On the Frontier of Cancer Care: Holland Helped Pioneer Psychosocial Treatment

OncologyLive, June 2013, Volume 14, Issue 6

In Partnership With:

Partner | Cancer Centers | <b>Memorial Sloan Kettering Cancer Center </b>

An Interview With Jimmie C. Holland, MD, on her research and role in the development of a vital area of cancer care.

Photo courtesy of Memorial Sloan-Kettering Cancer Center

An Interview With Jimmie C. Holland, MD

When Jimmie C. Holland, MD, first began to work in oncology in the 1970s, patients usually were not told their diagnosis of cancer, making it nearly impossible to talk with them about how they were coping with illness.

Times have changed a lot since then⎯thanks in no small measure to the efforts of the pioneering oncologic psychiatrist.

In 1997, the National Comprehensive Cancer Network wrote guidelines for distress management, and more recently, two leading medical organizations asserted in their own guidelines that quality routine cancer care should include attention to patients’ psychosocial needs.

“We’ve seen an overall humanizing of medicine,” said Holland, 85, who founded the nation’s first full-time psychiatric program in an oncology center at Memorial Sloan-Kettering Cancer Center (MSKCC) in New York City in the 1970s. She is still treating patients and conducting research at the institution, where she has held the Wayne E. Chapman Chair in Psychiatric Oncology since 1989.

“The humanist aspects are much more respected now,” she said. “We call it patient-centered medicine. Doctors are being taught how to talk to patients, how to give bad news, how to communicate about illness, and how to better understand patients’ responses, which they were not taught for so long before that. So, it’s coming.”

It was the Institute of Medicine that, after a year of research funded through a million-dollar government grant, for the first time declared that the psychosocial domain should be integrated into routine cancer care. Holland, a fellow of the Institute, served on the panel that reviewed data from clinical trials and found in 2007 that there was convincing evidence in the literature to support a range of psychotherapeutic and psychotropic drugs, but that many patients who needed them weren’t getting them. The panel released its findings in a report titled “Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs.”

“It was a big move forward,” Holland said, “because it was the first national health policy organization that had endorsed the fact that the psychosocial domain must be integrated into routine cancer care.”

Since then, she said, the Commission on Cancer of the American College of Surgeons—which regularly reviews and accredits more than 1500 American cancer centers—has passed a similar mandate: that, by 2015, accreditation will require a center to have in place a program to identify patients experiencing distress and refer them, when appropriate, for psychosocial care (tinyurl.com/bpo45rv).

Identifying a Need

“This is big stuff,” Holland said. “We’re very pleased this is happening, because now there’s a stick, as well as a carrot, for doing this kind of work. It will make a difference.”Holland’s interest in the way patients dealt with the range of responses to illness developed during her medical training.

“When I started my internship [at St. Louis City Hospital in Missouri],” she recalled, “I began to realize that I really liked the psychological aspects of patients: how they were coping with their illness or how they managed to deal with an acute heart attack or with polio, resulting in being paralyzed from the neck down.”

So Holland switched her focus to psychiatry, and kept it there through her training as a resident and research fellow at the Malcolm Bliss Mental Health Center and Washington University School of Medicine, both in St. Louis, and then a residency and fellowship at Massachusetts General Hospital in Boston.

But it wasn’t until she met her husband— James F. Holland, MD, a pioneer in the treatment of childhood acute lymphoblastic leukemia who is now Distinguished Professor of Neoplastic Diseases at Mount Sinai Medical Center in New York—that she realized that attention to psychosocial care was largely missing from routine cancer care. It wasn’t adequately considered in patients, and it wasn’t being studied. Social workers carried the front line, with the nurse and oncologist in second place.

“I thought, ‘I’d like to work with patients with cancer to see if we can understand how to help them cope with their disease, and get them through it,’ ” Holland said.

She saw an opportunity in the 1970s, when the stigma associated with cancer started to fade. Both Betty Ford and Happy Rockefeller had gone public about surviving breast cancer, and patients were no longer being kept in the dark about their diagnoses.

Holland encouraged her husband, who was chairman of the nation’s first cooperative clinical trials group for cancer, Cancer and Leukemia Group B (CALGB), to add a committee for psychosocial issues as the organization worked to adopt a multidisciplinary philosophy. He did, and Holland joined the effort, helping to conduct the first clinical trials on quality of life in patients with cancer.

