1. 1. PSYCHO-ONCOLOGY Psycho-Oncology 15: S1S478 (2006) Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/pon.1092 ABSTRACTS ABSTRACTS OF THE 8TH WORLD CONGRESS OF PSYCHO-ONCOLOGY 16TH21ST OCTOBER 2006 Ferrara}Venice, Italy 1 Global Psychosocial Oncology: 2006 Holland JC Wayne E. Chapman Chair in Psychiatric Oncology, Department of Psychiatry & Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, NY, USA Psychosocial oncology began in the early 1980s and the International Psycho-Oncology Society was founded in 1984 to link the small groups of clinicians and investigators studying the psycho- logical, social and behavioral aspects of cancer care. Over the past twenty years, they have developed valid tools to measure patient-reported outcomes (QOL) and they have developed, with the WHO, standards and guidelines for psycho- social care, modied to reect the resources available in countries with limited means. There are key psychosocial issues at each point in the cancer trajectory: changing lifestyle and behaviors to reduce cancer risk; psychological factors alter- ing participation in early detection and screening; control of physical and psychological symptoms during treatment (management of side eects, pain, anxiety, depression, delirium, fatigue); psy- chosocial sequelae in cancer survivors; and, signicant psychological support in palliative and end of life care. Psycho-oncology today has a broad research agenda which is being carried out by investigators from many countries and dierent disciplines (psychology, psychiatry, nursing, social work). They collaborate with all the clinical specialties of oncology, epidemiology, prevention, palliative care, and bioethics. The addition of psycho-oncology to the oncologic specialties has enhanced the understanding of the human experi- ence of cancer and has led to evidence-based treatment guidelines which are being applied to patient care. 2 Methods of Assessment of Depression in Cancer Patients Breitbart W Psychiatry Service, Memorial Sloan-Kettering Cancer Center, Department of Psychiatry and Behavioral Sciences, New York, NY, USA Depression is highly prevalent in cancer patients, however, it is frequently under-diagnosed, mis- diagnosed and under-treated. One of the obstacles to the accurate diagnosis and treatment of depression in cancer patients has been the lack of methods of assessment of depression that has been specic to medically ill populations such as cancer patients. Recent advances have been made in the assessment of depression in cancer patients that have helped improve the accuracy and specicity of such a diagnosis beyond the utiliza- tion of diagnostic criteria (DSM IV, RDC) that had originally been established and validated in physically healthy populations. The problem of the somatic symptoms of depression have been dealt with in several ways. This presentation will describe two approaches to increased accuracy of diagnosis of depression in cancer patients: the substitutive approach, and the high threshold approach. In addition, this lecture will review the currently available research/clinical methods and Copyright # 2006 John Wiley & Sons, Ltd.
2. 2. instruments for diagnosing depression in cancer patients, including novel brief single item screen- ing tools. Finally, new data on the relationship between pro-inammatory cytokines and depres- sion in cancer patients and the potential for the use of cytokines in the assessment of depression in cancer will be presented. 3 Psychotherapeutic Intervention for Depression in Cancer Patients Spiegel D Stanford University School of Medicine, Stanford, CA, USA As advances in medical treatment extend life with cancer, converting it in many cases from a terminal to a chronic illness, problems in coping with the disease and its treatment become more important. Depression is three times as common (11%) among medical inpatients, and twice as common (6%) among medical outpatients, than in the general population (3%), and aects some 25% of cancer patients. Half of all cancer patients have a psychiatric disorder, the most common of which are adjustment disorders with depression. Anxiety about illness such as cancer leads to delay in diagnosis which has been estimated to reduce prospects of long-term cancer survival by 1020%. Depression is often underdiagnosed in the medi- cally ill due to: (1) focus on somatic signs and symptoms; (2) misattribution of depressive symp- toms such as energy loss, appetite disturbance and sleep diculties as necessarily resulting from cancer or its treatment; (3) therapeutic nihilism regarding psychiatric conditions. Psychosocial problems that can exacerbate depression include fears of recurrence or death, family stresses, social isolation, energy reduction, alterations in body image, unanticipated demands on time, and nancial burden. Finding means of helping people live with a chronic life threat, cope with the side eects of arduous treatments, and manage the personal, social and vocational consequences of disease-related disability is of growing importance. In addition there is evidence that depression contributes to risk of breast cancer progression, so it requires vigorous treatment to ameliorate quality of life and potentially to improve survival time. There is a growing body of evidence that suggests that psychotherapeutic interventions for cancer patients, along with appropriate psycho- pharmacological treatment, can reduce symptoms of depression and anxiety, as well as improving coping, enhancing interaction with family and friends, and improving interactions with health care professionals and adherence to treatment. These interventions are safe and inexpensive. Supportive-Expressive Group Therapy is designed to help cancer patients build bonds of social support, express and manage emotion, deal with fears of dying and death, alter life priorities, adjust to changes in body image, improve relationships with their family and friends, enhance commu- nication with physicians, and develop cognitive and experiential skills to manage information and symptoms such as pain and nausea. Principles of psychotherapeutic intervention for depression among cancer patients will be reviewed, along with videotapes examples of the intervention. Additionally, there is some evidence that such interventions may have eects on disease course as well. Studies of these outcome eects will be reviewed. Possible mechanisms linking psychoso- cial intervention with eects on disease course will be described. Such therapeutic techniques have shown themselves to be humane, eective, and cost-ecient. 4 Depression as Systemic Disease: The Antidepres- sants Spectrum of Action Torta R Psychoncology Unit, University of Turin, Turin, Italy Mood depression is a systemic disease, not only related to the neurotransmission imbalance, but also to other neurotrophic, neurosteroidal, hor- monal CNS modications and diuse autonomic, immunological, metabolic somatic changes. Anti- depressants (ADs) induce systemic serotonergic, noradrenergic or dopaminergic modications, according to the somatic activity of these drugs. Stress circuits are activated during mood depres- sion: the hypothalamic paraventricolar nucleus (PVN) increases the release of the corticotrophin- releasing hormone (CRH) and, consequently, of ACTH and cortisol (Barden, 2004). ADs act not only in retoring neurotransmitters; level, but also in exerting a direct activity in the modulation of the receptor expression in hypothalamus, that normalizes the hyperactivity of hypothalamic- pituitary-adrenal (HPA) axis observed in de- pressed patients. Recent ndings demonstrate the involvement of neurotrophic factors, particularly Copyright # 2006 John Wiley & Sons, Ltd. Psycho-Oncology 15: S1S478 (2006) DOI: 10.1002/pon ABSTRACTS OF THE 8TH WORLD CONGRESS OF PSYCHO-ONCOLOGYS2
3. 3. the Brain Derived Neurotrophic Factor (BDNF), in the pathophysiology of mood disorders (Hashimoto et al., 2004). BDNF protects against stress-induced neuronal damage: chronic admin- istration of antidepressants increases the expres- sion of BDNF mRNA in limbic structures. Proinammatory cytokines within the central nervous system play a role in the pathophysiology of mood disorders and a modulation of these cytokines by chronic antidepressant treatment contributes to improve depression. Several of the aforementioned antidepressant mechanisms of action, represent the basis of the broad activity of AD in medical pathologies, such as pain, cardiovascular, metabolic and oncological dis- eases (Torta and Berra, 2002). This broad spectrum of ADs clinical activities suggest that term antidepressants is limited and that it would be better to dene these drugs as noradrenergic or serotonergic drugs. 5 The Assessment and Management in Patients with Advanced Cancer Bruera E Department of Palliative Care & Rehabilitation Medicine (Unit 8), UTM. D. Anderson Cancer Center, Houston, TX, USA Approximately 50% of patients in developed countries and more than 80% of patients in developing countries will die of advanced disease. These patients will develop a number of devastat- ing physical and psychosocial symptoms. In recent years there have been major developments in the state-of-the-art in the assessment and manage- ment of many of these syndromes. A number of very eective tools have been developed for the assessment of the intensity of physical and psychosocial symptoms. These tools have now moved from the research to the clinical setting. Multidimensional assessment of symptoms includes not just the intensity but also those major associated factors that can be appropriately corrected as part of the management of the dierent symptom complexes. Interdisciplinary care of dicult symptoms in patients with advanced cancer requires comprehensive multi- dimensional assessment and integrated pathways between dierent healthcare professionals. This presentation will discuss some of the areas where interdisciplinary care has been highly eective in controlling symptom distress. 6 Delirium in Cancer Patients: Assessment and Intervention Caraceni A Palliative Care Unit, Hospice Floriani, National Cancer Institute, Milan, Italy The diagnosis of delirium is a signicant clinical task in oncology for both psychiatrists and neurologists called to see patient with changes in mental status, cognitive impairment or neuropsy- chiatric symptoms. Delirium is a syndrome with a number of potential etiologies and its diagnosis and treatment can have a major impact on patient quality and quantity of life. Early recognition is fundamental to prevent more complicated courses and lack of recovery. Among the risk factors age, cognitive impairment and advanced disease play an important role. The context of care will inuence the outcome, as delirium can alterna- tively characterize the terminal evolution of an advanced illness or compromise the course of a patient that instead has still potential for recovery. For the elderly in particular delirium can herald a long and incomplete recovery and lack of auton- omy. Interventions range from prevention that has a potential in changing the care for the hospita- lized elderly to palliative pharmacological treat- ment. Palliation of symptoms is however required as delirium causes suering and although haloper- idol is the rst line of therapy optimal manage- ment would benet of more trials and indivi- dualized pharmacological strategies, including the observation that delirium is one of the most frequent indications to palliative or terminal sedation. The impact of delirium on the patient and his or her family still awaits for more research as the social domain of care is certainly relevant to this complex and fascinating syndrome and therefore the attention to contextual, communica- tion and nursing aspects of care should be also emphasized. 7 Dying with Dignity: Rhetoric, Data and Therapeu- tic Opportunities Chochinov HM Family Medicine and Community Health Sciences at the University of Manitoba, and Director of the Manitoba Palliative Care Research Unit at CancerCare Manitoba, Winnipeg, Canada Copyright # 2006 John Wiley & Sons, Ltd. Psycho-Oncology 15: S1S478 (2006) DOI: 10.1002/pon ABSTRACTS OF THE 8TH WORLD CONGRESS OF PSYCHO-ONCOLOGY S3
