This work is dedicated to my son, Spencer.

Thank you for sharing the world through your experience: You stop to see the beauty when others rush by, you love without condition, you laugh with your whole being, you open your heart to all around you, you are strong in life, you have an undying curiosity, you find hope and compassion when many do not, you believe, and you are amazing! I hope that you stay connected to who you are and what you are capable of doing even in times of pain and diversity. Know that I love you with all of my being, I will always be with you, and I am proud to be your dad.

I would like to thank my team for making this work a reality.

• Brittany Hamann – for all of your hard work, contributions, and dedication to this project.
• Meagan Karsten – for your passion and contributions.
• Dr. Amy Gimbel – for your willingness to do whatever is needed and for your contributions.
• Dr. Morgan Cusack – for believing in this work and your dedication.
• Dr. Lane Pederson – for your friendship and drive.
• Shelley – for your support and stability.
• Dr. Steve Girardeau – for your wisdom and guidance.
• The entire team at Wiley.
• Mom and Dad – for your unwavering support.
• Julie – for being there every step of the way!

When the word “cancer” is mentioned, people typically pay attention. When it is in the context of a medical appointment, or when discussing testing results, one of our biggest fears may become reality. Most everyone knows someone with cancer. There are stories of triumphs and stories of pain in every family. Reactions to the diagnosis of cancer, its treatment, and its course vary greatly between individuals. Although individual reactions may be quite different, there are many common themes found in what is experienced and what is needed. The first main theme is that cancer affects an individual's functioning and their quality of life. The other main themes can be organized into biological, psychological, and social perspectives. The focus of this manual is to address the complex needs of individuals diagnosed with cancer. Since there are more than 100 types of cancer, I have chosen not to focus on any one specific type. It seemed more appropriate to address the common reactions and issues that individuals with cancer experience. This is not designed to be an exhaustive and all-inclusive work, but rather another step in the direction toward treating the whole person.

Chapter 2 provides an overview of cancer statistics and treatments, to orient the reader to the enormity of the impact of cancer. Chapter 3 outlines a proposed treatment structure that addresses flexible treatment modalities for the professional. Chapter 4 makes up the bulk of the manual, and is organized into four sections: general, biological, psychological, and social. The general section consists of six headings that orient the clinician to the treatment of this population, ranging from skills training to work with safety issues. The biological section addresses themes such as treatment compliance and self-advocacy. The psychological section addresses issues of anxiety, depression, finding meaning, and more. The social section focuses on the individual's needs, as well as the needs of their support systems and strategies to increase healthy interactions.

Each section of Chapter 4 is presented with an outline of its contents, beginning with an introduction to the topic and points of discussion. The discussion points can be covered in either group or individual therapy as a way to ground the individual and explore their experience. The sections then transition into sets of skills to teach, which are designed to increase the patient's functioning and quality of life. They also provide assessments tools, which can be used to track progress or identify key aspects of the patient's functioning. Participants are encouraged to practice the skill sets in session using handouts, and to generalize what they are learning outside of the therapeutic sessions by completing the homework assignments/tracking tools and reviewing them in the following session. The sections conclude with notes to the clinician, which are designed to highlight key points and provide suggestions.

There is no “right” way to incorporate a manualized approach. The goal is to focus on the needs of the individual seeking services, while striving to increase their functioning and quality of life. Our health care system is moving toward integrated health care. This manual is designed to assist in narrowing the gap between health care professions by integrating different treatment approaches in order to increase overall health and wellness. The World Health Organization (1948) defines health as a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity. This definition has not changed since it was adopted in 1948, and I hope this work will help clinicians move in the direction of embracing it.

