Cancer care must incorporate the psychosocial and biological
The clinical oncologists of all stripes have, for too long, overlooked or ignored the psychological factors that may, for all we know at present, play a surprisingly large role in individual susceptibility to neoplasia. They are certainly influential in affecting the course of treatment, the adaptation to the illness, and hence, in some ways, not all of which are yet understood, affect the outcome of treatment.
Lewis Thomas in the foreword to the Handbook of Psychooncology, 19891
The publication of the Handbook of psychooncology,1 later to grow into the substantial textbook Psycho-oncology,2 heralded the beginning of the field of psychooncology. Psychological factors had long been linked with the cause or progress of much human illness, and yet were being increasingly ignored because of a lack of substantial evidence and a strengthening of the biological understanding of disease. The work represented by the publication of these volumes identified the beginning of both a clinical and research interest that continues strongly to this day.
Cancer is the first field of medicine where psychosocial factors have been taken seriously. This was partly because of the potency of cytotoxic drugs and the severity of adverse effects. This led to a need to consider “quality of life”, and to balance this with gains in longevity of life. Quality of life is a subjective matter that requires consideration of complex psychosocial and relational matters and values. These cannot be measured by blood tests. In addition, cancer, more than any other disease, confronts us all with serious existential issues. It challenges the sense of control we might think we have over our lives, and raises the possibility of the purposelessness and futility of life, as well as raising questions about what is a good life and a good death.
The field of psychooncology has contributed much over the years. We have seen serious attention given to communicating “bad news” to patients and to “truth telling”, maximising patients’ involvement in care decisions and maintaining dignity. Various behavioural and psychological interventions have been shown to be effective in relieving patients’ anxiety and depression. Attention has been given to the stress that carers and loved ones experience through the cancer journey, and how strained the support networks can be at times; at other times and for other people, the cancer journey can be a “growth” experience.3
The articles in this Medical Journal of Australia supplement showcase the quality of work currently being done in this area. They range from the use of a large epidemiological survey to tease out the connections between cancer and depression,4 to descriptions of systemic interventions of screening and psychosocial care.5
There is evidence for the effectiveness of psychosocial interventions in relieving distress and assisting in psychosocial adjustment for people in the experience of cancer, although much work remains to be done. Current levels of evidence have been well summarised in published National Health and Medical Research Council (NHMRC) guidelines.6 However, these interventions are not routinely offered by cancer services to patients and their families. So, despite the development of an evidence base over the past few decades, and the acknowledged good things happening in the clinical domain in the area of communication skills for health professionals,7 clinical practice lags behind evidence and standards of best practice. To correct this, we need champions in the field talking about the issue, consumers and carers participating in the research and sharing their experiences, and leading practice-policymakers and health providers with the moral courage to fully implement “evidence-based” and humane care beyond the trial phase.
The importance of this is not diminishing as medical science takes us into new areas (such as genetic screening, which is producing a cohort of people who, while well, live with the anxiety of developing cancer at any time in their life), which throw up ever- new ethical and clinical challenges. beyondblue and Cancer Council Australia are committed to working together towards seeing the development of an integrated approach to cancer care incorporating the psychosocial and biological; and beyondblue will continue to encourage and support research that advances knowledge and improved practice in the area by investing in applied research and by partnering with Cancer Australia in the NHMRC’s Priority-driven Collaborative Cancer Research Scheme.
- 1. Holland JC, Rowland JH, editors. Handbook of psychooncology. New York: Oxford University Press, 1989.
- 2. Holland JC, editor. Psycho-oncology. New York: Oxford University Press, 1998.
- 3. Carboon I, Anderson VA, Pollard A, et al. Posttraumatic growth following a cancer diagnosis: do world assumptions contribute? Traumatology 2005; 11: 269-283.
- 4. Banks E, Byles JE, Gibson RE, et al. Is psychological distress in people living with cancer related to the fact of diagnosis, current treatment or level of disability? Findings from a large Australian study. Med J Aust 2010; 193 (5 Suppl): S62-S67. <MJA full text>
- 5. Livingston PM, Craike MJ, White VM, et al. A nurse-assisted screening and referral program for depression among survivors of colorectal cancer: feasibility study. Med J Aust 2010; 193 (5 Suppl): S83-S87. <MJA full text>
- 6. National Health and Medical Research Council. Clinical practice guidelines for the psychosocial care of adults with cancer. Canberra: NHMRC, 2003. http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/cp90.pdf (accessed Aug 2010).
- 7. Butow P, Cockburn J, Girgis A, et al; CUES Team. Increasing oncologists’ skills in eliciting and responding to emotional cues: evaluation of a communication skills training program. Psychooncology 2008; 17: 209-218.
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