Psycho-Oncology Support

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals exploring the latest innovative research in clinical advances in the field of oncology. Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepard, a medical oncologist here at Cleveland Clinic overseeing our Taussig Phase 1 and Sarcoma Programs. Today I'm happy to be joined by Dr. Kaleena Chilcote, Director of Psycho-Oncology at the Taussig Cancer Institute. She's here today to talk to us about psycho-oncology support at Cleveland Clinic. So welcome Kaleena.

Kaleena Chilcote, MD: Hello. Thank you for having me.

Dale Shepard, MD, PhD: Absolutely. So maybe just start out, give us a general view of your role here at Cleveland Clinic

Kaleena Chilcote, MD: Sure. So, I'm a psychiatrist. I'm employed by the Department of Palliative Medicine and Supportive Care here at Taussig, and I serve as the Director of Psycho-Oncology, as you mentioned, so I, in that role, supervise a team of mental health providers.

Dale Shepard, MD, PhD:Excellent. So just so we can start off on the right foot here with everyone understanding this, psycho-oncology, what exactly is that?

Kaleena Chilcote, MD: Psycho-oncology is a term that describes a field of medical practice, just like cardiology or endocrinology or something, and it describes the practice of mental healthcare in patients who have cancer.

Dale Shepard, MD, PhD: What are some of the most common things that you would be seeing in your clinic and when patients are coming to see you?

Kaleena Chilcote, MD: Part of why I like the job is that it's very varied. We see a pretty wide range of things. One, because we see patients with new mental health symptoms, but we also see patients who have chronic struggles with their mental health, and so it's a good mix of people. Our most common referrals come for symptoms of depression, anxiety, or sleep disturbances, insomnia generally.

Dale Shepard, MD, PhD: And again, you said there's a wide range, are most of these patients that are sort of self-identified and say, ''Look, I need some help here.'' Or do you get a lot of referrals usually from their oncologist or other providers who say, ''Look, we need some help in managing this patient's symptoms.''

Kaleena Chilcote, MD: It's a mix. We certainly see a fair number of people who identify that they are struggling and seek care. But I think probably more than 50 percent of patients, the idea is brought up to them by a member of their care team, whether that's their oncologist, or maybe a social worker, or someone that has identified that they seem to be having some struggles that we could be helpful with. Sometimes that's a more mandated part of their treatment than other times. For example, if someone needs a stem cell transplant and their mental health is really increasing their risks for complications, they may be pushed a little bit harder to come and meet with our team and see how we might be helpful. And for others it's completely their idea on something that they want to participate in on their own.

Dale Shepard, MD, PhD: And this may seem, on the surface, a strange question, but just for perspective, we oftentimes think of managing somebody's blood pressure or managing other symptoms, but why psycho-oncology, and how does that really impact a patient's journey through cancer? And how the really adequate control of their mental health issues helps them in their journey through a cancer diagnosis?

Kaleena Chilcote, MD: Mental health struggles in cancer are incredibly common. We know, in general, probably 25 percent of patients who have cancer, at any given point in time, meet criteria for a depressive disorder. 25 percent, that's a lot of people. And it's probably a similar number when we look at anxiety. Insomnia, it's probably even higher than that. So, it's a huge part of the population that we serve. And we also know that cancer can exacerbate struggles that people are already having. And we know that when we struggle with our mental health, it can significantly impact our cancer care and perhaps our cancer outcomes. Just using depression as an example, we know that people who have cancer and also have depression at the same time are likely to make different choices with their treatments. They've done good studies, like with breast cancer, where they show patients who have depression and breast cancer are less likely to participate in adjuvant chemotherapy, compared to someone who does not have depression but has the exact same cancer features.

We know that people engage with their teams in different ways when they have depression. They're more likely to call frequently for appointments in between those that are scheduled, or to go to their local emergency department to request hospitalizations for symptom management. Depression increases all those things. And depression also increases cancer-related outcomes, maybe for reasons we don't always understand, but very specific studies have shown things like, someone who has depression and has a stem cell transplant is more likely to develop chronic graft-versus-host than someone who does not have depression. And we know even just mortality in general is higher in patients with comorbid depression as they go through their cancer journey. So, there are very clear reasons we as physicians should be paying attention to this, and why hospital administrators are starting to pay more attention to this as well.

Dale Shepard, MD, PhD: And just thinking of the importance of the psycho-oncology and things you're working with and helping oversee, something we call depression and that state of mind, is it really the same for someone who just was told they had cancer, compared to someone who has a history of depression? Is that really the same disease? Even though we're calling it the same thing, is it really the same disease?

Kaleena Chilcote, MD: Not necessarily. The terms that we use as psychiatrists are diagnoses that were put in a textbook that we all have to follow, that were mostly developed for the purposes of things like research, and billing, and reimbursement. Patients themselves don't always fit into those boxes, and yet we're sort of stuck using those terms a lot of the time. So, I think we focus a lot more on the symptoms when we think about how we're going to manage a patient. There is certainly a difference between someone with chronic depression they've had for years and years and years, and somebody who hears a very stressful thing, or experiences a very stressful thing and now has symptoms, that may be more like an adjustment reaction.

