Supportive Care of the Patient With Pancreatic Cancer: Role of the Psycho-Oncologist

September 1, 1996

Many people who are diagnosed with pancreatic cancer react with a normal level of sadness. In others, however, depression represents a concomitant illness, perhaps with a biologic basis. Regardless of their origin, these mood

ABSTRACT: Many people who are diagnosed with pancreaticcancer react with a normal level of sadness. In others, however,depression represents a concomitant illness, perhaps with a biologicbasis. Regardless of their origin, these mood disorders are controllable.The role of the psycho-oncologist is to distinguish normal emotionalreactions to having advanced cancer, in which depressive symptomsresolve gradually within a week or two with support from familyand friends, from symptoms of comorbid psychiatric illness, whichwarrant more extensive treatment, such as a combination of supportivepsychotherapy, cognitive-behavioral techniques, and psychopharmaceuticalagents. [ONCOLOGY 10(Suppl):33-34, 1996]

Introduction

Patients with pancreatic cancer, known for its frequent diagnosisat an advanced stage, rapid progression, extremely low survivalrate, and associated pain, are intuitively expected to presentwith depression and anxiety, based on the logic that feelingsof hopelessness, helplessness, sadness, and grief would be commonand even "normal" in these patients. Corroborating thisnotion, several studies have reported that depression and anxietyoccur in as many as 50% of patients with carcinoma of the pancreas[1-3].

Although sadness is a normal situational reaction to pain andpotential loss for many people with pancreatic cancer, for othersdepression is a concomitant illness. Many reports have noted anexcessive comorbidity between depression and pancreatic cancer,as compared with other types of cancer [1,4-6]. Even more striking,psychiatric symptoms appear in approximately 50% of these patientsbefore the diagnosis of cancer is made and somatic symptomsare noted [2,3,7]. In fact, psychiatric symptoms have been reportedto occur up to 2 years prior to the onset of abdominal symptomsin some pancreatic cancer patients [4], and it has been suggestedthat the presence of depression, anxiety, insomnia, restlessness,or agitation may sometimes aid in the earlier diagnosis of thisusually late-detected cancer [3,7].

This sequence of events suggests that pain, knowledge of a cancerdiagnosis, or worry over unexplained physical symptoms cannotbe the sole etiologic basis for psychiatric symptoms in many patients.Rather, it implies the existence of neuropsychiatric causes, suchas tumor-based biologic pathogeneses [3]; such factors potentiallyinvolve adrenocorticotropic hormone, parathyroid hormone, thyrotropin-releasinghormone, glucagon, serotonin, insulin, or bicarbonate [3,8]. Therole of the psycho-oncologist is to distinguish between normalemotional reactions to having advanced cancer and symptoms ofcomorbid psychiatric illness, perhaps with a biologic basis, whichwarrant more extensive treatment [9].

Diagnosing Depression

Depression is often overlooked in people with advanced pancreaticcancer because anorexia, weight loss, loss of energy, insomnia,loss of libido, and fatigue are more likely to be symptoms ofthe cancer than of a depressive syndrome [9]. Therefore, a diagnosisof major depression in cancer patients relies more on psychologicalsymptoms, such as dysphoric mood for 2 or more weeks, hopelessness,helplessness, and a sense of worthlessness or despair, than onsomatic complaints. In particular, anhedonia (total loss of interestor pleasure; not to be confused with a mere reduction in the numberof pleasure-providing activities) and suicidal ideation are dependablediagnostic markers for depression in patients with pancreaticcancer. When these cognitive or ideational symptoms are present,a family history of depression or a history of alcoholism, drugabuse, or two or more previous depressive episodes (particularlyif the first episode was before age 25 or after age 50) increasethe risk and further substantiate the diagnosis [9].

Treating Depression

For cancer patients whose sadness and grief are normal emotionalreactions to the grim medical situation that they are facing,depressive symptoms resolve gradually within 7 to 10 days withsupport from family, friends, clergy, and others. The medicalteam can assist by providing clear medical information and a treatmentplan that offers hope--if not for a cure, perhaps for controlof pain and suffering. For pancreatic cancer patients, this treatmentplan may include surgical resection, neoadjuvant or post-resectiontherapies, multimodality chemoradiation with or without surgery,enrollment in clinical trial protocols, or the assurance thatphysical and psychological symptoms will be addressed (ie, thepatient will not die alone or in pain).

