Disclosures: Dale, Fernandez-Robles, Han, Raphael and Schapira report no relevant financial disclosures.
April 23, 2021
14 min read

Growing focus on patients’ mental health appears to lower suicidality, improve cancer outcomes

Disclosures: Dale, Fernandez-Robles, Han, Raphael and Schapira report no relevant financial disclosures.
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During the past 2 decades, addressing the psychosocial needs of patients with cancer has become recognized as a crucial component of treatment, but experts said work remains to fully integrate mental health into routine cancer care.

In 2001, the Institute of Medicine released a paper on palliative care, that described the types of research needed to reduce distress among patients with cancer. National Comprehensive Cancer Network and ASCO followed suit with practice guidelines that recommend the incorporation of psychosocial care into cancer care.

Heightened feelings of despair among patients with cancer is an acute problem that has been exacerbated by the COVID-19 pandemic, according to Lidia Schapira, MD, FASCO.
Heightened feelings of despair among patients with cancer is an acute problem that has been exacerbated by the COVID-19 pandemic, according to Lidia Schapira, MD, FASCO. “Isolation can increase feelings of despair even among those who appeared to cope well before the pandemic,” she said.
Source: Steven Gregory Photography.

Twenty years later, these initiatives appear to have had a positive impact on the mental health and quality of life of patients with cancer.

Historically, patients with cancer have been at a higher risk for suicide due to a constellation of factors including psychological distress, treatment-related adverse events and cancer pain. However, a study published this year in Journal of the National Cancer Institute showed an overall decrease in cancer-associated suicide from 1999 to 2018, with substantially decreased rates observed among specific high-risk groups, including older patients, those with certain cancer types and men.

The widespread integration of palliative care and the evolution of psycho-oncology services may have helped to mitigate the suffering that contributes to the high rate of suicide among patients with cancer, according to Lidia Schapira, MD, FASCO, oncologist at Stanford Comprehensive Cancer Institute.

“This study serves as a good call to action for the psycho-oncology community to find ways to formally assess suicidality among its patients,” Schapira told HemOnc Today.

Still, challenges remain in readily integrating mental health services into cancer care, as many oncology professionals do not have formal training in assessing suicidality and may lack the tools necessary to identify high-risk individuals, Schapira added.

“Although there has been widespread implementation of distress screening and guidelines for making appropriate referrals for patients with cancer who appear in distress, the oncology community has not reached the necessary level of awareness about the risk for suicidality,” she said. “Moreover, there is not a universal, evidence-based mechanism for assessing suicide risk among patients with cancer, and that is a problem.”

HemOnc Today spoke with psycho-oncologists, epidemiologists and oncologists about factors that put patients with cancer at risk for psychological problems including distress and anxiety, major depression and suicide; the extent to which the oncology community is prepared to address patients’ mental health and how doing so can improve cancer outcomes; and how isolation due to the COVID-19 pandemic may exacerbate suffering in the cancer population.

Assessing suicidality

As suicide rates in the United States have increased overall during the past 2 decades, the trend of cancer-related suicide has followed the opposite trajectory.

Xuesong Han, PhD, scientific director of health services research at American Cancer Society, and colleagues used the 1999 to 2018 Multiple Cause of Death database to calculate an average annual percent change (AAPC) of age-adjusted cancer-related suicide of –2.8% (95% CI, –3.5 to –2.1) compared with 1.7% (95% CI, 1.5-1.8) for overall suicide among the general population.

Han and colleagues observed larger declines in the AAPC of age-adjusted suicide related to lung cancer (–4.7%; 95% CI, –6 to –3.3), prostate cancer (–5.1%; 95% CI, –7.5 to –2.7), and head and neck cancer (–3.7%; 95% CI, –9 to 1.9), as well as among men (–3%; 95% CI, –3.6 to –2.4) and older patients (aged 65-74 years, –3%; 95% CI, –3.9 to –2.1; aged 75-84 years, –3%; 95% CI, –3.9 to –2).

Those declines in suicide associated with specific cancers reflect the cancer types that historically have been associated with the highest risk for suicide. A high symptom burden, such as that associated with head and neck cancer, is one factor driving this association.

“We found that prostate, lung, and head and neck cancers were common cancer types contributing to suicide,” Han told HemOnc Today. “There can be a variety of reasons for this. They share common risk factors, and this also may be related to age, as these cancers cause more problems in an older population.”

Other cancer types that often appear to increase risk for suicide include gastric and pancreatic cancers, among others.

“In my experience working with cancer surveillance data, it is my observation that mental health issues tend to be prevalent in female cancers like breast, cervical, ovarian and uterine cancers, perhaps related to gender difference in reporting mental health problems or distress from sexual function,” Han said. “Patients with melanoma also tend to report more mental health issues, which may be related to race, as melanoma occurs predominantly among white patients.”

