What to Know About Mental Health Care and Cancer Care: Q+A with Jon Levenson, MD

A cancer diagnosis is life-changing, and the changes that cancer patients endure are not just physical, they can also be psychological as well.

At the Herbert Irving Comprehensive Cancer Center, Dr. Jon Levenson specializes in consultation-liaison psychiatry and psycho-oncology, helping patients cope with cancer and treating a range of psychiatric complications encountered in cancer care. As part of the psycho-oncology program at New York-Presbyterian/Columbia, Dr. Levenson and his colleagues, Drs. Ian Sadler and Adrienne Mishkin, care for patients suffering from the stresses of both a cancer illness and its treatment, as well as psychiatric complications that could interfere with their cancer treatment and outcome. They address a range of symptoms from diagnosing and treating post-traumatic stress disorder (PTSD) to helping manage emotional distress in patients with an anxiety disorder or depression; in the hospital setting, their team addresses acute psychiatric disorders such as delirium.

“Every cancer patient requires a whole-team, comprehensive approach and an integral part of that includes psycho-oncology care,” says Dr. Levenson. “We work hand-in-hand with all of our clinical programs such as our breast and pancreas cancer programs and our neuro-oncology program, and we also work closely with our palliative care colleagues to provide total cancer care to our patients and families.”

In the fall of 2020, Dr. Levenson was elected a Fellow of the American Psychosocial Oncology Society (APOS), in recognition of his commitment and dedication to the psychosocial care of cancer patients and their families. He had previously served as president of APOS earlier in his career. He is an associate professor of psychiatry at Columbia University Vagelos College of Physicians & Surgeons and director of undergraduate medical education in consultation-liaison psychiatry.

What are the most common psychosocial complications linked to cancer?

Cancer patients commonly experience anxiety, insomnia, fatigue, depression, as well as general emotional distress, and this can lead to social problems related to body image, or intimacy and communication with others. Increasingly, we are also recognizing PTSD in cancer patients. For example, a cancer patient can develop PTSD related to coping with a surgery such as a mastectomy or a limb amputation. Patients can also experience psychological distress from a lengthy course of chemotherapy with complications such as alopecia (losing hair) or neuropathy (nerve pain or numbness). Cancer patients who have needed an extended intensive care unit stay are also at increased risk of developing PTSD.

My team focuses on helping cancer patients cope with the demands and stresses of both an initial cancer diagnosis as well as managing behavioral complications associated with cancer treatments; examples include a young breast cancer patient who develops fatigue and depressive symptoms during chemotherapy, or an elderly patient who is overwhelmed with managing the demands of living with an ostomy after surgery to treat bladder cancer. 

At what point in their continuum of care, from diagnosis to treatment and beyond, do you see cancer patients?

We support our patients over the course of their often long cancer treatment which may include several different therapies like surgery, chemotherapy, radiation therapy, and immunotherapy. We care for patients beyond their initial treatments, into remission and eventually survivorship so we can make sure that their psychosocial oncology care continues. We may first consult on a patient during a surgical oncology admission and when she is discharged, we will help arrange outpatient care. We use several different types of therapies, including cognitive behavioral psychotherapy, interpersonal therapy, and supportive psychotherapy. Our group and our colleagues in breast oncology studied how these three different psychotherapies performed in treating major depression in women with breast cancer, finding that all three approaches are effective.

Within our consultation-liaison psychiatry service, our consultants diagnose and manage acute psychiatric complications like delirium, also known as an acute confusional state. We also manage depression and anxiety in hospitalized patients. Patients with multiple pain syndromes are often highly distressed and our service works closely with our oncology, pain service, and palliative care colleagues to address pain, distress, and co-existing psychiatric symptoms. For our cancer patients with severe and persistent mental illness such as schizophrenia, we will work closely with their outpatient mental health providers to coordinate psychosocial and psychiatric care in the context of their cancer care.

How do patients get connected with you?

We work closely with all the different cancer care programs at the Herbert Irving Comprehensive Cancer Center. We attend tumor board meetings and other interdisciplinary conferences during which new patient cases are reviewed, and we provide input about psychiatric and psychosocial issues and complications within the proposed oncology care plan. Patients may also be referred to our program from our oncology social work and our palliative care colleagues.

Does the patient’s family become involved in their psycho-oncology care?

We are very inclusive in our approach to providing psycho-oncology care. We will routinely include family members in our evaluation and will offer to meet with family members alone to provide support. We also will connect with a family, when appropriate, after a death and will assist with a referral for bereavement care. We can help provide short-term support for a grieving family who is dealing with bereavement-related distress. When family members have more severe symptoms, we will refer for psychiatric assessment as some family members may develop a newly recognized condition: prolonged grief disorder.

What new therapies for psycho-oncology are on the horizon?

There have been new psychotherapies surfacing in the oncology space and one that is very exciting is called meaning-centered psychotherapy—addressing a patient’s will to live meaningfully and helping access spiritual well-being. Particularly with patients who have far advanced cancer, we now have specialized psychosocial interventions that can greatly improve their quality of life and reduce suffering. The sub-specialty of geriatric oncology is another area where psycho-oncology has an evolving role, helping elderly patients cope with the demands from disease and treatment. As cancer becomes more of a chronic disease model of care, with patients thankfully living longer with their diagnoses, psycho-oncology will have an even more active role to support coping and address the psychosocial needs of people who have been dealing with cancer for a long time.

How do you support cancer survivors?

While survivors in general cope well, they can at times develop psychosocial conditions that can come from symptoms such as persistent fatigue, lack of stamina or focus, or sexual dysfunction. Psychological themes include an enduring sense of vulnerability and uncertainty about future recurrence that may persist in cancer survivors, and it is important that cancer survivors receive regular psychosocial assessment and psychosocial support when needed. Survivors often benefit from group support interventions including online platforms. On occasion, survivors may present with depressive symptoms that, once we perform a comprehensive assessment, leads to a new medical diagnosis which is causing the presenting symptoms such as depression or anxiety. In other words, our role in psychosocial oncology is to ensure that we are paying constant attention to coping, distress, and quality of life in our patients and this extends to cancer survivorship and all of its psycho-social and medical aspects.

How has the pandemic affected cancer patients differently during this time?

The global SARS-CoV-2 pandemic has greatly heightened stress and anxiety for our cancer patients and families. Not only are they dealing with their own distress around their cancer and treatment, now they are concerned that they are at higher risk of getting COVID. The pandemic exacerbates this already present stress, anxiety, and uncertainty which can  trigger problematic responses, including substance misuse that can affect adherence with cancer care. Our psychosocial oncology team provides extensive tele-mental health services for our cancer patients which has been quite successful at engaging and reaching patients who would not have been able to access on-site mental health care.