Facing a Cancer Diagnosis
December 21, 2008

Welcome to Yale Cancer Center Answers with Dr. Ed Chu and Ken Miller.  I am Bruce Barber.  Dr. Chu is Deputy Director and Chief of Medical Oncology at Yale Cancer Center and an internationally recognized expert in colorectal cancer.  Dr. Miller is the Director of the Connecticut Challenge Survivorship Program and he is also the author of "Choices in Breast Cancer Treatment."  If you would like to join the discussion, you can contact the doctors directly at canceranswers@yale.edu or 1-888-234-4YCC.  This evening Ken welcomes Dr. William Sledge.  Dr. Sledge is the George D. and Esther S. Gross Professor ofPsychiatry at Yale University, and he joins us this evening to discuss coping mechanisms for patients diagnosed with cancer.

Miller              
Let's start off by talking about cancer, and a perception that I think has been the case for many years, that it is a death sentence, which I do not think is true, but let's talk a little about the initial experience when people find out they have cancer. What is your experience with that?

Sledge             
It is true that it is a frightening moment in a person's life, and one of the great things that we can do is reassure them with the outstanding data we have on the progress we have made in some illnesses, and make sure that they understand that.  The best antidote to fear is knowledge and information, and patients and their families should be encouraged to ask questions. It is sometimes hard to do when you are worried and scared about what the future is, you cannot or do not want to know things. Physicians, and the people working in support of the physicians, need to be encouraging of that asking. Knowledge is the way out of this, as well as the reassurance of family, friends, and practitioners.

Miller
Let me ask you a question about statistics. We have information, and we could actually say to the patient, well there is a 59% chance of survival, or 72%, and in many cases we could give a number. What is your perspective on that? Is that useful? Is that harmful?

Sledge
I think it is very helpful, and what is even more helpful is some connection to somebody who has been through an illness similar to the patient, and talking to them about their experience. That is why survivor groups are so critical in this equation. Of course you know survivorship now starts the day you get the diagnosis, and that is appropriate given the effectiveness of our treatments, but it also is helpful in getting that bit of knowledge and that bit of experience into the mix. There is nothing like talking to somebody who has been through it, who has had the same illness and has come out on the good side of it. It is enormously reassuring.

Miller
We will skip ahead a little bit. I know that you are involved with a study looking at peers. Can you tell us a little bit about that?

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Sledge              
We are looking at a variety of ways that people respond to chronic illness. We have discovered over and over again that in a number of different chronic illnesses the sufferers of the illness get a lot of benefit from helping others who are suffering as well. This kind of altruism, medical altruism if you want to call it that, has intrigued us about how it works, so we have extended our look to the people who volunteer for survivor programs. We are trying to better understand how they experience the benefit to them of helping other people.

Miller
It is fascinating. We started out by saying that the newly diagnosed patients get a lot out of it, but so do the other people.

Sledge
Absolutely.  There is no question about it that it works in a way that we do not fully understand; it works to help others give back. To be of assistance to them is enormously invigorating and somehow helps restore people to their image of themselves before they get sick.

Miller
That is wonderful.  What are the phases for people who are just receiving the bad news of their cancer?

Sledge
There are several phases.  The first one is always shock and fear and imagining and fearing the worst. This is a particularly dangerous phase because you don't want to know anything and you can go into a state of resistance to that knowledge and finding out about it. That could lead into a bad kind of denial that keeps you from knowing the facts. This is a critical time to try hard to learn as much as you can and not become too caught up in resisting the knowledge. Then, as one gets familiar with the people involved and maybe starts talking to somebody who has been through it and understands more of the facts and figures, you get into a stage of a kind of engagement with problems where you adopt a strategy. The strategy is hopefully that you are going to fight it, and you are going to do everything you can on your side to reduce the risk factors, and you are going to cooperate with the caregivers and have a chance of beating it.  Then, as one gets more materially involved in it, by material I mean you get experience and you know more about it, then you start creating the life that you had before. It may be back to the way things were with monitoring and surveillance, or you may have to adjust to some kind of loss of function, or an illness that is going to be hard to make go away.

