Written by Dr. Zev Nakamura, Assistant Professor
Approximately 1 in 4 patients with cancer are diagnosed with anxiety and/or depressive disorders. These mental health conditions can be exacerbated or precipitated by the psychological stress of a new cancer diagnosis, physical symptoms (e.g., pain, shortness of breath, nausea), and fear of cancer progression or recurrence. Additionally, depression, anxiety, and other mental health symptoms can result from the direct effects of cancer and cancer treatment, hormonal changes secondary to treatment (e.g., suppression of sex hormones in prostate and breast cancer), and medications used to minimize symptoms experienced during treatment (e.g., steroids). Notably, suicide is 13 times as likely in the first week after a cancer diagnosis and remains 3 times higher than in the general population a year after diagnosis (Fang 2012).
A study from the UK of over 20,000 cancer patients found that only 5% who met criteria for major depressive disorder were receiving care from a mental health professional (Walker 2014). This discrepancy between mental health disorders being common and underappreciated is problematic not only because of the impact on quality of life, but because inadequately managed mental health symptoms can decrease patients’ acceptance of, compliance with, and tolerability of cancer therapies (Badger 2001, Nyrop 2019) and decreases survival (Satin 2009, Wang 2020).
It is well-appreciated by leading cancer organizations that racial and ethnic minorities, low-income and uninsured populations, and those living far from academic medical centers experience worse cancer outcomes (Goss 2009, Moy 2011). There is also a recognition about the importance of psychosocial care in oncology, but the degree to which this has been integrated into the discussion of health disparities is limited. For example, the population-based data typically used to measure socioeconomic status and its impact on inequalities in cancer care rarely account for psychological or behavioral factors that may contribute to these disparities.
Yet, recommended cancer screening occurs less often in patients with mental illness compared to the general population (Solmi 2020). These issues are even more pronounced in patients with severe mental illness (e.g., schizophrenia). People with severe mental illness die between 15 and 30 years earlier than the general population (Colton 2006) and cancer is their second leading cause of death (Brown 2010, Capasso 2008, Crump 2013, Saha 2007). This is due to many factors, including more often presenting with metastatic disease, having high rates of comorbidities that impact ability to tolerate cancer treatment, and decreased access to quality care, as well as high levels of poverty, social isolation, and stigma (Kisely 2013, Cunningham 2015, Irwin 2014). Recently, research has aimed to improve mental health symptoms, quality of life, and minimize disruptions in cancer care in patients with severe mental illness through early integration of psychiatric and cancer care (Irwin 2019).
In my role as a psychiatrist with the UNC Comprehensive Cancer Support Program (CCSP; https://unclineberger.org/ccsp/) psycho-oncology service, I’ve been impressed by our team’s commitment to reach as many patients who may benefit from our expertise as possible. We provide care that is coordinated with their oncology team (often at the same time and place to eliminate barriers due to time, transportation, cost, etc.). At the start of the pandemic, we, like many of our colleagues throughout UNC’s Department of Psychiatry, greatly expanded the use of telehealth, further improving access. Though much of what the CCSP does is for patients at the NC Cancer Hospital, the CCSP also supports a statewide network to disseminate public health and research projects across North Carolina. For example, Drs. Stephanie Wheeler and Donald Rosenstein are currently leading a groundbreaking study, funded by the National Cancer Institute, that aims to lessen the impact of the financial burden from cancer treatments and its associated distress for patients treated in rural areas of North Carolina. It should be noted that there are few programs like the CCSP in the country and that even at comprehensive cancer centers with robust psychosocial support services, many patients with cancer who would benefit from mental health care do not receive it.
An important step towards improving equitable access is to systematically identify patients in need. The Commission on Cancer (CoC) has mandated that all CoC-accredited cancer centers screen for psychosocial distress – an unpleasant emotional experience of psychological (cognitive, behavioral, emotional), social, and/or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatments – and refer, as indicated, to appropriate health care professionals. Despite the mandate, distress screening is still far from universal and specific interventions responding to distress remain loosely defined. It may be more prudent to screen explicitly for depression and anxiety for which there are many evidenced-based treatments. To that end, it was recently shown that depression screening in a large and diverse population within the Kaiser health system can in fact improve referrals to behavioral health care (Hahn 2022).
After patients are identified, it is then important that they can connect with mental health treatment. There is a major shortage of mental health providers and fewer for patients with limited financial resources, who live outside of urban centers, don’t speak English, or experience healthcare disparities for a multitude of other reasons. Additionally, some mental health providers may not feel comfortable working with medically complex patients, such as those with cancer, presenting yet another barrier to receipt of mental health care.
