The human body contains approximately 15 trillion cells. Every cell contains DNA or genetic material that is the blueprint for the body structures. Cancer is not one disease but many diseases. There are well over 100 types of cancer. Cancer can arise from a type of cell and cancers are classified according to this cell of origin.

A tumor, also called a neoplasm, is a new and abnormal growth of cells that series no useful function and may interfere with healthy tissue function. Not all tumors are cancerous. Tumors may be benign in that they grow slowly and do not invade surrounding tissue. They do no recur if removed. On the other hand malignant tumors are those capable of destructive growth and have the ability to invade surrounding tissues and move to other parts of the body. The movement of cancer cells from the original site to another part of the body is called metastasis.

The exact cause of cancer is not known. However, several factors are known to increase risk of cancer”

• Heredity
• Chronic physical irritation of a body part
• Smoking and tobacco use
• Radiation
• Ultraviolet rays
• Some viruses

Many modalities are available to prevent, control or cure cancer including chemotherapy, radiation therapy, immunotherapy, surgery or any continuation of these methods. A cure for cancer is usually defined as no evidence of cancer for 5 years after treatment. The goal of treatment may be armed at prevention of metastasis and this recurrence of disease or palliative which is directed toward relief of symptoms or complications of cancer.

Surgical procedures may be preventative, curative, palliative or reconstructive. Prevention procedures include removing a mole or polyp which may become cancerous. Curative surgery is most extensive and involves not only removal of a tumor but of the surrounding tissue. Palliative surgery is directed toward reducing the size or retarding the growth of a tumor. Reconstructive surgery is directed toward achieving maximal functioning or correcting disfigurement. Simple surgical procedures usually involve removal of the tumor while surrounding tissue is intact. Radical surgical procedures involve removal of some of the underlying tissue.

Chemical agents that destroy cancer cells are called antineoplastic medications. This type of therapy is called chemotherapy. Unfortunately these chemicals not only destroy cancer cells but may also damage normal cells that grow rapidly like hair follicles, skin, the lining of the digestive tract and bone marrow. The toxic effects of chemotherapy are hair loss, loss of appetite, nausea, vomiting, diarrhea, fatigue and suppression of bone marrow functions. These side effects add to the stress of the illness.

With radiation therapy high energy rays are used to damage cancer cells and prevent them from growing and responding. Radiation may be administered externally with machines that beam high energy beams at the body or internally with insertion of small amounts of radiation into the body. As with chemotherapy the procedures may also result in toxic side effects that add to the stress level and which can occur immediately or weeks and months later.

Not only the psychological aspects of the illness require addressing but also the distress and trauma that may occur as a result of treatment. The specific emotions associated with cancer include sadness, depression, fear, anxiety, and anger. Depression is the most common affect problem. The role of the psychologist includes but is not limited to:

• Management of affective dysregulation (e.g. depression)
• Promoting optimal response to treatments (e.g. chemotherapy)
• Helping with lifestyle change

-          Increase in social support

-          Impairment in management of stress

-          Stop smoking

-          Improved diet

One of the most vital things to learn about an individual patient is that patient’s perception of their illness, especially when dealing with cancer. Clarifying this perspective is the first step in any intervention. While the patient may not be adhering to the doctors view of the illness the chances are their behavior is consistent  with their own formulation. That is one of many reasons preaching to patients works so poorly for so many patients.

One very valuable strategy is the use of relaxation and visualization imagery to cope more with the trauma of the illness and the discussion of treatment. Self-regulation of emotional arousal is essential and is likely to be helpful for most patient while we explore further their own perceptions and the goals they set in the service of those perceptions.

In summary, for different individuals at different stages of cancer various psychosocial interventions are possible. However, these are some of the most common:

·         Emotional support

·         CBT to address fears and anxiety about the disease

·         Information about the disease and its treatment

·         Relaxation training/mediation

·         Cognitive coping strategies

While things have improved somewhat with greater understanding of the effectiveness of treatments, the word cancer remains a source of terror for some. The psychologist must assess the degree to which the patient may experiencing post traumatic affective disturbance.

