Psychotherapy for
Older Cancer Patients:
The CARE ProjectAndrew Roth, MD
Memorial Sloan Kettering Cancer Center
Weill Cornell Medical College
The 2nd Sapporo Conference for
Palliative and Supportive Care in Cancer
June 16, 2017

Disclosure

Geriatric Group Acknowledgment

Jimmie Holland, MD
Chris Nelson, PhD
Yesne Alici, MD
Andrew Roth, MD
Anne Martin, PhD/SW
Elizabeth Harvey, PhD

Take Home Points• The elderly appear to cope better than younger
people with cancer in some studies• However, it is more difficult to assess
psychiatric distress in the elderly, so it may gounrecognized• Many elderly patients, are less willing toaccept psychiatric and psychological treatmentin the cancer and palliative care setting, whenneeded• Psychotherapy and psychiatric medications canbe very helpful, but may need to be modified
to accommodate the elderly and end of life.
• The CARE Model addresses these issues

Cancer is a Geriatric Issue

Prevalence• Half of cancer cases occur in people above 66 years of age.
• One-quarter of new cancer cases are diagnosed in people 65 to 74• We soon will have more older people than children, and more
people at extreme old age than ever before.
• The proportion of older people and the length of life willcontinue to increase throughout the world.

Estimated Number of US Cancer Survivors by Sex and Age

at Prevalence as of January 1, 2016: (Male and Female)
Percent

Cumulative
Percent

NumberAll ages
0-14

65,190

<1%

<1%

15-19

47,180

<1%

1%

20-29

187,490

1%

2%

30-39

408,790

3%

5%

40-49

958,600

6%

11%

50-59

2,389,670

15%

26%

60-69

4,141,950

27%

53%

70-79

4,011,790

26%

79%

80+

3,322,560

21%

100%

Note: Percentages do not sum to 100% due to rounding.
Source: Surveillance Research Program, Division of Cancer Control and Population Sciences,
National Cancer Institute.

Challenges in Psycho-Oncology for
Elderly Cancer Patients• Elderly cancer patients are at increased risk forundetected and untreated depression, anxiety, pain,delirium, fatigue, and suicide at the end of life due to: Comorbid medical conditions
 Cognitive deficits
 Poor access to (mental) health care
 Decreased self-report Differences in assessment and treatment

Psychosocial Issues of The Double Whammy:
Cancer + Aging• Combining losses of aging with:
 Coping with cancer diagnosis
 Decisions on treatment—to treat or not to treat
 Side effects of treatment
 Ageism• Elderly do not easily express their loneliness ordepression so that these symptoms go unnoticed (~25%)• Urgency to review life and deal with practical matters ofwhat to pass on to whom, with concern about uptake.

Psychotherapeutic Challenges with Older Patients• “I’m old. Should I have treatment for the cancer or not?”• “Which treatment is best for me?”
 In terms of cure? In terms of quality of life?
• “I don’t have the energy to do what I used to do, so I don’t doanything.”• “I’ve lived my whole life without seeing a therapist, and it
has been a tough life.
Why do I need you now?”• “I don’t want to be a burden on anyone; let me die.”• “I have a lot of pain.
• If I can’t do what I used to do, what’s the point of living?”

Underdiagnosis & Undertreatmentof Depression in Older Adults• Depression/dysthymia underdiagnosed in the elderly
 “ Don’t ask, don’t tell”
o Feel stigma of “mental” issueso Minimize depressive symptoms and blame on illness
 Common depressive symptoms are:o Somatic complaintso ↓ sleepo ↓ appetiteo fatigue
 Physicians often assume these are related to “old age”
reflecting the cultural negative attitudes of ageism

Interventions for Depression• Older patients respond to both medication andpsychotherapy interventions.
• Strong evidence base in primary care that
depression can be treated.
Lapid et al, 2007
Rao A, Cohen HJ, 2004
Lander M et al 2000
Donnelly J et al, 2004

Gooen-Piels J et al 2007

Psychotherapeutic Treatments that Help
Older Depressed People:
Cochrane Database
Wilson et al, 2008
• Only a small number of studies and patients• Findings do not provide strong support forpsychotherapeutic treatments in the managementof depression in older people• CBT may be of potential benefit• Interventions not geared to elderly specifically.