4. 4. Over the past decade, our research group has conducted a number of studies addressing the issue of dying with dignity. Dignity is a highly politicized term, which has been used to support various approaches for care of the dying. While most palliative care providers attending to patients would espouse dignity as an overarching value or goal of end-of-life care, few empirical studies have provided guidance or direction on how this might be operationalized or system- atically achieved. Without such information, how are we to ensure that dying patients maintain their sense of dignity until the very end? To begin, one must appreciate how the terminally ill understand the notion of dignity, and what factors undermine or maintain dignity for those nearing death. This talk will address these issues, using clinical illustrations and research data, highlighting ther- apeutic considerations for patients near the end of life. An empirical model of dignity will be presented, along with the rational for a dignity model based therapy. This novel, individualize, brief psychotherapy has been designed specically to maintain the dignity of dying patients and their families. Results from one hundred patients who have completed this protocol will be presented, including data on the extent to which this intervention inuenced their sense of dignity, hope, meaning, preparedness for death, and will to live. Results will also be presented regarding the reactions this intervention has garnered from family participants. 8 Cancer Survival and Supportive Care: From Diagnosis, Through Therapy to Follow-up Aapro MS Dean, IMO Clinique de Genolier, Genolier, Switzerland Even if one does not look at pediatric oncology, survival in cancer patients has improved. There are two main reasons for this result: earlier detection and better treatment. This presentation will briey address the needs for support of cancer patients who survive the various forms of this, still today, demonized disease. Helping excellence in this support, through all stages of the cancer experience, is part of the denition of tasks of the Multinational Association for Supportive Care in Cancer (MASCC). At the diagnostic stage it is more and more recognized that society cannot oer early detection without immediate support in case of a suspicious lesion, let alone a conrmed diagnosis. And once treatment starts, the needs for support of our patients can be immense. In some cases the oncology community has responded well, and considerable progress has been made, among other areas, in psycho-social support, help to cope with consequences of surgery or radiation therapy, antiemetic treatment, control of infections, treat- ment of fatigue and anemia. In other instances, progress is slow to come, and mucositis, hair-loss, skin toxicity, diarrhea, are some of the areas which have not been given enough attention, even if some advances have been made. Patients who were often the center of the attention will nd themselves suddenly very much alone once the end of a successful treatment is announced. The need for support at this stage has not received wide attention in most cancer centers. 9 Cancer and the Family: Paradigms and Quandaries Within a Cultural Context Baider L Head Psycho-Oncology Unit, Department of Ra- diation and Clinical Oncology, Hadassah University Hospital, Jerusalem, Israel More than 75 million people in the United States alone will be diagnosed with cancer, aecting approximately three out of four families. Chronic illness, such as cancer, places unexpected demands on family resources and creates changes over time and during the illness trajectory. Cancer has become a regular feature of family life, ceasing to be an isolated calamity of private individuals. Awareness and perception of illness based on socio-cultural understandings include norms regarding how family members are expected to relate and care for one another in the event of illness. They become part of family legacies, which are passed down from one generation to the next. Notwithstanding the considerable number of studies and clinical research that has been focused on the subject of families and chronic disease, we are only now beginning to identify some of the factors that come into play. What basic aspects of the family context might serve as a basic frame- work to identify risks of poor disease manage- ment? Why do some families fare relatively well in managing a chronic medical condition over an extended period of time, while others fare rela- tively poorly? Furthermore, despite the recogni- tion that dierent chronic diseases place dierent Copyright # 2006 John Wiley & Sons, Ltd. Psycho-Oncology 15: S1S478 (2006) DOI: 10.1002/pon ABSTRACTS OF THE 8TH WORLD CONGRESS OF PSYCHO-ONCOLOGYS4
5. 5. demands for care on family members and that dierent developmental stages can cause families to respond dierently to similar chronic condi- tions, we still know relatively little about how to design, implement and assess family care pro- grams over various periods of time. If we succeed in distinguishing between families that do well and families that do poorly, then we can identify patients and families at risk of poor disease management and more appropriately redirect clinical resources. 10 The Implications of Neurosciences in Communica- tion and DoctorPatient Relationship Biondi M Department of Psychiatric Sciences and Psycholo- gical Medicine; University La Sapienza, Rome, Italy The scientic literature traditionally treats the therapistpatient communication in oncology according to a predominant psychological and/or humanistic approach. This communication often involves intense emotional distress, with patients anxiety, fear and preoccupation, sadness or despair, or outbursts of anger. The communica- tion process is accompanied by intense distress, although not overt, for doctors and psychooncol- ogists, too. Caring for cancer patients has a high emotional cost, resulting in a high rate of personnel burnout. Cynicism, scarce communica- tion with patients, avoidance and emotional attening are often psychological defence against distress. I suggest that doctorpatient communica- tion and relationship have a hidden biological dimension which can help to explain the burden of caring for severely ill persons, with its emotional and physical/psychosomatic costs. Studies sug- gested that distress of oncologists and psychoon- cologists after stressful communications with patient also appears in dream content (Costantini, 1998). Psychosomatic and neuroscience research strongly evidenced the biological correlates of aects and cognitive processes. This evidence can be applied to suggest a psychobiology of the doctorpatient communication: it ranges from brain neurotransmitter circuits (5HT, NA, GABA, DA), to psychoneuroendocrine (PNE) and autonomic nervous systems (ANS) modica- tions, and, at a nal level, to peripheral visceral and somatic responses which accompany arousing and distressing communications and interactions. Fear, anxiety and emotional arousal during communication involve limbic activation both for the patient and the doctor, with a role played by amygdala circuits, hypothalamicpituitary axes, and brainstem nuclei, while descending pathways nally result in peripheral somatic ANS and PNE stress responses. The simple registration of doctors electrodermal activity (such as skin conductance level and skin con- ductance responses) during communication shows its ANS correlates. Phases of distress}while discussing bad news or preoccupation for a cancer recurrence, issues of bad prognosis, complications of treatment, participating in episodes of patient despair and crying, all elicit signicant SCL changes in the therapist (personal observations). As brain imaging studies have shown, peripheral skin responses follow the activation of controlat- eral brain frontal circuits. The distress of dicult physician communication also displays moderate, transient heart rate increase, similarly related to emotional arousal and ANS central activation. Emotional stress results in several PNE changes, such as ACTH, cortisol, prolactin and catechola- mines transient increases. To my knowledge, there are few PNE studies about the doctorpatient relationship. However, we can hypothesize that relevant anxiety and distress interactions can elicit PNE activation while social support in an experi- mental frustrating situation can prevent stress and cortisol increases (Biondi et al., 1986). A recent brain imaging study shows specic circuits activa- tion while viewing the suering of ones own partner, suggesting a psychobiology of empathy and give us the evidence that emotional suering is also a biological, not only a psychological, matter. Caring for suering persons implies an inner suering of the caregiver, together with its psychobiological correlates. Courses in commu- nication skills, training and support personnel groups, can both improve caring skills and reduce the psychobiology of distress of therapists in oncology and psychooncology. 11 Seven Characters in Search of a Disease: The Social Construction of People with Cancer in the Mass Media Burfoot A Department of Sociology, Queens University, Kingston, ON, Canada This paper examines seven common and public manifestations of the cancer patient in popular Copyright # 2006 John Wiley & Sons, Ltd. Psycho-Oncology 15: S1S478 (2006) DOI: 10.1002/pon ABSTRACTS OF THE 8TH WORLD CONGRESS OF PSYCHO-ONCOLOGY S5