The human body contains approximately 15 trillion cells and every cell contains DNA or genetic material that is the blueprint for building body structures. Cancer is not one disease, but many diseases, in which the body’s building process goes wild. There are well over 100 types of cancer, which are classified according to the cell of origin.

A tumor, also called a neoplasm, is a new and abnormal growth of cells that serves no useful function and may interfere with healthy tissue function. Not all tumors are cancerous. Tumors may be benign, in that they grow slowly and do not invade surrounding tissue. They do not recur if removed. On the other hand malignant tumors are those capable of destructive growth and have the ability to metastasize, or invade surrounding tissues and move to other parts of the body.

Any type of cell in the body can be a source of cancer. They are named according to the tissue from which they arise:

• Carcinoma – epithelial cells
• Sarcoma – bone, muscle or other connective tissue
• Lymphoma – lymphatic system
• Leukemia – blood cells in blood precursor cells
• Melanoma – pigment-providing cells usually of the skin.

Each type of cancer may progress at a different rates and thus respond to treatment in different ways.

While survival rates have improved, for many patients and their families cancer means death. Patients and their families must make many decisions under intense stress. Treatment for cancer can be an emotional rollercoaster. Surgery, chemotherapy, radiation and immunotherapy and such treatments as bone marrow transplantation can have significant intrapersonal and interpersonal impact, and the trauma of diagnosis and treatment may persist for sometime. This led to the development of the field of psychosocial oncology (Holland & Rowland, 1990) and to methods of intervention that help with the stress of cancer.

Lazarus and Folkman (1984), in their classical contribution to the psychology of stress, identified two important forms of coping: problem-focused coping and emotion-focused coping. Problem-focused coping involves changing the objective problem situation or modifying the external environment. Emotion-focused coping is internally focused and involves changing the reaction or emotional response. Problem-Solving Therapy (PST) is a coping skills training method that involves teaching a set of skills valuable to resolving complex problems under stress like those associated with illnesses, while ensuring that both approaches to coping are used in a balanced way. Arthur M. Nezu (Nezu et.al., 1998) has pioneered its successful application to victims of cancer and their families.

Project Genesis (Nezu, et.al., 1998), funded by the National Cancer Institute under the leadership of Arthur Nezu, had the following goals:

(1)        Improve cancer patients overall problem-solving abilities and skills

(2)        Decrease their current emotional distress

(3)        Increase control by teaching them a set of generalizable coping skills

(4)        Improve the overall quality of life.

According to Nezu: “Findings from a variety of studies…support the validity of the model in general, as well as its application to cancer patients.” (Nezu, et.al., 1998, p. 65). Thanks to modern medicine patients live longer with cancer, but they are living longer under significant stress and the emotional disruption that attends such stress. The goal is to help the patient direct their coping efforts toward altering the situations, their reactions to their situations, or both, when helpful.

A problem is viewed as specific life circumstances (e.g., diagnosis of cancer) that demands an adaptive response. However, problems in illness are all the more of a challenge because of ambiguity, uncertainty, conflicting demands or conflict over resources. The natural human desire for health and well-being is compromised and a discrepancy is created. The most effective solution to such problems is not only to modify the situation, or one’s reaction to it, but also maximize other positive consequences and minimize negative consequences.

Cancer related problems include:

·        Physical Problems – such as pain, trouble walking, difficulty in completing routine tasks

·        Psychological distress – such as trouble sleeping, increased worry, feeling sad and being ashamed of physical changes

·        Medical interaction – such as trouble getting answers to questions, communication with medical staff, and understanding technical language

·        Family – change in roles with family, too little affection, intrusions by well-meaning family members

The orientation of the patient to problems and problem solving is a major factor in success or failure of PST. What is the dominant response of the patient when confronted with a problem? A positive orientation involves optimism and lower levels of anxiety and depression.  A negative orientation involves negative affect (e.g., anger, fear), impulsive behavior and avoidance or denial. Thus the first step in PST is to address those issues and provide an orientation to the patient in structured problem solving.

