Psychosocial Aspects of Melanoma

In discussing the "Psychosocial Aspects of Melanoma," it is a good idea to first put some warmth into the word "psychosocial." Like a lot of professional jargon, it isn't very expressive or humanistic, yet, it refers to the volume of human concerns that come with a diagnosis of cancer. To address the psychosocial aspects of melanoma is to tend to the emotional, to look after the well-being of mind and spirit in the face of physical disease. The benefits of doing that go far beyond relief of emotional symptoms. Some research suggests that psychosocial interventions, such as certain forms of group therapy, may actually extend the lives of those who participate.

When we talk about psychosocial interventions, we are talking about treatment to help patients and their families cope with distress. The word "distress" is a key word here. A panel of the National Comprehensive Cancer Network (NCCN) - of which Huntsman Institute is a part - has elevated the treatment of distress to a level of importance with that of treating and managing physical pain.

Distress and the Cancer Patient

The panel defines distress as "an unpleasant emotional experience of a psychological, social and/or spiritual nature that interferes with the ability to cope effectively with cancer and its treatment."

The definition goes on to say that distress ranges from feelings of vulnerability, sadness and fear to such disabling problems as depression, anxiety, panic, isolation and spiritual crisis. These are the psychosocial consequences of a cancer diagnosis, and they bear directly on a patient's ability to marshal inner reserves, physical and mental, to cope with disease and to maintain quality of life.

The NCCN panel chose the word "distress" because they believed it would eliminate the stigma associated with words like "psychological," "psychiatric" and even the word "emotional." In fact, the panel believed the stigma associated with those words was greatly responsible for what it considers under-recognition and under-treatment of distress. Patients suffering from distress are often reluctant to report it. They often try hard to hide their discomfort. Even when it shows, they can be reluctant to accept help, because of a fear of being stigmatized or being seen as somehow weak.

Assessment Can Lead to Better Quality of Life

Because of that, the panel has recommended guidelines that include the assessment of patients from the point of diagnosis on. Ideally, that initial assessment would be through a research-proven, self-report questionnaire, non-threatening in its presentation yet effective in detecting distress. The assessment could then be followed with a face-to-face interview with the patient. The goal is to ensure that no one in need of help escapes our attention.

Missing or minimizing our patients' emotional needs puts them at considerable risk. Studies have found that anywhere from 23 to 66 percent of cancer patients suffer clinically significant psychological disorders. The most common problems are depression and anxiety. No one who sees patients needs research to persuade them of how prevalent those two disorders are. Miserable as they are to the patient's state of mind, anxiety and depression also interfere with the functioning of the immune system at a time when it is most vitally needed. They also influence patient behavior, which can lead to difficulties in treatment compliance. Depression, for example, brings a sense of hopelessness, guilt, and often a sense of worthlessness. In the extreme, even patients with good prognoses may, in the depths of depression, decide they don't want to continue with treatment. With that may come thoughts of suicide. Studies vary on whether the rate of suicide among cancer patients is on a par with the general population or two to ten times greater. With anxiety and depression, concentration is also often poor, which can make it difficult for a patient to follow directions with medication and the general treatment plan.

Whatever the scenario, the patient's misery index goes up and with it the distress of family members and caregivers. As the body suffers, the mind suffers. As the mind suffers, the body suffers more. Quality of life becomes a foreign notion to the patient suffering such misery.

Interventions That Work

So, what can psychosocial interventions do about all this? One intervention, a form of group therapy, and its research results, show that psychosocial treatment has many benefits, and may even improve survival rates.

Researchers at UCLA's School of Medicine, Department of Psychiatry, evaluated the benefits for 68 patients with malignant melanoma who took part in a six-week psychiatric group intervention (Fawzy et al, 1990).

