Melhora no Tratamento do Câncer: Intervenções de Mudança de Vida
Psychologists’ research is preventing and reducing the burden of cancer.
By Amy Novotney
Despite decades of public health warnings about the dangers of a suntan, each year 1.3 million new skin cancer cases are diagnosed in the United States. Americans, it seems, still enjoy their hours at the beach and in tanning booths in pursuit of that sun-kissed glow.
Recently, psychologists may have found a way to get people to take those warnings more seriously: A study in the January Annals of Behavioral Medicine found that when men saw UV-filtered photos of themselves that revealed their sun damage, they were more likely to use sunscreen and wear long sleeves and hats than men who had not seen such photos.
“It’s kind of like ‘The Christmas Carol’ where you see what the version of yourself will be like if you don’t change,” says Rick Gibbons, PhD, a Dartmouth College psychology professor who conducted the study along with Meg Gerrard, PhD, a psychologist at the Dartmouth Medical School. The approach is similar to smoking-cessation interventions that use pictures of blackened lungs filled with tar, he says, but it’s even more effective because these photos are personal.
That cost-efficient way to influence behavior is just one example of psychologists’ innovations to eradicate cancer — or, short of that, make living with the disease more bearable, says Bill Klein, PhD, the National Cancer Institute’s director of behavioral research. Psychology plays a role in every stage of the cancer continuum, from changing behaviors to reduce risks of getting the disease, to making screening, treatment and other medical decisions, to providing insights on how people with cancer can live fuller, more active lives.
“Psychologists are trained to challenge common-sense assumptions about human behavior and often ask research questions in different ways than do scientists in other disciplines,” Klein says.
Among those questions: Are some people more genetically disposed to reap the positive effects of exercise? Can stress management help breast cancer patients recover faster from chemotherapy? How does the way a fact sheet presents a treatment’s risks and benefits influence which option patients choose?
Psychologists are stepping up to answer these questions and more.
The initial shock of a cancer diagnosis often can be hard for many patients to overcome. In fact, a study published online in March in the Journal of the National Cancer Institute finds that men who received a prostate cancer diagnosis were 90 percent more likely to commit suicide within a year than men who had no such diagnosis.
Research also shows, however, that psychological interventions are reducing cancer patients’ stress and can help them recover from treatment and enter remission faster. Psychologists’ work can even increase immunity to fend off a recurrence.
In a 2008 study in Cancer (Vol. 113, No. 12), researchers at Ohio State University’s Comprehensive Cancer Center found that patients who participated in a group-based psychological intervention reduced their risk of dying of breast cancer by 56 percent. Participants in the yearlong program, which taught clients strategies to reduce stress, improve mood and alter health behaviors through diet and exercise, also reduced the risk of breast cancer recurrence by 45 percent. Participants included 227 patients surgically treated for Stage II or Stage III breast cancer. Half of the patients were enrolled in the psychologist- led intervention, while the other half were only assessed by the research team on a regular basis. During the sessions — weekly for four months, then monthly up to one year — participants learned progressive muscle relaxation for stress reduction, problem-solving for fatigue and other challenges, how to find support from family and friends, and how to deal with treatment side effects. Among patients who eventually died of the disease, the median survival time for the intervention patients was 6.1 years versus 4.8 years for patients in the assessment-only group.
The study is part of the long-running Stress and Immunity Breast Cancer Project at Ohio State, led by professor of psychology Barbara Andersen, PhD. She says the program was based on evidence-based treatments for anxiety. “My hope is that these are the hard data that are needed to make the case that psychological interventions can have significant health benefits for cancer patients,” she says.
The program’s success may lie in its ability to reduce stress among these patients, which has an important effect on the body’s neuroendocrine and immune functions, says Michael Antoni, PhD, a professor of psychology and director of the Center for Psycho-oncology Research at the Sylvester Comprehensive Cancer Center, University of Miami. In a 2009 study in Brain, Behavior, and Immunity (Vol. 23, No. 5), Antoni’s team randomly assigned 128 women being treated for non-metastatic breast cancer to either a 10-week group-based cognitive behavioral stress management program or a one-day educational control group. The researchers found that, compared with those in the control group, intervention participants reported less anxiety about their cancer and showed lower cortisol levels — indicating lower overall stress — six and 12 months later. The stress-reduction intervention helped the women bounce back and recover immune-system function faster after chemotherapy and radiation, Antoni says.
