The following three
abstracts explore some complications of cancer. Gail Broder
briefly presents
the importance of communcation from the perspective of a cancer patient,
and
Carlos Sandoval-Cros, MD, and Ann Berger, RN, MSN, MD, summarize key
issues regarding
psychological problems and anorexia and cachexia.
A
Cancer Patient’s Perspective
Gail Broder
Founder
and President Emeritus, Cancer Survivorship Alliance of South Florida, Bethesda,
Md.
No one would
choose to be diagnosed with cancer. It is, perhaps, the most dreaded disease
in our country. Yet, according to the American Cancer Society, an estimated
8.2 million people are alive today following a diagnosis of cancer.1
Many have only recently been diagnosed and are undergoing treatment, while others
have survived for many years following a diagnosis of cancer. Still others have
recurrent or advanced disease and are facing the end of life. Regardless of
the stage of disease, each individual is a cancer survivor. From the moment
of diagnosis and for the rest of his or her life, that person is engaged in
the pursuit of life after cancer. We can see ourselves as victims, or we can
see ourselves as survivors — people with a bad disease who are striving to maintain
the highest quality of life for as long as possible. Those who view themselves
as survivors rather than victims are more likely to take a positive approach
to treating their cancers and managing their lives.
Quality of life depends
on many factors. As cancer patients, we want the best possible medical care
and treatment in order to survive longer, but we also search for ways to remain
healthy, relaxed, alert, productive, and engaged in normal activities of daily
living at home, at work, and in our communities. Quality of life focuses on
being and feeling like a "normal" person, the kind of person we would
choose to be, given that choice.
Physicians and other
health care providers can help us to achieve these goals in a number of ways.
Most important, the physician should be competent, well trained, experienced,
and committed to the health care profession. However, the ability of both the
physician and the patient to communicate effectively is another important element
that can affect every aspect of life after a cancer experience. Both patient
and physician can develop the skills needed to communicate effectively. Even
for those who already have good communications skills, there is always more
to learn.
Physicians are our guides
in the medical realm. As patients, we rely on them to help with choosing the
appropriate treatment, to discuss with tact and honesty what we can realistically
expect during and after treatment, and to help us to understand procedures,
side effects, and late effects. When cancer survivors are faced with issues
that physicians do not have the expertise to help with, effective communication
can assist in guiding us to the supportive and complimentary resources we need.
Physicians must listen to the concerns of their patients so that they can refer
patients to other experts and professionals who can help. Physicians do not
have to spend a great amount of time with their patients to communicate that
(1) they care about their patients, (2) they will do their best to provide their
patients with the best possible care and treatment, and (3) they will refer
their patients to other health care professionals if issues arise that can be
addressed more appropriately by others (eg, an oncology nurse, a nutritionist,
or a pharmacist).
Physicians not only
should be aware of all the services and resources offered by other professionals
who can help cancer patients, but they also should inform their patients of
the availability of these resources. While most physicians are faced with significant
time constraints, there is no excuse for behavior that is not courteous or respectful.
Likewise, patients need to understand that physicians cannot respond to all
their issues and concerns on demand. To obtain the advice and information they
need from their doctors, patients must enhance their communication skills. A
helpful publication, "Teamwork: The Cancer Patient’s Guide to Talking to
Your Doctor," is available from the National Coalition for Cancer Survivorship
(NCCS). To obtain a free copy, which is also available in Spanish, contact the
NCCS at 1-877-622-7937 or visit the NCCS Website at www.cansearch.org.
Reference
1. American Cancer Society.
Cancer Facts and Figures, 1999. Atlanta, Ga: American Cancer Society; 1999:1.
Common Psychological
Problems in the Cancer Patient
Carlos J. Sandoval-Cros,
MD
Assistant
Professor of Clinical Psychiatry, Director of Courtelis Center, Sylvester Comprehensive
Cancer Center, Miami, Fla
Introduction
The advent
of psychooncology as a subspecialty within the broader field of oncology has
brought the psychological, social, and behavioral dimensions of cancer to the
forefront. These issues are now receiving greater attention with the development
of training programs in this area and with the establishment of psychooncology
research and treatment centers. Psychooncology seeks to address the impact of
cancer on the physical, emotional, social, intellectual, and spiritual functioning
of patients and caregivers, as well as to identify psychological and behavioral
variables that may affect cancer risk and survival.1
Normal
Reactions to the Diagnosis of Cancer
The diagnosis of cancer
brings with it not only emotional distress as a normal response to the catastrophic
event the illness represents, but also a series of issues that reflect the patient’s
perception of the illness. Cancer causes feelings of alienation as patients
realize they have an illness that their peers do not have. Furthermore, it causes
feelings of imminent mortality, mutilation from a possible surgical intervention,
and vulnerability and loss of autonomy as patients realize they must depend
on others for help. Although these issues are common to all patients, the degree
of distress they cause varies.