The prevalence and cost of cancer are a growing concern in the United States and beyond our borders. There is an immense need for coordination of medical and psychological management to treat individuals suffering with cancer and residual conditions that often result from the disease. The American Cancer Society reported that in 2013 “about 1,660,290 new cancer cases are expected to be diagnosed in the US”, with “about 580,350 Americans…expected to die of cancer, almost 1,600 people per day.” It further estimated that in 2014 there were 14.5 million Americans alive with a history of cancer and that by 2024 there will be 19 million. Currently in the United States, “men have a 1 in 2 lifetime risk of developing cancer; for women, the risk is a little more than 1 in 3” (American Cancer Society, 2013). “Cancer is the second most common cause of death in the US, exceeded only by heart disease, [accounting] for about 1 of every 4 deaths in 2013” (American Cancer Society, 2013). Nearly one-fourth of people with chronic conditions also reported experiencing limitations to daily activity due to their illness and experienced clinical mental health concerns. “The 5-year relative survival rate for all persons diagnosed with cancer between 2002 and 2008 is 68%, which is up from 49% in 1975–1977” (American Cancer Society, 2013). This indicates that “60% of 1-year cancer survivors experience clinically significant concerns about disease recurrence influencing the individual's functioning and quality of life” (American Cancer Society, 2014).

Survival from chronic health conditions brings new challenges for individuals throughout their lifespan, including lifelong and acute physical, psychological, and social adjustment difficulties. According to the American Childhood Cancer Organization (2013), “Two-thirds of those who survive the disease develop at least one chronic health condition that is classified as severe or life-threatening caused by late-effects of treatment. These effects often include heart damage, lung damage, infertility, cognitive impairment, growth deficits, hearing loss, and second cancers.” Childhood cancer often results in lifelong disabilities, in addition to chronic health conditions. Because of this, cancer survivors are subject to ongoing monitoring across their lifespan. “Persons diagnosed with cancer will likely need physical and psychosocial care throughout their lives” (American Childhood Cancer Organization, 2013). “Patients and providers often are influenced by life circumstances and competing priorities, attitudes and beliefs about specific treatments, health literacy and understanding the health care system. These factors influence treatment compliance and overall cost” (American Cancer Society, 2014).

Health Care Costs

Cancer is linked with a wide range of illness, injuries, diseases, and mental health issues. “Cancer has been found to cause pain and the associated symptoms arising from a discrete cause, such as postoperative pain or pain associated with a malignancy. Millions suffer from acute or chronic pain every year and the effects of pain exact a tremendous cost on our country in health care costs, rehabilitation, and lost worker productivity, as well as the emotional and financial burden it places on Survivors and their families” (American Academy of Pain Medicine, 2015). According to a recent Institute of Medicine (IOM) report titled “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research,” “pain is a significant public health problem that costs society at least $560–$635 billion annually, an amount equal to about $2,000.00 for every person who lives in the United States. This includes the total incremental cost of health care due to pain ranging from $261–$300 billion and losses of productivity and associated issues ranging from $297–$336 billion. The costs of cancer can result in longer hospital stays, increased rates of re-hospitalization, increased emergency room visits, and a decreased ability to function that leads to lost income and insurance coverage. As such, Survivors' conditions often result in an inability to work and maintain health insurance, especially over the duration of their medical treatment.”

“The financial costs of cancer are high for both the person with cancer and for society as a whole” (American Cancer Society, 2013). According to the National Institutes of Health (National Cancer Institute, 2015a), cancer “is a significant public health problem that costs society an estimated overall cost of $201.5 billion annually: $77.4 billion for direct medical costs (total of all health expenditures) and $124.0 billion for indirect mortality costs (cost of lost productivity due to premature death).” According to the American Cancer Society (2013), in 2006, the average cost of a single 30-day cancer drug prescription was $1,600; it is even higher today. Newer cancer treatments can cost as much as $10,000 for a month, and many protocols require more than a month of treatment. The American Cancer Society (2013) reports that “while those with health insurance face less worry regarding payment for treatment, those with no health insurance acquire extra worries when facing such an expensive disease. There is no guarantee that cancer expenses will be covered through insurance plans. Most personal bankruptcies that happen as a result of medical problems are filed by people who have health insurance.”

