Transcription:
Coping with Cancer During COVID-19

Dr. John Leonard:  Welcome to Weill Cornell Medicine Cancer Cast, conversations about new developments in medicine, cancer care and research. I'm your host, Dr. John Leonard. And today, we will be talking about coping with cancer during COVID-19. My guest today is Dr. Guy Maytal, a psychiatrist and mental health specialist at Weill Cornell Medicine and New York Presbyterian Hospital, where he serves as the Chief of Integrated Care and Psychiatric Oncology.

He is widely regarded for his expertise working with oncologists to care for patients with chronic and life-threatening illnesses. Dr. Maytal, thanks for joining us today. This is really a topic I've been looking forward to. I think everybody, whether you have cancer or not, is dealing with elements of anxiety and stress among other things for a variety of reasons. And certainly patients who have cancer are particularly vulnerable to these sorts of issues. So thanks for joining us and thanks for what you do for our patients helping them through difficult times.

So I want to start by asking you, you know, people ask me as an oncologist, you know, I'll ask you as a psychiatrist, what drew you into not only psychiatry, but working with focus on patients with either cancer or other serious illnesses? What led you to work in this challenging area?

Dr. Guy Maytal: Yeah. Well, long before I even went to medical school, I was very interested in the human condition and what it is to be human. And one of the fundamental aspects of being human is that we're finite. And when I got to medical school and decided to become a psychiatrist, I fell in love with both psychiatry and internal medicine.

And throughout my career, I have often worked at the interface because I think it's a space where people are really grappling with the questions, not only of how do I get through this illness, but what does this illness mean for me, for my life, for my family, and how can I cope better during it? How can I recover from it? How can I deal with it if I'm not going to recover from it? So all of those things were things that I was interested in and became very passionate about. And like many of us who are in medicine, it's often one or two or three patients who taught me things and who inspired me to pursue this. All of those led me to this place.

Dr. John Leonard: Well, I think a diagnosis of cancer obviously leads a patient to deal with lots of different challenges and feelings and emotions. But I think we'll focus much of our talk today on kind of anxiety and stress around dealing with a cancer diagnosis. And now the whole issue of COVID has made things worse or at least made it more complex for many patients. And we'll talk about the ways in which that's been the case, but give us a sense of, if one can generalize, the general kind of experience of patients dealing with anxiety and stress relating to a cancer diagnosis, and then how COVID might make that worse.

Dr. Guy Maytal: Wow. Yeah. So that is obviously a very broad topic that we can spend hours on. So in brief, I think that one of the things for us to keep in mind is no one's ever prepared for this. That's one of the big things that I think leads to the experience that people have. Wherever they fall on the spectrum of experience is that nobody plans for it. Nobody prepares for it. It's not in my 10-year vision for myself to get a diagnosis of cancer.

So it lands in the middle of life. And wherever you are in life, it is unanticipated, whether you're young and middle age or later in life, whether you're financially stable or insolvent, whether you have kids or not, you know, whatever you're dealing with. So the thing to deal with is that it is a surprise and an unwelcome surprise and it amplifies everything.

And the second part of that is that the thing that it does for almost everybody involved is bring right to the forefront questions of my own mortality. You know, what we want to know as human beings, when they get this diagnosis, is am I going to live or die? And, well, all of us know that we're going to die at some point, none of us are planning to do so today. And all of that leads to a great deal of worry, distress and, in part, because the way I like to describe it is it's like you've been drafted to do a job that you didn't ask for and aren't prepared for and almost certainly know nothing about. And you got to go and do that job called being a cancer patient.

Dr. John Leonard: It strikes me that, as you describe it, which is I think a great dimension of the surprise is that there is kind of normal stress and anxiety brought on by that challenging experience. And then presumably, there's, in some patients, abnormal and maybe normal and abnormal is not the best term, but there's kind of the routine or the expected, and then beyond the expected. How do we kind of differentiate those? Or does it really matter from the standpoint of a patient and the patient's experience?

Dr. Guy Maytal: Well, I think of it more in terms of functional or non-functional. So let me take a step back, because when we talk about anxiety, all of us have anxiety. I think that if someone is given the diagnosis of cancer of any type and you don't have some feelings of worry or apprehension, then you have something to worry about, because that would be an expected response. But if the person is able to function in their life and whatever the word function means I think varies by individual, but meaning get through their life, and it could be functioning at a high quality of life, or it can mean just get through the day. But that's when I think about what's expected versus not expected.

