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Cancer Lecture for University of Pittsburgh Health Psychology Class

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  • SPEAK benign and malignant tumors can be a health problem Malignant more probably a problem because Grow faster Metastasize Different tumors have different propensities to metastasize to different areas
  • Retrieved 6/12/2010
  • Background: How Many People Alive Today Have Ever Had Cancer? The National Cancer Institute estimates that approximately 10.8 million Americans with a history of cancer were alive in January 2004. Some of these individuals were cancer-free, while others still had evidence of cancer and may have been undergoing treatment. How Many New Cases Are Expected to Occur This Year? About 1,437,180 new cancer cases are expected to be diagnosed in 2008. This estimate does not include carcinoma in situ (noninvasive cancer) of any site except urinary bladder, and does not include basal and squamous cell skin cancers. More than 1 million cases of basal and squamous cell skin cancers are expected to be diagnosed this year Cancer Facts and Figures 2008 American Cancer Society
  • From American Cancer Society Website
  • SPEAK- How a normal cell becomes cancer Normal body cells grow, divide, and die in an orderly fashion. During the early years of a person's life, normal cells divide more quickly until the person becomes an adult. After that, cells in most parts of the body divide only to replace worn-out or dying cells and to repair injuries. Cancer cells develop because of damage to DNA. This substance is in every cell and directs all of the cell's activities. Most of the time when DNA becomes damaged, either the cell dies or is able to repair the DNA. In cancer cells, the damaged DNA is not repaired. People can inherit damaged DNA, which accounts for inherited cancers. Many times though, a person’s DNA gets damaged by things in the environment, like,chemicals, viruses, tobacco smoke or too much sunlight
  • SPEAK- TNM staging TNM Staging is used for solid tumors, and is an acronym for the words "Tumor", "Nodes", and "Metastases". Each of these criteria is separately listed and paired with a number to indicate the TNM stage. For example, a T1N2M0 cancer would be a cancer with a T1 tumor, N2 involvement of the lymph nodes, and no metastases (no spreading through the body). Tumor (T) refers to the primary tumor and carries a number of 0 to 4. N represents regional lymph node involvement and can also be ranked from 0 to 4. Metastasis is represented by the letter M, and is 0 if no metastasis has occurred, or else 1 if metastases are present retrieved 2-20-09
  • Chronic stress accelerates ultraviolet-induced cutaneous carcinogenesis. Parker J, Klein SL , McClintock MK , Morison WL , Ye X , Conti CJ , Peterson N , Nousari CH , and Tausk FA Journal of the American Academy of Dermatology 51(6):919-22 2004 Dec - View abstract BACKGROUND: Physical and emotional stressors have been found to mediate a wide variety of biological changes including the facilitation of tumor progression; however most of these paradigms utilized artificial sources of neoplasms and stress. METHODS: Skh mice were exposed to carcinogenic doses of ultraviolet light ( UV ). The stressed group was subjected to the close proximity of fox urine as a source of stress from the presence of the odor of their natural predator, while the control group remained stress free. RESULTS: A significant acceleration in the development of cutaneous neoplasms was observed in mice that had been exposed to the stressor . The first tumor appeared in the group after 8 weeks, whereas nonstressed mice began to develop these by week 21. CONCLUSION: These results suggest that stress plays a role in potentiating cutaneous carcinogenesis . Add to paper collection Recommend to someone
  • Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., et al. (1998). Household Dysfunction to Many of the Leading Causes of Death in Adults The Adverse Childhood Experiences ( ACE ) Study. American Journal of Preventive Medicine , 14 (4), 245-258.
