Finding well-being where cancer and aging meet

Age is the single most important risk factor for cancer, but older adults with cancer can be a challenging research population. People in their 60s, 70s, and beyond are more likely to have multiple health problems, including physical illness and cognitive impairments. "Older adults with comorbidities are often screened out of research," said Kelly Trevino, PhD, codirector of the Psycho-Oncology in Aging and Cancer Laboratory at Memorial Sloan Kettering Cancer Center (PAC MSK) and an associate attending psychologist in the center’s Department of Psychiatry and Behavioral Sciences.

For Trevino and her colleagues, the complex physical and psychosocial factors affecting older adults with cancer aren’t beside the point. They are the point. The lab’s mission: Identify and address the unique psychosocial needs of older adults with cancer, as well as those of their loved ones and caregivers. "The problems facing older adults with cancer cross disciplines, so we take a collaborative approach to make sure our clinical care meets the comprehensive needs of these patients," Trevino said.

PAC MSK includes psychologists, psychiatrists, social workers, nurses, and health communications researchers—a well-oiled and influential team that won the 2020 APA Prize for Interdisciplinary Team Research. The lab was the brainchild of the late psychiatrist Jimmie Holland, MD, a founder of the field of psycho-oncology. The discipline focuses on how people react to life-threatening diagnoses and the challenges of treatment—and how best to support them during that period of their lives. Holland devoted her career to addressing the psychological needs of cancer patients and cancer survivors, cofounding the International Psycho-Oncology Society, the American Psychosocial Oncology Society, and the journal Psycho-Oncology. She passed away in 2017 at age 89, but her vision lives on in PAC MSK.

"When Dr. Holland started the field of psycho-oncology, there really wasn’t any attention being paid to the psychosocial needs of cancer patients," Trevino said. "The landscape is vastly different now."

Despite great strides, there is still much to learn about the unique needs of older adults with cancer. "That’s a guiding force for us," said Christian Nelson, PhD, codirector of PAC MSK and chief of psychiatry in Memorial Sloan Kettering’s Department of Psychiatry and Behavioral Sciences. "Whether it’s thinking about the best ways to diagnose depression or provide psychotherapy to older adults with cancer, or helping clinicians better engage with patients, our overall goal is to provide the best psycho-oncology care possible to older cancer patients."

Taking aim at depression and anxiety

Holland’s research focused broadly on the needs of cancer patients. But over time, she became increasingly interested in the unique needs of older adults—not only because she recognized that cancer is largely a disease of aging but also because she herself was growing older, Nelson said. PAC MSK officially launched in 2005 with support from the Silbermann Foundation, which has continued to provide funding as the lab has matured. What started as weekly brainstorming lunch meetings soon grew into support groups for older cancer patients, which continue to this day. Over the years, the lab also honed its research focus.

"From the beginning, we were interested in integrating developmental themes into psychotherapy for older adults with cancer," Nelson said. "These are concepts such as wisdom and mentorship, how to give back and pass on what you’ve learned to the younger generation, looking back at your life in review, and the idea of facing death as you’re still living."

Integrating those themes into psychotherapy, the PAC MSK team created the Cancer and Aging: Reflections for Elders (CARE) model, a telephone-based intervention to reduce depression, anxiety, and distress related to cancer diagnosis and treatment in older patients. In a pilot study, the intervention proved feasible and showed promising trends in reducing depression and anxiety among the participants, who were all over 70 and had been diagnosed with cancer at least 6 months prior (Nelson, C. J., et al., Psycho-Oncologyopens in new window , Vol. 28, No. 1, 2019). With funding from the National Cancer Institute, the team is now leading a larger randomized controlled study of the intervention.

Rebecca Saracino, PhD, an assistant attending psychologist at Memorial Sloan Kettering, has worked closely with Nelson to study interventions for depression as well as approaches to refine depression diagnoses in the context of cancer and aging. She received a 2015 APA Dissertation Research Award for the work, which she began as a fellow at PAC MSK and has continued after officially joining the team as a faculty member. Physical symptoms of depression such as fatigue, sleep disturbances, and loss of appetite can overlap with cancer treatment side effects, so they may not be as useful for identifying depression in cancer patients.

Alternative criteria for diagnosing depression in older cancer patients, proposed by psychologist Jean Endicott, PhD, of Columbia University, in the 1980s—including tearfulness or depressed appearance, social withdrawal, self-pity or pessimism, and an inability to be cheered up by good news or funny situations—may be more useful, Saracino and colleagues found (Psychological Assessmentopens in new window, Vol. 32, No. 1, 2020). "Overall, we’ve found that physical symptoms aren’t reliable indicators for diagnosing depression in older adults in the cancer setting," Saracino said. "We need to look toward more alternative criteria, including additional cognitive and affective symptoms."

Saracino is also launching a new study of behavioral activation in older adult cancer survivors with depression, with funding from the National Cancer Institute. Behavioral activation, which aims to increase people’s contact with rewards by helping them engage in positive experiences and social activities, is a key piece of many depression interventions. But scheduling meaningful and enjoyable activities can be challenging in a population of older adults who may have poor health or limited mobility. Saracino’s study will explore whether researchers can tailor behavioral activation interventions to the physical and cognitive status of older adults with a history of cancer. "We know they are at risk for depression, and they may have lost their social connections or stopped doing things they once enjoyed," she said. "We have this evidence-based treatment. Let’s make sure we can deploy it effectively to reach our patients."

Trevino, meanwhile, is taking aim at anxiety. With funding from the National Institute on Aging, she and her colleagues developed an anxiety intervention for older adults with cancer and their caregivers. The cognitive behavioral therapy–based intervention, delivered by social workers over the telephone, was modified to help older adults draw on their values and lived experiences. "In the first session, the therapist works with older adults to identify what is important to them, how those things have changed over time, and the areas of strength or expertise they’ve developed over their lifetime," Trevino said. "Throughout the intervention, the therapist taps into that life experience and works with them to find ways to apply those strengths to managing their anxiety."