In cancer, we also see demoralization a lot, which is subtly different than depression, and something that responds more to therapy. And that would be someone who now can't do the things that give them meaning and purpose, because they're ill. And now we need to rethink how we find value in our daily lives. And that's a really challenging thing to do. And that's different than regular old depression in a textbook as well.

Dale Shepard, MD, PhD: So, within our psycho-oncology support at Taussig, what kind of tools do we have? You mentioned that you're overseeing a group of psychiatrists and psychologists, what kind of services do we provide?

Kaleena Chilcote, MD: As a psychiatrist, I can prescribe medications when those are indicated to help with mood, or anxiety, or sleep, or some other struggle that someone might be having. We also have a team of psychologists, and on our team now they are all PhD psychologists who have done a lot of training and have a lot of experience specifically working with people who have cancer. And they can help with what we might commonly call talk therapy, where you get to come and talk with someone who has a great deal of experience to help maybe bounce ideas off of them, or have a good listening ear who's not a friend or family member. But more importantly who can help us to really start to identify patterns in the way that we think, and then actually change those patterns, so that we can see long-term improvements in the way that we deal with stress, and help to be more effective in that.

Dale Shepard, MD, PhD: And I know that certainly within my program, our social workers have been helpful at directing patients into the right path, and so how do you work with our social work support?

Kaleena Chilcote, MD: Our social workers at Taussig are not a direct part of our program, but I view them as an extension in a lot of ways.

Dale Shepard, MD, PhD: Oh yeah.

Kaleena Chilcote, MD: Yes, they are a fabulous group of people and I have contact probably with a dozen of them every single day. We are really integrated, in terms of working with individual patients to develop plans that will be supportive of them. Social workers are also often really important in screening patients. So, when another provider identifies someone who seems to be struggling, a social worker can do a little more in-depth assessment and decide what services might be most helpful for that patient. And they often communicate with me about folks ahead of time, so that we know what we're looking for and how we might be able to help.

Dale Shepard, MD, PhD: And so, what does that typically look like? That either a physician or a social worker, someone says, ''We need help.'' Where does it go from there?

Kaleena Chilcote, MD: It depends on the circumstances. I think most commonly it's not an urgent issue. It's something that the patient would be referred through Epic, they get scheduled with our team, we meet them to do an assessment, usually a 60 or 90 minute visit where we really get to understand their history, where they're coming from, how they might view the world, how those experiences they've had might be impacting how they think about things now. And then gather a good assessment of their current symptoms to figure out how we can, as a team, help them to move forward.

And that often involves the social workers. It might involve a combination of medications and therapy. It might mean that we help them get a gym membership, or hook them up with someone from our patient resources team, like Reiki, or yoga, or any of those other services that feel important to them. And we typically follow patients. I see patients who are getting medicine about once a month, our therapists might do once every two weeks, or once every four weeks, while people are struggling. And then once we start to do better, we start to space appointments back out again.

Dale Shepard, MD, PhD: And then along the same line of how logistically this work really is, a very practical question. As physicians, how can we be better partners to get you the patients that you can help?

Kaleena Chilcote, MD: I think one of the biggest challenges is often just making sure that we as a liaison service are making sure that we address the issues that the oncologists have identified. So, any information you can pass along about patients, because you know them better than us, any special things they said or things you want to make sure that we address, if we can include those in the order, or shoot a text message or an email, or whatever, that can really help us to make sure we're addressing the questions and the concerns that are on your mind.

Dale Shepard, MD, PhD: And when we think about issues, we see patients really in all stages of their cancer journey. We see them when they've just found out about their cancer, and the struggles during treatment, and then we have survivorship issues. And from a psycho-oncology standpoint, tell me a little bit about how you think through patients from beginning through survivorship.

Kaleena Chilcote, MD: That's a big question. People's needs certainly can change over time. So, what we tend to see when people are just diagnosed are high levels of anxiety, related to all the unknowns, all the things that are out of their control. And we see these spikes in that same way anytime people have scans coming up, or labs, or treatment's going to change, they're just finishing something, they just finished radiation, or they're about to start a new treatment. We see these spikes, where we might need to see people a little more frequently at times and then space them back out again. We continuously do assessments to make sure that we might at some points need to bump up medicines and then pull back on them. Someone might need a sleep medicine for a brief period and then they don't at other times. So, we really follow people pretty closely during those transition periods.

As we start to work toward survivorship, care can look different for different people who have had different circumstances. Some cancer types, we actually see that patients who complete their treatment and now have no evidence of disease, actually have the highest levels of distress in their whole course. That's been shown in groups like breast cancer, where they're so focused on treatment, they did really well, and now we get a big spike when we go into survivorship, when care is changing, our appointments are less frequent, we have less supports potentially.