Pioneering a Field

“We became involved in research here in this country to understand how people were coping, and that got easier after we could talk to people about their disease and begin to study distress,” she said. “How many people needed help, and how many were struggling to get along, were things we didn’t know at all. So that was our earliest research—the prevalence of different psychological consequences of illness.”In 1977, Holland was hired at MSKCC, where the head of Neurology, Jerome B. Posner, MD, and the head of the cancer center itself, physician/philosopher Lewis Thomas, MD, “recognized that the time had come to give attention to the psychological problems of patients.” The two leaders conducted a search, and Holland applied and was hired.

She and the fellows who came with her started by making rounds with other doctors in order to learn what patients were experiencing. Soon, physicians at the cancer center were referring their patients to Holland’s tiny group, Psychiatry Services.

Meanwhile, she and her colleagues worked to develop the tools they needed to help patients.

“We realized that if we didn’t have some way to measure subjective symptoms like pain, fatigue, anxiety, depression, and delirium, we were not going to have a true science. We had to find a way to quantitatively measure these symptoms,” Holland said. “In the ’80s we made our first big effort to develop and validate reliable patient self-report assessment tools, and today we have a valid way to measure people’s level of functioning, anxiety, depression, pain, fatigue, and subjective symptoms.”

The tools were all in the form of paper and pencil questionnaires, Holland pointed out, since “there’s no blood test” to determine how people are feeling.

Such tools represented a big change in philosophy in the oncology world, the doctor added. “When I started in the field, there was a strong sense that doctors believed that the valid assessment of patients’ symptoms was by observation,” she said. “What patients said about their feelings was considered unreliable.”

The next step, Holland said, was to begin implementing the tools in studies.

“We began to use these tools in clinical trials. We showed that, if we intervened with an antianxiety drug or talk therapy, we could reduce anxiety and make people less distressed,” Holland said. “Out of that has come our field of psychosocial oncology with its own evidence base. Now, we’re able to put forth standards of care and clinical practice guidelines about how you should manage patient distress.”

Along the way, Holland further helped her field evolve by launching two professional societies. The International Psycho- Oncology Society got off the ground in 1984, and in 1992 Holland cofounded its journal, Psycho-Oncology. She launched the American Psychosocial Oncology Society in 1986. Both societies are still thriving today.

Jimmie C. Holland, MD: Career Highlights

1984—Founding President, International Psycho-Oncology Society

1986—Founding President, American Psychosocial Oncology Society

1989—Wayne E. Chapman Chair in Psychiatric Oncology

1994—Medal of Honor for Clinical Research, American Cancer Society

1995—Chair, Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center

—Elected Fellow, Institute of Medicine

1997—Chair, National Comprehensive Cancer Network’s (NCCN) Panel on Management of Distress

2000—Presidential Commendation, American Psychiatric Association

2005—Adolf Meyer Award, American Psychiatric Association

2007—Member, Institute of Medicine, Panel on Care of the Whole Patient

Tackling the Myths

“I felt it was very important to develop the American group because there weren’t so many of us in this little area, and we needed to network,” Holland said. “I started the international society, and now it has national societies related to it in 40 countries, around 5000 people worldwide who are engaged in psychosocial issues in cancer.”Together, Holland hopes, her efforts have not only helped individual patients, but also banished myths that made life more difficult for cancer patients as a group.

“There’s a myth that you have to be positive to fight cancer,” she said. “I call it the tyranny of positive thinking. There’s no such thing as making cancer worse if you’re depressed. We just want patients to say when they are distressed and need help.”

Her efforts to spread that message haven’t slowed, despite her many years in the field. Holland works a 12-hour day, devoting about a quarter of her time to seeing patients.

Her only nod to her age is her interest in working with people of her generation.

“Because I’m older, I see a lot of older people,” Holland said. “We have a geriatric program, called 65+, to help older patients get through their cancer treatment, which can be hard for them because many are also facing a number of problems associated with aging.”

Similarly, Holland’s research within MSKCC’s Psychotherapy Laboratory, and via clinical trials, focuses on psychotherapy for elderly patients with cancer.

