|Ahead of print
Integrating psycho-oncology services in cancer care in India
Bincy Mathew, Bidhu Kalyan Mohanti, Saipriya Tewari, Anusheel Munshi
Department of Oncology, Human Care Medical Chartiable Trust, Manipal Hospitals, New Delhi, India
|Date of Submission||20-Mar-2020|
|Date of Decision||20-May-2020|
|Date of Acceptance||18-Jun-2020|
|Date of Web Publication||10-Dec-2020|
Department of Oncology, Human Care Medical Chartiable Trust, Manipal Hospitals, New Delhi
Source of Support: None, Conflict of Interest: None
Psychological distress is often an under-diagnosed problem in cancer care. Addressing psychosocial issues would enhance treatment compliance, physician–patient relationship, treatment efficacy and quality of life. This article emphasizes the importance of integrating psycho-oncology services in cancer care and attempts to define the various roles that a psycho-oncologist can play across the entire trajectory. It also highlights the indispensable role played by the oncologists' referrals in maximizing the benefits of psycho-oncology services received by patients and their caregivers.
Keywords: Oncologist referral, psychological distress, psycho-oncology
As the modern world sets its foot into the third decade of the 21st century, medical science has come a long way. The last 2 decades have witnessed radical changes in all spheres of human life. Significant advances in medical, surgical, and radiation oncology have heralded a new paradigm for cancer care. The focus is now shifting from a mere disease management enterprise to a more holistic and patient-centric approach. There is growing focus and attention to the psychological aspects, quality of life, patient rights, and empowerment and survivorship along with disease management. Emotional and psychological wellbeing are gaining recognition as essential components of cancer care. India and the other developing countries are poised to witness an increase in the incidence of cancer in the coming decades. However, it is also well known that more than 50% of cancer is either preventable or amenable through infection control, lifestyle changes, early detection, screening, and optimal treatment.
Embracing a better health-seeking behavior has proven benefits in an individual's wellbeing during illness trajectory, or in the survivorship period. The standard mandated by the Institute of Medicine (IOM) for quality cancer care demands that the psychosocial needs of patients would be integrated into routine cancer care. Addressing the patients' and the caregivers' emotional and psychological wellbeing always enhances the health status, physician–patient relationship, communication and satisfaction with the treatment. Psycho-oncology is a subspecialty which plays a pivotal role of addressing the two major psychological and behavioral dimensions of cancer: The psychological responses of patients to cancer at all stages of the disease (and that of their families and caretakers); and the psychological, behavioral, and social factors that may influence the disease process.
| » Psychological distress in cancer care|| |
Impaired psychological health is very common in cancer patients affecting 30-40% patients during the course of their treatment. This facet related to a cancer patient is often undetected and untreated. Irrespective of advancement in cancer management, a cancer diagnosis often generates a great deal of fear and uncertainty among cancer patients and family members. A landmark meta-analysis study conducted by Mitchell et al. found that cancer patients experience psychological distress and its negative impact on the quality of life. According to the National Comprehensive Cancer Network (NCCN), psychological distress comprises unpleasant psychological, social, and/or spiritual experiences that interfere with the ability to effectively cope with a cancer diagnosis, its symptoms, and subsequent treatment side-effects. The International Psycho-oncology Society endorsed distress as the sixth vital sign in cancer settings. In western countries, it is mandatory to assess the distress using a distress thermometer, whereas in India, it is not largely addressed. Left untreated, distress may lead to co-morbid clinical and psychiatric conditions like depression, anxiety, adjust-mental issues, and other issues. It is important to give adequate attention, if there is an indication of psychological distress and the imperative need to manage it appropriately. Even though there are many scientific studies discussing the indication of psychological distress, it lacks attention in most hospitals in India.
Integrating psycho-oncology services has been systematically established in developed nations. National guidelines and recommendations have been produced in many countries like the UK, the USA, and Australia for routine screening for psychosocial issues and their management in oncology. In contrast, there are no standard guidelines for psychosocial care in India. On a positive note, hospitals in many metro cities have begun to integrate the psycho-social-oncology services in their routine cancer care with immense effort.
