Psycho-oncology in Korea: past, present and future

Background Psycho-oncology in Korea was introduced among the circle of consultation-liaison psychiatrists, in the 1990s. For almost 25 years, the field has been developing at a steady pace as the psychosocial needs of patients with cancer continue to increase. In this study, we review the history of psycho-oncology in Korea, in a chronological order, within the domains of clinical practice, research activity, training, and public policy. Main body Before the 1990s, patients with cancer with psychiatric comorbidities were usually taken care of by consultation-liaison psychiatrists in general hospitals. In 1993, psycho-oncology was first introduced by psychiatrists. Psychologists, nurses, and social workers have also been increasingly involved in providing psychosocial care for patients with cancer. Professionals from various disciplines began to communicate, and agreed to found the Korean Psycho-Oncology Study Group (KPOSG) in 2006, the first academic society in this field. In 2009, National Cancer Center published the “Recommendations for Distress Management in Patients with Cancer”, which are consensus-based guidelines for Korean patients. In 2014, the KPOSG was dissolved and absorbed into a new organization, the Korean Psycho-Oncology Society (KPOS). It functions as a center of development of psycho-oncology, publishing official journals, and hosting annual conferences. There are many challenges, including, low awareness of psycho-oncology, presence of undertreated psychiatric disorders in patients with cancer, shortage of well-trained psycho-oncologists, stigma, and suicide risk. It is important to improve the cancer care system to the extent that psycho-oncology is integrated with mainstream oncology. Considering the socio-cultural characteristics of Korean cancer care, a Korean model of distress management is being prepared by the KPOS. Conclusion This article provides an overview of the development, current issues, and future challenges of psycho-oncology in Korea. Through its long journey to overcome the many barriers and stigmas of cancer and mental illnesses, psycho-oncology is now acknowledged as an essential part of integrated supportive care in cancer. Active research and international cooperation can gradually shape the Korean model of distress management.


Background
The age-standardized rate (ASR) of cancer incidence in Korea has decreased from 303.8 per 100,000 in 2011, to 290.5 in 2013. Cancer has, however, been the most common cause of deaths in Korea since 1983; the disease accounted for 28.3% of all deaths in 2013. The agestandardized rate of cancer mortality has decreased by 2.7%, annually, from 2002 to 2013. The 5-year cancer relative survival rate has improved, from 41.2% in 1993-1995, to 69.4% in 2009-2013. The number of Korean cancer survivors has increased steadily, with 1,370,049 having been identified, as of January 1, 2014 [1].
The diagnosis and treatment of cancer is often accompanied by psychosocial distress of patients and their families. Psychosocial distress increases the risk of psychopathology, lowers the quality of life of patients with cancer, and has a direct, or indirect negative impact on treatment and prognosis [2][3][4]. Because the number of patients with cancer has increased with a longer disease duration, management of their distresses has become important. Therefore, major cancer centers are focusing on distress management, from the initial treatment [5].
Psycho-Oncology, dealing with the psychological, social, and spiritual aspects of cancer, is recognized as an essential part of integrated cancer care in many developed countries. Since the World Health Organization (WHO) declared "no health without mental health" and emphasized on the importance of mental health, the need for psycho-oncological intervention has increased even further [6,7]. Psychosocial interventions for patients with cancer are reported to improve performance indicators, including treatment outcomes and the quality of life of patients [3]. Nonetheless, owing to various reasons, the field of psycho-oncology in Korea is still perceived as a minor area of oncology.
Several studies that review the history of psychooncology have been published in Korea [8][9][10]. However, those papers were written for domestic readers, and were not focused on the history of psycho-oncology in Korea. The authors describe the history of psychooncology in Korea in a chronological order in the areas of clinical care, research, training, and public policy.

