Adaptation to Cancer

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Cancer is universally feared. According to the American Cancer Society (ACS), cancer is an umbrella term for a group of diseases "characterized by uncontrolled growth and spread of abnormal cells.'' Not counting some highly prevalent, rarely fatal forms of skin cancer, the most common cancers are (in order of prevalence) prostate, lung, colon/rectal, and bladder (for men); and breast, colon/rectal, lung, and uterus (for women). For both men and women, lung cancer causes the most deaths. Although it kills far fewer people than CVD, cancer is perceived as more dangerous, destructive, and deadly. In reality, the survival rate for cancer has been climbing steadily throughout this century. Taking a normal life expectancy into consideration, the ACS estimates that 50% of all people diagnosed with cancer will live at least 5 years. Nevertheless, cancer remains the second-leading cause of death and is associated with significant pain and disability.

Because behavioral factors have been implicated in the etiology of many cancers (e.g., smoking, eating a low-fiber diet, sunlight exposure), behavioral scientists have developed a large number of programs designed to help people reduce their cancer risk. In addition, behaviorists have focused on what happens to an individual after a diagnosis of cancer is made. Partly because there are so many types of cancers, the experience of cancer is highly variable. Nevertheless, there are commonalities. Most cancer treatments, such as surgery, radiation, and chemotherapy, are

Behavioral Medicine extremely unpleasant. Surgery often requires a great amount of recuperation, sometimes causes new physical problems, and may cause substantial disfigurement. Radiation and chemotherapy often cause significant side effects, including hair loss, sterility, even nausea and vomiting, fatigue, and diarrhea. Anticipatory anxiety, classically conditioned by these treatments, may increase the severity of many of these symptoms. In the long term, cancer patients face problems with physical, psychological, and sexual functioning, as well as family and work difficulties. Many studies have demonstrated that cancer patients exhibit increased rates of depression, and some have demonstrated increased rates of anxiety. Behaviorists working in treatment settings have attempted to help individuals with cancer cope as well as possible with these difficulties.

Health researchers have found that cancer may result in self-concept problems. In addition, one study identified four major sources of stress experienced by people with cancer: (1) loss of meaning, (2) concerns about the physical illness, (3) concerns about medical treatment, and (4) social isolation. Social isolation and reduced social activity have been observed in both children and adults with cancer. Behavioral science practitioners are developing interventions to ameliorate the psychosocial effects of cancer.

Interesting and controversial intervention studies have examined the effect of positive attitude and social support in reducing the physical effects of cancer. According to some psychoneuroimmunology studies, depressed mood may reduce immune functioning. ''Wellness communities," startled by Harold Benjamin in Santa Monica, California, promote the idea that depression weakens immune response. They suggest that a positive attitude may likewise enhance it. Stronger immunity, it is argued, will lead to reduced physical manifestations of the disease.

The most well-known study of social support and cancer was undertaken with a group of 86 women diagnosed with metastatic breast cancer. (Metastatic means the disease has spread beyond the original organ or tissue site.) The women were randomly assigned to either a standard treatment control group or a group that included weekly support groups. The support groups were led by psychiatrists or social workers who were breast cancer survivors themselves. Women in the support group became highly involved in helping the other participants cope with their cancer symptoms, treatment, and difficulties.

Women assigned to the support groups survived an average of 36.6 months, while those in the control group survived an average of only 18.9 months. Support group members also experienced less anxiety, depression, and pain. This study's impressive results have sparked further research into the role of social support and immune functioning, as well as the role of psychotherapy in reducing the psychosocial difficulties of the cancer experience. The study is now being replicated with a larger group of women.

Another often-cited cancer intervention study examined the effects of a 6-week intervention on patients diagnosed with a deadly form of skin cancer known as malignant melanoma. The intervention included weekly 90-minute sessions focusing on relevant education, problem-solving skills, stress management, and psychological support. Outcome data indicated both short-term and long-term effects of the intervention versus the control group. At short-term (6-week and 6-month) assessments, immune markers were significantly better in the intervention group than in the controls. When studied 6 years later, the intervention group participants had lower mortality rates and fewer recurrences than did participants in the control group.

C. Functioning in Lung Disease

Another example of behavioral medicine practice comes from studies of rehabilitation of patients with chronic obstructive pulmonary disease (COPD), which is a common ailment among smokers. It is currently the fourth leading cause of death in the United States. Chronic bronchitis, emphysema, and chronic asthma are the three diseases most commonly associated with COPD. The common denominator of these disorders is expiratory flow obstruction (difficulty exhaling air) caused by airway narrowing, although the cause of airflow obstruction is different in each. Exposure to cigarette smoke is the primary risk factor for each of these illnesses. There is no cure for COPD.

Chronic obstructive pulmonary disease has a profound effect on functioning and everyday life. Current estimates suggest that COPD affects nearly 11% of the adult population, and that the incidence is increasing, especially among women, reflecting the increase

Behavioral Medicine in tobacco use among women in the latter part of this century. Medicines such as bronchodilators, cortico-steroids, and antibiotic therapy help symptoms, and long-term oxygen therapy has been shown to be beneficial in patients with severe hypoxemia. However, it is widely recognized that these measures cannot cure COPD. Much of the effort in the management of this condition must be directed toward preventive treatment strategies aimed at improving symptoms, patient functioning, and quality of life.

In one study, 119 COPD patients were randomly assigned to either comprehensive pulmonary rehabilitation or an education control group. Pulmonary rehabilitation consisted of 12 4-hour sessions distributed over an 8-week period. The content of the sessions was education, physical and respiratory care, psychosocial support, and supervised exercise. The education control group attended four 2-hour sessions that were scheduled twice per month, but did not include any individual instruction or exercise training. Topics included medical aspects of COPD, pharmacy use, and breathing techniques. In addition, subjects were interviewed about smoking, life events, and social support. Lectures covered pulmonary medicine, pharmacology, respiratory therapy, and nutrition. Outcome measures included lung function, exercise tolerance (maximum and endurance), perceived breathlessness, perceived fatigue, self-efficacy for walking, depression, and overall health-related quality of life.

In comparison to the educational control group, rehabilitation patients demonstrated a significant increase in exercise endurance (82% vs. 11%), maximal exercise workload (32% vs. 14%), and peak VO2, a measure of cardiovascular fitness (8% vs. 2%). These changes in exercise performance were associated with significant improvement in symptoms of perceived breathlessness and muscle fatigue during exercise.

Traditional models of medical care are challenged by the growing number of older adults with chronic, progressively worsening illnesses such as COPD. Cognitive - behavioral interventions may help patients adapt to loss of function and, when successfully used in a comprehensive rehabilitation program that includes training in energy conservation and the use of assistive devices, may even help to increase function. As a result, behavioral interventions can improve quality of life for patients with chronic pulmonary disease.

As in our discussion of behavioral medicine research, this section on the practice of behavioral medicine has highlighted some areas of active interest. Behavioral medicine practitioners have developed successful interventions in many other areas, such as diet and physical activity, tobacco use, and pain management.

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