Best Practices in Psychosocial Oncology

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Best Practicesin Psychosocial Oncology

• Katherine Walsh, PhD, MSW, LICSW
• Professor, Springfield College School of Social
  Work
• Past President Association of Oncology Social
  Work
• Psychotherapist Private Practice

Summit Hungary 2008
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Cancer Incidence and Mortality USA

Racial or Ethnic Variations All cancers
combined, men Incidence rates are highest among
black (607.3), followed by white (527.2),
Hispanic (415.5), Asian/Pacific Islander (325.8),
and American Indian/Alaska Native (288.6) men.
Death rates are highest among black (303.5),
followed by white (224.8), Hispanic (152.8),
American Indian/Alaska Native (151.2), and
Asian/Pacific Islander (137.0) men. All cancers
combined, women Incidence rates are highest
among white (405.9), followed by black (379.7),
Hispanic (318.6), Asian/Pacific Islander (267.4),
and American Indian/Alaska Native (242.2) women.
Death rates are highest among black (182.8),
followed by white (156.4), American Indian/Alaska
Native (110.7), Hispanic (101.9), and
Asian/Pacific Islander (92.3) women. Among four
races and Hispanic origin American Indian/Alaska
Native men have the lowest incidence rates of
cancer however, Asian/Pacific Islander men have
the lowest death rates from cancer. White women
have the highest incidence rates of cancer
however, black women have the highest death rates
from cancer. American Indian/Alaska Native women
have the lowest incidence rates of cancer and the
third-highest cancer death rates.
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A Historical Perspective on Psychosocial Cancer
Care United States of
America
First psychosocial research in oncology published
by psychiatrists and social worker team
Psychosocial Oncology
IPOS Is formed
The Psychosocial Oncology Group is formed
First Pediatric Oncology social Worker hired in
Boston
APOSW Is formed
AOSW Is formed
APOS Is formed
1971
1950s
1972
1984
1976-1981
1990s
1960s
Introduction of chemotherapy in Rx of Cancer
War on Cancer, P.L. 92-218, Nixon admin
National Cancer Plan includes rehabilitation,
cancer control, and psychosocial research
Combined Therapeutic Modalities Increase
Survival in Childhood leukemia
First decrease in cancer mortalities in US
Oncology
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Twenty to Twenty-first Century
National Coalition For Cancer Survivorship (NCCS)
sponsors first March on Washington
Mental Health Parity Act passed\ By US Congress
Patient Navigation Act passed by US Congress
2000
2006
2008
2007
Institute of Medicine Report
Institute of Medicine Report
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Factors contributing to Greater Emphasis on
Psychological and Social Issues in Cancer

• Societal Attitudes shifting away from fatalism
  about cancer
• Trend toward revealing diagnosis in many
  countries
• Patient participation in treatment decisions
  (autonomy, informed consent)
• Increased doctor-patient dialogue
• Development of valid instruments for measuring
  subjective symptoms and quality of life
• Recognition that effective cancer prevention and
  screening is dependent on changing behaviors
• Increased awareness of psychosocial sequelae of
  cancer and cancer treatment accompanying
  increased survival
• Holland, Jimmie (Ed.). (1998). Societal view of
  cancer and the emergence of psycho-oncology.
  Chapter 1 in Holland and Jacobson,
  Psycho-oncology. New York Oxford University
  Press p.9

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Factors influencing Funding and Psychosocial
Oncology

• Federal Government Legislation Funding
• Government Insurance for Elders and Disabled
  (Medicare) and the poor (Medicaid)
• For profit insurance companies (insurance
  provided through employers)
• For profit Pharmaceutical and other Suppliers
• Non-profit Organizations (American Cancer
  Society, LAF, Cancer Care, Wellness Community,
  Hospitals who employ Physicians, Psychiatrists,
  Psychologists, Social Workers)
• Private Practitioners (Physicians, Psychiatrists,
  Psychologists, Social Workers, Complementary care
  providers-eg massage

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Location of Service
Provision
Physician Practionter Offices
Non-Profit Organizations International National
Regional State Community
For Profit Organizations International National
Regional State Community
Institutions Acute Hospitals (NCI CCC) (For
Profit) (Community) Chronic/Rehab (Skilled
Nursing)
Clinics
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Four Broad Areas of Psycho-Oncology

• Psychosocial oncology services for patients (and
  families)
• Education and training programs
• Research addressing psychosocial issues
• Publications of research and scholarly papers
  Holland,J. (1998) p. 11

