Combating a killer: How to identify, address loneliness among patients with cancer
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Extended loneliness can have grave effects for patients with cancer, and the COVID-19 pandemic has compounded the potential risks.
Cancer is more common as people age, with about two-thirds of cases occurring among individuals aged 60 years or older. In this population, loneliness can be seen as a comorbidity of the disease.
Fortunately, there are ways providers can identify those at risk, as well as resources they can share with patients to help promote a sense of connection.
Dangers of loneliness
Prolonged loneliness is a killer.
Since the pioneering work of psychologist James Lynch, PhD, documented its deleterious effect on heart health in 1977, robust literature has emerged to show how loneliness and social isolation affect patient outcomes and biopsychosocial well-being.
Evidence suggests people who are lonelier take worse care of their health, feel more stressed and even heal less effectively. People with deeper social connections are more likely to be healthier, eat better, exercise more and see their physicians.
Among older adults, loneliness shortens lives. However, loneliness is more than living alone. A person can feel lonely even when surrounded by others.
The deep sense of connection with others — even pets — mitigates the sense of exposure and vulnerability. For those in relationships, the quality of respect, commitment and mutual support provides health benefits to both partners.
Research has demonstrated that social isolation is associated with higher cancer mortality.
In a paper published in 2017 in PLOS One, Marcus and colleagues used National Health and Nutrition Examination Survey and census data to examine how social isolation and neighborhood poverty influenced cancer mortality.
The study population included 16,044 adults, 1,133 of whom died of cancer during the study period.
Researchers scored participants’ social integration or isolation based on a modified Social Network Index that accounted for marital status, frequent contact with friends and family, church attendance and volunteerism.
Results adjusted for age, sex and race/ethnicity showed socially isolated individuals had a 25% higher risk for cancer mortality than socially integrated individuals.
When investigators stratified by sex, they determined socially isolated women had a 32% higher risk for cancer mortality than socially integrated women. By contrast, the difference in mortality risk was not statistically significant among men.
This makes sense, as women tend to be more social and loneliness may exact a heavier toll on them.
Identifying patients at risk
Over the past couple decades, screening patients for problem-related distress and social determinants of health has emerged as a best practice in cancer care.
In 2009, my institution implemented SupportScreen, a fully automated, patient-friendly questionnaire we developed.
This screening tool — which can be completed at home — is our care model’s first step in partnering with patients and their families. It helps identify problems, resource needs and high levels of risk. Hospitals interested in adopting SupportScreen may contact me at the email address at the end of this article.
There is one particularly powerful — and initially controversial — screening question that is important for opening the conversation about loneliness and several other sensitive issues:
Which statement is closest to your understanding of your present medical situation?
- Cure is very likely and is in the range of 76% to 100%;
- Cure is likely and is in the range of 51% to 75%;
- Cure is possible but not likely and is in the range of 26% to 50%;
- Cure is not at all likely and is in the range of 0 to 25%. The goal of treatment is to control the disease for as long as possible; or
- Cure is not at all likely and is in the range of 0 to 25%. The goal of treatment is to focus on comfort, time with family and quality of life.
Beyond indicating how closely a patient’s understanding of their prognosis matches reality, the question signals that the whole range of human experience is up for discussion — or, as I like to put it: “If it is on your mind, it is on the table.”
This is especially important for patients who are suffering from loneliness.
If initial screening indicates a lack of social support, there are questions clinicians can ask to get a better understanding of a patient’s circumstances. These include:
- Do you feel that you can take care of yourself?
- Do you feel that you can count on your family?
- Is there someone who lives nearby who can help you? If so, what is that person’s name?
- Is there someone you can talk to about your concerns and fears?
- Do you feel safe in your own home?
Certain scenarios require referrals to specific cancer experts. Examples include when:
- Symptom management problems indicate the need for physician or nursing intervention;
- A range of psychosocial issues — including a lack of basic resources — indicate the need for supportive counseling from a social worker as a link to psychology and psychiatry;
- Complex pain syndromes indicate the need for experts in palliative care or interventional pain;
- Neuropsychological issues indicate the need for support from a psychologist; or
- Psychiatric illness and severe responses indicate the need for a psychiatrist’s help.