  • Women Blame Stress For Their Breast Cancer, Attribute Positive Attitude For Remission Ask women what caused their breast cancer, and the most common answer will be stress, an unfounded belief that can affect how these women approach their treatment and survival. In a study of nearly 400 breast cancer survivors who had been disease-free for an average of nine years, 42 percent cited stress as one of the main causes of their breast cancer. This was many more than the 27 percent of the women who felt genetics was involved, the 26 percent who attributed a role to environmental factors, 24 percent who blamed hormones and 16 percent who thought diet was a contributing factor; the scientific evidence supporting these factors as potential causes of breast cancer is far stronger than that for stress. Sixty percent of the women also felt that a positive attitude helped them keep the breast cancer from returning, followed by diet (50 percent), healthy lifestyle (40 percent), exercise (40 percent), stress reduction (28 percent), prayer (26 percent), complementary therapies (11 percent), luck (4 percent) and tamoxifen (4 percent). The conviction that stress caused cancer or that a positive attitude has kept their breast cancer from recurring may give women a sense of control over the disease, say Donna E. Stewart, MD, and her associates at University Health Network and the University of Toronto. This belief can be beneficial when it helps women switch to a low-fat diet or exercise more, but can backfire in a feeling of "personal failure" if the disease returns. The study will be published in the March issue of Psycho-Oncology . They found that the women who believed their cancer was caused by stress were more likely to use complementary therapies and anti-depressants and were less likely to smoke, suggesting that women's beliefs about their disease may be "associated with specific health behaviors used to combat the illness," the researchers say. They mailed questionnaires to 500 women who had been disease-free for at least 2 years. The questionnaires were returned by 378 of the women. Of those, 322 answered the question on what they thought caused their disease, and 330 answered the question on what kept it from returning. The questionnaire also asked the women what advice they would give another woman who was recently diagnosed with breast cancer. More than half (52 percent), said they would tell the woman to have hope, have courage and be positive. And 58 percent said they would take more control of their treatment if they had to relive the experience. The researchers recommend that health care professionals talk to women about their beliefs. The patient's "views may assist in understanding how she perceives her condition, in encouraging lifestyle changes, and in framing disease management in meaningful ways that give a greater sense of personal control," said Stewart, who is professor and chair of women's health.
  • Personality and cancer development and progression Link between depression and cancer Carney, Jones, Woolson, Noyes, and Doebbeling, 2003 in Taylor Dattore, Shonz and Coyne, 1980, in Taylor Persky, Kempthorne-Rawon and Shekelle, 1987 in Taylor Linkins and Comstock (1990, in Taylor) found a 18.5 fold increase in risk for smoking related cancers in depressed smokers and a 2.9 fold increase in non-smoking related cancers. Link between depression and use of repressive coping strategies (McKenna, Zevon, Corn & Rounds, 1999 in Taylor) Pessimistic cancer patients have more rapid cancer progression (Schulz, Bookwala, Knapp, Scheier & Williamson, 1996, in Taylor) Personality and cancer onset – Nakaya et al. (2003) Personality and cancer progression American Journal of Epidemiology Vol. 132, No. 5: 962-972 Copyright © 1990 by The Johns Hopkins University School of Hygiene and Public Health research-article DEPRESSED MOOD AND DEVELOPMENT OF CANCER ROBERT W. LINKINS1,2 and GEORGE W. COMSTOCK1, 1 Department of Epidemiology, The Johns Hopkins School of Hygiene and Public Health Baltimore, MD 2 Current address: Epidemiology Program Office, Centers for Disease Control, Atlanta, GA Reprint requests to Dr. George W. Comstock , Training Center for Public Health Research, P.O. Box 2067, Hagerstown, MD 21742-2067 This study was undertaken to determine whether premorbid depressed mood is associated with the development of cancer. Scores on the Center for Epidemiologic Studies Depression Scale were available for 2,264 participants in a mental health study conducted in 1971–1974 in Washington County, Maryland, who were still free of cancer 2–4 years later. Over a 12-year follow-up period (1975–1987), 169 cancers were diagnosed among these persons. While there was only a slight association of depressed mood with subsequent cancer among the total study population, the association was much stronger among cigarette smokers. Compared with the risk seen in never smokers without depressed mood, depressed mood at the highest level of smoking was associated with relative risks of 4.5 for total cancer, 2.9 for cancer at sites not associated with smoking, and 18.5 for cancer at sites associated with smoking.
  • SPEAK The Nakaya study reported in this slide is important because Questionnaires were given to every person eliminating selection bias Questionnaires were given prior to development of cancer Questionnaires were psychometrically sound: the categories are valid Results do not suggest link between pre-cancer personality and development of cancer.