The team is now testing the intervention with low-income minority women, by partnering with their communities and holding groups in churches and other community organizations in Miami. The researchers are also beginning to test a similar intervention delivered via conference call with men diagnosed with prostate cancer.
Genetic differences in behaviors
A 2009 policy report by the World Cancer Research Fund and the American Institute for Cancer Research concluded that being overweight or obese is a major factor leading to 70 percent of endometrial, 69 percent of esophageal, 47 percent of stomach and 45 percent of colon cancer cases in the United States.
University of New Mexico psychology professor Angela Bryan, PhD, is working to reduce those numbers. She is examining how genetic differences influence a person’s adherence to an exercise regimen, a key factor in helping people lose weight and keep it off. With a grant from the National Cancer Institute, Bryan and her team are exploring why and for whom particular exercise programs are effective.
According to Bryan, some people who are just starting to become physically active may interpret muscle soreness as an injury that indicates they should stop exercising. More active exercisers may interpret soreness as a sign they got a great workout. While the two may be experiencing the same physiological response, their pain interpretations may be affected by their genes, Bryan says. These genetic markers can influence whether or not people continue to exercise. Designing interventions that provide other benefits — such as social interaction — might encourage people to exercise despite feeling sore.
Psychologists are also designing behavioral and pharmacological interventions to help people quit smoking in an effort to reduce their cancer risk. Even with the most effective medications, only one in four smokers stays smoke-free for a year, and biology may be partly to blame, says psychologist Caryn Lerman, PhD, who directs the University of Pennsylvania Center for Interdisciplinary Research on Nicotine Addiction. Her team is examining how individual genetic differences affect nicotine dependence and success in curbing addiction. In an in-press study for Neuropsychopharmaco logy, researchers found that variations in the choline acetyltransferase gene predicts smoking-cessation success among 472 smokers. Further research has identified the importance of genetic differences in nicotine metabolism rates in one’s ability to stop smoking (Clinical Pharmacology and Therapeutics, Vol. 84, No. 3). These findings, Lerman says, may be key for developing better medications and ways to help smokers quit for good.
Researchers are also using technology to tackle nicotine dependence among young adults. Michele Ybarra, PhD, a public health researcher with the nonprofit Internet Solutions for Kids, is collaborating with researchers from Hacettepe University in Ankara, Turkey, to develop and test a 10-week cognitive behavioral therapy-based, smoking-cessation program that would send participants targeted text messages. The project gives participants strategies for learning about their smoking behavior, identifying new behaviors to replace their old ones and ways to prevent relapse, as well as help them quit again if they resume smoking. Initial findings suggest that 13.3 percent of those who participate in the program were still smoke-free at 12 weeks after their quit date. While that rate is much lower than some in-person counseling interventions reported in the United States and other developed countries — some of which report success rates as high as 50 percent — Ybarra says the intervention aims instead to reach more people and have a broader influence on public health, in an inexpensive way. In partnership with Michigan State University and the University of Texas School of Public Health at Houston, Ybarra’s team is now testing the program with young U.S. adult smokers in a project funded by the National Cancer Institute.
Psychologists’ work on health communication is also helping to reduce the burden patients feel after being diagnosed as at high-risk for cancer, or worse — in the early stages of it.
“You hear the ‘c word’ and it knocks you down, so how well can your thinking process really be at that point?” says Angela Fagerlin, PhD, a psychologist at the University of Michigan and the Ann Arbor VA.
For the past 10 years, Fagerlin has been examining how the presentation of cancer-related information affects patients’ perception of risk, as well as their knowledge and behavior. So far, she and her team have found that patients are most likely to retain the information they read the most recently (Breast Cancer Research and Treatment, Vol. 119, No. 3). The researchers also found that patients who read the risks of a drug treatment after its benefits were more likely to perceive the drug as risky and were less likely to talk to their physicians about it, Fagerlin says.
Most cancer-related communications are written by clinicians who may not understand that how information is presented is almost as important as what information is presented, Fagerlin points out. As a result, they could “subtly bias people one way or the other just because the developers didn’t take into account the literature on judgment and decision-making,” she says. Fagerlin is now using her findings to test plain-language decision aids for men who have been biopsied for prostate cancer.
