DOI: 10.1002/pon.

4692

PSYCHO-ONCOLOGY, VOL. 27: 1364–1376 (2018)

PSYCHO-ONCOLOGY: OVERVIEW, OBSTACLES

AND OPPORTUNITIES
JIMMIE C. HOLLAND
Chief, Psychiatry Service and Wayne E. Chapman Chair in Psychiatric Oncology;
Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA

SUMMARY
Worldwide, psychological and social issues in cancer were not the subject of scientific inquiry until the past two
decades. Since then, a new subspecialty of oncology has evolved, psycho-oncology. It addresses two dimensions
of cancer: the emotional responses of patients at all stages of disease, as well as their families and caretakers
(psychosocial); and the pyschological, social and behavioral factors that may influence cancer morbidity and
mortality (psychobiological). Obstacles to development have been the facts of small numbers of clinicians and
investigators worldwide and the few valid assessment instruments and research methods available to the biomedical
community. These obstacles are increasingly giving way to the louder demand of the public for maximal quality
of life in cancer care. Psycho-oncology is attaining subspeciality status by presently bringing a set of clinical skills
in counseling, behavioral and social interventions to oncology, by providing training curricula which teach basic
knowledge and skills in the area, and through creating a body of research and scholarly information about
clinically relevant issues in the care of patients with cancer. Since it is increasingly recognized that psychological,
social and behavioral variables influence treatment outcome, attention will likely to continue to increase. The field
must meet the challenges of the 1990’s in psychosocial care and availability of services, support for training
clinicians and investigators in psycho-oncology, and implementation of an exciting research agenda. The focus of
new research will encourage collaborative investigations combining biological and psychosocial variables, quality
of life research in clinical trials, controlled studies of psychotherapeutic, behavioral and psychopharmacologic
research, and crosscultural studies that will examine differences in prevention and detection, health care systems,
alternative therapies and meta analyses.

HISTORY AND RATIONALE these universal human responses to cancer are

For centuries, cancer has aroused fear in individ-
uals throughout the world, representing a and psychological meaning of cancer in different
common disease for which no treatment existed
until the late nineteenth century. The fears were
so extreme that the word cancer was not spoken
to the patient, as described so movingly by
Tolstoy in The Death of Ivan llyich (Tolstoy,
1986). Humanistic and compassionate concerns
for the comfort of patients were an informal part
of care, but the nursing and non-medical aspects
of care did not receive systematic attention or
study until the last two decades. The psycho-
logical and social impact of cancer has been slow
to become the focus of scientific study, despite the
fact that cancer can occur at any age and the fact
that psychological and social issues are an integral
part of the care of all cancer patients and their
families throughout the world.
From an international perspective, studies of
critically important for two reasons. First, they
make it possible to examine changes in the social
parts of the world over time, as effective treat-
ments appeared and changed the prognosis of a
particular type of cancer from totally fatal to
largely curable. This has occurred, for example,
with Hodgkin’s disease and testicular cancer in
the last 20 years. Now that it is probably curable,
receiving a diagnosis of Hodgkin’s disease is a
very different experience today compared to prior
to the 1970s when the diagnosis was considered a
death sentence. Second, an international perspec-
tive encourages the development of cross-cultural
studies, which can examine the emotional impact
of cancer on patients and their families and how
it is affected by national models of health care,
cultural attitudes and religious beliefs. For these
reasons, psycho-oncology within cancer medicine
uniquely addresses these issues, providing the

Originally printed in Psycho-Oncology 1992, Volume 1,

Issue 1, pp. 1-13. https://doi.org/10.1002/pon.2960010103

© 2018 by John Wiley & Sons, Ltd.

 HOLLAND 1365

Table 1. Development of interest in psychosocial aspects of cancer

Year Cancer Psychosocial interest

1850-1900 Anaesthesia (1847) Cancer = death

Antisepsis
1900- Surgical excision
First radiation
1930-1940 Increased biomedical research
National cancer societies
formed
1940s Nitrogen mustards
First remission leukemia folic
acid antagonists
Increased radical surgery
1950s First cure by drug alone
(Choriocarcinoma, 1951)
1960s Increased survival
Increased combined modalities
Hospice programs
Word not used
First cancer surgery
First public education about
early signs
Increased education
Increased support to find cure
Increased optimism
Increased psychosomatic
concepts
Grief studies
First psychological studies
Debate about telling
Peer support
C/L psychiatry