Other risk factors for suicide include depression, hopelessness, lack of motivation, pain, lack of social support, not wanting to be a burden to others and existential angst, according to Schapira.

Carlos Fernandez-Robles, MD, assistant professor of psychiatry at Massachusetts General Hospital, agreed that lack of social support and low income are important risk factors.

Carlos Fernandez-Robles, MD
Carlos Fernandez-Robles

“These factors play an equally, if not more, important role in the mental health of patients diagnosed with cancer [than tumor type],” Fernandez-Robles told HemOnc Today.

“Let us move away from seeking differences between cancer types, acknowledging that cancer is an individual experience, and focus on identifying personal vulnerabilities so that early detection and interventions can reduce the impact of cancer-associated distress and mental illness,” he said. “Patients do appear to be ‘breaking away’ from any stigma of mental health issues and are now making mental health a priority and even making decisions based on the availability of these services. It is our hope that this trend continues to grow exponentially.”

When considering the mental health of patients with cancer, it is important to distinguish cancer-related distress from suicidality, according to Schapira.

“The treatment of severe mental health disorders and emergencies among patients with cancer require urgent referrals to psychiatrists, whereas distress screening has had widespread implementation and is readily available to oncologists,” she said.

This distinction also raises the question of whether oncologists — who typically are not trained in mental health — have the tools and skills to assess suicidality among patients, she added.

“We have worked very hard over the past 20 years to de-stigmatize cancer-related distress, which is in the spectrum of mental health effects and disorders caused by cancer,” Schapira said. “Anxiety and depression are real syndromes for which there are specific interventions that are evidence-based and effective. Suicide is on the far end of this spectrum and sometimes catches us by surprise because those of us who provide cancer care may have missed the warning signs and simply did not ask.

“The majority of patients with cancer and survivors with some mental health symptoms probably fall in the distress-anxiety range and can be supported with easily available interventions and therapies, but those with a preexisting mental health diagnosis or those for whom life becomes unbearable need far more than a well-meaning oncologist can provide,” she added.

Oncology professionals also have their own individual attitudes, moral views, personal experiences of or prevalent myths about suicide, which may impact their practice and ability to recognize a patient who is contemplating suicide, according to Schapira.

“We bring a lot of our own feelings and attitudes, and we sometimes rely on our impressions of whether somebody is at risk or not instead of doing formal assessments,” she said. “That is risky because we may miss people who really are at risk for suicide, have a plan or have suicidal ideation.”

Cancer-related distress

Data have suggested that as many as half of patients with cancer are significantly distressed.

A study published in Psycho-Oncology showed 52% patients with cancer had high levels of psychological distress. Prevalent problems in the population included fatigue (56%), sleep problems (51%) and difficulty getting around (47%).

The prevalence of cancer-related distress also can be measured by mental health care use.

In a study published this year in Journal of Clinical Oncology, Michael J. Raphael, MD, FRCPC, oncologist at Sunnybrook Health Sciences Center at University of Toronto in Canada, and colleagues found that compared with age-, sex- and geographically matched controls, survivors of testicular cancer had a higher rate of mental health care use before (adjusted RR = 2.45; 95% CI, 2.06-2.92) and after treatment (adjusted RR = 1.3; 95% CI, 1.12-1.52). The difference in mental health service use persisted for more than 12 years.

Much research has been done to describe the physical consequences associated with the diagnosis and treatment of testicular cancer, but the mental health consequences are less well-understood, Raphael told HemOnc Today.

“Survivorship care plans that screen for and address the mental health care needs of this patient population are needed,” he said. “It will be important to study how best to screen for mental health distress among testicular cancer survivors and what interventions are most effective to address their mental health needs. It will also be critically important to engage patients and families in these research efforts.”

Having other chronic medical issues appears to put patients at risk for mental health issues. In a study published this year in Psycho-Oncology, each additional physical comorbidity — including chronic back pain, asthma, bronchitis, urinary incontinence, and prostate or kidney problems — increased the odds of having psychological distress by 9% (OR = 1.09; 95% CI, 1.01-1.16).

Stage at diagnosis and overall prognosis are other predictors of distress.

William Dale, MD, PhD
William Dale

No matter the cancer type, patients, especially those who are younger, “struggle with the sudden imposition of a more limited prognosis,” William Dale, MD, PhD, director of the Center for Cancer and Aging and clinical professor in the department of supportive care medicine at City of Hope, said during an interview with HemOnc Today.

“Even more than whether a patient has prostate or lung cancer, a later stage at diagnosis, as well as lower survival outcomes due to poorer overall health, are predictors of mental health concerns,” Dale said.

“Having said that, by far the strongest predictor is having had prior episodes of depression and anxiety,” he added. “The likelihood that an individual will experience depression and/or anxiety again — with a significant stressor like a cancer diagnosis — increases dramatically.”