There were 34 patients (16 men, 18 women) in the experimental group; that is, the patients who participated in group therapy. There was an equal number of patients (17 men, 17 women) in the control group; that is, the patients who did not participate in group therapy. All had Stage 1 or 2 melanoma. All had had surgery an average of 112 days before the experiment began. None had received any other kind of medical treatment. None had ever had psychiatric treatment.

For six weeks, the patients taking part in group therapy received interventions that included 1) education 2) stress management 3) enhancement of coping skills and 4) psychological support. Those patients not taking part in group therapy did not receive any psychiatric intervention. The intervention was designed to provide far more than emotional support. The intent was to enhance coping so that patients might function resiliently outside the group and for the rest of their lives.

The patients were assessed for emotional distress and their ability to cope, both in terms of thinking and behavior. They were assessed just before and after the six weeks of group therapy, then again at six months, one year, three years and five years.

Immediately after the intervention, patients who participated in group therapy showed greater vigor and better coping styles than patients who did not take part. Six months after the intervention, the differences were even greater. Patients who took part in the group intervention showed significantly less depression, fatigue, and confusion than patients who did not. Their ability to cope cognitively and behaviorally also continued to improve.

The group therapy also appeared to have a positive influence on the immune system. After six months, the patients had more natural killer cells. There was a relationship between mood and immune system functioning. The researchers found that the larger the decrease in depression and anxiety, the greater the increase in immune system functioning. That much, the UCLA researchers reported in 1990.

Three years later, in a second article in the Archives of General Psychiatry, researchers had more to report. Their analysis showed that those patients who participated in the structured, six-week, psychiatric intervention had a statistically significant (P=.03) better survival rate five to six years after the group therapy than those patients who did not participate. Of the 34 patients who took part in group therapy, three had died. Of the 34 who did not, ten had died. Of the 34 patients who took part in group therapy, 7 experienced a recurrence of cancer. Of the 34 who did not, 13 experienced recurrence (Fawzy et al, 1993).

What was it that made a difference? Why had chances improved for patients participating in group therapy? The researchers offered a number of possible explanations. The intervention may have improved the patients' health habits, using sun protection, improving nutrition, exercising, and more. It might have improved coping, resulting in more positive mental attitudes and better compliance with medical treatment. The enhancement of problem-solving skills may have helped the patients deal with their stress by teaching them to perceive problems as less stressful and by increasing their confidence in their problem solving skills. Patients may also have learned to eliminate some sources of stress from their lives altogether. And last, learning relaxation techniques may have helped patients reduce the physiological impact of stress.

The UCLA study could not identify which parts of the intervention were most beneficial for given individuals. However, they did identify a significant increase in active-behavioral coping scores among patients, meaning that patients had likely adopted behaviors that helped them better manage their health.

In Conclusion

In conclusion, the researchers wrote, "Psychiatric interventions that enhance effective coping and reduce affective [emotional] distress appear to have beneficial effects on survival. However, the exact nature of this relationship warrants further investigation." The researchers also emphasized that psychosocial interventions are not proposed as an alternative or an independent treatment for cancer or any other illness.

There have been other studies with similar results. One notable study suggested psychosocial interventions had improved survival rates among breast cancer patients. Still other studies are underway, searching for a more certain link between psychosocial interventions and longevity. The FDA, in funding them, insists that these studies look not only at patient survival, but at the ability of these interventions to enhance quality of life. Whether or not psychosocial interventions affect survival, and that may be a controversial topic for years to come, interventions can help patients ease their distress and enhance their quality of life in general.

The one notable commonality between the UCLA study and others is the use of interventions that teach patients a problem-solving approach to their illness and their lives. It's an approach designed to give the patient a sense of control. It fits with Albert Bandura's theory of self-efficacy; that is, the more control patients believe they have, the more likely they will be to take action that actually gives them that control. That can mean beneficial lifestyle changes, better treatment compliance, and the quieting of anxiety and depression, both forms of distress associated with a sense of helplessness.

