Serious mental illness and cancer: A call to action for equitable care

Abstract

Cancer advances are not distributed equitably among many segments of the population. Specifically, individuals with serious mental illness (SMI) face compounded disparities in cancer detection, treatment, and survival. SMI, characterized by conditions such as schizophrenia, bipolar disorder, and severe major depression, is associated with significant functional impairment and a two‐to‐three‐decade reduction in life expectancy. Patients with SMI encounter unique challenges when navigating cancer care, including fragmented care pathways, less access to cancer therapeutics, limited psychosocial support, stigma, heightened vulnerability to diagnostic overshadowing where symptoms are attributed to their psychiatric rather than a medical or oncologic condition, and underrepresentation in therapeutic clinical trials. This review explores the intersection of SMI and cancer care starting with the conceptual background and its importance related to cancer outcomes and the delivery of ethical care to highlight unmet needs and a multitude of barriers. The paper proposes practical recommendations to improve cancer care for individuals with SMI who develop cancer including adopting the collaborative care model, enhancing psychosocial and psychiatric integration in oncology settings, and addressing biases inherent in clinician training. Interventions targeting individual, interpersonal, health system, and policy levels are essential to comprehensively mitigating disparities and developing durable cancer delivery strategies. Equitable cancer care for patients with SMI is both a moral imperative and a cornerstone of advancing social justice in oncology. Thus, there is a critical need to prioritize the translation of research advances, to close the gap in cancer outcomes and mortality, and to improve patient outcomes and wellbeing.

INTRODUCTION

Defining the issue

Individuals with serious mental illness (SMI) experience a reduction in life expectancy of 2–3 decades. ¹ Among those who develop cancer, diagnoses often occur at later stages, and they receive much less standard‐of‐care treatment compared with patients who do not have SMI, even after accounting for late‐stage disease. ² , ³ , ⁴ Despite these clear inequities, the coexistence of SMI and cancer has received little attention in cancer disparities research. People with SMI face unique and compounding barriers, such as stigma, fragmented care, and limited access to psychosocial and medical support, that affect how they engage with the health care system throughout life. Yet this population remains largely invisible in the United States and globally. The National Institute of Mental Health defines SMI as follows:

A mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities. The burden of mental illnesses is particularly concentrated among those who experience disability due to SMI. ⁵

SMI affects more than 15 million US adults and comprises a smaller and more severe subset of mental illnesses. It includes conditions such as schizophrenia and other psychotic disorders, bipolar disorder, and severe major depressive disorder. ⁶ SMI is typically defined by three core features—the three Ds: diagnosis (based on criteria from the Diagnostic and Statistical Manual of Mental Disorders, fifth edition), disability (significant functional impairment), and duration (a persistent or long‐term course). ⁷ , ⁸ , ⁹ These characteristics distinguish SMI from less severe or transient mental health conditions and often lead to difficulties in coping and adapting to life stressors. ¹⁰ Most individuals are diagnosed during adolescence or young adulthood, resulting in a long duration of illness and functional challenges over the life span. ¹¹ SMI is chronic and recurrent. The term does not include substance use disorders, neurodevelopmental conditions (e.g., autism spectrum or attention deficit/hyperactive disorder), or neurocognitive disorders (e.g., dementias). ¹¹ , ¹² The core elements of SMI (i.e., the three Ds) remain consistent worldwide even if there are slight variations in the definition across global regions. ¹³

Patients with SMI are significantly more at risk for adverse health behaviors like tobacco use, obesity, and poor executive function. ⁶ Patients who have psychotic disorders experience impaired reality testing, which means their perception of a situation may not be accurate. They can be preoccupied by constantly having to attend to correcting sensorial and cognitive perceptions. ¹⁴ Similarly, patients with bipolar disorder or severe major depression experience a dysregulation of affect and emotion that may override the ability to execute tasks and function in a consistent or predictable manner. These factors can undermine the ability to face the existential adversity of cancer. In terms of barriers to cancer early detection and screening, these factors are manifest in categories of: (1) coherence (i.e., the sense‐making work in which individuals engage when they encounter a new practice or intervention like cancer screening), (2) cognitive participation (i.e., efforts required to enact or engage with a new practice, such as self‐identifying signs and symptoms and presenting to a health care professional), and (3) collective action (i.e., collaborative work and coordination needed to execute screening). ¹⁵ Perhaps not surprisingly, the antidotes or facilitators needed to address these factors are social support, awareness, and education, which may originate from friends, family, and health care professionals. ¹⁵ , ¹⁶

In addition to cancer, the management of medical comorbidities is also challenging for similar reasons, leading to limited engagement with primary care and impaired integration of care. ¹⁷ , ¹⁸ These challenges can undermine prevention, treatment, and survivorship care through reduced adherence, fragmented follow‐up, and difficulty navigating complex health systems. For instance, patients with SMI undergoing radiation therapy often experience unplanned treatment interruptions because of logistical or psychological barriers, which, in turn, compromise continuity of care and treatment completion. ¹⁹ , ²⁰ Self‐management is a challenge, and becoming overwhelmed increases psychological, existential/spiritual, and logistical stressors associated with modern cancer care.

