold,
thepatientdescribedherex-husbandasbeingalcoholdependent,soshedidnotwanther
daughtertolivewithhim.
Thepatientseemedtornbetweenthehopeofcureandtherealisationofnearbydeath,
butthetruthwastoohardtobearsoshedenieditandseemedtoforceallotherstoshare
this denial with her. Her physician told me about her refusal to find a solution for her
daughter,whichneededtoberesolvedsinceshewasfacingdeath.
Duringournextsession,thepatienttoldmeintearsthatherparentssaidtoher:‘‘Girl,
makesureyougetbettersoon’’.Whenshewantedtotalkwiththemaboutherfears,they
both said: ‘‘Forget it, you will be better’’. This obviously did not help her, as she felt
utterly alone. In this situation, I decided to openly ask the patient about her feelings
regardingdeathanddying.Noonefromtheteamhaddonethisbeforefeelingsorryforthe
patientandbecausesheseemedtorefuseanyconversationaboutit.However,thepatient
nowreactedrelieved.Wetalkedaboutdying,herexperienceswithdeath,herideasabout
whathappensthereafter,andfinallyaboutherdaughterlivingwithouther.
Thepatientdeceasedtwoweekslater.
This example shows that, although patients often deny, they can at the same
timetalkaboutdistressingtopicsiftheyexperienceasupportingrelationshipwith
someone they trust and who is not in denial himself.
1.3 Co-morbid Mental Health Conditions
At times, psychological distress can be severe for cancer patients, resulting in
clinically relevant mental health conditions. Numerous studies have investigated
the frequency of these conditions in cancer patients over the past years.
Severalmeta-analysesandlargemulti-centrestudieshaveshownthat,duringthe
time of cancer diagnosis, about 30 % of the patients suffer from a mental health
condition(Mitchelletal.2011;Singeretal.2010,2013a;Vehlingetal.2012).Less
isknownhoweveraboutthecourseofthoseconditionsduringthecancertrajectory.
4 S.Singer
Available evidence suggests that their frequency does not decrease considerably
over time (Bringmann et al. 2008).
Known risk factors for mental disorders in cancer patients are pain, high
symptomburden,fatigue,mentalhealthproblemsinthepastanddisability(Akechi
etal.2004;Rooneyetal.2011;Banksetal.2010;Agarwaletal.2010).Thereare
no consistent correlatesof depression incancerpatients(Mitchellet al. 2011).
Insomestudiesalcoholdependencewasmorecommoninmen(Mathesonetal.
2012;Dawson1996;Kessleretal.1994;Bronischetal.1992;Kraußetal.2007)and
inpatientswithmalignanciesintheheadandneck,oesophagusandliver(Shimazu
etal.2012;Freedmanetal.2007;Hashibeetal.2007;Kugayaetal.2000).
Not only does psychiatric co-morbidity represent enhanced distress of the
patients calling for specific support from the medical team it also increases the
lengthofhospitalstay(Wancataetal.2001)andnegativelyaffectssurvival,ifnot
treated adequately (Kissane 2009; Pinquart et al. 2010). It is therefore highly
important to identify patients suffering from mental health disorders as soon as
possible. Unfortunately, health care providers often fail in identifying these
patients(Singeretal.2011a;Absolometal.2011;Fallowfieldetal.2001;Söllner
etal.2001),resultinginsevereunder-treatment(Singeretal.2005;Schwarzetal.
2006; Singer et al. 2011b; Oliffe et al. 2008; Stoppe et al. 1999; Werrbach et al.
1987; Wilhelm 2009).
In a large prospective study with cancer patients we found that of those with
mental health conditions, 9 % saw a psychotherapist within 3 months of the
diagnosis,19 %after9monthsand11 %after15 months.Mentalhealthcareuse
was higher in patients with children B 18 years (odds ratio 3.3) and somatic
co-morbidity (odds ratio 2.6) (Singer et al. 2013a). Interestingly, in this study,
uptake of mental health care was equal between men and women, in contrast to
findings from studies in the general population (Oliffe et al. 2008; Stoppe et al.
1999; Werrbach et al. 1987; Wilhelm 2009). The admission to mental health care
did not differ in patients with different educational attainments.
1.4 Potential Positive Impact
During the past decade, increasing interest has been given to potential benefits of
the experience ofcancerdespiteitbeingchallenging andoftenhighlydistressing,
i.e. whether traumatic experiences can lead to emotional growth in patients and
relatives (Hungerbuehler et al. 2011; Kahana et al. 2011; Kim et al. 2011; Love
etal.2011;Demirtepe-Saygilietal.2011;Frommetal.1996).Suchposttraumatic
growth has been defined as positive psychological change experienced as a result
of the struggle with highly challenging life circumstances (Calhoun et al. 2000,
2001).Itdescribestheexperienceofindividualswhosedevelopmenthassurpassed
what waspresent before thestrugglewiththecrises occurred,i.e.peoplefeel that
they did not simply ‘‘go back to life as usual’’ but that they feel enriched, wiser,
grown, etc. after the crisis.
PsychosocialImpactofCancer 5
According to Tedeschi and Calhoun (2004), positive changes can be found in
five dimensions, representing different types of posttraumatic growth: greater
appreciation of life and changed sense of priorities; warmer, more intimate rela-
tionships with others; a greater sense of personal strength; recognition of new
possibilitiesofpathsforone’slifeandspiritualdevelopment(Tedeschietal.2004).
Individuals’experienceofposttraumaticgrowthdependsonseveralpredictors.
Many facilitating factors have been reported: younger age, female gender, low
consumption of alcohol, low levels of pessimism and depression, high life satis-
faction, high levels of extraversion, having an active sexual life and receiving
counseling (Cormio et al. 2010; Milam 2004; Mols et al. 2009; Paul et al. 2010;
Sheikh2004; Jansen et al. 2011;Barskovaet al. 2009).Benefit finding,a concept
similar to posttraumatic growth, depends on the amount of time that has passed
since stressoronset, the instrument used and the racial composition of the sample
(Helgeson et al. 2006).
To date only a few studies have investigated whether or not psychosocial
interventions can help to increase posttraumatic growth after traumatic events or
serious illness. Especially in cancer patients, evidence is scare. Own research has
shown that art therapy once weekly over a period of 22 weeks in the outpatient
settingdidnotincreaseposttraumaticgrowth(Singeretal.2013b).Thisfindingis
in accordance with scepticism towards the concept of growth in the context of
adversity, including serious illness and towards positive psychology in general
(Coyne et al. 2010).
2 Social Impact
Humanbeingsaresocialbeings.Weallshareourliveswithothersandareclosely
related to others, willingly or unwillingly. This implies that a malignant disease
not only affects the psychological aspects of ones life but also social relations.
Both dimensions are closely intertwined.
Beingapartofasocietyimpliesacertainstatuswithinthatsociety.Thatstatus
shapes the image one has and increases or decreases the possibilities to exchange
goods. In high income countries, social status is usually defined by income,
educational attainment and employment, which is why the term preferred by
sociologistsis‘‘socio-economicposition’’.Eachofthesethreefactorsdefiningthis
position can be changed by a malignant disease.
2.1 Socioeconomic Position
Lowsocioeconomicpositionisknowntobeassociatedwithpoorhealthontheone
hand and with less access to healthcare on the other (Williams 2012; Garrido-
Cumbrera et al. 2010; Korda et al. 2009; Habicht et al. 2005; Celik et al. 2000;
Jenkinsetal.2008;Lorantetal.2007;Weichetal.1998,2001;Singeretal.2012).
