I think we’re on the brink of seeing [psychosocial strategies in routine cancer care] really change in a good way in the next decade. But it’s slow going, and there’s plenty left to be done.
— Jimmie C. Holland, MD
Although internationally recognized today as the founder of the subspeciality of psycho-oncology, the field of psychiatry held no interest for Jimmie C. Holland, MD, when she entered Baylor College of Medicine in Houston, Texas, in the mid-1940s. Born in 1928 at the dawn of the Great Depression, Dr. Holland credits her mother with instilling in her a sense of optimism and a drive to help people that contributed to her decision to pursue a career in medicine. At Baylor, she was one of only three women admitted to a class of 80 students—most of whom were returning World War II veterans. With plans to return to her hometown of Nevada, Texas, after graduation and become a country doctor, she hoped to tend to the general medical needs of her rural community. However, a rotation in psychiatry during her internship at St. Louis City Hospital altered that future—and the future of cancer care.
“I wasn’t interested in surgery,” said Dr. Holland. “I didn’t want to cut up people’s bodies—that was clear to me early on—and I found treating illnesses like congestive heart failure with the same drugs over and over boring. What really interested me was how people coped with their illness and how every patient had a different way of doing that.”
With her interest in psychiatry taking hold, Dr. Holland continued her residency at Massachusetts General Hospital in Boston, arriving at the peak of the polio epidemic sweeping Boston in 1955.
“People were crippled with paralyzed limbs, and we had to clear out a whole ward to install iron lungs. I became very interested in what happened to these young people who were healthy one day and then paralyzed from the neck down the next day,” said Dr. Holland. “We began studying how these patients coped with catastrophe.”
It was during this time that she met James F. Holland, MD, then the Chief of Medicine at Roswell Park Cancer Institute, where he was researching chemotherapies for children with acute lymphoblastic leukemia. She moved to Buffalo, New York, where they married in 1956 and began raising a family of six children. Working part-time while the children were young, Dr. Holland began solidifying the focus of her work on the psychological care of the medically ill, especially patients with cancer.
She asked her husband, who was then Chair of the Cancer and Leukemia Group B, to launch a psychiatry committee within the group to study the effects of cancer and its treatment on the mental health of patients. “This is where I found my real heart,” said Dr. Holland. “Because that’s what I was interested in learning: How do people manage catastrophic illness?”
In the early 1970s, Dr. Holland spent a year in Moscow, where she served as a Special Consultant on a National Institutes of Health joint schizophrenic research project (while her husband was a consultant to the Soviet Union for cancer research). In 1973, after returning to New York, she became Assistant Chief of the Psychiatric Consultation Services at Montefiore Hospital in New York. This is where the specialties of oncology and psychology began to merge, and the term “paradoxical anxiety” entered the medical lexicon.
“I started looking at how women with breast cancer reacted after going through surgery and radiation. You would think that they would be happy after finishing treatment, but we found that women were more anxious because they were not being treated anymore and they feared that the tumor would come back,” said Dr. Holland.
Breaking Down Barriers
In 1977, Dr. Holland launched the Psychiatry Service at Memorial Sloan-Kettering Cancer Center in New York, the first of its kind in the country. Nearly 2 decades later, she became the first Chair of the center’s Department of Psychiatry and Behavioral Sciences. She is currently Attending Psychiatrist and holds the Wayne E. Chapman Chair at the cancer center.
Under her leadership, Memorial Sloan-Kettering’s Psychiatry Service became the country’s leading training and research program dedicated to the field of psycho-oncology, conducting randomized clinical trials to prove that interventions combatting the anxiety and depression associated with cancer care can work. During those early years, Dr. Holland also founded the International Psycho-Oncology Society and the American Psychosocial Society. All of these efforts helped break down cultural barriers, both for women wanting to purse a career in medicine and for the field of psychiatry.
“When we first came to visit patients, people would say, why are you here? These people are sick, why do we need psychiatrists?” Dr. Holland said.
Today, hospitals and oncology practices across the country are adding programs to help patients cope with the psychological side effects of cancer, such as anxiety and major depression, which can influence how well patients fare. “Anybody who gets a cancer diagnosis is sad, but if you are so sad that you can’t get out of bed to get your chemotherapy and don’t adhere to treatment, it can alter outcome,” said Dr. Holland.
According to research Dr. Holland has conducted, one-third of patients with cancer experience clinically significant mental distress. Distress, said Dr. Holland, is the “sixth vital sign” when assessing a patient’s condition, following pulse, breathing, temperature, blood pressure, and pain score.
To help oncologists easily evaluate patients’ distress levels, Dr. Holland and her colleagues at the National Comprehensive Cancer Network developed a “distress thermometer” that measures a patient’s distress on a 0-to-10 scale, similar to the pain scale oncologists use to assess pain. If a patient scores 4 or higher on the distress thermometer, it is a signal that the individual should be further evaluated and, if necessary, referred to a mental health-care specialist and monitored closely.
Long Way to Go
In 2008, the Institute of Medicine (IOM) issued a report, Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs,1 which recommended the integration of psychological services into oncology care as a new quality standard for cancer care. The Commission on Cancer, which accredits centers that treat patients with cancer, has mandated that by 2015 providers must have a plan in place to evaluate patients for distress and refer them to programs for help.
How successful these efforts will be in garnering greater clinical attention to the psychological needs of patients remains to be seen. In a 2007 survey of 1,000 oncologists,2 only 14% said they used an evidence-based screening tool to measure stress in their patients.
“We still have a long way to go,” Dr. Holland admitted. “But [the 2015 mandate] is a foot in the door.”
The IOM report is already having an impact, with the Union for International Cancer Control, World Health Organization, and more than 45 other international societies endorsing the IOM recommendation. Such support is helping to cement recognition of the importance of psychosocial strategies in routine cancer care.
“I think we’re on the brink of seeing things really change in a good way for us in the next decade,” said Dr. Holland. “But it’s slow going, and there’s plenty left to be done.”
At 84, Dr. Holland plans to be around to witness the full success of her 4-decade-long effort.
“I’m still having too much fun to retire,” she said. ■
1. Committee on Psychosocial Services to Cancer Patients/Families in a Community Setting; Adler NE, Page AEK (eds): Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC, National Academies Press, 2008.
2. Pirl WF, Muriel A, Hwang V, et al: Screening for psychosocial distress: A national survey of oncologists, J Support Oncol 5:499-504, 2007.