Notably, patients who have cancer with preexisting SMI are particularly vulnerable to mental health relapses during their cancer journey. ²¹ The stress of coping with a cancer diagnosis and treatment can exacerbate underlying psychiatric conditions, leading to worsening symptoms or the recurrence of mental health crises. Individuals with SMI have higher rates of financial insecurity, unemployment, social isolation, exposure to previous violence, and abuse‐related traumas, all of which may be exacerbated by cancer diagnosis and treatment. ²² , ²³ Family members may not be available to provide support to those with SMI. ²⁴ The physical and emotional demands of cancer can overshadow emerging psychiatric symptoms, making it challenging for health care providers to recognize the pattern of recurrent or new psychiatric symptoms, especially in the absence of a long‐standing patient history. ²⁵

Moreover, many patients may be hesitant to seek professional mental health care during their cancer treatment. A significant proportion of individuals with moderate‐to‐severe psychiatric conditions do not pursue mental health services, often because of a preference for self‐reliance or low perceived need. ²⁶ Other barriers include negative experiences with previous health care encounters, dissatisfaction with care, and concerns about being stigmatized as mentally ill. ¹⁵ This reluctance to seek help can lead to untreated mental health conditions, which may manifest in severe emotional distress, self‐harm, or even suicidal behaviors. ²¹

Taken together, these factors illustrate the multidimensional challenges that patients with SMI face across the cancer care continuum, from screening through treatment and survivorship, and highlight the need for proactive, integrated psychosocial and psychiatric support to optimize care engagement and outcomes.

This review highlights: (1) the trajectory of SMI versus other psychiatric symptoms (or disorders); (2) the scope of the problem, including epidemiological findings of health disparity for people with SMI and cancer; (3) the origins or etiology of the problem; (4) its ethical foundation as an edict for change; and (5) current interventional data and future directions.

Trajectories of mental health and cancer: How does SMI fit in?

Neuropsychiatric symptoms and psychological strain are pervasive during the cancer trajectory. The field of psychiatric oncology has primarily focused on individuals without a history of psychiatric disorders who only develop psychological distress or new psychiatric symptoms after the development of cancer. Cancer diagnosis and treatment are associated with higher rates of depression, anxiety, delirium, insomnia, fatigue, mild cognitive impairment, and more than twice the rate of suicide. However, most patients experiencing these symptoms do not have a history of SMI, nor will they go on to develop SMI. For example, roughly 6% of the population carries a SMI diagnosis, but approximately 25% of patients with cancer will report depressive symptoms cross‐sectionally. ²⁷ , ²⁸ , ²⁹ In this review, we focus on patients with preexisting SMI who develop cancer. This is a unique population distinct from patients with cancer who develop transient psychiatric symptoms.

The first trajectory involves patients with no or minimal psychiatric history who experience significant psychiatric symptoms after a cancer diagnosis. This group encompasses roughly 40% of patients with cancer who experience prolonged periods of psychological distress. ³⁰ These patients have usually developed coping skills that ultimately will help them adapt to adversity. They benefit from short‐term psychotherapeutic support and have favorable mental health prognoses.

The second trajectory involves patients with preexisting SMI who develop cancer (approximately 6% of patients with cancer) and is the principle focus of this review. They face the same psychological strain and psychiatric symptomatology as patients in the first trajectory but without the same baseline ability to cope, social support structures, and resources. SMI, like other chronic illnesses, displays a relapsing and remitting pattern. It is managed and generally expected to recur and engender long‐term consequences. As part of the disease process, short‐term and long‐term sequelae should be expected. In addition, lifestyle and risk factors develop from periods of disease instability and even psychiatric treatment (e.g., development of obesity and metabolic syndrome from psychiatric medications). ³¹ These disease processes interfere with educational and employment trajectories early in life, and patients often are susceptible to a lack of support from family or societal resources. ³² Patients are at risk of not developing adequate coping skills from young adulthood, making subsequent health challenges all the more daunting. The sequelae of SMI, in addition to the mental health issue itself, create a situation of heightened adversity on top of what many patients without SMI are already experiencing once they develop a cancer diagnosis. They face challenges in navigating complex health care systems. Managing both SMI and cancer simultaneously requires substantial organizational and self‐management skills, which may be difficult for these patients to maintain.

The third trajectory consists of patients who never sought mental health services before the cancer diagnosis but will go on to need long‐term psychiatric attention after the cancer diagnosis. These patients were able to get by without mental health professional assistance, but their mental health decompensated after the diagnosis, and their psychiatric disposition remained guarded. This trajectory or group is not well defined in the literature but exists in clinical practice.

Patients with both SMI and a new cancer experience unique challenges, including the following:

• (1)Navigation of a fragmented system and need for rapid access to psychiatry and oncology expertise;
• (2)Increased risk for medication interactions (e.g., tamoxifen and antidepressants) and side effects of cancer treatment (e.g., steroid‐associated mania) as well as complexity with the differential diagnosis;
• (3)Higher rates of medical comorbidities; and
• (4)Effects on patient–clinician communication, prognostic understanding, and treatment decision‐making.

Many studies that focus on the effects of symptoms on cancer outcomes do not distinguish between groups or trajectories. ²⁴ , ³³ Although data suggest that outcomes such as depression adversely affect survival and quality of life broadly, patients with preexisting SMI encounter additional, compounding challenges. For example, cancer‐related anxiety, insomnia, or depressive symptoms can overlap with or exacerbate their underlying psychiatric illness, making it more difficult to recognize and manage new symptoms. Moreover, the complexity of coordinating oncologic and psychiatric treatments—including potential drug interactions and fragmented care delivery—further complicates outcomes in the SMI population.