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ADVOCACY

• To influence Policies and Funding
• To reduce health care disparities
• To improve quality of care
• To increase access to psychosocial care for all
• To fund psychosocial research
• To support education and training of psychosocial
  oncology experts
• NASW, AOSW, APOS, NCCS, NPAF, C-change

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AOSW Association of Oncology Social Work

• Mission To advance excellence in the
  psychosocial care of persons with cancer, their
  families, and caregivers through Networking,
  Education, Advocacy, Research, Resource
  Development
• Vision StatementAOSW envisions a global society
  in which oncology care meets the physical,
  emotional, social and spiritual needs of all
  people affected by cancer.
• AOSW Goals
• Increase awareness of the psychosocial effects of
  cancer. 
• Advance the practice of psychosocial
  interventions that enhance quality of life and
  recovery of persons with cancer and their
  families. 
• Foster communication and support among
  psychosocial oncology caregivers. 
• Further the study of psychological and social
  effects of cancer through research and continuing
  education. 
• Advocate for programs and policies to meet the
  psychosocial needs of oncology patients and their
  families. 
• Promote liaison activities with other
  psychosocial oncology groups and professional
  oncology organizations. 
• Promote the highest professional standards and
  ethics in the practice of oncology social work.

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IPOS

• International Psycho-Oncology Society (IPOS)
  was created to foster international
  multidisciplinary communication about
• clinical,
• educational and
• research issues
• that relate to the subspecialty of
  psycho-oncology and two primary psychosocial
  dimensions of cancer 
• Response of patients, families and staff to
  cancer and its treatment at all stages
• 2) Psychological, social and behavioral factors
  that influence tumor progression and survival.

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American Psychosocial Oncology Society

• The mission of American Psychosocial Oncology
  Society is to advance the science and practice of
  psychosocial care for people with cancer.This
  includes
• Providing a forum for professionals and
  individuals interested in the areas of
  psychological, social, behavioral, and spiritual
  aspects of cancer
• Raising the level of awareness of health
  professionals and the public about psychological,
  social, behavioral, and spiritual domains of care
  for patients with cancer
• Developing and implementing educational programs
  for health professionals, patients, and the
  public on the psychological, social, behavioral,
  and spiritual aspects of cancer
• Developing a research agenda to be used as a
  guide for scientific study in the field
• Developing standards of care for the management
  of the psychological, social, behavioral, and
  spiritual domains of cancer
• Assuring attention to the psychological, social,
  behavioral, and spiritual domains in the
  evaluation of the quality of care for patients
  with cancer by regulatory agencies
• Exploring innovative methods to enhance the
  recognition and treatment of psychological,
  social, behavioral, and spiritual aspects of
  cancer
• Promoting education and training of health
  professionals in the psychological, social,
  behavioral, and spiritual domains of cancer
• Addressing the special needs of children, the
  elderly, and the underserved.

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Model of Psychosocial
Oncology Research
Variables

• 
  
• 
  

Independent
Mediating
Outcome
Personal Medical Social Economic Life
Stresses
Quality of Life Survival Bereavement
Cancer Disease and Treatment effects
Interventions
( Adapted from Holland, p. 13)
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Complexity of Cancer

• The complexity and variability of psychosocial
  issues associated with cancer has created the
  demand for highly skilled practitioners who are
  trained to provide multilevel assessment and
  intervention throughout the illness continuum.
  (Smith, Walsh-Burke and Cruzan, 1998)

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Psychosocial services through the continuum of
cancer care
Counseling Individuals Families Groups
Education Pt/Caregiver Public SW Students
High Risk Screening for Psychosocial Distress
Comprehensive Psychosocial Assessment
Community Organization/ Coalition Building
Preventtion
Genetic Counseling
Treatment plan
SURVIVORSHIP
DX
RX
Pre-DX
Remission/ Recurrence
EOL/Palliative CARE
BEREAVEMNT
Adv Directives
Cancer Screening Events
Case Management
Patient Navigation
Prof Ed Research and Publication
Discharge Planning
Program Development
Evaluation
Referral, Linking, Advocacy
Supervision Administration
Legislation/ Policy
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Interdisciplinary Team Collaboration
Screening Assessment Case Management Medication
management Counseling and other Psychosocial
Interventions Financial Assistance Education
Advocacy Research
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Interdisciplinary Collaboration