Past
The psychiatric problems of patients with cancer had been recognized in Korea long before the field of psycho-oncology was introduced, in the 1990s. Psychiatrists were interested in cancer-related psychiatric disorders, such as delirium and adjustment disorder. Consultation and liaison activities were carried out by psychiatrists mainly at general hospitals. As early as the 1970s, and through the 1980s, research papers were published in the areas of diagnosis and treatment of psychiatric disorders, truth-telling practice, hospice and end-of life care, and psychosocial interventions for patients with cancer and families. In the 1990s, hospice/ palliative care, such as pain management for patients with advanced cancer, was extensively studied with the development of the hospice movement in the 1980s, and 1990s, in Korea. That was the basis of the establishment of the current hospice care system. Although studies on the quality of life, psychological symptoms of caregivers and patients with cancer, and the adaptation of the family of patients with cancer had begun to increase in the 1990s, there were limitations because of the lack of objective tools to measure such parameters.
In 1993, the concept of psycho-oncology was introduced for the first time at a symposium in the annual conference of the Korean Society of Psychosomatic Medicine [8]. The history, research field, and clinical application of the burgeoning discipline of psychooncology were presented by psychiatrists, and their presentations were published in the Korean Journal of Psychosomatic Medicine, in 1994.
In 1996, the Ministry of Health and Welfare of the Korean Government launched a National Cancer Control Planning Board, which embarked on the First Cancer Control 10-Year Plan (1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005). As the control tower of the national cancer control programs, the National Cancer Center (NCC) was established in 2000. The first decade of the 21st century witnessed a big increase of cancer centers and hospitals, in order to accommodate the increasing numbers of patients with cancer. Because issues regarding the quality of life of patients, during and after treatment, were raised, their psychosocial needs were increasingly addressed.
Research activities in the related fields of psychooncology were enriched with the establishment of the Korean Society for Hospice and Palliative Care in 1998 and the Korean Oncology Nursing Society established in 2002.
Since the 2000s, with Korean the validation of assessment tools for the symptoms and quality of life of patients with cancer and their caregivers, psychooncological studies using such tools have increased dramatically.

Present
The Korean Psycho-Oncology Study Group (KPOSG) was founded in 2006, with members from multidisciplinary mental health, and related professionals. It was organized by a core group of psychiatrists, psychologists, and nurses. They shared expertise in the field of psycho-oncology through participating in monthly seminars and cooperative clinical studies. The first conference on psycho-oncology, led by members of the KPOSG, was held in April 2007. They presented topics on the overview of psycho-oncology, research, and clinical practice, at the symposium of the Institute of Human Behavioral Medicine, Seoul National University. They also organized a symposium titled, "Mental Suffering of Patients with Cancer, How to Help?" at the 9th Cancer Control Forum, sponsored by the National Cancer Control Planning Board, in November of 2007. The KPOSG has continued to hold annual academic conferences since 2010. Those conferences have attracted attention from both people in academia and the general public.
In 2008, the group conducted at reliability and validity study of the Korean version of the problem list and distress thermometer [11], one of the first distress screening tools for patients with cancer validated in the Korean language. In 2008, "Guidelines for Cancer Center Accreditation Program," proposed by the National Cancer Center, included a section on psychosocial support for assessment (Table 1).
"The Recommendations for Distress Management in Korean Patients with Cancer" was published in 2009, by the National Cancer Center, with a grant from the National Research and Development Program for Cancer Control [11,12]. In the recommendations, 1) the concept of distress was described, 2) distress screening based on the Modified Distress Thermometer, which combines the Korean version of the distress thermometer and the NCC Psychological Symptom Inventory (NCC-PSI), was presented [13], 3) a triage algorithm, according to the results, was presented, and 4) symptom-specific management guidelines were proposed for depression, anxiety, insomnia, and delirium, which are known disorders to have a high prevalence in patients with cancer.
With an increasing acceptance of the importance of communication in quality cancer care, NCC introduced communications skills training (CST), using the manual of the Japanese SHARE protocol translated into Korean. NCC continues to hold CST workshops for its doctors, nurses, and other employees and is trying to expand this training nationwide.
The Korean Psycho-Oncology Society (KPOS) was founded on September 26, 2014 [14]. It consists of over 80 multidisciplinary professionals, including psychiatrists, psychologists, nurses, social workers, epidemiologists, and other physicians. The KPOS hosts annual conferences, with continuing-education programs. Since 2015, the Korean Journal of Psycho-Oncology (KJPO), an official peer-reviewed journal of KPOS, is published twice a year.

