Chapter 17 CANCER AND CHRONIC DISEASES

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Chapter 17CANCER AND CHRONIC DISEASES

• D.F.Marks, M.Murray, B.Evans, C.Willig, C.Woodall
  C.M. Sykes (2005)
• Health Psychology Theory, Research and Practice
  (2nd edition). London Sage.

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CANCER AND CHRONIC DISEASES

• CANCER
• CORONARY HEART DISEASE
• HIV/AIDS

What is? Interventions for Living with
Adaptation to Caring for someone with
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INTRODUCTION

• Chronic illnesses can strike at any age but more
  often in middle and older age groups.
• While they can be fatal, most people diagnosed
  with a chronic illness live for many years with
  the condition.
• Management of fatal or chronic diseases is a
  principal feature in the lives of 10-15 percent
  of the population.
• It involves juggling relationships with health
  professionals, family and friends and requires
  many adaptations and adjustments.

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INTRODUCTION

• Life-threatening diseases are associated with a
  great variety of metaphors and meanings.
• Metaphor can be a useful way of coping but may
  lead to guilt, self-blame and feelings of
  hopelessness.
• Petrie and Revenson (2005) identified three
  developments in psychological interventions for
  chronic illness
• Psychological interventions are becoming more
  theory-based and sophisticated in the behavioural
  targets they are seeking to alter.
• An increased awareness of sub-populations for
  whom the intervention may be more efficacious.
• An increasingly sharp focus on possible
  bio-behavioral and psychosocial mechanisms.

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INTRODUCTION
Comparison of three life-threatening conditions
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CANCER

• Psycho-oncology is the study of the psychological
  aspects of cancer care and treatment
• It is concerned with
• the psychological responses of patients, families
  and caregivers to cancer at all stages of the
  disease
• the psychosocial factors that may influence the
  disease process
• Unfortunately many cancer patients remain
  untreated owing to stigmatisation and lack of
  resources to diagnose, treat and support.
• Cancer causes anxiety and depression in more than
  one-third of patients and often affects the
  sufferers family emotionally, socially and
  economically.
• Inequalities in cancer treatment and care occur
  across different regions and social groups.

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CANCER Introduction

• Cancer is an umbrella term for more than 100
  different but related diseases.
• It occurs when cells keep dividing and forming
  more cells without internal control or order.
• This cell growth is known as a tumor or neoplasm.
• This can be either benign or malignant.

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CANCER Interventions

• Treatment can aim to cure the cancer, control it,
  or treat its symptoms.

• The type of treatment depends on the following
  factors
• Type of cancer
• The stage of the cancer
• Individual factors(e.g. age, health status,
  personal preferences of the patient and his/her
  family)

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CANCER Interventions

• The four major treatments for cancer are
• Surgery
• Radiation
• Chemotherapy
• Transplant option

• Psychosocial interventions for cancer include
• Counselling Psychotherapy
• Behaviour therapy
• Cognitive behaviour therapy
• Pain control techniques (see Chapter 16)
• Biofeedback, relaxation, hypnosis mental
  imagery
• Music art therapy
• Group support
• Complementary therapies

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CANCER Interventions

• Objective evidence of efficacy has not generally
  been very strong.
• Reviews focusing on the four main psychosocial
  interventions - behavioural therapy, educational
  therapy, psychotherapy, and support groups
  indicated some limited evidence of efficacy
• However, some encouraging research showed
• A reduction in the side effects of chemotherapy
  after biofeedback and relaxation therapy (Burish
  Jenkins, 1992) and
• A reduction in pain, less mood disturbance, and
  fewer maladaptive coping responses after
  supportive group therapy (Spiegel et al., 1989).
  
• Some researchers even claimed that their
  interventions extended their patients survival
  (Fawzy et al, 1995 Spiegel et al., 1989).

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Living with cancer

• There are several aspects of cancer experience
  that psychological expertise can help to
  understand
• PAIN
• FATIGUE
• DEPRESSION
• ANXIETY

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Adaptation to cancer

• A variety of factors have been associated with
  adaptation to cancer patients, partners and
  families, and the interactions between the
  patients and their families.
• A large amount of research on coping styles such
  as fighting spirit, helplessness/ hopelessness,
  denial, and avoidance has led to mixed and
  inconsistent findings.
• Women with high scores on depression,
  helplessness and hopelessness were at more risk
  of death from all causes of breast cancer (Watson
  et al., 1999) .
• In a literature review, little evidence was
  available on the relation of psychological coping
  to survival and recurrence in people with cancer
  (Petticrew, et al., 2002) .
• Watson, et al. (2003) contested the fairness of
  this review.
• Spirituality, particularly the existential
  component, was associated with less distress and
  better quality of life, regardless of life threat
  (Laubmeier, et al., 2004) .

