Mental health intervention benefits patients with cancer, may reduce costs
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Patients with cancer who received specialized mental health support experienced improved quality of life, as well as reduced pain, depression and fatigue.
The intervention also reduced costs, researchers reported in The Lancet.
“Screening and referral for treatment has been recommended by several national organizations, such as ASCO, College of Surgeons Commission on Cancer, National Comprehensive Cancer Network and CMS,” lead author Jennifer L. Steel, PhD, professor of surgery, psychiatry and psychology and director, center for excellence in behavioral medicine at UPMC, told Healio. “Unfortunately, the goal to improve patient quality of life by screening and referring patients for treatment has not been effective. As a result, our team designed an integrated screening and stepped collaborative care intervention to improve the uptake and quality of life of those diagnosed with cancer when compared with the current standard of care.”
Researchers evaluated the intervention in a randomized phase 3 trial that included 459 patients with cancer treated at 29 oncology clinics associated with UPMC Hillman Cancer Center. All patients were aged 21 years or older and had clinical levels of depression, pain and/or fatigue.
Investigators assigned 237 participants to a stepped collaborative care intervention.
The intervention included once-weekly telemedicine cognitive behavioral therapy, with sessions lasting 50 to 60 minutes. Patients started or changed pharmacotherapy for symptoms at the discretion of the treatment team or based on their preference.
The other 222 patients received standard care, which included screening and referral to a health care provider to treat symptoms.
Health-related quality of life at 6 months, measured by the Functional Assessment of Cancer Therapy General instrument, served as the study’s primary outcome.
Steel spoke with Healio about the study’s key findings, how the intervention performed and the impact efforts like this might have on quality of life for individuals with cancer.
Healio: Can you provide context for the prevalence of mental health challenges among people with cancer?
Steel: Over 50% of patients diagnosed with cancer report symptoms of depression, anxiety, pain and/or fatigue. These symptoms lead to poorer quality of life, decreased adherence to cancer-related treatments, higher rates of unplanned health care utilization and costs, and even poorer survival.
Healio: How did you conduct this study?
Steel: Patients who reported one or more of these symptoms in the clinical range were randomly assigned to the treatment arm or were referred to a community provider for treatment. Treatment duration was approximately 12 to 24 weeks, with the primary treatment being cognitive-behavioral therapy and, if indicated and preferred by the patient, pharmacotherapy. Patients were assessed at 6 months and 12 months with regard to their quality of life, symptoms, and biological mechanisms potentially underpinning the link between symptoms and survival. Family caregivers were included in the study but did not receive treatment. The caregivers were asked questions about psychosocial and behavioral factors, and blood and anthropomorphic data were collected to prospectively assess their risk for cardiometabolic syndrome and cardiovascular disease.
Healio: Can you describe the mental health intervention?
Steel: Although stepped collaborative care approaches vary regarding treatment modality — such as pharmacotherapy and psychotherapy, duration and delivery — the stepped collaborative care approach is effective because the treatment is based on patients’ preferences, evidence based, actively monitored for adherence and response to treatment, and systematically modified to achieve the best possible outcome for each patient. Our stepped collaborative care intervention is novel because cognitive-behavioral therapy was the primary treatment, and medication was initiated or changed only if indicated. Additionally, three symptoms — depression, pain and fatigue — were targeted versus only depression, and it was delivered via telemedicine.
Care coordinators were masters’ level-trained social workers or counsellors who served as a liaison between the patients’ medical team. Patients initially received at least eight to 12 sessions of cognitive-behavioral therapy depending on the presentation of symptoms at randomization. We used traditional cognitive-behavioral therapy strategies, such as identifying and changing maladaptive thoughts, relaxation techniques and changing core beliefs. We also used strategies to reduce pain and fatigue, which included cognitive techniques such as reducing cognitions related to pain and fatigue, as well as behavioral techniques such as sleep hygiene, stimulus control, pacing, rest activity cycle and increasing physical activity. If patients’ symptoms persisted above the clinical range at 12 weeks, then additional treatment was provided for up to 6 months. Participants who received the stepped collaborative care also had access to a website.
Healio: What did you find?
Steel: Patients allocated to the integrated screening and stepped collaborative care intervention had a greater 0- to-6-month improvement in health-related quality of life versus patients assigned to standard care, and these gains were maintained from 6 to 12 months. Patients assigned to the integrated screening stepped collaborative care intervention, when compared with standard care, had greater 0-to-6 months improvements on the emotional, functional and physical well-being. Family caregivers of patients allocated to the integrated stepped collaborative care had lower lifetime risk for cardiovascular disease than family caregivers of patients allocated to standard of care. Cost savings of $17,085 per patient allocated to the integrated screening and stepped collaborative care intervention versus standard of care was observed. The drivers of the lower activity-based costs for stepped collaborative care were shorter length of stay in the hospital, fewer emergency room visits and trends toward fewer 90-day readmissions.
Healio: What are the potential implications of this research?
Steel: We hope that cancer centers will adopt the integrated screening and treatment and offer the treatment at no charge to patients. We are planning to further test this integrated screening and stepped collaborative care intervention in a hybrid type I effectiveness-implementation trial with thousands of patients to better understand the facilitators and barriers to implementation in clinical practice, and develop a training institute to train health care providers to implement this approach and improve patient quality of life. We are also testing this intervention in other chronic medical conditions, such as end-stage kidney disease and transplant candidates.
Reference:
For more information:
Jennifer L. Steel, PhD, can be reached at steeljl@upmc.edu.
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