Emotional Distress and Cancer Outcomes

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic Podcast for medical professionals exploring the latest innovative research and clinical advances in the field of oncology. Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepherd, a Medical Oncologist and Co-Director of the Sarcoma Program at Cleveland Clinic. Today I'm happy to be joined by Dr. Shiyao Wang, a Psychosocial Oncologist in the Department of Palliative and Supportive Medicine here at Cleveland Clinic. He's here today to discuss emotional distress and outcomes with cancer treatments. So, welcome.

Shiyao Wang, MD: Thank you.

Dale Shepard, MD, PhD: So maybe just give us a little brief overview of what it is you do here at Cleveland Clinic.

Shiyao Wang, MD: I'm a psychiatrist by training. I'm a psychosocial oncologist under the Department of Pediatric Care Medicine and Supportive Care under Taussig, and I see patients for their emotional needs and psychiatric conditions while they're receiving their cancer treatment at the clinic.

Dale Shepard, MD, PhD: Excellent. So we're going to talk about a really interesting thought, and that's about emotional distress. And of course, that's not anything unusual, really, to a lot of our cancer patients and how it might impact actually their treatment. So, how do you as a psychiatrist define emotional distress?

Shiyao Wang, MD: Right, so emotional distress can entail so many different aspects of people's life. We always approach people from a biopsychosocial part. People can experience anxiety, depression, they can have issues with sleep, they can have anger, irritability, which can always get in the way for them to communicate with other people, with their medical team. Also, there are a lot of other things going on in their life, their school, their family obligation, their work, or just navigating finance and other distress in life. So everything they can boil down to this emotional distress, which requires a comprehensive assessment of what patients really needs.

Dale Shepard, MD, PhD: Not surprisingly, if people get a cancer diagnosis that ups the emotional distress. How do we measure that in the best way?

Shiyao Wang, MD: Right. So there are a few skills and questionnaires we use or we built in EPIC system, but everything's on a spectrum. During the cancer treatment, inherently it's one of the most difficult diagnosis people can receive and can certainly bring up a lot of emotions and feelings. When it comes to assessment, we sort of figure out what are the extent of their distress. And if there's anything we can intervene, and what is the best approach to help those people.

Dale Shepard, MD, PhD: We're going to talk about specifically emotional distress and how it might impact care. And we've always thought that being in the right mental space is important. So, how did you come to think about these relationships, and what have we known historically and what are we learning now?

Shiyao Wang, MD: Historically, we have a lot of data supporting that. Patients with depression, they tend to do worse with their cancer, especially in the breast cancer group that we know that people tend to make medical decisions that is not beneficial for their long-term survivorship. And we also know that people tend to have poor quality of life during the cancer treatment if they are suffering from mental health conditions. And we know for people go through bone marrow transplant, if they're having more psychiatric mental health conditions, they tend to have more chronic complications like GVHD. So in the past we know that there is a problem, but in this specific study we sort of trying to speak the language that oncologists speak. Specifically in the non-small cell lung cancer, we know that with emotional distress we tend to have poor treatment outcome. So we're trying to tune in the same channel and talk about the treatment outcome with oncologists.

Dale Shepard, MD, PhD: And so I guess you just alluded to, you are a co-author on an editorial about a trial that looked at immunotherapies and emotional distress. Why specifically is the thought that immunotherapies might be impacted more with emotional distress?

Shiyao Wang, MD: I think both mental health piece, when people are going through emotional distress and going through cancer treatment, one of the mediator between the two will be the immune system being compromised, or a very important part of cancer treatment is trying to boost the immune system so it can kill the cancer cell. And we have increasing amount of body of research showing that when people are having chronic mental illness, their cytokine, their HPA axis, they are out of whack, and people tend to have increased inflammatory markers. And I think that's really where the researchers find it's a good point to intervene and to research and investigate. And if they realize that there is a connection between the treatment outcome and emotional distress.

Dale Shepard, MD, PhD: When the study, the thing was called the STRESS-LUNG-1 trial, how did they set about looking at specifically what level of emotional distress? I mean, how much emotional distress was necessary to actually impact outcomes?

