Holland's Quest to Help Patients Cope With Cancer Launched a New Field

Jimmie C. Holland, MD

Cancer has been around for centuries, but talking about it is something relatively new. As recently as the early 1970s, cancer remained an illness cloaked behind whispers and closed doors—as Jimmie C. Holland, MD, found when she began working in oncology. While the young doctor’s goal was to help patients cope with their cancer, she discovered that was nearly impossible, since most were never even told they had the disease.

Forty years later, physicians and others who treat patients with cancer are not just encouraged, but in some cases required to speak with patients about how the disease is affecting their lives—thanks in no small measure to the efforts of the pioneering oncologic psychiatrist described as the “mother of psycho-oncology” in a 2004 interview published in the Journal of the National Cancer Institute.

Holland played a vital role in the transformation by founding the nation’s first full-time psychiatric program in an oncology center at Memorial Sloan Kettering Cancer Center (MSK) in New York City in the 1970s. Now 87, 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. Along the way, she helped create the first quality-of-life questionnaires used to monitor the distress level of cancer patients, and founded two societies—still in existence—dedicated to the support of her field.

Witnessing an Evolution

For her contributions, Holland was chosen by an advisory board of her colleagues to receive OncLive’s 2014 Giants of Cancer Care® Award in the Supportive Care category. “I’m honored,” she said, “and honored to be the first [to receive the award in the Supportive Care category], which is very nice.”It was 1997 when Holland first saw solid evidence that psychosocial medicine had become a widely recognized part of cancer care. That was when the National Comprehensive Cancer Network wrote its first treatment guidelines for distress management. 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,” Holland said. “The humanist aspects are much more respected now. 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 2007 when the Institute of Medicine, after a year of research funded through a million-dollar government grant, declared for the first time 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 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.”

After that, she said, the Commission on Cancer of the American College of Surgeons —which regularly reviews and accredits more than 1500 American cancer centers—passed a mandate stating that, by 2015, any center that wants to be accredited will need to have a program in place to identify patients experiencing distress and refer them, when appropriate, for psychosocial care. “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.”

Focusing on Older Cancer Patients

As a whole, Holland hopes, her work over the years has not only helped individual patients, but also banished myths that have 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.”Holland’s efforts to spread that message haven’t slowed, despite her many years in the field. The doctor 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.”

In part due to her work with that program, Holland has written a book, published by Oxford University Press in September 2014, titled Lighter as We Go: Virtues, Character Strengths, and Aging. Among the inspirations for the book was Holland’s Vintage Readers’ Book Program, which she started 2½ years ago. The program gave Holland a chance to speak with a lot of older people, she said. “Part of the reason aging is difficult is because of the stigma we put on aging people: ‘It must be so awful to be old; it means you’re about to die,’” she said. “We extol the value of youth and beauty, but we’re not too good when it comes to handling older people, and that’s part of what the book is about. Let’s get better communication and appreciation of old age. It has benefits as well as problems, so we should make it something more balanced. It’s not something to be afraid of.”

Similarly, Holland’s research within MSK’s Psychotherapy Laboratory, and via clinical trials, focuses on psychotherapy for elderly patients with cancer. One study focused on a telephone-based psychotherapy technique that Holland and her colleagues developed for older patients, who often have trouble getting out of the house.

Passionate From the Start

“We did a controlled trial of the psychotherapy, and it works,” she said. “People who have gone through six or seven sessions are less depressed, anxious, and lonely.”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 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.

Identifying a Need

“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’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 during a residency and fellowship at Massachusetts General Hospital in Boston.Holland met her husband, James F. Holland, MD, early in her career, and when they married, she moved to Buffalo, where he worked at the Roswell Park Cancer Institute.

Now the Distinguished Professor of Neoplastic Diseases at Mount Sinai Hospital in New York, her husband was a pioneer in the treatment of childhood acute lymphoblastic leukemia, and it was by learning about his work that Holland realized 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. She decided that she “would 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, then the 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.

Finding Her Way

“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.”Once married, Holland and her husband started a big family. He already had a daughter, and together the couple had five more children; now, they have 10 grandchildren.

But even while raising her children, 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.

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.

The family lived in the USSR for the academic year 1972-1973. 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.