When an individual receives
the diagnosis of cancer, learns of a relapse, or fails to respond to treatment,
the patient invaribly experiences a characteristic emotional response. The work
of Horowitz and coworkers2 on stress response syndromes and the observation
of cancer patients has led to a model of phases of normal adjustment to the
crises encountered with cancer. These phases are initial response, dysphoria,
and adaptation.
Disbelief, denial, or
despair characterizes the initial response to the diagnosis. This initial period
usually lasts a few days to a week, followed by a period of mixed symptoms of
anxiety and depression (dysphoria). In the absence of a crisis, these symptoms
would be considered pathological, but in this context, they form a part of normal
coping. These symptoms then resolve over several weeks as the patient enters
into the phase of adaptation, where he or she receives support from family and
friends, adjusts to the information and treatment plan outlined by the physician,
and finds reason for hope and optimism in the information given.
These responses are
best managed by the physician and members of the treatment team, including nurses,
social workers, clergy, and mental health professionals on site. They are responsible
for the patient’s treatment, they understand the reaction, and they
can offer reassurance, support, and compassion while sensitively discussing
the facts of the medical situation.
Barriers to Diagnosis and Treatment of Psychiatric Disorders
Unfortunately, the psychological
distress that develops in many patients is not diagnosed or treated. This can
be due to several factors from both the patients’ and the physicians’ perspective.
From the patients’ perspective, they may hesitate to voice their feelings for
fear of being perceived as weak in character and lacking the necessary strength
to cope with the illness. Also, they may be reluctant to use a "mind-altering"
drug if in fact a psychotropic medication may be beneficial. From the physicians’
perspective, the emotional distress may go unnoticed as they are concentrating
on the life-threatening illness. Furthermore, the physicians may assume that
this distress is a "normal response" to the diagnosis, which nonetheless
needs to be treated. Finally, the unfamiliarity of many physicians with psychotropic
medication leads them to concerns of untoward drug interactions or side effects.3
Prevalence
of Psychiatric Disorders
Though most patients
with a cancer diagnosis will experience a normal emotional response to cancer,
not all go into the adaptive phase; some may develop frank psychiatric disorders.
The Psychosocial Collaborative Oncology Group was the first cooperative group
to study psychiatric morbidity in cancer patients. It conducted a study of the
prevalence of psychiatric disorders in 215 randomly selected hospitalized and
ambulatory cancer patients in three cancer centers.4 More than half
of the patients (53%) were adjusting normally to the stress of the diagnosis,
while 47% had clinically apparent psychiatric disorders. Of this 47%, approximately
two thirds had adjustment disorders with depressed or anxious mood, while the
remaining one third experienced major depression, delirium, anxiety disorders,
personality disorders, and major mental illness. Nearly 90% of the psychiatric
disorders observed in this study were reactions to or manifestations of the
disease or treatment. Only 11% represented prior psychiatric problems.
The three most common
types of psychiatric disorders seen are anxiety disorders, depressive disorders,
and delirium. Adjustment disorders fall under either anxiety or depressive disorders,
depending on the predominant symptoms.
Anxiety Disorders
While anxiety
is relatively easy to diagnose in physically healthy individuals, it is more
difficult to diagnose in the physically ill, particularly those with cancer.
There is often no clear distinction between the normal fears and uncertainties
associated with cancer and the more severe symptoms that meet the criteria of
an anxiety disorder.
