The psychological side of cancer

A woman school teacher in her mid-forties diagnosed with cancer in her left breast underwent sessions of chemotherapy, radiotherapy and mastectomy (surgical removal) of the affected breast. The patient was on regular follow-up with her surgical and medical oncological teams.

Though her five-year survival prospect looked fairly certain, the doctors found that the woman was prone to spells of depression. She was very reluctant to resume her job as a teacher not because of cancer but because of body image issues. Alopecia (hair fall due to therapies) and removal of a breast was haunting the teacher, more than the malady.

Now, here comes the role of psycho-oncologists who have to deal with the psychological, emotional and behavioural responses of a cancer survivor. Similarly, a woman in her mid-twenties diagnosed with Acute Lymphatic Leukaemia refused a Bone Marrow Transplant because the diagnosis ended her relationship with her boyfriend.

Counselling by psycho-oncologists, interventional therapy by medical and surgical oncologists, and additional support system from the woman's family were extended to make it clear that her life was far more precious than her relationship with her boyfriend.

Surgical oncologists say: "It is cosmetically possible to aim at organ preservation, thus aiming at preserving the body image. Depending on the extent and stage of the disease, in case of breast cancers, we try to preserve the breast with mastectomy with immediate reconstruction of the breast, since most women feel breast is a symbol of femininity.

Likewise, during chemotherapy, we advise the procedure of 'hair cooling', to reduce hair loss. Women with long hair are advised to cut and use a wig made of their own hair to prevent scalp allergies, which may happen by using wigs made of someone else's hair".

Hence, dealing with body image issues by counselling and properly advocating alternate solutions is a major responsibility of psycho-oncologists.

Dr Brindha Sitaram, who has been a psycho-oncologist with the Bangalore Institute of Oncology and HCG-Cancer Care Hospital in Bengaluru for more than two decades, says: "Psycho-oncology doesn't merely refer to counselling alone. Psycho-oncology has a whole gamut of psychological, behavioural and cognitive assessment and interventional techniques evolved out of scientific principles, theories and models. It is a well-known fact that the patient's compliance increases with timely interventions by a psycho-oncologist. Thus, we work along with the oncological surgeons and medical oncologists."

Dr Brindha also says that since cancer is a chronic illness, it not only takes a toll on the primary caregivers, the family of the patient, but even professional cancer care providers like doctors and nurses tend to experience stress and burnout.

Elephant in the room

The issues that confront oncologists are: breaking the bad news, dealing with the financial concerns of patients, dealing with the patients FCR (fear of cancer recurrence), scanxiety (the anxiety of the patient about whether his/her repeat CT scan/PET scan would be normal), to decide about the end-of-life care (EOLC). Pre-treatment counselling becomes important since psychosocial screening can be the ice-breaker.

Fertility issues need to be addressed in young afflicted patients with testicular cancers and ovarian cancers. In such cancer survivors, anger, depression, a feeling of inadequacy, the stress of not being able to procreate have to be addressed by psycho-oncologists, along with the remedial measures advocated by surgical and medical oncologists.

Patients also feel a sort of personal discomfort with topics such as sexuality and fertility issues, hence therapeutic counselling by integrating the partners of cancer survivors is very vital.

The oncological team also needs to identify the triggers in a cancer survivor of FCR, since many times, follow-up medical appointments can trigger FCR. Anxiety about radiotherapy, wrong advice by other patients can also trigger FCR and influence the patients' decision making about the treatment schedule. Psycho-oncologists help remove the misconception and provide weekly group therapies for patients and their relatives.

Cancer survivors are also advised to write down their apprehensions or optimistic mood levels every day in the form of a narrative, which itself can be mentally soothing. Such narratives of real-life cancer survivors are made into booklets, which can become inspirational for newly diagnosed cancer patients. This reminds me of Dr Paul Kalanithi's memoir When Breath Becomes Air.

Dr Kalanithi was an Indian-American neurosurgeon and a postgraduate scholar in English Literature who died of lung cancer at 38 years of age, in 2015.