  • Research suggests though that personality affects the progression of cancer. Levy [1] finds apathy, depression, passivity and low energy are associated with poorer outcome Derogatis et al (1979) Metastatic Breast cancer patients: Those with more anger about diagnosis lived longer Greer et al (1979)- Breast cancer without metastasis Clinical interview separates 4 groups Deniers Fighters Accepters Helpless After 5 years, fighters and deniers did best. Problem: we still don ’ t know if this is cause or effect. We also don ’ t know if the progression could be affected by an intervention to increase assertion. [1] Levy, S.M., Herrberman, R.B., Maluish, A., M., Schlien, B. & Lippeman, M. (1985). Prognostic risk assessment in primary breast cancer by behavioral and immunological parameters. Health Psychology , 4 , 99-113.
  • Spiegel et al. (1989) reports in Lancet that breast cancer patients participating in long-term group therapy live longer and better than those in a standard-treatment control group Treatment group survives 36.6 months while those in control group survive 18.9 months. Treatment group is less depressed, copes better and has less pain and fewer fears. Problem- The control group lived only 18.9 months and this is less than would be expected if patients were selected randomly. In fact the survival rate of the general population is not significantly different from the treatment group's. Goodwin et al. (2001) New England Journal of Medicine (Vol. 345, No. 12) 235 patients randomized into supportive expressive (replicates original Spiegel) versus control group. Results of the study Improved emotional functioning, especially in those who were initially distressed Improved pain management, especially in those with higher levels of initial pain. No Survival time advantage Control survives 23.6 months Intervention survives 28.2 months Survival rates are even closer if accounting for the time since first diagnosed
  • Holland, Jimmie C (1987). Managing Depression in the Patient with Cancer. CA-A Cancer Journal for Clinicians 37 (6)
  • The statistics are from Kadan-Lottick et al. (2005). Psychiatric Disorders and Mental Health Service Use in Patients with Advanced Cancer. Most patients with cancer cope well [1] Only about 13-24% of patients with cancer have major depression. [2] Study of treatment accepters and rejecters [3] So, most patients were seen as not needing therapy But, if a patient was selected as needing therapy, then he or she was likely to accept therapy. Note that patients in the Linn study also accepted proffered therapy [1] Weisman, AD. 1979. Coping with Cancer . New York: McGraw Hill. [2] Holland, JC. (1987). Managing depression in the patient with cancer. CA- A Cancer Journal for Clinicians, 37, 366-371. [3] Worden, J. & Weisman, A.D. (1980). Do cancer patients really want counselling? General Hospital Psychiatry , 2 , 100-103.
  • Goldsmith, R. E., Jandorf, L., Valdimarsdottir, H., Amend, K. L., Stoudt, B. G., Rini, C., et al. (2010). Traumatic stress symptoms and breast cancer: the role of childhood abuse. Child abuse & neglect , 34 (6), 465-70. Elsevier Ltd. doi: 10.1016/j.chiabu.2009.10.007.
  • Redd WH, Andresen GV, Minagawa RY: Hypnotic control of anticipatory emesis in patients receiving cancer chemotherapy. J Consult Clin Psychol 50 (1): 14-9, 1982 Kolko DJ, Rickard-Figueroa JL: Effects of video games on the adverse corollaries of chemotherapy in pediatric oncology patients: a single-case analysis. J Consult Clin Psychol 53 (2): 223-8, 1985 Lyles JN, Burish TG, Krozely MG, et al.: Efficacy of relaxation training and guided imagery in reducing the aversiveness of cancer chemotherapy. J Consult Clin Psychol 50 (4): 509-24, 1982. Burish TG, Shartner CD, Lyles JN: Effectiveness of multiple muscle-site EMG biofeedback and relaxation training in reducing the aversiveness of cancer chemotherapy. Biofeedback Self Regul 6 (4): 523-35, 1981 Morrow GR, Morrell C: Behavioral treatment for the anticipatory nausea and vomiting induced by cancer chemotherapy. N Engl J Med 307 (24): 1476-80, 1982
