Studies show that people suffering from serious mental illness are at increased risk for poor cancer outcomes and mortality due to inequities in their cancer care. Although psychiatric care at the time of diagnosis may improve care, current models for integrating psychiatric interventions and cancer care are lacking. To understand more about this issue, The ASCO Post recently spoke with Kelly E. Irwin, MD, MPH, of the Massachusetts General Hospital, Center for Psychiatric Oncology and Behavioral Sciences.
Kelly E. Irwin, MD, MPH
Clinician and Researcher
Please tell the readers a bit about your background and your current work.
I’m a psychiatrist at Massachusetts General who specializes in psycho-oncoloy and community mental health. I’m a clinician and health services researcher who focuses on how to improve cancer outcomes for people living with serious mental illness. Many people with serious mental illness (including schizophrenia, bipolar disorder, and major depressive disorder) experience barriers to accessing quality cancer and mental health care. Individuals with serious mental illness die 15 to 30 years earlier than patients without mental illness, and cancer is the second leading cause of death. These individuals are therefore dying earlier and having poorer end-of-life outcomes than their counterparts without mental illness. So, our research looks at ways to identify this disparity in cancer care and then to develop strategies to address it.
For instance, compared with people without mental illness, individuals with serious mental illness have two to four times greater mortality from breast, lung, colorectal, and oral cancers.1-3 Patients with serious mental illness are more likely to be diagnosed with metastatic disease and are less likely to receive timely, guideline-concordant treatment. And despite leading oncology organizations’ focus on health disparities, the disparities experienced by patients with mental illness are understudied. Approximately 50% of clinical trials exclude patients with mental illness, which is another reason this underserved population faces barriers to cancer care.
“Population-wide estimates show that up to one-third of patients with cancer will be affected by some type of mental illness.”— Kelly E. Irwin, MD, MPH
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Mental Illness and Cancer
Are there data showing the extent of serious mental illness in patients with cancer?
First, serious mental illness is common. More than 20 million U.S. adults are affected by schizophrenia, bipolar disorder, and major depressive disorder. Since cancer is the number two cause of death in the United States, just behind cardiovascular disease for people with serious mental illness, we wanted to look at the prevalence of serious mental illness among patients with cancer. Depending upon how it’s defined, if you look at population-wide estimates, it shows that up to one-third of patients with cancer will be affected by some type of mental illness, which might range from adjustment disorder, depression, and anxiety to schizophrenia or bipolar disorder.
At the Mass General Cancer Center, we found that about 25% of patients with cancer had a documented history of depression, bipolar disorder, or a psychotic disorder; major depression was the most prevalent. Although psychosocial care is essential for quality cancer care, access to psychiatry remains limited for people with mental illness and cancer. Involving psychiatry at the time of cancer diagnosis has the potential to protect against disruptions in cancer care for patients with serious mental illness. New models of integrated cancer and mental health care are urgently needed, and that is where we’re focusing much of our work.
Please tell us about the purpose of your recent study, the development process of “Bridge” intervention, and how it was used to help outcomes in this patient population.
We realized that the initial cancer diagnosis and first time accessing cancer care is a critical time for intervention. Patients with comorbid mental illness face many complex issues, and mental illness was not documented comprehensively in oncology care. Part of that lack of documentation is because oncology and mental health care tend to be highly fragmented, and clinicians may experience barriers communicating across systems. At our academic cancer center, we found that one in two patients with schizophrenia and breast cancer was not receiving guideline-concordant breast cancer care; documented psychiatry care and antipsychotic medication at the time of cancer diagnosis was strongly associated with fewer cancer care disruptions after accounting for insurance type, cancer stage, and access to primary care. This was a retrospective study and only suggested a hypothesis of a potential modifiable factor that could be targeted. We therefore aimed to develop a systematic way to target this population and link them to proper mental health–care services and grounded our approach in the evidence-based collaborative care model, which increases access to psychosocial care and improves depression symptoms among patients with cancer.
We developed “Bridge,” which is a person-centered model of early, integrated psychiatry and cancer care for patients with a serious mental illness, to improve cancer care outcomes. To that end, we conducted qualitative interviews with oncology and mental health clinicians and applied the core principles of collaborative care to the needs of patients with mental illness and cancer. Instead of a stepwise approach, we hypothesized that a proactive Bridge model would be a feasible way to deliver a continuum of good quality care for patients with cancer and a serious mental illness. In this single-group pilot trial, we found that it was feasible to identify patients with serious mental illness at the time of cancer diagnosis and to modify trial procedures to achieve high rates of consent and trial completion. Patients, caregivers, and oncology clinicians found that the intervention was acceptable and useful in facilitating cancer care. We examined change in psychiatric symptoms, quality of life, and the frequency of disruptions in cancer care.
We are currently conducting a follow-up randomized controlled trial to determine whether the Bridge model (proactive team-based mental health and cancer care) can improve cancer care in patients with serious mental illness.
“We can develop a systematic way to target patients with schizophrenia and breast cancer and link them to proper mental health-care services.”— Kelly E. Irwin, MD, MPH
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Role of Socioeconomic Status in Disparity
Patients with cancer who have serious mental illness fall into the disparity-of-care issue. Did you and your colleagues discover any contributors, such as socioeconomic status?
We know from several larger studies that a double disparity exists in this population. Socioeconomic status contributes to a portion of the disparity in cancer mortality, but there is a distinct disparity due to serious mental illness, which many oncologists are not equipped to deal with. Our Bridge model uses a person-centered team (a social work case manager, navigator, and consulting psychiatrist) to partner with the oncology team and attempt to address the issues involved with mental illness—whether it’s helping provide transportation, tailoring communication to make sure a patient is fully informed about the diagnosis and treatment plan, or treating psychiatric symptoms. Moreover, many patients with mental illness are homeless or have difficult financial issues, which also require attention.
Please share some closing thoughts on this issue as it pertains to the broader landscape of oncology.
As a psychiatrist, it is incredibly rewarding to partner with the oncology community. I am hopeful that we can continue to do more research that includes patients with complex needs who face barriers to cancer care, which will help us take meaningful steps in providing high-quality equitable care. This care includes a proactive model to identify patients with cancer who have serious mental illness and decrease barriers to accessing the continuum of cancer care, including clinical trials.
DISCLOSURE: Dr. Irwin reported no conflicts of interest.
1. Crump C, Winkleby M, et al: Comorbidities and mortality in persons with schizophrenia. Am J Psychiatry 170:324-333, 2013.
2. Chang T, Hou S, Su Y, et al: Disparities in oral cancer survival among mentally ill patients. PLoS One 8:e70883, 2013.
3. Cunningham R, Sarfati D, Stanley J, et al: Cancer survival in the context of mental illness: A national cohort study. Gen Hosp Psychiatry 37:501-506, 2015.