Miller
Let's talk a little bit more about that. You talked about people drawing back and there is some denial. Is that a backward step? How do you look at it?

Sledge
It is an inevitable step and denial is a complex mental mechanism. It has a good side, in that it protects you from knowing things or experiencing things you are not ready to, and in

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that sense it is something that we should respect and not try to bull our way through.  On the other hand, there is a bad kind of denial which keeps you from knowing the things you need to know to recover and take control of your life and your circumstances. Practitioners have to be careful to make the distinction between these kinds of denials and help people maintain a certain ability; don't tell them too much or things they are not able to hear, and don't try to force them, but on the other hand, gently urge them to learn more, to understand more, to appreciate the facts and details, and the reality of what they are facing.

Miller
There are people listening to the show who have been diagnosed recently, or have been through the cancer experience before. Let's focus on those recently diagnosed; what are some ways to manage that news?

Sledge
One is to have a good trusting relationship with the people taking care of you. Engage them and ask them questions when you have questions. There are always questions, and there are things that you are told initially when you hear the bad news that you do not remember, or do not understand. You have to keep coming back to them and you have to just keep plugging away at understanding it.  The other is to talk to your family and your friends and be open about it. You do not have to go around proclaiming it of course, but do not let yourself get caught up.  Sometimes cancer, like some mental illnesses, has a kind of stigma associated with it and people feel ashamed that they have this illness and they feel they cannot talk about it to others or speak to their best friends or their family about it. That is a state of mind that frequently ends up putting people in a feeling of being isolated and cutoff from the natural supports.  Everybody needs to work on maintaining those natural supports of family, friends, and professional practitioners, and looking out particularly for the emergence of depression, which is a very common sequela of any kind of chronic illness, but particularly cancer.

Miller
Let me ask you about this because you were saying that a person just diagnosed may not be willing, or may not want to talk to their family or to a friend. Filling in the blank here, I do not want to talk to my family because…what would be the reason?

Sledge
Because they are afraid.  They are afraid of being a burden and afraid of how their family is going to react.  People fear the worst, which is an early death and a painful death, or a burdensome death, but in fact, knowledge and technology is very much ahead of that.  It does not mean that we can always cure cancer, and it does not mean that we can always prevent death, or an early death, but we have made such great progress on it that that kind of response, that first response, it is usually not realistic. What is more realistic is facing the fact that you have an illness. It is going to require intensive treatment for awhile that may be burdensome and troublesome, but one which you will likely come through with some

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element of success, if not a major element of success. The focus really needs to get away from the fearful, unrealistic part of it, and focus on the realistic part of dealing with some time off from work, some discomfort of maybe chemotherapy or radiotherapy, and forging an adaptive response to that.

Miller
People or patients may be hesitant to tell their doctors that they are worried, or concerned, or afraid, and they may say they do not want to talk to their doctor.  What would be the reasons for that?

Sledge
They are afraid of what they might find out, and they are afraid that what they might find out is they have got some awful illness. This is a very understandable and natural human response; we all put off facing possible bad news.  It is just human nature and that is the way we are, and for the most part it is not so bad to do that, but when you are talking about something that can be treated in early stages more effectively, you do not want to put that off, you want to participate.  People who have a family history of cancer should be assiduous and assertive about all the different kind of screening tests and approaches available to surveil their potential for getting the illness early on.  Typically, the earlier it is diagnosed, the better your chances of defeating it.

Miller
William, you mentioned depression, for the listening audience, can you tell me what depression may look like to a family member who is watching it?

Sledge
Depression is a complex idea. Depression is a natural feeling that we all experience, and we call it sadness or depression. It is not necessarily an illness, but when we talk about depression as an illness, then we have major interferences with function.  People who are depressed as an illness are very pessimistic, irritable, have trouble sleeping, lose weight, and have trouble concentrating. They have this feeling of gloomy sadness that permeates everything and they feel very pessimistic and cannot see any future or the bright side.  Depression associated with any illness always complicates the illness and makes it harder to recover from the illness and harder to get the proper treatment.  Depression is like a risk factor, it ought to be treated aggressively. It is kind of like smoking.  If you are smoking and you have cancer, you need to stop smoking. If you find out you got cancer and you get depressed, you need to take care of the depression. It will make your recovery much more effective.

