ORLANDO--For the first time, the keynote address at the American Society for Therapeutic Radiology and Oncology (ASTRO) meeting was delivered by a psychiatrist--Dr. David Spiegel, of Stanford University School of Medicine--who advised the group on how to help their cancer patients cope with their diagnosis.
Patients need what Dr. Spiegel referred to as the three C’s--communication about their disease and its process, control in the form of making informed decisions about their treatment, and the caring of those providing treatment.
Dr. Spiegel is widely known for his studies of the effects of group therapy on breast cancer outcomes. While he encourages doctors and their staff to set up group therapy programs, he also believes that there is much oncologists can do personally in the course of office visits to help their patients.
Those patients who do best are those who have a realistic optimism as to what can and can’t be done for them. "They have a fighting spirit," Dr. Spiegel said, "which allows them to express their emotions honestly and commit to doing whatever it takes within the framework of what is possible."
Dr. Spiegel then outlined four "themes" that oncologists and other physicians can incorporate into patient care to help patients better cope with their illness and, if necessary, help them face and prepare for the possibility of death.
Building social support. Dr. Spiegel cited a study done by James House in the late 1980s that found roughly a twofold higher risk of dying of all causes among people with low social integration. "This means that social isolation elevates your risk of dying as much as smoking or high serum cholesterol," he said.
Cancer patients may face a form of social isolation very soon after their diagnosis, he said. After the first round of well-wishing from friends and family, people around them may begin to withdraw because they simply do not know what to say.
Support groups can help alleviate this feeling of isolation. In groups, patients have what Dr. Spiegel calls the common bond of illness. "They are with a group of people who really ‘get it,’" he noted. Thus, physicians should talk to patients about their social situation and encourage them to join support groups.
Expressing emotions. In medical school, he said, doctors are trained to treat crying as if it were a hemorrhage to be staunched. But, he explained, when patients are told to stop crying, they get the message that the doctor simply does not want to deal with their emotions. In fact, Dr. Spiegel said, a good cry can sometimes make a patient feel immensely better. "We’ve never lost a patient from terminal crying," he said.
Detoxifying dying. Our culture, he said, pretends that dying doesn’t happen. But those in the oncology field and those living with cancer face the prospect of death daily. "Most patients are more concerned about the process of dying than death itself," he said, "which relates to fear of dying in pain and isolation."
He said that doctors can reassure their patients that cancer pain can and will be dealt with. Social isolation can be combated, he said, by creating an environment in which people can talk about their cancer and even laugh at it. He related the story of a woman with advanced breast cancer who was in a breast cancer support group, and had decided she wanted to be buried at a certain upscale cemetery. She called the cemetery for information and was astounded at the high cost. She paused and then asked, "Do you have a group discount? You see I represent a group of women . . ."
Taking time. This theme has two points: Physicians need to take time for their patients, and patients need to take time for themselves. For the patient with terminal cancer, this means facing the limitations of time. "Patients often have projects they want to complete or family obligations they want to settle before their death," he said. "Patients need to examine their lives and ask themselves what really matters in the time that is left."
In an interview with Oncology News International, Dr. Spiegel said that physicians who take the time to listen to patients can make a difference. Many doctors, he said, feel that if they are not curing the disease, they are not really doing anything. "That’s not true," he said. "You’re doing something active, and it might affect the course of the disease."
Effects of Psychotherapy
Dr. Spiegel has conducted several studies in which he looked at the effect of psychotherapy in both group and individual settings on breast cancer patients.
He emphasized that he is not of the "wish your cancer away" school of "pop" psychology. Yet, he said, his studies showed that breast cancer patients who were in group therapy lived longer. While the disease-free interval was about the same as that of the control group, the average overall survival time was 19 months for the controls vs 37 months for the group who had intervention.
Dr. Spiegel and his colleagues are in year 8 of a similar trial with metastatic breast cancer patients in which they hope to replicate the original findings.
