Navigating the Mental and Emotional Landscape of Cancer

Boris M. Kiselev, MD, discusses the role of psycho-oncology in comprehensive cancer care, addressing barriers and offering a vision for the field’s future.

In the complex journey of a cancer diagnosis and treatment, the patient’s physical battle is often paralleled by a profound emotional and psychological one. The field of psycho-oncology is a multidisciplinary specialty dedicated to addressing these critical, yet often overlooked, aspects of cancer care.

This specialty recognizes that managing psychological, social, and emotional symptoms—such as distress, anxiety, depression, and existential concerns—is as vital as treating the disease itself. Boris M. Kiselev, MD, outlines the comprehensive scope of psycho-oncology, which extends from the initial moment of diagnosis through active treatment, into long-term survivorship, and even end-of-life care.

He highlights that by integrating psychological care, clinicians are not only improving a patient’s quality of life but are also enhancing their ability to adhere to and benefit from medical interventions. This holistic approach is supported by professional guidelines and is essential for providing complete and compassionate cancer care.

Kiselev is a consult liaison psychiatrist at Atrium Health, an assistant professor of the Psycho-Oncology Program in the Department of Supportive Oncology at Atrium Health Levine Cancer, and an assistant professor in Internal Medicine.

Are you able to provide a brief overview of the psycho-oncology landscape?

Psycho-oncology is a multidisciplinary specialty that focuses on the psychological, social, emotional, and behavioral aspects of cancer and cancer treatment. We are focused on addressing the psychological and psychiatric symptoms like distress, anxiety, depression, fear of recurrence, and existential concerns that patients across the entire cancer spectrum continue to face. We are working with people all the way from diagnosis to treatment through survivorship and into the end of life as well. It includes broad screening for all patients dealing with cancer, as well as targeted management, and ideally support for families and caregivers. Because of the complex nature of psychosocial concerns, it is by necessity a multidisciplinary specialty, and that involves nursing, psychotherapists, psychologists, physicians, and social workers.

What role does psycho-oncology play for patients who are undergoing treatment or who have survived cancer?

The role that psycho-oncology [creates] in in the care of any patient depends a lot on the severity of their distress and their most pressing symptoms. For some patients with high levels of distress, psycho-oncology can play a central role. At some point, a high level of those types of concerns will interfere with a patient’s ability to receive treatment. By addressing those symptoms directly, we are not only improving their quality of life, but we are improving their ability to get the care that they need during and after treatment. Every patient should be screened for distress, and that is recommended by the [American Cancer Society] Commission on Cancer guidelines, as well as the [American Society of Clinical Oncology] and other guidelines. The idea is that [when] there are some needs identified, there should be an appropriate referral to services. During treatment, patients with identified concerns will be matched with the options that fit them best, whether that be individual or group psychotherapy, peer support, [and] outpatient or inpatient psychiatric treatment.

Patients with social concerns that are improving with treatment, things like transportation or housing, food insecurity, they should be connected with a dedicated social worker that can assist with working through those barriers, and the goal as well that psycho-oncology care should be integrated into the greater cancer treatments that should allow for collaboration between the patient’s psycho-oncology providers and their oncology team. For survivors, psychological and emotional issues can sometimes be even more [impactful] than they were during treatment. We often will frame the process of adjusting to life after cancer, like one of grief, or people are processing losses that they experience, whether that be their physical health they had before their work, their finances that can be affected, or sometimes even their relationships. They will have had changes to how their physical body is, and they will often have chronic symptoms afterwards, whether that be pain, neuropathy, or other complications of treatment. In that survivorship phase, things like fear of recurrence can be extremely disabling for patients, and that is where psychotherapy and other psycho-oncology care can be helpful for them.

Looking at the space, are there any key trials in the psycho-oncology space that you believe could make an impact?

For anybody working in the oncology space, I would refer them to the excellent professional guidelines that are out there. I would recommend reviewing the ASCO guidelines and management of anxiety, depression, adult survivors of cancer, and the NCCN guidelines for stress management and fatigue. These professional organizations have fantastic guidelines that are extremely thorough and provide a good overview of the field, and they incorporate a lot of the most impactful trials and evidence that is out there.

Beyond standard antidepressants, what are some of the novel or non-traditional psychiatric interventions you have found effective for managing cancer-related depression and anxiety?