Intervention beyond that provided by empathic physicians, nurses,social workers, and clergy is usually not required unless symptomsof emotional distress are sustained, intolerable, or interferewith functioning [9]. However, prescribing a hypnotic or low-doseantidepressant to permit normal sleep and/or a benzodiazepineto reduce daytime anxiety can assist the patient through crisisperiods and facilitate adaptation.

For patients who meet the Diagnostic and Statistical Manual-IV(DSM-IV) criteria for mood disorders or adjustment disorders,a combination of supportive psychotherapy (in the form of eitherindividual or group counseling), cognitive-behavioral techniques(such as relaxation and distraction with pleasant imagery), andantidepressants has been shown to decrease psychological distressand depressive symptoms [9-11].

Psychopharmacologic Interventions

Psychopharmacologic interventions are the centerpiece of treatmentof severe depression [10] and especially merit a trial in patientswhose depressive mood disorder has a hormonal or neuropsychiatriccomplication, such as disruption of serotonin synthesis. Tricyclicantidepressants are the most commonly used antidepressants incancer patients because of their analgesic properties and sideeffects that can alleviate cancer symptoms. For example, tricyclicswith sedating properties, such as amitriptyline or doxepin, canbe helpful in patients with agitation or insomnia [9,10]. If apatient does not respond to a tricyclic or cannot tolerate itsanticholinergic side effects, a second-generation tricyclic (eg,trazodone), heterocyclic (eg, amoxapine or maprotiline), or serotonin-selectiveantidepressant (eg, fluoxetine [Prozac], sertraline [Zoloft],or paroxetine [Paxil]) can be used. Trazodone is strongly sedatingand can be used at bedtime for insomnia. Serotonin-selective reuptake-inhibitingantidepressants have fewer sedating and autonomic effects thanthe tricyclics, but because they can be associated with nausea,weight loss, and anorexia, their usefulness may be limited inpatients with pancreatic cancer [10].

In addition, psychostimulants, such as dextroamphetamine, methylphenidate,and pemoline (Cylert), can also be used for managing depressionor advanced cancer-related fatigue and can have a dramatic impacton patients' functioning [10]. Psychostimulants have been shownto improve attention and concentration, and low doses may stimulateappetite, promote well-being, improve feelings of weakness andfatigue, and reverse the sedating effects of opioids used forpain management [10].

Crisis Intervention

For the person without an extensive psychiatric history who isundergoing the crises inherent in coping with pancreatic cancer,reducing symptoms of distress is the key to facilitating betteradjustment. The goal of the psycho-oncologist performing crisisintervention therapy is to restore the patient's baseline (precancer)psychological functioning by using hypnosis, relaxation therapy,and other psychotherapeutic techniques and modalities that reducepain and distress. Crisis intervention focuses on solving concrete,daily-life problems, including teaching specific coping skills(eg, how to take analgesics correctly), emphasizing past strengths,and mobilizing inner resources [9]. Referrals to such "low-tech"interventions as support groups and cancer survivor networks areoften successful because for some patients less stigma is attachedto participating in such groups than to seeing a psychologistor psychiatrist. Suggestions of coping techniques are sometimesbetter received from other patients than from mental health professionals.

Summary

Psycho-oncologists who care for pancreatic cancer patients canattest that depression and anxiety are neither inevitable noruntreatable in this population. Regardless of whether the depressionand anxiety accompanying a patient's pancreatic cancer are thenormal results of anticipatory grief, pain, and distress or arecomorbid psychiatric conditions, these mood disorder symptomsare controllable using supportive psychotherapy, cognitive-behavioraltechniques, crisis intervention, and/or psychopharmaceuticals.

References:

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3. Green Al, Austin CP: Psychopathology of pancreatic cancer:A psychobiologic probe. Psychosomatics 34:208-221, 1993.

4. Joffe RT, Adsett CA: Depression and carcinoma of the pancreas.Can J Psychiatry 30:117, 1985.

5. Joffe RT, Rubinow DR, Denicoff KD, et al: Depression and carcinomaof the pancreas. Gen Hosp Psychiatry 8:241-245, 1986.

6. Holland JC, Korzun AH, Tross S, et al: Comparative psychologicaldisturbance in pa-tients with pancreatic and gastric cancer. AmJ Psychiatry 143:982-986, 1986.

7. Fras I, Litin EM, Bartholomew LG: Mental symptoms as an aidin the early diagnosis of carcinoma of the pancreas. Gastroenterology55:191-198, 1968.

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