Dr. Antonella Surbone (right) and friend in Italy

From the moment researchers first observed a placebo effect, the connection between mind, body, and wellness has been evident, albeit mysterious. In the world of cancer care, the link between mental and physical health has spurred the evolution of psycho-oncology, a discipline uniquely focused on the psychosocial effects of cancer on patients and their families.

The underlying premise of the field, according to Antonella Surbone, MD, PhD, FACP, Ethics Track Leader of the ASCO Cancer Education Committee, is that cancer care “is not just about giving the right drug. A complex interaction of factors affects the quality of the care that we provide,” including cultural, familial, social, and psychological issues that must be addressed.

Dr. Surbone is a medical oncologist who has practiced both in the United States, where she is an adjunct professor of Medicine at New York University and a faculty member in the Interpersonal Communication & Relationship Enhancement (I*CARE) Program at the University of Texas M. D. Anderson Cancer Center, and in Italy, where she lectures on clinical bioethics and palliative care at numerous institutions. While continuing to practice medical oncology, she became interested in the ethics of cancer care and subsequently pursued a doctorate degree in philosophy, based on her observations of physician-patient communication in her native Italy and in the United States.

Evolution of the field
Since 2006, Dr. Surbone has served as an Invited Director and medical oncology representative on the Board of the International Psycho-Oncology Society (IPOS; ipos-society.org), an organization she described as being “strongly connected with the history of psycho-oncology as a discipline” since it was founded in 1984. She credits the work of ASCO member Jimmie Holland, MD, of Memorial Sloan-Kettering Cancer Center, and Lea Baider, PhD, of Haddassah University Hospital, Israel, among others, with the establishment of and advocacy for psycho-oncology as a unique and necessary field in the community of cancer care professionals.

In its mission statement, IPOS encourages “a humanistic approach” to oncology in order to “provide leadership and development of standards for education and research on the psychological, social, and spiritual factors that affect the quality of life of cancer patients and their loved ones.”

Assessing distress
A critical priority for IPOS is the assessment of distress as a vital sign (along with temperature, blood pressure, pulse, respiratory rate, and pain) in order to integrate the psychosocial domain into the routine provision of oncology care. Appropriate therapeutic interventions such as psychotherapy, cognitive behavioral therapy, or family therapy would be recommended based on the patient’s level of distress, just as appropriate medical therapies are currently provided for the management of physical symptoms related to cancer and its treatment. Ideally, Dr. Surbone noted, every patient with cancer would be assessed by a psycho-oncologist at the time of diagnosis and throughout the treatment process in order to reduce distress and its associated negative effects on patient satisfaction, quality of life, and cost of care.

“There is still a certain level of stigmatization associated with mental health care, so you want to offer the intervention as early as possible, to make it routine. Distress has a significant cost impact on the health care system, the patient, and the family. Earlier identification and intervention of distress can significantly improve patients’ and families’ quality of life and also lower the costs associated with delayed care of cancer-associated distress,” she said.

Improving multicultural clinical encounters
Dr. Surbone’s field of interest and research within psycho-oncology is cross-cultural communication and cultural competence as a way of improving multicultural clinical encounters in oncology and of reducing disparities in cancer treatment. Understanding a patient’s cultural values, beliefs, and attitudes provides a necessary context for quality care, she believes, and cited the shifting value of autonomy across cultures as an example.

“The word ‘autonomy’ in the United States is synonymous with freedom and self-determination and is a highly positive, highly valued concept. When I first trained in Italy in the 1980s, ‘autonomy’ was rather synonymous with isolation,” she explained. “Since the 1990s, there has been a major worldwide shift toward disclosure and informed consent as a way to foster patients’ autonomy and active participation to their cancer care. Still, in many cultural contexts, if you tell a patient with cancer, ‘You are autonomous, you must make your own decision,’ the cultural perception may be, ‘I’m left alone. I don’t have the support of my doctor or my family.’”

Addressing the family dynamic
Along with cultural context, the patient’s family dynamic is an important focus of psycho-oncology. “From the beginning, psycho-oncology has treated cancer as a family illness. When someone has cancer, thefamily—the people who love and care for that patient—is affected and the family routine is disrupted,” Dr. Surbone said. A distressed caregiver not only experiences varying degrees of physical and psychological suffering, but can also negatively affect the well-being of the patient in treatment; psycho-oncologists are trained to discern such distress in family members and recommend therapy as needed.

Learn more about the principles of psycho-oncology on Virtual Meeting. Visit ASCO.org, search “caregiving in context,” then select “Caregiving in Context: The Role of Family and Culture” from the 2006 ASCO Annual Meeting to watch presentations on:

• The Family and Cancer Care—Jimmie Holland, MD
• Epidemiology of Caregiving throughout the World— Christoffer Johansen, MD, PhD
• Family as the Unit of Care— Lea Baider, PhD
• Family Autonomy and Cultural Differences—Antonella Surbone, MD, PhD