dimension of cultural influences on adaptation.
As a background to understanding these inter-
relationships, it is helpful to trace the develop-
ment of interest in the psychological, social and
behavioral dimensions of cancer as it varies with
reference to changing medical knowledge and
treatment (Table l). The present status of psycho-
oncology within oncology, and its potential con-
tributions to research, training and clinical care,
can be better understood within that context.
The belief that cancer was equated with death
was valid until the first effective treatment for
cancer by surgery became possible in 1847, follow-
ing the successful demonstration of ether as an
anesthetic. Antiseptic surgical techniques were
developed which enhanced the potential for effec-
tive treatment of early, locally contained cancer.
For the first time, education of the public about
the warning signals of cancer became important to
encourage early detection and to influence the
fatalistic attitudes of both doctors and patients
about cancer. Bt 1912, radiotherapy had begun to
be used in Europe as a treatment for cancer. In
1950, chemotherapy was added as a modality for
cancer treatment with rapid development of
several highly effective anti-cancer agents. During
the 1960s, multimodal therapy, combining these
three treatments with immunotherapy, began to
have a significant impact on the survival statistics,
especially in children and young adults. Figure 1
outlines the impact on survival of childhood
tumors. These changes slowly began to alter the
belief that cancer equalled death, and the
optimism generated interest in psychological
issues other than dying and death (Table 2).
By the late 1960s, as survival improved, the
diagnosis of cancer was more frequently revealed
to patients in some countries, particularly the
USA. At about the same time in the UK, there
were increased efforts to provide more humane
care to patients dying with cancer, notably in the
beginning of the hospice movement. Prior efforts
had been mainly from religious groups in their
traditional work of caring for indigent, dying
patients. Social forces, more openness in revealing
the diagnosis, increased concern for d y i n g
patients and enlightened public concern about
quality of life during chronic, serious illness
slowly began to direct more concerted attention
toward these humanistic and supportive aspects of
care. In addition, evidence of the link between
environmental exposures and cancer, particularly
cigarette smoking gave new impetus to examining
the role of psychological and behavioral factors in
cancer prevention.
Also during the late 1960s, there was greater
interest in the psychological and supportive
aspects of cancer care by oncologists, nurses,
1366 PSYCHO-ONCOLOGY OVERVIEW

Figure 1. Progressive improvement in survival of children with solid tumors, 1940-1980. Proportion surviving two years from
diagnosis. Data from multiple sources are shown relative to the chronology of the general applications of the 3 principal
therapeutic modalities to the tumors of children. Reproduced by permission from Hammond, D. Progress in the study, treatment
and cure of the cancers of children, in: Burchenal, J. H. and Oettgen, H. F., eds., Cancer: Achievement, Challenges, and
Prospects for the 1980s, Vol. 2, Qrune & Stratton (1981).

Table 2. Factors contributing to greater emphasis on
psychological aspects of cancer
Societal changes in attitudes toward cancer with shift toward
less pessimism
Greater attention to palliative and supportive care through
hospice movement
Increased frequency of revealing cancer diagnosis to patient
Increased concern for patient autonomy and human aspects of
care
Recognition of psychological and behavioral influences in
cancer risk, early detection, and prevention
Emergence of consultation-liaison psychiatry and health
psychology with their emphasis on psychological care of
medically ill
social workers, social scientists, psychologists and
psychiatrists, and research was begun on these
issues. However, appropriate assessment tools for
scientific study of largely subjective phenomena
were not available; they either had to be modified
from those developed for other purposes or devel-
oped de novo. Investigators with knowledge of
both clinical aspects of cancer and psychosocial
research methods were few. The biological assess-
ment methods of ‘hard science’ did not apply and
social science methods were poorly understood by
biomedical scientists. This led some scientists,
inappropriately, to assume that the potential for
rigorous research in the psychological and
behavioral aspects of cancer was limited. This
attitudinal barrier and the absence of established
working ties between the researchers in biome-
dical and social sciences slowed the development
of effective collaboration between these two
groups. Progress began from the 1970s, particu-
larly in Europe and North America, where
increased attention was given to the two most rel-
evant psychosocial issues in patient care at that
time: delay in seeking consultation for a suspi-
cious symptom of cancer and treatment com-
pliance. Behaviors related to early detection of
cancer and avoidance of exposure to environ-
mental carcinogens, particularly those from
occupational sources, became important. The
association between cigarette smoking and lung
cancer was a major impetus to the study of a
behavior change.
Early developments in psychological research
In the period after World War II, the first syste-
matic research into the psychological aspects of
cancer began in the USA (Table 3). In 1950,
 HOLLAND 1367

Table 3. Early contributions to psycho-oncologic research (1950-1980)

Year Name Director Place

1950- Psychiatric Research Unit Sutherland Memorial Sloan-Kettering, New York, USA
(1950-1959)
Psychiatry Service Mastrovito
(1960-1977)
(1977-present) Holland
1967- St Christopher’s Hospice Saunders London, UK
1970- Psychosomatic Unit Feigenberg Radiumhemmet, Karolinska, Stockholm,
(1970-1982) Sweden
Psychosocial Unit Bolund
(1982-present)
1971-1989 Faith Courtauld Unit Greer King’s College, London, UK
(1971-1979)
(1979-1989) Pettingale
1974- International Working Group on Dying, Outgrowth of International
Death and Bereavement ‘Ars Moriendi’
1976- Psychiatry Committee, Cancer and Leukemia Holland National Cancer Institute, USA
Group B
1977-1987 Psychosocial Collaborative Oncology Group Schmale National Cancer Institute, USA
1977- EORTC, Quality of Life Committee and Van Dam European: The Netherlands
Dutch Cancer Institute
1978-1988 Project Omega Weisman Massachusetts General Hospital, Boston, USA