The causes
of anxiety can be varied. Anxiety can be reactive, ie, an exaggerated response
to the normal responses of having cancer. It can also be caused by the physical
symptoms of cancer (eg, pain) or by the treatment of cancer (eg, side effects
of medications such as prednisone or metoclopramide used as an antiemetic agent).5
Anxiety can also be part of a major psychiatric disorder such as depression,
or it can be caused by medical factors such as hypoxia, sepsis, electrolyte
imbalance, or poorly managed pain. Regardless of the cause of anxiety, its subjective
and physical symptoms are similar. These include tension, constant worrying,
trembling, insomnia, and irritability.
Anxiolytic
treatment consists of the judicious use of benzodiazepines such as lorazepam,
a short-acting agent, or clonazepam, a longer-acting one. Buspirone can be useful
in mild to moderate anxiety, but it takes several weeks to be effective. Severe
anxiety and agitation can be treated with neuroleptic agents such as thioridazine,
haloperidol, and perphenazine. Antihistamines (eg, hydroxyzine), anti-anxiety
agents (eg, buspirone), and even some antidepressant agents (eg, trazodone and
nefazodone) are useful.6 Progressive muscle relaxation, meditation,
biofeedback, and hypnosis are also effective in addressing the symptoms of anxiety.
Depressive
Disorders
While sadness
and grief are normal responses to cancer, it is important to differentiate between
"normal" degrees of sadness and "abnormal" levels of depression
in cancer patients. Depending on the severity, duration, and number of symptoms,
a patient may be diagnosed as either having an adjustment disorder with depressed
mood or experiencing major depression.
Symptoms of
depressive disorders include a pervasive depressed mood, sleep disturbances,
decreased interest, feelings of guilt or worthlessness, lack of energy, distractibility,
anorexia, psychomotor disturbances, diminished sexual drive, and suicidal ideation.
Furthermore, there is a direct relationship between physical performance status
as measured by the Karnofsky scale and the prevalence of the depression. A low
Karnofsky score correlates with a high rate of depression.7
As with anxiety
disorders, depression can also have organic causes. These include preexisting
medical conditions (eg, hypothyroidism, HIV, or dementia) or the use of chemotherapeutic
agents, corticosteroids, alcohol, and whole-brain radiation. It is important
to screen patients for depression because the risk of suicide in cancer patients
is twice that of the general population.
The treatment
of depression consists of a combination of psychotherapy (individual, family,
or group) and pharmacotherapy. The main goal of psychotherapy is to help the
patient regain a sense of self-worth, to correct misconceptions about the past
and present, and to integrate the present illness into the patient’s life experience.
Psychotherapy
emphasizes the individual’s personal strengths and personal resources, and it
helps the patient to acquire coping mechanisms. Many antidepressants are available.
The first line is composed of the serotonergic agents such as fluoxetine, sertraline,
and paroxetine. Since these may cause insomnia, a hypnotic agent may have to
be added at first. Newer drugs such as nefazodone and mirtazapine have anxiolytic
and sedating properties and are also effective. Finally, a psychostimulant such
as dextroamphetamine sulfate or methylphenidate can be used as an adjuvant in
apathetic and withdrawn states of depression.8
Delirium
Delirium is
common in patients with cancer. It occurs both as a transient central nervous
system complication of disease and as a treatment side effect. In its early
stages, delirium can be mistaken for depression or anxiety, and it is difficult
to differentiate between delirium and early dementia. Therefore, recognizing
the symptoms of delirium early in its course is important in order to do an
appropriate workup and establish the causes of delirium. It can then be treated
appropriately and prevented from progressing to coma and death.9
Symptoms of delirium include disorientation (particularly worsening at night),
distractibility, memory impairment, perceptual disturbances (eg, illusions and
auditory or visual hallucinations), language disturbances, and fluctuating consciousness.
While depression or dementia can cause these symptoms, the most common cause
is delirium.10
The causes
of delirium are manifold. In the case of cancer, delirium can result from either
direct effects (eg, a primary brain tumor or metastatic spread) or indirect
effects, which occur more frequently. Indirect effects include metabolic encephalopathy,
organ failure, electrolyte imbalance, drug or radiation side effects, infection,
vascular complications, paraneoplastic syndromes, and nutritional deficiencies.