Cancer and Functioning

A diagnosis of cancer causes distressing emotional experiences that decrease a person's ability to cope with their disease and treatment effectively. It is common for signs of impaired coping abilities to go unnoticed due to the severity and symptoms of the disease and treatment. Medical teams can assist patients in managing various side effects and symptoms, but patients may also benefit from mental health, social work, and counseling services to restore their quality of life and teach them coping skills (American Cancer Society, 2014). The American Cancer Society (2014) has found that 30–40% of patients have diagnosable mood disorders. Additionally, it suggests that psychological interventions can improve treatment adherence and patient–provider communication. Complete treatment adherence and improvements in communication between patients and their care teams were found to be correlated with low levels of depression and anxiety among cancer patients. Subpopulations at particular risk for elevated distress include racial/ethnic minorities, people diagnosed at younger ages, and those of lower socioeconomic status. These subpopulations have also been found to report greater difficulty regaining their quality of life in recovery. Distress is reported to negatively impact education and employment, at great cost to society (American Cancer Society, 2014).

The American Cancer Society (2014) states that “cancer patients experience pain at the time of diagnosis, during the course of active treatment, and after treatment has ended, even if their cancer does not return.” Among cancer patients, pain is often underreported and undertreated. It has been found that 59% patients in active treatment report significant pain and about 33% of survivors report significant long-term pain post-treatment. Surgery, radiation therapy, and chemotherapy drugs can cause nerve damage. What manifests is chronic pain and a heightened risk of suicide among this population (American Cancer Society, 2014).

The comorbidity of mental health and physical problems resulting from pain is well established in research (Gatchel, 2004). Common comorbidity includes anxiety, depression, adjustment disorder, obsessive–compulsive disorder (OCD), histrionic personality disorder, and borderline personality disorder (BPD). The triggers are the pain and the uncertain prognosis of the diagnosed condition – specifically around progression of the disease, recurrence, reduced lifespan, end-of-life issues, treatment and side effects, cognitive, physical and behavioral impairments, and functional limitations (Ownsworth, 2009). Pain often results from chronic illness, injury, degeneration, and many related triggers in a chronic population. “People who experience chronic pain often experience a decrease in quality of life including: overall physical and emotional health, psychological and social well-being, fulfillment of personal expectations and goals, economic burden and financial stability, functional capacity to carry out daily routines, and activities of daily living. Additionally, destruction of family and social life, problems with treatment adherence and support systems, and decreased participation in sports or leisure activities have been found to increase the risk of clinical anxiety and depression, resulting in greater functional impairment and poor quality of life” (Pao & Weiner, 2011). This functional impairment and reduction in quality of life often leads to a variety of mental health concerns, including demoralization and a reduction in effective participation in treatment, as well as in life in general.

Cancer and Suicide

Cancer is often seen as a death sentence by mainstream society. Within the past decade, research has consistently demonstrated a strong correlation between cancer and suicide. In a survey of 2,924 cancer outpatients treated at one regional cancer center, 7.8% thought they would be “better off dead” or had considered hurting themselves in response to their diagnosis. While the general American population has a suicide rate of 10.6 out of every 100,000 persons per year, about 24 cancer patients out of every 100,000 complete suicide. Gender, prognosis, type of cancer, stage of disease, ethnicity, and family situation all contribute to suicide risk. Male cancer patients are nearly five times more likely to commit suicide than female patients, which remains consistent with suicide rates in the general population. Given the correlations, cancer patients may benefit from psychosocial support (Kendal & Kendal, 2012).