I’ve recently had the opportunity to learn about and use an app designed to target anxiety and depression specifically in cancer patients. The app-based treatment uses principles of evidence-based psychotherapies and recognition of the unique stressors facing cancer patients in self-paced psycho-educational and skill-based modules. While treatments like this have clear limitations, they also have the potential to overcome the major barriers to access currently facing patients with cancer. Another way to improve the reach of expert mental health treatment to patients with cancer is through collaborative care. Collaborative care can be employed at any point in a patient’s journey with cancer, but a particularly impactful one may be as patients transition from active treatment into survivorship and primary care providers assume responsibility for cancer survivors’ often many and intertwined physical and mental health symptoms. In this setting, mental health providers can work closely with primary care providers to offer consultation and evidence-based care to a broad range and large number of patients for whom there would otherwise be limitations to appropriate assessment and treatment.
Those of us working at the intersection of mental health and cancer are committed to what Jimmie Holland, MD (one of the founders of psycho-oncology) referred to as “the human side of cancer”. To provide care that is truly human-centered, we must recognize the diverse background of our patients, how their differences can result in disparities in the care that they receive, and develop solutions that ensure equitable access.
References
Fang F, Fall K, Mittleman MA, Sparén P, Ye W, Adami HO, Valdimarsdóttir U. Suicide and cardiovascular death after a cancer diagnosis. N Engl J Med. 2012 Apr 5;366:1310-8.
Walker J, Hansen CH, Martin P et al. Prevalence, associations, and adequacy of treatment of major depression in patients with cancer: A cross-sectional analysis of routinely collected clinical data. Lancet Psychiatry 2014;1:343–350.
Badger TA, Braden CJ, Mishel MH. Depression burden, self-help interventions, and side effect experience in women receiving treatment for breast cancer. Oncol Nurs Forum 2001;28: 567–574.
Nyrop KA, Deal AM, Shachar SS et al. Patient-reported toxicities during chemotherapy regimens in current clinical practice for early breast cancer. The Oncologist 2019;24: 762–771.
Satin JR, Linden W, Phillips MJ. Depression as a predictor of disease progression and mortality in cancer patients: A meta-analysis. Cancer 2009;115:5349–5361.
Wang X, Wang N, Zhong L et al (2020) Prognostic value of depression and anxiety on breast cancer recurrence and mortality: a systematic review and meta-analysis of 282,203 patients. Mol Psychiatry 25:3186–3197
Goss E, Lopez A, Brown C et al. American Society of Clinical Oncology policy statement: Disparities in cancer care. J Clin Oncol 2009;27:2881–2885.
Moy B, Polite B, Halpern M et al. American Society of Clinical Oncology policy statement: Opportunities in the patient protection and affordable care act to reduce cancer care disparities. J Clin Oncol 2011;29:3816–3824.
Solmi M, Firth J, Miola A, Fornaro M, Frison E, Fusar-Poli P, Dragioti E, Shin JI, Carvalho AF, Stubbs B, Koyanagi A. Disparities in cancer screening in people with mental illness across the world versus the general population: prevalence and comparative meta-analysis including 4 717 839 people. The Lancet Psychiatry. 2020 Jan 1;7(1):52-63.
Colton C, Manderscheid R. Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in 8 states. Prev Chronic Dis. 2006;3:A42.
Brown S, Kim M, Mitchell C, Inskip H. Twenty-five year mortality of a community cohort with schizophrenia. Br J Psychiatry. 2010; 126:116-121.
Capasso RW, Lineberry TW, Bostwick J, et al. Mortality in schizophrenia and schizoaffective disorder: an Olmsted County, Minnesota cohort: 1950-2005. Schizophr Res. 2008;98:287-294.
Crump C, Winkleby MA, Sundquist K, Sundquist J. Comorbidities and mortality in persons with schizophrenia: a Swedish national cohort study. Am J Psychiatry. 2013;170:324-333.
Saha S, Chant D, McGrath J. A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time? Arch Gen Psychiatry. 2007;64:1123-1131.
Kisely S, Crowe E, Lawrence D. Cancer-related mortality in people with mental illness. JAMA Psychiatry. 2013;70:209-217.
Cunningham R, Sarfati D, Stanley J et al. Cancer survival in the context of mental illness: A national cohort study. Gen Hosp Psychiatry 2015;37:501–506.
Irwin KE, Henderson DC, Knight HP et al. Cancer care for individuals with schizophrenia. Cancer 2014;120:323–334.
Irwin KE, Park ER, Fields LE, Corveleyn AE, Greer JA, Perez GK, Callaway CA, Jacobs JM, Nierenberg AA, Temel JS, Ryan DP. Bridge: person‐centered collaborative care for patients with serious mental illness and cancer. The Oncologist. 2019 Jul;24(7):901-10.
American College of Surgeons Commission on Cancer: Cancer Program Standards 2012 (version 1.2): Ensuring Patient-Centered Care. http://facs.org/cancer/ coc/programstandards2012.html
Hahn EE, Munoz-Plaza CE, Pounds D, et al. Effect of a Community-Based Medical Oncology Depression Screening Program on Behavioral Health Referrals Among Patients With Breast Cancer: A Randomized Clinical Trial. JAMA. 2022 Jan 4;327(1):41-49.
Holland J, Lewis S. The human side of cancer. New York: HarperCollins; 2000.