Psycho-Oncologists Gather in Banff for Largest Such Conference

This year's World Congress of Psycho-Oncology, held in Banff, Alberta, this spring, was the largest to date, with nearly 700 participants from 33 countries and more than 500 abstracts. The meeting was designed to bring together a variety of professionals—including clinical researchers, psychiatrists, psychologists, and social workers—with members of the wellness community and patient advocacy groups. The meeting was designed to bring together a variety of professionals—including clinical researchers, psychiatrists, psychologists, and social workers—with members of the wellness community and patient advocacy groups. Jimmie C. Holland, MD, Chairman of the Department of Psychiatry and Behavioral Sciences at Memorial Sloan-Kettering Cancer Center and the Wayne E. Chapman Chair of Psychiatric Oncology, a co-founder of both the International Psycho-Oncology Society and the American Psychosocial Oncology Society, gave the Sutherland Lecture, an honor awarded to a pioneer in the field. She used the opportunity to describe what she sees as the major challenges facing the psycho-oncology community today, issues important on both the national and international level. “We have to find some way to impact health policy so that there is some kind of reimbursement for these type of services and some kind of parity for mental health services, rather than their being reimbursed at a rate much lower than for medical services,” Dr. Holland said in a subsequent phone interview. “It is a disservice to patients who want these services, need these services, but nobody thinks they are important enough to really pay for them.” Teaming Up To affect policy and achieve parity, Dr. Holland emphasizes that professional groups must team up with the wellness community and the advocacy groups—a point she says was not lost on the audience at the meeting. As an example of how effective such a pairing can be, she pointed to Australia, where good psychosocial care is now considered part of standard breast cancer care. Such a standard was achieved when the two traditionally disparate groups joined forces. “When clinicians and researchers combined their efforts with these consumer groups, they were able to lobby policy changes,” Dr. Holland said. “They got much more response. Patients can say ‘We want this. We need this.’ But if professionals say it, it can seem self-serving.” Another major issue is the need for large population-based research studies that will begin to provide data on not only what interventions work but also about how to incorporate them into regular practice and how much they will cost, she continued. “We are going to have to come up with some way to show that these don't cost so much money and that the benefits make them cost-effective: The people who get these services very often have fewer calls to the doctor, they may adhere to their treatments better, they are better able to tolerate what is going on.” Tackle Prevention She also thinks it essential that the psycho-oncology community begin to tackle issues in prevention, particularly with regards to tobacco control. This is an enormous worldwide problem, Dr. Holland said, pointing out that more women die of lung cancer than breast cancer, a fact the public seems not to notice. And, she said, the problem is getting worse as smoking habits change and increase in developing countries. On the global level, Dr. Holland says that with many countries lacking the resources for sophisticated medical care, prevention and palliative care need to be emphasized and incorporated more completely. For that reason, she wants to see both the International Psycho-Oncology Society and the American Psychosocial Oncology Society work more closely with the World Health Organization to improve palliative care, especially psychological aspects.Figure: Jimmie C. Holland, MD: “We have to find some way to impact health policy so that there is reimbursement for these kind of services and parity for mental health services, rather than their always being reimbursed, always much lower than medical services. It is a disservice to patients who want and need these services, but nobody thinks they are important enough to really pay for them.”Set Palliative Standards Finally, she points out that the issue of setting palliative care standards is critical. Once standards of care are in place, then patients and clinicians have the right to expect a certain level of care—and if it does not occur the providers can be held accountable. “The patient's level of distress ought to be inquired about and monitored,” Dr. Holland said. “If it is high, the patient ought to be referred for further evaluation, mental health care, or social work intervention. “These kinds of things are not in any way standardized now, so we are working hard to develop them. If we can say this is expected practice, that we know from our evidence-based research that you must be doing these things, and then when people aren't doing that, you have some standard you can hold them to. “But until you have those standards and get those guidelines, everybody just says ‘You are touchy-feely. You don't know what you're doing. How do you know that talking does any good?’ We are trying to move beyond that.” In Australia, good psychosocial care is now considered part of standard breast cancer care. Nonpharmacological Interventions Another well-received plenary address at the World Congress was given by Paul B. Jacobsen, PhD, Professor of Psychology at the University of South Florida and Program Leader in the Psychosocial & Palliative Care Program at Moffitt Cancer Center. Dr. Jacobsen's research focuses on psychological interventions that help with the medical or physical symptoms of cancer, such as pain, nausea, and fatigue. “Most of the research on symptom management has been on the so-called psychological symptoms, the mental symptoms, and we know these psychological interventions make people feel less anxious and less depressed,” he said. “But there is a literature out there that suggests that these interventions may also help with so-called physical symptoms of cancer treatments.” During his presentation, Dr. Jacobsen reviewed the literature, suggesting that there may be in part a psychological basis to pain, nausea, and fatigue, and that cognitive behavioral interventions are effective in relieving them. However, he noted that many physicians are unaware that there are clinical trial data showing that such interventions are effective for physical symptoms. At Moffitt, the palliative care and mental health services are wrapped into one department, which Dr. Jacobsen thinks facilitates the use of nonpharmacological agents in treating physical symptoms. For example, someone who is not getting full or adequate relief from their pain medication will often be perceived as having mental health issues, such as distress or depression. When they come into Dr. Jacobsen's clinic, the clinicians can treat both the mental health issues and help relieve the underlying pain using such measures as relaxation training, exercise, or physical therapy approaches. “There are some patients who are only going to get partial relief from tried and true pharmacologic approaches,” said Dr. Jacobsen. “It may be that they are only getting partial relief because of the nature of their underlying pain syndrome, and the current therapies are not entirely effective. We need to give them some way to deal with the residual pain that the medication doesn't touch.”Figure: Paul B. Jacobsen, PhD: “Most of the research on symptom management has been on the so-called psychological symptoms, the mental symptoms, and we know that these psychological interventions make people feel less anxious and less depressed. But there is a literature out there that suggests that these interventions may also help with so-called physical symptoms.”Sometimes it is not the physical nature of the pain that prevents the therapies from working. Rather, he said, “There is something about them that isn't psychologically being touched by the medication; their anxiety about these symptoms, their values about these symptoms, their fears about addiction and taking the medication, and concurrent depression that aggravates their symptoms. These are things that are not going to be touched by the medication” but can be treated with psychological interventions. Dr. Jacobsen said that at Moffitt, the medical oncologists are appreciative of his teams' work. “Certainly many oncologists are competent to diagnose pain in patients and identify the appropriate therapy and know the indications for opioids, for example. I think where we get involved, is when the typical presentation is not there or the typical therapy for that presentation is not working.” He said that more and more large cancer centers are building multidisciplinary teams such as the one at Moffitt and that patients are benefiting from such efforts. “These are things people can do themselves,” Dr. Holland said about Dr. Jacobsen's work and presentation. “A lot of people say they don't want to take any more medication because they've got enough already with the chemotherapy. If someone has bad pain, it is not enough just to help them with relaxation and breathing and so on, but it can help reduce the pain and the total dose of medication they have to take.” She was particularly impressed with a randomized controlled trial in which Dr. Jacobsen could show that women who had access to a videotape that taught them some relaxation and exercise plans before they began their chemotherapy had less distress than the women who did not have the video information. Dr. Holland said she thinks these women may have had less distress because they felt some measure of control. “That is very useful data to have” she said.

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