THE EPIDEMIOLOGIC PERSPECTIVE: EXAMINING THE MORTALITY GAP

SMI has a complex and detrimental impact on physical health and well‐being, contributing significantly to the high morbidity and mortality rates observed in patients with comorbid SMI and cancer. ³⁴ , ³⁵ , ³⁶ Many factors intertwined with SMI and its attendant ramifications are correlated with excessive morbidity and mortality.

Epidemiologic studies consistently demonstrate that patients with SMI have substantially higher mortality than the general population. ³⁷ , ³⁸ Overall, SMI is associated with a 20‐year to 30‐year reduction in life expectancy. ³⁹ , ⁴⁰ A meta‐analysis indicated that all‐cause mortality among individuals with SMI was approximately twice that of the general population irrespective of the time span studied. ⁴¹ Notably, most deaths in this population are attributable to physical illness rather than psychiatric causes ⁶ ; approximately 80% of the excess mortality is caused by medical conditions such as cardiovascular, metabolic, and oncologic diseases. ³⁵ Although patients with SMI and comorbid physical illnesses, such as cardiovascular or endocrine disorders, experience poorer outcomes, advances in these fields have led to gradual improvements in survival, especially when the chronic condition requires regular medical visits. ⁴² In contrast, the mortality gap for cancer is widening (i.e., overall survival benefits are not distributed evenly), suggesting that improvements in cancer detection and treatment have not been equally realized among individuals with SMI. ³² Cancer screening and meeting with new clinicians may present a particular burden for patients with SMI, especially when considering the threat of mortality implications. This persistent inequity underscores the critical need to understand the etiology of the mortality gap and to integrate psychiatric and oncologic care.

Some evidence suggests that cancer incidence is actually higher in patients with SMI, especially for those cancers with well developed screening procedures (e.g., breast, cervical, and colon cancers). ⁴³ , ⁴⁴ , ⁴⁵ However, other studies do not, ⁴⁶ which has led some researchers to explore anticancer properties among psychotropic medications given the presence of elevated cancer risk factors in the SMI population. ⁴⁷ Competing comorbidities and earlier mortality (e.g., from cardiovascular disease or other etiologies) even may explain the discrepancy. Although evidence that patients with SMI have higher cancer incidence is inconclusive, data clearly demonstrate delays in diagnosis, later stage disease at diagnosis, higher rates of hospital‐based diagnoses, and worse cancer‐related outcomes for this population. ⁴⁸

Similar to the general population, patients with SMI experience cancer as the second most common cause of death after complications from cardiovascular illnesses. ⁴³ , ⁴⁹ However, cancer‐related deaths may be even more common in younger patients with SMI. ⁴⁹ The case fatality rate for patients with SMI is 30% higher than that in other patients with cancer, even when accounting for later stage diagnosis. ³⁶ Once diagnosed with cancer, complicating comorbidities (e.g., physical and mental factors and tobacco dependence) also limit overall survival. Therefore, cancer‐related morbidity, in addition to cancer progression, drives lower survival rates in this population. ⁴

Screening and early detection

Potential malignancy is often overlooked when patients with SMI are contending with the management of psychiatric symptoms and other chronic or more immediately effective physical illness. ⁵⁰ Patients with SMI and cancer are less likely to undergo regular health screenings and follow‐up care. ⁵¹ Symptoms of SMI, such as delusions, paranoia, or severe depression, can prevent patients from seeking care or complying with screening recommendations. ⁵² In addition, clinicians may overlook the importance of screening in this population, either because of assumptions about the patient's ability to participate in follow‐up or because of a focus on managing the SMI rather than addressing signs and symptoms of potential malignancy. ⁵² Patients with SMI are less likely to get diagnosed through a primary care office and more likely to get diagnosed through unplanned hospital admissions. ⁴⁸ Both primary diagnostic routes (e.g., screening or symptom evaluation) are under‐used and inadequate in patients with SMI. ⁵³

Many patients with SMI receive their psychiatric diagnosis by early adulthood. ⁵⁴ Consequently, they often have longstanding and repeated contact with health care systems well before a cancer diagnosis. Yet, despite these interactions, many do not receive age‐appropriate cancer screening or timely evaluation of physical symptoms suggestive of malignancy. ⁵¹ , ⁵⁵

In addition, there is some evidence of screening variation among patients with SMI that varies by mental health diagnosis, cancer type, and health care context. A Dutch study indicated significantly lower screening rates for bowel, breast, and cervical cancers among patients with SMI, and with the greatest deficits were observed in those who had schizophrenia compared with other psychotic disorders or bipolar disorder. ⁵⁶ Similarly, a Canadian study demonstrated variation in screening uptake because of a primary care payment model in, with patients who had schizophrenia receiving care under a fee‐for‐service model less likely to undergo mammography by age 50 years than those enrolled in the medical home model. ⁵⁷ , ⁵⁸ In contrast, a UK study found that, when patients with SMI had more frequent health care consultations, breast and cervical cancer screening rates approached those of the general population. ⁴⁵ Together, these findings suggest that both the type of SMI and the structure of health care delivery meaningfully influence cancer screening participation. Of note, discrepant cancer care for patients with SMI is a global concern even in countries with a nationalized health care system, such as the United Kingdom, the Netherlands, and Canada. Screening variation among patients with SMI may also be explained by a nuanced understanding of the barriers to and facilitators of cancer screening. For example, the paradoxical risk profile of breast cancer screening among women with SMI, who are less likely to undergo screening despite having a higher incidence of breast cancer and are 33% less likely to receive recommended screening, may be explained by the presence of more severe psychiatric symptoms, such as delusions or comorbid substance use disorders, which put them at greater risk of missed or delayed screening opportunities. ⁵¹ Recognizing these intersecting vulnerabilities underscores the importance of tailored interventions that address both mental health severity and structural barriers to preventive cancer care.