Ultimately, this approach is a type of precision medicine. Care follows from who an individual is, the issues they are facing and what they can afford.
How to address loneliness
When screening and a clinician’s assessment identify social isolation or loneliness as a problem, social workers — available in comprehensive cancer care settings — offer psychological support, help with practical problems and guide people to resources.
They also have expertise about when to advocate for other essential services.
What’s available changes over time, and social workers stay up to date on all options as a fundamental duty of their profession. They serve as a gateway to helping patients connect with community-based support systems.
Of course, cancer has not stopped because of COVID-19.
NCI-designated comprehensive cancer centers, including City of Hope, have worked to ensure patients receive uninterrupted care in a safe environment. Social workers and other supportive care professionals often connect with patients through video calls to offer them necessary social support without exposing them to unnecessary risk.
Interventions must be selected based on unique characteristics of each patient — demographical, geographical, financial or otherwise.
This comes from comprehensive biopsychosocial screening.
Resources are based around, for example, the illness a person has, the faith they practice, their age, and where and how they live. It is critical for clinicians to see people who they are and tailor the care they provide accordingly.
Resources specific to age usually come first. For an older patient who is socially isolated, the AARP website is an excellent place to start.
Connecting with a faith community through a synagogue, church, temple or mosque can be very helpful — albeit with limitations on in-person gatherings due to the pandemic.
The American Cancer Society and Cancer Support Community websites have superb lists of psychosocial resources searchable by zip code.
Hundreds of organizations — such as The Leukemia & Lymphoma Society or Susan G. Komen — provide support based on patients’ diagnosis. Many are grassroots organizations, and they are very helpful.
Although certain resources are grounded in in-person experiences, help for individuals with cancer who are dealing with loneliness is increasingly web-based. This facilitates access for those who must be especially careful about avoiding COVID-19 infection.
Given the shift toward virtual support, it is important that we put to rest the myth that older individuals are uncomfortable or inept with technology. In my experience, many older people live on Facebook and go everywhere with their smartphones.
To combat the killer that is loneliness — more prevalent than ever during the pandemic — patients deserve every tool we can provide to help them enjoy longer, more meaningful and healthier lives.
References:
- Banet AG. The broken heart: The medical consequences of loneliness. James J. Lynch New York: Basic Books. 1977.
- Cacioppo JT, et al. Annu Rev Psychol. 2015;doi:10.1146/annurev-psych-010814-015240.
- Hawkley LC and Cacioppo JT. Brain Behav Immun. 2003;doi:10.1016/s0889-1591(02)00073-9.
- Holland JC, et al. J Natl Compr Canc Netw. 2015;doi:10.6004/jnccn.2015.0129v.
- Holt-Lunstad J, et al. Perspect Psychol Sci. 2015;doi:10.1177/1745691614568352.
- Killgore WDS, et al. Psychiatry Res. 2020;doi:10.1016/j.psychres.2020.113117.
- Luanaigh CO and Lawlor BA. Int J Geriatr Psychiatry. 2008;doi:10.1002/gps.2054.
- Luo Y, et al. Soc Sci Med. 2012;doi:10.1016/j.socscimed.2011.11.028.
- Marcus AF, et al. PLoS One. 2017;doi:10.1371/journal.pone.0173370.
- Perissinotto CM, et al. Arch Intern Med. 2012;doi:10.1001/archinternmed.2012.1993v.
- Reynolds P and Kaplan GA. Behav Med. 1990;doi:10.1080/08964289.1990.9934597.
- Taylor SE, et al. Psychol Rev. 2000;doi:10.1037/0033-295x.107.3.411.
- Umberson D, et al. Annu Rev Sociol. 2010;doi:10.1146/annurev-soc-070308-120011.
- Yang CY, et al. Proc Natl Acad Sci U S A. 2016;doi:10.1073/pnas.1511085112.
For more information:
Matthew J. Loscalzo, LCSW, FAPOS, can be reached at mloscalzo@coh.org.
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