  • Cancer powerpoint bw

    1. 1. Cancer: The Effects of Stress & Personality Outcomes of Psychological Interventions Bruce A. Sorkin, Ph.D. University of Pittsburgh Health Psychology
    2. 2. What is the difference between a benign and malignant tumor? Are benign tumors “o.k.?” <ul><li>Cancer (Malignant tumors) </li></ul><ul><ul><li>Uncontrolled Growth </li></ul></ul><ul><ul><li>Invasion into and destruction of healthy tissue </li></ul></ul><ul><ul><li>Possible metastases </li></ul></ul><ul><ul><ul><li>Pieces of tumor break off and spread to distant sites by </li></ul></ul></ul><ul><ul><ul><ul><li>Blood </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Lymph system </li></ul></ul></ul></ul><ul><ul><ul><li>Once implanted they grow into tumors there </li></ul></ul></ul><ul><li>Benign tumors </li></ul><ul><ul><li>Encapsulated </li></ul></ul><ul><ul><li>Don’t invade other tissue </li></ul></ul><ul><ul><li>Don’t metastasize </li></ul></ul>
    3. 3. Metastases of Pancreatic Cancer Invading a Human Liver
    4. 4. Where do different cancers metastasize? (National Cancer Institute, 2010) Primary Site Metastases Lung Brain, Bones Colon Liver Prostate Bones Breast Bones, Lung, Liver, Brain
    5. 5. How many people have cancer? American Cancer Society (2008) <ul><li>10.8 million Americans alive today either have or previously had cancer. </li></ul><ul><li>1,437,180 new cases of cancer will be diagnosed. </li></ul><ul><li>1,000,000 cases of basal and squamous cell skin cancers will be diagnosed. </li></ul>
    6. 6. What is the Lifetime Risk of Developing Cancer ? (American Cancer Society, 2008) <ul><li>The risk of contracting cancer of any kind is </li></ul><ul><ul><li>1 in 3 for women </li></ul></ul><ul><ul><li>1 in 2 for men </li></ul></ul>
    7. 7. Causes of Mortality – 2007 <ul><li>Heart disease: 616,067 </li></ul><ul><li>Cancer: 562,875 </li></ul><ul><li>Stroke : 135,952 </li></ul><ul><li>Chronic lower respiratory diseases: 127,924 </li></ul><ul><li>Accidents (unintentional injuries): 123,706 </li></ul><ul><li>Alzheimer's disease: 74,632 </li></ul><ul><li>Diabetes: 71,382 </li></ul><ul><li>Influenza/Pneumonia: 52,717 </li></ul><ul><li>Kidney Disease: 46,448 </li></ul><ul><li>Blood Poisoning: 34,828 </li></ul><ul><li>Source: Retrieved 06-03-2011 </li></ul>
    8. 8. 2008 Estimated US Cancer Deaths* ONS=Other nervous system. Source: American Cancer Society, 2008. Men 294,120 Women 271,530 <ul><li>26% Lung & bronchus </li></ul><ul><li>15% Breast </li></ul><ul><li>9% Colon & rectum </li></ul><ul><li> 6% Pancreas </li></ul><ul><li>6% Ovary </li></ul><ul><li>3% Non-Hodgkin lymphoma </li></ul><ul><li> 3% Leukemia </li></ul><ul><li>3% Uterine corpus </li></ul><ul><li>2% Liver & intrahepatic bile duct </li></ul><ul><li>2% Brain/ONS </li></ul><ul><li>25% All other sites </li></ul>Lung & bronchus 31% Prostate 10% Colon & rectum 8% Pancreas 6% Liver & intrahepatic 4% bile duct Leukemia 4% Esophagus 4% Urinary bladder 3% Non-Hodgkin 3% lymphoma Kidney & renal pelvis 3% All other sites 24%
    9. 9. What causes cancer? <ul><li>Damaged DNA </li></ul><ul><ul><li>Rarely, this is inherited </li></ul></ul><ul><ul><li>Mostly, this is a mutation </li></ul></ul><ul><ul><li>Normally, cells with damaged DNA die or repair the damage. </li></ul></ul><ul><ul><li>In cancer, the DNA is not repaired and the cell receives the order to keep dividing infinitely. </li></ul></ul><ul><li>What Causes DNA Damage? </li></ul><ul><ul><li>Chemicals (like in tobacco smoke) </li></ul></ul><ul><ul><li>Viruses </li></ul></ul><ul><ul><li>Mechanical irritants (asbestos) </li></ul></ul><ul><ul><li>Radiation (X-rays, Sunlight, Tanning Beds) </li></ul></ul>