The other aspect is the timetable of it because often the shock of the diagnosis and the uncertainty around even around the diagnosis, you know, often it takes some time to come to a definitive diagnosis for a lot of cancer cases, and then the unfamiliarity of the new patterns of life around treatments. So all of that can lead to uncertainty and worry which sometimes it's a synonym for anxiety. The trouble is it's kind of a word we use in everyday language and it's also a clinical term and that makes it a little muddy. Anxiety is any sort of feeling of worry or uneasiness about something that you can't quite be certain about. And it also refers to a clinical state, which often requires some sort of help or treatment. So it's useful to differentiate between the two.

Dr. John Leonard: It strikes me that when we talk about these issues, there is somewhat say a bell-shaped curve. If you're not worried or anxious about an issue, whether it's cancer or COVID, you're not going to do what you need to do to take care of it or to prevent it in some cases on the other hand, as you alluded to, too much may be paralyzing or may interfere with your functioning. So how can we differentiate those? Because I'm sure for some patients, it's hard to know where they are on that curve. How do you know that you're in, if there is, a right spot or at least in that middle ground?

Dr. Guy Maytal: Yeah. So I'm glad you added that last clause because the spot is broad. Again, just to underline what you're saying, normal anxiety is actually adaptive. It's inborn, it's wired into the brain. It's a response to a perceived threat or to the absence of something that signifies safety. You can imagine a baby who can't find its mother or father for a moment gets very anxious. And as you just said, too much of it leads us to freeze or runaway, avoid, which is that old fight-flight reaction and it's actually fight, flight or freeze. And the place I look to is impaired function. In the case of patients who are dealing with cancer, on one extreme people who are canceling appointments, people who are avoiding talking about important issues, people who are unable to leave their house because of fear or worry, that's pretty obvious that needs some attention.

And if you're unsure, ask the people around you, one of the themes in my conversations with patients is pick the people you trust and then trust them, whether that's your oncologist, nursing staff, social worker, clergy, family, friends, whoever it is. They will tell you, they'll say, you know, "You're not yourself. Maybe you could use some help." Because sometimes we are right, we just don't know, because we're navigating this new world called being a cancer patient.

Dr. John Leonard: One scenario for some cancer patients is the concern, which is understandable about their diagnosis and their treatment, which leads them to seek a lot of opinions, to seek a lot of information, to question every decision or many decisions. You know, it strikes me again that's can be good and that they're becoming informed, but on the other hand, it can be challenging if it becomes more than a full-time job and where it's overkill in some cases where someone is really thinking about their treatment or their diagnosis or their plan probably more than they need to and second guessing decisions. How do you approach that in some patients or how do you advise patients to kind of find the right amount there?

Dr. Guy Maytal: Yeah. As you said, some people have what we call high information needs. So in order to get through life, some of us need to know a lot and that helps us get through life. And then some of us use the search for or pursuit of information to deal with or address the anxiety. And of course, no amount of additional information addresses something that is fundamentally about fear or worry.

So when people are dealing with that, the first thing I often check in is if have you done something like this before? Typically that is a particular way to avoid engaging with or about the anxiety or worry itself, because maybe this one will be it, maybe this one will be it, maybe this scan or this consultation, et cetera.

And what's usually helpful in those situations is to really invite them to trust someone who you're going to trust. Because at some point, we put our nickel down with this medical oncologist or with this surgeon or with this radiation oncologist, and they're going to be my person. And then what the patient has to deal with and what the family has to deal with often is their worry about what they're really worried about, which is some version of will this treatment really help? Will this cure me? Will this get me to remission? Which is what they're really worried about a lot of the time and it's a bit of a dance. Can you trust me? Can I trust you like that? And sometimes it takes a directive from someone in a position of trust and authority, either a family member or advisor of some sort, be it a doctor or someone else, to say it's time to stop.

Dr. John Leonard: You referenced family. And obviously families are very important to many patients dealing with cancer. And we'll come back to how families can be helpful specifically in certain cases. But a followup to this scenario we just talked about, in some cases, the family members may be driving some of the information seeking, which again can be a good thing if it's an adult child helping an elderly patient who can't navigate the second opinions or the information, but in some cases that may make things worse in some scenarios. How does one at least recognize that? Is it the same sort of thing from the standpoint of making the patient as comfortable as possible with the plan and the decisions? Or are there other things to kind of help make sure that families stay on track in this situation?