Shiyao Wang, MD: The tool they were using, the study they were using PHQ-9, which is the screening tool for depression, and using the GAD-7 which is screening tool for anxiety, they cut a score of PHQ-9 is five and cut a score of GAD-7 is seven. So every patients who scored higher than that threshold is deemed as under the emotional distress and they compare the outcome for those who do not have emotional distress.

Dale Shepard, MD, PhD: And then what was the impact on response rates or survivals? How big was the impact? Was it a big change?

Shiyao Wang, MD: Right, so the study, they involved over 200 patients and the primary endpoint analysis they showed that patients with emotional distress, they tend to have significantly shorter median progression free survival compared to those who do not have emotional distress. And also they realize the emotional distress is associated with lower objective response rate, and the difference can be over 46% versus 62%, and reduced the two-year overall survival rate and overall decrease quality of life. They also found these outcomes were consistent across the subgroups, whether patients having PD-L1 expression, their gender, their age, whether they smoke with their pathological histology or whether they have metastasis. So, it's something that can be generalized to this patient population.

Dale Shepard, MD, PhD: That's pretty impressive. So the response rate, nearly 20% difference in response rates. I mean, we have treatments that we give that don't lead to that big of a difference in response rates, right? I guess, being mindful of something like emotional distress is pretty important. How do we do better at recognizing emotional distress? As an oncologist, you're going to seeing patients, you're trying to take in everything, but I got to admit, oftentimes that's something we don't necessarily pick up on as well as we should. How do we do better?

Shiyao Wang, MD: We have very limited clinical time and you have so many things to cover for a follow-up, especially when somebody is going through cancer treatment. I think being aware of the emotional piece, the psychiatric piece, bring this up. And just put this as part of the review of system during your assessment, I think that's the very good first step. And once you realize patients start to have signs and symptoms of emotional distress, we will involve social worker team or psychiatry, psychology team to do a more thorough assessment, understand what their needs are. But oncologist are the first point of contact. It's very essential for them to be able to at least bring this up and let the patient know we have this service being offered in the clinic.

Dale Shepard, MD, PhD: What have we done here at Cleveland Clinic in terms of having patients fill out questionnaires before visits or having screening by social workers to catch this?

Shiyao Wang, MD: For all the cancer patient, every cancer patient over here, they have a clinical social worker who establish relationship with them upon the cancer diagnosis and understanding their social background and the things that can be supported with the clinic. And a lot of times what happened is during the visit when patients bring up their distress, bring up their struggles, the oncologist would page the social worker to come to meet the patient and do a safety assessment, and understand at this point what can be the best approach to help this patient.

Dale Shepard, MD, PhD: I guess, just back to sort of really quickly to the results showing differences in response rates and things like that. And I know how much this has been studied, but how much of it is the biology, which you mentioned things about emotional distress and how that might impact the immune system? How much is biology and how much of it is just simply things like people emotional distress may be more likely to miss appointments or not come for therapies? How do we differentiate those things?

Shiyao Wang, MD: I think it's very hard to peel things off, but we know more and more when people are under chronic distress, we see the biomarkers that is consistent with patients. Patients have cardiac issues, cancer or other medical issues. I think a few reasons can be contributing to that effect, the dysregulation of HPA axis and increase the inflammatory biomarkers. And also we know that when people are under chronic distress, they tend to have decreased CD8 activity or NK cell activity, which plays an important role. Of course, not being able to communicate with better or well with oncology team, when they start to have symptoms, they're not reaching out. Or they're just genuinely not making good decisions when being presented with various options of next step treatment or effectively engage the caregivers in their cancer treatment can all have impact on their final cancer treatment outcome.

Dale Shepard, MD, PhD: You mentioned biomarkers, at this point, immunotherapies, maybe even with other therapies down the line, do you think we may get to a point where some of these assessment tools are essentially a psychological biomarker for a need to improve emotional distress before starting treatment? I mean, we've talked to the physical medicine folks about prehab. How can you optimize someone before they get treatment? Is it possible maybe we have these as a marker to say, "Look, we need to do something before we even start treatment."

