Race and Medicine

Race and Medicine

Disclosures: Hong reports being a co-inventor on a pending patent related to machine-learning algorithms for acute-care episodes during radiation treatment unrelated to this study. Please see the study for all other authors’ relevant financial disclosures. Benton and colleagues reported no relevant financial disclosures.
December 23, 2021
4 min read

Mental health diagnosis linked to race, mortality among patients with cancer

Disclosures: Hong reports being a co-inventor on a pending patent related to machine-learning algorithms for acute-care episodes during radiation treatment unrelated to this study. Please see the study for all other authors’ relevant financial disclosures. Benton and colleagues reported no relevant financial disclosures.
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Individuals who experienced a mental health condition with a psychometric prescription after cancer diagnosis had an elevated risk for all-cause mortality in the short term, according to a study published in Cancer.

The results of the large, retrospective, single tertiary-care institution cohort study also showed some populations, including Black, Asian and Hispanic patients with cancer, were less likely to have a mental health-related visit or receive a psychotropic prescription, highlighting missed opportunities that may exist in identifying and improving cancer-related distress.

Adjusted odds ratios.
Data derived from Chen WC, et al. Cancer. 2021;doi:10.1002/cncr.33903.

“We originally set out with a couple of major goals. The first was to investigate how mental health diagnoses impact cancer outcomes, and the second was to see if there are opportunities to improve the timely referral to our psychiatry and supportive care colleagues,” Julian C. Hong, MD, MS, associate professor and medical director of radiation oncology informatics in the department of radiation oncology and Bakar Computational Health Sciences Institute; Lauren Boreta, MD, assistant professor in the department of radiation oncology; and William C. Chen MD, radiation oncology resident, all of University of California, San Francisco, told Healio in a statement. “As we were exploring these data, we found that race was correlated with mental health diagnoses and treatment. Our study demonstrates another area of disparity for our patients living with cancer.”

The analysis included 54,852 adults (median age, 62.1 years; interquartile range [IQR], 51.9-70.2; 54.1% men; 62.6% white; 10.8% Asian; 9.8% Hispanic; 3.8% Black) diagnosed with cancer at UCSF between January 2012 and September 2019.

Researchers used electronic health record data to identify those with an early mental health diagnosis within 12 months of cancer diagnosis, as well as those requiring medication.

All-cause mortality served as the primary outcome.

Results showed 4,476 patients (8.2%) received a new mental health diagnosis at a median 197 days (IQR, 61-553) after cancer diagnosis. About one-third (31%) of them received a psychotropic medication prescription and 3.7% had at least one mental health-related visit. Among them, Asian, Black and Hispanic patients had reduced adjusted odds of mental health diagnoses, psychotropic medication prescriptions and mental health-related visits compared with white patients, particularly for generalized anxiety (Asian: OR = 0.66; 95% CI, 0.55-0.78; Black, OR = 0.6; 95% CI, 0.45-0.79; Hispanic, OR = 0.72; 95% CI, 0.61-0.85) and selective serotonin-reuptake inhibitors (Asian, OR = 0.43; 95% CI, 0.37-0.5; Black, OR = 0.51; 95% CI, 0.4-0.61; Hispanic, OR = 0.79; 95% CI, 0.7-0.89).

In addition, investigators reported associations of new early mental health diagnosis with psychotropic medication and elevated all-cause mortality at 12 to 24 months (HR = 1.43; 95% CI, 1.25-1.64) that waned by 24 to 36 months (HR = 1.18; 95% CI, 0.95-1.45).

Julian C. Hong, MD, MS
Julian C. Hong

“Mental health diagnoses are associated with short-term mortality — this may be due to an association with cancers with a poorer prognosis. Patients of racial/ethnic minority groups were less likely to receive a mental health diagnosis or undergo related treatments, despite being more likely to have cancers with poorer prognoses,” the researchers told Healio. “Given the well-documented disparity in cancer care/outcomes, we unfortunately were not surprised by these findings, and we are actively working toward providing equitable access and care for our patients.”

Study limitations included a lack of cancer stage and treatment data, limited availability of medication prescription indication and confirmation of administration, and the lack of a more granular cause-of-death data. The researchers attempted to mitigate significant variations in general prognosis by adjusting for cancer site, and they noted that sensitivity analyses using a subset of patients with metastatic disease at diagnosis yielded similar findings.

The results suggest underdiagnosis and undermanagement of mental health diagnoses in the Asian, Black and Hispanic populations, according to the researchers, who noted that investigating patient-reported outcomes may help better identify patients who may benefit from psychiatric care.

“There may be some differences in the degree of disparity depending on cancer type, as well as racial/ethnic group, and further research is needed to understand these findings in greater detail and granularity,” the researchers told Healio. “Our goal is to develop methods to facilitate earlier and equitable recognition of patients who will benefit from referral to psycho-oncology and symptom management services.”

In an accompanying editorial, John Z. Benton, BS, of Medical College of Georgia, and colleagues wrote the study provides both a comprehensive evaluation of race as a factor in mental health diagnosis and psychotropic drug prescription, as well as important results with respect to timing of new-onset mental health diagnosis in patients without a preexisting psychiatric history and its association with survival.

“Importantly, racial bias in mental health diagnosis was cancer-site dependent,” Benton and colleagues wrote. “Prior studies have also shown site and stage dependence in mental health diagnosis and outcomes among patients with and without preexisting psychiatric history. Certainly, further study is needed to evaluate the impact of race on mental health screening, diagnosis and treatment outcomes in [patients with cancer]. Subsequent research efforts will likely benefit from using cancer-site-specific populations able to be matched for stage and prior oncologic treatment.”


Benton JZ, et al. Cancer. 2021;doi: 10.1002/cncr.33901.
Chen WC, et al. Cancer. 2021;doi:10.1002/cncr.33903

For more information:

Julian C. Hong, MD, MS, can be reached at Department of Radiation Oncology and Bakar Computational Health Sciences Institute, University of California, San Francisco, 1825 Fourth St., Suite L1101, San Francisco, CA 94158; email: julian.hong@ucsf.edu.