COLORECTAL CANCER: PROGRESS AND PROSPECTS

1. COLORECTAL CANCER: PROGRESS AND PROSPECTS Presentation 20th May 2018 Psychological support of patients with digestive cancer : The role of relatives and the patients’ associations Dr. Spiros Kalimeris Psychiatrist Psychotherapist

2. Digestive Cancer Incidence & Mortality Both Sexes WHO – Globocan 2012 - http://globocan.iarc.fr/Pages/fact_sheets_population.aspx

3. Prevalence of Psychiatric Disorders Prevalence of psychiatric disorders in cancer patients varies greatly among studies ranging from 9% to 60%Combination of all types of depression and adjustment disorder showed a prevalence of emotional disorders of up to 38,2%Mitchell AJ, Chan M, Bhatti H et al.   Lancet Oncol2011 27% of recovered cancer patients suffered from anxiety, depression, or both. Loge JH, Abrahamsen AF, Ekeberg O, Hannisdal E, Kaasa S. Psychological distress after cancer cure 1997

4. Digestive Cancer : Some Facts Patients with Stomach cancer suffer from greater psychological distress than those with colorectal cancer Matsushita T, Matsushima E, Maruyama M. Psychiatry ClinNeurosci2005, 59:576–583 Anxiety Disorder : 17%Major Depression : 21%Anxiety Symptoms : 57%Depressive Symptoms : 47%Nordin K, Glimelius B. ActaOncol1997, 36: 803–810 • Pancreatic cancer : • Increased rate of emotional disorders often early before the diagnosis • Increased suicidality • Turaga KK et al 2011, Green et al 1993

5. Meta-analysis of 25 studies (2009): Depression is a small but significant predictor of mortality in cancer patients • 26% greater mortality rate among patients endorsing depressive symptoms • 39% higher mortality rate among those diagnosed with major depression Satin, J. R., Linden, W. and Phillips, M. J. (2009), 115: 5349–5361. doi:10.1002/cncr.24561

6. Systematic Review 2018 : Distress and neuroticism, measured around the time of cancer diagnosis, are the only consistent indicators of vulnerability to long-term emotional distress Other possible predictors with less validity • Younger Age: 4 out of 27 studies • Female Gender : 1 out of 13 studies • Socioeconomic status • Education : 3 out of 12 studies • Income : 1 out of 2 studies • Clinical, treatment, and tumour characteristics : 2 out of 10 • Physical health : 5 out of 10 • Relationship status and social network : 1 out of 11 • Perceived social support : 3 out of 9 • Negative life events : 0 out of 3 Cook SA, Salmon P, Hayes G, Byrne A, Fisher PL. Psycho-Oncology. 2018;27:791–801. https://doi.org/10.1002/pon.4601

7. Stress Factors • Cancer diagnosis announcement • Treatment decisions • Financial management • Surgery • Chemotherapy side-effects • Stoma : permanentdeformation/body image/sex life • Quality of life/functionality • Life expectancy • Fear of death • Fear of recurrence • Guilt & shame feelings if present, are usually hidden

8. Role of patients’ relatives • Dealing with cancer is a family affair • Relatives are the main support frame for the cancer patient • However relatives are also in need of psychological support even if they are not always aware of it

9. How to support • Just be there - Sometimes presence is enough • Acknowledge what you can and want to do • Encourage talking about feelings and burdens • Be a good listener • Help with small and practical things • Encourage recreational activities if possible • Respect their wishes Source : www.macmillan.org.uk

10. Benefits of expressing • It is a myth that avoiding any reference to distressing matters is the ideal approach • There are no perfect words or right things to say • Talking releases stress • Finding the words to describe events and feelings can help to make sense of them • Enhances the feeling of not being alone Source : www.macmillan.org.uk

11. What you could avoid • Phrases like : • ‘I know you’ll be fine.’ • ‘You are so strong.’ • 'You need to think positively.' • ‘You look really tired.’ • ‘If you need anything, just give me a call.’ • Offer advice not asked for, needed or based on your own assumptions • Fixate on being there 24/7 Source : www.macmillan.org.uk

12. Caregivers’ burden • Mental & physical fatigue, sleep disturbance, appetite loss, pain, loss of libido • Frustration, uncertainty, anxiety, anger, guilt, helplessness • Impaired social, work, family functionality • Fears of genetic risk, recurrence, metastasis, deterioration Stenberg U, Ruland CM, Miaskowski C. Review of the literature on the effects of caring for a patient with cancer. Psychooncology 2009

13. Families as Part of Patients’ Supportive Psychotherapy • Dealing with the patient’s family is not a choice, but a necessity. • Caring for the primary caregiver • To tend to one’s self needs will emerge, despite of shifting the weight to the patient care • Tending to one’s self need will enhance ongoing support for the patient as well as his/her own well being • Address distressing thoughts for example the concept of the “helpless bystander” • Encouraging the emotional expression • Accepting the negative feelings – it is normal to have them • Positive thinking is not an absolute or obligatory guideline

14. Cancer Patients’ Foundations Role • Provide expert information on health issues during and after treatment • Manage treatment choices & save money • Inform about new research • Address risk taking behavior and decompose magical/natural treatments credibility • Promote cancer prevention measures and behavior • Socializing & recreational activities

15. Cancer Patients’ Foundations Role • Cancer patients’ rightspromotion • Facilitate medicine access • Highlighting hospital dysfunctions and intervening with authorities • Connect with individual or group supportive psychotherapy specialists

16. Health Provider Approach • The psychological dimension of cancer disease is sometimes undervalued or even not acknowledged • Psychological distress cannot be measured with blood tests, x-rays, MRI, e.t.c. so theevidence-based clinician can feel bewildered about how to deal with it • The psychological burden of the health provider is also underestimated (burn-out) • Health providers (doctors, nurses) dealing every day with cancer sometimes repress their feelings in order to stay effective • Support groups and/or individual psychotherapy for cancer related health providers can offer burn-out treatment, tension release, psycho-education and more.

17. Oncologist’s Burden • Study among U.S. Oncologists in 2003 • Burnout Prevalence : 60% ! • Top three symptoms : • frustration (78%), • emotional exhaustion (69%), • lack of satisfaction with their work (50%) • Oncology specific stressogenic factors • frequently dealing with death and suffering, • delivering bad news • administering toxic therapies • being unable to cure many patients Shanafelt TD, Bradley KA, Wipf JE, Back AL. Ann Intern Med. 2002 J. Allegra, Carmen & Hall, Ray & Yothers, Greg. (2005)

18. Diagnosis Announcement • Bad news cannot be transformed into a positive sterilized message • Reassurance and/or evasive tactics will not be preferred by the patients • Empathy: Ability to understand the psychic burden without identification with it • Tolerance of the uncomfortable moments by the health providers as part of an inevitable reality • Inclusion of the psychic burden in the therapeutic treatment • Knowledge of the patient’s psychosocial background/history • Co-operation with other specialties like psycho-oncologists, social workers, nurses Nicole Pélicier La Revue du Praticien, 56 (30 Novembre 2006), 1997-2003

19. Diagnosis Announcement as part of a complete Intervention Plan • Therapeutic strategy formulation by different specialties • One or more sessions for the announcement and the presentation of a personalized care plan • Supportive period providing further information and access to every available service for the patient and his/her family : psychologist, psychiatrist, social worker, cancer patients’ foundation • Interconnection with the personal/general m.d. of the patient’s area Plan Cancer (www.e-cancer.fr)

20. Thank You spiroskalimeris@gmail.com