For instance, in a study published in Journal of Psychosocial Oncology Research and Practice that showed substantially higher levels of clinically relevant depressive symptoms among 238 Dutch women newly diagnosed with high hereditary-risk breast cancer compared with 165 Norwegian women with unknown risk (P < .001), women who reported having children and psychological problems within the year before diagnosis were more likely to experience depression and anxiety after diagnosis.

A perception exists that women have a greater propensity for depression and anxiety than men, but the way patients are asked about mental health concerns may lead to underreporting among men, according to Dale.

“Men may be reluctant to report mental health concerns when asked directly; older adult men are especially resistant due to generational views,” he said. “And, importantly, men who are depressed are at far higher risk to complete a suicide attempt than similarly depressed women. Their likelihood of a catastrophic outcome from mental illness is higher, even if the prevalence is thought to be lower.” In short, it is always important to ask, either directly or indirectly, about mental health concerns in a patient with cancer.


Experts with whom HemOnc Today spoke said there have been greater efforts to address the psychosocial needs of the cancer population within the last 2 decades.

The Institute of Medicine, now known as the National Academy of Medicine, issued guidance in 2001 on improving palliative care for patients with cancer, which included a section on reducing distress, and again in 2008 specifically on psychosocial health needs of patients with cancer. NCCN and ASCO subsequently also issued guidance on addressing the psychosocial needs of patients with cancer.

These changes in policy — and their potential impact on the mental health and quality of life of patients with cancer and survivors — prompted Han and colleagues to evaluate suicide incidence. The downward trend they observed suggests an evolving role of psychosocial, palliative and hospice care for patients with cancer, Han said.

“Whether this reduction can be attributed to more attention given to mental health issues is not fully known,” Han said. “The mortality data that we used from death certificates did not allow us to assess a causal association, but our findings certainly support this hypothesis because during the same time period, changes were made to mental health recommendations for patients with cancer.”

The 2014 guidelines from ASCO recommended that all patients be screened for depressive symptoms using validated and published tools at their first visit and subsequently at appropriate intervals and after changes in disease or treatment status.

NCCN guidelines — the most recent of which were released in January — call for a similar screening approach, defining distress as “a multifactorial unpleasant experience of a psychological (ie, cognitive, behavioral, emotional), social, spiritual and/or physical nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment. It extends along a continuum, ranging from common, normal feelings of vulnerability, sadness and fears to problems that can be disabling, such as depression, anxiety, panic, social isolation, and existential and spiritual crisis.”

These recommendations reflect a growing general acknowledgement of the importance of screening patients with cancer for distress, Dale said, adding that early identification of patients with psychosocial concerns — which are present among 20% to 50% of patients — can improve outcomes.

“We improve outcomes by addressing their depression, anxiety and stress upfront along with their cancer treatment, but we can also improve cancer outcomes by improving their adherence to treatment,” he said. “People who are suffering from depression are far more likely to not be able to complete or adhere to treatments, and those with anxiety concerns also may miss treatments from avoidant behavior. As physicians, finding these patients early can be really important.”

A study of more than 55,000 U.S. veterans with non-small cell lung cancer demonstrated that addressing mental health issues improved cancer outcomes.

Berchuck and colleagues found that among the veterans who had a preexisting mental health disorder, participation in a mental health treatment program was associated with a lower likelihood of receiving a late-stage diagnosis (OR = 0.62; 95% CI, 0.58-0.66) and a higher likelihood of receiving stage-appropriate treatment (OR = 1.55; 95% CI, 1.26-1.89). Moreover, such programs were associated with reduced risks for all-cause mortality (adjusted HR = 0.74; 95% CI, 0.72-0.77) and lung cancer-specific mortality (adjusted HR = 0.77; 95% CI, 0.74-0.8), with similar improvements in outcomes observed for participation in housing and employment support programs.

Data have shown that complementary and alternative treatment approaches also may have an impact.

In a study presented last year at San Antonio Breast Cancer Symposium, Ganz and colleagues showed a mindfulness meditation intervention program conferred sustained reductions in depression-related symptoms, such as fatigue and sleep disturbance, among a cohort of early-stage breast cancer survivors.

“The implications of mental health issues for patients with cancer are underrecognized,” Dale said. “If we studied this more and addressed the issues upfront, mental health care would not only be better, but also less expensive.

“Perceived barriers are not actual barriers if we think in a more comprehensive way,” he added. “An investment in identifying these issues should be a high priority compared with some of the other things that we have spent a lot of time and money on with regard to cancer care.”

Ensuring uptake

However, such perceived barriers may be preventing widespread use of mental health services in the oncology community.

Surveys that ask oncology practices about whether they are screening patients for distress on a regular basis show screening rates as low as 10% to 20%, according to Dale.

