SPECIAL ISSUE ON CANCER

Psychology and medicine connecting in war on cancer

Proving their mettle as cancer-fighters, psychologists are being welcomed as part of the team.

By Patrick A. McGuire
Monitor staff

For decades, as psychology has carved out and become expert in cancer research and cancer caregiving, it has also struggled for recognition as a legitimate partner in the battle against the disease.

Now, after years of being inconsistently funded in cancer-related behavioral research, and in having the mind-body connection downplayed by cancer's medical model, the two streams of psychological progress and medical acceptance are flowing together.

Public interest in changing unhealthy behaviors has grown and research funding has dramatically increased. Everyday, it seems, practitioners and researchers demonstrate how their methods and psychological training enhance the knowledge and treatment of cancer:

* Through psychoneuroimmunology, psychologists have explored the connection between the brain and the immune system--theorizing that stress and anxiety can impact the progress of, and even the vulnerability toward, the disease.

* Psychologists have shown that more carefully framed cancer-prevention messages stand a better chance of being heeded. Using cutting-edge information technology, they have designed sophisticated cancer educational campaigns aimed at individuals and cultures rather than the one-size-fits-all approach.

* They have argued that decisions about undergoing genetic testing for cancer can psychologically affect individuals and their families--and that physicians need the expertise of psychologists to address those issues.

* Psychologists have shown that psychosocial support, given to cancer patients through and beyond medical treatment, enhances quality of life, and, according to two studies, may even extend it.

Practitioners today are helping family members cope with the stress of a loved one's cancer, often by making them active partners in the treatment itself. And they are more likely to use education to ease the often paralyzing fears women suffer related to breast cancer.

"It's becoming fairly common for cancer patients to receive some form of care from a psychologist," says Edwin B. Fisher, PhD, at Washington University's School of Medicine in St. Louis.

"By and large, the contribution of psychology is getting much more recognized," adds Gary Morrow, PhD, of the University of Rochester's Cancer Center, "because psychology has a tremendous amount to offer."

Those contributions will be examined in depth at this year's APA Annual Convention, Aug. 20-24, in Boston, where President Richard Suinn, PhD, will convene a miniconvention to highlight the changing roles psychologists are playing in cancer prevention and treatment (see page 10 for programming listing).

The basic facts

Cancer is the second most common cause of death in men and women in the United States--behind heart disease. Since 1990, 12 million people have been diagnosed with cancer, and 5 million have died. Experts predict 2 million new cases of cancer in 1999, and more than half a million deaths. Ultimately, it is estimated that one of every four Americans will die of cancer.

At the same time more than 8 million Americans have survived cancer for at least 5 years. Some studies show the chances of recovery have risen from one out of two in the early 1980s to three out of five today.

And in its annual report, the American Cancer Society says that cancer incidence fell a steady 2.2 percent a year between 1992 and 1996. Much of that, it says, is attributable to the large number of men who have stopped smoking--their death rates are dropping more rapidly than for women who have been slower to quit, and whose lung cancer rates are still rising.

As the expectation of survival has increased, so has the need for psychosocial supports aimed at maintaining quality of life. The day is gone when saving a patient's life was the only concern of an oncologist. In the area of pediatrics, for instance, psychologists have helped force attention and resources on helping children and their families cope with learning disabilities caused by anticancer drugs, or with social adjustment problems caused by disfigurement or loss of school time.

But, while psychosocial interventions are more frequent--many cancer centers now provide referrals to psychologists--it is still unusual to see them built into routine care as at Washington University's Cancer Center in St. Louis.

There, as a regular member of the multi-disciplinary breast-cancer treatment team, a psychologist helps medical professionals understand the psychological status of a patient, and then provides psychosocial support as needed. Often these are 50-minute sessions that deal with issues of anxiety or stress.

"Making psychosocial services an integral part of a multidisciplinary team and having a psychologist see everybody," says Fisher, director of the Division of Health Behavior Research, "normalizes the psychosocial dimension of cancer care."

Funded by the university and affiliated hospital system, psychologists this year will join teams dealing with head, neck and colorectal cancer, says Fisher, initiator of the approach.

Among other successful psychosocial programs is the Breast Cancer Demonstration Project, created by APA's Practice Directorate and cited by The American Association of Health Plans and the Commonwealth Funds as an outstanding women's health project. The project takes procedures from research literature--those stressing the value of psychosocial interventions in helping women diagnosed with breast cancer to better cope--and to move them into real-world health-care systems and then measure their effects.