Interventions that Help Older Cancer Patients
Lapid et al, 2007
• Improving the quality of life of geriatric cancer
patients with a structured multidisciplinary QOL
intervention while getting radiation therapy:
 A randomized controlled trial.

• A multidisciplinary team offered treatment to older
adults with cancer, including physical therapy
exercises, cognitive behavioral training, education
regarding issues such as symptoms, spiritual guidance
and financial resources, and a 200 page manual• Intervention not geared to elderly specifically.

IMPACT Model in Older
Depressed Cancer Patients

Fann 2009• Primary care clinics• Improving Mood-Promoting Access to CollaborativeTreatment (IMPACT) program vs Usual Care
 Education; Care Management; Support ofantidepressant management; Brief, structured
psychosocial interventions including behavioral
activation and problem-solving treatment.

• Intervention not geared to elderly specifically.

Hospital Anxiety & Depression Scale:
Total Distress Score
12108Tel Monitoring
Educ Materials

64p< .0001

20Baseline

6 monthsPsychotherapeutic Flexibility• May need to decrease length or
frequency of sessions• May need to focus on physical andpsychological symptom interplay and relief• May need to be flexible with therapy style: Education
 Support Cognitive-behaviorally oriented
 Insight-oriented

 Existential: Dignity; Meaning-Centered• May need to have spouse in session

How Do Older Men Cope withProstate Cancer?

• Cross sectional• Archival data
• Prostate cancer patients• Two validation studies of the MAX-PC1,2
 Memorial AnXiety Scale Prostate Cancer (MAX-PC)

 Anxiety scale specific to prostate cancer
 Questionnaires completed in waiting room
 Inclusion: PC, PSA test
1Roth, Cancer, 2003; 2Roth, Psychosomatics, 2006

FACT Emotional Well-Being
Mean Score by Age Group(Nelson et al 2008)
4.6

4.54.4

4.3

4.2

FACT
Emotional
Well-Being

4.1

4

3.9
50-55

55-60

60-65

65-70

70-75

75-80

80-85

85-90

90+

r = 0.13, p < .01

Distress Thermometer by
Age Group(Nelson et al 2008)
3.5

DistressThermometer

32.5

r = -0.13, p < .01
2

1.5

150-55 55-60 60-65 65-70 70-75 75-80 80-85 85-90 90+

HADS Anxiety Total Score by
Age Group(Nelson et al 2008)
76.5

HADS Anxiety

65.5

5
4.5

4

r = -0.21, p < .01

3.5

3
2.5

250-55 55-60 60-65 65-70 70-75 75-80 80-85 85-90 90+

HADS Depression Total by
Age Group(Nelson et al 2008)
65.5
54.5
HADS Depression
43.5

r = 0.18, p < .01

32.5
250-55 55-60 60-65 65-70 70-75 75-80 80-85 85-90 90+

HADS Depression and Anxiety by
Age Group(Nelson et al 2008)
HADS Depression

76.5

HADS Anxiety
65.5
5
4.5
4
3.5
3
2.5
250-55

55-60

60-65

65-70

70-75

75-80

80-85

85-90

90+

The Relationship Among Age, Anxiety, andDepression in Older Adults with Cancer(Weiss, JCO ASCO, 2012)• Secondary analysis of a prospective
longitudinal study investigating chemotherapy
toxicity in older adults with cancer.
• Cross-sectional, pre-chemotherapy analysis• This study supports previous research thatanxiety decreases with age in older adults withcancer. However, depression remained
constant with increasing age.

HADS Depression by Age Group:
Women w/Breast Cancer (Weiss, 2012)
54.5

43.5
HADS Depression
32.5
70-75

75-80

80-85

85+

Would Older Depressed Cancer Patients Benefit
From an Age-Specific Intervention?
• About 25% of older patients go untreated.
• Life experience of older adults leads to: broader life perspective (i.e. wisdom) shorter time perspective for goals
 more careful selection of goals for improving emotion
regulation
 improved ability to manage emotions• However, despite these strengths, older adults with cancer:
 have to cope with significantly more physical limitations
 potential cognitive declines
 the reduction of social networks
 unique issues of diagnosis and treatment of cancer• Importantly, older patients are more likely to be homebound oralone.