“So, while there’s an understanding that screening is important, the actual uptake is low and there are not typically systems in place to do the screening,” he said, adding that the lack of resources is usually a main barrier to uptake.

“There may not be an established workflow or enough personnel in a particular practice — and that’s already busy with a new cancer diagnosis, laboratory studies and imaging — to also include a mental health screening,” he added. “If such practices identify a patient who is having significant mental health concerns, they may not have a systematic way to connect people with mental health professionals. Screening then identifies issues that he practice can’t help with. So, screening falls off because the follow-up plan is unclear.”

Once patients at risk have been identified and referred for mental health care, sometimes their insurance doesn’t cover such services.

“In California, for instance, the type of insurance you have may dictate who you can see for mental health, and it may be very difficult to find a covered provider if you’re a patient with cancer who needs a qualified provider who understands particular problems related to cancer, unless you’re very well-insured or get very, very lucky,” Schapira said.

Fernandez-Robles described the ability to provide the appropriate level of care in a consistent, scalable and sustainable manner as a “critical gap.”

“Merely increasing the number of clinical staff does not guarantee that we are closing this gap,” he said. “Process innovation requires research and diffusing thoughtful top-down strategies that ensure proper mental health care reaches all patients with cancer. Initiatives to increase early detection measures and expand embedded mental health services across cancer centers, both nationally and internationally, speak to the fact that cancer care is moving away from tumor-centric to patient-centric delivery.”

Another challenge is that mental health care, in general, is insufficient in the U.S., Han said.

“Not everyone who needs mental health care can get it, and even those who receive it still have many unmet needs,” she said. “A substantial gap in knowledge is knowing practically how to identify and reach those in need of mental health care services and what the best strategy for delivery of care is. We also need policy advancements to ensure that there is equitable access to mental health services for all.”

An exacerbated effect

Isolation and distress associated with the COVID-19 pandemic may be exacerbating mental health concerns among the cancer population.

Lou and colleagues conducted a cross-sectional anonymous online survey of 543 adults living in the U.S. from April 3 to 11 of last year and found that those who reported receiving active cancer treatment had significantly more concern about infection from SARS-CoV-2 than with those who had completed treatment or who had no history of cancer (71.9% vs. 47.9% vs. 51.9%; P < .001). The active-treatment group also reported higher levels of family distress related to the pandemic (P = .004) and greater concern that the general public did not adequately understand the seriousness of COVID-19 (P = .04).

Experts with whom HemOnc Today spoke agreed that it is more important now than ever to check on patients’ mental health given the fact that they may not be able to take part in activities to cope with distress as a result of social distancing and lockdown restrictions.

“Isolation can increase feelings of despair even among those who appeared to cope well before the pandemic,” Schapira said. “This is one acute problem that we have seen exacerbated by the COVID-19 pandemic. We need to integrate good evidence-based assessments into our practices, open the space to make it safe for patients to talk to us and share their worries and distress, and then refer patients to those who work in the mental health field to help. This is really important.”

Dale agreed.

“The COVID-19 pandemic has taught us a lot of things and one of them is how mental health concerns are even more important now perhaps than we ever realized,” he said. “Many people who may have been at risk, but for the most part appeared OK, are now at higher risk for mental health concerns. Loneliness is known to be more dangerous than social isolation, and the pandemic has heightened both loneliness and social isolation. Getting some type of social interaction, even via the telephone or computer, is important to help minimize this risk.”

Many patients also have forgone office visits due to pandemic concerns.

“Information is now coming in on how cancer screenings and visits to the doctor via telehealth have helped with this to some extent,” Dale said. “Half of my patient visits are conducted via telehealth, but we still cannot do everything via telehealth. I truly look forward to the day that we can see all of our patients in person again more regularly.”


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For more information:

William Dale, MD, PhD, can be reached at City of Hope, 1500 E. Duarte Road, Duarte, CA 91010; email: wdale@coh.org; Twitter: @WilliamDale_MD.

Carlos Fernandez-Robles, MD, can be reached at Massachusetts General Hospital, Psychiatry, Warren 615, 55 Fruit St., Boston, MA 02114; email: cfernandez-robles@mgh.harvard.edu.

Xuesong Han, PhD, can be reached at American Cancer Society, 250 Williams St. NW, Atlanta, GA 30303; email: xuesong.han@cancer.org.

Michael J. Raphael, MD, FRCPC, can be reached at Sunnybrook Health Sciences Center, 2075 Bayview Ave., Toronto, ON M4N 3M5; email: mraphael@qmed.ca.

Lidia Schapira, MD, FASCO, can be reached at Stanford Comprehensive Cancer Center, 875 Blake Wilbur Drive, Palo Alto, CA 94304; email: schapira@stanford.edu.