Dr. Guy Maytal: Yeah, I think it's a complicated situation because from the family member's perspective that you're describing, they're really doing their very best to take care of their loved one. And to others from the outside, it looks like they might actually be interfering with care, meaning at least delay in care that might benefit their loved one.

So, again, it's kind of a tricky situation because one of the things I sometimes suggest is simply asking the patient what would they like to do. And then often we get a sense of, "Oh, are they going along simply to please their loved one or because they really want to do this." And if there is that space, "Oh, I'm doing this just to please my son or daughter," then maybe you'll have a conversation with the family about how do we reconcile that and it's delicate. And obviously everyone intends the best and means well most of the time. So you have to figure out a way to get everyone on the same page. And that's where the art of these conversations is. There's no simple, obvious recipe for doing this, but that's kind of how I think about it.

Dr. John Leonard: So I want to get into in a minute how patients can deal with these issues, what tools they have. But first I want to ask you, clearly you're a psychiatrist, but there are others that play a role in the care team in helping patients deal with these issues, whether they're counselors of some sort or another psychologist, social workers. What are the rules of thumb that people should keep in mind as they think about the type of professional or the type of support that's going to be most helpful to them so we can guide people in the right direction?

Dr. Guy Maytal: Yeah. So the first thing I ask-- I even go back one step before what you were just talking about, Dr. Leonard. I just ask patients what have you done in the past to get you through tough times? I really just start by finding patients resilience. And the three questions I ask and I invite people to ask themselves is have you gotten through tough times before? Most people have gotten through something difficult in the past. What's worked?

And then the other two are what have you stopped doing recently that you used to do to either make yourself feel better or take care of yourself? Or what have you started doing recently to feel better that might not be so good for you? For example, drinking more alcohol or eating bad foods or things like that, or like avoiding people that are typically nurturing to you.

I find that for many people, the first place to start is the people in your community who offer support, whether that's family or friends or clergy or volunteer or other communities where many of us who work in this field have heard many stories about how wonderfully pleased patients are when folks seem to come out of the woodworks to offer support. And that's really all they need.

And if that's not sufficient, and here's what I really mean, like the anxiety is really interfering in your life. And by anxiety, I mean thoughts of worry, the body sensations and the emotions. So anxiety, just to again take a little bit of a detour, anxiety, as a clinical phenomenon, isn't one thing. It's a collection of experiences, because if I would ask anyone, tell me how you know when you're anxious. You'll get a variety of answers. Some people will say, "Well, I feel tightness in my chest or my throat or other physical experiences." Some people will say, "Well, I worry constantly, like I can't sleep because my thoughts go on and on in my head. Other people will say, "I'm afraid. I'm really afraid. And I can't stop feeling afraid." And it's that triad of feelings of worry, thoughts of impending awfulness and the physical sensations that altogether is the syndrome called anxiety.

If that's getting in the way, if that's happening in a way that is disruptive, for example, disrupts your sleep; for example, disrupts your ability to enjoy moments when you're feeling well enough to enjoy moments, then professional help is probably indicated. And as you were saying, there are many people on the team. You know, most cancer clinics have some sort of mental health person affiliated right there. That's often a social worker or another type of licensed counselor, like a licensed mental health counselor. And those people are trained in dealing with many, if not, most of the worries or concerns that people come in with. Because it's usually immediate, it's usually circumstance-driven and it usually can pass or at least be calmed down inside of a few conversations.

Sometimes people need more rigorous or structure treatment, like more formal psychotherapy. There are people who are trained to do that. Sometimes they're licensed social workers, sometimes they're psychologists, and there are various types of psychotherapy. But fundamentally what that is it's a regular regimented set of conversations that help you think newly or differently about your experience so as to feel less distressed about it. And sometimes what's needed is to see a psychiatrist, who can think about all of this, but also thinks about how medications might be helpful and how your treatment might be causing some of these symptoms, which can happen from time to time.

Dr. John Leonard: We're very fortunate here at Weill Cornell in New York Presbyterian to have you and your team available for input and consultation and really being very readily able to step in and help people out. I think that at many centers and for some patients, there's this reaction to,"Just give me some medication. Give me some Valium" or something like that, and some patients often ask for that. What's your general advice to people in those scenarios where they're asking for medication or being offered medication without a lot of depth, not because doctors are doing the wrong thing on purpose, but maybe don't have the time or the expertise? How do you guide people as far as that goes?

