Growing focus on patients’ mental health appears to lower suicidality, improve cancer outcomes


Sumary of Growing focus on patients’ mental health appears to lower suicidality, improve cancer outcomes:

  • During the past 2 decades, addressing the psychosocial needs of patients with cancer has become recognized as a crucial component of treatment, but experts said work remains to fully integrate mental health into routine cancer care..
  • In 2001, the Institute of Medicine released a paper on palliative care, that described the types of research needed to reduce distress among patients with cancer..
  • National Comprehensive Cancer Network and ASCO followed suit with practice guidelines that recommend the incorporation of psychosocial care into cancer care..
  • Heightened feelings of despair among patients with cancer is an acute problem that has been exacerbated by the COVID-19 pandemic, according to Lidia Schapira, MD, FASCO..
  • Twenty years later, these initiatives appear to have had a positive impact on the mental health and quality of life of patients with cancer..
  • Historically, patients with cancer have been at a higher risk for suicide due to a constellation of factors including psychological distress, treatment-related adverse events and cancer pain..
  • However, a study published this year in Journal of the National Cancer Institute showed an overall decrease in cancer-associated suicide from 1999 to 2018, with substantially decreased rates observed among specific high-risk groups, including older patients, those with certain cancer types and men..
  • The widespread integration of palliative care and the evolution of psycho-oncology services may have helped to mitigate the suffering that contributes to the high rate of suicide among patients with cancer, according to Lidia Schapira, MD, FASCO, oncologist at Stanford Comprehensive Cancer Institute..
  • Still, challenges remain in readily integrating mental health services into cancer care, as many oncology professionals do not have formal training in assessing suicidality and may lack the tools necessary to identify high-risk individuals, Schapira added..
  • “Although there has been widespread implementation of distress screening and guidelines for making appropriate referrals for patients with cancer who appear in distress, the oncology community has not reached the necessary level of awareness about the risk for suicidality,”.
  • “Moreover, there is not a universal, evidence-based mechanism for assessing suicide risk among patients with cancer, and that is a problem.”.
  • HemOnc Today spoke with psycho-oncologists, epidemiologists and oncologists about factors that put patients with cancer at risk for psychological problems including distress and anxiety, major depression and suicide;.
  • the extent to which the oncology community is prepared to address patients’ mental health and how doing so can improve cancer outcomes;.
  • Assessing suicidality As suicide rates in the United States have increased overall during the past 2 decades, the trend of cancer-related suicide has followed the opposite trajectory..
  • Xuesong Han, PhD, scientific director of health services research at American Cancer Society, and colleagues used the 1999 to 2018 Multiple Cause of Death database to calculate an average annual percent change (AAPC) of age-adjusted cancer-related suicide of –2.8% (95% CI, –3.5 to –2.1) compared with 1.7% (95% CI, 1.5-1.8) for overall suicide among the general population..
  • Han and colleagues observed larger declines in the AAPC of age-adjusted suicide related to lung cancer (–4.7%;.
  • Those declines in suicide associated with specific cancers reflect the cancer types that historically have been associated with the highest risk for suicide..
  • A high symptom burden, such as that associated with head and neck cancer, is one factor driving this association..
  • “We found that prostate, lung, and head and neck cancers were common cancer types contributing to suicide,”.
  • They share common risk factors, and this also may be related to age, as these cancers cause more problems in an older population.”.
  • Other cancer types that often appear to increase risk for suicide include gastric and pancreatic cancers, among others..
  • “In my experience working with cancer surveillance data, it is my observation that mental health issues tend to be prevalent in female cancers like breast, cervical, ovarian and uterine cancers, perhaps related to gender difference in reporting mental health problems or distress from sexual function,”.
  • “Patients with melanoma also tend to report more mental health issues, which may be related to race, as melanoma occurs predominantly among white patients.”.
  • Carlos Fernandez-Robles “These factors play an equally, if not more, important role in the mental health of patients diagnosed with cancer [than tumor type],”.
  • “Let us move away from seeking differences between cancer types, acknowledging that cancer is an individual experience, and focus on identifying personal vulnerabilities so that early detection and interventions can reduce the impact of cancer-associated distress and mental illness,”.
  • “Patients do appear to be ‘breaking away’ from any stigma of mental health issues and are now making mental health a priority and even making decisions based on the availability of these services..
  • When considering the mental health of patients with cancer, it is important to distinguish cancer-related distress from suicidality, according to Schapira..
  • “The treatment of severe mental health disorders and emergencies among patients with cancer require urgent referrals to psychiatrists, whereas distress screening has had widespread implementation and is readily available to oncologists,”.
  • This distinction also raises the question of whether oncologists — who typically are not trained in mental health — have the tools and skills to assess suicidality among patients, she added..
