A cancer diagnosis and cancer treatment can be traumatic. An experience with cancer can lead to serious psychological distress that should be addressed. In this webinar, Schuyler Cunningham, Clinical Social Worker, talks about what trauma is, how to identify it, and what steps to take next.

1. Cancer and Trauma: Psychosocial Distress
and Trauma in the Medical Setting

2. TODAY’S WEBINAR
 SPEAKER(S)
 Schuyler Cunningham, MSW, LICSW, LCSW-C, BCD
 QUESTIONS
 Ask a question in the panel on the RIGHT SIDE of your
screen
 WEBINAR ARCHIVE
 FightCRC.org/webinar
 TWEET ALONG
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3. RESOURCES
TABOO-TY PODCAST MINI MAGAZINES CLINICAL TRIAL FINDER

4. FIGHTCOLORECTALCANCERDISCLAIMER
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5. SchuylerCunninghamMSW,
LICSW,LCSW-C,BCD
Mr. Schuyler Cunningham (schuyler@cancertrauma.com), MSW,
LICSW, LCSW-C, Board Certified Diplomate is an award winning social
worker and researcher. His extensive experience includes practicing
social work at the Washington Cancer Institute, the DC Rape Crisis
Center, the National Institutes of Health Clinical Center, and The
Washington, DC Center for Neurocognitive Excellence. Schuyler’s
clinical experience includes Consultant status in Eye Movement
Desensitization and Reprocessing (EMDR), providing supervision to
EMDR practitioners, providing Infra-Slow
Frequency neurofeedback therapy, and training bachelors and
masters students in clinical care and research. He is a sought after
speaker and has published on various aspects of mental health
counseling including an upcoming paper on distress and traumatic
stress in people with cancer, first person narratives of cancer related
traumatic stress, screening for psychosocial distress in non-oncology
patients, cancer rehabilitation, innovative treatments for smoldering
multiple myeloma, and palliative care for people with
mesothelioma. Mr. Cunningham obtained his Masters in Social Work
from the National Catholic School of Social Service at the Catholic
University of America and holds advanced social work licenses in
both DC and Maryland.

6. Psychosocial Distress and
Trauma in the Medical Setting
Schuyler Cunningham, MSW, LCSW-C, LICSW, BCD
Cancer Trauma Project
www.cancertrauma.com
schuyler@cancertrauma.com

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Learning Objectives
1. Describe the spectrum of distress
related mental health conditions
2. Provide an overview of traumatic
stress symptoms in medical setting
3. Describe the prevalence of
distress and TSS in cancer
population
4. Discuss a recent study about TSS

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Who am I?

9. 9
Why Do I Care?

10. 10
Definitions
Distress - an unpleasant emotional
experience that interferes with the ability
to cope with [cancer] treatment. (NCCN, 2017)
Acute Stress Disorder (ASD)
Traumatic stress symptoms (TSS)
Post Traumatic Stress Disorder (PTSD)

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How is Distress Measured?

12. 12
How is Distress Measured?

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Psychosocial Distress
Psychosocial distress can be debilitating in
people with cancer (Mosher, 2012)
30 - 43% - prevalence of distress across 14
different cancer diagnoses
•32% in Colon Caner (Zabora, 2001)
Since 2015, the American College of Surgeons
requires all accredited cancer hospitals to
screen for distress (American College of Surgeons Commission on Cancer, 2013)

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How Does Distress Effect Us?
1. Declines in treatment adherence
2. Barriers in communication between
patient and provider
3. Increased health care costs
4. Poorer quality of life
(DiMatteo, 2000; Stoudemire, 1993; Lerman, 1993; Simpson, 2001; Shim, 2006; Skarstein, 2000)

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Impact of Distress and CRTS
Intrusive or avoidant thoughts or memories
Nightmares
Flashbacks
Amnesia
Reactivity
A distorted sense of blame
Reduced interest in activities
Feel detached from people around them
Difficulty concentrating
Sleep disturbances
Source: American Psychological Association, 2013

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Most Stressful Moments
Diagnosis
Restaging or reevaluation of disease
Provider communication
Procedures
Telling family and friends medical information
(Gurevich et. al., 2002)

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Prevalence of PTSD
Incidence of PTSD following the end
of treatment ranged from 3-32%
(Kangus et. al. 2005)
Fully diagnosed PTSD
•Early-stage cancer 3% to 4% (Einsle, 2012)
•Following treatment 35% (Mundy, 2000)

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Risk Factors
A review of 39 studies between 1992 & 2001
found that known risk and protective factors in
other trauma contexts are relevant to cancer
(Gurevich, 2002)
Most Common:
• Female
• Young at diagnosis
• Lower SES
• Limited social support
• Reduced physical functioning
• Advanced stated of disease
• Experiencing recurrence
• Significantly reduced QoL – even if temporary

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Cancer Related Traumatic Stress
“You have cancer”
It is similar to PTSD but may not be
as severe
It can occur anytime during or after
treatment
Source: www.cancer.gov

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Prevalence of CRTS
A cancer diagnosis is a threat to life and
bodily integrity
Overwhelming a patient’s adaptive
capacity consistent with traumatic stress
exposure (Lerman, 1993; Törer, 2003; Simpson, 2001; Shim; 2006).
Symptoms of traumatic stress:
•20% with early stage cancer
•80% in recurrent disease (Gurevich, 2002; Einsle, 2012).