Dr. Guy Maytal: Yeah, on the one hand, someone's in distress with you in the office, right there, it's perfectly fine to give them a medicine that for a short while will reduce their distress. Obviously, all we want to do in the medical profession is reduce people's distress, be it physical or psychological. And I think that the other side of that is it's useful to meet people where they are. So if someone says, "Listen, I'll do whatever you say and get something for the anxiety." I'd say, "Sure. Here's something for the anxiety. And I want you to consider talking to a social worker about what you're doing."

The challenge right there is a lot of people on both the medical provider side, as well as patients and families come in with a lot of preconceived notions about what that looks like. We even have this phrase that's cropped up in the last decade "Maybe you should talk to somebody." Everyone knows what we're talking about, but the sentence itself is quite vague. Because I think most of us, unless you've been in therapy before or even met with a therapist, don't really know what it is, how it will help, or we have kind of this fantasy that someone will be able to see through us, like we're a transparent in some way. And I just want to reassure people that's not the case,

What it is is a conversation where you get to talk. They listen and they can offer things that might be helpful. And at times they might not be helpful. But I find that the simple act of talking to them about what you're worried or afraid of with someone who is there exclusively for you is quite helpful, even if it's only for one or two visits.

Dr. John Leonard: You alluded to the issue of asking people what they've done before in difficult situations. And I think that's a great one. What are some of the other kind of common techniques that you find yourself recommending and that many people tend to benefit from in these sorts of situations?

Dr. Guy Maytal: Yeah. I can divide them into kind of two broad categories. One is perspective to consider taking, and the other is action to take. And so on the I'll start with a category of actions because, first of all, it sounds strange to say it as an action, but practicing kind of self-kindness and forgiveness. I think some people, when they get a diagnosis of cancer, they use it as a time to take on their health at a new level. They start eating differently. Maybe they attempt to exercise more, which is wonderful. And at times what that leads people to do is to, for lack of a better phrase, beat themselves up when they don't do that.

So I really invite people to be okay with where they are and that whatever's happening is simply what's happening and to practice being kind. I think it's really important. You know, one of the things I advise people to do particularly in this past year is to limit their exposure to the news. Everyone was home. The political situation, at least in the United States, was quite complicated and people were watching news and getting anxious. And one of the interventions was stop watching the news or at least read it.

The other thing I advise people, for example, there are a couple of pretty simple things, is what I call a worry budget, meaning you're allowed to worry only for a certain amount of time per day. And then when a worry comes up, you don't worry. You just write it down and go about your day. It's a bit of a practice. It seems corny, but it's actually kind of effective, meaning for the next half hour, I'm going to worry about everything that I worry about. But for the rest of the day, every time I have a worry, I'm going to write it down in some notebook. And it's useful. It's practical. It's something family can support patients around. It's simple. And once you get past the hokey flavor of it, it's pretty effective.

And whatever people need to do regarding connection with others. Some people really need to connect and some people don't. And especially now, judging where you are. I think it's important to know what you need in terms of human connection and how are you going to get it, be it in person or by phone or by video chat. But that's really important right now.

Dr. John Leonard: So I want to spend the last part of our time talking about COVID in particular and how that has made things more challenging not only for people with cancer, but for those that don't have such significant medical issues, but it seems to me like COVID has kind of exacerbated potentially so many of these things. It's harder to have your family in some cases or your friend or your loved one come to treatment with you in some cases or come to be there physically to support you at your doctor's office or at home, if you're not feeling well, you may have that, and then obviously just the support and the general interactions with people.

How have you advised people? You touched on kind of the video chats. Any other thoughts about dealing with COVID and the isolation and other issues around COVID that have been helpful to your patients?

Dr. Guy Maytal: Yeah. Thank you. There are a couple of things. One is that you're not alone even if you're physically isolated. There are lots of people and it's easy to forget when we're physically isolated that we're actually not alone. There's always someone to reach out to. Even if you have no one in your personal life, you've got a clinical team that can always be of support.

And the other is that we're figuring this all out together. Like this is a once in a century event. So what it comes with is a whole lot of uncertainty. I mean, we just don't know. And I think that's driving up everyone's anxiety. I don't think there's much more to do other than what I've already said, besides acknowledging that this is really unusual and really difficult. And feeling more distressed and worried is completely appropriate.