Medical Interventions

“Cancer is a group of diseases characterized by uncontrolled growth and spread of abnormal cells. Cancer can result in death, if the spread of abnormal cells is not controlled” (American Cancer Society, 2013). The American Cancer Society (2014) reports that cancer can be caused by both external factors (including tobacco, infectious organisms, chemicals, and radiation) and internal factors (including inherited mutations, hormones, immune conditions, and mutations that occur from metabolism). Together, these factors initiate or promote the development of cancer. The World Cancer Research Fund estimates that factors including obesity, physical inactivity, and poor nutrition will contribute to about one-quarter to one-third of new cancer cases expected to occur in the United States. Thus, with adequate lifestyle modification, cancer can be prevented.

A variety of medical interventions are frequently implemented in the treatment of cancer. The American Cancer Society (2013) reports that cancer is treated with surgery, radiation, chemotherapy, and hormone therapy. The recommendations for use vary based on cancer conditions. Attending to risk factors and engaging in regular medical screening tests that allow the detection and removal of precancerous growths can prevent cancer, but these procedures are costly. According to statistics provided by the National Cancer Institute (2010), 70% of cancer patients are treated with primary medical interventions of chemotherapy and radiation, and are subject to secondary medical interventions. By default, the majority of medical interventions used to treat cancer can result in costlier medical conditions among survivors. Bone and heart issues are two documented impairments. Many cancer treatments result in osteoporosis and heart damage due to reduced bone density and sustained high blood pressure. Increased risk of fractures and heart failure is associated with poorer quality of life among the general population; therapeutic interventions can improve these impairments among survivors (American Cancer Society, 2014).

Pharmacotherapy

Pharmacologic management is often included in the treatment regimen of cancer conditions; however, protocols vary according to individual differences, including the disease state and treatment response. The average cancer drug therapy costs over $100,000 per year (Sikora, 2004). Pharmacologic management of cancer tends to be unique and is tailored to the individual based on treatment response. Pain is comorbid with cancer. Pharmacotherapy for the treatment of pain includes the use of anticonvulsants, antidepressants, benzodiazepines, N-methyl-D-aspartate (NMDA) receptor antagonists, nonsteroidal anti-inflammatory drugs (NSAIDs), opioid therapy (e.g., oral, transdermal, transmucosal, internasal, and sublingual), skeletal muscle relaxants, and topical agents (American Society of Anesthesiologists, 2010).

Physical Therapy

The use of physical or restorative therapies for the treatment of chronic pain caused by cancer has been popular. A review of available research on the use of physical or restorative therapies conducted by the American Society of Anesthesiologists (2010) indicated promising results. Randomized controlled trials (RCTs) that incorporated a variety of these therapies, including fitness classes, exercise therapy, and physiotherapy, were effective in treating low back pain. American Society of Anesthesiologists and American Society of Regional Anesthesia members recommended that physical or restorative therapies be implemented in the treatment strategy for patients with low back pain and other chronic pain conditions. Additionally, restorative therapies may be beneficial in restoring function lost due to the cancer itself.

Palliative Care

Palliative care is care given to improve the quality of life of patients who have a serious or life-threatening disease, such as cancer. The goal of palliative care is to prevent or treat, as early as possible, the symptoms and side effects of the disease and its treatment, in addition to any related psychological, social, and spiritual problems. The goal is not to cure. Palliative care is also called “comfort care,” “supportive care,” and “symptom management” (National Cancer Institute, 2015a).

Integrated Behavioral Health

Integrated medical care will require more than just “integrating” mental health and behavioral health clinicians into the existing health care team of physician, nurse practitioner, nurse, physical therapist, and nutritionist: it will require “integrated behavioral health,” meaning that behavioral health clinicians must provide “integrated” services that combine and integrate individual and family dynamics and individual and family or systemic interventions. The need for behavioral health is important because about 50% of all patients in primary care present with psychological comorbidities, and 60% of psychological or psychiatric disorders are treated in primary care settings (Pirl et al., 2001).