Miller
We are going to come back to that in a couple of minutes. We are going to take a break for a medical minute. We will return to talk more with Dr. William Sledge, Professor of Psychiatry and active in the Psychosocial Support Program here at Yale Cancer Center.

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Miller
Welcome back to Yale Cancer Center Answers.  This is Dr. Ken Miller and I am joined today by Dr. William Sledge to discuss methods of coping with the diagnosis of cancer.  William, we were just talking about depression a couple of minutes ago, what can you tell us about that in terms of treatment and success rates in treating depression?

Sledge
The success rates are pretty good.  We have two major approaches to treating depression and typically they should be combined. They both do better if they are combined with each other.  One is medication, and we have a variety of medications. Science is rapidly developing the specificity and ability to be able to figure out exactly who should get what kind of medication, but right now it is kind of trial and error. We have to try one, see how it works, and if that does not work, we move to another kind.  The other kind of treatment that is very effective is psychotherapy, and there are different versions of it, but they all work pretty well in the hands of skillful practitioners that know how to do it. These forms of treatment can be considered brief treatment, where they go on for a limited number of sessions, 10 or 12 or so, or an ongoing treatment of a supportive nature that is more open-ended. The combination of those two is very effective for treating most kinds of depressions, particularly depressions that are precipitated by the experience of having cancer.

Miller
My own experience as a clinician is that most of us as people, and certainly people going through the cancer experience, have some experience with depression, is that your feeling as well?

Sledge
It is.  It is sometimes hard to distinguish distress from depression, but there is virtually no way to have cancer and not have something like depression and anxiety or worry and disturbance; that is completely normal and by itself it does not necessarily require

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treatment.  It should be considered something that requires treatment when it persists, when it is more unrelenting, when it begins to interfere with decision-making, interfere with normal function, where you cannot sleep, when you are thinking all the time about it, when you get irritable and are unable to carry out normal everyday functions, then you need to step back and say, maybe I need some professional help with this.

Miller
Something that I think you have a lot of expertise on in your career and your research is differences in coping strategies as we age. What have you seen in terms of young adults and older adults?

Sledge
People are more alike across the age spectrum than they are different, but obviously according to your age you have different ideas about what is ahead of you. The older you are the less likely you are to feel like you have something undone that has to be done, and you are less likely to have people who are dependent on you.  One of the major issues is if you have people that you support and are dependent on you. If you are going to be sick and disabled for a while, that is obviously a big worry and a concern.  The presence of family makes a lot of difference, and the kind of family.  Young people, really young people, children, have a hard time really understanding what the illness is and they tend not to be as upset about it as older people who can really think about the prospects of it and can understand it.  Young people tend to be resilient and have a great capacity to put off and not worry too much about the consequences, but when are in that kind of middle period where you have got young children and a family to support and people dependent on you, then of course that is the hardest time.

Miller
Let's look at the flip side, which is a positive outlook and optimism, what effect does that have on the process for both patients and their caregivers?

Sledge
It is a good question and the science on this issue is mixed.  We all think that being optimistic makes a difference.  The science is not so clear about whether or not it makes a difference.  Clearly, being optimistic and being in charge of your circumstances makes it easier for everybody to help you, take care of you, and work with you.  Usually the person who does feel that they are going to fight it and win out has a more positive experience throughout the course of the illness.  What is not clear is whether survival is any different. You cannot necessarily control how you feel, you cannot make yourself be optimistic when you are not, and so if you have this experience and you feel very pessimistic and you are having trouble, you can't just make yourself be positive. This is when you might need some help either from family, friends, or professionally if that is not enough.

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Miller
It is a good point. Sometimes we feel like telling a friend or relative to just shake themselves out of it and move on, and like you said, it is difficult to do.

Sledge
It is very difficult to do and that's usually not very good advice.

Miller
Is acceptance a part of moving on beyond treatment?