Sutherland, a psychiatrist who became interested
in cancer, developed the Psychiatric Research
Unit at the Memorial Sloan-Kettering Cancer
Centre in New York. His group reported the first
papers on reaction to mastectomy and colostomy
(Sutherland et al., 1952; Bard and Sutherland,
1955). The group continued under Mastrovito
(1960-1977) and since 1977 by Holland. Their
work continues to explore the epidemiology of the
psychiatric and psychological comorbidity which
occurs by site, stage and treatment of cancer.
While there was no formal group at the
Massachusetts General Hospital in Boston, social
worker, Abrams, together with a psychiatrist,
Finesinger, reported changes over time in the
communication of patients with cancer, which
constituted an important contribution to psycho-
logical observations (Abrams and Finesinger,
1991).
In 1967, Cicely Saunders opened St
Christopher’s Hospice in London, a hospice that
focused on improving symptom control and pal-
liative care of terminally ill patients including
those with cancer. In addition, it became a center
for training professionals in supportive care and
for research studies in symptom control. Three
years later in 1970, Feigenberg, a Swedish
psychiatrist, became interested in the psycho-
logical care of patients at the Radiumhemmet,
Karolinska Institute in Stockholm. The Psycho-
somatic Unit was established in 1970, becoming
the Psychosocial Unit under Bolund in 1982. In
1971, the Faith Courtauld Unit was formed
at King’s College in London under Greer and
Pettingale and focused on psychological research
in cancer.
Also in the 1970s, several organizations contrib-
uted significantly to collaborative research and
training despite not representing discrete geo-
graphic units. The International Working Group
on Dying, Death and Bereavement began in 1974
as a cross-cultural group interested in education in
psychosocial aspects of advanced and terminal ill-
ness. In the late 1970s, two collaborative clinical
trials groups included research on psychosocial
aspects and quality of life in the areas covered by
their biomedical research. The Cancer and
Leukemia Group B (CALGB), funded by the US
1368 PSYCHO-ONCOLOGY OVERVIEW
National Cancer Institute (NCI), formed
the Psychiatry Committee in 1976, chaired by
Holland, as part of its expanded multimodality
effort. At about the same time, the US National
Cancer Institute funded the multicentre Psycho-
social Collaborative Oncology Group (PSYCOG)
under Schmale’s leadership.
In Europe, van Dam expanded his psycho-
logical research interests in cancer at the Dutch
Cancer Institute in Amsterdam to develop a
Quality of Life Clinical and Research Committee
within the European Organization for Research in.
the Treatment of Cancer (EORTC). This has been
a potent force in improving psychometric assess-
ment and research into quality of life. With
Aaronson, these efforts culminated in the estab-
lishment of a World Health Organization Collab-
orating Center in Quality of Life Measurement.
For a decade, beginning in 1978, Weisman
headed Project Omega at the Massachusetts
General Hospital in the USA and together with
Worden contributed to conceptual approaches
and research methods in cancer (Weisman, 1979).
During the 1980s, national and international
cancer societies actively began to foster the
development of psychosocial and quality of life
research, contributing to the growth of the pro-
grams currently in operation. The field widened to
accommodate more centers devoted to research-
ing quality of life in clinical trials, psychological
reactions and management, and psychological
and social factors influencing survival.
Definition
In 1992, the interest in psychological, social and
behavioral issues of cancer has led to defining a
subspecialty within oncology. Although known as
psycho-oncology in the US, the term psychosocial
oncology is preferred throughout most of Europe.
Psycho-oncology is concerned with two psycho-
logical dimensions of cancer:
(i) the emotional responses of patients at all
stages of disease, their families and care-
takers (psychosocial);
(ii) the psychological, behavioral and social
factors that may influence cancer morbidity
and mortality (psychobiological).
It is a new field, less than 20 years old, in which
assessment tools are still in the process of develop-
ment. There is only a small number of scattered
groups of clinicians and investigators in the
world, and few available training programs, espe-
cially those teaching research methodology. In
addition, the diverse backgrounds of clinicians
and investigators make the assimilation of effec-
tive collaboration more difficult. The field is,
nevertheless, growing and advancing.
The subspeciality involves professionals from
diverse disciplines and medical specialties who
are using their clinical observations, unique
investigative methods, and expertise gained in
their various disciplines and applying them to
cancer. These individuals have joined the medical
oncologists, radiotherapists and surgeons, who
have primary responsibility for the care of cancer
patients, in developing a better awareness and
understanding of the psychological, social and
behavioral dimensions of cancer and their man-
agement. Psychiatry, social work, psychology and
nursing in particular have contributed to the
methodological and clinical knowledge and exper-
tise. The psycho-oncologist who collaborates with
traditional oncologic specialists offers a perspec-
tive and expertise that can contribute substantially
to clinical care, research and training in oncology.
Objectives
The objectives of psycho-oncology, identified by
individuals from the major oncologic special-
ties and disciplines, are listed below:
(i) to foster the education and training of a
group of clinicians and investigators whose
special expertise is identified as psycho-
oncology, and whose special training iden-
tifies them as psycho-oncologists;
(ii) to foster concern for integration of psycho-
logical care into the total care of all
patients with cancer, at all levels of illness,