• Patients who are significantly depressed or
  experiencing severe anxiety and who are not
  responding to counseling or other psychosocial
  interventions should be discussed with
  interdisciplinary colleagues. There is a risk of
  suicide for those experiencing depression in the
  context of a life-limiting illness and suffering
  can be alleviated through appropriate
  intervention. Pain and fatigue can be
  contributing factors to anxiety and depression
  and addressing these is essential
• Psychiatric referral may be advisable to address
  the pharmacological agents for treatment of
  depression or anxiety. There are a variety of
  anxiolytic (or anti-anxiety) and anti-depressant
  medications that can be helpful in alleviating
  anxiety.
• AOSW Social Work and End of Life course
  www.dynamic-learning.com

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Scope of Practice

• Services to cancer survivors, families, and
  caregivers through clinical practice providing
  comprehensive psychosocial services and programs
  through all phases of the cancer experience
• 2. Services to institutions and agencies to
  increase their knowledge of the psychosocial,
  social, cultural and spiritual factors that
  impact coping with cancer and its effects, and to
  insure provision of quality psychosocial programs
  and care. 
• 3.Services to the community through education,
  consultation, research and
• volunteering to utilize, promote or strengthen
  the community services, programs, and resources
  available to meet the needs of cancer
  survivors. 
• 4.Services to the profession to support the
  appropriate orientation, supervision and
• evaluation of providers in oncology
  participate in and promote student training
• and professional education and advance
  knowledge through clinical and other research.

(AOSW) Scope and Standards of Practice (1998)
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AOSW Standards of Practice

• Use of high risk screening criteria to identify
  survivors and families in need of Social Work
  services. 
• Completion of a psychosocial assessment to
  determine survivor and familys strengths and
  needs relative to coping effectively with cancer
  diagnosis, treatment and follow-up cares. 
• Development of a multidisciplinary care plan with
  survivor and family input and based on mutual
  goals. 
• Use of a range of therapeutic and other
  interventions, including supportive counseling,
  group work, and education to address issues in
  each phase of the illness. 
• Provision of pre-admission, transfer, and
  discharge planning. 
• Provision of case management services. 
• Provision of direct assistance to meet financial,
  transportation, lodging and other needs. 
• Advocacy to remove barriers to quality care, to
  address gaps in service, to help survivors and
  families secure the protection of existing laws,
  and to work for any changes needed to policies,
  programs and legislation. 
• Involvement conducting and publishing research to
  advance knowledge about the impact of cancer,
  refine interventions, and evaluate practice
  outcomes.

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• 1. Services to cancer survivors, families, and
  caregivers
• through clinical practice providing
  comprehensive psychosocial services and programs
  through all phases of the cancer experience

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Example Services to cancer survivors, families,
and caregivers
The Cancer Survival Toolbox is a free audio
program designed to help cancer survivors and
caregivers develop practical skills to deal with
the diagnosis, treatment and challenges of
cancer.
The Toolbox is made possible by unrestricted
educational grants from the Amgen Foundation and
the EliLilly and Company Foundatio
www.cancersurvivaltoolbox.org
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• 2. Services to Institutions and Agencies
• The goals of practice in providing to
  institutions and agencies are
• To insure that the agencies and institutions are
  responsive to the needs of both individual cancer
  survivors, families and caregivers, as well as
  groups.
  
• To contribute the multidisciplinary effort to
  provide quality medical psychosocial care to
  oncology survivors. 
• To assist social work colleagues and members of
  other disciplines to manage the stress of
  clinical practice.
• The functions necessary to such services are
• Education and consultation to professionals and
  staff regarding the biopsychosocial,
  environmental, spiritual, and cultural factors
  affecting cancer care. 
• Collaboration with other professionals in the
  delivery of quality psychosocial care, education
  and research. 
• Recording, statistical reporting, and evaluation
  to improve services, assist in identifying gaps
  in services and programs, and assure quality
  care. 
• Development of programs and resources to address
  the needs of cancer survivors. 
• Provision of support services to aid in stress
  management.

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Example Service to Institutions
and Agencies
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3. Services to the Community Goals


Assure that community programs and
resources address and are responsive to the needs
of cancer survivors, families, and caregivers. 
Provide expertise to communities as they work to
assist cancer survivors. Functions Education
of communities to increase awareness of the
psychosocial needs of cancer survivors, families,
and caregivers.  Collaboration with community
agencies to remove barriers to cancer prevention,
screening and early detection, and access to
care.  Collaboration in the development of
special programs and resources to address
community-based needs.  Consultation with
voluntary cancer agencies, such as the American
Cancer Society and the Leukemia and Lymphoma
Society to provide community education and
develop programs to benefit cancer survivors.
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Examples Service to the Community
http//www.helpstartshere.org/health_and_wellness/
cancer/resources/understanding_cancer_course.html
Online Courses Understanding Cancer Course To
understand cancer and cancer care for
individuals with cancer and their loved ones
http//www.naswwebed.org/
Online courses Achieving Cultural Competence to
Reduce Health Disparities in End of Life Care
http//www.apos-society.org/professionals/meetings
-ed/webcasts.aspx

