When Julie began chemotherapy for breast cancer, her oncologist adjusted antiemetics weekly and carefully tracked neutrophil counts. Still, no one asked about the panic attacks that kept her awake at night. She told herself this was just part of cancer. It was not until she stopped showing up for treatment that her distress was recognized for what it was: a treatable, predictable part of the cancer experience that had gone unnoticed.
While cancer treatment has advanced rapidly, care for the mental health of our patients has not kept pace. Distress, depression, and anxiety affect approximately one-third of patients with cancer during treatment, yet most community oncology clinics lack consistent processes to identify and manage these concerns. The gap is not simply an omission of compassion, but one that impacts patient outcomes. Untreated distress contributes to delayed treatment initiation, decreased adherence, avoidable emergency utilization, and increased mortality.1 Evidence-based behavioral interventions and integrated delivery models such as the Collaborative Care Model (CoCM) are scalable, financially viable, and proven to improve outcomes. Here we outline the magnitude of unmet need, the drivers of psychological morbidity in cancer care, and actionable strategies to integrate whole-person mental health care into routine oncology practice.
Invisible Mental Distress in Cancer Care
Cancer care has achieved extraordinary advances in precision diagnostics, treatment, and survivorship. Yet, the emotional and psychological burden that accompanies nearly every diagnosis has not benefited from the same systematic rigor.
Meta-analyses indicate that 8% to 24% of patients meet criteria for major depressive disorder, and roughly one-third meet criteria for a mood, anxiety, or adjustment disorder during treatment.2,3Many patients enter treatment with a pre-existing mental health condition, compounding their vulnerability. Despite abundant evidence linking psychosocial distress to poorer outcomes, emotional and supportive care needs remain insufficiently addressed in U.S. oncology practice.4–11 As one oncology colleague remarked, “We have protocols for neutropenia, but not for despair.”
Tyler G. Jones, MD, MBA, FAPA
Elizabeth Cleary, PhD
Ramy Sedhom, MD, FASCO
Barbara L. McAneny, MD, MACP, FASCO
In a nationally representative cohort, only one in three cancer survivors reported a detailed conversation with their oncology clinician about emotional or social concerns, and those without such discussions had higher depressive symptom burden.8 Likewise, in a large ambulatory oncology sample, nearly one in five patients reported at least one unmet supportive care need, most often coping or emotional support, despite ongoing treatment, and these unmet needs were associated with greater emergency department and hospitalization risk.9 As Julie told us, “My oncologist is great and supportive, but it was necessary for me to receive the mental health support as well. I am not sure I would have been able to follow through with the full treatments without this support.”
Clinical and Operational Consequences of Untreated Distress
The consequences of untreated mental health disorders in cancer care are both human and systemic. Clinically, they correlate with delayed time to treatment initiation, lower adherence to therapy, poorer survival, and diminished quality of life.5,7,12,13 A recent review found a weak-to-moderate relationship between distress and overall survival in patients with cancer.4 Another meta-analysis found that depression after a cancer diagnosis is associated with substantially worse survival, with cancer-specific mortality increasing by 30% to more than 70% in several tumor types, including lung and colorectal cancer.6 Operationally, they drive avoidable health care utilization, especially emergency department (ED) visits and hospital admissions, often related to poorly controlled pain or distress.
Evidence-based psycho-oncology interventions, including cognitive behavioral therapy, mindfulness-based programs, meaning-centered psychotherapy, and problem-solving treatment, have consistently demonstrated reductions in distress, fatigue, and sleep disturbances, as well as improvements in quality of life.7 Most community oncology practices, and even many health systems, lack the infrastructure to deliver these services. As one of our authors noted, “We have known for a long time that our patients were suffering from depression and anxiety from their cancer diagnosis. With this [model], we can fill an essential patient need with a choice of therapists with psychiatrist oversight without incurring the expense of hiring a mental health department.” Contributing factors include psychiatrist shortages, limited behavioral-health staffing with cancer-specific knowledge, fragmented screening pathways, and reimbursement models that undervalue care coordination and follow-up time.1 As a result, a gap persists between the strong evidence base and the care most patients receive.
The Biology and Psychology of Distress
Psychological distress in cancer is complex, arising from both biological and experiential sources. Cancer and its treatments alter inflammatory, endocrine, and hematologic pathways that directly affect mood and cognition. Elevated cytokines, anemia, hormonal depletion, and neurotoxic chemotherapy can all induce biologically mediated depressive syndromes.14,15
Medications such as corticosteroids, hormone therapies, and biologic therapies may prompt clinically significant mood changes within days. A patient’s anxiety or irritability may be as biologically driven as their fatigue or neuropathy. At the same time, the lived experience of cancer including repeated scans, invasive procedures, and prognostic uncertainty, exerts its own psychological weight. Together, these forces create a feedback loop in which biological and psychological suffering reinforce one another.
Without structured systems for detection and intervention, distress is often dismissed as ‘expected sadness,’ leading to missed opportunities for early support. This complex presentation is best supported by a multidisciplinary approach that does not over-index on any one clinical professional.
Symptom Clusters and Overlapping Suffering
Pain, fatigue, sleep disturbance, nausea, and cognitive fog are among the most common symptoms reported across cancer types. These symptoms interact synergistically, forming “clusters” that amplify distress and degrade function. Depression intensifies fatigue; anxiety disrupts sleep; pain fuels hopelessness. Each symptom diminishes motivation to engage in self-care, compounding physical decline.
Yet, in most clinics, each symptom is treated separately: opioids for pain, hypnotics for sleep, antidepressants for mood—often prescribed by different clinicians with little coordination. This fragmented model risks polypharmacy and missed root causes.