6. 6. culture: The tragic victim; the doomed patient with a cancer diagnosis; the courageous survivor; the infantilized breast cancer patient; the asexual cancer patient; the childless cancer patient; the miracle. This analysis is based on literature that cites popular culture and mass media as a place where meaning is both constructed and contested. In this paper, it is argued that cancer is much more than a medical diagnosis and that the disease is also culturally produced with serious psycho- social outcomes. With the public framing of the cancer patient in terms of the characterizations above, the person becomes identied as the disease and in ways that diminish the full human potential typically awarded to the healthy person or even people with other illnesses or injuries. The material examined comes from popular lms and television, as well as from cancer research fund- raising campaigns. 12 Journey in Cancer Experience: A Journalist Changes his Life Terzani Staude A Writer, Florence, Italy T.T., a journalist and acclaimed foreign corre- spondent, is diagnosed with cancer. His immediate reaction is to go to the best cancer center he knows in order to submit to the classical cure: chemo- therapy and radiotherapy. He is well taken care of, but when he is told to go back to his normal life he is puzzled: wasnt it precisely his normal life that made him ill? To this question his American doctors have no answer. But he knows that it is his depression in Japan in front of a horrifying society and a horrifying prospect of life for the whole of mankind that made him ill. Therefore, he certainly does not go back to his old life. Instead, he gives up his job as a journalist and withdraws to India and nally into the Himalayas. There, with the help of several teachers, and particularly one old man, he starts to reect upon the meaning of life and death. In the end he nds his answer and dies peacefully at his home in Italy, surrounded by his family, after having conded the lesson he learned to two books. One appeared in the last months of his life, the other is posthumous, both are now helping a huge number of readers to make sense of their own troubles and sorrows and to accept the fact that all of us have to face illness and death. 13 Communication Competency in Oncology: Legal, Ethical and Humanistic Imperatives Baile WF Professor and Chief, Section of Psychiatry, Uni- versity of Texas, M.D. Anderson Cancer Center, Houston, USA The relationship with the patient has been called the cornerstone of comprehensive cancer care. This phrase acknowledges that the clinician can inuence, through their interpersonal and com- munication skills, outcomes critical to the mission of cancer care. Legal, ethical and humanistic issues in the relationship with the patient transcend and augment the technical and medically-oriented care which every oncologist and oncology clinician is focused on: the ability to diagnosis the illness and apply appropriate biological anti-cancer interven- tions. However, this latter goal falls drastically short of the idea of comprehensive cancer care. Instead we can argue that issues related to informed consent, shared decision-making and other communication issues such as discussing prognosis and transitioning patients to palliative care have important medico-legal and ethical implications and obligations for the cancer care- giver. Moreover in this era when cancer has become a survivable disease patients desire a relationship with their caregivers that is empathic and provides support to them across the trajectory of the illness. Competency in communication has also been shown to lessen the likelihood of burnout acknowledging the benets of competent communication for clinician well-being. Despite these imperatives very few oncology trainees receive meaningful communication skills prepara- tion during their training or afterwards. This presentation will review the ethical legal and humanistic imperatives for communication com- petency among cancer caregivers, review several studies which show that communication skills can be taught and learned, discuss several psy- chodynamic principles which characterize the therapeutic aspects of the oncologistpatient relationship and identify barriers to teaching and learning communication skills. 14 Psychosocial Oncology: A Real Necessity? Cavalli F Copyright # 2006 John Wiley & Sons, Ltd. Psycho-Oncology 15: S1S478 (2006) DOI: 10.1002/pon ABSTRACTS OF THE 8TH WORLD CONGRESS OF PSYCHO-ONCOLOGYS6
7. 7. FRCP Director, Oncology Institute of Southern Switzerland (IOSI), President, International Union Against Cancer (UICC) There are dierent possibilities to demonstrate the necessity of psychosocial oncology. One might be the denition. If the only duty of health professionals is to carry out technical acts, then psycho-oncology might be regarded as somewhat of a luxury. Although this might be the opinion of some healthcare-managers, I believe that the majority of health professionals currently have a more holistic approach to disease, which includes also the necessity to help the patient solve his/her social, psychological, familial, etc. problems, in order to create the best conditions to fully allow the healing process. Another way of demonstrat- ing this necessity, is more empirical: if I consider, e.g. the weekly rounds of my in-patients wards, I must conclude that at least in 3040% of the cases I will encourage my co-workers either to seek help by a psycho-oncologist or at least to discuss the case within a psycho-social discussion group. But is that just something which might be helpful in the auent world? My 20 years experience with all developing projects in paediatric oncology in Managua, Nicaragua tells me that psycho-oncol- ogy was one of the most important elements which led to the success of the sustainability of this endeavour: this will be discussed in detail. Psycho- Oncology or psychosocial Oncology are a key element in the process of humanisation of cancer: i.e. to allow patients to cope in a human way with this disease, which represents always an existent deadly danger. As such, psycho-oncology is a corner stone of palliative care which inturn presents an absolute necessity for a modern approach to cancer. Since cancer is a global problem, the UICC-policy concerning psycho- oncology and particularly palliative care will be presented in detail. 15 Psychological and Ethical Implications of Medical Errors Surbone A European School of Oncology, Milan, Italy; Department of Medicine, New York University, New York, USA While many aspects of patient safety are common across diseases, errors and adverse events have important specialty-specic dimensions. Special issues arise related to errors in clinical oncology such as the severity, pain and uncertainty of the cancer patients condition; the tension inherent in patientdoctor communication about cancer; the complexity of cancer diagnosis and treatment; and the toxicity of many cancer therapies, coupled with the prominent role of experimental treat- ments. By understanding the problem of medical errors within their specic context, specialty societies can contribute to change the culture of medicine and to develop eective strategies for reducing medical errors (e.g. by improvement of communication with patients and proper counsel- ling for patients, family and physicians involved in medical errors). Psycho-oncology may act as the fundamental liaison between patients and physi- cians when an error has occurred and the tendency is to avoid any confrontation or to resort to legal measures. Silence in particular spoils the trust necessary to the patientdoctor relationship and it negatively aects the physicians inner life and moral integrity and the psycho-oncologist may greatly contribute to the process of healing and repair. After reviewing the ongoing empirical research on patients and doctors attitudes regarding error disclosure, I will present excerpts from patient and doctors narratives, with special focus on the emotional reactions of physicians to errors that they have committed or observed. I will conclude with an analysis of the ethical implica- tions of medical errors in oncology, including team errors, errors in clinical trials, improper communication and individual and institutional arrogance. 16 E-learning: the On-line IPOS/ESO Multilingual Core Curriculum on Psychosocial Aspects of Cancer Care Grassi La , Johansen Cb a Section of Psychiatry, Department of Medical Sciences of Behaviour and Communication, Uni- versity of Ferrara, Italy; b Institute of Cancer Epidemiology, The Danish Cancer Society, Copen- hagen, Denmark In 2004 the International Psycho-Oncology So- ciety (IPOS) in cooperation with the European Society of Medical Oncology (ESO), developed a multilingual core-curriculum on Psychosocial Aspects of Cancer Care to be delivered on line. The core-curriculum consists of 10 presentations (of which 5 are available at the moment) aimed at Copyright # 2006 John Wiley & Sons, Ltd. Psycho-Oncology 15: S1S478 (2006) DOI: 10.1002/pon ABSTRACTS OF THE 8TH WORLD CONGRESS OF PSYCHO-ONCOLOGY S7
8. 8. sensitizing and updating oncologists, GPs, nurses and health professionals in cancer care on the main psychosocial oncology issues. Each presen- tation was prepared in English and then translated and adapted into French, German, Hungarian, Italian, and Spanish. Key thought leaders and experts in the eld were contacted to devise one- hour lectures on ve important subjects: Commu- nication Skill in Cancer Care, Distress Manage- ment, Anxiety and Adjustment Disorders, Depression and depressive disorders, and Psycho- social Assessment. The translations, in each instance, have been modied to be culturally specic. An evaluation form accompanies each lecture in order to have a feedback on the quality, characteristics and learning objective of each lecture. Some strength points of the lecture are the internal structure and rationale, its specicity of being multilingual (with possible more transla- tion), the evaluation form (with possible feedback for the improvement of the lecture) and the easy process of updating (peculiar elements in compar- ison with similar program in English taken from congresses or seminars). 789 people completed the evaluations by June 2006, with 222 regarding Communication, 161 regarding Anxiety, 151 regarding Distress, 149 regarding Depression and 106 regarding Psychosocial Assessment. The analysis of data showed that the lecture were considered generally good with indications of usefulness in clinical terms. 17 Education and Training in Psycho-Oncology: the Creation of the Psycho-Oncologist Kissane D Alfred P. Sloan Chair, Chairman, Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center Department of Psychiatry, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, USA New specialties mature through the establishment of dedicated training programs, not only teaching an agreed curriculum, but assessing and certifying clinical competence. Fellowship programs in Psychosomatic Medicine, Consultation-Liaison Psychiatry or Post-doctoral Research Fellowships are examples. Some universities have established Diploma/Masters Programs in Psycho-Oncology. Competencies include knowledge, skills and atti- tudes, but also the ability to problem-solve and think critically, work in a team, conduct research and continue learning. Graduates need to be able to conduct comprehensive psychiatric evaluations and both diagnose and treat eectively, including cancer-site and treatment-specic problems. Psy- chotherapy needs to be delivered to individuals, couples, groups and families and draw from the full range of therapy models, complemented by psychopharmacology. The liaison role invites support of sta and community education. Curri- cula are enriched by the Humanities, while the nurturance of a reective style promotes quality assurance and life-long learning. Supervision is vital in developing psychotherapy skills; peer- group supervision is a hallmark of maturity. Communication skills training focusing on the clinicianpatient encounter becomes a prime method for the psycho-oncologist to optimize psychosocial care by their whole treatment team. A basic curriculum covers breaking bad news, discussing prognosis, responding to distress, shared treatment decision-making, transition to palliative care and preparation for death and dying. Attendance at multi-disciplinary meetings within their oncology service provides opportu- nities for continued education. Finally, research is the source of new knowledge and rened treat- ments. Future psycho-oncologists need excellent scholarship to expand the evidence-base of the discipline and inform teaching and training of the next generation. 