New study suggests cancer patients do better with mental health treatment
Almost everyone knows someone with cancer, and they might also know how challenging the diagnosis can be for their loved one’s mental health. But while almost half of cancer patients in the U.S. report depression and many report anxiety, very few follow through with mental health treatment when referred, a new Pitt study found.
The study supports the idea that mental health care improves quality of life for both cancer patients and caregivers, and saves hospitals millions of dollars. Experts in the niche field of onco-psychology think mental health care for cancer patients should be required, and that the new study could encourage the American Society of Clinical Oncology to adjust current guidelines.
A third of all women and half of all men will develop some type of cancer in their lifetimes, according to the Centers for Disease Control and Prevention. And the illness is the second most common cause of death in the U.S., preceded only by heart disease, per the American Cancer Society.
“Cancer impacts almost everything in life,” said Shawna Ehlers, an associate professor of psychology at Mayo Clinic Rochester and director of the onco-psychology program at the clinic’s Comprehensive Cancer Center.
“Most people don’t think about that. It often blindsides people. We live very busy, hectic lives. We don’t have time for cancer,” she said. “For people who are generally healthy, it’s often the first time they’ve dealt with a life-threatening condition.”
In a randomized control trial of 459 patients with a variety of cancers, and 190 caregivers, Pitt researchers discovered that just 4% of patients initiated care when referred to a specialist — while 75% of patients in a group receiving what’s called stepped collaborative care group did so. The study was a Phase III trial, conducted between 2016 and 2021 at 29 outpatient cancer clinics associated with UPMC Hillman Cancer Center.
Stepped collaborative care is a model providing once-weekly cognitive behavioral therapy (CBT) to cancer patients to tackle the specifics of their cancer and mental health struggles.
A typical CBT session with an oncopsychologist might entail the patient sharing pertinent thoughts and worries regarding their diagnosis and working together with the doctor to reframe those thoughts. The model recommends 50 to 60 minutes per therapy session, which can be done virtually.
“Cognitive behavioral therapy reduces cancer-related pain and fatigue by reducing maladaptive thoughts associated with pain and depression,” said Jennifer Steel, professor in the surgery department at Pitt School of Medicine and first author on the paper. “It allows the patient to reframe what’s happening and regulate their views of the world. We address existential issues as well to help people deal with potential prognosis.”
The study found that after six months of CBT via telemedicine, cancer patients in the stepped care group had improved health-related quality of life scores and increased scores for emotional, physical and functional well-being, compared to patients in the control group, who received treatment based on current guidelines. They also showed greater reductions of depression, pain and fatigue comparedto controls.
And results showed an estimated $4 million in savings because of reduced hospital readmissions and utilization of health care services.
“There has been a lot of research prior to this showing that people with lots of depression and pain use health care more. Reducing depression and pain also reduces cost,” said Steel, also the director of UPMC Liver Cancer Center’s quality of life program. “We are hoping these findings will drive reconsiderationof the current guidelines.”
Other experts not involved in the research thought the results were in line with what they have noticed from their own cancer patients.
“The study was exciting to read about,” said Matthew Iwaniec, director of health psychology at Allegheny Health Network, who also works with cancer patients. “It demonstrated empirically what we’ve known about for a long time. We know that referring people out does not work. Cancer patients are already overwhelmed.”
Iwaniec said most of his patients experience debilitating anxiety, which is improved by reframing opportunities from CBT. While the study did not specifically address anxiety, he said that “increasing access to interventions is important, and this goes a long way in demonstrating that.”
That the authors illustrated the money-saving component was important, said Iwaniec, potentially motivating the American Society of Clinical Oncology to rethink guidelines.
“This is right in line with our findings, that if you treat the psychological, you reduce health care costs,” said Ehlers, who also was not involved in the study.
Current guidelines state that all cancer patients should be screened for depression and anxiety at varying intervals during their treatment and be provided education and mental health resources. Patients with moderate to severe symptoms should be referred out to additional care. The guidelines also recommend a “stepped care model” when it’s available. But it’s likely that not all hospitals have access to the resources neededto establish that model in-house.
The study also looked at caregivers’ health and found that their lifetime risk of developing cardiovascular disease, stress and depression went down when in the stepped collaborative care group, compared to those in the control group. Iwaniec called those findings “a big deal.”
The scientists thought that establishing mental health in-house could reduce another barrier to patients accessing care: stigma.
“In our society, we don’t really talk about mental health as a normal part of cancer, but it is,” said Ehlers. She tries to remind each of the cancer patients she sees that their anxiety and/or depression are normal and can be treated.
Iwaniec says he has seen stigma hinder cancer patients from seeking mental health care, although attitudes around it are improving.
“Reducing that stigma is so important,” he said. “The more people you have that participate in programs like this, the better able we are to target stigma. From my own experience, stigma really stops patients from signing up, particularly men.”
Establishing this model as a requirement could also standardize care on a system level, not just on an individual one, as each cancer patient is screened for mental health issues and treated at the same location, providing a built-in safety net.
“Many leading cancer centers have that care in-house, but it should be required,” said Ehlers. “It gets back to [the idea that] stress is a normal part of cancer. It should just be part of every patient’s’ care.”
“We are hoping these findings will drive reconsideration of the current guidelines.” Jennifer Steel Pitt professor