Identifying the cause and correcting it are the first steps in the treatment
of delirium. Symptomatic treatment consists of the use of neuroleptic agents
(eg, haloperidol) that control both agitation and hallucinations, and antianxiety
agents (eg, lorazepam).11
Complementary Therapies
Along with the conventional
therapies for the treatment of cancer — radiation, systemic, and surgical —
other therapeutic options can be considered, including complementary approaches
and alternative treatments. Generally, complementary approaches are designed
to enhance coping and adaptation, and they are typically used by patients to
supplement conventional cancer treatment, whether curative or palliative. Psychotherapeutic
interventions such as the different modes of psychotherapy and group interventions
fall under this category. Spirituality, prayer, nutrition, exercise, and other
mind-body techniques are considered to be part of complementary medicine. All
of these have the goal of enhancing mental and general physical well-being.12
Alternative treatments
are generally aimed at slowing, stopping, or reversing the spread of the malignancy.
Some patients use alternative treatments either because they do not accept the
conventional therapy offered or because the conventional treatment has failed
to produce the desired result. However, some patients use alternative treatments
along with conventional therapies, hoping for a synergistic effect.
Many complementary therapies,
including nutrition and psychotherapy, are available to patients within the
conventional medical care system. Others, such as spirituality and exercise,
may form part of the patient’s culture and lifestyle. Though some oncologists
may question the benefit or efficacy of complementary therapies, few question
their safety.
This is not the case
for alternative therapies, which are viewed by many oncologists as fraudulent
or even harmful. These therapies are accessible only outside of conventional
care, through providers of alternative medicine (eg, chiropractors and homeopaths)
or through health food stores. Laetrile, essiac, and shark cartilage are among
the many alternative medicine products. Despite conventional medicine’s indifferent
or negative view toward these therapies, many people use them. In 1993, Eisenberg
and colleagues13 reported that an estimated 60 million Americans
used alternative medicine therapies in 1990 at an estimated cost of $13.7 billion.
Furthermore, the number of annual visits to providers of alternative medicine,
425 million, exceeded the number of visits to all primary care physicians in
the United States, 388 million. Moreover, more than 70% of patients who acknowledged
using alternative therapies did not mention their use to their physicians.13
These therapies are popular in part because underlying all these treatments
are common philosophical principles that are also the principles of holistic
medicine. These include (1) focusing on empowering the individual to accept
responsibility for at least part of the task of recovery and future health maintenance,
(2) emphasizing sound nutrition as a core requirement for health, (3) recommending
a balanced lifestyle, adequate and appropriate exercise, rest, sleep, and emotional
tranquility as prerequisite for a state of health, (4) attempting to ensure
detoxification and the efficiency of the organs and systems of the body, (5)
recognizing the importance of the musculoskeletal system as a potential source
of interference with nerve transmission and the body’s energy pathways and as
a reflection of the individual’s internal physical and emotional state, and
(6) most important, treating the individual instead of his or her symptoms.14
An Integrative Approach to Cancer Treatment
Many of these principles are also at the core of conventional
medicine and, in particular, preventive medicine. Therefore, the treatment of
persons living with cancer should not be viewed as an "either/or"
situation in which the patient must choose among conventional, complementary,
or alternative treatments. In developing a treatment plan, an integrative approach
should be followed that incorporates the philosophical principles of holistic
medicine. This includes conventional, complementary and, when appropriate, alternative
treatments to provide an effective, person-oriented continuum in cancer care.
By conceptualizing health as optimizing one's physical, emotional, social, intellectual,
and spiritual well-being, the psychooncologist empowers the individual to use
all means available to fight cancer, to eliminate a sense of helplessness, and
to regain hope.
References
1. Holland JC. Psychologic
aspects of cancer. In: Holland JF, Frei E III, eds. Cancer Medicine.
Philadelphia, Pa: Lea & Febiger; 1982:1175-1203.
2. Horowitz M. Phase
oriented treatment of stress response syndromes. Am J Psychother. 1973;27:506-515.
3. Massie MJ, Holland
JC. Overview of Normal Reactions and Prevalence of Psychiatric Disorders.
Handbook of Psychooncology. New York, NY: Oxford University Press; 1990:273-281.
4. Derogatis LR,
Morrow GR, Fetting J, et al. The prevalence of psychiatric disorders among cancer
patients. JAMA. 1983;249:751-757.
5. Holland JC. Anxiety
and cancer: the patient and family. J Clin Psychiatry. 1989;50:20-25.
6. Hyman SA, Arana
GW, Rosenbaum JF. Handbook of Psychiatric Drug Therapy. New York, NY:
Little, Brown and Co; 1995:145-178.
