Oncology and mental health

Guidelines in Oncology care recommend patient-reported outcome measures (PROMs) for mental health screening. How can they benefit patient care?

Onkologie und psychische Gesundheit
Mental wellbeing influences cancer survival

Cancer is never simply a disease that patients grapple with, it is a drawn out, tiresome odyssey with effects stemming into patients‘ physical health and emotional wellbeing. From diagnosis to therapy to possible recovery patients experience a profound amount of therapeutic side effects in conjunction with the effect of the disease itself. The psychological and emotional stresses endured during the various stages of patients‘ disease journey bear weight on their overall health. The influence of such physiological distress is so great that an estimated 1 in 3 patients develop a mental disorder in the course of the disease.1

Often this stress manifests itself in some form of anxiety and panic disorders or depression.2 – 4 A great deal of support is required before and during oncological therapy. In the event of a positive therapeutic outcome, many survivors remain needing psychological help.5 Studies into this field have revealed that approximately a third of patients report increased stress levels in the years following breast cancer diagnosis and surgical intervention. Whilst some patients experienced post-traumatic stress disorder triggered by their cancer diagnosis. 5

This also has implications for the physical health of cancer patients. Early philosophers such as Plato indicated that the state of the mind has effects on the physical being and so the balance of the two must be valued. In the field of oncology, depression is associated with increased mortality in these patients.8

Moreover, there is evidence that depression has a negative influence on treatment adherence, health behaviour, length of hospital stay and quality of life.9 Observations have illustrated that a correlation exists between depression and a faster disease progression or increased risk of suicide.8 – 9

Psycho-oncology maintains and increases quality of life

The early recognition of such psychosocial stress factors and the initiation of appropriate psycho-oncological measures is one of the primary goals of psycho-oncology. The overall aim is to maintain and improve the subjective quality of life of cancer patients.

Psychotherapeutic interventions have positive effects on the severity of symptoms of psychiatric illness, quality of life, illness behaviour and the time to return to work.8 Psychotherapeutic drugs not only improve depression or anxiety and panic disorders, but also have a positive effect on tumour-related symptoms such as hot flashes or pain.11 The Symptom Management Research Trials (SMaRT) in the United Kingdom demonstrated positive results with an enhanced integrated mental health focus oncology therapy regimes. Patients received screening and management of depressive symptoms in subspecialty oncology clinics by trained cancer nurses and psychiatrists. In the SMaRT Oncology 1 and 2 trials, this treatment was found to improve depression scale scores more than typical care.12

In the United States, the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology for Distress Management outlines the identification and treatment of psychosocial problems in patients with cancer. They are intended to aid oncology teams identify patients who require referral to psychosocial resources and to give oncology teams guidance on interventions for patients with mild distress to ensure that all patients with distress are recognised and treated appropriately.13

From a European perspective, the German Cancer Society, the German Cancer Aid and the Association of Scientific Medical Societies (AWMF) recommend in the current S3 Guidelines on Psycho-Oncology (2014) that “all patients” should receive “screening for psychosocial stress”.[14] This should be carried out as early as possible and repeated at appropriate intervals or in the event of the physician requiring additional checks. According to the consensus provided by the devising panel, early screening can prevent a chronification of psychological stress and is therefore an important component in the diagnostic process.14 Considering the above, the guidelines state that psychological monitoring should therefore be an aspect of every patient‘s comprehensive oncological therapy.

German S3 Guideline recommends PROMs as a psycho-oncological screening tool

Patient-reported outcome measures (PROMs) are instruments with which the effects of a disease or therapy on individual symptoms, quality of life or health status of patients can be recorded from their own perspective.15 Often questionnaires which are validated in studies are used for this purpose. This type of standardised, direct patient survey is advantageous due to the higher quality of methodological information derived compared to the that obtained informally in a physician-patient discussion.16 The uncomplicated application and low costs associated also qualify PROMs as implementable screening instruments.17 More detailed information on PROs in oncology has been compiled here.

Many PROMs enable screening for mental stress

In the S3 guideline for psycho-oncology the authors explicitly recommend the use of validated PROMs for screening for mental stress in oncological patients.  Adhering to best practice evidence, the Hospital Anxiety and Depression Scale (HADS-D) questionnaire is recommended as a screening tool for mental stress amongst patient cohorts. However, a complicated cut-off calculation and royalties limit the suitability of this instrument for everyday use.14

Nevertheless, there is validated evidence for the Center for Epidemiologic Studies Depression Scale (CES-D) and the Patient Health Questionnaire 9 (PHQ-9),  which has a performance comparable to that of the HADS-D as a screening instrument in an oncological setting.17

Appropriate Screening allows for efficient deployment of resources

According to the International Psycho-Oncology Society (IPOS), there are significant gaps in provision of psycho-oncology services across Europe: 40–60 percent of cancer patients and family members experience psychological distress that could benefit from appropriate intervention, but currently only a minority receive psychological support and care.19

Good screening could benefit this deficiency of provision in a bid to distribute the few available resources more efficiently. Whilst also making it possible to objectively determine the overall need and thus create arguments for increased care services. Regardless of the disease in question, PROMs are generally recommended as a screening tool for mental stress. Several questionnaires that are easy to use and inexpensive meet the psychometric quality criteria required for screening. It should be mentioned as a limitation that recommendations of this kind are often based on an expert consensus. Although the link between mental health and cancer is undisputed, more comprehensive studies should be conducted to confirm future guidance recommendations across different regions.20

heartbeat has also been supporting cancer centres for years in measuring quality of life and mental health with PROMs. We are acutely sensitive to the need to enhance monitoring of psychological and emotional stress in the realm of oncology and make monitoring more implementable in clinical use. heartbeat endeavours to continue to follow guidelines in oncology that put emphasis on the patient voice and provide support based on our experiences.

Oncology and mental health 1
written by:

Lion Thiel

Medical student at the Charité. Writes for heartbeat about science, medicine and politics.

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