Managing Pain

Among other uses, psychosocial interventions are helpful in managing pain. In fact, the American Cancer Society says they ought to be part of any pain management program. Cognitive-behavioral therapy, guided imagery, hypnosis, meditation, relaxation techniques - all have been found useful in controlling acute and chronic pain. Although Cornell Medical Center already employs cognitive-behavioral therapy in pain management, it is just beginning a new study on the effectiveness of cognitive-behavioral and supportive therapy in controlling chronic cancer pain. Its effort is but one example of research being conducted into the benefits of psychosocial interventions in the United States and around the world.

This pursuit of mental and spiritual well-being requires much more than consoling patients. It requires a great deal of mental and emotional work. Whether through individual, group, or family therapy, or through work with clergy or other trusted aides, patients must discover capacities they've never known they had.

Essential to a cancer patient's emotional well-being

Consider the 10 steps of mental adjustment that clinicians at University of California-San Francisco's Melanoma Center believe are necessary. Andrew Kneier, PhD, and Ernest Rosenbaum, MD, believe they are essential to a cancer patient's emotional well-being. They enumerate them as follows:

1. Face the reality of the illness

   This has nothing to do with resignation. Just the opposite. A patient who can face the reality of the situation is likely to be more active in their treatment and more active in educating themselves about the disease and collaborating with doctors. That activity has been found to help greatly with psychological adjustment.

2. Maintain hope and optimism

   This has nothing to do with denial. Kneier and Rosenbaum say optimism must be realistic. They say they've found in most cases that there is a solid and realistic basis for a certain degree of hope and optimism.

3. Proportion and balance

   This means that patients should ideally not be so unrealistically optimistic as to minimize the threat of their condition, nor so pessimistic that they become fatalistic. Either of these interferes with coping.

4. Express emotions

   Expressing emotions permits patients to work through them, to cope with them and to find emotional support from others. There is nothing wrong with expressing negative emotions. It is a healthy way of coming to grips with them.

5. Reach out for support

   Patients who reach out for support show better psychological adjustment to cancer than those who don't. Whether the support be from loved ones, from support groups, or from both, it can help ease fears and encourage better coping.

6. Adopt a participatory stance

   Patients who take an active role in understanding their illness and seeking the best treatment suffer less distress than those who do not. They have a greater sense of control and that belief leads them to action that can actually give them greater control. That sense of control goes a long way in quieting anxiety and depression, two forms of distress that, as we've seen, impairs the functioning of the patient and the immune system.

7. Find a positive meaning

   The Chinese have a symbol for crisis that is the same symbol for opportunity. In the crisis of cancer, many patients manage to reevaluate their lives and find a greater purpose and meaning in what they've done and in what they will do. This can bring about a sense of fulfillment that aids coping and enhances quality of life.

8. Call on spirituality, faith, and prayer

   Doing this can help patients rely on a strength beyond their own and find solace and courage in the belief in something greater than themselves.

9. Maintain self-esteem

   Cancer can threaten a patient's usual sources of self-esteem, such as physical appearance or work life. A patient must find new sources of self-esteem. Pride in the ability to cope is one example. Continued self-esteem is critical in avoiding depression and remaining resilient.

10. Come to terms with mortality

    This is not about giving up. Rather, it is about facing the fear of death and reaching some sense of peace about it so that a patient might spend his or her days living life without dread.

Clearly, achieving a mindset that encompasses these 10 points is not easy. That's why social work at Huntsman Cancer Institute offers individual, group and family therapy. In addition, social workers can refer patients to other sources of help when needed.

If you'd like more information, please contact

Vaughn Roche, LCSW
at (801) 587-9606.

References:

Fawzy et al, Archives of General Psychiatry, Vol. 47, Aug. 1990.

Fawzy et al, Archives of General Psychiatrcy, Vol. 50, Sept. 1993.

By Vaughn Roche, LCSW, Huntsman Cancer Institute, Salt Lake City, UT.

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