Psychologists are also examining the psychological predictors and barriers associated with cancer screening and detection, particularly among minority populations. Although U.S. cancer deaths have declined in recent years, the death rate for all cancers combined is still 25 percent higher for blacks than for whites, according to the National Cancer Institute.
This disparity may be partly attributable to lower rates of cancer screening among blacks, says Washington University in St. Louis clinical psychologist Vetta Sanders-Thompson, PhD. Research shows that developing more culturally appropriate screening information may be one way to close the gap, she says.
To increase screening and detection among blacks, her team is testing the effects of two culturally targeted colorectal screening brochures. One emphasizes statistics related to incidence, mortality and screening rates in the black community. The other depicts more church, family and community scenes and encourages trust in the medical system, which many blacks struggle with, research suggests. The study is under review with Patient Education and Counseling, Sanders-Thompson says.
Yet even the most targeted screening communications may not be enough to combat the mixed messages patients receive in today’s health-care system, which can actually keep patients from cancer screenings, says social psychologist Amy McQueen, PhD, of the Washington University School of Medicine. In a 2009 study she led, published in the Journal of General Internal Medicine (Vol. 24, No. 11), researchers examined the results of physician visits to discuss screening for colorectal cancer. During the visits, most physicians recommended colonoscopy for colorectal cancer screening, despite the fact that the American Cancer Society endorses multiple, less intensive, screening options. Most physicians also did not ask patients about the kind of test they’d prefer, nor did they seem to include the patients in the decision-making process. As a result, some patients left the visit feeling resistant to any screening at all.
These findings show that, while it’s possible to provide interventions that increase people’s intentions to get screened for colon cancer, if their physicians don’t agree with the patient’s selected screening test, that intention won’t lead to more screening, McQueen says. “We may need new conceptual models to figure out what we really should be looking at.”
The National Cancer Institute estimates that there are more than 11 million cancer survivors in the United States. As survival rates improve, cancer is being viewed less as a death sentence and more as a chronic disease, and psychologists can help those survivors live out those years in healthy, meaningful ways.
Psychologist Bernardine Pinto, PhD, for example, studies the effects of exercise among cancer survivors. She has partnered with the American Cancer Society to incorporate physical activity into the organization’s “Reach to Recovery” program for women being treated or recovering from breast cancer. Program volunteers — all breast cancer survivors — will provide weekly telephone counseling to help participants stay motivated to continue their individually tailored and physician-approved exercise programs. A 2008 pilot study of the intervention in Psycho-Oncology (Vol. 17, No. 5) showed that after 12 weeks, program participants had increased their level of physical activity and reported improved quality of life, increased vigor and reduced fatigue.
“These lifestyle changes, just as they are relevant to people to prevent cancer, may also be relevant later on to prevent or manage cardiovascular disease, osteoporosis, diabetes or other chronic diseases for which cancer patients may be at increased risk,” says Pinto, a research professor at the Miriam Hospital and the Warren Alpert Medical School of Brown University.
Psychologists are also working with minority and other medically underserved populations to ensure that they have the support they need to maintain healthy behaviors and continue follow-up care when their cancer goes into remission, says Kimlin Ashing-Giwa, PhD, a psychologist at the City of Hope Comprehensive Cancer Center in Duarte, Calif. In a 2009 study in Gynecologic Oncology (Vol. 112, No. 2), Ashing-Giwa found that compared with whites, low-income, Spanish-speaking Latina cervical cancer survivors report significantly lower levels of psychological well-being and social support, weaker physician-patient relationships and increased life stress and medical co-morbidities. English-speaking Latinas also reported lower levels of psychological well-being, though not as low as monolingual Spanish-speakers.
These findings, she says, suggest that psychologists can help by steering survivors to health and support services throughout the cancer experience, rather than just after patients receive a cancer diagnosis. Providing such services may particularly benefit cancer patients who are economically and linguistically challenged.
In the end, psychologists’ biggest role might be in helping cancer patients turn their experiences into opportunities to live more purposefully.
“We can help them communicate their fears and navigate the system, and get them to the place where they go from patient to survivor to victor, and that’s a truly amazing experience,” says Ashing-Giwa.
Artigo publicado na revista Monitor on Psychology.
July 2010, Vol 41, No. 7
Print version: page 64