Integrated Care Improves Depression Symptoms in Cancer Patients

In 2008, the Institute of Medicine issued a report recommending that cancer care include provisions for a patient’s psychological and social well-being. While challenges to implementing an integrated “whole-person” system do exist at the patient, provider, and institutional levels, they should not be insurmountable. Indeed, studies have shown that integrating psychiatric care into a standard care regimen can improve the well-being of cancer patients with depressive symptoms.

A pair of related clinical trials in the United Kingdom has now advanced the potential of integrated care in cancer therapy even further. The two studies, SMaRT Oncology-2 and SMaRT Oncology-3, not only provided some of the most striking data on the positive impact of integrated care compared with usual care, but also showed that it can alleviate depression even in people with a poor cancer prognosis.

University of Oxford

“Depression gets frequently overlooked in cancer patients because the main business of cancer care is prolonging life,” said Michael Sharpe, M.D., a professor of psychological medicine at the University of Oxford and principal investigator of the Oncology-2 trial. “We need to balance that quantity of life with a better quality of life for these patients.”

The SMaRT Oncology-2 trial findings, which were published in Lancet, enrolled 500 adults from three cancer centers in Scotland who were diagnosed with both depression and a cancer with a good prognosis (more than a year life expectancy). The group was randomly divided to receive either usual care or an approach known as Depression Care for People with Cancer (DCPC).

DCPC is a multicomponent program that provides both antidepressants and psychological therapy in a systematic fashion, bringing cancer specialists, psychiatrists, and primary care physicians together on the same page. The cogs in this collaborative machine are specially trained oncology nurses who establish relationships with the patients and continually oversee their progress.

“The patients told us that they wanted the focal point to be someone who understands cancer, knows what they are going through, and will help them stick through this intensive depression treatment regimen,” Sharpe said.

After 24 weeks, 62 percent of patients receiving DCPC responded to treatment—classified as at least a 50 percent reduction in depression severity—compared with only 17 percent receiving usual care. DCPC recipients also reported less anxiety, fatigue, and pain.

“That 45 percent difference in response to care is astounding,” Sharpe told Psychiatric News. “And all we did was just package together some of the evidence-based treatments we already have available on the shelf.”

Sharpe was particularly surprised by the low numbers for usual care. “These people all attended specialist cancer clinics,” he said, “and the primary physician and oncologist were both informed of the major depression diagnosis. This definitely shows that simple awareness of the diagnosis of depression among cancer patients is not enough to improve their outcomes.”

Patients With Poor Prognosis Benefit

University of Oxford

But would DCPC work for depressed patients who have less to fight for? SMaRT Oncology-3 enrolled 142 lung cancer patients, a diagnosis that has an average six-month life expectancy, and assigned them to usual care or DCPC, which was adapted to factor in the physical deterioration of these patients and achieve a quicker response. However, DCPC enrollees still reported greater improvements, with 51 percent achieving a treatment response after 12 weeks, compared with 15 percent for usual care. This study was headed by Sharpe’s colleague at Oxford, Jane Walker, M.D., and published in Lancet Oncology.

“What makes these studies unique is that the patients were closely monitored so that the depression treatment could be intensified or otherwise adjusted as needed, which may have influenced the strong results,” said Jesse Fann, M.D., M.P.H., a professor of psychiatry and behavioral sciences at the University of Washington. “It’s also the first time collaborative care has integrated the specialty cancer clinic in addition to the primary care setting.”

It’s an important aspect to the study, since starting in 2015, the American College of Surgeons will require all cancer centers in the United States to evaluate cancer patients for psychosocial issues that could negatively impact care and to provide resources or referrals for psychosocial care.

While there are differences in the U.K. and U.S. health systems, a model like DCPC should work stateside. “Every cancer center is different in structure and staffing, but the core components of DCPC can be effectively adopted at any location,” said Fann. “Each center can then make small adaptations that better fit its specific situation.”

Fann pointed to an integrated care model at the Seattle Cancer Care Alliance (SCCA), where he serves as director of psychiatry and psychology services, as an example. The SCCA model is similar to Sharpe’s, though it uses social workers instead of oncology nurses as the care managers. It also goes beyond depression to help patients with psychosocial and physical aspects of cancer, such as increased anxiety, fatigue, pain, substance abuse, and sleep disorders.

More DCPC Uses Being Studied

Back in the United Kingdom, Sharpe and his team are exploring further uses for DCPC as well. He envisions it could be integrated into palliative care and used more broadly in end-of-life situations. His group will also tackle the critical issue of cost-effectiveness, though a preliminary analysis of SMaRT Oncology-2 found that DCPC added about only $1,000 in costs per patient, which is a small fraction of the average total cancer care costs.

The SMaRT Oncology trials were funded by Cancer Research UK, with additional support from the Chief Scientist Office of the Scottish Government. ■