Personal control beliefs are also a major issue. Effective problem involves viewing common life problems, including illness, as being caused by controllable factors. Primary control involves belief that one’s actions can have a direct impact on the illness. Secondary control involves one’s acceptance of a lack of control but a willingness to change the emotional reaction to the illness. An overly rigid stance is problematic. Flexibility is a key and PST should encourage just that. Some problems do not permit a change in the objective situation. For example, the diagnosis itself must be accepted and emotion-focused approaches become essential. It is important to communicate the value of adaptability and flexibility and the risks of knee-jerk automatic solutions particularly when driven by anger, fear or dread.

It is preferable to discuss each of the common beliefs that can be counterproductive openly with the patient and counter each one. Misconceptions include:

1.         Most people do not have problems coping with illness.

2.         All my problems are caused by my cancer.

3.         It is better to avoid problems. They disappear on their own.

4.         The first solution is always the best solution.

5.         There is one perfect solution to all problems.

6.         Nobody can understand unless they have cancer.

7.         People cannot change.

Since a problem well defined is half-solved, the first step in structured problem-solving is Problem Definition and Formulation.  Patients should be trained that the best way to start is to:

·        Seek all available facts and information about a problem

·        Describe such facts in clear language

·        Differentiate relevant from irrelevant information and objective facts from assumptions

·        Identify the facts and circumstances that make the situation a problem

Leaping too quickly to solutions that are driven by negative emotions is significant risk with cancer patients. Thus it may be that training in generating alternatives is the most valuable aspect of PST. In highly stressful situations, with high levels of emotionality, the first alternative that comes to mind may very well prove to be dead wrong. So the rules of brainstorming, or idea funding, apply. The three principles are:

            1.         Quantity principle

            2.         Deferment of judgment principle

            3.         Strategies and tactics principle

The quantity principle suggests that the more alternative solutions that are generated, the more likely it will be that the list includes the best ideas for a solution. Patients should be taught to defer judgment and avoid premature evaluation and conclusions. The distinction between a strategy and a tactic should be taught. Strategies are the general ways to solve a problem, and tactics are the specific steps used to accomplish those strategies. Once completed the list should be reviewed to find ways to contrast ideas, modify or improve them or elaborate on the ideas. Patients should keep alternatives on the table until the effort to compare and contrast or elaborate have been completed. Often that process produces the best ideas for solutions. Yet it is too often skipped when trying to make decisions under stress.

Once a wide range of alternatives are on the table, the cancer patient must learn how to evaluate each solution and select the most effective for implementation. There are two major concerns:

·        Estimation of value

·        Estimation of likelihood of effects

In making judgments about value there are four categories of consequences that must be considered:

1.         Short-term or immediate consequence

2.         Long-term consequence

3.         Personal consequences

4.         Social consequences

All must be considered. Considering just short-term or immediate consequences is all too common under stress.

Estimating the likelihood of effect means asking the question: “Will it work?”  We must look at each option that remains on the table to determine the likelihood that each alternative will actually solve the problem.

In the final step the cancer patient implements the selected solution. There is more to it than meets the eye. The patient must carry out the solution, evaluate the effectiveness of the solution and, if necessary resume the problem solving process to search for a more effective alternative.

In their book Helping Cancer Patients Cope: A Problem-Solving Approach Nezu and his colleagues provide a step-by-step treatment manual with valuable forms for copying and immediate applications. It may be worth a visit to Amazon. PST is an excellent way to serve cancer patients and their families.

References

Bucher, J.A., (1999), The Application of Problem-Solving Therapy to Psychosocial Oncology, Hayworth Medical Press: Binghamton, N.Y.

Holland, J.C. and Rowland, J.H. (Eds), (1990), Handbook of Psychooncology, Oxford University Press: New York.

Lazarus, R.S. and Folkman, S., (1984), Stress, Appraisal and Coping, Springer Publishing Company: New York.

Nezu, A.M., Nezu, CM, Friedman, S.H., Faddis, S. and Houts, P.S., (1998), Helping Cancer Patients Cope: A Problem-Solving Approach, American Psychological Association: Washington,D.C.