Patients with SMI receive less cancer treatment

Treatment inequities contribute substantially to poorer cancer outcomes among patients with SMI. They are less likely to be offered surgery, radiation, or systemic therapy, even when clinically indicated, and are more likely to experience treatment delays or early discontinuation. ⁵⁹ Patients with SMI are more likely to be diagnosed at an advanced disease stage compared with those without SMI, but they are also less likely to receive guideline‐concordant therapy or to complete treatment once initiated. ² , ³ , ⁴ , ⁴⁸ Their underrepresentation in therapeutic clinical trials and limited participation in patient advocacy further compound these disparities, resulting in a persistent gap in both knowledge and outcomes for this population. ⁶⁰ , ⁶¹ , ⁶²

Why do patients with SMI receive less cancer treatment?

There is not a one‐size‐fits‐all answer to this question. Multiple intersecting factors underlie treatment inequities, including health care provider stigma and diagnostic overshadowing, fragmented coordination between oncology and psychiatric care, and patient‐level barriers, such as cognitive impairment, treatment‐related fatigue, or difficulties navigating complex health systems. ⁶³ In addition, patients’ exclusion from certain clinical trials or advanced treatment options may be caused by unwarranted concerns about their mental health, further limiting their access to potentially life‐saving interventions, palliative care, and appropriate end‐of‐life medical care. ⁶³ , ⁶⁴ Together, these factors reflect a systemic failure to integrate mental health and cancer care, leading to preventable disparities in survival and quality of life.

These fundamental factors contribute to reduced survival. The amount by which each factor precludes survival may depend on individual patient factors as well. Furthermore, patients with SMI who are never diagnosed with cancer and do not receive treatments are generally not considered in the development of cancer guidelines and practice patterns. They are effectively invisible. Therefore, their unique set of needs is rarely considered in the complex web of cancer care delivery.

A CLOSER LOOK AT THE MORTALITY GAP: WHEN PATIENTS WITH SMI DEVELOP CANCER

The last few decades have delivered increasing attention within oncology to the emotional well‐being of patients with cancer. These efforts have culminated in better and more immediate care for patients who develop psychiatric/psychological symptoms after a cancer diagnosis but have no history of mental illness. ⁶⁵ Unfortunately, these efforts may not benefit patients with a history of SMI to the same extent, suggesting that a concomitant decrement in cancer‐related mental health care may further worsen their cancer care. Gunther et al. demonstrated that 72 patients with cancer who had a history of SMI, evaluated from a sample of 10,945 patients who had any cancer diagnosis and 1056 who had another non‐SMI mental disorder, were less likely to undergo distress screening or be informed about psycho‐oncologic support services. ⁶⁶ These findings suggest that patients with SMI benefit less from National Comprehensive Cancer Center–mandated distress screening than patients without SMI. ⁶⁶ That is, even resources designed to address general psychiatric symptoms in patients with cancer may not benefit patients who have cancer and a previous SMI diagnosis to the same extent. Although that study has not been replicated, it highlights a significant discrepancy that underscores the problem of coordinated cancer care for this population. Factors on multiple levels appear to contribute to the problem. Of note, a singularly powerful factor or multiple additive factors may result in predictably adverse outcomes. These factors are interrelated and dynamic within care systems (e.g., clinicians are trained within health systems to meet their community health needs).

Health care system–level factors

Patients with SMI often fall through the cracks of fragmented health care systems. Cancer centers are rarely equipped to manage SMI‐related psychiatric conditions, whereas mental health facilities seldom provide comprehensive medical evaluation or cancer screening. This structural divide—rooted in a long‐standing separation between mental and physical health services—creates barriers to timely diagnosis, continuity of care, and treatment adherence for individuals who have SMI and cancer. ³⁶ , ⁶⁷ , ⁶⁸ , ⁶⁹

The consequences of this fragmentation are amplified by systemic and financial models that prioritize disease‐specific interventions over integrated, patient‐centered care. Fee‐for‐service payment structures and institutional silos make coordination between psychiatry and oncology a challenge, leaving patients who have SMI to navigate complex systems with limited support. Historical policies, such as deinstitutionalization in the United States, further contributed to gaps in care continuity and reinforced inequities in access to medical and psychiatric services. ⁷⁰ , ⁷¹ , ⁷² , ⁷³

Ultimately, the lack of integrated models for the co‐management of SMI and cancer perpetuates disparities in diagnosis, treatment, and survival. Addressing these system‐level barriers requires not only clinical collaboration but also structural and policy‐level reforms that enable comprehensive, equitable care for this vulnerable population.

