Cancer takes a significant psychological toll on affected individuals. Cancer survivors have a significantly elevated risk of developing a mental health disorder compared with the general population, yet their psychological symptoms are often underrecognized and undertreated. To help equip health-care providers to provide effective mental health care for adults diagnosed with cancer, ASCO has published an evidence-based guideline update that addresses the management of anxiety and/or depression in adult cancer survivors.1
The guideline was developed by a multidisciplinary panel and designed for use by a variety of professionals, including oncologists, psychologists, psychiatrists, psychosocial and rehabilitation professionals, integrative medicine practitioners, primary care providers, social workers, nurses, and others. Some aspects of the prior 2014 version are still relevant, particularly the recommendations on screening and assessment, but other recommendations have changed based on evidence, including the role of pharmacotherapy and the general management strategy.2
Screening for Depression and Anxiety
Screening for depression and anxiety is the first step in addressing issues. Depression and anxiety screenings are conducted using the Patient Health Questionnaire 9 (PHQ-9) and the Generalized Anxiety Disorder (GAD)-7 scale, respectively.1
Guideline Co-Chair Barbara L. Andersen, PhD, of The Ohio State University, noted that a cancer diagnosis and the start of cancer treatment are recognized as the most stressful times for patients, making screening at those times “of immense importance.”
Barbara L. Andersen, PhD
Other appropriate times for screening include changes in disease or treatment status, transition to palliative and end-of-life care, and when clinically indicated. Dr. Andersen added that “it is a myth that screening takes a long time. . .. Rather, it is the effort thereafter that is time- and resource-intense and incurs the greatest ‘cost’ for the patient when not provided.”
Of note, if screening and further assessment finds that patients are at risk of harm to themselves and/or others, clinicians should refer them for emergency evaluation by a licensed mental health professional and initiate interventions to reduce the risk of harm.1
The guideline recommends offering information and resources regarding depression and anxiety to all oncology patients and any patient-identified caregiver, family member, or trusted confidant. For patients with anxiety and/or depression, a stepped-care model is recommended in which the most effective and least resource-intensive intervention is selected based on symptom-level severity.1
Recommended modalities offered in the updated guidelines vary based on the severity of symptoms and include cognitive behavior therapy and behavioral activation, which Dr. Andersen called “the two most efficacious treatments for anyone with depression or anxiety.” Other recommendations include mindfulness-based stress reduction, structured physical activity, acceptance and commitment therapy, and psychosocial interventions.
Evidence supporting the use of pharmacologic management of anxiety and depression in cancer survivors was not consistent. Therefore, unlike the prior version of the guideline, the updated guideline does not recommend pharmacotherapy as a first-line treatment of anxiety or depression in adult cancer survivors.1
However, pharmacotherapy may be considered in select circumstances, including in patients without access to mental health resources, those expressing a preference for pharmacotherapy, and those who do not improve after first-line psychological or behavioral management. Pharmacotherapy should be considered for patients with depression who have responded well to pharmacotherapy in the past and for those with severe symptoms or psychotic features.1
Today, “we are in the midst of a mental health-care crisis,” Dr. Andersen said, adding that organizational and workforce obstacles, including a shortage of mental health professionals and limited referral networks, contribute to the problem. The guideline also noted that the current evidence did not sufficiently include survivors from minoritized groups and that this should be a consideration for providing appropriate care to minority individuals.
Overall, work remains to better address the mental health needs of cancer survivors. Dr. Andersen said that the concept of “prehabilitation” is beginning to gain traction, in which physical, dietary, and mental health status are enhanced prior to the start of treatment.
2. ASCO Guidelines: Screening, assessment, and care of anxiety and depressive symptoms in adults with cancer. Available at https://old-prod.asco.org/sites/new-www.asco.org/files/content-files/practice-and-guidelines/documents/depression-anxiety-summary-of-recs-table.pdf. Accessed May 24, 2023.
Originally published in ASCO Daily News. © American Society of Clinical Oncology. ASCO Daily News, April 20, 2023. All rights reserved.