Uncomfortable Emotions

Uncomfortable Thoughts

Uncomfortable Behaviors

Anxiety

Repetitive thought loops/PSA
predictions

Drinking more alcohol

Fear

Unfocused

Smoking more

Worry

Difficulty concentrating

Not exercising

PanicPreoccupied

Eating more junk foodSadness

Forgetful

Using drugs/meds
inappropriately

Depressed; unable to enjoy“I’m going to die”

Apathy/not motivatedDemoralized“Why me?”Not productive at work

Hopeless“This is unfair”

Stop planning for future

Anger

Upset at others’ healthArguing more

Irritability“Why can’t he get off his cell
phone and take my order?”Others say I yell more often
for little reason

Loneliness“Who would want to spend
time with me?”Social withdrawal/isolation

Emotional Judo(©2015 AJRoth; OUPress)• EJ combines aspects of supportive psychotherapy,cognitive behaviorally oriented psychotherapy,problem-solving therapy, and Acceptance andCommitment Therapy into a practical method foreasy teaching, understanding and practice for men
with all stages of prostate cancer.
• Found to be successful in real clinic time withmen with prostate cancer.

Enter the DRAFT of Emotional Judo(©2015 AJRoth; OUPress)

Detect uncomfortable emotions, thoughts, or behaviors.
Recognize the rational and irrational aspects of theemotions, thoughts, or behaviors.
Acknowledge and accept your current circumstances andthe good that still exists and how the irrational aspects ofyour emotions, thoughts, or behaviors pull you away fromwhat you really want.
Flip your attention away from the distress and back to thepresent with the however statement.
Transform through relaxation, distraction, or quick-list
activities to a pleasurable or meaningful activity.

Creation of a Geriatric Expert Panel•

Goal: To determine what elderly cancer patientsneed from a psychotherapy− Over 70 years,− Have/or had cancer, and− Were articulate, thoughtful and willing• Two separate panels totaling 14 people participatedin this initial phase− First group brainstormed on themes and content− Second group experienced group intervention andgave feedback

Geriatric Expert Panel

Geriatric SpecificPsychotherapy Intervention
C.A.R.E.
Cancer and Aging: Reflections for Elders• 5-session phone psychotherapy intervention• Based on developmental stage and cognitive
coping models• Developed with input from older cancer patients• ManualizedAims
Primary Aims:
1. To test the feasibility of the intervention.
2. To examine the impact of this geriatric-specific psychotherapy
primarily on depressive symptoms.
Secondary Aim:
1. To examine the impact of this geriatric specific psychotherapy
on anxiety, demoralization, spiritual well-being, and loneliness.

Theoretical Models & Framework
COPING MODEL:• FOLKMAN – Reappraisal through Meaning-Based Coping(Situational Meaning)
DEVELOPMENTAL MODEL:• ERIKSON – Psychosocial Tasks associated with theseventh & eighth final stages of life
• VAILLANT – Elaboration of Erikson’s later stages ofdevelopment (Book: ‘Aging Well’)Erikson’s Psychosocial
Tasks in Older Years
MIDDLE ADULTOLDER AGE

(50’s - 60’s)(70’s - onward)

Developmental Task: Generativity

Developmental Task: Ego Integrity• Capacity to unselfishly guide thenext generation• Making peace with one’s life as a
unified whole• “Care” for younger as mentor,guide, consultant• Wisdom through life’s experienceand lessons‘Keeper of Meaning’:• Concern with life in the face ofdeath & teaching the young notto fear death• Preserving the culture in which onelives• Link between the past and future• Struggle to accept inalterability ofpast & unknowable futureLife Lesson: CARELife Lesson: WISDOM
Adapted from Erikson, 1950

CARE Model
DISTRESSINTERVENTIONOUTCOMEACHIEVEMENTPoor coping withaging andillness/cancer

Identify and use
coping tools thatworked before↑ COPING

Coping well with
infirmity andillness

Feelings of social
isolation

Reframe issuesof aging/illness

Regrets aboutlife lived

Problem solve
daily challenges

Bitterness facing
uncertainty &mortality

Strengthensocial ties

Sad/DepressedPut past in atolerable
perspective

Process
uncertainty about
mortality↑SOCIAL
CONNECTION↑QOL↓DEPRESSION

Maintaining
connections
Accepting life as
lived
Finding
pleasure/ humor
Living withequanimity
despiteuncertainty
Decreased
depressive
symptoms

