Hello and welcome. My name is Michelle Riba. I am a professor in the Department of Psychiatry at the University of Michigan and also the Director of the Psych Oncology Program at the University of Michigan Comprehensive Cancer Center. I'm also Past President of the American Psychiatric Association and Associate Director of the University of Michigan Comprehensive Depression Center. It's really my great pleasure and honor to speak with you today about the psychological and emotional issues of patients undergoing treatment for lung or esophageal cancer. Many people with cancer, and lung or esophageal cancer in particular, often say that the emotional aspects of having cancer are sometimes the same or even more difficult than the physical symptoms of having cancer. So this is a very important topic for both patients and families. It got increased emphasis in 2007 when the United States Institute of Medicine came out with this report. And it was called Cancer Care for the Whole Patient. And it said addressing psychosocial needs should be an integral part of quality cancer care.. It also said further that evidence supports the effectiveness of services aimed at relieving the emotional distress that accompanies many chronic illnesses, including cancer. Even in the case of debilitating depression and anxiety. So this is really an important juncture for us and understanding and emphasizing the need for all of us oncologists, surgeons and psychiatrists and all mental health professionals to look at, evaluate, screen for, treat and manage emotional and psychological issues for patients with cancer. The objectives for this presentation today will be to review the distress and cancer, focus on depression and anxiety in particular, because those are two of the major psychiatric conditions that we see in patients with cancer. We will discuss treatment options, the impact on families, and then some take home points. So let's first start with a question to get us going. For patients with lung or esophageal cancer, distress is A Prevalent in about 5% of patients, B Not as important as other quality measures, C A condition that may relate to depression, anxiety, adjustment or D Always attributable to past psychiatric history. And through the course of this lecture we will try to answer this question. So distress and cancer. Why is distress important? It can impact on the emotional well-being of patients and families. And we will talk about how that can be. If one is distressed, it can impact on decision making. So for example, when somebody is getting the diagnosis of cancer, lung or esophageal for example, they may be in such distress that it may be difficult for them to decide what should come next, and to make that decision with their surgeon or oncologist. It may prolong medical treatment. So the psychiatric issues, the distress, may make it difficult for patients to adhere to the treatment, come in for regular appointments etc. And it may contribute to adverse medical events and outcomes. Such as not being able to come for their treatments, taking their medications, talking to their family members, etc. The National Comprehensive Cancer Network, which is a consortion of comprehensive cancer centers throughout the United States, develop guidelines for distress. Jimmy Holland, who's the Professor at Memorial Sloan Kettering, and former Chair of psychiatry at Memorial Sloan Kettering, chaired this guidelines committee, where we each year look at these guidelines and discuss distress management in cancer. We developed this definition of distress, which is, distress is a multifactorial unpleasant emotional experience of a psychological, social and/or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment. Distress extends along a continuum ranging from common 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 importance here is to note that distress may be very normal. And it may be normal during several points in the continuum of care for cancer. The issue is whether it's disabling, whether it impacts on function, and whether it impacts on the ability for the patient and in conjunction with the family to enjoy life, to have a good quality of life. The NCCN also in its distress guidelines came up with standards of care for distress management. So we note and this is available to anyone on the web if you go to the nccn.org. And it's available for clinicians as well as for patients and their families. So we said that distress should be recognized, monitored, documented and treated promptly at all stages of cancer care. That all patients should be screened for distress at their initial visit and than at appropriate intervals as clinically indicated. The screening should identify the level and the nature of the distress. Distress should be assessed and managed according to clinical practice guidelines. And in fact, in the last year or so, the American College of Surgeons Commission on Cancer developed this even further and says that it's important and that they mandate it. That the stress be evaluated in patients with cancer, reaffirming what NCCN has developed and what the IOM said in their 2007 report. So what's the prevalence of psychosocial distress in cancer patients? About 25 to 30% of all newly diagnosed patients and those with recurrence of cancer have significantly elevated levels of emotional distress. That's about a third of patients will have some important aspect of distress. And up to 47% will have a psychiatric diagnosis and we'll talk more about what that means when I say psychiatric diagnosis. This is a slide, it's a very busy slide but Jim Zibora In his work looked at a number of different types of cancers and I highlight for you lung and head & neck cancer, showing that many patients have depression, anxiety and screen positively in their global symptom inventory, GSI scales. This is to show that other cancers in patients with cancer may often also have depression, anxiety, etc.. So let's talk about lung cancer. Distress in newly diagnosed patients with lung cancer. Well, the prevalence is very high. Approximately 51% of patients who are newly diagnosed with lung cancer, and there are many different types of lung cancer, but about 51% of them will screen highly for distress. When we say distress, what are looking for? Well, we in the NCCN have correlated distress to a number of factors but in terms of psychiatric conditions, the distress can be related