18 Psychosocial Aspects in Global Cancer Control: A WHO Perspective Sepulveda C WHO Cancer Control Programme The number of people living with cancer is increasing worldwide, and represents a tremen- dous burden on patients, families and societies. The World Health Organization estimates that 84 million people will die in the next 10 years if action is not taken. Cancer does not only have a physical impact on those aected by cancer, but also has a psychosocial impact on patients, family members and care givers. Hence the need to address the psychosocial aspect of the disease, which is often neglected. WHOs cancer prevention and control policy emphasizes the need for providing routine psychosocial services for cancer patients, family members and health care providers when neces- sary. These services include the assessment of patients for anxiety and depression; support to Copyright # 2006 John Wiley & Sons, Ltd. Psycho-Oncology 15: S1S478 (2006) DOI: 10.1002/pon ABSTRACTS OF THE 8TH WORLD CONGRESS OF PSYCHO-ONCOLOGYS8
9. 9. help patients adhere to treatment plans; skill building for coping with cancer; information and basic emotional support to patients and families; and continuous training and support to health care providers and family care givers. WHO strongly supports self-care and home-care pro- vided by trained family care givers, to ensure wide coverage of supportive care and end-of-life care including psychosocial support particularly in low-resource settings where health professionals are very scarce. A resolution on cancer prevention and control was adopted by the World Health Assembly in May 2005 which focuses particularly on the development of comprehensive cancer control programmes. The cancer resolution is the reection of the strong support from governments to intensify action against cancer and provides new opportunities to foster policies and pro- grammes, which include the psychosocial aspects. 19 From Cancer Patient to Cancer Survivor: Advo- cacy, Action, Access and Accountability: Using Public Policy to Advance the Delivery of Quality Cancer Care Stovall E President & CEO, National Coalition for Cancer Survivorship, USA The advocacy continuum begins with self-advo- cacy and progresses to a level of empowerment that allows individuals to advocate for many others. This presentation highlights how one national survivor-led nonprot cancer advocacy organization is inuencing nationwide policy changes to advance the delivery of quality, comprehensive cancer care. NCCS describes com- prehensive care to include the integration of psychosocial services and palliative care from diagnosis and for the remainder of life. 20 The Wellness Community Twenty-ve Years Later: The Role of Community-based Organizations in Psychosocial Oncology Thiboldeaux K President & CEO, The Wellness Community, Washington, DC, USA The Wellness Community (TWC) is an interna- tional non-prot organization dedicated to pro- viding support, education and hope for people with cancer and their loved ones. TWCs program is based on the Patient Active Concept, where people with cancer are empowered to make active choices throughout the continuum of the cancer experience and reduce the three most signicant psychosocial stressors that people with cancer face}loss of control, loss of hope and unwanted aloneness. The Wellness Community has 21 centers in the United States, two centers abroad in Tel Aviv and Tokyo, The Virtual Wellness Community on the Internet at www.thewellness- community.org and ve new centers in develop- ment. TWC reaches more than 150 000 people aected by cancer each year. Celebrating its 25th anniversary in 2007, The Wellness Community has established a unique community-based cancer support model grounded in evidence-based psy- chosocial oncology. TWC oers a wide range of direct services to cancer patients including support groups, educational seminars, nutrition programs, exercise and stress reduction. In addition, the organization participates in and conducts peer- reviewed research with academic, government and non-prot partners and serves as a seamless delivery mechanism for the positive ndings of such research. This blend of ongoing research and direct community-based services makes TWC a distinctive model in the eld of psychosocial oncology and underscores the importance of community-based organizations in the continuum of cancer care. 21 Joining Voices for Best Cancer Care: The Role of Patients Associations Faulds Wood L President European Cancer Patient Coalition, Twickenham, UK How do patients in your countries feel after a diagnosis of cancer? Is the emotional impact of cancer harder to cope with than the physical or practical aspects of the disease? A recent UK report (2006 Macmillan Cancer Support) found 6 in 10 people with cancer felt their emotional needs suered in comparison to their physical and practical needs. Four in ten said they were unable to get information, advice or support for the emotional aspects. Reports across Europe reect the same lack of awareness of and emphasis on patients emotional needs. The European Cancer Patient Coalition, launched in 2003, is an umbrella organisation for European cancer patient organi- Copyright # 2006 John Wiley & Sons, Ltd. Psycho-Oncology 15: S1S478 (2006) DOI: 10.1002/pon ABSTRACTS OF THE 8TH WORLD CONGRESS OF PSYCHO-ONCOLOGY S9
10. 10. sations, with over 200 member groups represent- ing the major and rarer cancers. With our slogan Nothing About Us Without Us!, ECPC aims to be the unique voice of European cancer patients. Surveys of our members have revealed the lack of good information available to patients. Care and quality of life is an important focus for ECPC and we hold annual Masterclasses/Summits bringing together hundreds of patients groups to campaign for better treatment. We see National Cancer Plans as a key target to encourage more emphasis on quality of life as cancer increasingly becomes a chronic rather than a lethal condition. We are promoting the French Cancer Plan, with its emphasis on psychological aspects and encourag- ing national health ministries to include psycho- logical assistance with example of patient lobbying as a powerful tool. 22 Life After Prostate Cancer: What To Tell Couples about Sex and Intimacy Lyon Howe D, Howe D American Medical Systems, MD Anderson Cancer Center Board, Houston, USA; American Porphyria Foundation, USA Prostate Cancer is the most prevalent cancer in men in the United States, with 235 000 men being diagnosed this year. The primary detection vehicle is the PSA test, which remains controversial in providing a guideline for treatment pending more data. Plus, the optimum treatment for a given diagnosis has not been clearly dened. Thus, men face more complex treatment decisions than people diagnosed with other types of cancer. Also, the fear of having the potential side eects, namely, urinary incontinence (UI) and erectile dysfunction (ED), often leads men to avoid having PSA tests or making timely treatment decisions. Most men are often hesitant to openly discuss these two side eects, even with their own partners or physicians. Since many physicians are equally uncertain as to the most recent treatments for these side eects or may also be uncomfortable discussing the subject, many men are left unaware of available treatments or remain under-treated for ED and UI. The partners are also greatly aected by these side eects, particularly ED. Often a conspiracy of silence results because couples do not have the comfort level or skills to broach this issue. Their relationships may become strained and their physical intimacy further jeopardized, which aects their overall sexual function. In this discussion, we will review the side eects of prostate cancer treatment and the common problems in communication between couples aected by this problem. We will discuss up-to-date treatments, including medication, mechanical devices and alternative techniques for enhancing psychological and sexual intimacy. 23 Depression and Pain: Coincidence or Connection? Demyttenaere K Department of Psychiatry, University Hospital Gasthuisberg, Belgium There is a growing interest in better dening the role of chronic painful physical symptoms in major depressive disorder. The presentation will rst focus on the available epidemiological evi- dence for a close link between painful physical and depressive symptoms. Depressive symptoms are predictive for the development of painful physical symptoms and vice versa. Moreover, both add independently to the work loss days. However, the presence of somatic disorders (e.g. cancer) and of painful physical symptoms results in poorer recognition rates of depression. There are multiple models for understanding the relationship between painful physical and depressive symptoms with pathophysiological and psychopathological me- chanisms. Painful physical symptoms do predict a higher severity of depression and a poorer outcome. Both serotonin and epinephrine play a role in pain perception and this could explain the higher ecacy of dual acting agents in the treatment of painful physical symptoms in depressed as well as in non-depressed patients. ACKNOWLEDGEMENTS: This Meeting of the expert session has been supported by Eli-Lilly and Boehringer-Ingelheim. 24 Psychosocial Oncology in China: Present Status and Future Directions. Challenges and Opportu- nities Zhang ZWa , Tang Lb , Grout Jc , Bultz Bc a Secretary-General of Chinese Anti-Cancer Asso- ciation (CACA), Beijing, China; b Department of Psycho-Oncology, Beijing Cancer Hospital, Beijing, China; c Department of Psychosocial Re- sources, Tom Baker Cancer Centre, and Faculty of Medicine, University of Calgary, Calgary, Canada Copyright # 2006 John Wiley & Sons, Ltd. Psycho-Oncology 15: S1S478 (2006) DOI: 10.1002/pon ABSTRACTS OF THE 8TH WORLD CONGRESS OF PSYCHO-ONCOLOGYS10