But there are other cancer groups where survivorship may be a time where things really drop off and we start to do well, and we get back to life, and our routines, and the things that are meaningful to us. And then there are other groups where there's lots of chronic distress. Head and neck cancer is a great example of that, where people had interventions as part of their treatment plan that cause a lot of impact on their daily life. And so now we're dealing with this distress that continues, perhaps for years, and maybe that survivorship time is where the most help is actually needed to help people to become a little more functional, feel like themselves and move forward.

Dale Shepard, MD, PhD: During the survivorship period, one thing I try to keep an eye out for, is fear of recurrence, and not even just about the scan times, it sometimes is a just pervasive problem. How common is fear of recurrence and what can we do to help our patients?

Kaleena Chilcote, MD: Fear of recurrence is incredibly common. The data on it is kind of crappy, they show something like a range of 23 percent to 97 percent or something, in the studies. So, it's a lot of people is the takeaway. And one of the tricks with fear of recurrence is actually that it doesn't necessarily get better over time. And there have been a lot of studies that show some people actually continuously have more fear the further out they get. I hear from patients a lot, this sort of idea like there's a ticking clock, 'The statistics say my time is getting shorter and shorter.'' And so, we see this fear continue to go up each time they get scanned.

And the other real challenge is that medications are often not as helpful for that, as we might see with other kinds of anxiety, because even the best medicine I can give you for anxiety is not going to make you just forget you had cancer. All they can do is help maybe give us some breath so that we can tolerate a little more, take a pause before we respond or our emotions take over, get a little time to think about what coping skills we can use, or bring things down so they're not quite so spiky but more manageable. And so, therapy really becomes super important for patients where fear of recurrence is so big, because we can start to identify those patterns and how we think and work on them, and that's been shown to be quite helpful.

Dale Shepard, MD, PhD: What are some of the biggest challenges in getting patients involved in a psycho-oncology program?

Kaleena Chilcote, MD: There's probably two big ones. One is simply access to care. There are not a lot of mental health providers that do this work. There aren't a lot of training programs that specifically train people, and the pathophysiology and the pharmacology is fairly complex in this population. And there's a lot of medicine actually, which for a lot of psychiatrists doesn't have to be a huge part of their daily life, and so it kind of self-selects for a small group of people who really are passionate about this work. And that's an area that we're really focusing on, getting more people who are appropriately trained to work with patients who have the complexity of cancer. It's also a very therapy heavy job, compared to a lot of others, and so working on how we can train psychiatrists to feel more confident using those therapy modalities in their care is a big focus across the country right now.

On a patient level, I think just the stigma of mental health care is our biggest barrier. Even today, where it seems like, at least to me, we talk about mental health all the time. You see it on TV, you see commercials for medicines, you hear celebrities talk about their bipolar diagnosis. And yet, the idea of engaging in mental health care is really scary for people. They feel like they're going to be judged by their family, or their friends, or their community, maybe even their doctors. And so, getting over the stigma of that is really challenging for a lot of folks. Once we get them in the door, we're usually okay.

Dale Shepard, MD, PhD: Yeah, I mean, I always try to introduce the psycho-oncology service as just part of the team, just like we're using palliative medicine, and we're using these other things to help out. But you think that there's a way that we can overcome that? I mean, people used to whisper the word cancer and now that's more generally embraced. Is there hope that this can change?

Kaleena Chilcote, MD: Oh, absolutely. And I think it's moving in the right direction, certainly. Unfortunately, I think as mental health providers historically, we've actually done some disservice in the way that we talked about mental health issues. I mean, we had a lot of founders of the field who talked about depression like it was a failure of strength. Someone's failing to cope, or they have some issue with their mother, and it sounds like this very sort of abstract thing that is very personal.

And the more we learn about what actually contributes to depression and anxiety development, the more we can really talk about it as a scientific thing, with real pathology on a cell-based level. And I think that that's really helpful for patients, especially in the cancer world. I can talk to people about how when we do studies on people with depression and anxiety, they have higher levels of interleukin-2 and interleukin-6, and guess what? So do people with prostate cancer. So maybe that makes a lot of sense, that someone with prostate cancer is going to struggle more with depression and anxiety. There's something to that. And that just education and rethinking how we think about our mental health impacting us makes a big difference.

Dale Shepard, MD, PhD: From the standpoint of either therapies or medications, what do you see coming up in the future that's most exciting?

Kaleena Chilcote, MD: I think just the idea of evidence-based medicine in the future of this field is really exciting. As you know, for many, many, many years, cancer drug trials often excluded our population of patients. If you had a severe persistent mental illness, or a substance use disorder, you weren't included in those drug trials. And the opposite is also true. Psychotropic drug trials excluded people with things like HIV and cancer. So, it's a pretty new frontier actually, for our patients with these overlapping symptoms to really be included in evidence-based practice. And that is a new thing just in the last few years that's really opening up a lot of opportunities for us to provide better care for patients in the future.

Dale Shepard, MD, PhD: Well, you and your group are doing some fantastic work and I appreciate you giving some insights today.

Kaleena Chilcote, MD: Yeah, thank you so much for having me.

Dale Shepard, MD, PhD: To make a direct online referral to our Taussig 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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