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Adaptation to cancer

• In a study on how psychological therapy may
  prolong survival in metastatic cancer patients,
  survivors displayed a higher degree of early
  involvement in their psychological self-help than
  did their non-surviving peers, suggesting that
  healing may be assisted by a greater
  authenticity of thought and action (Cunningham
  Watson, 2004) .
• In a systematic review of research on the effects
  of parents' behaviour on children's cancer
  coping, parents who criticized, or apologized,
  had more distressed children while parents who
  were permissive had more problems with adherence
  (Vance and Eiser, 2004).
• In a study on empathy in the psychological
  adjustment in siblings, empathy was found to be a
  significant predictor of externalizing and total
  problems. Empathy may play an important role in
  sibling adjustment following diagnosis (Labay
  Walco, 2004) .
• In a study of couples' support-related
  communication, psychological distress, and
  relationship satisfaction, partner responses play
  a role in women's adaptation to breast cancer
  (Manne et al., 2004)

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Caring for someone with cancer

• The stress experienced by the family members can
  often be high.
• The condition can create emotional turmoil with
  fear, anxiety, stigma, depression, hopelessness,
  fatigue, pain and insomnia all entering the
  relationship at various stages.
• The social support provided by the immediate
  family and friends can be a key factor in the
  promoting the patients adaptation and QoL.

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CORONARY HEART DISEASE Introduction

• Coronary Heart Disease (CHD) occurs when the
  walls of the coronary arteries become narrowed by
  a gradual build-up of fatty material called
  atheroma.

• The two main forms of CHD are
• Myocardial infarction (MI)
• Angina

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Myocardial infarction (MI)

• Myocardial infarction (MI) occurs when one of the
  coronary arteries becomes blocked by a blood clot
  and part of the heart is starved of oxygen.
• It usually causes severe chest pain.
• A person having a heart attack may also
  experience sweating, light-headedness, nausea or
  shortness of breath.
• A heart attack may be the first sign of CHD in
  many people.

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Angina

• Angina is the most common form of CHD.
• Characteristics include heavy or tight pain in
  the centre of the chest that may spread to the
  arms, necks, jaw, face, back or stomach
• Symptoms occur when the arteries become so narrow
  from the atheroma that insufficient
  oxygen-containing blood can be supplied to the
  heart muscle when its demands are high
• There are two categories of angina -
• Stable angina is characterised by chest pain
  relieved by rest, resulting from the partial
  obstruction of a coronary artery by atheroma.
• Unstable angina occurs with lesser degrees of
  exertion or while at rest. This requires
  immediate medical attention. If left untreated,
  it can result in heart attack and irreversible
  damage to the heart.

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CORONARY HEART DISEASE Interventions

• Diagnostic tests for CHD include
• Exercise tolerance test (EET)
• Electrocardiogram (ECG)
• Coronary angiogram
• Many people with CHD take a regime of medication
  such as
• ACE inhibitors
• Statins
• Anticoagulant drugs
• Betablockers

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CORONARY HEART DISEASE Interventions

• Other invasive forms of treatment may be
  necessary for some patients
• Revascularisation
• Percutaneous coronary intervention (PCI)
• Coronary artery bypass graft (CABG)
• Seeking diagnosis and treatment may be stressful
  for both the patient and the family.
• An angina plan can aid in the psychological
  adjustment of patients with CHD

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The Angina Plan (Lewin et al., 2002)

• The Angina Plan consists of a patient-held
  booklet and audio-taped relaxation programme.
• Before commencing the 3040 minute Angina Plan
  session, the patient is sent a questionnaire
  designed to establish if s/he holds any of the
  common misconceptions about angina -
• For example, each episode is a mini heart attack
  or angina is caused because your heart is worn
  out
• The patients partner or a friend is invited to
  the session.

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The Angina Plan (Lewin et al., 2002)

• After blood pressure and body mass index have
  been taken, the facilitator discusses any
  misconception that were revealed in the
  questionnaire.
• Personal risk factors are then identified.
• Personal goals to reduce the risk factors are
  then set.
• They are provided with a relaxation tape and
  encouraged to use it.
• The Plan also contains written information
• The role of frightening thoughts
• Misconceptions in triggering adrenaline release
• Anxiety and how this can result in poor coping
  strategies

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The Angina Plan (Lewin et al., 2002)

• The patient is contacted by the facilitator at
  the end of weeks 1, 4, 8 and 12.
• During these phone calls, the patient is praised
  for any success.
• They are also asked if they want to extend
  successful goals.
• Unsuccessful goals can be revisited.
• Adding procedures that encourage specific
  implementation intentions to this programme could
  well improve the success of the Angina Plan.