    10. 10. A closer look at tobacco smoke: Chemical Carcinogens <ul><li>Benzopyrene is found in cigarette smoke </li></ul><ul><ul><li>Is toxicated (metabolized into a more toxic compound) into an epoxide (type of organic compound) that irreversably attaches to nuclear DNA. This can either </li></ul></ul><ul><ul><ul><li>Mutate the cell and cause programmed cell death (apoptosis) </li></ul></ul></ul><ul><ul><ul><li>Mutate the cell but inhibit apoptosis and lead to cancer </li></ul></ul></ul><ul><li>Other cancerous tobacco substances </li></ul><ul><ul><li>Polynuclear aromatic hydrocarbons </li></ul></ul><ul><ul><li>Acrolein </li></ul></ul><ul><ul><li>Nitrosamines </li></ul></ul><ul><ul><ul><li>Source: Feng, Z.; Hu, W.; Hu, Y.; Tang, M. (2006). &quot;Acrolein is a major cigarette-related lung cancer agent: Preferential binding at p53 mutational hotspots and inhibition of DNA repair&quot;.  Proceedings of the National Academy of Sciences of the United States of America   103  (42): 15404–15409.  Bibcode 2006PNAS..10315404F .  doi : 10.1073/pnas.0607031103 .  PMC   1592536 . PMID   17030796 </li></ul></ul></ul>
    11. 11. A closer look at cigarette smoke: Radioactive Carcinogens <ul><li>Cigarette smoke also contains </li></ul><ul><ul><li>Lead-210 </li></ul></ul><ul><ul><li>Polonium-210 </li></ul></ul><ul><li>Because the tar in cigarette smoke does not dissolve in lung fluid these radioactive particles are not readily expelled and thus have a longer time to undergo radioactive decay </li></ul><ul><li>These particles linger in secondhand smoke and are a particular problem because people inhale more deeply and for longer times when breathing normally. </li></ul><ul><li>Source: alpha-Radiation dose at bronchial bifurcations of smokers from indoor exposure to radon progeny . EA Martell. PNAS March 1, 1983, 80 (5) 1285-1289 . </li></ul>
    12. 12. TNM Stages of Cancer <ul><li>T = Tumor </li></ul><ul><ul><li>Grading increases from T 0 (none) to T is (Tumor in situ) to 1-4 based on size and number of tumors. </li></ul></ul><ul><li>N = Lymph Node Involvement </li></ul><ul><ul><li>Grading increases from L0 (no lymph node involvement) to 1-4 depending on the number of lymph nodes involved and the distance away from the tumor </li></ul></ul><ul><li>M = Metastases </li></ul><ul><ul><li>0 = No Metastases </li></ul></ul><ul><ul><li>1 = Metastases </li></ul></ul>
    13. 13. Stress and Cancer in Animals: Research Paradigm <ul><li>It would be unethical to subject humans to this paradigm </li></ul><ul><li>This paradigm has been used with laboratory animals </li></ul><ul><li>Caution generalizing results to humans because human and animal cancer vary </li></ul>Experimental Tumor Implantation Control No Tumor Implantation Stress No Stress
    14. 14. Does stress cause cancer in animals? <ul><li>Sakakibara (1966) </li></ul><ul><ul><li>Rats exposed to bright randomly flashing lights develop malignant tumors at a higher rate </li></ul></ul><ul><li>Amkraut & Solomon (1977) </li></ul><ul><ul><li>Mice subjected to stressful overcrowding develop malignant tumors at a higher rate </li></ul></ul><ul><li>Parker et al. (2004) </li></ul><ul><ul><li>Mice genetically predisposed to develop skin cancer exposed to carcinogenic doses of UV light. Stress group exposed to fox urine. In stress group tumors appear in 8 weeks and in non-stressed 21 weeks. </li></ul></ul>
    15. 15. Does Stress Cause Cancer in Humans? <ul><li>Stress is neither necessary nor sufficient for cancer. </li></ul><ul><li>The Adverse Childhood Experiences (ACE) Study (Felitti et al., 1998) </li></ul><ul><ul><li>Questionnaire about adverse childhood experiences was mailed to 13,494 adults who had completed a standardized medical evaluation at a large HMO </li></ul></ul><ul><ul><li>9,508 (70.5%) responded </li></ul></ul><ul><ul><li>Categories of adverse childhood experiences: </li></ul></ul><ul><ul><ul><li>Psychological abuse </li></ul></ul></ul><ul><ul><ul><li>Physical abuse </li></ul></ul></ul><ul><ul><ul><li>Sexual abuse </li></ul></ul></ul><ul><ul><ul><li>Violence against mother </li></ul></ul></ul><ul><ul><ul><li>Living with Drug Addict/ Alcoholic </li></ul></ul></ul><ul><ul><ul><li>Living with Mental ill or Suicidal person </li></ul></ul></ul><ul><ul><ul><li>Living with person that was imprisoned </li></ul></ul></ul>
