Opportunities, problems for cancer research and practice

By Andrew Baum, PhD

R ecent developments in psychological research and clinical applica- tions in cancer prevention and control have called attention to these rapidly growing activities but this belies the commitment and expertise of many behavioral scientists and psychotherapists who have been working in this field for a long time.

Interest in prevention, including reduction of tobacco use, in early detection and surveillance for cancer, and in care of cancer patients who are experiencing distress, is decades old. Considerable progress has been made in several areas and there are now a number of behavioral scientists and clinicians who specialize in cancer-related problems.

A resurgence of interest and activity in this area has been fueled by recent findings in related fields like psychoneuroimmunology, by impressive progress in investigation of and intervention in other chronic diseases--such as cardiovascular disease--and by provocative findings in studies of people at risk for cancer, or who already suffer from it.

These developments introduce enormous new opportunities; because of the nature of cancer and people's reactions to it, there is a lot of work to be done. However, with these opportunities come potential problems and the need for a fresh way of looking at many of the issues we have studied for years in other contexts.

One important issue is the extent to which traditional models are useful in psychological research on cancer or in care of patients. Prevention research is focused for the most part on tobacco use, notable for its large contribution to cancer morbidity and mortality. Clearly, new approaches have been critical in the effort to curb tobacco use, but even as we succeed, we still see substantial amounts of unhealthy behaviors.

Genetic, social and psychological factors offer insight into the best means of preventing or eliminating tobacco consumption, as we consider new approaches that emphasize sociological, pharmacological and behavioral perspectives. Unfortunately, research on other behaviors that could contribute to cancer risk reduction, including diet (and obesity) and exercise, lags behind other prevention efforts.

Equally encouraging are findings that relate early detection and surveillance for signs of cancer to knowledge, fear and stress. People are often resistant to messages about cancer screening, and education has not been sufficient to increase this vital behavior. Fear and worry appear to characterize the daily lives of people at risk for cancer and as long as this distress is manageable, it may motivate screening behavior.

When it becomes excessive, or uncomfortable, however, it appears to reduce surveillance behavior as avoidance becomes a modal coping device. Strategies for managing stress related to risk and for shaping cancer worry in order to make it a positive, rather than a negative, stimulus seem to hold a good deal of promise for boosting early detection efforts.

Another issue concerns the applicability of mental health models to cancer care. Studies suggest that psychopathology is not a common outcome of cancer. Post-traumatic stress disorder, major depression and anxiety disorders may occur more frequently than in the general population, but not much more often.

One study found that most mental health problems were characterized as adjustment disorders and a meta-analysis indicated that with the exception of depression, mental health problems among cancer patients were comparable to the general population (Derogatis et al, 1983; Van't Spijker et al, 1997). These data suggest that traditional psychological and psychiatric emphases on psychopathology may be less relevant for cancer than are approaches that focus on healthy individuals dealing with extraordinary circumstances. Recognition of the unusual nature of cancer is important, but so are the commonalties across diseases and stressors.

A comprehensive approach that seeks to prevent mental health disorders as well as treat them when they occur seems warranted, just as multifactorial models of behavior and illness provide the best predictions about cancer etiology and progression.

Training issues are also important in light of the unique features of cancer. Although some psychology training programs emphasize behavior change or include more preventative or pre-emptive approaches, much of the work we learn about is more appropriate for other types of investigation. We embrace the holistic notion of an integrated mind_body approach, but most of us have learned little about the body and graduate training remains light on basic human physiology, pharmacology and the like. If we are to be credible as scientists and/or practitioners in medical settings or in intervention with cancer patients, we must do a better job of learning about the fundamental properties of the disease, its treatment and the mechanisms underlying relapse and disease progression.

Appropriate collaborative activity as a part of a medical treatment team, complex interactions within medical centers or in cases of life-threatening illnesses, and strategies for establishing interdisciplinary medical_psychological teams are increasingly important but are often neglected. The need to better understand such issues is not unique to cancer work, but is particularly important in this case.

Side effects of cancer treatment, for example, may be mistaken for distress or psycho- pathology, but their basis in bodily changes suggests more complicated causes. Likewise, emphasis on conventional psychotherapy to treat these symptoms or to help cancer patients manage distress may not be the best approach, and students learning about applied psychology should be provided with a broader and more eclectic course of study.

At issue here are the implications of our discipline's continued metamorphosis as it becomes a major component of public health and medical or life sciences. Our field has evolved from its roots in philosophy and physiology and has changed as it has discovered new and important areas of activity. Because the implications of mind and behavior are so extensive and the fruits of psychological intervention are potentially so great, we have often found ourselves studying, treating or trying to head off conditions and reactions that are challenging and new.

Historically, this has been the sustaining spirit of the field and an important reason for its longstanding popularity and growth. Just as the parts of psychology that address issues such as human engineering or the legal system have embraced new and challenging knowledge and approaches, the parts of our field that interface with cancer must incorporate new ways of thinking, studying and helping.