Shiyao Wang, MD: Right. There's a trend of immune psychiatry, right? More and more stuff are being identified from a structure or biomarker standpoint of psychiatry, but at this point we do not have any evidence based approach to suggest to do any of the tests before the treatment, and to determine the efficacy of potential treatment. But I think it's ultimately on the way to get developed.

Dale Shepard, MD, PhD: And I guess in a similar line is, does it seem likely that people that already come in with a mental health issue that we should make sure that that's optimized? And I think it's something we sort of consider as we think about starting treatments, but maybe not as rigorous a way as we should?

Shiyao Wang, MD: Over here, a lot of patients we see it'll be their first contact with mental health providers. However, there are fair amount of patients who come over here, they have pre-existing anxiety, depression or other mental illness that is very much exacerbated during the whole cancer treatment. For folks like that, certainly get us involved or have our team to be part of the cancer treatment team can help them to navigate through this very difficult time.

Dale Shepard, MD, PhD: How can we do a better job of educating providers to be mindful of that? I mean, busy clinics, people... I think sometimes hesitate to even find out about these things. They're not really quite sure what to do about it once they know. It's an unfortunate reality. How do we do a better job of educating providers about these sorts of things?

Shiyao Wang, MD: If there's difficulties to provide intervention, sometimes we are very hesitant to figure out whether we should identify that problem. But whether you identify it or not, the problem is still there. So being able to understand while you have a whole team here, you have the whole mental health team and social work team to work around this matter with you. Oncologists, your job is to identify and refer patient to proper resources. We do not expect you to intervene with acute psychiatric presentations, but be aware there's likelihood, patient might be going through of this, and just treat this as part of the screening of your review of system. When you go through the whole GI symptoms, respiratory symptoms, ask about the mental health as well. And if there's something shows up, let us know and we will help.

Dale Shepard, MD, PhD: And unfortunately, there's a stigma associated with mental health concerns. And so, how do we do a better job of educating the patients to be forthcoming? Because sometimes they just don't tell us things.

Shiyao Wang, MD: That's a great question. A lot of job we do over here, the two cancer psychiatrists and our cancer psychologist, we tend to do a lot of work on the psycho education and destigmatize the mental health in general because we would take the approach of how we can support them to achieve their goal during the cancer treatment as to how can I treat your depression? A lot of times we just bluntly tell the patient, "We're here to help your symptoms. You mentioned that you are crying a lot, you are lashing out quite often. You are having issues with sleep. Can we work together to help those symptoms?" Instead of saying, "Can we take away your depression," right? So when we word it this way, it really helps people to understand, "Oh, it's part of my cancer treatment. I'm feeling better once I start to work with this group of people." And they really are supportive during this very difficult time.

Dale Shepard, MD, PhD: So if you think about it, the resources we have here on main campus, we have the psychologists, we have the social workers, we have the psychiatrists, we have a pretty well integrated group of people. How does that compare to the regional hospitals? How could people in our regional hospitals and our community practices utilize the support that you can provide?

Shiyao Wang, MD: Yeah. So over here our program, we have two full-time cancer psychiatrists and three cancer psychologists. We'll have another cancer psychiatrist joining us in January next year. We do take referrals from all Cleveland Clinic sites as long as patients are receiving their care under the clinic. And even if the patient is receiving their care in the regional hospitals, the mental health services remain available for them. We also have a lot of resources in the community like peer support group with 4th Angel Program. We have other services, the massage therapy, reiki over here that patient can also utilize. So it doesn't matter which part patient is located, as long as they're part of the clinic, we're here to help them.

Dale Shepard, MD, PhD: And so those regional hospitals, there's social workers that can do assessments and do referrals and that sort of thing as well, right?

Shiyao Wang, MD: Yes.

Dale Shepard, MD, PhD: Okay. It's a really, really important topic. This emotional stress is a very important part of cancer journey. And seeing data where it actually impacts on the benefits of the treatments themselves is really eye-opening. And I appreciate you coming and giving some insights.

Shiyao Wang, MD: Thank you for having me.

Dale Shepard, MD, PhD: To make a direct online referral to our Cancer Institute, complete our online cancer patient referral form by visiting clevelandclinic.org/cancerpatientreferrals. You will receive confirmation once the appointment is scheduled.

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