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What we are doing
Study - Influence of Psychosocial distress and
lifetime trauma exposure on traumatic stress
among oncology patients on clinical trials
Purpose – To explore the relationships
between:
•Levels of distress
•Reported life time traumas
•Level of traumatic stress symptoms

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Background
Stress Model Theory
How emotions are generated based on
stressful events
The outcome of the stressful event in this
study manifests as psychosocial distress
and traumatic stress symptomatology, or
the emotional reaction.
Source: Nilsson, 1999; Helgeson, 2011; Lazarus, 1991

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Stress Model Theory
Source: Nilsson, 1999; Helgeson, 2011; Lazarus, 1991

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Methods
 Sample
•Drawn from NIH Clinical Center Patients
Instruments
•Brief symptom inventory - BSI-18
•Lifetime Events Checklist – LEC-5
•PTSD Checklist – PCL-5
•Demographic survey
•Medical record data

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Design
Exploratory, Cross Sectional Study
Independent Variables:
•Level of Distress (BSI-18)
•Number of Life Time Traumas (LEC-5)
Dependent Variables:
•Level of TSS (PCL-5)
20 Potential Covariates
•Demographics Questionnaire
•Medical Records
Multiple regressions analysis

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How are TSS Measured?

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How are past events controlled for?

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Results (n = 53)
Demographics
Percent Count
Male 81% 43
White 74% 39
Married/
Partnered 59% 31*
*One participant did not provide marital status data
Age: Mean = 56.2 (+ 16.2); Range = 19-84

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Results (n = 53)
Diagnosis of Sample
Percent Count
Prostate Ca 42% 22
Lymphoma 26% 14
Leukemia 21% 11
Mesothelioma 11% 6

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Results (n = 53)
Treatments Received
Percent* Count
Immunotherapy 57% 30
Chemotherapy 45% 24
Surgery 28% 15
Radiation 13% 7
Hormone 11% 6
Allogeneic BMT 9% 5
*>100% due to more than one treatment received

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Results (n = 53)
Number of Treatment Modalities Received
Percent Count
0 11% 6
1 26% 14
2 49% 26
3 13% 7
Patients in Active Treatment = 43% (23)

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How is Distress Measured?

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Results (n = 53)
Clinically Significant Distress on BSI-18
Male* Female**
Percent 30% 20%
Count 13 2
Total 28% (15)
*Clinical cut off = 10
**Clinical cut off = 13

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Summary BSI-18 Scores)
BSI-18 (n = 53)
Mean SD
Actual
Range
Possible
Range
8.0 9.3 0-53 0-72

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How are past events controlled for?

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Summary LEC-5 Scores
LEC-5 (n = 53)
Mean SD
Actual
Range
Possible
Range
11.5 8.2 0-32 0-85

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How are TSS Measured?

38. 38
Summary of PCL-5 Scores
PCL-5 (n = 53)
Mean SD
Actual
Range
Possible
Range
9.6 9.3 0-44 0-80

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Bivariate Analysis
Level of distress and level of TSS had a
significant positive relationship (F=50.99, p
< 0.0001)
Number of lifetime traumatic events and
TSS had a significant positive relationship
(F=9.53, p < 0.01)

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Multivariate Analysis
Getting fancy!
There were 23 candidate variables
ECOG was excluded (n = 13)

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Multivariate Analysis
Psychosocial distress, marital status,
and TSS had statistically significant
relationship (F=32.04, p < 0.0001)
Level of distress and marital status
explain 56.7% of the variance in TSS
Those with clinically significant distress
and not currently married or partnered
are more likely to have high TSS

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One Last Really Cool Thing
1 point increase on the BSI-18 was
associated with a 0.67 points increase in the
PCL-5 score (95% confidence interval: 0.47-0.87, p<0.0001,
effect size = 0.39)
On average, participants who were married
or partnered had 4.4 points less on the PCL-
5 than those not married or not partnered (95%
confidence interval: 0.69-8.11, p=0.021, effect size = 0.04)
What?!?

43. 43
Discussion of Study
Among the study sample, those that were not
currently married and reported a higher level of
distress were more likely to report higher levels of
TSS
Patients on clinical trials may be experiencing more
TSS than is currently identified
Screening for distress and TSS may increase
awareness of patients’ symptoms and allow for
interventions that may lead to more successful
participation in clinical trials

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How Can Hospital Staff Help?
 Education of Interdisciplinary
Team
 Bridge to trauma informed care
in the community

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Gentle Screening
Intrusive or avoidant thoughts or memories
Nightmares
Flashbacks
Amnesia
Reactivity
A distorted sense of blame
Reduced interest in activities
Feel detached from people around them
Difficulty concentrating
Sleep disturbances
(American Psychological Association, 2013)

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Treating Trauma in Hospital
Contextualize symptoms
Contain
Bridge to therapy

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Trauma Informed
Exposure therapy
Based in neuroscience
Body focused
“I’m going crazy!”

48. 48
Examples of Trauma Informed Treatment
Trauma Focused CBT (TF-CBT)
Eye Movement Desensitization
and Reprocessing (EMDR)
WWW.EMDRIA.ORG
Neurofeedback
WWW.EEGINFO.COM

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Resources For Finding a Therapist
Psychologytoday.com
Therapyden.com
EMDRIA.org

50. Thank you!
Schuyler Cunningham, MSW, LCSW-C, LICSW, BCD
Cancer Trauma Project
www.cancertrauma.com
schuyler@cancertrauma.com

51. Q
&
A
SNAP A #STRONGARMSELFIE
In 2018, up to $55,000 will be donated thanks to our
sponsors: Bayer, Fujifilm, Myriad Genetics and Taiho
Oncology!
Flex a “strong arm” & post it to Twitter or Instagram using the
hashtag #StrongArmSelfie

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