Clinician‐level or care team–level factors

A key provider‐level factor contributing to disparities in outcomes is the variable training and preparedness among oncology clinicians to care for patients with SMI. Ideally, psychiatric and cancer care should proceed in parallel, with clear communication and defined collaboration between oncology and mental health teams. This partnership can inform management decisions regarding those who require primary psychiatric input versus those within oncology’s scope of practice. However, these interprofessional boundaries are seldom addressed systematically in medical training in oncology, in which exposure to mental health expertise is not considered. Mental health stigma is pervasive and affects systems, clinicians, and patients. Studies delineate how explicit and implicit biases (both self‐reported and observed) in clinicians' behavior negatively affect clinical decisions that are made for patients with SMI. ⁷⁴ This provision of discrepant care, perhaps reflecting attitudinal bias or stigma, may lead to significant cancer‐related mortality for patients with SMI that is independent of cancer stage. ⁴ , ⁶⁷

The very basis of providing equitable care means that enhanced care (e.g., spending more time or greater resources) is an agreed upon necessity when approaching certain demographic populations of patients but when systems are not designed to support this ethical mandate. In addition, doing more for patients with SMI is not possible without understanding their needs. For example, patients with psychotic disorders (e.g., schizophrenia or schizoaffective disorders) get more attention from clinicians for their so‐called positive symptoms (e.g., delusions and hallucinations) than for their negative symptoms (e.g., apathy, decreased executive functioning, or volition), although negative symptoms are clearly associated with worse psychiatric outcomes. ⁷⁵ In addition, clinicians often assume that patients with SMI are unable to decide for themselves autonomously and lack decision‐making capacity. A qualitative systematic review included seven studies and highlighted four themes, two of which dealt with decision‐making capacity: decision‐making capacity depending on the assessor and cancer must give way to severe mental illness or vice versa. ⁷⁶ This assumptive attitude precludes patient participation in their treatment decisions and even their clinical trial options. This is truly unfortunate because rates of decisional incapacity for psychiatrically ill patients are generally no greater than the decisional incapacity demonstrated by medically ill patients. Predictably, clinicians presume that medically ill patients retain decisional capacity, whereas psychiatrically ill patients lack decisional capacity. A systematic review by Lepping et al. identified no significant difference between rates of decisional incapacity between medically versus psychiatrically ill patients, whereas another systematic review by Sessums et al. indicated that clinicians generally overestimate decision‐making capacity retention in medically (not psychiatrically) ill patients. ⁷⁷ , ⁷⁸ This presumption not only perpetuates inequality, it violates principles of patient‐centered care delivery in which decisional capacity (and the ability to speak for oneself) should be assumed until proven otherwise (i.e., Common Law). ⁷⁹ , ⁸⁰

Within oncology, presumptions, unhelpful attitudes, and a superficial understanding of the psychosocial conditions in which patients exist may have lasting consequences that undermine patient‐centric care, especially when clinicians do not use a comprehensive or patient‐based heuristic. A large study of over 2000 patients who had schizophrenia and advanced cancer demonstrated that they were more likely to accept hospice versus continued cancer treatment. ⁸¹ However, a closer look at those findings suggests that hidden biases and presumptions about patients' accepting treatment and their ability to tolerate treatment also could influence decision‐making. An unrelated study by Morán‐Sánchez et al. similarly indicated that 107 patients with schizophrenia or bipolar disorder preferred a passive role in the therapeutic relationship. ⁸² Advanced age, being disabled, and the view that one's health depends on what health care providers say similarly accentuated a passive stance toward the therapeutic relationship. The late medical ethicist Kenneth Kipnis described what vulnerable populations theoretically have in common, which may predispose patients toward passivity given the disease state but may run counter to who they are as individuals. ⁸³ Given the vulnerability factors of deference toward authority and identification with illness (i.e., SMI) described by Kipnis, a predisposed inclination toward passivity almost certainly originates from an underlying proclivity toward passivity in the face of medical authority rather than a true preference. To prove this theoretical point with data, when adequate services are available to meet the needs of patients with SMI, differences in all‐cause mortality between patients with or without SMI disappear, as demonstrated by proactive community treatment orders in Australia and integrated care systems in the United Kingdom. ⁸⁴ , ⁸⁵ , ⁸⁶ Participants with SMI in the study by Morán‐Sánchez et al. may have been misunderstood by their investigators. The passivity they exhibited was likely a product of assimilated deference behavior and other care environment factors. Consensus level data suggest that clinician biases can be lessened with appropriate support toward shared decision‐making and a clear definition of patient‐centric care. ⁸⁷ , ⁸⁸ An encouraging systematic review of 103 studies indicated that short‐term interventions can address clinician implicit biases and cultural competency, furthering a patient‐centered approach. ⁸⁹ Alternative models of care highlight the power behind respect for various types of autonomy, namely, relational or delayed autonomy, and the patient‐centric notion of building decisional capacity. ⁹⁰

Clinicians can play an invaluable and pivotal role in countering stigma, unhelpful attitudes, and hostility while simultaneously working to promote patients’ sense of self‐actualization in getting their medical needs met.

Patient‐level factors

Lifestyle factors associated with a history of SMI (e.g., smoking, obesity) are associated with worse cancer outcomes. A psychiatric disorder may challenge typical communication efforts and undermine executive functioning skills needed to pursue the work‐up and treatment of cancer. Individual patients with SMI may be balancing multiple crises (e.g., housing, comorbid substance dependence, financial insecurity) and lack the usual support systems that are needed in times of emotional or existential duress. Idiosyncratic understanding of physical threat, health literacy, and previous negative experiences with the health care community may have an adverse effect on the ability of patients with SMI to engage with cancer. It is conceivable that many of these patient‐level factors couple upon themselves and lead to worse cancer‐related outcomes. In addition, they may interact negatively with adverse health system–level or clinician‐level factors.

INTERVENTIONS: ADDRESSING SMI‐RELATED CANCER CARE DISPARITIES

Relatively few interventions dedicated to SMI and cancer care inequities have been studied. Interventions may address one factor or multiple factors (i.e., selective vs. comprehensive) and may be directed toward various end points (e.g., enhanced screening and early detection, reducing delays in care, facilitating treatment compliance). Figure 1 illustrates the interrelatedness of intervention domains (e.g., patient, clinician, health systems, and policy levels) and their relevant cross‐sectional versus longitudinal approaches to reducing cancer care disparities.

