Although mandates by ASCO and the American Cancer Society to meet the needs of underserved populations have drawn much-needed awareness to the issue, patients with cancer who experience bipolar disorder, schizophrenia, and other debilitating mental illnesses continue to experience significantly worse outcomes than other vulnerable populations and face barriers to accessing care. The ASCO Post spoke with Kelly E. Irwin, MD, MPH, a psychiatrist at Mass General Cancer Center, Boston, who specializes in the research and care of patients with cancer who also have mental illness.
Balancing Roles in Psychiatric Oncology
Please tell the readers about your current position.
I am Director of the Collaborative Care and Community Engagement Program and Assistant Professor of Psychiatry at Harvard Medical School. Our program is based at the Massachusetts General Hospital (MGH) Cancer Center, at the Center of Psychiatric Oncology. I’m a clinician and researcher, so my time is spent balancing those two roles, which inform and complement each other. Additionally, we created the Engage Initiative, a stakeholder collaborative dedicated to ensuring that mental illness is never a barrier to cancer care.
Please talk about your role as Director of the Collaborative Care and Community Engagement Program.
The primary mission of the Collaborative Care and Community Engagement Program is to promote equity of care for patients affected by mental illness and to support their families and caregivers. Through clinical innovation, research, education, and advocacy, the program aims to prevent premature cancer mortality and improve the quality of life for those patients with cancer who have serious mental illness.
To that end, we need to be creative, persistent, and respectful as we try to understand what matters to patients. With the overall goal of promoting equity in cancer care, we can build teams to make it possible for individuals who are affected by mental illness to receive the best possible cancer care.
The Bridge Trial
Please describe the purpose, structure, and status of the Bridge trial.
I’m the principal investigator of the Bridge trial (ClinicalTrials.gov identifier NCT03360695), which is a National Cancer Institute–funded randomized trial of a person-centered collaborative care model that we previously piloted. This is the first randomized trial that includes adults with serious mental illness and a recent cancer diagnosis.
The goal of the Bridge trial is to examine the impact of person-centered collaborative care on cancer care and patient and caregiver outcomes for adults with serious mental illness and a recent cancer diagnosis. The model utilizes a registry embedded in the medical record to proactively identify patients. The inclusion criteria were serious mental illness (schizophrenia spectrum disorder, bipolar disorder, or major depressive disorder with prior psychiatric hospitalization) confirmed by a study clinician at consent; invasive breast, lung, gastrointestinal, or head and neck cancer or stage IV cancer that can be treated with curative intent according to the judgment of the oncologist; and a medical, surgical, or radiation oncology consultation at MGH Cancer Center or referral for a new consultation within the past 8 weeks.
“We are really excited by a new model of care delivery we’re adapting to help community oncologists deliver care to their patients with mental illness.”— Kelly E. Irwin, MD, MPH
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In short, the Bridge intervention includes proactive psychiatry consultation and a person-centered, team-based approach designed to improve communication among the patient, oncology team, and mental health clinicians; increase engagement of patients and caregivers; and increase access to evidence-based cancer and mental health care. The psychiatry and oncology teams collaborate starting at cancer diagnosis to support patients through cancer treatment. The Bridge team monitors psychiatric and cancer-related symptoms and cancer care delivery to measure progress and rapidly adjust treatment as needed.
The trial examines the impact of the Bridge model on cancer care, psychiatric symptoms/illness severity, and examines barriers to dissemination and implementation. We hope to identify strategies to improve cancer care and outcomes, despite the significant challenges posed by mental illness. We also hope to understand how to best support oncologists caring for this complex population who may lack access to psycho-oncology care. We met accrual goals for the trial and were able to conduct trial procedures in-person and virtually during the pandemic. The initial feedback is promising, and we are now awaiting the data to be analyzed and reported.
Mental Illness and Cancer
Please give the readers a sense of the scope of serious mental illness in patients with cancer and how it affects access to care.