A unified behavioral health framework can disentangle these overlapping syndromes and restore coherence to care. Evidence from programs such as the Fred Hutchinson Cancer Center Psychiatry & Psychology Service and the University of Washington AIMS Center demonstrates that structured behavioral interventions can reduce distress, improve function, and even influence survival.1,16
Common, low-cost modalities include psychoeducation, behavioral activation, mindfulness-based stress reduction, problem-solving therapy, active coping, solution-focused brief therapy, cognitive behavioral therapy, cognitive behavioral therapy for insomnia, dialectical behavior therapy–informed skills coaching, and health-behavior change with motivational interviewing. In practice, this might entail weekly 30-minute behavioral activation/cognitive behavioral therapy check-ins for 6 to 8 weeks, with adjustments based on scores.
These approaches are modular, teachable, and well-suited to stepped-care delivery. Although these interventions can have a scalable impact even in resource-limited settings, they require intentional, cancer-specific behavioral health expertise to implement.10,17
Evidence-Based Interventions Oncology Can Actually Deliver
Leading professional organizations, including the National Comprehensive Cancer Network (NCCN),18 the Oncology Nursing Society (ONS),10 and the American Society of Clinical Oncology (ASCO),1 recommend distress screening and intervention as core components of quality cancer care. Key evidence-based practices include using standardized screening at diagnosis and during important treatment transitions with validated tools such as the PHQ-9, GAD-7, and Distress Thermometer, applying measurement-based care to track symptoms over time, incorporating brief interventions with established efficacy, and creating clear follow-up workflows that connect patients with social work, palliative care, and other supportive services.18,19
Importantly, reimbursement is no longer a barrier. Collaborative care codes (99492–99494) and related reimbursement mechanisms fund psychiatric case review, follow-up tracking, and care management. By embedding these workflows, oncology practices can align clinical benefit, operational efficiency, and financial sustainability; the triad needed for durable change.
Collaborative Care: A Proven Path for Community Practices
The Collaborative Care Model (CoCM), developed at the University of Washington’s AIMS Center and advanced in oncology by Jesse R. Fann, MD, MPH, and colleagues at the Fred Hutchinson Cancer Center, offers a scalable blueprint for integrated mental health.17 CoCM links oncologists with behavioral health care managers and psychiatric consultants through shared registries, structured follow-up, and evidence-based interventions, such as problem-solving therapy and behavioral activation.
Further support comes from the SMaRT Oncology series. These trials demonstrated significant improvements in depression remission, pain control, anxiety, and quality of life, along with better adherence to cancer treatment and lower overall symptom burden.16,20 The Fann et al model further validated CoCM’s ability to use diverse staffing models and remote psychiatric consultation to broaden reach.1 Additionally, a Cochrane review confirmed that collaborative care consistently improves depressive symptoms across heterogeneous populations, underscoring its generalizability and scalability beyond single institutions.21 Finally, a national review from the Association of Cancer Care Centers (ACCC) documented successful implementations in community oncology practices, including rural clinics, demonstrating real-world feasibility and sustained impact on depression outcomes across varied demographic settings.17
During the COVID pandemic, the need for behavioral health support became acute, and one author’s practice studied multiple options to address the need. We hired an in-house behavioral health clinician (LISW), but one provider could not meet the growing demand, and patients who did not build rapport had few alternative options. The number of patients our in-house clinician could see was not sufficient to sustain the position financially, leaving the practice subsidizing the care despite clear patient need.
These challenges highlighted the value of CoCM principles as a more reliable framework. By using a team-based approach with care managers, psychiatric consultation, and structured follow-up supported through measurement-based care, CoCM allows a broader range of patients to be reached than a single clinician model can offer. Providing services in a timely manner has allowed us to take advantage of the “teachable moment” of the importance of adding mental health to the patient’s care team. Patient satisfaction with telehealth behavioral health services has been consistently high, and reimbursement has been stable, making this a sustainable model for providing integrated psychosocial care within oncology.
The model’s reimbursement under Medicare and most commercial plans makes it both clinically effective and financially sustainable for oncology practices committed to whole-person care. In community cancer centers nationwide, these principles are being implemented successfully.22 CoCM requires no new buildings or large budgets. Just intentional workflow design, leadership buy-in, and a shared belief that emotional care is medical care.1,10
A Standard We Can—And Must—Achieve
Whole-person oncology care is not an aspirational ideal; it is the current standard of evidence-based practice. Integrating mental health into cancer care improves survival, adherence, and the overall patient experience. The same flow sheets that track hemoglobin and creatinine can track PHQ-9 or distress scores. The same commitment to offering therapeutics that extend survival should exist to support the persons living with cancer.
For Julie and countless others, integrating mental health care into community oncology remains an unmet need. The evidence exists, the reimbursement supports it, and the moral imperative is clear. What remains is the will to make mind and medicine inseparable in modern oncology.
DISCLOSURES: Dr. Jones, Dr. Cleary, Dr. Sedhom and Dr. McAneny, reported no conflicts of interest.
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Dr. Jones is the Chief Medical Officer for Colla Health, Senior Medical Director at Optum, and Clinical Associate Professor of Psychiatry at Oregon Health & Science University. Dr. Cleary is a Clinical Psychologist and Clinical Advisor at Colla Health. Dr. Sedhom is Medical Director of Oncology and Palliative Care at Penn Medicine, Princeton Health, and Assistant Professor of Clinical Medicine at the University of Pennsylvania. Dr. McAneny is a Medical Oncologist, Co-Chair of the ONCare Alliance, and CEO of New Mexico Oncology Hematology Consultants, Ltd. Her clinic is contracted with Colla Health.
