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 BOOK REVIEWS

Psycho-Oncology

Richard Balon, MD

Wayne State University, Detroit, Michigan, USA

Edited by Thomas N. Wise, Massimo Biondi, and Anna Constantini. Arlington, VA: American Psychiatric Publishing; 2013; ISBN 978-1-58562-423-2; pp 360; $74 (paperback).

As the editors of Psycho-Oncology aptly write, “research has transformed many types of neoplastic disease into curable or chronic conditions rather than rapidly fatal disease. With an increasing number of long-term treated “cancer survivors,” there is a greater recognition of the psychosocial and psychological reactions to, and psychopathological consequences of confronting the threat of recurrence—the sequel of life-saving but traumatic and possibly disfiguring treatments. Despite such medical advances, surveys indicate that cancer is the most feared disease state. Such interactions between a disease label and an emotional reaction, fear, underscore the profound psychosocial issues involved in oncology. Because more than 40% of individuals will experience a diagnosis of cancer during their lifetime, practitioners in all health care specialties must have a knowledge base in oncology” (p xiii). The role of psychiatry and allied mental health professions in helping patients and their families cope with cancer-related fears, depression, demoralization, anxiety, and other psychological sequelae is paramount. The field of psycho-oncology, a derivative of psychosomatic medicine (p xiv), has developed to better address the needs of the growing number of cancer patients and their families. There also has been an increased need for communication and education in this developing area of medicine. The journal Psycho-Oncology was established 22 years ago, and various texts and textbooks have appeared on the subject. The latest volume of Psycho-Oncology, edited by Drs. Wise, Biondi, and Constantini is not to be confused with Psycho-Oncology edited by Jimmie Holland and others, which was published originally in 1998 and then as a second edition in 2010.

This volume, authored by an international group of experts, offers an overview of clinical issues with “a core focus on the essential caregiver-patient dyad” (p xiv). The authors’ intent was to provide “a ‘bench-to-bedside’ approach to benefit the everyday clinical practice for all health professionals who treat patients with neoplastic disease” (p xiv). Wise and colleagues used the concept of psychosocial staging to frame their writing. The first stage is the initial diagnostic stage (the discovery of cancer); the second stage is the treatment of cancer. The first stage is usually a time of great anxiety while the second stage is frequently a time of demoralization and depression. Skillful communication with patients and their families is an essential ingredient for both these phases.

The book includes an Introduction and 12 chapters. All chapters conclude with key clinical points, some of which include solid, clinically oriented case vignettes and appendices. Chapter 1, “The crisis of discovery: psychological and psychopathological reaction to the disease,” begins by addressing death and the disease in a historical context (in the 14th century, life expectancy in Europe was between 30 and 35 years!). The chapter then discusses reaction to the diagnosis, which has all the characteristics of shock trauma. The impact of cancer on people’s lives is related to 4 areas: the existential threat of the disease, psychosocial consequences, consequences of the morbid disease process (eg, pain, fatigue), and treatment and its effects (p 5). The determinants of the reaction to the diagnosis represent a complex interplay of biological, psychological, spiritual, and social factors. The style of coping process can be divided into 2 sequential stages: evaluative and executive (p 9). There are 3 different types of coping strategies: emotion-focused (aimed at “affect regulation”); problem-focused (directed at mitigation or resolving the impact of stress); and avoidant (eg, escape) and approach (eg, confront). Chapter 1 also deals with the discovery of cancer in advanced stage. Here the text reviews some of the writings of Heidegger, Jaspers, and Kübler-Ross (the stages she described are denial, anger, bargaining, depression, and acceptance). The text also emphasizes the importance of differentiating between a “normal” reaction and “psychopathological” reaction to cancer (p 13). This chapter includes 2 appendices: 1-A (Consultation-liaison clinical cases), and 1-B (Existential psychotherapies [supportive-expressive group psychotherapy; dignity therapy; meaning-centered psychotherapy]).

Chapter 2, “Cancer: a family affair,” notes that “when a person develops cancer, it is the family members who endure this experience. However, the family itself is often profoundly affected by the intrusive presence of the disease and the unpredictable outcome” (p 33). Family adaptation to cancer is a continuous process with many critical cycles (p 33). Families cope in different ways, based partially on family resilience; there are low-resilience variables (eg, rigidity, helplessness, and resentment) and high-resilience variables (common values, meaning, flexibility, and problem-solving). Within and outside the family, patients often cite their spouses as their primary source of support (p 37). The authors also emphasize that “the prognosis of chronic and terminal illness reverses the illusion of immortality and takes away the fantasy of an infinite tomorrow for the intensity of today” (p 41). The text reviews some psychological family interventions, emphasizing empathic listening. “Family intervention should be seen as an educational approach in which the therapist respectfully accepts each member’s thoughts and feelings, regardless of differences among them” (p 49). The chapter also suggests that although family members have the ability to decide who they will or will not reveal news of the illness to, yet they “may be psychologically unprepared to hear and communicate the diagnosis or prognosis at one specific moment.” (p 51). Chapter 3, “Communicating with cancer patients and their families,” is probably the most important and useful chapter of this volume. Reading it, one feels like paraphrasing James Carville and saying, “It’s the communication, stupid.” The authors emphasize the relationship-centered model of oncology in contrast to the “traditional,” medical model, and provide examples of different characteristics of communication in these 2 models (eg, the provider explains treatment options vs the provider chooses treatment). “Communication skills, especially the more complex ones, must be learned and practiced in order for clinicians to be effective in using them” (p 62). This chapter further reviews cancer and mood disturbance (including the mistaken belief that depression is a normal part of cancer experience), purposes of communication, key communication skills for routine encounters with patients and families, communication challenges in the clinical setting, and how to communicate “bad” news. Chapter 3 also contains a useful list of web-based resources on effective communication.

