The psychosocial and pain management team at Cedars-Sinai Comprehensive Cancer Center is led by Tom Strouse, M.D., and includes Corinne Manetto, Ph.D., Denice Economou, R.N., Felicia Robertson, R.N., Tina Williams, M.S.W., Jill Seidel, M.S.W., Jill Gross, A.T.R., M.F.C.C., Lauri Seamark, Alida Narguizian, R.D., and Lynn Weiss.

Why is psychosocial support so important to cancer patients and their families?
Tom Strouse, M.D.: Here at Cedars Comprehensive Cancer Center, the strong emphasis on psychosocial support reflects the vision of the original founder, Dr. Salick, and what ideal cancer care delivery should contain. The founding concept was 24-hour comprehensive care without internal barriers to access, with psychosocial and pain management services on site. That emphasis emerged directly from the Salick family's own experience and what was wrong about cancer care delivery for them. The reduction in suffering is one of the core values in medicine, and we know that having psychosocial services on site helps with that. There is evidence that distress reduction contributes to better medical outcomes, as well as to lower health care costs.

Why is a multi-disciplinary team important and how does that work here at the Cancer Center?
Tina Williams: We each bring different approaches to the table, and we also overlap in some areas. Social workers try to meet as many of the patients here as possible. We try to make a connection with them when they first arrive at the center. We work on a broad base, getting to know the families and what their strengths are as well as where they need extra help, and we try to fill in those gaps. Social workers provide supportive and therapeutic counseling. We also help with concrete services, such as navigating the medical system here at the center, as well as systems outside our offices such as social security, MediCal and disability. When appropriate, we also make referrals to other member of the psychosocial team. Dr. Manetto, our psychologist, does biofeedback, relaxation and other interventions which enhance coping. Jill Gross, the art therapist, does art therapy as well as relaxation and visualization.

If someone is admitted to the hospital, could you follow them at that point or does care shift to a new team of people?
TW: We continue to be in contact with the patients, and collaborate with the inpatient social workers. We work together, and we visit the patients while they are in the hospital.

Dr. Strouse, what is your role as psychiatrist?
TS: My primary roles are as clinical and administrative director of the department and also as a provider of direct patient care, typically in concert with other staff in the department. In my role as clinical psychiatrist, I work as a physician with knowledge of the psychology of medical illness and the interactions between cancer and mood, anxiety, cognition and distress. My charge is to provide the most sophisticated biopsychosocial assessment of what's going on for patients suffering with psychological symptoms, whether they're reactions to life circumstances, or the chemotherapy, or a metastatic deposit. I do treatment planning, which involves other disciplines, to determine where medication or specific interventions are appropriate. My major clinical activity is as director of the cancer pain management service. In that area, we look at the interweaving of physiologic pain processes like pain from a tumor in the liver, as well as the distress that goes with a diagnosis of cancer, or whatever else might be happening. We look at physical pain as well as distress--the pain related to the psychological experience of loss and grief and fear and disfigurement. Our goal is to provide the best integrative care for patients dealing with all of these things.

I've heard it said that cancer doesn't just happen to the patient but to the family as well. What are your specific roles in working with patients and their families to cope?
TW: Our goal as social workers is to treat the patient as a whole person, and part of that is dealing with patients' relationships with family members or those close to them. If the primary care givers are coping well, the patients' own coping will be enhanced. We try to find out what the families are like, who is important in the patient's life, whether they have people who can help them. If patients don't have a support system, we try to find ways to connect them with resources in the community. We also work supportively with caregivers. We periodically offer support groups for caregivers, and we connect them with community services when appropriate. TS: We have some specific services for family members and caregivers. It's routine for one or more family members to be part of the pain management treatment process, helping in our assessment and in treatment, by logging the effects of treatment, for example. There are many ways in which we can work collaboratively with families, which benefits family members by making them an active part of the treatment plan.

What new developments in psychosocial services for cancer patients are particularly exciting?
TS: There are new conceptualizations in the roles psychosocial services play in treatment, and a movement spearheaded by Jimmie Holland and a consortium of people involved in psychosocial oncology from the NCI-certified cancer centers. It is a distress recognition and management initiative, designed like the pain recognition and management initiative of a decade ago, looking at distress as a highly prevalent symptom in malignant disease that is under-recognized and under-treated. This may change standards of care for cancer patients in very positive ways. I think we are in a time when there are many interesting drugs available to help with pain and symptom management. Newer analgesics, psychotropics for depression and anxiety, and other medications have proved very beneficial.

Do you see herbal or alternative medicines playing a role in treatment?
TS: There are some specific compounds, like St. John's Wort, which seem to have mild to moderate effects in certain circumstances, although there is very little data about the use of these medicines specifically for cancer patients. I'm interested in what draws people to unproven remedies, and the psychology behind that. There is an overlap between what we do and what patients are doing themselves and we try to understand why they may want to try other methods. We try to keep the lines of communication about these issues open with their oncologists.
TW: I think that there are many patients who are very interested in complementary medicine, and use it in conjunction with more traditional medicine. I think that the physicians and staff who work here are respectful of that and try to provide as much clinically-based information about alternative medicine as possible.

Tell me about the leadership position CSCCC has taken in pain management - how did the program begin and how has it been developing?
TS: The program developed from secondary visions that cancer pain management services could be effectively delivered by a relatively low-tech team led by a medically-oriented psychiatrist. That model was started by Dr. Corinne Manetto and Dr. Deane Wolcott and others who were committed to making that idea a reality. It is a very logical piece of the 24-hour outpatient care notion. Patients can use a 24-hour center to provide excellent pain and symptom management with all the efficiencies that come from knowing the staff, having access at night, and having regular follow up. Rather than having to send someone with a pain crisis to the ER, we have an accessible program with the patient's regular doctors always on call. We don't admit patients to the hospital with uncontrolled pain in this system. We admit between 15-25 patients a month to the treatment area for pain intervention. Out of the last 300 patients we've tracked, we've only had one hospital admission for unmanaged pain.

What have been your greatest challenges in doing this work? TS: The greatest challenges for me include putting together the incredible complexities of cancer and psychological and biological complications of cancer as they manifest as psychiatric symptoms. Maintaining technical skills which require a large amount of knowledge translated into a way of practicing clinically is always a challenge. Also, as the administrator of a department of people who do this work, it's a challenge to find ways of attaining a sustainable pace for working. 24-hour outpatient care is relentless and happens at a faster pace than in an inpatient setting. That puts incredible stresses on all the clinicians here.
TW: Sustaining the pace is challenging. Other challenges include helping families cope with loss and grief, as well as helping staff to deal with these issues and to communicate openly with the patients.

What are your greatest rewards?
TS: You meet people under extraordinary circumstances and you have the ability to greatly alter their experience, hopefully in a positive way.