11. 11. PURPOSE: To enhance awareness of the current status of psychosocial oncology in China with attention to its unique cultural concerns, obsta- cles, and opportunities. METHOD: A selected literature review of academic papers in Chinese and English language journals and web sites was analyzed for the current status, challenges, and opportunities for psychosocial oncology in China. RESULTS: Chinas enormous population (1.3 billion), its booming economy, trends to urbaniza- tion, improved standard of living, increased life- span and one child policy has increased the focus on public health. In this regard, cancer has become Chinas most important public health concern. Chinas national cancer strategy (2004 2010), based on WHO guidelines, focuses on cancer prevention and treatment, as well as quality of life among cancer patients and their families. The Chinese Anti-Cancer Society is now funding research, training an international collaboration in psychosocial oncology. The newly organized Chinese Psychosocial Oncology Society aims to provide a national forum for psychosocial oncol- ogy research Cultural and systemic challenges to establishing psychosocial oncology as a core discipline in China include: (1) the familys desire to protect cancer patients by withholding cancer- related information; (2) stigma and privacy regarding mental health issues; (3) biomedical practitioners claims that psychosocial oncology is not suciently evidence-based; and (4) limited funding for psychosocial oncology care and research. CONCLUSION: In China, psychosocial oncology has emerged as a new program over the past decade. IPOS is considered a valuable resource towards Chinas interest in partnering with the international psychosocial oncology community to enhance the discipline globally. 25 Partners in Survival: Men Helping to Improve Survivorship for Minority Women Loscalzo Ma , Zabora JRb , Heyison Mc , Crews Cd a University of California-San Diego, CA, USA; b Dean, National Catholic School of Social Service, The Catholic University of America, Washington, DC, USA; c Men Against Breast Cancer, Adams- town, MD, USA; d Eastern Virginia Medical School, Norfolk, VA, USA A number of studies have found a lack of information and targeted educational materials that engage minority women during their survi- vorship of cancer. Unmet needs in the areas of socioeconomic, cultural, and language continue to persist. Minority women are at particular risk because of a lack of access to overall health care overall, and to any types of health promotion and prevention programs. Committed spouses, part- ners, fathers, brothers, sons, and close friends comprise the vast majority of relationships that women with cancer share with men. Almost all women have men in their lives on whom they expect varying degrees of support. Men are excellent problem-solvers, and are most comfor- table undertaking clearly dened activities in which they see a positive outcome. Men Against Breast Cancer (MABC) has partnered with lead- ing survivorship experts from Johns Hopkins University, University of California-San Diego, and Catholic University to develop a health program which addresses this lack of psychosocial support and quality care for underserved survivor populations. The Partners in Survival program utilizes problem-solving education which has been proven to reduce depression, stress, and to improve the overall mental health of the survivor. 26 Psycho-oncology Development Nationwide: A Japanese Perspective Uchitomi Y Psycho-oncology Division, Research Center for Innovative Oncology, National Cancer Center Hospital East, Kashiwa, Japan With encouragement from the IPOS, the Japan Psycho-Oncology Society (JPOS) was established in 1986. Dr Hiroomi Kawano, a founding President, enlightened the importance of psycho- spiritual care for cancer patients, incorporating palliative care. In 1990s, the move towards truth- telling in cancer care was advancing slowly in Japan. But a dramatic increase of truth-telling practice in cancer care resulted from strict regula- tion of hospital stay in 2000s. There is an emergent need to establish psycho-oncology service with the aim of ameliorating psychological distress after cancer disclosure and supporting communication between medical professionals and cancer patients and their families. Our Psycho-Oncology Division, established in 1995 under auspice of the Japanese Ministry of Health and Welfare (JMHW), and the JPOS have been providing psycho-oncology post-graduate residency program and workshops. The JMHW has supported several nationwide Copyright # 2006 John Wiley & Sons, Ltd. Psycho-Oncology 15: S1S478 (2006) DOI: 10.1002/pon ABSTRACTS OF THE 8TH WORLD CONGRESS OF PSYCHO-ONCOLOGY S11
12. 12. palliative and psycho-oncology research groups; one by a Grant for Second-Term Comprehensive 10-Year Strategy for Cancer Control, focusing on management of distress, especially depression after cancer disclosure since 1994. The research opens new avenues for communication, psycho- biology and neuro-imaging research in the eld of psycho-oncology in Japan. The Law on Measures for Cancer will come into operation in April 2007. The 30 Cancer Centers and 135 aliated hospitals in Japan are expected to have a palliative care team including psycho-oncologist as an essential member. The team were also to provide training program of psycho-oncology with supportive and end-of-life care in the community, in cooperation with medical schools where such training in clinical oncology has not yet been established. Intersociety Symposium: American Psychosomatic Society (APS)}Biobehavioral Oncology: IPOS- American Psychosomatic Medicine Inter-Society Exchange 27 Cognitive Behavioral Stress Management Facil- itates Adaptation During Breast Cancer Treatment: Examining Biobehavioral Mechanisms Antoni Ma , Carver Ca , Lechner Sb , Blomberg Bc a Psychology University of Miami, Coral Gables, FL, USA; b Psychiatry University of Miami, Miller School of Medicine, Miami, FL, USA; c Microbiol- ogy/Immunology, University of Miami, Miller School of Medicine, Miami, FL, USA PURPOSE: We developed a Cognitive Behavioral Stress Management (CBSM) intervention based on a biobehavioral model of adaptation to cancer treatment. We tested eects of CBSM on multiple indicators of adaptation, and neuroendocrine and immunological functioning in women being treated for early-stage breast cancer. METHODS: In two randomized clinical trials (Study 1, N 99; Study 2, N 199), women with Stage 13 disease were randomized 28 weeks after surgery to either a 10-week CBSM group or a one-day informa- tional seminar and followed up to 15 months to test whether CBSM can facilitate adaptation and biological indices after adjuvant therapy. CBSM provides training in relaxation, coping skills, and other stress management techniques, in a suppor- tive group. RESULTS: CBSM improved adapta- tion as indicated by decreased depression, negative aect, intrusive thoughts and interviewer-rated anxiety symptoms; and increased optimism, ben- et nding, positive aect, and improved physical quality of life (ps 50.050.001). Latent Growth Modeling analyses demonstrated that increases in emotional processing and perceived relaxation skills during the intervention explained its eects on adaptation. CBSM participants also showed decreased evening serum cortisol levels, and increased lymphocyte proliferation and Th1 cyto- kine production, ps 50.05). Women show- ing larger improvement in psychological adapta- tion during CBSM revealed greater changes in endocrine and immunologic functioning. CONCLUSIONS: Future work examines whether CBSM-related changes in biobehavioral factors can explain its eects on longer-term quality of life and health outcomes in these women. ACKNOWLEDGEMENTS: This work was sup- ported by grants from the National Cancer Institute. 28 Randomized Trial of Yoga in Women with Breast Cancer Undergoing Radiation Treatment Cohen La , Chandwani Kb , Thornton Ba , Perkins Ga , Rivera Ea a Department of Palliative Care & Rehabilitation Medicine, MD Anderson Cancer Center, Houston, TX, USA; b Swami Vivekananda Yoga Anusandha- na Samsthana, Bangalore, India PURPOSE: We tested a yoga program for breast cancer patients undergoing radiotherapy. METH- ODS: Sixty-one women with breast cancer were randomly assigned to either a yoga program or to a waitlist group. Bi-weekly classes were taught during the 6 weeks of radiotherapy. Patients completed measures of intrusive thoughts and avoidance behaviors, depression, sleep, fatigue, and QOL at baseline, and 1, 4, and 12 weeks after the last treatment. Women also collected saliva samples 5 times/day for 3 days to measure cortisol and blood samples were obtained to assess immune function at baseline and 1 week after the last radiotherapy. We report on the 1-week assessment point. Immune assays are still pending. RESULTS: ANCOVA revealed that the yoga group had signicantly better physical functioning (means adjusted for baseline: yoga 81.8; control 68.6, P50:01), signicantly higher general health (yoga 78.3; control 67.9, P50:03), marginally better social functioning (yoga 85.3; control 76.0, P 0:1), signicantly lower levels of sleep-related Copyright # 2006 John Wiley & Sons, Ltd. Psycho-Oncology 15: S1S478 (2006) DOI: 10.1002/pon ABSTRACTS OF THE 8TH WORLD CONGRESS OF PSYCHO-ONCOLOGYS12
13. 13. daytime dysfunction (yoga 0.5; control 1.2, P50:04), and marginally lower levels of fatigue (yoga 1.9; control 3.1, P50:06). Slope analyses of cortisol revealed no group dierences. There was a positive correlation between cortisol slope and sleep-related daytime dysfunction (P 0:02) and fatigue (P 0:1), and a negative correlation between cortisol slope and social functioning (P 0:08). As sleep-related daytime dysfunction and fatigue increased cortisol slope was less steep, and as social functioning increased cortisol slope was steeper. CONCLUSIONS: The yoga program was associated with statistically and clinical signicant improvements in aspects of QOL. 29 Extending Psychoneuroimmunology To The Tumor Microenvironment Lutgendorf Sa , Sood Ab , DeGeest Kc , Anderson Bc , Penedo Fd a Psychology University of Iowa, Iowa City, IA, USA; b Gynecologic Oncology, MD Anderson Cancer Center Houston, TX, USA; c Gynecologic Oncology, University of Iowa, Iowa City, IA, USA; d Psychology University of Miami Coral Gables, FL, USA PURPOSE: Our ongoing work addresses links between psychosocial factors, cellular immunity, and tumor progression in peripheral blood and in the tumor microenvironment of ovarian cancer patients. METHODS: Patients awaiting surgery for suspected ovarian cancer completed psycholo- gical measures and gave pre-surgical peripheral blood (PBL). Samples of tumor and ascites were taken during surgery. We examined relationships among social support, distress, and natural killer cell activity (NKCC), TH1, TH2, TC1, and TC2 lymphocytes isolated from 3 compartments (PBL, ascites, and tumor [TIL]). Unstimulated, tumor- stimulated, and PMA/Ionomycin stimulated In- terferon-? and interleukin-4 producing T cell populations were determined by intracellular stain. Production of the angiogenic cytokines interleukin-6 (IL-6), interleukin-8 (IL-8) and vascular endothelial growth factor (VEGF) was also examined. RESULTS: Social support was related to signicantly higher NKCC in PBL and in TIL, adjusting for stage (p50:05) whereas distress was related to lower NKCC in TIL (p 0:018). Multivariate modeling indicated independent contributions of distress and social support to NKCC in TIL (p values 50.02). Greater distress was also related to lower PMA/I stimulated TH1/TH2 ratios across all 3 compartments. Greater distress was related to elevated peripheral IL-8 and VEGF (ps 50.05) whereas higher levels of perceived stress were related to elevations of IL-8 and IL-6 in ascites. CONCLUSIONS: These ndings demonstrate psychosocialimmune relationships in the tumor microenvironment and suggest that psychosocial factors may play a role in impaired host resistance to ovarian carcinoma. ACKNOWLEDGEMENTS: Grants # 1R21 CA88293-01 and #RO1-CA1045-25-01 to Susan Lutgendorf from the National Cancer Institute. 