Integrative Oncology

Patients with cancer often seek an integrative approach to their care in hope of a cure or symptom management. The integrative care plan requires a patient-centered approach that involves attention to their concerns and developing a comprehensive plan involving physical, mind-body, and social modalities in collaboration with the patient’s main oncology team and colleagues in palliative care, pain management, psychiatry, and rehabilitation. A personalized symptom management strategy utilizing an evidence-based application of conventional and nonconventional therapies can help improve quality of life and optimize treatment outcomes. Recommendation of modalities such as acupuncture, massage, and mind-body practices, as well as open communication and discussion on herbs and supplements, their safety, and interactions with cancer and chemotherapy, is critical to achieve optimal clinical outcomes.

Communicating with the Older Adult Cancer Patient

The older adult population continues to increase. Among all known risk factors for developing cancer, the most important is growing old. Thus, caring for older adults with cancer is of increasing importance. This chapter describes important considerations involved in communicating with cancer patients including sensory impairment, cognitive impairment, multiple morbidity, polypharmacy, and psychological distress. It also describes how stereotyping and ageism affect communication with older adults with cancer. Finally, the chapter discusses ways to facilitate communication with older adult cancer patients and their families and provides an example of a training program that was created specifically to enhance communication between healthcare providers and older adult cancer patients and their families.

Couples Facing Cancer

Cancer survivors experience significant physical, psychological, and social challenges that contribute to poor quality of life. Intimate partners provide critical care and support across the cancer continuum, but they report psychological distress, lack basic healthcare knowledge and skills, and experience increased tension and conflict in their relationships with survivors. Couple-based interventions hold great promise in cancer because they can simultaneously address survivor, partner, and relationship concerns. However, they are seldom implemented in healthcare settings as part of routine care. This chapter will therefore integrate what research has taught us about couples and cancer and what we have learned from couples in the clinical setting. We begin with an overview of challenges faced by couples across the cancer continuum, including biopsychosocial stressors. Next, we describe different perspectives that have shaped descriptive and intervention research on couples’ psychosocial adaptation to cancer. We conclude with clinical implications and directions for future research.

Treatment Decision Making

This chapter focuses on the different facets of treatment decision making that have been empirically derived and are part of the peer-reviewed literature. These facets are approaches of treatment decision making (i.e. exploration and uptake of shared decision making, the current gold standard of treatment decision making); optimal treatment decision making (i.e. barriers and facilitators to engaging in optimal treatment decision making); support for treatment decision making (i.e. decision tools, nomograms, and seeking guidance on the Internet); the psychosocial state of patients following treatment decisions; and considerations related to studying treatment decision making (i.e. racial/ethnic disparities, cultural differences in decision making). Areas in which research is lacking or nonexistent (i.e. ensuring the patient understands the goals of treatment before making a treatment decision) are also highlighted as directions for future research.

Delivering Integrated Psychosocial Oncology Care

This chapter describes how the collaborative care model can be used to integrate psychosocial care into cancer care. It also describes the evolution of, and evidence for, the collaborative care approach in cancer services. Collaborative care consists of systematic identification of need, integrated delivery of psychosocial care by care managers with specialist supervision, and the stepping up of care based on the systematic measurement of outcomes. Trials of this approach for the management of depression and pain in patients with cancer have found it to be feasible to deliver, effective in improving outcomes, and cost-effective. The chapter describes how to overcome patient, provider, and institutional challenges in providing psychosocial care in diverse oncology settings. It concludes by proposing practical steps for implementing and sustaining an integrated psychosocial oncology service based on the principles of collaborative care.

Meaning-Centered Psychotherapy

Existential concerns carry significant distress, particularly among patients with advanced cancer. For patients who are facing death, a sense of meaning—and the preservation of that meaning—is not only clinically and existentially important but also central to providing holistic, high-quality end-of-life care. Nearly two decades ago, the authors’ research group at Memorial Sloan Kettering Cancer Center began to understand that a meaning-centered approach to psychosocial care was imperative to alleviate the existential distress that plagued many patients with advanced cancer. Based on Viktor Frankl’s work on the importance of meaning and principles of existential psychology and philosophy, they developed Meaning-Centered Psychotherapy (MCP) to help patients with advanced cancer sustain or enhance a sense of meaning, peace, and purpose in their lives in the face of terminal cancer. This chapter provides an overview of MCP in working with patients with cancer. It summarizes the ever-growing body of research that has demonstrated the effectiveness of MCP in improving meaning, spiritual well-being, and quality of life and in reducing psychological distress and despair at end of life. Adaptations of MCP for other purposes and populations, such as cancer survivors, caregivers, and bereavement, are mentioned but are elaborated on in other specific chapters related to these issues in this textbook.

Cognitive and Behavioral Interventions

Cognitive and behavioral interventions are effective in treating mood and anxiety disorders in patients with cancer. Screening for disorders is more common, but referral (and uptake) of psychosocial services remains low relative to patient need. Efficacious, cognitive behavioral treatments (CBTs) are first-line treatments for adults with major depressive disorder (MDD) and generalized anxiety disorder (GAD), and there is accumulating evidence for CBT effectiveness for individuals with cancer. For those not yet diagnosed but with elevated symptoms, CBT has reduced symptoms and shown physical symptom and health-related quality-of-life improvements. Fewer studies have accrued patients diagnosed with MDD or GAD, but those studies also show CBT to be similarly effective. Thus far, CBT trials with MDD/GAD comorbidity, a common occurrence and negative prognostic factor, have not been conducted. CBT replication and extension trials are needed to confirm CBT as the treatment of choice for patients with psychiatric disorders.

Sleep and Cancer

Sleep disorders are common, yet underdiagnosed, in cancer care. This chapter focuses on three of the most prevalent disorders: sleep apnea, circadian rhythm disruption, and insomnia, with insomnia being the main focus. Causes and consequences are discussed through the lens of Spielman’s 3P model of chronic insomnia. The chapter discusses the challenges of screening and diagnosing sleep disorders in cancer and gives recommendations for establishing and improving these practices. It also reviews interventions used to treat insomnia and the varying degrees of empirical support that currently exist. Finally, the chapter discusses barriers to treatment and special groups of individuals that require special consideration.

Financial Toxicity in Cancer Treatment

Financial toxicity is a preventable cancer treatment side effect, encompassing the subjective financial distress and objective financial burden that result from increased spending and decreased earning after diagnosis. The prevalence of financial toxicity has increased with new expensive cancer treatments and insurers gradually shifting costs to patients. Patients with financial toxicity experience increased symptom burden, treatment nonadherence, and cancer-related death. The patients at highest risk are young, female, and nonwhite. For low-income patients, the indirect costs of cancer care can be especially burdensome and include child/elder care, transportation, unpaid work absences or job loss, cancer-related comorbidity treatment costs, and fulfilling dietary requirements. Psychosocial impacts include depression, emotional distress, and reduced quality of life. Patients in palliative care have rated financial distress as more severe than physical, familial, and emotional distress. Interventions and policy changes are needed to ameliorate the effects of financial toxicity, especially for the most vulnerable groups.

Principles of Communication Skills Training in Cancer Care across the Life Span and Illness Trajectory

Evidence is growing that communication skills training can help clinicians to become more empathic and use open questions in a patient-centered manner. More work is needed to see these gains translate into improved patient outcomes. A core curriculum has matured as a conventional component of training in cancer care. Strong evidence supports the use of question prompt lists, decision aids, and audio recording of important consultations for later review by the patient and family. Gains are being made with communication challenges such as discussing internet-derived information. Patient training about optimizing their communication has started to complete the reciprocal interaction.