Sledge
Acceptance is a very interesting concept.  If acceptance means that you appreciate the reality of what you are going through and you make an adjustment, then that is clearly a good thing, but if acceptance means a kind of passivity of giving up, that is probably not a good thing.  Acceptance from the point of view of being realistic and understanding what kind of limits you may or may not have presently and in the future, that is good, that helps everybody make good decisions, make the right decisions for themselves, but if it is just simply "giving up," that is not such a good thing. It is a demoralizing thing, demoralizing for the sufferer and demoralizing for those around them as well.

Miller
When our patient cancer survivors are finishing treatment and going back to what we call "normal life," or the regular day-to-day life, what are some of the issues that they face and what are some tips for them?

Sledge
Some of the issues are what to tell people about your illness and how much to go into it.  For the most part, strangers, or people not close to you, will ask but they do not really want to know. You should not be too offended if they seem to turn away or do not make eye contact after the first couple of sentences. You have to find a strategy for what you tell people about your circumstance.  The other thing I think is important is to get over any sense of shame or stigma about it and feel comfortable telling people what has been going on and how you have adapted.  My sense of people who have been through cancer, even those who have been very successful, have with them a residue of worry about recurrence, and that is completely understandable and appropriate.  They have got to have a way of handling that, and that is usually between them and their practitioner as a way of following up, checking on early sign indicators in a regular systemic way, and that needs to go forward and be accomplished and not be allowed to slip into that world of bad denial and dropped.  The other thing is sometimes there are real limitations; there are surgeries that may have been transformative of one's body, where your body is different, and there may be consequences of some of the treatments that make you feel different for a long time. You may look different, and so you have got to have an approach. It is best to have a conscious clearheaded approach to dealing with these differences.  They may be
differences in function, they may be differences in appearances, but they need to have a strategy for how to handle it.

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Miller

As you know, and I will share with the audience too, early in 2009 I am going to be leaving Yale and moving on to a different position, but it has been very exciting seeing what's happened, and what will be happening, in terms of psychosocial support here at Yale. Can you tell us a little bit about what you are excited about?

Sledge
The dedication of the University and the hospital in creating the Smilow Cancer Center, and the citizens of Connecticut who have supported it, is really a great thing for the region. It is going to become a much more comprehensive approach to cancer care and that is going to entail not only the medical and biomedical approaches that we will be able to bring to bear, and the kind of people we will be able to attract here to work, but also the psychological and psychiatric side of things. We are working hard now to come up with a plan for that, and as you know, there is recruitment for a Yale Cancer Center Director that is underway, and we have to see exactly who that is going to be and what their approach is going to be, but the Department of Psychiatry is eager to be of assistance and help in all of this and we are looking forward to it.

Miller
The team of healthcare professionals who are available for patients with cancer and their families includes whom?

Sledge
That is an excellent question and sometimes very puzzling to people.  It should be a multidisciplinary approach, including people from many different disciplines, all of whom have something specific to offer; medical social workers, nurses trained in psychiatric oncology, psychologists, and the medical practitioners who are psychiatrists trained in particularly mental illness, but also specific aspects of the mind-body interface and has to do with cancer. The best of circumstances is all those groups, including psychologists, working together in a coordinated approach, each doing the thing that they do best in helping one another to help other people.

Miller
If someone wants to seek resources through Yale Cancer Center, or through their oncology provider, how do they do it?

Sledge
The best approach is through their provider. The services are changing, and whatever I tell you right now is probably not going to be up-to-date, but the best place to start is through the various clinics and survivor program that you are associated with.

Miller
Thank you, and actually thank you for that little plug for the Survivorship Program.  You have been listening to Yale Cancer Center Answers and I would like to thank my guest, Dr. William Sledge, for joining us.  Until next week, this is Dr. Ken Miller from the Yale Cancer Center wishing you a safe and healthy week.

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If you have any questions for the doctors, or would like to share your comments, go to yalecancercenter.org where you can also subscribe to our podcast and find written transcripts of past programs.  I am Bruce Barber and you are listening to the WNPR Health Forum from Connecticut Public Radio.