and of their families, by all health pro-
fessionals in oncology;
(iii) to develop training curricula in psycho-
oncology which contain a common core of
information relevant to all professionals,
and specific components to address the
particular educational needs of specific
oncologic disciplines (oncologist, nurse,
social worker) to assure psychological prin-
ciples of good care are incorporated into
total care;
(iv) to foster study of psychological, social and
behavioral factors in cancer prevention
and detection, and to explore the impact of
 HOLLAND
psychological, social and behavioral
factors on survival;
(v) to foster cross-cultural research in which
the universal stresses of cancer are studied
in relation to the influences of cultural
factors in adaptation;
(vi) to encourage controlled trials of,
psychotherapeutic, behavioral and
psychopharmacologic interventions, singly
and combined, for control of distress in
patients stratified by disease site, stage and
treatment;
(vii) to heighten awareness of the psychological
and social problems and their management
which are relevant to patients receiving
active treatment, palliative and terminal
care, and patients who have successfully
completed treatment (survivors);
(viii) to give attention to humanistic, ethical and
spiritual values in patient care, especially
as they relate to terminal decisions, and as
they pertain to the rights of patients being
treated by experimental protocols;
(ix) to study the psychological stresses on
health care professionals who provide
oncologic care and to study means of
avoiding an adverse impact on their well-
being and on the quality of care they
render;
(x) to encourage quality of life as an outcome
variable in clinical trials research, as a way
of improving information provided to
patients in making treatment decisions;
(xi) to foster the concept of broad treatment
goals which include quality of life and well-
being, and seeking to attain a disease-free
state that includes achievement of func-
tional outcome in the major domains of
life (rehabilitation);
(xii) to advocate for resources designed to
reduce cancer risk and to promote optimal
rehabilitation and survival at the local
(hospital/clinic), community, state,
national and international levels, with
adequate access of all persons to these
resources.
Groups of individuals working in particular
aspects of psycho-oncology usually form natural
alliances in cancer centers which result in collab-
orative ties. These ties represent the specific areas
in which psycho-oncologic issues interface and
overlap with the traditional specialties. The major
1369
interfaces of psycho-oncology are with the follow-
ing: (i) the clinical disciplines (surgery, medicine,
pediatrics, radiation, rehabilitation), for clinical
care; (ii) epidemiology, cancer control and pre-
vention, for behavioral, psychological and social
aspects of prevention, detection and influences on
survival; (iii) pharmacology, for research in
psychotropic drugs to reduce distress; (iv) the bio-
logical sciences, for examining the influence of
psychological, social and behavioral variables on
cancer morbidity and mortality; (v) bioethics, for
humanistic and spiritual issues; (vi) palliative and
supportive care, for its psychosocial aspects; (vii)
clinical trials research and clinical decision
making, for the quality of life dimensions in
outcome research.
One result of the boundaries and interfaces of
psychosocial issues with every area of oncology,
and the relatively recent development of a specific
body of knowledge and a research data base, is
that at each interface, psychological and social
issues could be incorporated as components of the
other area (e.g. epidemiology incorporating
behavioral aspects, or palliative care incorpor-
ating psychosocial aspects). Some would argue
that there is no rationale for maintaining psycho-
logical and social issues in a separate domain.
While there is merit in encouraging psychosocial
and quality of life concerns as part of other areas,
there remains, nevertheless, a strong argument for
maintaining the central focus in a single area. For
the present, in order to achieve parity with older
established oncologic disciplines, it is necessary to
retain all facets in the one subspecialty to assure
the development of a specific group of clinicians
and investigators who are well trained in and
devoted to progress in these issues in cancer. In
turn, this group of professionals, whose major
clinical work and research address this domain,
will be better able to draw attention to the import-
ance and application of psychosocial principles in
the care of all cancer patients.
There have been many important contributions
from the traditional oncologic specialists, particu-
larly adult and pediatric oncologists. However,
these individuals have usually devoted only a part
of their time to psychological concerns, main-
taining their primary identification elsewhere (e.g.
medical oncology, surgery), while continuing to
manifest interest in the psychological aspects of
care. The professionals who have devoted all their
time to this effort have been primarily from
behavioral and mental health disciplines (psychia-
1370 PSYCHO-ONCOLOGY OVERVIEW
trists, psychologists, social workers, nurses) and
the social sciences (sociology and anthropology).
This cadre of individuals constitutes an important
presence in cancer centers whose goal is to assure
that all health professionals directly engaged in
the care of cancer patients (physicians, nurses,
social workers, technicians) are able to recognize
distress and psychiatric disorder.s and can apply
appropriate management principles. Skills in con-
ducting the sensitive interpersonal communi-
cations with patients and families (e.g. how to
present the diagnosis and how to convey a poor
prognosis) are part of the purview as well. The
psycho-oncologist ideally is personally engaged in
the care of patients, their families and their care-
givers, but is also the person identified to teach
these principles and skills to oncology staff.
