David Henry, MD: Welcome to this episode of Blood And Cancer. I’m your host, Dr. David Henry, and I’m joined today by another host in the MDedge family, Dr. Lorenzo Norris, who is the host of MDedge Psychcast onor wherever you get your podcasts. He is associate dean of student affairs and administration at the George Washington School of Medicine in Washington, DC. Dr. Norris, thank you so much for taking the time to do this today.
Lorenzo Norris, MD: Dr. Henry, thank you so very much. It’s always great to participate with the MDedge family and do a collaborative podcast, so I’m really looking forward to it.
Dr. Henry:I know you wrote a really nice article on cognitive behavioral therapy (CBT) in breast cancer patients ( ). So could you talk a bit about that -- what did you do, and what did you find using CBT for breast cancer patients?
Dr. Norris: CBT in a nutshell -- how you think influences greatly your emotions, which influences your behavior. Very simple and very powerful. With breast cancer, as an example, patients are dealing with a great deal of stress. They are literally fighting for their lives.
So there are going to be various thoughts associated with that...One of the uses of CBT when working with patients is to help them think about and work with adaptive thoughts that are going to help them effectively cope as well as problem solve. So for instance, in regard to breast cancer, one of the first things that you’re going to want to do is just to think about, one, helping the patient understand where they’re at, because it’s going to be a shock level type of thing.
Make sure that they don’t have unnecessary or problematic distortions, whether it’s about the treatment, the prognosis, or what they themselves are capable of. And those three areas become actually rather important. Now with a diagnosis of cancer, a number of patients are going to have a period of adjustment. One of the first things that we’re thinking about is where do our patients fit along a continuum of distress.
They could be having an adjustment disorder or none whatsoever, just normal mood or an adjustment disorder with depressed mood. They could actually be in the midst of a unipolar depression. They could have a mood disorder secondary to the effects of the cancer itself. That would be more applicable to brain cancer or pancreatic cancer. Or they could have another category of mood disorder, such as a substance abuse mood disorder. But CBT is a very useful intervention, regardless of whether a person is having a normal syndrome of distress with a very challenging diagnosis or if they’re suffering from full-on psychiatric symptomatology such as a major depressive disorder.
Dr. Henry: In my practice I see a couple of things relevant to that discussion. I’ve always felt fear of the unknown is the worst fear, and fear of the known really helps you.
Medical students say to me sometimes, you just told this patient the same thing three times. They asked you the same thing three times. Well, I say, watch their eyes. Because as their eyes drift off, they’re thinking about their family, their financials, life and death. We’ve got to bring them on back because they’re afraid and not focused. I, in my amateur way, try and bring them back to the discussion to focus on what’s going on, what’s known, and how will we address it.
Interestingly, very rarely do I get, “So how long am I going to live?” You know, you see that in movies and Hollywood, and the doctor says six months, and it’s right on the button. I rarely get that question, because I think they’re afraid of the answer. If I do, I say, “Well, therapy works. You’ll do better and live on. If therapy doesn’t work, we got a problem, and it can be mortal”-- so they wouldn’t believe me if I just tiptoed around that-- but we have a second through-line. “I can always help you, win or lose.” So is that the similar way you approach those kinds of conversations?
Dr. Norris: Absolutely, Dr. Henry. I love how you described it in regard to that willingness, and I love how you described it to the medical students. A lot of being a physician or a healer is just that willingness to stay in a place with a patient and just repeat back the same thing in a different way until we make sure that they’ve heard it and we’ve heard it. And I think that’s very important.
But to get back to that “you have six months to live” type of thing. I actually find that patients actually do-- in my experience, do not immediately go there.
Dr. Henry: Agree. Agree.
Dr. Norris: There is the concept of...I wouldn’t even call that denial. But just that ability to focus on what is immediate. There are some aspects of protective denial. People intrinsically know how much information they need to focus on and deal with at the moment. Why focus on something that is outside of their control? Actually, when I see people jumping to conclusions like that, or catastrophizing, that’s a cognitive distortion. Black and white thinking is another cognitive distortion, as well as maladaptive denial, where you just kind of deny reality. Not discussing prognosis immediately--I would consider that focusing. Denying that you have cancer--that’s problematic denial to say the least.
Dr. Henry: Whole different problem.
Dr. Norris: I agree with you. I find that patients do not immediately jump to that in terms of prognosis or things of that nature. But their oncologist can do a great deal and actually level the distress just by doing what you did right there. Speaking with your patient three or four more times, repeating the same information, not using jargon, but also not sugarcoating anything, but giving what’s needed to get to the next step. And that’s probably what I think is one of the things that I focus on in therapy a lot. Let’s level the distress. Let’s focus on what’s needed to get to the next step and let’s not do anything that, if you’re not in a unipolar depression or major depression, could further exacerbate you developing it. So let’s stay focused on the treatment. And I find that a number of patients rally behind that.