"Quality of life involves a number of issues and dimensions for which psychology has terrific contributions," adds Morrow, at the University of Rochester, where he is professor of radiation oncology. "Cancer puts a challenge on any relationship. It's literally something that rips the human out of its usual social context. We psychologists know something about those kinds of things. We can help people adapt and cope."

Unparalleled opportunity

A perfect example, he says, comes at "one of the worst times in a cancer patient's life," when treatment is finished, and they are anxious about what will happen next.

"The medical profession says, 'Why isn't this person thrilled to be through with treatment?'" says Morrow. "But we, as psychologists, have insights into the human condition. That is why a medical center is really where psychology has an unparalleled opportunity to do wonderful things."

The problem, he says, is that psychology hasn't interacted well in such settings.

"I tell postdocs never to forget you're a guest in somebody else's house," he says. "The reality is, once medical people understand you're not going to try to take over, that you're there to contribute, the contributions are really quite welcome."

One of Morrow's contributions years ago was in recognizing that nausea and vomiting related to chemotherapy were often caused by conditioned responses.

"Patients were getting sick at the same time every day," he explained. "I simply saw the phenomenon in terms of conditioning, while the medical people saw it in pathophysiological terms. And it's why the opportunity for psychology has never been greater in health related areas."

The National Cancer Institute has added to that opportunity by creating a separate behavioral research program, headed by a psychologist, that actively encourages proposals. The turnabout has stunned and delighted psychologists.

"There was a time," admits Barbara Rimer, PhD, director of NCI's new Division of Cancer Prevention and Control "when it was verboten to contemplate submitting a grant proposal here. People here used to think studying health behavior was just a little above being in building maintenance."

Then and now

The modern link between cancer and psychology, says Rimer, dates to personality research in the late 1960s and early 70s, which nurtured a growing sense that psychologists had a role to play in changing behaviors related to the disease. That led to long-term psychological involvement in smoking-cessation programs.

By the early 80s, psychological research-ers had begun studying motivators behind cancer screening, and were partnering with physicians to develop interventions. Still, says Rimer, "it was a relatively new field in terms of having a cadre of people who felt like they were cancer researchers."

During this period, NCI limited its interests in cancer behavioral work to the support of studies in tobacco control, research related to cancer screening and some research on interventions related to drugs. The larger supporter of behavioral research in those days was the smaller American Cancer Society.

"The role of the ACS in all of this can't be overstated,"says Morrow. "It has always been the lead sled dog in helping to develop psychology and psychosocial influences in cancer--what we have called the human side of cancer."

Most recently, according to the ACS, it has conducted a study of 100,000 cancer survivors and families, while also supporting studies of quality of life assessments of culturally diverse populations.

Meanwhile, a key factor in changing NCI's priorities--and a significant segue between the role of psychology in the 1980s and now--was the start of behavioral science research in cancer genetics.

According to Robert T. Croyle, PhD, the associate director for behavioral research at NCI, that work "demonstrated how psychology and psychological research was relevant to the whole range of basic and applied research questions undertaken by NCI." Early on, he adds, NCI was impressed that "psychology was involved in ethical, social and psychological issues concerning cancer genetics research."

Several other factors played a role. A report of an external advisory group, chaired by psychologist David Abrams, PhD, recommended NCI expand its support of basic behavioral scientific research. Rimer was appointed chair of the National Cancer Advisory Board--which has final funding authority for NCI--and became influential in advocating greater support of behavioral research. And it helped, too, that in various congressional appropriations bills, NCI was urged to give more support to programs that could change people's unhealthy behaviors.

"Behavior change, a domain in which psychologists have expertise, is the major weapon we have to reduce premature disease and deaths due to cancer," says Croyle. "Avoiding lung cancer by not smoking, or avoiding colon cancer by exercising and by eating a diet high in vegetables--these kind of things are still the best method of reducing the incidence of cancer."

Which is why, he says, research on communication and communication processes will become a top priority at NCI. Croyle foresees support of basic research on risk perception, physician-patient communication, development and testing of messages, "because we need to better understand the most effective means of helping people adopt healthy lifestyles."

One only has to look at research funding now available through ACS and NCI, says Morrow, to see how psychology's role in cancer has been recognized.

Even at NCI, Rimer says, she experiences heady days when the notion that "we are actually making a difference," sinks in.

"Now, we not only have a division of population sciences, we have a whole program in behavioral research headed by a psychologist," she says. "It's a very different world from the 1970s and 80s and most of the 90s."

Charts by Angela e. Terry



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