Sheila Lahijani, MD, FACLP, gives her perspective on the need for psycho-oncologists to help patients during their cancer journeys.
Over the last 15 years, data have continued to emerge that highlight the large disparities in both the screening and treatment of cancer in individuals with (vs without) serious mental illness. The authors of this review effectively present practical guidance for oncology clinicians to enhance the person-centered approach to treating patients with the “double stigma,” cancer and serious mental illness.1,2 Specifically, the authors focus on the importance of a communication style that is engaging and intended to be respectful and curious. They also acknowledge the effects on clinicians of individual and systemic factors, such as cognitive biases, suboptimal distress screening and management, provider burnout, and limited access to clinical trials.
The multidisciplinary field of psycho-oncology is uniquely positioned to address and manage the challenges associated with caring for this vulnerable patient population.3 As psycho-oncologists, we tailor our approaches to the patient interview and exam with our knowledge of the impacts of cancer and its treatments on mental health. We can apply our armamentarium of psychotherapeutic modalities as well as our expertise in psychopharmacology to cancer care. Educational efforts and training led by us across a cancer setting can empower nonpsychiatric providers and trainees in medicine to care for patients with psychiatric symptoms and disorders, and support them as they do so.
While psycho-oncologists are not accessible in every cancer care setting, this review emphasizes that improving access to psychiatric services through other approaches, such as collaborative care and community outreach, can also improve cancer outcomes. Yet while many organizations and agencies have mandated distress screening in the cancer setting, patients with psychiatric symptoms, and specifically those with serious mental illness, may not be identified through these traditional methods. These individuals may also not disclose their psychiatric history to their oncology providers. The effects of self-stigma, as stated in this review article, can be profound, influencing health behaviors and how and when patients access medical care. Patients with cancer and serious mental illness consequently can have poorer prognoses and shorter survival times.4
It is imperative to bridge these gaps in cancer care. Earlier diagnosis and treatment of cancer in patients with serious mental illness is needed. We can develop more population-based methods to assure that these patients are being identified and offered medical care in a timely and effective matter.5 We must thereby confront the biases in medicine about patients who suffer from psychiatric disease. While there may be higher comorbidity indices, more potential for significant drug-drug interactions, changes in decision-making capacity, and/or difficulties with adherence and coping, generalizing these associations to an individual patient can be a deterrent to providing comprehensive cancer care. We need to leverage the involvement of psycho-oncology clinicians, social workers, patient navigators, caregivers, primary care providers, chaplains, and others who can collaboratively participate in a patient’s cancer care and advocate for the patient with mental illness; that strategy can help harvest good clinical outcomes along the care continuum.
Psycho-oncologists can and do treat patients’ psychiatric distress and illness. We can and do evaluate patients for suicide, which is prevalent in patients with cancer. We can and do diagnose and treat cognitive problems, such as delirium. We can and do promote health behaviors, such as intentional physical activity and sleep management. However, this can all be done more expansively and sustainably with the right prioritization of institutional efforts and allocation of funding. We need to address the insurance barriers, delays in scheduling, limited availability of mental health specialists, and provider burnout, which are but a few of the remarkably widespread problems in our medical system. Inherently, formal and informal caregivers can also suffer distress due to demands of multiple roles and unmet psychosocial needs, all of which have been amplified during the COVID-19 pandemic.6,7
Access to mental health services in general is a pervasive problem. When an individual with serious mental illness is diagnosed with cancer, processes must be in place that facilitate the medical and psychiatric care of that individual—specifically, so that treatment is not withheld or minimally offered and that potential medical and psychiatric emergencies are not overlooked. This would not only help individual patients, but it would improve population health and the distribution of clinical services and efforts. It would also enhance our understanding of the interplay between oncologic and psychiatric disease. By having these processes in place, we can develop more effective treatments, decrease health care costs, and customize our models of care to the needs of patients who suffer from the “double stigma.” If we, as a nation, are truly aiming to provide comprehensive cancer care, we must collectively improve the care of our most vulnerable and marginalized patients.
We can lead and implement more of these endeavors and practices while we also take care of the health care providers and caregivers. In these unprecedented times, greater attention is rightfully being given to the health disparities in our medical system. In parallel, there is more recognition that health care providers and caregivers are suffering from burnout, increased workload, and fatigue.8 Furthermore, among the general population, physicians and nurses populate the groups at highest risk of suicide.9 Research has shown that long-lasting changes in health care provider wellness take place by intervening at the organizational level, which requires support from leadership.10
To serve more of our most vulnerable patient populations, we must also consider the health of those who are treating them and doing the caregiving. Interventions must take place to assure that we are creating environments that are psychologically safe and that foster more self-care. By prioritizing clinician well-being, we can work toward lessening the stigma associated with seeking mental health care. We can demonstrate the importance of preventive care. We can increase the opportunity for good health behaviors, such as exercise, mindfulness, and sleep routines. By doing so, we can henceforth provide better and safer patient care.11
When it comes to caring for our patients with cancer and serious mental illness, we can all work together to advocate for earlier and more effective screening, diagnosis, and treatment. We can advocate for safe practices while also encouraging the enrollment of these patients in clinical trials. We can work together to promote and enforce organizational changes to support clinicians and caregivers who are at the helm of caring for these individuals with medical and psychiatric illness. We can do better for them and for ourselves.
Dr. Lahijani is an associate clinical professor in the Division of Medical Psychiatry at Stanford University School of Medicine and the medical director of the Stanford Cancer Center Psychosocial Oncology Program, Palo Alto, CA.