Recurrent Disease: Learning to Live With Cancer



Shubham Pant, M.D.: Dr. Hirst, Dr. Eskander is obviously a very accomplished physician. He really talks to his patients, communicates with them. But what would you talk about regarding general health care out there? In a way, what could physicians do better in dealing with patients with recurrent disease? What could we be doing to help patients navigate this all over again?

Jeremy Hirst, M.D.: I think a place to start is even before recurrence. I think for a lot of patients with any type of cancer, and with ovarian cancer, the idea that this might come back is there. Clearly there are some folks who are able to say, “OK, if it comes back, we’ll deal with it.” But for a lot of patients, there’s this tickle in their brain, and for a significant percentage we start to see sort of a hyperalert state of any type of physical symptom. “Oh, I have a twinge,” or, “Oh, I feel a little off today,” or, “Oh, is that feeling I have normal?” They can drive themselves crazy with anxiety that they’re feeling of, “Oh, is this meaning it’s recurred?”

Starting there, how do you manage the new experience you had that your body is all done with cancer? How do you not let worry about recurrence totally overtake your life? And then if recurrence does occur, patients may think, “Oh, gosh, did I not take the chemotherapy as strong as I should have? Did that delay make this happen?” Try to get away from beating oneself up or thinking they did something wrong and that’s why it’s back. In a sense, instead of thinking, “Oh, this is just what my disease is doing, and I’ve got my team here and we’re going to meet it head on and look at where we are today,” think, “OK, this is the genetics, this is the disease, and these are some treatment options.” Again, support the patient so they feel well enough to get those therapies.

Shubham Pant, M.D.: Tell me, I would say there are different nuances and psychological care about having had cancer before, and now you’re in remission, versus living with cancer. And if it recurred, then you are undergoing treatments and everything. Can you discuss the differences in those two aspects? In remission, now it’s a chronic thing that we’re dealing with. You’re seeing the oncologist a lot more; just a lot more visits and everything, being monitored for toxicities a lot more. What can you say, as far as the difference between those two things?

Jeremy Hirst, M.D.: Right, it can be exhausting. And I think it can take over one’s life if you let it. Well, yes, the cancer is always there, but is there a way to put it aside? I really like the sense of, I put it in a box for right now. Or I see patients use that technique frequently. OK, I go to infusion, I go see the doctor, I’m dealing with cancer, but right now I have my grandkids, or I have my kids, or I’m going to do my hobby. I’m going to try to put the cancer aside, try to dose up on my antiemetic or whatever it may be, so I can enjoy this moment without constant reminder of the cancer. That is important, because it is a marathon.

Shubham Pant, M.D.: Right, you’re exactly right. And one of the other things is health care resources obviously. Physicians are seeing more and more patients. One is talking about treatment therapy, but one is addressing the psychological aspect of things, and that can be another discussion. Just as Dr. Eskander was saying, for genetic discussions, everything can be an hour, hour and a half. So what do you think medical professionals, as a profession, can do better with patients in addressing these very important issues? Should mental health folks like you be incorporated in the discussion as part of the care team? What are your thoughts on that?

Jeremy Hirst, M.D.: I may be biased with it. At our center we are very lucky in that we have a very robust psychiatric and psychological service component, and we have phenomenal social workers on all our teams. And it’s a really robust emotional support network that some patients need but others don’t. We do find that general counseling and talking about distress of disease is very therapeutic for a lot of patients. Certainly, in your community, finding a mental health professional with expertise in cancer is important. We don’t want to find someone who doesn’t have any experience, who thinks all people with cancer are going to die, or who will approach it not in the right way.

Shubham Pant, M.D.: Not the right person.

Jeremy Hirst, M.D.: Right, right. Or just blow it off or whatever. But someone with experience who knows some of the ups and downs and how to deal with the uncertainty is important. Just being able to talk about it and share that is important. There are more specific therapies: cognitive behavioral therapy, meeting center therapy, dignity therapy. More very specific psychotherapies for patients with serious illness have been developed, and finding practitioners to build in those would also be very helpful for those patients who need it.

Shubham Pant, M.D.: Cognitive therapies. Can you expand a little on that? What kind of cognitive therapies? How do you do that?

Jeremy Hirst, M.D.: The basic behavior of cognitive behavioral therapy is that our thoughts and our behaviors are tightly wound. If we can change one, we can start changing the others. Identifying some of our negative thoughts, recognizing them as such, and then countering them with more positive actions, more framing — that’s the basic explanation of cognitive behavioral therapy. And it’s been applied to all things from general anxiety disorders to general mood disorders, and in the cancer world it can be very helpful in terms of recalibrating our thoughts around disease and our bodies.

Shubham Pant, M.D.: Dr. Eskander, do you think there should be coordination between patients, oncologists, and mental health professionals, just like Dr. Hirst? I know in your center it’s there, but do you think it should grow? Should we have more of these resources available to our patients?

Ramez N. Eskander, M.D.: Undoubtedly. Just as you said, we’re fortunate enough to be able to work together and to have the resources available to us in our cancer center. I think it’s a tremendous resource for many of our patients because the reality is you can’t, no provider can, do it alone. They can claim that they are, but I don’t think they’re doing the service that the patient deserves necessarily alone. If you’re able to collaborate and develop these programmatic initiatives to really provide all the resources, including the mental health and supportive care, it’s really invaluable for the patients throughout the process.

Shubham Pant, M.D.: Doña, what do you think about that? By kind of incorporating these into care of patients?

Doña Harman: I think it’s a great idea. You’re treating the mind and the bodies together.

Transcript Edited for Clarity

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