CARE Sessions
Session #1: Introductions & Overview
Introduce intervention, session themes, and story of cancer
Session #2: Coping with Losses & Facing the Unknowns of Cancer & Aging
Theme: Dealing with the combined problems of illness and aging; Coping withpresent and future fears, concerns, & worries
Session #3: Loneliness & the Experience of Cancer & Aging
Theme: Loneliness and reduced social circles in later years; Dealing with the stigma
attached to aging in our society

Session #4: Making Peace with One’s Life and Acquiring Wisdom
Theme: Who am I?: Coming to terms with one’s changing sense of self;
Contributing to the greater good: Passing on one’s worth and wisdom
Session #5: Reflection & Review

Pilot study• Telephone intervention• Randomized:− CARES Intervention• Five session intervention− Enhanced Social Work Control• Standard Social Work intake• Four “check-in” sessions• Recruit by letter

CARE: IDEA
• (I)ntroduce session topic and theme related to aging and cancer• (D)efine problems or challenges associated with given session
topic and theme• (E)xplore ‘guiding questions’ in light of personal reflections,attitudes and stories• (A)ppraise strategies and reappraise problems and challenges
with new strategies identified during the session

Session #2: Coping With Cancer & Aging
Theme: Dealing with the combined problems of illness & aging
Problem or Challenge

Ways to Cope

Looking at the Here &Now: Losses &Limitations of Agingand Illness

Adapting and making themost out of life and thepresent

Guiding Questions:
What are the major losses thatcome with aging?
With having cancer?
Reflecting on your illness, how has
your life been changed?
What can’t you do?
What can you still do?

 Maintaining connections
with family, friends, pets
 Engaging in pleasurable
activities (theater, music,arts, entertainment,hobbies)
 Using humor
 Reappraise life goals
 Seeking meaning throughprior beliefs and values

Eligibility Criteria••••••

Age: > 70 years
Diagnosis: Prostate, Breast, Lymphoma, GYN, or Lung
On active treatment or within 6 months post-treatment> 6 months post-diagnosis
All Stages
Documented Distress:
 Distress Thermometer > 4 or
 Hospital Anxiety and Depression Scale (HADS) > 6• The Blessed Orientation-Memory-Concentration test < 11

Assessment Schedule• Patients complete a battery of questionnaires
 Hospital Anxiety and Depression Scale (HADS) Demoralization Scale UCLA Loneliness FACIT Spiritual Well-Being Scale• Complete at: Baseline
 End of intervention (2m)

 2-months after treatment (4m)Subject Characteristics
Total Sample
N
N by Group
Mean age (years)

61
Intervention
Control

322976 + 4

Race

95% CaucasianRelationship Status

28% Married
18% Single
31% Divorced
23% Widowed
77% College Degree

Education

HADS Total
14
12108

ControlIntervention

64
20Baseline

Follow-up 1
2 months

Follow-up 2
4 months

HADS Depression
8765Control

4Intervention

32
10Baseline

Follow-up 1

Follow-up 2

Baseline-Follow-up 1: p = 0.01, d = 0.59
Baseline-Follow-up 2: p = 0.20, d = 0.27

HADS Anxiety
7654
Control
3Intervention

210
Baseline

Follow-up 1

Follow-up 2

Baseline-Follow-up 1: p=0.44, d= 0.15
Baseline-Follow-up 2: p=0.10, d= 0.42

Loneliness
19.5
1918.518
Control

17.5Intervention

1716.516
Baseline

Follow-up 1

Follow-up 2

Baseline-Follow-up 1: p = 0.11, d = 0.32
Baseline-Follow-up 2: p = 0.46, d = 0.17

COPE-Planning15
14.5
14ControlIntervention

13.5
1312.5Baseline

Follow-up 1

Follow-up 2

Baseline-Follow-up 1: p = 0.18, d = 0.23
Baseline-Follow-up 2: p = 0.88, d = 0.03

Meaning25
24.5
2423.5Control23Intervention

22.5
2221.521
Baseline

Follow-up 1

Follow-up 2

Baseline-Follow-up 1: p = 0.27, d = 0.23
Baseline-Follow-up 2: p = 0.04, d = 0.46

Conclusions: CARE Model•

A brief psychotherapy intervention
 Specifically designed for aging and cancer
 Conducted by phone Manualized Delivered by those with counseling degrees (Master)•••

Produced moderate effect sizes
Additional strategies may be needed to help sustain
intervention effects over time but started to break ground onachieving wisdom
A larger study: Partner with the Cancer Support Community
 Utilize large volume cancer call center