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Living with CHD

• Waiting for invasive treatment to improve or
  prolong life can be very stressful and have
  deleterious effects on the quality of daily life.
  
• In a qualitative analysis into the experience of
  waiting for a CABG in Northern Ireland, three
  central themes have been identified (Fitzsimons
  et al., 2000)
• Uncertainty
• Chest pain
• Anxiety
• Physical incapacity, reduced self-esteem and
  altered family and social relationships, again
  pointed to a need for psychological intervention
  during this period.

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A systematic review of social support and its
relationship to morbidity and mortality after
acute myocardial infarction (Mookadam Arthur,
2004)

• The authors were interested in the socioeconomic
  determinants of health, including social change,
  disorganization, and poverty that have been
  associated with an increased risk of morbidity
  and mortality.
• Social support is a possible mediator linking
  these factors to health and illness.
• Having low social support networks was a
  predictor of 1-year mortality following acute
  myocardial infarction.
• Low social support is equivalent to many
  classic risk factors, such as elevated
  cholesterol level, tobacco use, and hypertension.

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Adaptation to CHD

• Cognitive adaptation has been shown to predict
  psychological adjustment to diseases such as
  arthritis, cancer, AIDS and heart disease.
• According to the cognitive adaptation theory,
  some people who are faced with a chronic illness
  maintain or develop an optimistic outlook,
  attempt to regain control or mastery over the
  event and find ways to restore or enhance their
  self-esteem (Taylor, 1983).
• A large number of MI patients do not return to
  work or regain normal functioning despite being
  physically well.
• There is evidence that cardiac rehabilitation
  programmes can reduce distress and disability,
  increase confidence and improve modifiable risk
  factors (Horgan McGee, 1995).
• Unfortunately, many patients do not attend
  rehabilitation programmes after their MI.

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Caring for someone with CHD

• Moser and Dracup (2004) compared the emotional
  responses and perception of control of MI and
  revascularisation patients and their spouses and
  examined the relationship between spouses
  emotional distress and patients emotional
  distress and psychosocial adjustment to their
  cardiac event. They found that -
• Spouses had higher levels of anxiety and
  depression than the patients.
• There were no differences in level of hostility.
  
• The patients also had a higher level of perceived
  control than did the spouses.
• Spouse anxiety, depression and perceived control
  were correlated with patient psychosocial
  adjustment to illness even when patient anxiety
  and depression were kept constant.
• The patients psychosocial adjustment to illness
  was worse when spouses were more anxious or
  depressed than patients.
• Patients psychosocial adjustment was best when
  patients were more anxious or depressed than
  spouses.

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Caring for someone with CHD

• Interventions that address the psychological
  distress of spouses may well improve patient
  outcomes.
• Attention should also be given to the
  psychological needs of spouses of patients who
  have suffered a cardiac event.

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HIV/AIDS Introduction

• Human immunodeficiency virus (HIV) is a
  retrovirus that infects and colonises cells in
  the immune system and the central nervous system.
  
• Initial flu-like symptoms are followed by a
  quiescent, asymptomatic period during which the
  immune system battles the virus.
• Acquired immune deficiency syndrome (AIDS)
• develops when the immune system becomes
  overwhelmed and the individual becomes vulnerable
  to opportunistic diseases.

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HIV/AIDS Introduction

• In 1996, the introduction of highly active
  antiretroviral therapy (HAART) redefined the
  illness and improved the outlook for infected
  individuals.
• However, antiretrovirals do not eliminate the
  virus, but only suppress it.
• Currently, only
• 1 in 10
• who need the treatment
• actually receive it

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HIV/AIDS Interventions

• Since HIV rapidly replicates and mutates, vaccine
  development is problematic and increases the
  likelihood of drug resistance.
• Combination therapies (HAART) have been shown to
  decrease an individuals HIV viral load to
  undetectable levels, reducing associated
  morbidity and mortality (Kelly et al., 1998).
• However, 95-100 adherence is required to
  produce and maintain successful virologic
  suppression (Chesney, 1997).
• HIV combination drug therapies involve complex,
  disrupting and challenging medication regimens
  involving numerous drugs taken several times a
  day with specific food instructions.
• In addition, treatment often commences during the
  asymptomatic phase. Drug toxicity commonly
  results in severe, unpleasant side-effects and
  treatment must continue for the rest of the
  persons life.

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HIV/AIDS Interventions

• The chronic status of HIV/AIDS and the limited
  accessibility to HAART for many PLWHA means that
  psychosocial support interventions are
  increasingly important.
• Pain management programmes, stress management,
  coping effectiveness training, sleep disorders
  and exercise promotion, have been found to
• Enhance immune system function, medication
  adherence and adaptive coping and
• Decrease anxiety, stress and depression (Chesney,
  et al. 2003)
• Supportive interventions, especially those that
  improve function and self-management and maximise
  independence, represent an essential part of
  HIV/AIDS treatment.