  • “We have worked very hard over the past 20 years to de-stigmatize cancer-related distress, which is in the spectrum of mental health effects and disorders caused by cancer,”.
  • Suicide is on the far end of this spectrum and sometimes catches us by surprise because those of us who provide cancer care may have missed the warning signs and simply did not ask..
  • “The majority of patients with cancer and survivors with some mental health symptoms probably fall in the distress-anxiety range and can be supported with easily available interventions and therapies, but those with a preexisting mental health diagnosis or those for whom life becomes unbearable need far more than a well-meaning oncologist can provide,”.
  • Cancer-related distress A study published in Psycho-Oncology showed 52% patients with cancer had high levels of psychological distress..
  • Raphael, MD, FRCPC, oncologist at Sunnybrook Health Sciences Center at University of Toronto in Canada, and colleagues found that compared with age-, sex- and geographically matched controls, survivors of testicular cancer had a higher rate of mental health care use before (adjusted RR = 2.45;.
  • Much research has been done to describe the physical consequences associated with the diagnosis and treatment of testicular cancer, but the mental health consequences are less well-understood, Raphael told HemOnc Today..
  • “Survivorship care plans that screen for and address the mental health care needs of this patient population are needed,”.
  • “It will be important to study how best to screen for mental health distress among testicular cancer survivors and what interventions are most effective to address their mental health needs..
  • In a study published this year in Psycho-Oncology, each additional physical comorbidity — including chronic back pain, asthma, bronchitis, urinary incontinence, and prostate or kidney problems — increased the odds of having psychological distress by 9% (OR = 1.09;.
  • William Dale No matter the cancer type, patients, especially those who are younger, “struggle with the sudden imposition of a more limited prognosis,”.
  • William Dale, MD, PhD, director of the Center for Cancer and Aging and clinical professor in the department of supportive care medicine at City of Hope, said during an interview with HemOnc Today..
  • “Even more than whether a patient has prostate or lung cancer, a later stage at diagnosis, as well as lower survival outcomes due to poorer overall health, are predictors of mental health concerns,”.
  • “The likelihood that an individual will experience depression and/or anxiety again — with a significant stressor like a cancer diagnosis — increases dramatically.”.
  • For instance, in a study published in Journal of Psychosocial Oncology Research and Practice that showed substantially higher levels of clinically relevant depressive symptoms among 238 Dutch women newly diagnosed with high hereditary-risk breast cancer compared with 165 Norwegian women with unknown risk (P <.
  • A perception exists that women have a greater propensity for depression and anxiety than men, but the way patients are asked about mental health concerns may lead to underreporting among men, according to Dale..
  • Their likelihood of a catastrophic outcome from mental illness is higher, even if the prevalence is thought to be lower.”.
  • In short, it is always important to ask, either directly or indirectly, about mental health concerns in a patient with cancer..
  • Interventions Experts with whom HemOnc Today spoke said there have been greater efforts to address the psychosocial needs of the cancer population within the last 2 decades..
  • The Institute of Medicine, now known as the National Academy of Medicine, issued guidance in 2001 on improving palliative care for patients with cancer, which included a section on reducing distress, and again in 2008 specifically on psychosocial health needs of patients with cancer..
  • These changes in policy — and their potential impact on the mental health and quality of life of patients with cancer and survivors — prompted Han and colleagues to evaluate suicide incidence..
  • The downward trend they observed suggests an evolving role of psychosocial, palliative and hospice care for patients with cancer, Han said..
  • “Whether this reduction can be attributed to more attention given to mental health issues is not fully known,”.
  • “The mortality data that we used from death certificates did not allow us to assess a causal association, but our findings certainly support this hypothesis because during the same time period, changes were made to mental health recommendations for patients with cancer.”.
  • NCCN guidelines — the most recent of which were released in January — call for a similar screening approach, defining distress as “a multifactorial unpleasant experience of a psychological (ie, cognitive, behavioral, emotional), social, spiritual and/or physical nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment..
  • These recommendations reflect a growing general acknowledgement of the importance of screening patients with cancer for distress, Dale said, adding that early identification of patients with psychosocial concerns — which are present among 20% to 50% of patients — can improve outcomes..
  • “We improve outcomes by addressing their depression, anxiety and stress upfront along with their cancer treatment, but we can also improve cancer outcomes by improving their adherence to treatment,”.
  • veterans with non-small cell lung cancer demonstrated that addressing mental health issues improved cancer outcomes..
  • Berchuck and colleagues found that among the veterans who had a preexisting mental health disorder, participation in a mental health treatment program was associated with a lower likelihood of receiving a late-stage diagnosis (OR = 0.62;…

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