CURRENT STATUS
The development of psycho-oncology to the status
of a subspecialty is reflected by the fact that its
activities can now be outlined in four broad areas:
identification of psycho-oncology as a core part of
the services offered in patient care; growth of edu-
cational and training programs; research
specifically addressing psychosocial issues; and
publications of research and scholarly papers in
the field.
Clinical Programs
The present professional status of psycho-
oncology can be judged, in part, by its represen-
tation and function within oncology units and
cancer centers. Most centers and divisions have an
identified staff member or members who are
responsible for providing psychological and social
support. The units vary from a single individual,
who can request the help of other professionals,
to a team providing a broad array of services
designed to assist patients with significant distress
or overt psychiatric disorders, including support
for their families and for the staff. There are only
a few centers in the world that have well devel-
oped psycho-oncologic programs incorporating
research and training: the Royal Marsden Hos-
pital in London; the Memorial Sloan-Kettering in
New York; and the Jules Bordet Institute in
Brussels. Many outstanding programs are largely
dedicated to a single aspect of support, with inte -
gral ties to psychosocial issues (e.g. pain control).
Some are incorporated in supportive care pro-
grams which espouse symptom control of all
types, such as the Palliative Care Unit developed
by Mount in Montreal. The important contri-
butions to pain control by Ventafridda and Foley,
as well as the palliative and supportive care effort
under Saunders and Twycross, overlap with
psychosocial issues of patients with advanced and
terminal illness. Psycho-oncology programs are
now being developed for the first time in many
regions. The program in Budapest under Muszbek
at the National Institute of Oncology is an
example.
The composition of the staff on these programs
varies. The staffing is usually multidisciplinary
and may include a psychologist, social worker,
psychiatrist, nurse, or clergy with consultation
from the unrepresented disciplines on the primary
team as needed. Some programs depend heavily
on volunteers, who give important psychological
and practical support to patients, especially in
North America. The Hope and Cope Program in
Montreal, developed by Kussner, and the Patient-
to-Patient Volunteer Counseling Program at
Memorial Sloan-Kettering in New York are
examples.
In terms of specific programs, several are
worthy of note, both as models and for their con-
tributions to this new subspecialty. The Psycho-
logical Medicine Research Group at the Royal
Marsden Hospital under Greer had been focused
on developing a specific psychological therapy
program to improve quality of life and on evalu-
ating this therapy in clinical trials. Greer and
Watson are also researching the measurement of
various coping responses to cancer and their con-
tribution to survival. The group in Switzerland,
originally started by Meerwein and now under by
Hurny, has pursued similar goals. Maguire at
Manchester has been active in the training of
doctors to improve communication with patients.
Achte has provided both research and clinical
observations in cancer over m a n y years in
Helsinki. Also outstanding for their singular con-
tributions have been Kerekjarto, in Hamburg;
Zittoun, a hematologist in Paris; Razavi in Brussels;
and, DeNour and Baider in Israel.
Education and training
Role of societies. Several organizations in
Europe and North America have contributed to
 HOLLAND
the early professional development of psycho-
oncologists. The European International Psycho-
somatic Study Group, and in France, Psychology
and Cancer, each provided early networks study-
ing cancer from different, but important perspec-
tives. The German Psychosocial Postcare Unit
and Training Center was an early proponent of
training. The British Psychosocial Oncology
Group has been a significant force since 1983,
holding regular meetings and publishing mono-
graphs which have represented pioneering efforts
in the field. A psychosocial society has developed
in Italy as well as an active organization of
psychologists interested in studying these issues of
cancer in Europe. Growing out of the efforts
within the EORTC network of psychosocial clini-
cians and researchers, the European Society for
Psychosocial Oncology (ESPO) was formed in
1986. Under Zittoun as its first President, it has
enhanced both clinical teaching and research in
Europe by its conferences and collaborative
efforts.
T h e International Psycho-oncology Society
(IPOS) was formed in 1984 as a recognition of the
need for communication among the small scat-
tered groups with interests in psycho-oncology. It
has served as a source of international exchange
through a newsletter and has encouraged inter-
national training opportunities for psychosocial
researchers to study in different countries and to
learn new clinical and research skills. In 1988, the
Board of Directors requested that the Society
develop guidelines for a psycho-oncology cur-
riculum, starting formal efforts in Venice one year
later. With encouragement from IPOS, the
Mexican and the Japanese Psycho-oncology
Societies were formed: by Romero in Mexico in
1984 and by Kawano in Japan in 1985. Romero
has developed an academic program with univer-
sity credit in Mexico City at the PhD. level for the
training of psychologists in psycho-oncology.
Argentina and Brazil are leading the way towards
a South American group, under Fisman and
Penna, and an Australian society is being
planned. The Belgian society is well established,
and a Nordic society is developing.
The Norman Cousins International Fellow
Award and Norman Cousins Traveling Scholar-
ships were important resources for international
education in 1988. In the same year, the American
Society for Psychiatric Oncology/ AIDS was
formed to encourage training in clinical care and