I think sometimes people feel like they shouldn't be upset or worried. Sometimes family members think that patients shouldn't be upset or worried. And in some families, in some cultures, people say, "Well, if you think negative thoughts, that will bring about negative outcomes." So reassuring people that's not the case also is really helpful because, as much as we would love to see people the way we did before the pandemic, we're constrained by the current constraints, but it's all for the greater good of everyone's health and we're in it together. Patients have their families and patients have their medical providers. And for me, that has been the critical piece.

Dr. John Leonard: One of the things that I find fairly commonly I'm sure you see as well in people dealing with cancer is the lack of control that so many things are kind of out of your hands. And one observation I'm interested in your thoughts is that while COVID is obviously challenging on many levels for cancer patients, one thing that it does in some ways is add a little bit of control from the perspective of being able to take precautions for those who can and, obviously, some can't because they have to go to work or they have challenging living situations or whatever. But I have noted a number of patients that being able to take precautions to distance and to wear masks and other things actually, it's almost like project that has focused some people in being able to do something proactively that they wouldn't otherwise need to do. And I think that's something that some people react too well because, obviously, hopefully that's doesn't go over to the other side where people are paralyzed to go outside or do things they need to do. But I do think that having something to do in that area for some people has been a helpful sort of thing. I don't know if that's something you've observed.

Dr. Guy Maytal: Well, it's interesting. I hadn't probably because people who are behaving like that wouldn't need to see me, because they're feeling fine and feeling more in control and less worried. I've seen where that goes to the extreme, where people are so worried about taking precautions, that they are paralyzed and in fact, prevent their loved ones the people whom they share a home with from doing what they need to do because of the fear and worry.

The other side of that is one of the things I've observed as some people, especially people who are actively immunocompromised during the height of the pandemic and currently feel a lot more reassured because before the pandemic, everyone knew that someone walking around with a mask and gloves likely had cancer. Now they just fit in. So they actually strangely or ironically feel more connected because everyone now has to put on the same precautions that they previously were the only ones who had to.

Dr. John Leonard: So I'll finish up by asking you to predict the future a little bit, not so much in the cancer way, but in the COVID world, you know, you're used to dealing with people going through challenging illnesses and conditions. How do you think collectively our psyche is going to be as we come out of COVID as people, hopefully soon obviously-- but as people, I don't want to say re-enter the world, but kind of come out of this pandemic. It seems to me like there'll be some positive and some negative things as far as how people have coped in their resilience and how they face the stresses and anxieties of the world ahead. Any thoughts about how you see that kind of playing out on a global scale? I know it's a tough question, but it seems like in some ways there'll be different pathways probably.

Dr. Guy Maytal: I think so. I think on the one hand, to give you as big an answer as the question is big, I think it really will be what we make of it. I am hopeful though. I think that we could either go back to the way it was, which there's nothing wrong with the way it was, but I think we have an opportunity to elevate our empathy for one another, our connection and the deeper understanding that we are all interconnected in a way that is now more visceral than ever.

I think that one of the things we'll have to relearn is how to be with people again in kind of a funny sort of way. Socializing is a skill like anything, and we'll have to practice how to actually be with people without masks. Do we shake hands? Do we hug? I don't know. I think we'll have to relearn how to do that. And it will be interesting to see that. But I'm hopeful that we'll come out of this more connected and more cognizant of our dependence on one another.

Dr. John Leonard: Well, I think that's a great final thought. And I think you're right. We're all in this together as we kind of try to navigate this as something that hopefully will translate to greater support for each other and for patients dealing with cancer and other serious illnesses in the future.

So I want to thank you for joining us today. This has really been a great discussion and I think given us some good suggestions to navigate the world that we're in and the challenges that our patients are facing.

Again, I want to appreciate all the support you have provided for our patients at Weill Cornell in New York Presbyterian. It's great to have colleagues that really collaborate in the care of all of the needs of our cancer patients, including the areas we've talked about today.

I want to invite our audience to download, subscribe, rate, and review Cancer Cast on Apple podcasts, Google podcasts or online at WeillCornell.org. We also encourage you to write to us at cancercast@med.cornell.edu with questions, comments, and topics you'd like to see us cover more in depth in the future.

That's it for Cancer Cast, conversations about new developments in medicine, cancer care and research. I'm Dr. John Leonard. Thanks for tuning in.