FIGURE 1.

The inter‐relatedness of intervention domains (e.g., patient, clinician, health systems, policy levels) and their relevant cross‐sectional versus longitudinal approaches to reducing cancer care disparities. SMI indicates serious mental illness.

Screening, early detection, and prevention

These interventions address delayed diagnosis of malignancy in patients with SMI. Encouragingly, they are generally successful, as explained comprehensively by Lamontagne‐Godwin and colleagues’ review, which evaluated 22 studies, indicated that all interventions improved the uptake of health screening, and provided it for patients who would not have received it otherwise. ⁹¹ Interventions were divided into health service delivery changes and tests of tools designed to facilitate screening. Staff and stakeholder involvement in screening, staff flexibility, and involvement of primary care and pharmacists were linked to intervention success. ⁹¹ However, a Cochrane review of interventions to encourage uptake of cancer screening for people with severe mental illness indicated that, without randomized controlled trial data, it is not possible to recommend any specific approach over another. ⁹²

While acknowledging key design limitations (i.e., the lack of randomized controlled trial data), screening and early detection initiatives specifically designed to meet the needs of patients with SMI are mostly intuitive and appear to be effective. Of note, many of the studies described below are small feasibility studies highlighting a proof of concept. For example, a collaborative effort to enhance lung cancer screening and education between primary care, radiology, and mental health clinicians was feasible and potentially scalable. ⁹³ That educational initiative on SMI and lung cancer screening was adapted for radiology staff who interface with this population. Also, patients with SMI were educated on the clinical importance of lung cancer screening. The study met its feasibility criteria by enrolling 15 of 30 eligible participants who had SMI (50%), all of whom completed the educational initiative, and 14 of 15 reported overall satisfaction (93%) with the initiative. Notably, that study crossed system and provider levels to reduce bias and enhance care for patients with SMI.

Another collaborative effort streamlined the work‐flow process of radiologists and radiology technicians and enabled them to provide greater access to same‐day breast biopsies and reduce SMI‐related disparity. Specifically, Wang et al. observed that, before the intervention, 8.4% of patients with SMI (seven of 37) underwent same‐day biopsy compared with 15.6% (303 of 1943 patients) without SMI. The rate of same‐day biopsy was even lower for patients with SMI on public insurance (only one of 37 patients; 2.7%) versus patients without SMI on public insurance (47 of 296 patients; 15.88%; p = .031). After attending to their workflow, the initiative reduced this gap. Same‐day biopsies increased from 310 of 2026 patients (15.3%) before the intervention to 852 of 2361 patients (36.1%) after the intervention without any significant differences between payer populations or patients with or without SMI. ⁹⁴

A secondary analysis of a smoking cessation intervention compared the demographics and results of patients with SMI (n = 31) and without SMI (n = 272). Steffens et al. observed that patients with SMI were equally motivated to quit smoking but were less frequently recommended to stop smoking by their oncologists (48% vs. 61%). Smoking‐cessation medications were offered to 47% patients without SMI and to 32% of patients with SMI. ⁹⁵ Despite this difference, participants with SMI enrolled in the study completed all requirements at the same rate as other participants. They completed a similar amount of smoking‐cessation counseling sessions (6.5 vs. 7.3), had similar self‐reported medication use, and had similar quit rates at 6 months (32% vs. 28%). These findings suggest that patients with SMI are equally engaged in trial participation and smoking cessation.

Comprehensive or parallel cancer and psychiatric service delivery

An intervention that proactively identified patients with SMI who had developed cancer followed patients throughout their cancer trajectory and aligned psychiatric care with oncology care for patients with schizophrenia, bipolar disorder, and severe major depression was feasible and led to improved patient outcomes. ⁹⁶ This intervention developed by Irwin and colleagues was entitled Bridge and enabled patients to initiate and complete cancer treatment while accessing psychiatric care and fostering trust. Specifically, the Bridge intervention incorporates person‐centered collaborative care, proactive psychiatry consultation, linkage to a social work/navigator team, and co‐management with oncology across care settings. The trial randomized patients with SMI and potentially curable head/neck, lung, breast, or gastrointestinal cancers to either the intervention or enhanced usual care, which included proactive identification at cancer diagnosis to inform cancer teams of their SMI diagnosis and psychosocial resources. The primary outcome was clinically significant cancer care disruptions over 24 weeks, such as delays in treatment initiation, deviations in guideline‐concordant care, or disruptions in planned cancer treatment. Oncologists were blinded to the intervention or enhanced usual care groups. Secondary outcomes included psychiatric illness severity, objective global functioning, and symptoms of depression and anxiety. One hundred twenty patients were enrolled, over one half relied on public payer assistance, 38% were on disability, and 49% reported chemical dependence as well. Participants assigned to Bridge had less treatment disruptions (17.2% vs. 35.1%; p = .035) and improved psychiatric illness severity and anxiety compared with enhanced usual care participants. ⁹⁷ Of note, this model builds on an evidence‐based approach to integrating mental and physical health care for common conditions like depression and anxiety called the collaborative care model (CoCM). Patients, primary care providers (or oncology clinicians), behavioral care managers, and psychiatric consultants work together in a specific, stepped base format that is cost‐effective and agile to provide resources when they are necessary and reserve them when they are not. The Centers for Medicare and Medicaid Services reimburse directly to the primary clinical provider when implementing the CoCM or this specific form of collaborative care. ⁹⁸

A qualitative study of 11 Canadian social workers suggested that comprehensive psychosocial interventions thoroughly addressing the diverse, tangible, emotional, and interpersonal needs of patients with SMI extending support throughout the treatment process would enable patients to successfully complete the treatment without exacerbating psychiatric symptoms. ⁹⁹ Moreover, those authors emphasized that psychosocial interventions that encompass family members and emphasize the alleviation of tensions and conflicts between patients and their relatives often succeed in engaging family members in the support of patients and can promote reconciliation and the strengthening of familial relationships. ⁹⁹ These data suggest potential intentional trial design strategies and clinical approaches to enhance cancer outcomes for patients with SMI.