She also finds time to supervise fellows in psychology and psychiatry, training them in the psychological care of patients with cancer, and providing them with the history of the evolution of the field.

Passionate From the Start

She wants her students to understand that “you have to treat the whole person, not just the tumor,” she said. “To do that, you must have a good sense of your own vulnerability, because they need to sense that you are someone who’s there with them, that you’ll go through the illness with them. Patients are very keenly aware of whether a doctor is concerned for them. The bottom line is, as Francis Peabody said, ‘The secret of caring for the patient is caring for the patient.’”Holland grew up an only child on a cotton farm near Dallas, Texas, when the area was still countryside.

She had an ordinary Texas life and an ordinary Texas name⎯“girls get boys’ names and boys get girls’ names,” Holland said⎯but unusual aspirations.

She planned to become a nurse, until she realized that women could be doctors.

“There weren’t many around,” Holland recalled. “There was a woman doctor in Dallas that I knew by her reputation, although I didn’t know her well. But I began to realize it was possible.”

Holland was given a lot of encouragement, and went on to earn her BA at Baylor University in Waco, Texas, and her MD at Baylor University School of Medicine in Houston.

“My parents were tremendously supportive and were right there to help me,” she recalled. “They were both farm folk, but they were wonderful in their idea that their daughter should have better than they had, and they made sure I did. They made sacrifices and borrowed money to send me. By my second and third years I had gotten a scholarship, but that wouldn’t have happened if they hadn’t worked hard and the country bank hadn’t lent them the money.”

Holland met with acceptance in medical school, even though she was one of only three women in the class that started in 1948, competing with returning World War II veterans for the opportunity to attend.

“I had a minimal amount of problems,” she said. “I found that, if indeed people recognized that I was working hard, they wanted to help me. I didn’t feel a lot of that kind of bias that you hear about.”

Holland met her husband, who then worked at Roswell Park Cancer Institute in Buffalo, when she went to visit a woman surgeon colleague there. A year later, they married, and she moved to Buffalo.

Her husband had a daughter, and together the couple had five more children; now, they have 10 grandchildren.

Finding Her Way

From 1956 through 1973, Holland moved up the ladder from clinical instructor to associate clinical professor in the Department of Psychiatry at the State University of New York in Buffalo. During most of those same years, she held roles at a teaching hospital, moving up from attending psychiatrist to director of the Department of Psychiatry.

From 1972 to 1973, the family moved to the USSR for an academic year. Her husband consulted with the Russian Cancer Institute, and Holland worked as a consultant to the Russian Psychiatric Research Institute on a Joint Schizophrenia Research Study. This was during the Cold War, but their work was part of a cultural exchange program between the two countries.

Photo by © ASCO/Scott Morgan 2012

Jimmie C. Holland, MD, attends the World Oncology Leaders Reunion during the American Society of Clinical Oncology Annual Meeting in Chicago, Illinois, in 2012. In photo, from left, are Gabriel N. Hortobagyi, MD, of The University of Texas MD Anderson Cancer Center; Charles M. Balch, MD, of UT Southwestern Cancer Center; and Holland’s husband, James F. Holland, MD, of Mount Sinai Medical Center.

Back in the United States, she spent four years at the Albert Einstein College of Medicine and Montefiore Hospital, in the Bronx, New York, where she rose to the rank of associate professor. With the acceptance of the job of chief of the first Psychiatry Service at MSKCC in 1977, she became a professor at Weill Medical College of Cornell University in New York City. This began the building of the psychosocial care program at MSKCC, which has had national and international ripple effects on the care of patients with cancer.

It’s all been a wonderful journey for Holland, who is proud to have helped develop a vital area of cancer care, and happy to have been “in the right place at the right time.”

“I’ve been blessed with a wonderful husband, kids, and colleagues who worked hard with me,” she said, “and I’ve been able to combine my personal and professional lives in a very pleasant way that’s made for a very satisfying life. I could not ask for better at 85.”

But even while raising her family, Holland found time to establish a place for herself as a leader in her field. “I worked only part time when the children were small, so it was a more sequential career than most young women today, who do both at the same time. Even so, I could not have done it without the help of my supportive husband,” she said.