Artigo Acesso aberto Revisado por pares

Adverse Effects of “Teachable Moment” Interventions in Lung Cancer: Why Prudence Matters

2017; Elsevier BV; Volume: 13; Issue: 2 Linguagem: Inglês

10.1016/j.jtho.2017.10.018

ISSN

1556-1380

Autores

Friedrich Stiefel, Céline Bourquin,

Tópico(s)

Cancer survivorship and care

Resumo

Thanks to medical progress, we not only treat patients with cancer but also care for those who live "with, after, or in spite of a diagnosis or traumatic event"1Bell K. Remaking the self: trauma, teachable moments, and the biopolitics of cancer survivorship.Cult Med Psychiatry. 2012; 36: 584-600Crossref PubMed Scopus (64) Google Scholar and who, in the cancer setting, are now called survivors. Survivorship care is not restricted to surveillance and treatment of potential disease consequences, it also consists of education: it is recommended that survivors engage in healthy lifestyle behaviors, for instance, by eliminating the use of tobacco products, including cigarettes.2Campo R.A. Rowland J.H. Irwin M.L. Nathan P.C. Gritz E.R. Kinney A.Y. Cancer prevention after cancer: Changing the paradigm—a report from the American Society of Preventive Oncology.Cancer Epidemiol Biomarkers Prev. 2011; 20: 2317-2324Crossref PubMed Scopus (22) Google Scholar Such recommendations are especially relevant for thoracic oncologists, who often face patients with a diagnosis of lung cancer who are finally forced to acknowledge the fatal effects of tobacco use. Now that they know, it is "better late than never" to stop smoking. Nevertheless, surveillance data show that many cancer survivors do not adhere to health recommendations and continue smoking.3Underwood J.M. Townsend J.S. Stewart S.L. et al.Surveillance of demographic characteristics and health behaviors among adult cancer survivors: behavioral risk factor surveillance system, United States, 2009.MMWR Surveill Summ. 2012; 20: 1-23Google Scholar For some patients, a time of cancer-related stress and distress thus seems to be the worst moment to quit smoking. Be that as it may, a cancer diagnosis is the occasion to start a new and healthier life. This is the very idea behind the so-called teachable moment interventions, an educational approach that "has been applied to survivorship questions, positing that health events (e.g., cancer diagnosis) may 'cue' survivors to perform healthy behaviors."4Bluethmann S.M. Basen-Engquist K. Vernon S.W. et al.Grasping the 'teachable moment': time since diagnosis, symptom burden and health behaviors in breast, colorectal and prostate cancer survivors.Psychooncology. 2015; 24: 1250-1257Crossref Scopus (78) Google Scholar The physician treats and the psychologist or specialized nurse teaches. So far, so good. As clinicians we know that effective medical interventions have side effects, but what about educational interventions? In an attempt to examine this question more deeply, we will address some concerns that we have with the increasingly promoted opportunistic attempts to influence or change lifestyle and health behaviors of patients with cancer.1Bell K. Remaking the self: trauma, teachable moments, and the biopolitics of cancer survivorship.Cult Med Psychiatry. 2012; 36: 584-600Crossref PubMed Scopus (64) Google Scholar, 5McBride C.M. Emmons K.M. Lipkus I.M. Understanding the potential of teachable moments: the case of smoking cessation.Health Educ Res. 2003; 18: 156-170Crossref PubMed Scopus (853) Google Scholar Educational interventions aiming at preventing cancer, or at enhancing survival of it, are indeed part of the mission of oncology. However, when it comes to diseases such as lung cancer, this type of intervention has to be carefully considered and critically evaluated. Because health events such as receiving a diagnosis of cancer have indeed been demonstrated to motivate individuals to adopt risk-reducing or health-protective behaviors, systematic proposal of teachable moment interventions in oncology,4Bluethmann S.M. Basen-Engquist K. Vernon S.W. et al.Grasping the 'teachable moment': time since diagnosis, symptom burden and health behaviors in breast, colorectal and prostate cancer survivors.Psychooncology. 2015; 24: 1250-1257Crossref Scopus (78) Google Scholar especially interventions associated with smoking, is increasingly being advocated.5McBride C.M. Emmons K.M. Lipkus I.M. Understanding the potential of teachable moments: the case of smoking cessation.Health Educ Res. 2003; 18: 156-170Crossref PubMed Scopus (853) Google Scholar, 6Ganz P. A teachable moment for oncologists: cancer survivors, 10 million strong and growing!.J Clin Oncol. 2005; 23: 5458-5460Crossref PubMed Scopus (137) Google Scholar, 7Cooley M.E. Finn K.T. Wang Q. et al.Health behaviors, readiness to change, and interest in health promotion programs among smokers with lung cancer and their family members: a pilot study.Cancer Nurs. 2013; 36: 145-154Crossref PubMed Scopus (28) Google Scholar In these interventions the trauma of the illness experience is viewed as having a positive role and utility because it can trigger a transformation or remaking of the psychological self, with patients becoming psychologically and spiritually healthier and fitter.1Bell K. Remaking the self: trauma, teachable moments, and the biopolitics of cancer survivorship.Cult Med Psychiatry. 2012; 36: 584-600Crossref PubMed Scopus (64) Google Scholar Central to the concept of intervening and thus triggering or facilitating such "posttraumatic growth" is the assumption that one can take advantage of the trauma, which is consequently conceived not solely as a source of stress and distress but also as an opportunity for new self-development. But teachable moment interventions may— if the illness-induced psychological vulnerability is underestimated—harbor the risk of different types of "collateral damage." From an individual perspective, teachable moment interventions are certainly welcomed by those patients who perceive them as a means to improve well-being, to restore a sense of control, or to cope with anxiety and who successfully achieve their goals. But what about those who fail to improve? They not only suffer from their physical ailment but then have to face their unsuccessful attempts and feelings of guilt and shame, which are already prevalent in some patients with lung cancer because of their unhealthy and disease-provoking habits.8Stiefel F. Bourquin C. Good cancers–bad cancers: good patients–bad patients?.J Thorac Oncol. 