    16. 16. Incidence of Adverse Childhood Experiences (Felitti et al. 1998) <ul><li>More than one half report one adverse experience </li></ul><ul><li>One quarter report more than two experiences </li></ul>
    17. 17. Adverse Experiences and probability of smoking (Felitti et al. 1998) Smoking Number of Adverse Events Odds Ratio 0 1.0 1 1.1 2 1.5 3 2.0 4 2.2
    18. 18. Adverse Experiences and probability of suicide (Felitti et al. 1998) SUICIDE Number of Adverse Events Odds Ratio 0 1.0 1 1.8 2 3.0 3 6.6 4 12.2
    19. 19. Adverse Experiences and probability of cancer (Felitti et al. 1998) CANCER Number of Adverse Events Odds Ratio 0 1.0 1 1.2 2 1.2 3 1.0 4 1.9
    20. 20. Summary of ACE Study (Felitti et al. 1998) <ul><li>Childhood abuse and adverse events are relatively common. </li></ul><ul><li>Abuse and adverse events are associated with the development of multiple health risk factors </li></ul><ul><li>Abuse and adverse events are associated with the development of various illnesses including cancer. </li></ul><ul><li>People with four or more adverse consequences in childhood are roughly twice as likely to develop cancer. </li></ul><ul><li>It is not clear if this increase is due to heath risk factors (smoking) or to other factors. </li></ul>
    21. 21. Stress and Cancer in Humans: No Relationship for Breast Cancer (Stewart et al., 2001) <ul><li>325 long-term female breast cancer survivors were asked what caused their cancer and what caused or prevented cancer recurrence. </li></ul><ul><ul><li>42% cited stress </li></ul></ul><ul><ul><li>60% believed their positive attitude helped keep them in remission </li></ul></ul><ul><li>Stress is not related to development of breast cancer </li></ul><ul><li>Positive attitude is not related to recurrence of breast cancer but is related to coping and well-being. Having a positive attitude does not protect you from getting breast cancer again. </li></ul>
    22. 22. Does depression increase cancer? Linkins and Comstock (1990) <ul><li>Good evidence of pre-existing depression is associated with cancer onset. </li></ul><ul><ul><li>Large study with 2,264 patients </li></ul></ul><ul><ul><li>12 year follow-up looked at relationships between smoking, depression and cancer. Depressed smokers were </li></ul></ul><ul><ul><ul><li>18.5 times more likely to get cancer in sites associated with smoking (e.g., lung) </li></ul></ul></ul><ul><ul><ul><li>2.9 times more likely to get cancer in sites not associated with smoking (e.g., breast) </li></ul></ul></ul><ul><li>Pessimistic patients with cancer have more rapid cancer progression. </li></ul>
    23. 23. Type C Personality and Cancer <ul><li>Type C (cancer-prone) personality </li></ul><ul><ul><li>Responds to stress with depression and a sense of hopelessness </li></ul></ul><ul><ul><li>Introverted </li></ul></ul><ul><ul><li>Respectful </li></ul></ul><ul><ul><li>Eager to please </li></ul></ul><ul><ul><li>Conforming </li></ul></ul><ul><ul><li>Compliant </li></ul></ul><ul><li>There are no data that support this. </li></ul><ul><ul><li>Type C is not necessary for cancer </li></ul></ul><ul><ul><li>Type C is not sufficient for cancer </li></ul></ul>
    24. 24. Is personality associated with cancer? <ul><li>Nakaya, et al. 2003 </li></ul><ul><ul><ul><li>Questionnaires given to 30,000 Japanese </li></ul></ul></ul><ul><ul><ul><li>Based on response, people classified as one of four types: </li></ul></ul></ul><ul><ul><ul><ul><li>Sociable and lively </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Anxious and emotionally unstable </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Aggressive, cold and egocentric </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Conformist and socially naïve </li></ul></ul></ul></ul><ul><ul><ul><li>986 people developed cancer over the next 7 years </li></ul></ul></ul><ul><ul><ul><ul><li>No association between personality and cancer </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Associations between cancer and the usual behavioral risk factors </li></ul></ul></ul></ul>
