Psiconcologia e Breast Unit: psiche e soma

Transcription

1 99 Simposio Fondazione Arturo Pinna Pintor Qualità di Vita e Terapia Oncologica: dal modello bio-medico a quello bio-psico-sociale Torino 12 ottobre 2013 Psiconcologia e Breast Unit: psiche e soma Riccardo Torta SCDU Psicologia Clinica e Oncologica Dipartimento di Neuroscienze Università di Torino

2 Psicologia Clinica e Oncologica Città della Salute e della Scienza e Università di Torino

3 COES BREAST UNIT COES SGAS BREAST UNIT RIABILITAZIONE accoglienza screening supporto presa in carico consulenza guarigione accompagnamento REPARTI AMBULATORI REPARTI APOD HOSPICE DOMICILIO APOD Hospice SCDU Psiconcologia Torino 2013

4 Psychological factors Environmental factors Biopsycosocial model Biochemical and physiological factors Somatic disease Psychological response (losses) Treatment side effects Biological background Emotional disturbances (mood depression, anxiety, chronic stress) Quality of Life

5 physical symptoms (from disease and its treatments) functional status (work, interests, daily living) Quality of Life spiritual aspects existenzial aspects sexuality body image patient s s satisfaction emotional aspects (anxiety, depression, chronic stress) socialization (interpersonal relations, social role) Emotional aspects of breast cancer (depression) 539 pts 4 weeks after diagnosis 2 weeks before surgery HADS Hospital Anxiety Depression Scale Tesio, Ieraci, Stanizzo et al., 2013

6 Emotional aspects of breast cancer (depression) HADS Tesio, Ieraci, Stanizzo et al., 2013 (2011) European Journal of Cancer Care 20, HADS can be considered a sufficiently effective screening tool for depression when a cut-off of 8 is used

7 reduced brain monoaminergic transmission oxidative stress and nitric oxide Major depression neurotrasnmitter receptor dysfunction reduction of neurotrophic factors increase of proinflammatory cytokines dysregulation HPA HPG HPT axis Emotional aspects of breast cancer (stress) DT Distress thermometer Tesio, Ieraci, Stanizzo et al., 2013

8 Cancer, 1;119 (9): DT 37 % 1108 outpatients with cancer from 38 oncology centers DT and Problem List Hospital Anxiety Depression Scale (HADS) Brief Symptom Inventory (BSI-18)

9 DT Thermometer Distress Thermometer and brain metabolism in cancer patients: a [18F]FDG PET correlation study DT scores correlated with midbrain structures as periventricular nucleus and dorsal medial hypothalamus. Problem Checklist patterns correlated with the same midbrain areas and included also more regions in the limbic forebrain and brainstem. Castelli, Torta et al., Stress and Health 2013

10 Genetic aspects of stress Struttura del gene umano per il trasportatore della 5HT Variante Allelica 5-HTTLPR s Allele l Allele Mosaicismo Variante Somatica Promotore SP1 delezione 381-bp AP1 AP1 SP1 CRE AP2 TATA +1 Exon I gene 5-HTT umano II III VII XII XIV 5 3 ATG VNTR-17 Leu255Met

11 Emotional aspects of breast cancer (stress) 5HTTR Torta et al., 2011 DT Tesio, Ieraci, Stanizzo et al., 2013 Psychological factors Social factors Biopsycosocial model Biochemical and physiological factors

12 Correlations analyses resilience influenced by cognition repeated losses and dysfunctional coping strategies Mood Depression Quality of Life Cognitive impairment Physical symptoms

13 Mood depression and cognition pathogenic factors sharing neurotransmitters hormons Serotonin Noradrenaline Dopamine Acetylcholine Glutamate HPA axys HPT axys HPG axys citokines IL-1 IL-2 IL-6 TNFα growth factors BDNF NGF GDNF Many cancer patients complain of chemo fog or chemo brain, cognitive changes that they attribute to their chemotherapy. there is an increased risk of cognitive impairment also in cancer patients who have had no chemotherapy exposure Thus, assessment before and after chemotherapy is necessary in order to conclude that any cognitive deficits observed following chemotherapy are attributable to chemotherapy exposure.

14 Objective cognitive deficit resulted independent from the emotional status. On the contrary, self-perceived mental dysfunction was unrelated to the objective cognitive decline, but it was associated with depression and anxiety. Twin A demonstrated much broader spatial extent of activation in typical working memory circuitry (bifrontal and biparietal regions) than twin B. However, twins A and B did not differ in task performance accuracy (Fergusson et al., 2007) genetic susceptibility Variability of APOE, BDNF genes might increase the individual vulnerability to chemotherapy-induced cognitive changes. blood brain barrier Chemotherapy agents do not significantly cross BBB, but also small doses cause cell death and reduced cell division in brain structures crucial for cognition brain function cognition DNA damage by cytotoxic agents, increased oxidative stress, shortening of telomeres oestrogen or testosterone reduction by chemotherapy and hormonal treatments, such as tamoxifen or aromatase inhibitors cytokine deregulation Cytokine deregulation and inflammation increase oxidative stress and DNA damage that trigger additional cytokine release.

15 Psycho-Oncology Volume 18, Issue 8, pages , August 2009 Patients and methods: Breast cancer patients scheduled to receive adjuvant chemotherapy (n = 61) completed comprehensive cognitive testing before and after treatment. A control group of women receiving adjuvant hormonal therapy (n = 51) was tested at comparable intervals (2-3 months) The chemotherapy patients were 3.3 times more likely than the hormonal patients to show reliable cognitive decline (31 and 12%, respectively). The involvement of frontal lobes could be a factor guiding the changes and the adaptation mechanisms activated as a response by the system (e.g. cytokines production, stress system activation, immune system responses). High cytokines levels correlate with mood depression, cognitive dysfunction, pain and stress levels

16 Antidepressants : < proinflammatory cytokines > antinflammatory cytokines

17 The purpose of this study was to evaluate the preliminary efficacy and satisfaction/acceptability of training in memory or speed of processing versus wait-list control for improving cognitive function in breast cancer survivors. 82 breast cancer survivors completed a three-group randomized, controlled trial. speed of processing training resulted in immediate and durable improvements in objective measures of processing speed and verbal memory.. For this is the great error of our day in the treatment of the human body, that physicians separate the soul from the body. Hippocrates, ac