2015; 10: 407-408Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar From a social perspective, patients who fail to make healthier lifestyle changes do not correspond to the ideal patient, who learns the lesson of having fallen ill and successfully becomes more health conscious, thereby contributing to reducing health care expenditure costs. This is even more problematic for patients with lung cancer, who already have a negative public perception. Indeed, when it comes to cancer, one can observe a kind of binary opposition: nowadays breast cancer exemplifies the blameless cancer ("a twist of fate"), whereas lung cancer, which is associated with the notion of self-inflicted disease, is the blameworthy one.8Stiefel F. Bourquin C. Good cancers–bad cancers: good patients–bad patients?.J Thorac Oncol. 2015; 10: 407-408Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Therefore, to target this population with teachable moment interventions may also increase the perceived or enacted stigma associated with lung cancer Such interventions can thus contribute to blur the fragile borders between the disease and the person, with patients having a "bad cancer" becoming "bad patients" or ultimately "bad persons." From a therapeutic perspective, teachable moment interventions may also be harmful. To assume a positive aspect in trauma may alienate the traumatized patient who might have feelings of not being fully understood in his suffering. As such, they may weaken the therapeutic alliance, which is at the core of the clinical relationship, especially with regard to trauma.9Cronin E. Brand B.L. Mattanah J.F. The impact of the therapeutic alliance on treatment outcome in patients with dissociative disorders.Eur J Psychotraumatol. 2014; https://doi.org/10.3402/ejpt.v5.22676Crossref PubMed Scopus (46) Google Scholar Although the honorable intent of teachable moment interventions has to be acknowledged, an attitude of beneficence implies, above all, full recognition of the trauma, leaving no space for its denial, downplay, or positive interpretation. Moreover, from a societal perspective, teachable moment interventions may fuel the ideology of blaming the victim, which has regularly been brought into the public debate, as in 1975 when John Knowles, president of the Rockefeller Foundation, stated during the Conference on Future Directions in Health Care: "The idea of individual responsibility has been submerged in individual rights…. One man's or woman's freedom in health is now another man's shackle in taxes and insurance premiums."10Conference on Future Directions in Health Care: The Dimensions of Medicine. Sponsored by Blue Cross Association, The Rockefeller Foundation, and Health Policy Program. University of California, New YorkDecember 1975Google Scholar Robert Crawford, who analyzed the discourse of that conference, warned that this ideology of victim blaming tends to obscure the impact of social inequality on health and serves to justify a retreat from the language of rights and the policies of entitlements.11Crawford R. You are dangerous to your health: the ideology and politics of victim blaming.Int J Health Serv. 1977; 7: 663-680Crossref PubMed Scopus (407) Google Scholar This stance is nowadays largely shared: for instance, a 2015 survey quizzed 4000 adults about their feelings toward UK National Health Service treatments and revealed that 52% think the National Health Service should not fund treatment if the illness was a consequence of smoking.12Pickles K. Smokers and heavy drinkers should pay for treatment of "self-inflicted" illnesses rather than expect NHS to foot the bill.Daily Mail UK. August 21, 2015; Google Scholar Do we really need to discuss who should be held responsible for health and disease? Is it the patient or is it the tobacco, food, and polluting industries that are at the origin of many (modern) diseases? Should we blame the patient for his or her condition, or the states that fail to protect the citizen-patient? From this 1975 discourse to this recent survey, it is merely a new twist to an old story. This story is much older than these debates and reveals broader issues than health, illness, and medicine, as is evidenced in the following Biblical passage: "As he went along, he saw a blind man from birth. His disciples asked him, 'Rabbi, who sinned, this man or his parents, that he was born blind?' 'Neither this man nor his parents sinned,' said Jesus." The history of medicine shows that it has been repeatedly instrumentalized, as witnessed in early repressive psychiatry, eugenic interventions, and obedience to totalitarian regimes. However, medicine has also experienced moments of glory when it has succeeded, for example, at destigmatizing diseases such as leprosy, acquired immunodeficiency syndrome, alcohol abuse, and (more recently) obesity. In times of increased economic pressure that leave behind many, especially the ill, medicine must carefully consider its role. Its efforts should be concentrated on meaningful interventions that are in the best interest of the patient. As with any other interventions with effects and side effects, indications are of utmost importance. A systematization of teachable moment interventions is not sane. It is up to the patient to indicate if and when he is motivated to initiate possible modifications of lifestyle to achieve health-protecting behaviors.

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