Future
The diagnosis of cancer is not considered a death sentence any more. Cancer will, however, continue to be a major health threat to people all over the world, because of the fatality and chronicity associated with the disease. Because there is an increased acceptance of the importance of quality of life in patients with cancer and families, a steady development of psycho-oncology in Korea has become possible. Awareness of psychooncology is still low, and the psychiatric disorders of patients with cancer tend to be under-diagnosed, and undertreated, in actual clinical practice [15,16]. Only 10% of patients with cancer were diagnosed with comorbid psychiatric disorders, with a quarter of these patients having never had received psychiatric care [16].
According to the International Federation of Psychooncology Societies' report on the disparities in psychosocial care, the development of psycho-oncology in Korea was graded as "isolated care provision' [17], compared to the most developed level of 'advanced integrated into mainstream service provision." It is important to improve the cancer care system, so that psycho-oncology is well integrated with mainstream oncology. In the Third National Cancer Control Plan (2016-2020), the scope of cancer care has been expanded, to include the quality of life of cancer survivors. The Korean government is planning to establish 13 regional integrated supportive care centers in provinces, for cancer survivors living in the community, by 2020. Those centers are going to provide comprehensive supportive care, including psychosocial service, rehabilitation, and nutritional counseling. Korean psychooncologists are moving toward integrated cancer care that incorporates psychosocial care as an essential component of patient care. Although the needs for mental health professionals in the field of psycho-oncology are increasing, there is a shortage of well-trained psycho-oncologists in Korea. The Advanced Program for Psycho-Oncology (APPO), developed by NCC in 2015, is the first course to train psycho-oncologists. It is a 12-week program for psychiatrists, psychologists, social workers, and other healthcare professionals interested in psycho-oncology. Further development and expansion of training programs for psycho-oncologists would help expand the number of experts in psycho-oncology in Korea.
The effectiveness of psychosocial interventions should be proved further in order to raise awareness of psychooncology. Large-scale clinical studies need to be done to support the biopsychosocial model for cancer treatment.
Cancer stigma often causes psychosocial distress. According to a national survey in Korea, more than half of the public had negative attitudes, stereotypes, and discriminating attitudes toward patients with cancer in spite of clinical progress and improved survivorship [18]. A recent study in Korea reported that over 30% of Korean cancer survivors had negative attitudes toward cancer, and held stereotypical views of themselves. Furthermore, about 10% of the patients with cancer experienced social discrimination due to cancer [19]. Stigma of mental illness is a barrier for patients with cancer that needs psychiatric or psychosocial interventions. Patients with cancer with psychological problems therefore face even greater stigma. This situation should be taken into consideration in clinical practice.
Cancer is an illness that increases the risk of suicide in Asian countries [20][21][22]. One epidemiological study found that the suicide rate among Korean patients with cancer was approximately twice that of the general Korean population [23]. Suicide risk was higher in patients with cancers that have a poor prognosis, especially within the first year of diagnosis [23,24]. Appropriate psycho-oncological intervention could reduce the suicide risk of patients.
With the development of information and communication technology, e-health and m-health are emerging. In psycho-oncology, there have been various studies to improve self-management and support patients with cancer, using mobile applications [25], tablet PCs [26] and touch-screen computers installed at kiosks [27]. More studies using information and communication technology will be conducted in the future.
Psycho-oncological knowledge can be universally applied, and it is beyond race, culture, and socioeconomic status; however, it is necessary to consider the sociocultural specificity of each country. Considering the socio-cultural characteristics of Korean cancer care, a Korean model of distress management is being prepared by the KPOS, with a revision in the recommendation published in 2008.
The KPOS, as the only academic group of psychooncology in Korea, should tighten the cooperation with the International Psycho-Oncology Society (IPOS) and other academic communities in the world.
International cooperation with many East-Asian experts who share similar cultural and healthcare system backgrounds would help with the promotion of psychooncology in Korea.

Conclusions
The introduction of psycho-oncology to Korea was relatively late, and its growth was not fast enough, compared to Western countries and Japan. There has, however, been a steady development of psycho-oncology, with a successful launching of a national academic society and growing numbers of enthusiastic professionals in Korea. This article provided a brief overview of the development, current issues, and future challenges of psycho-oncology in Korea. Psycho-oncology should be an integral part of integrated supportive care for cancer in Korea.