Integrated Psychosocial Care for Cancer Patients

This month, Dr. Jesse Fann reflects on his experience with collaborative psychosocial oncology care. After more than two decades of clinical work and research in psycho-oncology, he has developed a keen appreciation for the challenges and opportunities related to improving the lives of cancer patients, and he knows how gratifying it can be for a psychiatrist to work as a member of an integrated psycho-oncology team. —Jürgen Unützer, M.D., M.P.H.

Over 14 million Americans, or 4 percent of the population, are living with a cancer diagnosis. Each year, over 1.6 million people are diagnosed with cancer. Nearly 1 in 2 males and more than 1 in 3 females will be diagnosed with cancer during their lifetime. Fortunately, in most cases, cancer can be managed as a curable or “chronic” condition. Attention has increasingly turned to improving not just survivors’ length of life but their quality of life.

Cancer care has become more complex with the advent of personalized treatment regimens and complex health care systems. Meanwhile, we have new quality standards and guidelines that mandate universal screening and provision of comprehensive psychosocial care integrated into routine care. This convergence requires integrated systems of psychosocial care that are cost-effective and adaptable to diverse cancer care systems. While screening patients for distress has received primary focus, it is the subsequent steps—what to do with the information to best benefit patients—that pose the most challenges. Research in oncology has confirmed findings in other medical settings that screening without an integrated system to ensure appropriate triage, treatment, and follow-up is not likely to be cost-effective in improving outcomes.

A framework for an integrated psychosocial model was presented in the 2008 Institute of Medicine report “Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs” and emphasizes five key components: (1) identification of patients with psychosocial health needs; (2) care planning to address these needs; (3) mechanisms to link patients with psychosocial health services; (4) support of illness self-management; and (5) follow-up on care delivery.

While referral to community mental health providers remains an important option, many patient- , provider- , and system-level advantages exist for providing “in house” psychosocial oncology services when possible. For example, patients typically prefer to receive centralized health care, especially during intensive cancer treatment; providers benefit from comprehensive health records during complex treatment regimens; and care can be better coordinated within a single institution. These advantages, however, weigh against the costs of providing psychosocial care that is potentially resource-intensive and often not revenue-producing.

A viable solution is the application of integrated collaborative care principles to the cancer setting. There is growing evidence that this is convenient for patients, reduces the stigma associated with treatment for mental disorders, builds on existing multidisciplinary systems and relationships, and improves outcomes. At least six published randomized, controlled trials have illustrated successful application of the collaborative care model, compared with usual care, among patients with cancer, including low-income racial and ethnic-minority patients. The role of the care manager can be filled by nurses, psychologists, or social workers. The unique components of these studies highlight the model’s flexibility and adaptability.

The Indiana Cancer Pain and Depression (INCPAD) trial used telehealth technologies to provide care management for depression and pain in 16 community-based oncology clinics. INCPAD demonstrated the viability of using telehealth and remote collaborative care teams to increase the reach of psychosocial oncology care for patients with multiple conditions. Most recently, multicenter studies in the United Kingdom, known as Symptom Management Research Trials (SMaRT) Oncology-2 and -3, were conducted in a large, pragmatic, cost-effectiveness trial and in a trial of patients with lung cancer. Both showed robust advantages of collaborative care over usual care for depression as well as an array of other important cancer-related outcomes, such as anxiety, pain, fatigue, functioning, and quality of life.

Ultimately, innovation and flexibility will be required to develop effective adaptations and enhancements to the collaborative care approach to meet the needs of diverse oncology settings, identify optimal reimbursement mechanisms, overcome institutional resistance and inertia, and ensure sustainability.

Technology can improve the provision of psychosocial care by addressing the identification of patient needs as well as the provision of information, coordination of care, and psychosocial support while potentially reducing cost.

One of the barriers to the implementation of collaborative care in cancer settings, particularly in rural and remote areas, is the lack of psychiatrists and other psychosocial specialists, particularly those experienced in treating cancer patients. Thus, the potential utility of telemedicine/telemental health and videoteleconferencing technology, coupled with task shifting and task sharing, in the context of the collaborative psychosocial oncology care model warrants further exploration. Having an option for community or home-based treatment might also add efficiency, acceptability, and reach. For example, potential barriers to implementation like patient reluctance to enroll and low patient appointment attendance could be overcome with a community-based approach. Home-based collaborative care might be especially beneficial to patients with comorbidities that make clinic attendance difficult.

From our experience implementing collaborative psychosocial oncology care at the Seattle Cancer Care Alliance, we have found that collaborative care has many inherent advantages. First, oncology care by nature embraces a culture of multidisciplinary collaboration. Second, collaborative care encompasses measurement-based care, the foundation of current oncology practice. Third, collaborative care has a history of working closely with primary providers, a core component of the growing emphasis on smooth transitions to survivorship care in oncology. Fourth, collaborative care integrates well with the principles of many quality-improvement programs being embraced by health care systems, such as Lean Management and Patients Are First. Finally, the Affordable Care Act and the mental health parity law have created opportunities to provide mental health care to a larger number of patients.

Despite the cumulative evidence in favor of collaborative psychosocial oncology care, we need further implementation and dissemination research in diverse clinical settings that pays attention to implementation outcomes such as fidelity, penetration, sustainability, uptake, and costs as well as service outcomes such as efficiency, equity, patient-centeredness, and timeliness. Finally, we need ongoing exploration of sustainable payment structures for collaborative psychosocial oncology care programs. ■