30 Psychosocial Correlates Of Natural Killer Cell Cytotoxicity (NKCC) In Men Treated For Early Stage Prostate Cancer (CaP) Penedo Fa,b , Siegel Sa , Kinsinger Da , Traeger La , Rasheed Ma a Psychology, University of Miami, Coral Gables, Florida, USA; b Biobehavioral Oncology & Cancer Control, Sylvester Comprehensive Cancer Center, Miami, FL, USA PURPOSE: NKCC is associated with disease severity and progression, presence of tumor cells in circulation and tumor response to treatment in CaP. Studies have documented associations among psychosocial factors (e.g. distress) and NKCC across various cancer populations, but not in men treated for CaP. This was the focus of the present study. METHODS: Participants (N 190) were men treated (i.e. radical prosta- tectomy or radiation) for stage I/II Cap, with no history of other cancer and older than 50 years. All participants completed a psychosocial battery that included measures of distress, depression, social support, sociability and quality of life (QoL) using the POMS, BDI, ESSI, IIP and FACT-P, respectively. Peripheral morning blood was col- lected via venipuncture. NKCC (CD56+CD3) was assessed using a 51Cr release assay in triplicate at 4:1 eector-to-target cell ratio. RE- SULTS: The average age of participants was 64 years. (SD 7:4), 77% were married. Men had been diagnosed and treated for CaP 15.1 (SD 4:6) and 10.1 (SD 7:1) months, respec- tively. Greater levels of social support, optimism, sociability and QoL were signicantly associated with greater NKCC (all rs>0.17, ps50.05). Greater levels of distress, depression and anxiety Copyright # 2006 John Wiley & Sons, Ltd. Psycho-Oncology 15: S1S478 (2006) DOI: 10.1002/pon ABSTRACTS OF THE 8TH WORLD CONGRESS OF PSYCHO-ONCOLOGY S13
14. 14. were signicantly associated with lower NKCC (all rs>0.18, ps50.05). CONCLUSIONS: Several modiable psychosocial factors are asso- ciated with a marker of immunocompetence in CaP. Future work should assess the ecacy of psychosocial interventions in modifying these factors and possible immune and physical health benets of such changes. 31 Coping with Lung Cancer: Biological Pathways and Quality of Life Sephton Sa,b , Weissbecker Ia a Department of Psychological and Brain Sciences, University of Louisville, Louisville, KY, USA; b James Graham Brown Cancer Center, University of Louisville, Louisville, KY, USA PURPOSE: Lung cancer patients often experience a loss of physical function and quality of life (QOL) related to rapid disease progression. Shapiro (1994) identied two dimensions of the coping response to such losses: positive versus negative, and assertive versus yielding. Studies suggest cancer patients who balance positive yielding (e.g. acceptance) and positive assertive (e.g. active) coping eorts experience better QOL. We investigated potential endocrine and immune pathways by which coping may be related to lung cancer outcomes. METHODS: Non-small cell lung cancer patients (n 56) provided self-reports of coping, functional status, and quality of life. Overnight urinary catecholamines, diurnal sali- vary cortisol, and pro-inammatory cytokine levels were assessed. Bivariate correlations identi- ed relevant medical and demographic control variables. Subsequent hierarchical regressions examined relationships between variables of inter- est. RESULTS: Active coping was signicantly associated with functional well-being and lower endocrine activation. Acceptance predicted lower proinammatory cytokines. Cortisol elevation was related to poor functional well-being and overall QOL. The eect of active coping on functional well-being was reduced (beta 0.389 versus 0.297) and lost signicance when cortisol was entered (Baron and Kenny, 1986; Holmbeck, 1997). CONCLUSIONS: Results demonstrate interrela- tionships between coping, endocrine and immune function and quality of life. The cross-sectional design and multicollinearity issues preclude direc- tional conclusions. However, these data suggest future longitudinal research should examine glucocorticoids and inammatory mediators as potential biological pathways by which coping might aect lung cancer outcomes. ACKNOWLEDGEMENTS: This research was supported by the Kentucky Lung Cancer Re- search Board. Intersociety Symposium: European Association of Consultation Liaison Psychiatry and Psycho- somatics (EACLPP)}Randomised controlled trials of psychotherapeutic interventions in cancer patients 32 A Brief Psychological Intervention to Prevent Aective Disorders in Cancer Patients}Methodo- logical Considerations and Overview of Results Pitceathly Ca , Maguire Pa , Fletcher Ia , Parle Ma , Creed Fb a CRC Psychological Medicine Group, University of Manchester, Manchester, UK; b Division of Psy- chiatry, University of Manchester, Manchester, UK A brief psychological intervention to prevent aective disorders in cancer patients}methodo- logical considerations and overview of results. PURPOSE: Aective disorders are common in the year following a diagnosis of cancer. We tested whether a 3-session, concerns focused interven- tion based on cognitive-behavioural principles could prevent these disorders developing amongst newly diagnosed cancer patients. METHOD: Patients beginning cancer treatment who did not have an aective disorder were randomised to receive immediate intervention (at the start of their treatment), delayed intervention (8 weeks after starting treatment) or usual care. The groups were stratied according to patients risk of developing aective disorders (high risk was poor coping or previous psychiatric history). Assess- ments were completed 2, 4, 6 and 12 months after recruitment. Primary outcome was any aective disorder in the year following the cancer diagnosis measured by standardised psychiatric interview (SCID). Secondary outcomes were a checklist of Concerns and the Hospital Anxiety and Depres- sion Scale (HADS). Data were analysed using ANCOVA and conditional odds logistic regres- sion models. RESULTS: 465 patients were recruited. 313 (79%) of the 397 well enough to be interviewed completed the study. During the 12-month study period signicantly fewer high- risk patients who received intervention developed Copyright # 2006 John Wiley & Sons, Ltd. Psycho-Oncology 15: S1S478 (2006) DOI: 10.1002/pon ABSTRACTS OF THE 8TH WORLD CONGRESS OF PSYCHO-ONCOLOGYS14
15. 15. aective disorders compared to those who re- ceived usual care (OR 0:29; 95% CI: 0.100.91 p 0:034). At the 4-month assessment, HADS and Concerns scores were signicantly lower amongst high-risk patients who had received intervention (p50.05). CONCLUSION: A brief intervention, delivered by non-specialists, pro- moted adjustment amongst newly diagnosed cancer patients at high risk of developing aective disorders. There were no benets for low-risk patients. 33 Expressive-supportive Group Psychotherapy vs Sports Therapy in Breast Cancer Patients}Feasi- bility and Preliminary Results of a 3-armed RCT Maislinger Sa , Drobil-Unterberger Aa , Essmann Ia , Lukas Pb , Ninkovic Mc , So llner Wd a Department of Medical Psychology & Psychother- apy, b Radiooncology, and c Surgery, Medical Uni- versity Innsbruck; d Department of Psychosomatics, General Hospital, Nuremberg, Germany INTRODUCTION: 2040% of breast cancer patients suer from anxiety, depression, body image disturbances, and marital problems. Previous research shows that psychotherapy as well as sports therapy may lead to better quality of life in these patients. However, in most studies eect sizes are low. It is unknown which patients gain more prot from psychotherapy or sports therapy. METHODS: Within the framework of a RCT, 12-session group psychotherapy was com- pared to sports therapy and to a control group receiving standard treatment. We used standar- dised instruments measuring psychological symp- toms (HADS), QoL (FACT), and adaptation to illness (MAC) at the beginning and at the end of the intervention and after 1 year. RESULTS: From 313 eligible consecutive patients undergoing radiotherapy 55 took part in the RCT (17.6%). Main reasons not to participate were no distress, sucient support from family, wish to dissociate from hospital, wish to go back to work and no interest in participation in a group. We included 20 patients in the psychotherapy group, 15 in the sports therapy group, and 20 in the control group by now. Numbers of drop outs were 3 patients in the sports therapy group and 2 in the control group. Compared to controls, reduction of anxiety could be shown in both intervention groups at 1-year follow-up (F 4:11; P 0:026; ESpsth 0:46; ESsport 0:13). CONCLUSION: Participa- tion in the RCT in consecutive patients during oncological treatment was low. Further trials should include only patients with higher levels of distress and use a stepped-care approach including individual psychotherapy. 34 Preventing Aective Disorders in Partners of Depressed Cancer Patients: A Randomised Con- trolled Intervention Study Pitceathly Ca , Fletcher Ib , Creed Fc a Maguire Communication Skills Training Unit, Christie Hospital, Manchester, UK; b Division of Clinical Psychology, University of Liverpool, Liver- pool, UK; c Department of Psychiatry, University of Manchester, Manchester, UK PURPOSE: To evaluate a brief psychological intervention to prevent aective disorders amongst partners of depressed cancer patients. METHODS: Partners of patients diagnosed with an aective disorder as well as cancer were randomised to receive one-to-one psychological intervention or usual care. The six-session inter- vention was based on cognitivebehavioural methods and delivered by a social worker or psychiatric registrar. Study arms were stratied for partners risk of developing an aective disorder (high or low), gender and social class. Assessments were completed at recruitment; 6 months and 12 months later. Primary outcome was measured using a standardised psychiatric interview (SCID) to detect cases of aective disorder that developed during the study. Second- ary outcome measures were a checklist of Partners Concerns and the General Health Questionnaire (GHQ). Data were analysed using ANCOVA and conditional odds logistic regres- sion models. RESULTS: 323 partners were recruited, 232 (72%) were male. 241 (75%) partners completed the study. 132 (81%) of the 163 partners randomised to intervention attended at least one session. 57 partners were diagnosed with aective disorders at recruitment. 42 partners developed disorders during the 12-month study period. Partners in the intervention arm recorded lower concerns scores (p50.07) at the 6-month assessment than partners who received usual care. CONCLUSIONS: Psychological morbidity is high amongst partners of depressed cancer patients. The intervention is acceptable to partners and appears to accelerate a reduction in partners concerns levels. The presentation will discuss the Copyright # 2006 John Wiley & Sons, Ltd. Psycho-Oncology 15: S1S478 (2006) DOI: 10.1002/pon ABSTRACTS OF THE 8TH WORLD CONGRESS OF PSYCHO-ONCOLOGY S15