Serious mental illness, defined as schizophrenia, bipolar disorder, or severe major depression affects more than 15 million people in the United States, and 40% lack access to treatment. Individuals with serious mental illness die 15 to 30 years earlier than the general population, and cancer is the second leading cause of death. Furthermore, adults with serious mental illness, particularly bipolar disorder and schizophrenia, have two to four times higher mortality from breast, lung, colorectal, and oral cancers than adults without mental illness, in part due to inequities in cancer care. Individuals with serious mental illness are less likely to receive guideline--concordant cancer care and are frequently excluded from clinical trials.
“As a social justice advocate, I think we need to be honest as a society that access to cancer care is a human right.”— Kelly E. Irwin, MD, MPH
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First, patients experience multiple challenges accessing care including the lack of financial resources and social support. The second issue focuses on clinician-related factors, including limited training across disciplines, barriers to communication and diagnostic overshadowing, or the tendency to attribute medical symptoms to a patient’s mental health condition. At a structural level, mental health and cancer care are frequently delivered in separate health systems without a shared medical record. Despite mandates for psychosocial distress screening, funding for psycho-oncology care remains inadequate, with no shared access to medical records and limited access and funding for mental health care.
Mental health stigma also affects patients, clinicians, and the health-care system. Clinicians may be more likely to attribute medical symptoms to the psychiatric illness and less likely to refer patients to specialized treatment or clinical trials. In addition, disparities in care may be more prominent when patients have poor hygiene or when there is clinical uncertainty about the best management strategy. Many oncologists lack access to psycho-oncology expertise and the team-based approach needed to address complex needs.
As a follow-up, do you have a feel for how busy community oncologists are meeting these challenges?
I think that most oncologists in community settings are underresourced to care for patients who also have mental illness. Mental health needs continue to increase, and it has become even more challenging to refer patients to timely, expert mental health care. We are very excited by a new model of care delivery we are adapting to help community oncologists deliver care to their patients with mental illness. The structure is like that of a virtual tumor board that uses monthly video-conferencing to connect clinicians. However, these tumor boards rarely (if ever) include people from psycho-oncology or social work, as they generally focus on the biologic aspect of the disease. What if instead we developed a tumor board for cancer and mental illness that uses a person-centered approach and brings together expertise in oncology, mental health, social work, and navigation to guide an integrated assessment and plan?
Furthermore, virtual video conferencing offers an incredible opportunity both to expand and enhance cancer care, for all patients with cancer, but especially for those with serious mental illness. This model has the potential to build capacity for psycho-oncology care beyond academic cancer centers. We were able to launch a virtual tumor board for cancer and mental illness during the height of the COVID-19 pandemic and hope that this model can continue to expand, increasing access to care for underserved patients with mental illness, increasing access to psycho-oncology expertise, and supporting oncologists on the front line.
Oncology Organizations Step Up
How have ASCO and other leading cancer organizations addressed the issue of mental illness and cancer?
I’m very encouraged by the way ASCO has stepped up to increase the diversity in clinical trial participation, helping to enroll groups that have had historic access issues. In fact, several leaders from ASCO came to our institution to discuss issues of inclusion for patients with certain mental illnesses, who are being excluded for trial participation without clear justification. I’m confident that ASCO will continue to advocate for inclusion in clinical trials. Additionally, ASCO guidelines call for distress screening and management for all patients affected by cancer and recommend collaborative care as an evidence based approach to increase access to psycho-oncology care.
Please share a closing thought or two on this issue.
More broadly, as a social justice advocate, I think we need to be honest as a society that access to cancer care is a human right.However, access to care remains inadequate for many patients with cancer and mental illness. Recognizing patients with serious mental illness as a disparities population is a critical step to inform future research and care delivery.
Oncologists are doing the best they can with the tools and resources they have. To help address these issues, we need to establish team-based models that can be integrated into cancer care and strengthen bridges between the cancer center and community.
DISCLOSURE: Dr. Irwin reported no conflicts of interest.