Dr. Henry: Very well put, very well discussed. And we will have on our web page, the reference for the CBT article.
Dr. Norris: If you’re referring to the reference that was in an issue of “Psychiatric Annals,” that was a number of years ago. Because the actual reference you’re referring to () was part of a themed issue that I guest edited. It was called Cancer and Depression, and all the articles in there were focused on cancer. At that time, I was actually working with the American Cancer Society in regards to developing cancer survivorship guidelines.
Dr. Henry: So as we record this, of course, it’s the COVID era, and we’re taking care of patients with cancer who have to deal with the cancer and deal with themselves, family, and what’s happening in the world. I have found much more anxiety, much more depression than I’m used to seeing. Because they’re coming to see me, am I going to give it to them? Coming into the office, will they get it getting upstairs in our treatment area? So what are you seeing? And how are you handling taking care of patients with cancer in this time?
Dr. Norris: I hope everyone out there that’s listening is safe and well, and I hope your families are safe and well. The COVID pandemic has really unleashed something on the world as well as society that people have not seen basically since the Spanish Flu. But whether you’ve been through the AIDS epidemic or anything like that, you’ve never seen this.
So what are we seeing out there? We’re seeing that, definitively, more anxiety and depression across the board. We know that with the data now that’s been coming out that we are seeing an increase in anxiety and depression in the general population. The data in regard to cancer patients is limited, but we can start with what we know, and from that we can extrapolate and say that we would expect to see an increase in depression and anxiety.
We know that in cancer patients, depending on what study you look at, there’s going to be anywhere from a 0% to 38% prevalence of major depressive disorder and a 0% to 58% prevalence of any depressive spectrum disorder. Depending on the study, it’s going to level out somewhere around a 15% to 22% prevalence rate, regardless of cancer, of depressive symptoms. That’s usually across other medical conditions. Now the general rate of depression in a population is 6.6% with a 12-month prevalence. And the lifetime is 16.6%. So the take-home point is, with cancer, you have a two to four times greater risk of developing depression, whether you had it or not.
There’s a couple of reasons why we might be seeing an increase in depression and anxiety in this COVID era. One is isolation and lack of control. Due to quarantining and social isolation, our patients’ relationships with their oncologists can absolutely positively be disrupted. That is a very anxiety- and depression-inducing situation. One of the themes that came out of the survivorship literature when patients actually transition out of active treatment, one of the most distressing things for them, was the loss of their treatment team and their oncology provider. It almost can’t be said or overestimated the impact that the treatment team and a primary oncologist has on a patient’s life. I just wanted to make sure the audience realized that.
For your patients, you really, really, really are exceedingly important to them, as you are very much aware of that, but to levels you may or may not fully appreciate. So one of the things that COVID does, not only is it this deadly virus that our patients have to worry about in terms of it taking their life, as well as delaying treatment. It separates them from the people that have become paramount in their life, which for a number of folks is their oncology treatment team.
So when we take all of that into account, particularly isolation and loneliness, fragmentation, as well as any type of economic difficulties, that can be resulting due to the COVID-19 pandemic, you would absolutely suspect and predict that anxiety and depression in our patients would definitively increase. And a big part of that is them not being able to connect, certainly with others, but it’s [also] definitely their treatment team.
Dr. Henry: It’s been a stress on all of us, our caregivers as well as care receivers. And then back to putting on our regular oncology/hematology hats, seeing patients when COVID isn’t around. I remember a study long ago, maybe back when I was in training. I think it came out of Memorial Sloan Kettering.
It’s that fully 50% of our active advanced cancer patients are clinically depressed to the point where we should be considering intervention/medication. And if that’s still true, I’m a terrible doctor, because I am not recognizing and prescribing for that. Can you comment on how much depression and anxiety are in the average advanced cancer patient? And should we go after that in treatment?
Dr. Norris: When we’re talking about the advanced cancer patient, I definitely feel as though we should be screening as well as treating. Now as I mentioned before, in regards to the prevalence of depression or depressive spectrum disorders, it can be anywhere from 0% to 58%. In advanced stage cancer, you certainly are going to be thinking that risk is going to be high, probably anywhere from 25% to 33% or maybe even up to 50% of our patients can be suffering from symptoms of depression.
So when we’re talking about treating or referring, a big question you want to ask yourself is, what screening instrument are you using for depression? Some people argue just simply asking a patient whether they’re depressed or not would be perfectly acceptable. That is provided that you have enough time to do it, and you have enough time to follow up and you are pretty standardized with your approach.
However, clinicians just miss it. That’s well established and evidence-based. Clinicians just miss it. What I would recommend that folks consider doing is using the, the two-question version called the PHQ-2 and the PHQ-9, the nine-question version. The PHQ-2 is actually a very good screening tool in regards to detecting depression. It has very good sensitivity and specificity.