Chapter 4, “Demoralization and depression in cancer,” points out that there is a difference between depression and demoralization, although those are interrelated experiences. “Depression is a very common consequence, but no cause, of cancer. Demoralization develops when the meaning and purpose of life are lost, limiting coping and reducing the value anticipated in life” (p 108). The chapter also touches upon the treatment of depression (therapy, medication) and demoralization (for demoralization without depression: dignity therapy, meaning-centered therapy). The following chapter, “Counseling and specific psychological treatments in common clinical setting. An overview” notes that as in other areas, the effectiveness of therapy rests with the skills or competence of the therapist, and the strength of the therapeutic relationship (p 121). The chapter provides an interesting example of recommendations for a 4-tier psychological provision used in the UK cancer services. Chapter 6, “Genetic counseling and testing for hereditary cancers: psychosocial considerations,” summarizes the area of genetic counseling for cancer (ie, the hereditary breast ovarian cancer syndrome-related mutations, Lynch syndrome-related mutations, issues such as the psychological impact of undergoing genetic testing, and counseling and family communication about genetic testing).

Chapter 7, “Dimensional psychopharmacology of the cancer patient,” promotes a shift from categorical to dimensional psychopharmacology. Although these 2 are complementary, the authors suggest establishing the categorical diagnosis first and following up with a dimensional diagnosis. They do not consider anxiety or adjustment disorders as separate entities from depression. The dimensional approach helps in defining the treatment of psychopathological syndromes rather than entities. Dimensions to consider for treatment in patients with cancer include sadness/demoralization, apprehension/fear, anger/irritability, activation, apathy, obsessionality and somatic preoccupation, and reality distortion and thought disorganization. Appropriate psychopharmacological treatments for each dimension are discussed. This chapter also includes common drug interactions, and a discussion of psychotropic drugs to target somatic symptoms and psychiatric referral for psychopharmacological treatment. Chapter 8 reviews how to advance medical education in existential dimensions of advanced cancer and palliative care, and chapter 9 is a nice summary of a rapid psychometric assessment of distress and depression. A good summary table of rapid psychometric methods (scales) for emotional disorders is included. Chapter 10 then discusses “The value of quality of life assessment in cancer patients,” including the interpretation of quality of life scores. An interesting part of this chapter also reviews the telemonitoring of quality of life.

Chapter 11, “Support of the dying patient: psychological issues and communication,” is another very important part of this book. It discusses 5 key elements of psychological support for a dying patient, including an integrated model of adaptation to existential threat; discussion of the main psychological challenges that impending death represents for the patient; different psychotherapeutic interventions in palliative care; the support for clinicians which includes physicians, nurses and other health professionals working with the dying patient; and identification of communication challenges in palliative care, together with information about communication skills training (p 289). Support for clinicians, physicians, nurses, and other health care professionals working with a dying patient is also discussed. In the interesting discussion on coping and defense mechanisms, the authors remind the reader that “coping strategies, which are conscious and modifiable through learning, can help to resolve problems or emotional tensions and must be distinguished from defense mechanisms” (p 292). The discussion on psychological challenges of a dying patient includes loss of control, facing uncertainty and separation, and facing the future and reflecting on the past. The text reviews different psychotherapies used in palliative care (ie, psychodynamic, cognitive-behavioral therapy, existential, and systemic), and includes a section on supporting the supporters—up to 30% of oncologists experience psychiatric morbidity and report high levels of exhaustion, demotivation, and low levels of achievement! The final chapter, “Psycho-oncology and optimal standards of cancer care: developments, multidisciplinary approach, and international guidelines,” is a standard feature in many books like this, and includes examples from various countries throughout Europe and the rest of the world.

This is a clinically useful and easy to read book that would be a welcome addition to the libraries of all clinicians involved with cancer patient care. It would also be useful for training psycho-oncology specialists (either in psychosomatic medicine fellowships or other specialized training programs). Many clinicians may find at least parts of this book educational and thought provoking. I especially enjoyed the chapter on communication, as it addressed a major issue for many clinicians I know—a lack of solid, thoughtful communication skills. The discussion of palliative care also is quite revealing for those, like myself, who are not involved in this difficult and stressful area of medical care. This text is a definite buy.