• Multidisciplinary Training in Psycho-Oncology
• The "Multidisciplinary Training in
  Psycho-Oncology" is offered by the APOS Institute
  for Research and Education (AIRE) at no cost and
  is intended to train cancer care professionals in
  key areas of psychosocial oncology. The program
  includes fifteen Webcast lectures in the five
  following tracks.
• Introduction to Oncology
• Program Administration
• Symptom Detection and Management (eight webcasts)
  
• Interventions (four webcasts)
• Population-Specific Issues

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Example Cancer Care

• ICAN
• Teleconferences
• Financial Assistance
• Online Support Groups
• Individual, Group, Family Counseling
• Special programs serving Diverse populations
• Doula programs for End of Life Care

http//supportgroups.cancercare.org/index.php/topi
c,1267.0.html
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Services to the Profession The goals of providing
services to the profession are To assure that
oncology social workers have the necessary
knowledge, skills, resources, time, funding, and
support to deliver quality psychosocial services
to all cancer survivors, families and caregivers.

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EXAMPLE Oncology Social Work Brochure Produced
by NASW AOSW
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NASW Public Education Campaign
Oncology Social Work Advertisement
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Example IPOS Multilingual Multidisciplinary
Online Lectures
Új!"A Daganatos Betegség Mint Családi Probléma" by Lea Baider PhD Translator  Tamás HalmaiIPOS Reviewer  Katalin Muszbek MD Narrator  Zsuzsa Adorjáni (Adorjáni Zsuzsa színészno, a Magyar Hospice Alapítvány támogatója)
Új!"Veszteség és Gyász" by David Kissane MD Translator  Tamás HalmaiIPOS Reviewer  Katalin Muszbek MD Narrator  György Csapó (Csapó György színész, a Magyar Hospice Alapítvány támogatója)
"Communication and Interpersonal Skills in Cancer Care" by Walter F. Baile, MD Translator  Dr. Mária MolnárNarrator  György Csapó
"Anxiety and Adjustment Disorders in Cancer Patients" by Katalin Muszbek, MD Translator  Tamás HalmaiNarrator  Zsuzsa Adorjáni
"Distress Management in Cancer" by Jimmie C. Holland, MD Translator  Tamás HalmaiNarrator  Zsuzsa Adorjáni
http//www.ipos-society.org/professionals/meetings
-ed/core- curriculum/core-curriculum-pres.htmHung
arian
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Case Example What this means for the Patient and
Family

• 32 yr old caucasian nurse discovers lump during
  pregnancy mamogram
• dx w triple negative breast ca in 8th month of
  pregnancy 4/07
• (risk factorsage, pregnancy)
• Husband is psych nurse. Insurance through his
  employer Both have hx of alcohol abuse in 12 step
  recovery (risk factor) Pt unemployed
  (socioeconomic risk factor)
• Delivers healthy baby 5/07
• Mastectomy and reconstruction 6/07
• Begins AC and Herceptin after birth 7/07
• Sees osw in clinic-distress screen anxiety
• Case management by OSW begins given Cancer
  Survival Toolbox
• Referred to support group, attends 2x
• Referred to family retreat program, d/n attend
• Referred to Licensed Independent Clinical Social
  Worker for psychotherapy and begins 9/08
• Completes chemotherapy 10/07, Completes
  reconstruction 11/07
• Husband self-refers for counseling 4/08
• Recurs w metastasis to liver, lung, bones 6/08
• Marital counseling session w husband 6/08
• Radiation to bones begins 7/08
• Herceptin,Zometa, Taxol begin 8/08
• Acupunture, massage, self-hypnosis begin,
  psychotherapy continues

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Psychotherapy

• Cognitive-behavioral therapy for anxiety
• (Cognitive restructuring, progressive
  muscle relaxation and guided imagery)
• Solution-focused marriage therapy sessions
• Motivational interviewing for cessation of
  alcohol and tobacco use
• Self-advocacy training for adequate medication
  for side effects of chemo
• Advocacy for financial support in day care
• Disability income, Palliative Care

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Cancer Patient Bill of Rights