Treating Beyond the Tumors | May Editor’s Choice
By Zachary Friedrich | Senior Editor
Illustration by: Michelle Shi | Director of Art & Layout
Paul Kalanithi was just short of finishing his training as a neurosurgeon when he received his diagnosis. Suddenly the future doctor and father-to-be became a patient fighting for his life. In his memoir, When Breath Becomes Air, he painfully describes coming to terms with his fate:
“I began to realize that coming in such close contact with my own mortality had changed both nothing and everything. Before my cancer was diagnosed, I knew that someday I would die, but I didn’t know when. After the diagnosis, I knew that someday I would die, but I didn’t know when. But now I knew it acutely. The problem wasn’t really a scientific one. The fact of death is unsettling. Yet there is no other way to live.” (2016)
Paul passed away at age 37 in March of 2015.
In 2018, approximately 1,735,350 people will be diagnosed with cancer in the U.S. alone (American Cancer Society). For these unfortunate people, staying optimistic throughout treatment will be indescribably difficult, but interventions involving medical staff and the patient’s family members and friends can help. Sameer Khan’s Fall 2016 Medical Dialogue Review (MDR) article entitled “The Importance of Psycho-Oncology” does a good job of conveying just that: the necessity of providing psychological assistance to cancer patients. Khan discusses many of the options available to cancer patients with regard to psychiatric and psychological care, as well as the many potential reasons patients forego these options. As an example, support group sessions can enhance cancer patients’ all-around quality of life and renew their hope, but often patients do not make use of them since they are afraid to meet other cancer patients in worse condition, perhaps worsening their anxiety about cancer (Khan, 2016). In fact, only about 59% of cancer patients with depression and/or anxiety, which commonly occur in cancer patients, receive any kind of treatment for their mental illness. While this is greater than the 27% of the general population with depression and/or anxiety that access treatment (Nakash et al., 2014), there is certainly a need for improvement across the board.
There is even evidence to suggest that cancer patients’ odds of surviving decreases if they have depression. A meta-analysis found a slight increase in the mortality of cancer patients with depression, but no differences in the progression of their cancer (Satin, Linden, & Phillips, 2009). It is worth noting that while the meta-analysis found no relationship between depression and cancer progression, there were only three relevant papers to analyze. It is still likely that further studies would reveal such a relationship, especially considering that chronic stress has been found to contribute to cancer progression in mice (Thaker et al., 2006).
A number of models have been proposed to explain depression’s effects on cancer patients. One such model posits a link between behavioral and biological pathways. Depression is characterized by maladaptive activation of the hypothalamopituitary-adrenal (HPA) axis. This compromises the patient’s cellular immune system, leading to dysregulation of the production and function of inflammatory molecules called cytokines. The progression of malignant tumors could be accelerated by the increased production of pro-inflammatory cytokines and modulation of anti-inflammatory cytokines caused by depression (Satin et al., 2009).
Regardless of the explanation for the likely relationship between cancer mortality and depression, alleviating depression in cancer patients should be an important part of treatment. Medicine’s job goes beyond simply treating the physical ailments of the body. In the words of Paul Kalanithi,
“The physician’s duty is not to stave off death or return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence.” (2016)
This sentiment could not be more true in the case of cancer patients and their families, whose lives have been violently redefined by a sudden terminal illness.
American Cancer Society. Cancer Statistics Center. Retrieved from http://cancerstatisticscenter.cancer.org. Accessed April 22, 2014.
Kalanithi, P. (2016) When Breath Becomes Air. New York, NY: Random House.
Khan, S. (2016). The Importance of Psycho-Oncology. Medical Dialogue Review, 11(1), 23-25.
Nakash, O., Levav, I., Aguilar-Gaxiola, S., Alonso, J., Andrade, L., H., Angermeyer, M. C., … Scott, K. M. (2014). Comorbidity of common mental disorders with cancer and their treatment gap: Findings from the World Mental Health Surveys. Psychooncology, 23(1), 40-51.
Satin, J. R., Linden, W., & Phillips, M. J. (2009). Depression as a Predictor of Disease Progression and Mortality in Cancer Patients. Cancer, 115(22), 5349-61.
Thaker, P. H., Han, L. Y., Kamat, A. A., Arevalo, J. M., Takahashi, R.., Lu, C., … Sood, A. K. (2006). Chronic stress promotes tumor growth and angiogenesis in a mouse model of ovarian carcinoma. Nature Medicine, 12(18), 939-944.