16. 16. challenges in delivering a preventative intervention to this group of careers. ACKNOWLEDGEMENTS: This work was funded by Cancer Research UK. 35 Development of a Method Investigating Meaning in Life in Cancer Patients Stagno Da , Krenz Sa , Zdrojewski Ca , Luthi Fb , Leyvraz Sb , Stiefel Fa a Service de Psychiatrie de Liaison, Departement Universitaire de Psychiatrie Adulte, CHUV, Lausanne, Switzerland; b Centre Pluridisciplinaire dOncologie, CHUV, Lausanne, Switzerland Meaning in life is an important source of adaptation to somatic diseases. AIM OF THE STUDY: The goal of this study is to validate the Schedule for the Meaning in Life Evalua- tion (SMiLE), a qualitative and quantitative instrument evaluating the meaning in life per- ceived by patients suering from advanced cancers. The rst step of this project is to develop and evaluate psychotherapeutic interventions centered on the meaning in life. METHODS: Cancer out patients in a palliative phase of disease were approached and possibly included. The SMiLE is an instrument, which helps patients to identify a maximum of seven elds which pro- duces or could produce meaning in life. The relative importance of each eld is weightened by means of a visual scale. The overall meaning in life is scored by a visual analogue scale (VAS) ranging from 3 to 3. Patients are then asked to rate their satisfaction for each eld and to dene its importance on VAS ranging from 0 to 5. Face validity, feasibility and acceptability is also evaluated by VAS. Reliability has been assessed by test/retest at a three days interval in a sample of medical students. External validity will be evaluated by means of a comparison with the under-scale MEANING of the question- naire Functional Assessment of Chronic Illness Therapy (FACIT-Sp) and a VAS measuring the perception of the total meaning given in life. With the index of Karnofsky, VAS of physical symptoms and the Edmonton Symptom Assess- ment Scale (ESAS) potential sources of con- founding variables are identied. Generalisation, comparison with a healthy population and cross- cultural dierences will be evaluated by means of research centres (Lausanne, Munich, Dublin). RESULTS: After 4 months of study, 35 patients are included in the study. So far, results indicate satisfying face validity, feasibility and accepta- bility. The study will be completed before June 2006. CONCLUSIONS: Preliminary results indi- cate that the SMiLE is an adequate instrument to identify and evaluate elds that produce or could produce meaning in life in patients with advanced cancer. 36 Depression Among Cancer Patients: A Randomised Controlled Trial Comparing Standard Care With a Short Psychodynamic Psychotherapy Stiefel Fa , Krenz Sa , Zdrojewski Ca , Luthi Fb , Leyvraz Sb , Stagno Da a Service de Psychiatrie de Liaison, Departe- ment Universitaire de Psychiatrie Adulte, CHUV, Lausanne, Switzerland; b Centre Pluridisciplinaire dOncologie, CHUV, Lausanne, Switzerland About 40% of the cancer patients suer from depressive disorders which are seldom identied and even more rarely treated. Depression leads to a reduction in quality of life, diminished medical treatment compliance, prolonged hospital stays, and a reduction of global functioning. AIM OF THE STUDY: The purpose of the study is to compare the eectiveness of a standard treatment based on the guidelines for the management of major depression in the medically ill (1) with a short psychodynamic psychotherapy for major depression (MD) and adjustment disorders (AD) with depressive symptoms in an oncology popula- tion (2). METHODS: Cancer patients fullling the DSM-IV criteria for a MD and AD are randomly assigned to two groups. The rst group receives standard treatment (pharmacotherapy, regular consultations by an oncologist) and the second a short psychodynamic psychotherapy of 16 ses- sions. Evaluation of eectiveness consists of pre and post intervention results, as well as inter- mediary and follow-up out-comes. RESULTS: Up to now, a total of 30 patients were included in the study. Results indicate a decrease of depressive symptoms in both groups. DISCUSSION: dier- ent questions are raised by this study, such as the diculties with recruitment in psycho-oncology studies, with randomisation and with drop out [(1) Voellinger R et al. 2003. Major depressive disorder in the general hospital: adaptation of clinical practice guidelines. Gen Hosp Psychiatry 25(3): Copyright # 2006 John Wiley & Sons, Ltd. Psycho-Oncology 15: S1S478 (2006) DOI: 10.1002/pon ABSTRACTS OF THE 8TH WORLD CONGRESS OF PSYCHO-ONCOLOGYS16
17. 17. 185193. (2) Stiefel F, Stagno D. Interven- tion psychothe rapeutique aupre` s des patients cance reux sourant dune symptomatologie de pressive; une e tude clinique randomise e. Fonda- tion Kisane 20052006]. Intersociety Symposium European Association of Palliative Care (EAPC)}Pain at the End of Life: The Response is not only Medication 37 Pain at the End of Life. Resilience in Palliative Care Patients with Pain Oliviere D St Christophers Hospice, London, UK Resilience is a concept that is attracting growing interest (Bluglass, 2003; Huppert, Baylis and Keverne, 2005; Newman, 2005). Vanistendael (2003) has dened it as the capacity to do well when faced with dicult circumstances and the International Resilience Project which collected data from thirty countries described resilience as a universal capacity which allows a person, group or community to prevent, minimise or overcome damaging eects with adversity (Newman and Blackburn, 2002). The concept has considerable relevance to palliative care. A focus on resilience can assist practitioners to hold on to the increas- ingly important balance between a medical model that assesses for risk of health problems within individuals and the founding ethos of the hospice and palliative care movement in empowering individuals and promoting their strengths and resources and those of their families and commu- nities (Monroe and Oliviere, 2005). This paper oers an introduction to a resilience-promoting approach to patients with pain; overviews meth- ods of working with patients strengths; and critiques aspects of assessment and intervention. An improved focus that emphasises resilience rather than risk or vulnerability in the social, spiritual and psychological dimensions of pain, is the major theme. 38 Opioids for Advanced Cancer Pain: Is Morphine Enough? Kaasa S Department of Cancer Research and Molecular Medicine, Faculty of Medicine, The Norwegian University of Science and Technology, Trondheim, Norway Pain at the end of life is a clinical challenge in many patients due to the possible changes in the pathophysiology of the patient, as well as changes of social and psychological nature. Many patients have reduced cognitive function, which makes the diagnosis of pain a challenge, as well as the follow- up of the eect of the interventions. Pain treatment should be based upon an understanding of the disease, the pain and the patients conceptualisation of the complex multiple symptomatology. Observer ratings in the cognitively impaired are often necessary to perform. However, there is no consensus on which instrument to use and the one developed seems to have some limitations. Morphine and other opioids will often be the drug of choice. Many patients will be in the need of opioid rotation and/or combined modality treatment. Analgesics need often to be supplemented by treatment modalities that have an eect on the cancer, such as bisfosphanates, cytotoxic agents, new targeted chemotherapy, as well as radiotherapy. Dierent patients may respond dierent to various opioids due to genetically inter-individual variability. New data within this eld of transla- tional research may in the near future shed new light on the inter-individual opioid (and pain) treatment. 39 Psychological Aspects of Pain in Advanced Illness Lloyd-Williams M Academic Palliative and Supportive Care Studies Group, School of Population, Community and Behavioural Sciences, University of Liverpool, UK There are many aspects to the management of pain in advanced illness and true holistic care should include an assessment not only of the physical pain experienced by a patient but also explore the psychological, social and spiritual issues which may be contributing to the total pain experienced. This paper will explore how such issues can be addressed in the context of advanced disease and will focus on the complex symptom of depression in advanced illness. This paper will also introduce new research carried out by our research group which allows a deeper insight into the meaning of depression in patients with advanced illness and how depression can inuence the Copyright # 2006 John Wiley & Sons, Ltd. Psycho-Oncology 15: S1S478 (2006) DOI: 10.1002/pon ABSTRACTS OF THE 8TH WORLD CONGRESS OF PSYCHO-ONCOLOGY S17
18. 18. symptom management of patients in the latter stages of illness. Intersociety Symposium Italian League Against Cancer (LILT) and European Cancer League (ECL)}Understanding and Supporting 40 Eects of Living with an Increased Risk of Breast Cancer Caruso Aa , Vigna Ca , Sega FMb , Cognetti Fc , Savarese Ac a Department of Prevention and Formation in Psycho-Oncology, Regina Elena Cancer Institute, Rome, Italy; b Department of Surgery, Regina Elena Cancer Institute, Rome, Italy; c Department of Medical Oncology, Regina Elena Cancer Institute, Rome, Italy PURPOSE: Evaluate psychosocial variables of individuals who approach genetic counseling in order to: modulate intervention of team on patients needs; survey psychosocial impact of counselling and surveillance program; survey possible correlation between psychosocial vari- ables and development of cancer. METHODS: Subjects recruited: April 2002March 2006. Psy- chological assessment performed at: collection family history}eligibility communication (T0); blood-withdrawal (T1); communication test out- come (T2). Assessment follows surveillance pro- gram. Instruments: MMPI-2 annually performed; FACES-III; HADs; Genetic Risk Perception (GRP). RESULTS: Data are preliminary. T0: N 210 subjects; cancer aected 115/210; eligi- ble135/210; median age 49. MMPI-2: signicant dierences between aected/unaected women in the scales: K (13.43/15.80); PA (10.00/11.29); HS(12.15/9.76). HADs. Anxiety: Normal 48%, Borderline 26%, Disturb 26%. Depression: Nor- mal 78%, Borderline 12%, Disturb 10%. FACES- III: Real Cohesion (40.75), Ideal Cohesion (43.82), Real Adaptability (31,92) Ideal Adaptability (34.70). GRP: I dont know=6%; Low- risk=34%; Average-risk=45%; High-risk=15%; aected=48.33%; unaected=35.94%; eligible= 48.43%; not eligible=29.92%. CONCLUSION: Respect unaected subjects, aected are more hypochondriacs, they have less emotional control and disclose fewer of their doubts. The anxiety is higher than depression. Cohesion is higher than adaptability. Only 6% of subjects answer I dont know about their genetic risk, aected and eligible women perceived higher risk of being mutation carrier than non eligible unaected. That seems to show that information provided by physicians is adequate. 