7. Buckberg J, Penman
D, Holland JC. Depression in hospitalized cancer patients. Psychosomatic
Med. 1984;46:199-212.
8. Hyman SA, Arana
GW, Rosenbaum JF. Handbook of Psychiatric Drug Therapy. New York, NY:
Little, Brown and Co; 1995:182-190.
9. Lipowsky ZJ. Transient
cognitive disorders (delirium, acute confusional states) in the elderly. Am
J Psychiatry. 1983;140:1426-1436.
10. Freemon FR. Delirium
and organic psychosis. Organic Mental Disease. SP Medical and Scientific
Books. 1981:81-94.
11. Massie MJ, Holland
JC, Glass E. Delirium in terminally ill cancer patients. Am J Psychiatry.
1983:1048-1050.
12. Holland JC, Geary
N, Furman A. Alternative cancer therapies. In: Holland JC, Rowland JR, eds.
Handbook of Psychooncology. London: Oxford University Press; 1989:508-515.
13. Eisenberg DM,
Kessler RC, Foster C, et al. Unconventional medicine in the United States: prevalence,
costs, and patterns of use. N Engl J Med. 1993;328:246-252.
14. The Burton Goldberg
Group. Alternative Medicine. Tiburon, Calif: Future Medicine Publishing,
Inc; 1995:3-17.
Anorexia
and Cachexia in Patients With Cancer
Ann Berger,
RN, MSN, MD
The Robert
Wood Johnson Medical Center at Camden Cooper Cancer Institute, Cooper Hospital,
University Medical Center, Camden, NJ. Director of Pain/Supportive Care Services,
Assistant Professor of Oncology, UMD-NJ.
Introduction
Cachexia is
a major cause of morbidity and mortality in cancer. It is characterized by anorexia,
early satiety, fatigue, generalized weakness, decreased function, and progressive
wasting. The loss of lean body mass in cachexia associated with cancer usually
exceeds that which can be accounted for by reduced fluid intake alone. The loss
of muscle and adipose tissue often precedes a decrease in food intake. Approximately
50% to 80% of all patients with cancer experience significant nutritional losses
that may ultimately contribute to their death. The extent of weight loss varies
with tumor type, occurring in 30% of patients with non-Hodgkin’s lymphoma to
nearly 90% of those with gastric and pancreatic cancer. One study demonstrated
that 54% of patients entered into Eastern Cooperative Oncology Group chemotherapy
trials experienced weight loss that significantly affected survival.
Metabolic Derangements in Cancer Cachexia
Cancer-associated weight
loss was initially thought to be due to an increase in energy expenditure as
a result of the tumor burden. However, this has not been proven. The energy
expenditure associated with disease in patients with cancer may be reduced,
normal, or increased in comparison with a control group. Anorexia is a common
symptom typically present in cancer cachexia, although it appears to be an effect
rather than a main cause of weight loss. Anorexia can occur after weight loss
is evident. Among the many risk factors for anorexia and cachexia include surgery,
chemotherapy, polypharmacy, radiation, antiviral therapy, alteration of taste,
nausea, vomiting, constipation, and infections. Anorexia can occur after weight
loss is evident. Elevated energy expenditure that occurs in conjunction with
anorexia and a decrease in caloric intake distinguishes cancer cachexia from
starvation, in which overall energy expenditure is reduced. Many metabolic alterations
are associated with cancer cachexia. Cancer patients with cachexia characteristically
have depleted fat stores, increased mobilization of free fatty acids, a loss
of most adipose tissue, and overall loss of body lipids, as well as protein
catabolism and skeletal muscle breakdown. Also present are alterations in carbohydrate
metabolism.
Tumors consume large
quantities of glucose anaerobically, resulting in the massive release of lactate
that is used primarily in the Cori cycle. Normally, the Cori cycle is involved
in approximately 20% of glucose turnover. This increases to 50% in cancer cachexia
patients and accounts for the disposal of 60% of the lactate produced. The Cori
cycle leads to increases in hepatic conversion of lactate to glucose, creating
a futile energy-consuming cycle. In contrast, a reduction in hepatic glucose
production is seen in starvation. Cachexia is also associated with glucose intolerance
and an abnormal insulin response.