to depression, anxiety, adjusting to the diagnosis or the treatment or its management. Patients can be distressed because of substance abuse or dependence, personality problems, delirium or a change in mental status, or poor coping with family, job, and others. The National Comprehensive Cancer Network NCCN Distress Thermometer is one way to evaluate for distress. There are others but this has been validated and is reliable and has been used throughout the world. This is also available on the web page nccn.org if you look under distress guidelines. So, we've developed this visual analogue for distress going from zero distress to extreme distress and patients can look at this either on paper, on a computer or on a iPad, etc.. And they can tell us, they can rate themselves. And then if you move over the page we ask them what their distress may be related to. So you can see at the top where it says practical problems, patients can be distressed because of housing. Because of transportation issues, because of work issues related to their cancer. Patients can be distressed because of family issues. And that could be dealing with children or, partners, or other family health issues. They can have emotional issues. Again the patients self-rate themselves. The emotional issues and the distress can be related to depression, fears, sadness, etc. It could be related to spiritual or religious concerns. And then patients have the opportunity to say that the distress could be related to physical issues, such as appearance, breathing, and that could be an important aspect of patients with lung cancers. They could have a problem with eating, diarrhea. And some of this may be related to a cancer such as esophageal cancer. They could be related to mouth sores, or nausea. So it gives the patient a chance to tell us their level of distress and then why they think they might be distressed and then this opens up the opportunity for the clinician to talk to the patient about this level of distress and how we could seek to understand it better, manage it and treat it. This is very much like the pain P-A-I-N thermometer and some of us talk about this as another vital sign. This distress thermometer, like the pain thermometer, has become a vital sign that we all need to ask patients about pain. So too in distress with patients who have lung or esophageal or other kinds of cancer, that it's important for us to screen for this and manage it. So question one, factors that increase psychological distress in patients with lung or esophageal cancer include cognitive impairment, middle age, good access to medical care or private schooling and we'll talk about this. Factors that can increase psychological distress in patients with lung cancer include cognitive impairment. Well if patients have difficulty comprehending what is being said following the prescribed outline of treatment, taking medications as prescribed, because of the cognitive impairment, that may increase the psychological distress for patients with lung or esophageal cancer. Which patients are at increased risk for distress? There are many reasons why patients can be at increased risk for distress in those patients who have longer esophageal cancer. There could be a history of psychiatric disorders or substance abuse for that individual patient. For example, smoking or alcohol use may have been very troublesome and difficult for the patient to get treated appropriately, or adhere to a no-smoking or no alcohol use. This may be specifically problematic for a patient who may now have a diagnosis of lung or esophageal cancer. There may be a history of depression or a suicide attempt for that patient, and so they may be at increased risk for distress. As we talked about, cognitive impairment may increase the problems for patients with a newly diagnosed lung or esophageal cancer, or through the course of treatment, may impact on this patient's ability To adhere to treatment. There may be communication barriers for this patient. Having lung or esophageal cancer may be particularly difficult for the patient to understand or communicate their needs for the clinicians. Just because patients have cancer doesn't mean that they don't have other medical conditions such as, for example diabetes or heart disease or arthritis. And there may be worries that the treatments for the cancer may impact on their other conditions. So that may be difficult. Patients may have spiritual or religious concerns about taking medications, coming for certain kinds of treatment. Patients may worry about uncontrolled symptoms they have related to other medical or psychiatric conditions. And they may have social issues. They may have ongoing conflicts with family members, children, parents and worry about the impact of their cancer and its treatment, and what they might need from their family members for ongoing care for their cancer. They may have limited access to other medical care and so it may be difficult. They may live in rural communities, may live a distance from a large university center or from their oncology practice that they need to go to. Patients worry if they have young or dependent children and wanting to see their children graduate from high school or college, or see their children have a partner or be independent. Patients who are younger who may not have a partner, who don't have children, may worry about their fertility. They worry about meeting somebody and so these are important issues. Gender sometimes is an important factor so females may have differential problems and distress compared to males. There may be a history of abuse, both physical, sexual, emotional, that may impact the patient's ability to come for care and may impact on their distress, and there are probably a host of other stressors and factors that may make patients with lung or esophageal cancer at increased risk for distress. So question two, common reasons for depression and anxiety to be underdiagnosed or undertreated in patients with cancer may include patients are generally eager to talk about their depression and anxiety with the oncologist or doctors are generally eager to spend time talking about depression and anxiety in a busy oncology office. Families are generally feeling empowered to talk about distress, depression, and anxiety. Or the last would be stigma. The answer to this question is stigma, answer d. And we will talk about stigma in our next lecture.