Blood Cancer in the Elderly: European Expert Forum, Rome, 19—20 March 2011
Dr Luzia Travado (Central Lisbon Hospital Centre, Portugal)

Assessing psycho-oncology

ecancer.tv is reporting here from the Rome meeting on Blood Cancers in the Elderly and now Luzia Travado from Lisbon, you are here to tell me about psycho-oncology which is a relatively new field. Now why is psycho-oncology important in patients who are older?

Well the psycho-oncology field is a recent field because it addresses the psychological and social implications of patients that are facing cancer and its treatment. The patient is multi focal; it is not only a biological system; it has emotions and connections and contacts and all of this is affected when the patient is diagnosed with the cancer.

More important than the body, psychological issues can be paramount.

Exactly, because cancer still has a tremendous effect on people and almost everyone feels like a death sentence when it is diagnosed so the shock is there and people strive to deal with not only that effect on them and the fears and concerns and difficulties that arise from the treatments that are also difficult and provoke side effects. And so having a team that includes a psycho-oncologist to help the team and patient, and the family, deal with these issues and symptoms and additional problems in their lives is quite helpful.

How do you measure that big impact and how do you compare the importance of the psychological impact with the clinical benefits of any particular therapy?

Well the National Cancer Comprehensive Network has developed some years ago a thermometer, that is called the distress thermometer, which is a zero to ten scale, in which you ask the patient how distressed have you been during the past week or four weeks? Then the patient says a number between zero and ten and you know the rate and then there is a list of problems coming from practical, emotional, family, financial, social and physical complaints that the patient lists. And so you can have a pretty idea of how these different issues may have an impact and then you can develop a plan to help the patient cope with the additional issues.

So, let me guess, one of the things you might advise doctors to do is actually to do is actually to be aware of this and ask the questions.

Exactly, exactly. There is now a world call to have the distress become the sixth vital sign to be assessed in cancer centres and cancer facilities because distress, as you know, is not seen; you cannot do a blood test to assess distress. You have to ask the question. So when you ask then you will have this new problem that then you have to develop a plan to address it and to help.

When you have analysed what’s going wrong what do you do about it?

We can do interventions: problem solving interventions, symptom management; if there is depression, depressive symptoms or anxiety because this stress can develop into more complicated issues and so we can have different types of psychological interventions: educational, counselling, symptom targeted, to help the patient deal with the uncertainty of the disease and the side effects of the disease.

But how effective are those interventions?

There have been randomised controlled trials that have proved efficient in reducing the symptoms, in improving quality of life and also in improving patients’ resources and skills to deal with those difficulties and adjust better to the disease process and treatment. They also foster compliance which is quite important for the treatment course, and so there are a number of benefits for the patient. And also when you treat the whole patient and not only the disease, the benefits are not only for the quality of life but for the person to be re-integrated in their social and family life again. So it is quite important not only to address the disease but the patient and their difficulties as a way to improve the quality of life and well-being of the patient.

How do these psychological needs change, though, as the patient goes from one stage of the disease to another and perhaps into a stage from which the patient knows they are not going to survive?

Well that is called the advanced disease and then the end of life issues. Of course then you will have the palliative care teams. Palliative care teams are multidisciplinary teams that are designed to address not only the medical issues but the social, the psychological, also the dependency issues, the home care facility. So a whole range of complexities that need to be addressed as a way to help the patient. Of course the burden, the psychosocial burden, is much increased as the disease progresses and these essential issues as well as the spiritual issues also need to be dealt with as a way for the person not only to have more quality of life during the time that they still have as also to die with dignity and die peacefully.

What are the specific issues, though, that are concerned with older patients with cancer?

Well you have different older patients; you can have older patients that are quite well and doing very well functionally and cognitively but you then have older patients that are not doing so well so you need to make a full assessment, not only of the physical status, the cognitive status, the psychological status, the social status, to see what are the complexities that then need to be inputted into treatment decisions along with patients’ preferences, concerns and needs. So it is a whole more complex system that requires a multidisciplinary clinical team to address those complexities and then helping the patient to make informed decisions.

And then finally, what would be the brief guidelines that you would leave doctors here from your talk here in Rome with to remember in terms of the psychological impact of cancer in other patients?

Well you have to ask the patients what are their main fears, their main concerns and their needs as to bring those into the equation. Of course if you are dealing with the elderly patients you have also to address the cognitive impairments that might be already happening; to see if the patient fully understands what is going on and is responsible for making those informed decisions. So I would say that in patient-centred care, a really a good communication with the patient is essential.

Dr Luzia Travado, thank you very much indeed.

Thank you very much for this good conversation.