research. In the USA, the Linda Pollin Founda-
tion has been a strong support for training pro -
1371
fessionals to counsel patients with chronic
diseases, including cancer. The Foundation sup-
ported five Fellows in 1989 and six in 1990; one
international Fellow is appointed each year. The
International Pollin Fellow in 1989, Die-Trill,
developed a curriculum for medical crisis coun-
selling in oncology. The Foundation has also sup-
ported four national conferences (in 1989, 1990,
1991 and 1992) to develop guidelines for training
in medical crisis counselling.
The Canadian Psychosocial Oncology Society
(CAPO) was formed in 1986. The second WHO
Collaborating Center for Quality of L i fe
Research, located in Winnipeg under Olweny, was
opened in 1990.
Conferences. Evidence of a subspecialty status
is also determined by the number of educational
meetings occurring annually. In North America,
the first conference that brought together the few
investigators in psycho-oncology was held in 1975,
which resulted in a monograph (Cullen et al.,
1976). The American Cancer Society (ACS), and
especially its California Division, saw the need for
support and encouragement of this emerging
subspecialization in the early 1980s. The ACS has
sponsored three workshops (1982, 1984, 1989),
which produced monographs that were bench-
marks in the field (American Cancer Society,
1982; 1984; 1991). The first addressed the goals in
education and research areas of the psychosocial
field. It resulted in the establishment of a national
peer review committee for review of grant support
in psychosocial and behavioral research (pre-
viously reviewed by basic scientists without social
science backgrounds) and a national advisory
committee. Over five million dollars has sup-
ported psychosocial and behavioral research
through the ACS awards since the peer review
body was formed. The second conference focused
on research method development and identified
barriers to improvement in research methodology.
The last workshop updated research issues in the
field and proposed a research agenda. The US
National Cancer Institute has begun to recognize
the importance of quality of life assessment as an
outcome variable in clinical trials. A conference in
1990 on methodology was published (Mayfield
and Hailey, 1991).
In 1989, the European School of Oncology held
the first course on psychosocial issues in cancer in
Venice (Holland and Zittoun, 1990). The first
meetings of this kind in Brazil and India were held
in 1989. And, in London, the first joint British
1372 PSYCHO-ONCOLOGY OVERVIEW
and European Psychosocial Oncology Society
meeting was held. A psychosocial component
was included in the WHO Expert Committee
on Pain Relief/Supportive Care held in Geneva
which resulted in a successful publication for
international distribution.
In 1990, a meeting of the Japanese Psycho-
oncology Society was held in Kyoto and a Quality
of Life meeting in Sapporo. The first joint
European Psychosocial and International Psycho-
oncology Society meeting also took place in 1990
at the UICC Cancer Congress in August in
Hamburg. In 1991, the European School of Onco-
logy and the International Psycho-oncology
Society co-sponsored, with the Psychiatry Service
of the Memorial Sloan-Kettering Cancer Center,
the presentation of Update on Psycho-oncology
IV held at the medical center in New York City.
In 1992, the first World Congress devoted to the
subspecialty will be held at Beaune, France, spon-
sored by the European Society for Psychosocial
Oncology, in conjunction with other societies,
and a second is being planned for 1994 in Japan.
Training programs. Training of full-time
psycho-oncologists who treat patients and who
can teach these principles to general oncology
staff has been a major concern of those develop-
ing psycho-oncology. A clinical training program
was begun at Memorial Sloan-Kettering Cancer
Center in New York City in 1977, with support
for its development from the National Institute of
Mental Health and the American Cancer Society.
Since then, four to six Fellows per year have been
trained in the clinical aspects of psycho-oncology
and six to ten Fellows in research aspects. Their
backgrounds are largely in psychiatry or psycho-
logy, with programs also for nurses and visiting
scholars. The first year of the two year clinical
training is entirely clinical and in the second year,
the Fellow is encouraged to develop skills in a par-
ticular area and to undertake a clinical investi-
gation. During the first year, Fellows consult on
hospitalized and ambulatory patients with
psychiatric disorders and are responsible, under
supervision, for their psychological care and
psychiatric management. They learn management
of emergencies by 24-hour coverage of the 565
bed hospital. They are assigned within six months
as liaison to a special unit, such as bone marrow
transplantation. Orientation lectures and weekly
conferences cover major topics at which they
present patients for discussion. Research Fellows
may concentrate on research projects for a 1-2
year program, but they must attend clinical con-
ferences and gain sufficient clinical information to
assure that their research is clinically relevant.
In general, formal training should be for at
least one year, adding to the training achieved in
the individual’s primary discipline and tailoring
the program to complement areas and skills in
need of expansion to work effectively in cancer
(e.g. evaluation of cognitive deficits or delirium).
The training should consist of supervised tutorial
experiences with hospitalized and ambulatory
patients, combined with didactic lectures and con-
ferences. Ideally, the clinical training should
include exposure to research methods. A second
year is highly recommended to learn research
design, instrumentation and to design and carry
out a study under supervision. Research training
must also include enough clinical exposure to
ensure that the researcher has a solid understand-
ing of clinical problems.
The content of the didactic part of a training
program should include the following areas:
(i) Major factors in psychological adaptation
(Holland and Rowland, 1989): medical
(stages, sites, treatments); psychological
(coping, prior adjustments, developmental
stage); social (supports, social/family/en-
vironmental system).
(ii) Common psychological and psychiatric
problems (Derogatis et al., 1983): adjust-
ment disorders; anxiety; depression and
suicide (Bolund, 1985; 1986); organic
mental disorders; personality disorders.
(iii) Types of therapeutic interventions: psycho-
therapeutic; behavioral; pharmacologic.
(iv) Special problems: pain and symptom con-
trol; fear; cancerophobia; bereavement
counseling; staff problems (Holland and
Kash, 1989; Whippen and Canellos, 1991);
sexual dysfunction; special patient groups
(child, older adult, colleagues); ethics
(Zittoun and Sancho-Garnier, 1989).
(v) Research methods (Cullen et al. 1976; de
Haes and van Knippenberg, 1985; Coates et
al., 1987).
Current status of research
As assessment methods improve and as more
and better psychometric tools are developed or are
adapted for use with cancer patients, the quality
of scientific investigation is improving. In
addition, more studies are being undertaken
 HOLLAND
which collect concurrent psychological and bio-
logical data. There is also increasing consideration
being given to cross-cultural research topics; one
of the earliest, excellent examples is the cross-
cultural study of cancer survivors by Sullivan in
Sweden with Cohen in the US (Sullivan et al.,
1988a; 1988b).
Major areas of current research efforts are:
(i) Psychobiological - collection of concurrent
psychological and biological data;
(ii) Quality of life measurement in clinical trials
(de Haes, 1985a, 1985b; Coates et al, 1987;
Holland and Rowland, 1989); Correction
factor in survival (Gelber and Goldhirsch,
1986);
(iii) Intervention research (Maguire et al.,
1983);
(iv) Supportive, palliative, pain control, ethics
(Razavi et al., 1987);
(v) Quality of life in patients: high risk, active
treatment (Silberfarb et al., 1983; Osaba,
1991), palliative care (Silberfarb et al.,
1983; Maguire, 1985; Razavi, 1987), sur-
vivors (Koocher and O’Malley, 1981), staff
(Holland and Rowland, 1989);
(vii) Detection, prevention, and compliance.
The major psychosocial units established to
date have research programs which address one or
more of these areas, usually in close collaboration
with investigators in other oncologic specialties.
Funding for research and research training are
major issues for continued growth of the field.
The chronic problem of securing adequate
funding for psycho-oncologic research and
research training is fundamental to the further
recognition and development of psycho-oncology
as a legitimate subspecialty. The most hopeful
signs are those arising from members of the public
who increasingly demand greater concern for the
quaJity of life related to treatment. Their pressure,
exerted in part by cancer survivors themselves and
by those committed to psycho-oncology, is the
driving force which can influence publicly elected
officials to alter their health care policy to recog-
nize and support these needs. This should, in
turn, encourage funding for this dimension of
health care that, although patients have repeat-
edly stated that they want it, has been consistently
neglected.
1373
Publications
Another measure of the development of a field
is the presence of publications, journals and texts
which reflect the body of knowledge constituting
the field. Major textbooks of both oncology and
psychiatry in the US have included chapters on
psychosocial issues in cancer since the early 1980s.
The British Psychosocial Oncology Group has
encouraged pubJication of several books devel-
oped from their annual meetings. The Handbook
of Psychooncology, provides a comprehensive
review of the current practices and references in
all major areas (Holland and Rowland, 1989).
The European School of Oncology published a
monograph in 1990, Psychosocial Aspects of
Oncology, bringing together a largely European
faculty (Holland and Zittoun, 1990). The Journal
of Psychosocial Oncology, has been published
since 1982 and is devoted to these issues; papers
appear in Social Science and Medicine and in the
standard journals of oncology and psychiatry as
well as in psychology journals. The new European
Journal of Oncology is giving special attention to
psychosocial research. Psycho-Oncology: Journal
of the Psychological, Social and Behavioral
Dimensions of Cancer is a new international
journal, starting in 1992, with the aim of reaching
beyond national boundaries to exchange research
findings.
DIRECTION AND CHALLENGES OF THE
1990s
The direction which psycho-oncology will need to
take to assure further development will depend in
part on encouraging networks of collaborating
psychosocial investigators and clinicians and on
the work of investigators and clinicians from
interfacing areas of oncology, who will be able to
identify and explore new problems that will arise
as new treatment regimens develop. Each new
therapy, such as bone marrow transplantation,
carries with it a new set of psychological
challenges.
At the joint IPOS/ESPO meeting in Hamburg
in 1990, a Round Table chaired by Sullivan
identified several challenges facing the field which
also fall within the areas of clinical care, training
and research (Table 4).
In clinical care, it will be important to have an
impact on health care policy decisions in such a
1374 PSYCHO-ONCOLOGY OVERVIEW
Table 4. Challenges of the 1990s
Area Action
Clinical Impact of health care policy decisions to support
Care psychosocial care
Implement present knowledge
Training Develop training centers for clinical and research
training
Obtain support for training of young clinicians and
investigators
Set standards for training and curriculum for
professionals (by discipline and specialty) and
for volunteers
Research Encourage collaborative and psychobiological
research
Improve research methodology
Conduct controlled trials of psychotherapeutic,
behavioural and pharmacologic interventions