Patients’ caregivers often experience anxiety as well, including worries about what the future holds and whether they are doing enough to care for their loved one. Trevino’s intervention also included one-on-one phone sessions with caregivers to address those concerns in a confidential space, without the care recipient present. The initial pilot study suggested the intervention was associated with reductions in anxiety in patients, and even larger reductions in caregivers (Journal of Geriatric Oncologyopens in new window, Vol. 11, No. 8, 2020). "It was a small study, but promising. We’re hoping to get funding for a larger trial to more closely examine the effects and also to take a closer look at the intervention for caregivers," Trevino said.

Improving communication

While most of the lab’s research focuses on the experience of patients and caregivers, the team is also interested in helping clinicians improve the way they think about and interact with older adult patients. Since 2005, Memorial Sloan Kettering’s Communications Skills Training Program and Research Laboratory (Comskil) has developed trainings for health care providers on a variety of topics, based on clinical need. For several years, Comskil and PAC MSK have collaborated to develop trainings to improve providers’ ability to communicate with older adult patients and their caregivers—skills that are often lacking in health care training. "Many of our participants say they’ve had no specific training for working with older adult patients," said Patricia Parker, PhD, a psychologist and director of Comskil.

She’s leading a project to study a training program for providers including oncologists, primary care physicians, nurses, psychologists, social workers, and physical and occupational therapists. The two-day program aims to help providers better assess patients for cognitive impairment and communicate more effectively with patients and their caregivers. For example, participants learn skills related to recognizing ageism and geriatric syndromes, improving communication with patients who have functional or sensory impairments, and ensuring that both patient and caregiver are included in discussions. "This provides an opportunity to introduce providers to ideas they haven’t thought about and teaches them concrete skills they can use when working with older adults," Parker said.

The Comskil model follows a predictable process, said behavioral scientist Smita Banerjee, PhD, a Comskil faculty member whose work focuses on health communication. The researchers take a deep dive into the literature, develop a training model based on the research, and test it with providers. If it seems promising, they follow up with a larger study to evaluate its effectiveness, offering the training to providers both within and outside the Memorial Sloan Kettering system. With colleagues from the geriatrics division, Banerjee developed and tested a geriatrics-focused training program to improve verbal and nonverbal communication between oncology care providers, older adult patients, and their caregivers. The training involves didactic learning modules as well as hands-on practice communicating with patient-actors. In one role-play scenario, for instance, clinicians practice speaking with an 85-year-old patient with colon cancer and the patient’s adult child caregiver, who is worried about the parent’s weight loss, weakness, and ability to continue living alone. In another, the provider practices a difficult conversation with a patient who wishes to discontinue cancer treatment and the patient’s adult child, who is unwilling to accept that option.

The results are not yet published, but Banerjee said participants showed improvement in their communication skills. Participants were more likely to ask patients for permission to include caregivers in the conversation and to connect patients with additional resources and referrals. The participants also rated the training positively, reporting significant improvements in feelings of self-confidence and self-efficacy. "In a busy clinical setting, clinicians don’t often have time to stop and reflect on what went well and what didn’t," Parker said. "What really differentiates our trainings is the experiential component and the opportunity for immediate feedback from the facilitators, from colleagues, and from the actors themselves."

Leaders in team research

The core PAC MSK team includes nine faculty and five research staff members. The faculty members all have dual roles as clinicians and researchers—experience that closely informs the lab’s mission. "Because we are also clinicians, we’re all very aware of the day-to-day struggles our patients are having," said Saracino. "When someone discusses a new idea or a new project, it resonates because many of us have seen the same thing in our clinical practice."

Working with older adults with cancer requires flexibility. "The people in our study samples are sick, and many of them are going through toxic treatments. Their lives have been significantly disrupted," said Trevino. "That creates challenges for recruitment, but it also means we have to be particularly sensitive to our participants’ needs. At the end of the day, we’re focused on patient care."

The lab faculty and their collaborators come from psychology, psychiatry, nursing, oncology, geriatrics, social work, and health communication backgrounds. That commitment to collaboration—and the scientific contributions that were born from the teamwork—is what earned the lab APA’s interdisciplinary research prize last year. The interest in collaboration dates back to Holland, who was known to have an open-door policy for clinicians and researchers from any department, Saracino said. "Our lab perpetuates that by welcoming people from disciplines across the hospital and having new voices represented," she said. "We have a team that’s nonjudgmental and receptive to getting feedback. To do interdisciplinary work, you need to be humble enough to recognize you have a lot to learn."

Indeed, Trevino added, almost all psychologists would benefit from being open to learning more about the unique needs of older adults. "The population is getting older, and most of the people working in psychology will interface with older adults in some way," she said. "There are so many myths about older adults. There’s a real benefit for psychologists to gain knowledge of adult development and the unique issues facing this population."

Identification and treatment of depressive disorders in older adults with canceropens in new window
Saracino, R. M., & Nelson, C. J., Journal of Geriatric Oncology, 2019

Symptomatology, assessment, and treatment of anxiety in older adults with canceropens in new window
Trevino, K. M., et al., Journal of Geriatric Oncology, 2021

Addressing communication challenges in older patients with cancer and geriatric syndromes: A communication skills training module for health care providersopens in new window
Alexander, K., et al., European Geriatric Medicine, 2019

Addressing the quality of communication with older cancer patients with cognitive deficits: Development of a communication skills training moduleopens in new window
Korc-Grodzicki, B., et al., Palliative & Supportive Care, 2020