41 End-of-life Care in Italy: Understanding Family Dynamics. A Qualitative Study From the Italian Survey of the Dying of Cancer (ISDOC) Morasso Ga , Costantini Mb , Di Leo Sa , Roma Sa , Miccinesi Gc a Unit of Psycho-Oncology, National Cancer Insti- tute, Genoa, Italy; b Unit of Clinical Epidemiology, National Cancer Institute, Genoa, Italy; c Clinical Epidemiology, CSPO, Florence, Italy PURPOSE: This is a qualitative study aimed at describing and analysing the emotional and practical experience of a representative sample of Italian non-professional caregivers when caring for a terminally ill family member. METHODS: This is a secondary analysis from the Italian Survey of the Dying of Cancer. ISDOC is a mortality follow-back survey of 2000 adult cancer deaths, identied with a 2-stage probability sample representative of the whole country. Information on patients experience was gathered from non-professional caregivers with an inter- view conducted by trained professionals. A specic question of the interview asked about the caregivers emotional and practical experience of assisting a terminally ill relative. DATA ANA- LYSIS: The answers to the specic question about the caregivers experience were transcripted and analysed using the constant comparative method according to the grounded theory. Three research- ers independently generated categories. Subse- quently, areas where they diered were reconsidered and an interpretation was agreed upon. Descriptive coding was used to explore emotional experiences, practical needs and di- culties perceived by caregivers. RESULTS: Valid interviews were obtained from 1.289 caregivers (64.5%), but this qualitative analysis was carried out on 1158 non-professional caregivers. Answers were classied according to the perception of the experience as positive (33.1%), negative (65.1%) or neutral (1.8%). Then we identied subcate- gories detailing the emotional impact of the caregiving experience, and we tried to connect the perception of the caregivers experience (positive, negative or neutral) with some charac- teristics of the patients and the caregivers: Copyright # 2006 John Wiley & Sons, Ltd. Psycho-Oncology 15: S1S478 (2006) DOI: 10.1002/pon ABSTRACTS OF THE 8TH WORLD CONGRESS OF PSYCHO-ONCOLOGYS18
19. 19. previous experiences of loss, the social and family network, unresolved conicts with the patient, provision of palliative care services. 42 Changing Perspectives}From Micro Wishes to Macro Plans Vollmer TC Division of Psycho-Oncology, Department of Inter- nal Medicine III, University of Munic Grosshadern, Munich, Germany What do we see, when we listen carefully to patients stories and needs? Do Metaphors help us, understanding patients needs? Could we develop supportive structures by understanding patients metaphors? The presentation will ques- tion the current oers and possibilities of Psycho-Oncology using a new approach in Bibliotherapy. This approach tries to illuminate cancer patients psychological core questions and needs by working with graphical metaphors. The presentation will introduce this new way of understanding and supporting cancer patients and their families. It will provide the rst results of a small qualitative study that enables thera- pists to categorise cancer patients psychological needs and compare them with current psycho- oncological oers. Within the talk the audience will graphically be guided through the psycholo- gical journey of the ve categories of patients needs, their micro wishes, and psychological perspectives, the macro plans. For instance, anxiety increases and decreases at dierent stages of the cancer journey from the worry of thinking something is wrong to the anxiety of awaiting test results, to a state of shock at diagnosis. Becoming actively involved in dealing with cancer can help decrease anxiety, as can support from all those around the person with cancer, from family and friends to the whole medical team. The very clear micro wish is to exterminate the anxiety, which is an unrealistic goal. Only psychological support can help the person with cancer to learn living with anxiety by changing the perspective. But do we have the right supportive tools already? Intersociety Symposium European Federation of Psycho-Oncology Societies (EFPOS)}A Euro- pean perspective on psycho-oncological services and guidelines 43 Psycho-Oncology Services and Guidelines in the United Kingdom Sharp DMa , Cox Kb , Walker Mc , Walker LGa a Postgraduate Medical Institute, University of Hull, Hull, UK; b School of Nursing, University of Nottingham, Nottingham, UK; c Oncology Health Centres, Hull & East Yorkshire Hospitals, NHS Trust, Hull, UK There are several models for the design of psycho- oncology services which provide ongoing psycho- logical support and intervention for cancer pa- tients and their relatives. Across Europe the design of such services is also inuenced by national political and economic considerations. This pre- sentation will discuss the variety of psycho- oncology services available in the United King- dom. A number of diering models of service delivery are described highlighting issues such as multidisciplinary working and degree of func- tional integration with wider oncology services. The national policy documents which inuence the development of psycho-oncology services in the UK such as the National Institute for Clinical Excellence guidance Improving Supportive and Palliative Care for Adults with Cancer, will also be discussed. The current issues of importance in the development of psycho-oncology services in the UK will also be discussed as will possible templates for the further development of such services in the future. 44 A European Perspective on Psycho-oncological Services and Guidelines Schumacher Aa , De Walden-Galuszko Kb , Keller Mc , Monteiro Ld , Remie Me , Sharp DMf a Medizinische Klinik A, Universitatsklinikum Munster, Munster, Deutschland; b Department of Palliative Medicine, Medical University, Gdansk, Debinki 2, Poland; c Klinik fur Psychosomatische Medizin, Psychoonkologie, Heidelberg, Deutsch- land; d Unidade de Psiquiatria, Instituto Portugues de Oncologia, Lisboa, Portugal; e De Vruchtenburg, Straatweg 171, Rotterdam, NL; f Oncology Health Centres, University of Hull, Postgraduate Medical Institute, Institute of Rehabilitation, Hull, UK An overview will be given about the latest psycho- oncological developments in Europe. Speakers from dierent European countries will present Copyright # 2006 John Wiley & Sons, Ltd. Psycho-Oncology 15: S1S478 (2006) DOI: 10.1002/pon ABSTRACTS OF THE 8TH WORLD CONGRESS OF PSYCHO-ONCOLOGY S19
20. 20. a talk about the design of the clinical services in their countries: how they work, how they are organized, which professions are involved, about the most important issues as well as the major obstacles in their work. To promote high standards of psychological and social support for cancer patients and their families and to improve the quality of psychosocial care, psycho-oncological guidelines need to be estab- lished and implemented into clinical oncology across Europe. To inuence policies on psychoso- cial care within Europe collaboration must be fostered and maintained. European psycho- oncological societies and working groups should exchange ideas and experiences and could thus benet from each other. Ways to achieve this goal will be elaborated. Psycho-oncologists from all over Europe are invited to attend and to join the discussion. Intersociety Symposium European Oncology Nur- sing Society (EONS) and International Society of Nurses in Cancer Care (ISNCC)}Psychosocial Issues in Cancer Care: Nursing Roles and Practice Implications 45 Living After Cancer: Challenges in Being a Survivor Fitch MI Psychosocial and Behavioral Research Unit, Sunnybrook Regional Cancer Centre, Toronto, Ontario, Canada The cadre of individuals who are living after a diagnosis of cancer is growing steadily. Therapeu- tic successes are common today with the overall 5- year survival rate for all types of cancer at 64% (ACS, 2005). But this survival often comes with a cost. Cancer and its treatment have more than a physical impact. In addition to late physical eects of cancer treatment, there can be psychological, social, spiritual, and existential long-term eects. These issues can be present for those who may never experience clinical evidence of disease again or for those who may eventually face recurrence and disseminating disease. This growing cadre of survivors possesses an incredible expertise and wisdom regarding what it means to experience cancer and what it means to cope with, and adjust to, the aftermath of its impact. Health care professionals need to look to this group to gain insight about how help can be provided in appropriate and meaningful ways. Achieving a person-centered perspective within our cancer services and programs is more likely to be achieved through collaboration with survivors in our midst. This presentation will highlight current thinking about the needs of cancer survivors and the role that health care professionals, particularly nurses and psychosocial experts, can play in working together to improve the cancer care delivery system. 46 Psychoeducational Interventions: Rationale, Struc- ture, and Nursing Sensitive Outcomes Fawzy NW UCLA School of Nursing, CA, USA The United States National Cancer Center Net- work (NCCN) denes DISTRESS is a multi- factorial unpleasant emotional experience of a psychological (cognitive, behavioral, emotional), social &/or spiritual nature that may interfere with the ability to cope eectively with cancer, its physical symptoms, and its treatment. DISTRESS extends along a continuum, ranging from com- mon normal feelings of vulnerability, sadness and fears to problems that can become disabling such as depression, anxiety, panic, social isolation, and existential and spiritual crisis. The term distress is more acceptable and less stigmatizing than psychiatric, psychosocial, or emotional. It sounds normal and is less embarrassing. The possible manifestations of this distress that can occur in the diagnostic and initial treatment phases of cancer may have signicant impact on aective state, quality of life, treatment decision making, compliance, and long term outcome. Comprehensive psychoeducational interventions encompassing health education, stress manage- ment techniques, coping and problem solving skills, as well as individual and group emotional support have been shown to be eective dealing with this distress. It is within the scope of nursing practice for nurs