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HIV/AIDS related stressors
HIV/AIDS related stressors
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Adaptation to HIV/AIDS

• Adaptive coping strategies along with good social
  support can moderate the negative effects of
  stress.
• Finding meaning in the experience of HIV/AIDS has
  been associated with medication adherence, lower
  distress, and perceived control.
• Interventions that target adaptive coping skills,
  emotion work and increasing social support appear
  to be most effective in helping patients to adapt
  to living with their illness.

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Caring for someone with HIV/AIDS

• The burden of care for people with HIV/AIDS, both
  formal and informal, is being borne primarily by
  lay carers within the family or the community,
  the majority of whom are women and girls (DCruz
  2000 UNAIDS, 2004).
• There is some evidence that the least
  acknowledged carers are children and that older
  women, already vulnerable through higher levels
  of chronic poverty, lack of resources and their
  own substantial health problems, are
  disproportionately affected (Tallis, 2002).

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Caring for someone with HIV/AIDS

• Caring involves a broad spectrum of
  psychological, spiritual, emotional and practical
  work throughout the course of the illness (Stetz
  and Brown, 1997).
• It can be a rewarding undertaking that caregivers
  derive purpose and self-esteem from (Paxton,
  2002).
• However, the caring literature consistently
  reports the inherently stressful nature of caring
  for someone with a chronic illness (e.g. Chesler
  and Parry, 2001 Radina and Armer, 2001).
• Many of the stressors and negative psychological
  outcomes experienced by PLWHA equally affect
  their carers.

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Caring for someone with HIV/AIDS

• The needs of carers are rarely prioritised and
  burnout is a common problem.
• Burnout is defined as emotional exhaustion,
  depersonalisation and a damaged sense of personal
  accomplishment.
• Emotional support and stress management
  programmes can help prevent stress, depression
  and burnout in carers.

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Summary General points

• Chronic illnesses can strike at any age but more
  often in middle and older age groups.
• This involves restrictions on activities of daily
  living, increases in pain and fatigue.
• Life-threatening diseases are associated with a
  great variety of metaphors and meanings.
• Metaphor can be a useful way of coping but may
  lead to guilt, self-blame and feelings of
  hopelessness.
• Stigmatization adheres to people with cancer and
  chronic diseases. This can be a heavy extra
  burden for victims to carry.
• It is important to consider the needs of the
  family members of people with cancer and chronic
  diseases.

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Summary Cancer

• Cancer occurs when cells keep dividing and
  forming more cells without internal control or
  order.
• Treatment can aim to cure the cancer, control it,
  or treat its symptoms.
• The type of treatment depends on the type of
  cancer, the stage of the cancer, and individual
  factors such as age, health status, and the
  personal preferences of the patient and his/her
  family.
• The patient ideally is empowered to discuss with
  the professionals the treatment choices.
• The four major treatments for cancer are surgery,
  radiation, chemotherapy, and biological therapies
  such as hormone therapies and transplant options.
• Interview and diary studies suggest common themes
  among long term survivors "authenticity",
  "autonomy" and "acceptance.

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Summary CHD

• CHD is a leading cause of death in Western
  countries.
• The two main forms of CHD are myocardial
  infarction and angina.
• Decreases in the CHD death rates are mainly due
  to a reduction in major risk factors, principally
  smoking.
• Spending on primary prevention does not reflect
  this finding.
• Seeking treatment for CHD can be stressful for
  both people with CHD and their family members.
• It is important to tailor the information about
  CHD to the needs of individual patients.
• Psychological disease management can help angina
  patients to adjust but psychological services are
  currently patchy and inadequate.

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Summary HIV/AIDS

• HIV/AIDS has become a worldwide pandemic that has
  infected around 60 million people, and become the
  fourth largest killer in the world.
• There are around five million new cases each
  year.
• HIV is a retrovirus that infects and colonises
  cells in the immune system and the central
  nervous system.
• The most effective treatment consists of
  combination therapies (HAART), which have been
  shown to decrease an individuals HIV viral load
  to undetectable levels, reducing associated
  morbidity and mortality.
• Adaptive coping strategies along with good social
  support can moderate the negative effects of
  stress.
• Finding meaning in the experience of HIV/AIDS has
  been associated with medication adherence, lower
  distress, and perceived control.
• Interventions that target adaptive coping skills,
  emotion work and increasing social support appear
  to be most effective in helping patients to adapt
  to living with their illness.