Furthermore, a Danish study entitled CAncer and preexisting SEvere MEntal Disorders, or CASEMED, presented an iterative model of feasibility in which local barriers were assessed, then stakeholders were interviewed and provided feedback while the prototype was refined. ¹⁰⁰ The study involved 162 informal interviews of health care providers, patients, and patient representatives. After the model prototype was refined through four workshops with 16 health care providers and 16 patient representatives, they pilot‐tested their adapted model with 13 patients. The investigators found that their model could be adapted to identify psychiatric comorbidity (SMI) early, engage significant caregivers, educate oncologic health care providers, and secure continuity and enhanced collaboration throughout the patient's experience interfacing with their cancer care. The final model incorporated not only family and other support systems but continual education of nonmental health clinicians and timely multidisciplinary team conferences. They also attributed their success to early identification of psychiatric comorbidity, engagement of significant caregivers, continuity of health care providers, and the use of known communication and collaboration strategies consistent with their local workflow. ¹⁰⁰ This type of iterative experience demonstrates that an institution may be able to create its own way of identifying patients with SMI early on and of maintaining enhanced collaboration around the patient’s needs.

Specific recommendations

Theoretical frameworks and empirical data are invaluable, but this is a real‐time health inequity that clinicians and administers may want to act upon urgently. Table 1 lists specific considerations itemized by individual patient, interpersonal, health system, and policy levels and by cancer screening or diagnostic/treatment settings. Intervention is needed in each of these areas to enhance care and affect meaningful change. ¹⁰¹ Because resources and infrastructure vary widely across and within countries, including between urban and rural areas, these recommendations should be viewed as adaptable frameworks rather than prescriptive standards. Flexibility in implementation is key to ensuring feasibility and sustainability in diverse care settings.

TABLE 1.

Practical suggestions for addressing serious mental illness and cancer detection and treatment. ^a

Organization level	Screening/precancer	Improving cancer treatment
Individual	‐Tailored screening environment ‐Wait‐time considerations ‐Orientation to procedures ‐Integrated tobacco treatment ‐Incorporate EHR for up‐to‐date cancer screenings for patients with SMI	‐Specific accommodations (e.g., hospitalization after initial systemic treatment to assess side effects and tolerability) ‐Address invasiveness component of radiation therapy (e.g., pretreatment visit to therapy suite with explanation of equipment and procedures; minimize receiving instructions from voice outside of radiation suite; consideration for perceptual disturbances) ‐Incorporate EHR to screen for patients with SMI: Proactive psychiatry or mental health consultation
Interpersonal and clinical	‐Shared decision‐making tools ‐Integrate mental health worker, peer specialist, navigator or caregiver to help navigate	‐Avoid diagnostic overshadowing ‐Consider peer specialists or navigators for coordination of care and integration ‐Attend to information sharing strategies (e.g., review EHR, permission to share data across systems) ‐Assess decisional capacity on an individual and situational basis ‐Tailor communication based on quality and quantity of psychiatric symptoms ‐Attend to potential drug–drug interactions and drug toxicity profiles (e.g., acute movement disorder with anti‐emetic prochlorpromazine + antipsychotics) ‐Involve staff from community‐based programs as social support early in diagnostic and treatment process
System	‐Increase awareness of screening disparities ‐Integrate primary and behavioral health services ‐Decrease complexity to obtain screening services ‐Leverage telehealth and mobile platforms to expand reach of screening and psychiatric support in rural or resource‐limited settings ‐Partner with community mental health agencies to provide joint training and decrease barriers to care	‐Address barriers (e.g., housing, food insecurity, transportation) in partnership with social work ‐Address barriers to trial inclusion; begin with assumption that patients with SMI can participate in clinical trials and interventions ‐Fully consider wrap‐around care that includes pivotal end‐of‐life conversations and the use of advance directives ‐Build collaborations with community clinics or mental health centers to maintain continuity when oncologic resources are distant or limited ‐Partner with palliative care services; provide education and resources to support serious illness conversations for adults with SMI
Policy	‐Advocate for enhanced reimbursement for interdisciplinary care coordination and preventative care services ‐Promote funding mechanisms and telehealth reimbursement policies to support integrated psychiatric‐oncologic care in rural and underserved settings	‐Reduce health inequities by ensuring equitable access to treatment as appropriate (e.g., right‐to‐try initiatives or access to novel therapeutics) ‐Develop incentives for rural providers to adopt collaborative or shared‐care models ‐Define workforce recommendations to meet guidelines for distress screening and management

Abbreviations: EHR, electronic health record; SMI, severe mental illness.