Encourage quality of life assessment in clinical
trials
Prevention and detection behavioural research
Conduct cross-cultural research into
Impact of health care systems on quality of life
Ethical dilemmas (informed consent, truth
telling)
Meta analysis; replication studies
Alternative therapies (use/type)
way that quality control of patient care includes
attention to the quality of their psychosocial care;
reporting of psychosocial programs in cancer
centers and supporting training and clinical pos-
itions in cancer centers for psycho-oncologists will
assure ongoing attention to this aspect of care. In
addition, present knowledge gleaned from clinical
research about the positive value of psychosocial
and behavioral interventions and psychotropic
drugs is not being aggressively implemented in
most cancer centers (Maguire et al., 1978; Fawzy
et al., 1990a; 1990b; Watson, 1991).
In the training area, it will be necessary to
develop several internationally recognized com-
prehensive centers for psycho-oncologic training
and research in which high quality training is
offered in both domains. Critically important is
the obtaining of fellowship support for outstand-
ing young clinicians and investigators which will
encourage them to undertake careers in this area,
when independent financial support cannot be
sought by the individuals. These centers will need
to provide leadership in setting standards for
qualifications of graduates of the programs, their
training and curriculum. They must determine the
core knowledge required of all trainees and the
modules that are needed for trainees from specific
disciplines. In addition, there is a need for curri-
cula for training the oncology professional (e.g.
oncologist, nurse) who wishes to be more profi-
cient in these skills. Several models of training,
either using intensive short programs or part-time
over longer periods, are available but none has
been scrutinized, evaluated and compared. Volun-
teers are widely utilized in psychosocial programs.
They are trained by each institution, but as yet no
standards have been developed for their training.
This is a responsibility the field must face shortly.
In the research area, many exciting challenges
immediately arise. Collaborative ties to tra-
ditional oncologic specialties assure attention to
new therapies with psychiatric or psychological
sequelae (e.g. interleukins, interferon). In
addition, psychological data increasingly should
be collected in conjunction with biologic and
oncologic variables to assess better the possible
interaction, as represented by psychoneuroim-
munologic research (Stein et al., 1991). Assess-
ment techniques require care and ongoing
attention to validation and improvement of
methods, especially comparison of their use
across languages and other cultural factors.
Clinical trials are needed for the current actively
utilized interventions: psychotherapeutic,
behavioral and pharmacologic. There are few
controlled trials of single interventions. There are
no combined modality studies, despite the fact
that at least two modalities are usually used
concurrently.
Clinical trials in cancer are increasingly con-
taining quality of life as an outcome variable in
assessing treatment efficacy (defined as the level
of ability to function in the major domains of
living, e.g. physical, psychological, social, work)
(Sugarbaker et al., 1982; Silverfarb et al., 1983;
Coates et al., 1987; Osoba, 1991). Ability to
change· attitudes and behavior constitutes the
chief way to control development of neoplasms
which are dependent upon exposure to carcin-
ogens. Social scientists provide the resource to
examine how to change behaviors related to sun
exposure, smoking and occupational exposures.
International collaboration of psycho-
oncologists may have most to contribute by the
opportunity to study the effect of cultural vari-
ables on psychosocial adaptation to cancer. Sul-
livan and Cohen have presented a model which
 HOLLAND
needs to be followed by comparing psychosocial
variables based on US or Swedish health care
(Sullivan et al., 1988a; 1988b). Practices vary
widely across countries in terms of the patient’s
participation in informed consent discussions and
about truth telling (Razavi et al., 1987; Zittoun
and Sancho-Garnier, 1989). These ethical issues
lend themselves well to cross-cultural analysis.
Meta analysis of studies done in different
countries on psychosocial issues will be revealing
concerning universal versus cultural factors in
adaptation. Some studies offer the challenge of
replication in different ethnic and cultural groups
to determine their consistency across different
social settings.
Alternative cancer therapies are widely used
internationally. Prevalence, types employed and
reasons for their use, in relation to available
psychosocial support given in cancer centers,
could provide helpful answers (Cassileth et al.,
1984; Cassileth and Brown, 1988).
SIGNIFICANCE
The development of psycho-oncology is contribu-
ting substantially to the humanism that is increas-
ingly being attached to care of patients with
cancer, especially during palliative care.
Enhanced communication with patients and
concern for quality of life and well-being are
resulting in greater patient participation in treat-
ment decisions (Maguire et al., 1983; Maguire,
1985). The significance of these changes will be
seen by evidence of the routine consideration of
psychosocial aspects in the total care of each
patient with cancer. Growing sensitivity on the
part of staff, as well as data from research, make
it clear that these issues are increasingly receiving
the attention they deserve since they can substan-
tially influence outcome of treatment.
ACKNOWLEDGEMENTS
The authors gratefully acknowledge the assistance in
the preparation of this review by members of the Inter-
national Psycho-oncology Society and in particular Dr
Julia Rowland, Dr Frits van Dam, Dr Michael Trew,
Dr Andrea Patenaude, Mr Anthony Marchini, Dr
Marianne Sullivan and Dr Brian Doan.
1375
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