    25. 25. Does personality affect cancer progression? <ul><ul><li>Levy- personality affects progression. </li></ul></ul><ul><ul><ul><li>Overly polite, passive associated with faster progression of cancer. </li></ul></ul></ul><ul><ul><ul><li>No treatment implications as yet. </li></ul></ul></ul><ul><ul><li>Derogatis et al. </li></ul></ul><ul><ul><ul><li>Anger about diagnosis associated with better prognosis. </li></ul></ul></ul><ul><ul><li>Greer et al. </li></ul></ul><ul><ul><ul><li>Fighter & deniers did better than accepters & helpless. </li></ul></ul></ul>
    26. 26. Questions concerning psychotherapy and cancer <ul><li>Does psychotherapy increase the lifespan (survival) of people with cancer? </li></ul><ul><li>Does psychotherapy improve the mood and general sense of life satisfaction in people with cancer? </li></ul><ul><li>Can psychotherapy decrease specific cancer treatment side effects like nausea and vomiting after chemotherapy? </li></ul>
    27. 27. Does psychotherapy increase the lifespan (survival) of people with cancer? <ul><li>Psychotherapy does not increase survival time. </li></ul><ul><ul><li>Spiegal (1989) study that suggested that group support improves survival for breast cancer patients was flawed. </li></ul></ul><ul><ul><li>Goodwin et al. (2001) New England Journal of Medicine (Vol. 345, No. 12) </li></ul></ul><ul><ul><ul><li>Replicated the study with 235 patients </li></ul></ul></ul><ul><ul><ul><li>Improved emotional functioning and pain management </li></ul></ul></ul><ul><ul><ul><li>No survival advantage </li></ul></ul></ul><ul><ul><li>Several other studies with breast cancer and other cancers fail to find that psychological therapy improves survival times. </li></ul></ul>
    28. 28. Does psychotherapy improve the mood and general sense of life satisfaction in people with cancer? <ul><li>Positive effects of psychotherapy in cancer </li></ul><ul><ul><li>Decreased depression </li></ul></ul><ul><ul><li>Decreased pain </li></ul></ul><ul><ul><li>Improved family function </li></ul></ul><ul><ul><li>Improved ability to function in early stage cancers </li></ul></ul>
    29. 29. Initial Psychological Reactions to the Diagnosis of Cancer <ul><li>Acute Stress Response </li></ul><ul><ul><li>Lasts about 7-10 days </li></ul></ul><ul><ul><li>Resolves with consultation and onset of treatment </li></ul></ul><ul><ul><li>Symptoms are </li></ul></ul><ul><ul><ul><li>Depression </li></ul></ul></ul><ul><ul><ul><li>Anxiety </li></ul></ul></ul><ul><ul><ul><li>Irritability </li></ul></ul></ul><ul><ul><ul><li>Sleeplessness </li></ul></ul></ul><ul><ul><ul><li>Loss of concentration </li></ul></ul></ul><ul><ul><ul><li>Loss of appetite </li></ul></ul></ul><ul><li>Initial (first year) response to cancer </li></ul><ul><ul><li>Most patients with depression or post traumatic symptoms return to normal baseline within 1 year. </li></ul></ul><ul><li>At risk for onset of prolonged depression </li></ul><ul><ul><ul><li>Prior emotional adjustment problem </li></ul></ul></ul><ul><ul><ul><li>Low levels of social support </li></ul></ul></ul><ul><ul><ul><li>Women </li></ul></ul></ul><ul><ul><ul><li>Younger </li></ul></ul></ul>
    30. 30. Rates of Psychological Illness in Patients with Advanced Cancer <ul><li>Estimates of rates of psychopathology in advanced cancer patients vary between about 12% and 47%. </li></ul><ul><ul><li>7-13% have Major Depression </li></ul></ul><ul><ul><li>3-4% have Generalized Anxiety Disorder </li></ul></ul><ul><ul><li>5% have Panic Disorder </li></ul></ul><ul><ul><li>2.5% have PTSD </li></ul></ul><ul><ul><li>8% have encephalopathy from cancer or treatment. </li></ul></ul><ul><ul><li>4% have Personality Disorder </li></ul></ul><ul><ul><ul><li>Source: Kadan-Lottick et al. (2005). Psychiatric Disorders and Mental Health Service Use in Patients with Advanced Cancer. </li></ul></ul></ul>