^a Adapted from: Weinstein LC, Stefancic A, Cunningham AT, Hurley KE, Cabassa LJ, Wender RC. Cancer screening, prevention, and treatment in people with mental illness. CA Cancer J Clin 2016;66(2):134‐151. ¹⁰¹

In addition, several novel paradigms of care offer competitive advantages in minimizing this cancer care inequity when compared to usual care. Over several decades, researchers have studied the CoCM paradigm that specifically aligns meeting psychiatric symptom needs with receiving medical care. Although most research efforts have been in primary care, several large‐scale randomized interventions in cancer settings clearly demonstrate significant psychiatric symptom reduction with concomitantly improved medical (or cancer) outcomes using the treatment pillars of measurement‐based standards, maintenance of a registry, the use of a care manager for triaging purposes, and external psychiatric consultation. ¹⁰² , ¹⁰³ , ¹⁰⁴ , ¹⁰⁵ , ¹⁰⁶ , ¹⁰⁷ This overarching, inclusive, population‐based approach minimizes health inequities while optimizing resources to meet the greatest psychiatric need. ⁹⁷ That is, it can facilitate psychiatric symptom reduction (e.g., depression) equitably in patients with or without SMI. The CoCM decreases depression symptoms, mitigates cancer care disruptions, and is cost‐effective while expanding limited resources. ⁹⁷ As long as certain criteria are met, the Centers for Medicare and Medicaid Services will reimburse oncologic services for using the CoCM to meet psychiatric symptom needs, and extensive teaching materials are available for programs that want to begin using this model. ¹⁰⁸ , ¹⁰⁹ These efforts underscore the necessity of integrating psychiatric care into oncology practices as part of standard care protocols. The CoCM steps far beyond traditional distress screening by needing additional resources in place and following patients longitudinally. Although the CoCM is occurring at selective cancer centers to target psychiatric symptom management, it holds tremendous promise for patients who have been overlooked by traditional models of care and warrants further attention in the setting of SMI and cancer.

Cancer centers offer variable access to psychiatric or psychosocial resources, which generally do not specifically address patients with SMI. Therefore, additional collaborative attention is required to think through how patients with SMI will interface with cancer care. This may be part of community outreach and advocacy, or it may be internally instigated by faculty and staff who advocate for equitable care. In addition to consultative services, some facilities also have dedicated med‐psych inpatient units, which may be an invaluable resource in longitudinally and comprehensively addressing their care. Finally, professional societies and services are available on regional and national levels that also may offer additional assistance in the care for these patients. However, for rural or resource‐limited regions, such resources may not be readily available. In these contexts, scalable, lower cost strategies can help bridge service gaps for patients with SMI. Examples include leveraging telepsychiatry and tele‐oncology platforms for consultation and follow‐up, training community health workers or peer navigators to assist with care coordination, and partnering with primary care or community mental health clinics to maintain continuity of care. Mobile health technologies (e.g., symptom monitoring, screening reminders) and shared‐care protocols can further extend the reach of specialty care. At the policy level, reimbursement for telehealth‐based collaborative care and incentives for rural provider participation in integrated care models are critical steps toward ensuring equitable access to high‐quality cancer care for patients with SMI across diverse settings.

Additionally, psychoeducational models for clinicians and patient navigator systems have shown promise especially in delivering care to under‐resourced areas. Project ECHO (Extension for Community Healthcare Outcomes) is a large, multicenter patient navigator initiative to provide care in under‐resourced areas. Project ECHO was evaluated for its potential to use in teleconferencing to improve the capacity of clinicians to manage complex psychiatric patients. This initiative, although not cancer‐specific, demonstrated that clinician‐based knowledge and confidence to manage difficult psychiatric patients was significantly improved over a waitlist control condition. ¹¹⁰ In addition to models like Project ECHO, the virtual tumor board model for addressing equitable cancer care has shown promise in extending the reach of mental health care with the use of monthly videoconferences, case discussion, sharing of expertise, and focusing on addressing barriers to care and possible cancer trial participation. ¹¹¹ Mental health tumor boards that integrate expertise in mental health, oncology, and local community resources may overcome barriers to equitable cancer care. Navigator systems may help implement cancer care delivery for patients who otherwise would struggle to meet the demands of cancer care logistics.

CONCLUSION

Longstanding inattention to the fractured and inadequate care of patients with cancer who have SMI, who represent roughly 6% of the global population, should be alarming to the cancer care community. In particular, the risk of not receiving standard‐of‐care treatments (e.g., foregoing quality‐of‐life and survival benefits) will continue to increase as cancer treatment innovation continues. This gap in cancer care delivery has historical underpinnings that are perpetuated from within our current systems of care.

A paradigmatic shift in cancer care delivery systems for patients with SMI is needed. Global institutions and leadership have taken notice of these stark differences in cancer care outcomes, but a seismic change in cancer care delivery has not yet occurred. Health systems are uniquely empowered to address this health inequity because patients living with SMI inevitably interface with the medical community long before developing cancer.

This review has provided a framework to guide the consideration of this health disparity. We need to address the limitations in cancer care delivery based on the fundamental structure and processes of our health systems, the clinicians/care teams, and patient‐level factors while strategically targeting age‐appropriate cancer screening and early detection and the parallel delivery of psychiatric and cancer care once the patient is diagnosed.

Closing this care gap means generating essential knowledge around the difficulties patients with SMI face in managing both their physical and mental health. ¹¹² Although patients with SMI experience the same array of existential stressors and psychological distress in confronting cancer as patients without SMI, circumstances and underlying vulnerability factors stemming from living with SMI challenge the traditional system of cancer care delivery on multiple levels and sectors. ⁷⁶ Ultimately, cancer care that reaches patients with SMI requires concerted efforts by psychiatric and oncologic communities of care.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.