[Many] times when people think about psycho-oncology, they are thinking about antidepressants and what other things are out there. The idea that even though antidepressants are helpful and there is a good evidence base to support their use for anxiety, depression, and cancer, and their use is recommended by guidelines, we still want to make sure we are using all the tools available to us. Psychology guidelines do recommend considering things like mindfulness-based interventions. This includes things like mindfulness-based stress reduction when that is administered in a group or individual setting that has good, randomized trials supporting efficacy for anxiety and depression in patients dealing with cancer. There is good evidence for things like music therapy, relaxation interventions, for moderate quality evidence. There is also good evidence for exercise being helpful for patients dealing with cancer, and that not only helps with both anxiety and depression, but also with sleep and fatigue. That is supported by the American College of Sports Medicine Physical Activity Guidelines for adults dealing with cancer.

Additionally, there are other integrative approaches too. You can consider things like Tai Chi, acupuncture, those all have lower quality evidence, but have been studied. Here at [Atrium Health Levine Cancer], where I work, we have a robust integrative oncology department, and we are often coordinating with them, referring patients to them, to get them connected with those types of treatment.

Other things to think about when managing these symptoms for patients, especially for those who are working in oncology is to make sure that we are thinking about their medical comorbidities. For instance, thinking about patients who [receive] immunotherapy, considering endocrinopathies, it could be contributing to their psychiatric symptoms, or thinking about sleep disorders.

In terms of interventions, another thing I want to make sure I talk about as well is psychotherapy, and so the idea is that that is going to help in many ways when we are dealing with cancer, to process their experience. Talking about processing grief, learning tools and techniques can help them manage the symptoms day to day, develop coping skills, and help them to get just gain insight into themselves. The great thing about psychotherapy is that even after they complete the psychotherapy treatment that they are doing, they will have those tools that they can take with them afterwards that will continue to be helpful to them in a longitudinal way.

How do you approach the management of fatigue and pain in oncology patients, considering both their physical and psychological components?

Fatigue is the most frequent complaint for patients dealing with cancer, with rates over 85% in most studies. There are good guidelines for fatigue management from NCCN and ASCO. The key portions of those are based on identifying elements that are contributing to fatigue, whether that be treatment-related, their medical comorbidities, sleep disturbances, psychiatric symptoms, and trying to identify and address as many of those different elements as possible. That is the same way that we are approaching pain as well.

We are thinking about what the cause of pain is, where the pain is coming from, and what we can do to alleviate that symptom. Opioids are going to be super helpful, but we want to make sure [clinicians are] thinking about all the other tools in the toolbox, like multimodal treatments, physical therapy, integrative treatments, and even interventional procedures that can help improve pain. Where I work at here at [Atrium Health Levine Cancer], we are collaborating with palliative care and thinking through these issues of pain and fatigue, because they have a bidirectional relationship with anxiety and depression and mood symptoms from a psychological standpoint.

The common issue in patients experiencing both pain and fatigue is that having these symptoms will affect a lot of our beliefs about ourselves, the world, and will often affect patient behavior as well. That is where cognitive behavioral therapy [CBT] can be used as an intervention that can be helpful, that has been shown to be helpful, both for improving quality of life for pain as well as for fatigue. For example, how that information might look for patients who deal with severe pain or fatigue, a common concern or issue that comes up is what is called catastrophizing. They develop this worry that the pain or fatigue will become so bad that they will not be able to function, and that will lead them to then start avoiding things, [such] as avoiding different activities around the home, or avoiding even leaving the home. That is where this worry around the symptom is causing functional impairment. CBT is looking for ways to try to understand, explore, and sometimes challenge limiting beliefs that could be unhelpful or not accurate for the patient, and looking at ways that we can modify the behavior to try and improve someone’s functioning.

From your perspective, what are the most common barriers that prevent oncology clinicians from recognizing and addressing psychiatric comorbidities in their patients, and how can we overcome them?

The 2 most common barriers are lack of time and lack of resources. Oncologists have so much on their plates already with how complex cancer treatment is and how it is evolving, and all the different factors they have to address. It can be hard to add more things for them to address, and that is where universal screening is important, andwhy it is recommended. These care concerns might be difficult for patients to talk about, and clinicians might not have the time to even bring them up. Having that screening done, knowing that is there, and when we see there are positive findings, that can trigger us to ask about it, or to clarify and try to understand more. Sometimes, patients can be under the impression that having a lot of depression or anxiety might be normal during treatment; they might not even know that it can be addressed.