A major meta-analysis of 91 studies published between 1967 and 1997 provided evidence for what researchers call the “medical cost-offset effect.” Behavioral health interventions, including various forms of psychotherapy, were provided to medical patients with a history of overutilization, as well as to patients being treated for only psychological disorders, such as substance abuse. Average savings resulting from the implementation of psychological interventions were estimated to be about 20% (Chiles et al., 1999). In short, the medical cost-offset effect occurs when emotionally distressed medical patients receive appropriate behavioral health treatment. As a result of this treatment, they tend to reduce their utilization of all forms of medical care. Even though there is a cost associated with behavioral health treatment, the overall cost savings is considerable.

Clinical Implications of Integrated Behavioral Health

The emerging integrated health care philosophy is that integrated behavioral health care will utilize behavioral interventions for a wide range of health and mental health concerns. The primary focus will be on resolving problems within the primary care setting, as well as on engaging in health promotion and compliance enhancement for “at-risk” patients. The goal of health care integration is to position the behavioral health counselor to support the physician or other primary care provider and bring more specialized knowledge to problems that require additional help.

Accordingly, the behavioral health counselor's role will be to identify the problem, target treatment, and manage medical patients with psychological problems using a behavioral approach. They will help patients replace maladaptive behaviors with more adaptive ones. In addition, they will use psychoeducation and client education strategies to provide skills training.

More specifically, the behavioral health counselor will be expected to provide expertise in dealing with undermotivated, noncompliant, or otherwise resistant patients. They will utilize motivational interviewing (MI) with individual patients (Rollnick et al., 2008) and with patients' families to increase readiness for change. They will also utilize focused cognitive behavioral strategies to increase compliance with treatment regimens, reduce symptoms, and increase acceptance of chronic and life-threatening illnesses (Sperry, 2006).

Cognitive Behavioral Therapy

Cancer has a significant impact on patients' lives and on the support systems around them. Adult cancer patients and their family members suffer from traumatic psychological distress, and psychological interventions may be beneficial (Butler et al., 2006; Han et al., 2005; Koopman et al., 2002). Cognitive factors play an important role in the experience of cancer (Gatchel et al., 2007). Group therapy, using cognitive behavioral therapy (CBT), has been found to be successful in treating anxiety and depression among those diagnosed with cancer (Edelman et al., 1999; Monga et al., 2009). Clinical insight suggests that group therapy can be an effective intervention for parents of this population, and can decrease anxiety (Edelman et al., 1999; Gilder et al., 1978; Mitchell et al., 2006).

According to Gatchel et al. (2007), CBT interventions are based on the view that an individual's beliefs, evaluation, and interpretation of their health condition, in addition to their pain, disability, and coping abilities, will impact the degree of both physical and emotional disability of the disease condition. Currently, CBT-based techniques vary widely in the literature; they can include distraction, imagery, motivational self-talk, relaxation training, biofeedback, development of coping strategies, goal setting, and changing maladaptive beliefs about pain and disease.

It is common for cancer patients to experience acute and chronic pain. Morely et al. (1999) conducted a meta-analysis of randomized trials of CBT in the treatment of chronic pain. They concluded that the use of CBT treatment to replace maladaptive patient cognitions and behaviors with more adaptive ones is effective for a variety of pain conditions. More recently, Linton & Nordin (2006) reported a 5-year follow-up of an RCT of CBT intervention for clients suffering from chronic back pain. They found that CBT interventions (compared to the control group) resulted in significantly less pain, a more active life, higher perceived quality of life, and better overall health. In addition, significant economic benefits were associated with the clients who had completed CBT treatment.

Scope of the Book

Psychological interventions are supportive and typically ancillary in nature for most cancer patients. There are many individuals who have exhausted their options for primary medical interventions and are faced with the challenge of having pain and disease as a part of their lives, with little or no hope for positive change or a cure. Demoralization is a common reaction to this reality. The field of psychology has few treatment manuals and integrated treatment options for clients as they move through the process of finding a cure, or learning to live with disease. One of the goals of this book is to provide practitioners with one of the first comprehensive manuals for the treatment of cancer patients, which can be applied across modalities and levels of care.