    31. 31. History of Child Abuse Increases the Risk of Developing Trauma Symptoms for Breast Cancer Patients Goldsmith et al. (2010) <ul><li>Trauma Symptoms </li></ul><ul><ul><li>Intrusive symptoms </li></ul></ul><ul><ul><li>Avoidant Symptoms </li></ul></ul><ul><li>Goldsmith et al. (2010) gave questionnaires on child abuse and cancer trauma symptoms to women with newly diagnosed breast cancer. </li></ul><ul><li>Physical, Sexual and Emotional abuse are all associated with the development of intrusive symptoms of stress disorder and Emotional Abuse was particularly strongly linked with cancer trauma symptoms . </li></ul>
    32. 32. Psychotherapy is underutilized in cancer treatment. <ul><li>Utilization of mental health is seen in 28% of all patients. </li></ul><ul><li>Only 55% of those with major psychiatric disorders were seen by mental health. </li></ul><ul><ul><li>Frequently mental health was not assessed by Oncologists. </li></ul></ul><ul><ul><li>90% of patients were willing to see mental health when it was recommended </li></ul></ul><ul><li>Conclusion: Ask patients about mental health symptoms. They are willing to discuss them with physicians and be referred to mental health this is especially important in high risk populations like those with abuse history, prior mental illness or low levels of support. </li></ul>
    33. 33. Psychotherapy decreases specific cancer treatment side effects like nausea and vomiting after chemotherapy. <ul><li>Anticipatory Nausea Occurs in 29% of chemotherapy patients </li></ul><ul><li>Anticipatory Vomiting seen in 11% </li></ul>
    34. 34. Classical Conditioning Model
    35. 35. Classical Conditioning in Chemotherapy
    36. 36. Characteristics of Patients Likely to develop ANV <ul><li>Physical Response to Chemotherapy </li></ul><ul><ul><ul><ul><li>Presence of nausea and vomiting after chemo </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Other autonomic signs after chemo such as lightheadedness, dizziness, racing heart, sweating, feeling hot, etc. </li></ul></ul></ul></ul><ul><li>Emotional Factors </li></ul><ul><ul><ul><ul><li>High levels of anxiety </li></ul></ul></ul></ul><ul><ul><ul><ul><li>High expectancy of ANV </li></ul></ul></ul></ul><ul><li>Characteristics of the chemotherapy </li></ul><ul><ul><ul><ul><li>More chemotherapy sessions </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Higher emitogenic potential of chemo agent </li></ul></ul></ul></ul>
    37. 37. Treatment of ANV <ul><ul><ul><li>Anti-nausea drugs are ineffective once ANV develops </li></ul></ul></ul><ul><ul><ul><li>Prevention or treatment of ANV with </li></ul></ul></ul><ul><ul><ul><ul><li>Hypnosis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Distraction with videogames </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Relaxation with guided imagery </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Systematic Desensitization </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Biofeedback </li></ul></ul></ul></ul>
    38. 38. Example of Desensitization with ANV <ul><li>Learn to relax via patterned breathing. </li></ul><ul><li>Relax while visualizing these scenes </li></ul><ul><ul><li>At home drinking coffee </li></ul></ul><ul><ul><li>Driving to hospital </li></ul></ul><ul><ul><li>Enter hospital, notice medical smells </li></ul></ul><ul><ul><li>Sit in chair where chemotherapy is received </li></ul></ul><ul><ul><li>Preparation of IV site </li></ul></ul><ul><ul><li>IV insertion </li></ul></ul><ul><li>Relax while </li></ul><ul><ul><li>Watching a video of chemo </li></ul></ul><ul><ul><li>Smelling hospital disinfectant </li></ul></ul>