by FIONA MULLEN
Melanoma is considered to be one of the best examples of an immunogenic tumor. This means modulation of our immune response can influence melanoma tumor biology. As a result, immunotherapy has been found to extend survival for patients with melanoma that has spread in the body.
However, an individual’s response and the duration of any response to immunotherapy cannot be predicted, which can make it difficult to plan for the future. In addition, treatment-related toxicities, such as fatigue can significantly impact on quality of life. Toxicities can develop within days of commencing treatment or after several months.
Whilst patient experiences of immunotherapy are similar to those of patients receiving chemotherapy, it is important to note that the duration and frequency of immunotherapy treatments far exceeds treatment with chemotherapy. Consequently patients are more likely to be facing treatment-related toxicities for an extended period of time.
Active coping skills
If you are receiving immunotherapy, there is a need to think about melanoma as a chronic illness and to take steps to enhance your coping skills. This is because the ways in which you cope with melanoma may have a profound influence on your immediate and long-term psychological, social, and physical health. The best strategies you can use to cope with your diagnosis and/or treatment include:
facing the reality of one’s illness maintaining hope and optimism expressing one’s emotions
seeking support from others
adopting a participatory (as opposed to avoidant or passive) stance, and maintaining self-esteem
In contrast, avoidance coping methods are typically associated with anxiety, depression, confusion, and total mood disturbance in patients with early-stage melanoma. Avoidance coping, refers to our attempts to actively avoid the problem or indirectly reduce emotional tension through the use of distraction. Taking stock of your coping skills (which essentially refers to problem solving) may be one of the most useful things you can do.
Active coping with fatigue
As a worked example of active coping, fatigue is presented as an especially difficult issue for patients with melanoma. Fatigue impacts on our overall health, comfort, and functional ability, and it has psycho-social and financial implications. However, unlike other treatment-related side effects, patients receiving immunotherapy for melanoma do not appear to know how to manage fatigue.
The development of active coping strategies in relation to fatigue would need to addressed at both the cognitive and behavioural levels. Active cognitive coping, includes consideration of one’s attitudes, beliefs, and thoughts about fatigue. Active behavioral approaches include attempts to deal directly with fatigue (e.g. exercising and improving diet).
Active cognitive coping
Emotional distress and fatigue tend to go together. Becoming aware of how fatigue impacts on your well-being at a psycho-social level is critical. In the first instance, referral by your GP for a few sessions with a therapist trained in cognitive behavioural therapy (CBT) may be an important step towards taking stock of your coping style. CBT addresses the functionality of our emotions, behaviours and cognitive processes and applies them to goal oriented activities. A clinically significant decrease in fatigue severity and functional impairment has been demonstrated with this approach.
Active behavioural coping strategy
An active behavioural coping strategy would be to find a GP/specialist you can communicate well with. Over time, a wide range of issues can impact your fatigue levels so it is important to be alert to these factors and keep talking to your doctor about it. Topics for discussion can include but are not limited to quantifying the level of your fatigue since starting treatment:
How much is it interfering with your usual routine?
Can you still mow the lawn or do the shopping?
Exercise can reduce cancer related fatigue, however, you may have difficulty maintaining an exercise routine on your own. Exercise physiologists can provide invaluable support to help you overcome barriers to exercising. Your GP can refer you, as an individual with a chronic disease, to an exercise physiologist for 5 sessions per year.
Your GP can assess the likelihood that you have depression. Cancer related fatigue can overlap with depression however depression may require a different emphasis in terms of management.
Are there other compounding problems such as nausea and pain that could be better managed? Your doctor can consider whether you have co-morbidities that are also impacting on your levels of fatigue such as anemia.
Complementary medicines are used by an increasing number of patients with cancer. For example, ginseng has been investigated with mixed results for cancer related fatigue. However, ginseng may affect drug metabolism and potentially increase toxicities. For this reason it is very important that you discuss any complementary medicine usage with your specialist.
Immunotherapy treatment, in relation to melanoma, has given us cause for optimism. However, the intensity of treatment side effects are likely to be greater than for those undergoing chemotherapy because immunotherapy can be ongoing. As a result, melanoma survivors receiving immunotherapy need to be on the front foot in terms of developing positive coping strategies. Fatigue is one the most difficult issues faced by patients receiving immunotherapy. Examples of positive coping strategies in relation to fatigue may include keeping the dialogue open for an extended period of time with your GP/specialist because the causes for fatigue may change.
However, you are encouraged to use your imagination and develop your own personalised active coping strategies to enhance your ‘immunity’ to fatigue.
Fiona has worked both as a registered nurse and hydrogeologist. As a hydrogeologist, she has an interest in the sustainable use of natural resources and she has published some of her work in the Groundwater Journal. As an RN, she has experience working in oncology/haematology at Sir Charles Gardener Hospital and in cancer research at Royal Perth Hospital in Perth Western Australia. She has an interest in the use of complementary approaches to health as a strategy to engage patients positively in their journey towards healing.