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Psychological intervention may ease burden of advanced cancer
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CHICAGO — Patients with advanced cancer who underwent a psychological intervention reported a significant reduction in depressive symptoms compared with those who received usual care, according to a randomized clinical trial presented at the ASCO Annual Meeting.
At 3 months, 52% of patients who participated in the psychological intervention — called “Managing Cancer And Living Meaningfully”, or CALM — had a clinically important reduction in depressive symptoms, compared with 33% of patients who received usual care, according to the researchers.
“The intervention addresses both practical problems that people face — like pain management — and also the meaning behind being diagnosed and what it means in a patient’s life,” Gary Rodin, MD, department head of supportive care at Princess Margaret Cancer Centre in Toronto, said during a press conference. “Although these challenges are predictable in causing a lot of distress, there has not been a systematic approach to help people with these problems. We developed an onsite therapy to alleviate and prevent distress and help people manage these challenges associated with advanced cancer.”
Rodin developed CALM with assistance from Princess Margaret Cancer Centre colleagues Sarah Hales, MD, PhD, FRPC(C), a psychiatrist, and Chris Lo, PhD, a psychologist.
CALM is a psychological intervention consisting of three to six sessions that range from 45 to 60 minutes in length and occur over 3 to 6 months. Patients and caregivers consult with trained health care professionals, such as social workers, psychiatrists, psychologists, palliative care doctors, nurses and oncologists. The sessions are centered around four broad domains:
- symptom control, medical decision-making and relationships with health care providers;
- changes in self-concept and personal relationships;
- spiritual well-being and the sense of meaning and purpose in life; and
- future-oriented concerns, hope and mortality.
“CALM is distinct from other interventions in that it is meant to help patients live with advanced disease rather than just prepare them for the end of life, and in that it is focused on both the practical and the more existential concerns faced by those with advanced cancers,” Rodin said in a press release.
The analysis included 305 patients with advanced cancer from outpatient clinics at a comprehensive cancer center in a large urban area in Canada. Researchers randomly assigned patients to CALM therapy plus usual care (n = 151) or to usual care alone (control group, n = 154). Nearly 78% of patients recruited complied with the study; 16% died during the study, 8% were lost to follow-up and 4% withdrew.
Participants in the control group received routine oncology treatment and follow-up, as well as a clinic-based distress screening. About one-third of patients in the control group received some specialized psychosocial oncology care, and less than 10% received any structured or semi-structured psychotherapy.
Depressive symptoms at 3 and 6 months — measured using the Patient Health Questionnaire-9 — served as the primary endpoint.
Among patients with depressive symptoms of at least subthreshold severity at study entry — or those clinically significant and associated with impairment without meeting full criteria for diagnosis of a major depressive order — a greater proportion of those who participated in CALM showed a clinically important reduction of severity of symptoms at 3 months (52% CALM vs. 33% usual care) and 6 months (65% vs. 35%).
“We found there was a clinically meaningful reduction in depression,” Rodin said during the press conference. “We also found the [CALM intervention] not only treated depression, but had a preventive effect.”
CALM helped prevent depression in 137 patients who did not have depressive symptoms at study entry. Thirteen percent of those who received CALM developed depressive symptoms of at least subthreshold severity at 3 months compared with 30% of those who received usual care.
Additionally, participants in the CALM intervention reported greater preparation for end of life, greater opportunity to talk about concerns regarding the future and to be less frightened, and a greater ability to express and manage feelings. These effects appeared strengthened at 6 months, along with CALM participants’ ability to understand their cancer experience, deal with changes in relationships as a result of cancer, explore ways of communicating with their health care team and family, and clarify their values and beliefs.
“There were a variety of secondary outcomes, including feeling understood about having cancer, management of cancer in the future, seeing the health care community as a family, and dealing with the challenge of relationships,” Rodin said. “We conclude that CALM is an effective intervention that alleviates distress in people with advanced metastatic cancer and helps them to manage profound and practical problems that exist.”
The CALM intervention provides a new approach that can ease the emotional burden of patients with cancer, according to Don S. Dizon, MD, FACP, clinical co-director of gynecologic oncology at Massachusetts General Hospital, who was not involved in the study.
“We have embraced the concept that care is important along the cancer continuum, particularly for patients who are living with disease that is not curable,” Dizon said. “These data add much more importance to the concept of paying attention to patients’ symptoms beyond cancer’s specific outcomes. Patients facing advanced disease still need our help and as oncologists our job isn’t just to treat our patients’ physical symptoms. It’s also to connect them with other forms of support to help them cope and plan for the future.”– by Chuck Gormley
Reference:
Rodin G, et al. Abstract LBA10001. Presented at: ASCO Annual Meeting; June 2-6, 2017; Chicago.
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Holly Prigerson, PhD
Confronting death is one of the most frightening prospects for patients with cancer to endure. CALM is a welcome, novel, multifaceted approach that appears effective to help patients keep calm and carry on in the face of life-threatening illness and impending death. It addresses the important attachment issues that influence relationships with family members as life draws to a close and promotes better communication with health care providers, many of whom are reluctant to discuss end-of-life issues. It focuses on existential concerns related to meaning-making akin to Breitbart’s meaning-centered therapy and Chochinov’s Dignity therapy. Its focus on attachment and existential concerns appear to target issues of paramount importance to patients with advanced illness. Importantly, CALM appears to be brief, requiring only a few sessions over 3 to 6 months. For patients with late-stage cancer, however, 45-minute sessions in clinic may not be feasible. Attrition was remarkably low, but there are questions about selection of subjects into CALM that may have excluded more debilitated and potentially more distressed patients, many of whom might benefit most from CALM. For this reason, Rodin and colleagues might consider a more portable or briefer version of CALM so more patients can benefit from it.
Cancer clinics have limited support for psychosocial interventions like CALM, despite the high need and potential benefit. The issue with psychosocial interventions is the need for appropriate training and support of these resources in resource-strapped medical settings. The issues of insurance coverage for mental health care are notable barriers to delivery of these needed services in the United States.
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