Pioneering a Field

Back in the United States, Holland 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. Then, in 1977, she accepted the job of chief of the first Psychiatry Service at MSK, and became a professor at Weill Medical College of Cornell University in New York City. This began the building of the psychosocial care program at MSK, which has had national and international ripple effects on the care of patients with cancer.Holland was hired because both the head of neurology at MSK, 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,” she said. Holland 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.”

It’s 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.”

Praise for Holland as an Inspiring and Welcoming Leader

William S. Breitbart, MDChair, Department of Psychiatry & Behavioral SciencesJimmie C. Holland Chair, Psychiatric OncologyChief, Psychiatry ServiceMemorial Sloan Kettering Cancer CenterNew York, NY

“Jimmie created this environment at Memorial Sloan Kettering that spawned a whole generation of clinical and scientific leadership. These leaders were innovators and developers in the burgeoning field of psycho-oncology. The entire landscape of psycho-oncology is filled with people who were either directly trained by Jimmie, or who have one degree of separation from being trained by her.

“She inspired and welcomed all these people interested in getting involved and she just created this atmosphere, this sense of mission, this sense of connection and network and family. It is an all-engaging, all-encompassing sense of urgency, dedication, commitment to care, research, and excellence.

A Research Sampler

• Holland JC, Lazenby M, Loscalzo MJ. Was there a patient in your clinic today who was distressed? J Natl Compr Canc Netw. 2015;13(9):1054-1056.
• Chambers SK, Zajdlewicz L, Youlden DR, et al. The validity of the distress thermometer in prostate cancer populations. Psychooncology. 2014;23(2):195-203.
• Dunn J, Ng SK, Holland J, et al. Trajectories of psychological distress after colorectal cancer. Psychooncology. 2013;22(8):1759-1765.
• Holland JC, Andersen B, Breitbart WS, et al. Distress management. J Natl Compr Canc Netw. 2013;11(2):190-209.
• Weiss T, Weinberger M, Schwerd AM, Holland J. A 30-year perspective on psychosocial issues in lung cancer: how lung cancer “Came out of the Closet.” Thorac Surg Clin. 2012;22(4):449-456.
• Tomarken A, Roth A, Holland J, et al. Examining the role of trauma, personality, and meaning in young prolonged grievers. Psychooncology. 2012;21(7):771-777.
• Nelson CJ, Cho C, Berk AR, et al. Are gold standard depression measures appropriate for use in geriatric cancer patients? A systematic evaluation of self-report depression instruments used with geriatric, cancer, and geriatric cancer samples. J Clin Oncol. 2010;28(2):348-356.
• Tomarken A, Holland J, Schachter S, et al. Factors of complicated grief pre-death in caregivers of cancer patients. Psychooncology. 2008;17(2):105-111.
• Komblith AB, Dowell JM, Herndon JE 2nd, et al. Telephone monitoring of distress in patients aged 65 years or older with advanced stage cancer: a cancer and leukemia group B study. Cancer. 2006;107(11):2706-2714.
• Murillo M, Holland JC. Clinical practice guidelines for the management of psychosocial distress at the end of life. Palliat Support Care. 2004:2(1):65-77.
• Hurria A, Rosen C, Hudis C, et al. Cognitive function of older patients receiving adjuvant chemotherapy for breast cancer: a pilot prospective longitudinal study. J Am Geriatr Soc. 2006;54(6):925-931.
• Hurria A, Goldfarb S, Rosen C, et al. Effect of adjuvant breast cancer chemotherapy on cognitive function from the older patient’s perspective. Breast Cancer Res Treat. 2006;98(3):343-348.
• Kornblith AB, Herndon JE 2nd, Zuckerman E, et al. Social support as a buffer to the psychological impact of stressful life events in women with breast cancer. Cancer. 2001;91(2):443-454.
• Holland JC, Passik S, Kash KM, et al. The role of religious and spiritual beliefs in coping with malignant melanoma. Psychooncology. 1999;8(1):14-26.
• Holland JC, Kash KM, Passik S, et al. A brief spiritual beliefs inventory for use in quality of life research in life-threatening illness. Psychooncology.1998;7(6):460-469.

“She is a true pioneer and pioneers are the people who have that first idea. But an idea doesn’t take hold and it doesn’t flourish into a real discipline unless you’re the kind of person who attracts other people and persuades others to share in your idea. She didn’t try to own the idea; she never was that self promotional. That is the impact that she’s had on the field.”