The other barrier, I would say, is this lack of resources. Recognizing how complex these symptoms are and how much time it takes to address them, clinicians can sometimes avoid bringing them up because they know they open this bag of worms, and they may not be sure what to do with it. The best way to address that is if cancer centers were able to invest in having more psycho-oncology treatment and programs available. If we can hire more therapists and more social workers, that will give oncologists the backup they need that if they identify an issue, they will have someone they can refer the patient to, who can work with them on [resolving] it.

What advice would you give to oncology clinicians on how to initiate difficult conversations about mental health with patients who may be hesitant or resistant to discussing their emotional well-being?

These can be difficult conversations to have, both for patients and providers. That is where screening is helpful. Because it can reveal the level of stressor symptoms that the patients may not be bringing up or may not be readily apparent. Usually, whenever we are talking about these things, we start with open-ended questions, so we try to understand how the patient is doing. For instance, after reviewing their treatment so far, you can ask them, “I know it has been a lot to deal with. How have you been managing with everything?” and see how they respond. [Many] times, giving patients a safe space to talk about their experience and paint a picture of how they are doing will be helpful, and it also can be therapeutic for them, because it gives them a chance to talk about what they have been experiencing when they might be talking about things that might be difficult for them to discuss with their with their families or caregivers.

Terms like anxiety or depression can be loaded terms for some patients or have a stigma. It is a lot easier to start talking about just stress in general. Asking about how stress has been in general. How are they managing stress? As you are talking about the stressors, you can clarify what the things are in their life that are causing their stress. Is it just the cancer treatment? Often it is other things as well, whether it be their finances or their relationships, or other things that have been affected by the cancer treatment, or even things that are separate from it.

Once we have a sense of what their stressors are, then we can start asking about specific symptoms. We want to start asking about anxiety and depression symptoms, and that [includes] things like mood changes, having any worrying irritability, changes in sleep. In medical school, we are taught the SIGECAPS as symptoms of depression, but we all know that during cancer treatment, things like sleep, energy, concentration, appetite, those are all going to be affected, especially people getting traditional chemotherapy or radiation. When we are screening for depression or anxiety, you want to be asking about the psychological symptoms of depression, and that includes things like anhedonia, feelings of guilt, worthlessness, hopelessness, helplessness, irritability, loss of interest, and social withdrawal. Patients with cancer do have a 4 times elevated risk of suicide. Every patient where there is a concern about depression, anxiety, or distress should be asked about suicidal ideation as well.

How can you make your colleagues more aware that a supportive care resource like this exists?

The biggest thing that will help with connecting more patients to these services would be systemic changes. The more cancer centers invest in our psycho-oncology programs, the more oncologists will feel comfortable starting to ask about these things, because they will have a place to refer those patients to. For instance, we might see an oncologist who does not refer us much. They will send us a patient, and then we will connect with them, and the oncologist will see how valuable our services are, and we will start seeing many more referrals from that provider.

The biggest thing is to start by thinking about what resources are available where [I am]. Even if it is connecting with 1 person that you can refer the patient to, whether that be a social worker or a therapist that you trust. If there is no one in your institution, even connecting with someone in the community whom perhaps a patient has had a good experience with. Starting that connection, that collaboration––the more you look for it, the more you will find it, and then that can grow. It is one of those things where it can be difficult to connect patients with these services if they are not available where people are practicing. The more cancer centers invest in psycho-oncology, the more they will find that the need and demand for it will expand.

Where would you like to see the psycho-oncology field headed?

It has to do with growth. Thinking about how prevalent these symptoms are, the need for these services, and how much these symptoms affect patients’ quality of life. The more cancer centers can expand their offering of psycho-oncology treatments to patients, that would be the biggest thing that makes a difference for the lives of [patients], dealing with cancer. That would be the biggest thing I would be most excited about. Hearing more people entering this field, more positions opening, and more investment in psycho-oncology would be the biggest things that would help. We have good evidence-based approaches. We have effective tools that help patients. It is about getting those tools into the hands of people who can leverage them and work with patients. The more we can expand psycho-oncology, that is going to support the oncology providers as well, because they will know their patients are being taken care of in a holistic way that considers their mental health. Anytime we are a provider, knowing that our patient is being taken care of in a complete way that addresses all the aspects of their well-being is much more fulfilling and meaningful. We know that even if we treat the cancer, recognizing that there is untreated depression or anxiety, that is affecting the patient, that weighs on us, that is a burden, and knowing that there is an effective way to get that improved for a patient lifts that burden and that weight off the oncology teams as well.