Cytokines and Cachexia
The etiology of cancer
cachexia is multifactorial and not completely understood. A number of mediators,
mainly cytokines and hormonal factors, are implicated in the pathogenesis of
cancer cachexia. Tumor necrosis factor-alfa (TNF-alpha), a cytokine, is one of the
most likely mediators of cancer cachexia. TNF-alpha can mimic most of the abnormalities
that occur in cancer cachexia such as weight loss, anorexia, increased thermogenesis,
changes in lipid metabolism, insulin resistance, and muscle wasting.
Not all of the cachectic
metabolic arrangements that occur in different types of human cancer and experimental
tumors can be entirely explained by the physiologic effects of TNF-alpha. It is
speculated that TNF-alpha that is produced locally can lead to systemic metabolic
changes without a discernible alteration in circulating serum TNF-alpha concentration.
The absence of detectable serum levels of TNF-alpha in tumor-bearing patients should
not preclude a possible role of TNF-alpha in mediating cancer cachexia or the possible
use of TNF-alpha antagonists in ameliorating the condition.
Studies of nude mice
inoculated with TNF-alpha-secreting tumors also become increasingly wasted and die
more rapidly than control animals inoculated with non-TNF-alpha-secreting tumor
cells. Wasting syndrome and its associated systemic symptoms — anorexia,
fever, and general debility — may be mediated by excessive TNF-alpha production.
Administration of antibodies against TNF-alpha in animals can partially reverse
anorexia, body weight loss, and the depletion of host protein and fat. Other
cytokines possibly involved in cachexia include interleukin-6, interleukin-1,
leukemia-inhibiting factor, and interferon gamma. To date, no experimental or
clinical data indicate that wasting can be decreased by using specific antagonists
to these agents.
Pharmacologic Agents for Anorexia and Cachexia
Many pharmacologic agents
have been studied for the treatment of anorexia and cachexia, but few have been
found to be efficacious. Megestrol acetate remains the gold standard. Cannabinoids
are also useful in anorexia and cachexia. While corticosteroids have a role
in treating anorexia, their use does not result in weight gain. Pharmacologic
agents that have been investigated with little efficacy include cyproheptadine,
hydrazine sulfate, and pentoxifylline.
Growth hormones and
anabolic steroids also have potential roles. In pilot studies, metoclopramide
has been shown to be effective in treating early satiety as well as increasing
appetite. Others drugs that may be effective include omega-3 fatty acids and
thalidomide. Thalidomide has not been studied in cancer cachexia. However, it
reverses the wasting syndrome associated with HIV disease, with its mechanism
possibly being a decrease in the production of TNF-alpha. Enteral nutrition is useful
for patients who may be unable to use the oral route. Total parenteral nutrition
decreases perioperative morbidity and mortality and may allow some patients
to complete radiation therapy, but studies have shown that it has not improved
patients’ tolerance or response to chemotherapy. Neither enteral nor parenteral
nutrition has improved survival, tumor response, or quality of life in patients
with either end-stage cancer or AIDS.
Conclusions
Progressive nutritional deterioration, wasting, and weakness are
characteristics of anorexia and cachexia. They are associated with an underlying
wide range of pathologic and metabolic derangements. Anorexia and cachexia often
precede the onset of weight loss, they represent a major source of body image
concerns to many palliative care patients, and they are associated with decreased
physical and psychological function. Treatment is focused on identification
of reversible causes, and pharmacologic interventions are beneficial. Further
research should probably concentrate on the use of other agents in comparison
with megestrol acetate and with combinations of agents.
General References
1. Loprinzi
CL, Goldberg RM, Peethambaram P. Cancer anorexia/cachexia. In: Berger A, Portenoy
RK, Weissman DE, eds. Principles and Practice of Supportive Oncology.
Philadelphia, Pa: Lippincott-Raven; 1998.
2. Grace M, Alexander
HR. Prevalence and pathophysiology of cancer cachexia. In: Portenoy RR, Bruera
E, eds. Topics in Palliative Care. Vol 2. New York, NY: Oxford University
Press; 1998.
3. Loprinzi CL. The
pharmacological manipulation of appetite. In: Portenoy RR, Bruera E, eds. Topics
in Palliative Care. Vol 2. New York, NY: Oxford University Press; 1998.