Living with Cancer and Mental Illness – Developing a More Integrated Care System
Last week I attended one of the Irish Cancer Society’s Decoding Cancer events. The event was one of a series of public talks held across Ireland every year to discuss the latest hot topics in cancer prevention, diagnosis, treatment and survivorship. These talks are led by experts in the field and are aimed at cancer patients, their families and all members of the general public interested in cancer and cancer research. A range of topics are covered from debunking myths about cancer, to diet and exercise and the latest advances in precision medicine. These talks end with an opportunity to ask the speakers questions and to engage in interesting discussions. These talks are recorded and can be viewed on the Irish Cancer Society’s YouTube Channel.
The topic addressed in last week’s talk was: “Bridging the Gap between Cancer and Mental Health” . We heard from two speakers, Dr Kelly Irwin (Psychiatrist, Massachusetts General Hospital, MGH, Cancer Center and MGH Schizophrenia Program) and Dr Paul D’Alton (Clinical Psychologist, St Vincent’s University Hospital).
The speakers highlighted some harsh statistics…People with serious mental illness, such as schizophrenia or bipolar disorder, have a 15 to 30 year shorter life expectancy than the general population. Despite improvements in early detection and advances in treatments available, they are 2 to 4 times more likely to die from breast, colorectal, head/neck, and lung cancers. Importantly, these figures can be explained by the fact that people with serious mental illness and living with cancer are often diagnosed later and have less access to treatments.
People with severe mental illness are also excluded from approximately half of clinical trials because of ethical concerns. However issues relating to concerns over a person’s capacity to provide informed consent for example could be addressed by modifying consent procedures to include a two-stage evaluation process which consists of a formal cognitive assessment and clinical judgment (for an example see Resnick et al.’s (2007) Evaluation to Sign Consent). Dr Irwin provided an example of a patient with schizophrenia who, through their involvement in research, received access to treatment they would not have received otherwise. The question then becomes not “What harm will come to the patient if they participate in this research?” but “What risks do they incur by NOT participating?”. The message here is not to minimise valid ethical concerns relating to the participation of people with serious mental illness in research, but instead to reflect on our assumptions relating to perceived risk.
Raising public awareness and training health professionals in delivering cancer care to people with severe mental illness are some of the solutions available to reduce stigma and inequities in care for this population. Another potential solution, which has been successfully piloted by Dr Irwin, is that of integrated psychiatry and cancer care.
Developing more integrated care is also a key message in Ireland’s National Cancer Strategy 2017-2026. By putting patient needs at the centre and facilitating effective communication, collaboration and coordination across services, the aims of integrated care are to provide the highest quality of care and the best outcomes for patients with multiple healthcare needs.
At present, there are only two designated cancer centres which provide psycho-oncology services in Ireland. While a system is needed to ensure patients can receive support for any mental health concerns they might have, integrating these services within a designated cancer centre does not mean that all cancer patients require formal psychological support. The level of input will depend on an assessment of the patient’s needs. The stepped model of care, proposed in the National Cancer Society and presented by Dr D’Alton, identifies fives levels of care ranging from support from family and friends to alleviate transient distress, to formal support provision for clinical disorders from psychology and psychiatry.
The work being undertaken to integrate systems of care for cancer and mental health shows a lot of promise in adapting the current system to the patient and responding to their needs. In this talk, I admired both the speakers and the audience’s drive to challenge the status quo and change healthcare provision and research practices. They are not afraid to ask the difficult questions, defy commonly accepted assumptions and implement novel ideas to reduce inequities in care.
 Resnick, B., Gruber-Baldini, A. L., Pretzer-Aboff, I., Galik, E., Buie, V. C., Russ, K., & Zimmerman, S. (2007). Reliability and validity of the evaluation to sign consent measure. The Gerontologist, 47(1), 69-77.