Psycho-oncology has a role to play in all tiers of primary, secondary, tertiary, and quaternary prevention in the cancer care trajectory. However, at present, we continue to focus on the tertiary hierarchy of preventive psycho-oncology, stressing most on the management of emotional issues and quality of life. Although it is recognized that behavioral factors play an important role in the development of cancer and the recurrence of the disease, we still have a long way to go in integrating preventive psycho-oncology in routine patient care. In the context of cancer, the goal of psycho-oncology in the primary prevention is to control cancer incidence by avoiding known causes of disease (such as tobacco use, physical inactivity, diet, alcohol abuse, etc.), creating awareness, facilitating lifestyle, and behavioral changes. In the secondary prevention, psycho-oncology plays a role by ensuring and educating the appropriate early screening and detection among those who are at high risk. At the same time, in the tertiary and quaternary prevention is about the management of early and late emotional and behavioral issues, by improving the quality of life and minimizing the suffering. The possible role of psycho-oncology in different phases of cancer care is enumerated in [Figure 1].
| » Oncologist referral matters!|| |
Studies have shown that while one third of cancer patients indicate a desire for psychosocial support, one fourth state a wish for talking to someone about their distress caused by the disease. Only up to half of those classified as showing elevated distress levels reported having supportive needs, whereas up to one fourth of those classified as distressed nevertheless reported a need for psychosocial support. There are several reasons for this discrepancy of availing psycho-oncology services. The primary oncologist is a vital link between the patient and the psycho-oncologist. After the cancer diagnosis, always the patient builds a firsthand relationship with the oncologist. If the patient and caregiver have any issues, their prime contact point is the oncologist. If the oncologist emphasizes seeking help from the mental health professionals for their emotional issues, then patients become receptive and cooperative. There is a scarcity in research which supports this finding with the Indian context; however, many western studies have proven that oncologist recommendation to mental health therapists really matters in their emotional wellbeing. Lack of awareness about the role of psycho-oncology among oncologists themselves is a significant factor which needs to be addressed. In this context, involving the other multidisciplinary team members during the decision-making process, tumor board, grand rounds, etc., can enhance the care trajectory for individual patients. Insufficient human resources, financial constraints, and lack of awareness among the patients about psychological interventions are the various challenges in making the distress screening as a standard of practice. Though they have moderate to severe psychological distress, many eligible patients do not take advantage of support services due to attitudinal barriers. Social stigmas, myths, and fallacy about both mental health and cancer prevail in the society. Often, such wrong perceptions of getting labeled as 'mentally ill', 'weak', 'psychic' by society, adds fuel to the fire leading to patients prioritizing physical health and dismissing emotional wellbeing to avoid dealing with any additional unpleasant experiences.
| » Psycho-oncology progress in India|| |
The biomedical world recognized psycho-oncology as a formal field of study in cancer care about four and a half decades ago. India saw its arrival in the beginning of the 21st century, with steady progress ever since. Today, India has three institutions providing professional degrees in psycho-oncology i.e., Cancer Institute (WIA), Chennai; Center of Psycho-oncology for Education and Research (COPER), Bangalore, and Tata Medical Center, Kolkata [Table 1]. Additionally, there are trained professionals from various institutes from India and other parts of the world, who are also providing internship/observer-ship opportunities for graduate and postgraduate students of psychology. Psycho-oncology professionals are also part of comprehensive cancer centers, pain, and palliative units and NGOs across the country. However, considering the large demography of the country and its growing need, India needs more trained people in the near future. Apart from that, to meet the larger demand of providing psychological support we can look into up-skill the existing pool of counselors and social workers to deliver the care under the supervision of trained professionals.
Availability of trained professionals allows the conduct of scientific research, academic workshops, and seminars related to the field of psycho-oncology. This gives the professionals an opportunity to network with the other cancer specialties and also the much needed recognition to their work. A recent review analysis pointed out that many scientific studies produced in India are a cross-sectional single point study. The same study mentioned the lack of scientific evidence based on coping, resilience, burden, spirituality, and post-traumatic growth of cancer patients in the country. The need of the hour is conducting longitudinal, multiple endpoints, multi-centric collaborative study related to psycho-oncology with adequate sample size. Developing psychometric standardized tools and assessment based on our socio-culturally-responsive and sensitive manner would further benefit the patient and their caregivers.
| » Integration of psycho-oncology in cancer care management|| |
Dealing with uncertainty is part of cancer care. Whether at the start of a cancer diagnosis, during the cancer management trajectory, as cancer survivor or a cancer previvor, these individuals face uncertainties, fears, distress, anxiety, and depression. Providing emotional and psychological support to these patients can make a huge difference by exponentially improving the quality of care that matters. Addressing the psychological distress would enhance the adherence toward treatment, social and emotional functioning, the relationship between doctors and patients, quality of life and death of the patient and their caregivers.
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Conflicts of interest
There are no conflicts of interest.
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