Public Health Efforts to Address Mental Health Conditions Among Cancer Survivors

The Centers for Disease Control and Prevention (CDC) examines mental health indicators and trends, conducts surveillance of mental health concerns, and supports programs to address the mental health needs of men, women, and children (www.cdc.gov/mentalhealth/learn/index.htm). The Healthy People 2020 objectives (www.healthypeople.gov/2020/topics-objectives/topic/mental-health-and-mental-disorders) and National Prevention Strategy (www.hhs.gov/sites/default/files/disease-prevention-wellness-report.pdf) offer examples of public health objectives that can improve mental health through prevention by ensuring access to appropriate, quality mental health services.

The CDC routinely publishes findings from population- and state-based surveys, including the Behavioral Risk Factor Surveillance System, the National Health Interview Survey, and the Medical Expenditure Panel Survey. These data sets are used to provide information on state-specific and national benchmarks for cancer prevention and early detection, describe the health status of cancer survivors (i.e., those who have received a cancer diagnosis), examine quality of life, and estimate the cost of cancer care. Details of these data sets are available at www.cdc.gov/cancer/survivors/what_cdc_is_doing/index.html.

The CDC also supports research and partners with government and nongovernment organizations to examine mental health research topics, which include (1) psychosocial barriers and facilitators to cancer clinical trial enrollment; (2) surveillance of mental health disorders, psychosocial concerns, risk factors, and service utilization among cancer survivors by cancer type; (3) health care costs related to mental health conditions among cancer survivors; (4) health care provider knowledge and practice-based behavior regarding distress management of cancer survivors; and (5) cancer prevention services at community mental health centers.

In this editorial, we describe an area of mental health—a public health approach to addressing the mental health needs of cancer survivors—in which the CDC is active. This approach, which is not covered in this supplement issue of AJPH, illustrates the breadth of the mental health needs to be addressed in populations. The CDC’s Division of Cancer Prevention and Control uses data, knowledge translation, and public health partnerships to support cancer survivors, including those with psychosocial needs, to live longer, healthier, and more productive lives (www.cdc.gov/cancer/survivors/what_cdc_is_doing/index.html). This work includes conducting surveillance and research and implementing programs to understand and address the mental health needs of cancer survivors.

MENTAL HEALTH ISSUES AMONG CANCER SURVIVORS

Over the past decade, the medical and public health communities have recognized the need to address the mental health concerns of cancer survivors (www.nap.edu/catalog/11993/cancer-care-for-the-whole-patient-meeting-psychosocial-health-needs). The CDC characterizes mental illness as diagnosed changes in a person’s cognition, emotions, or behavior, which affect his or her ability to function (www.cdc.gov/mentalhealth/learn/index.htm). For the estimated 16.9 million Americans who have received a cancer diagnosis (www.cancercontrol.cancer.gov/ocs/statistics/statistics.html), risk of mental illness or poor mental health (i.e., their mental well-being) is especially salient.

For cancer survivors, the risk of psychological disability is high; survivors are twice as likely to have serious psychological distress as those without a history of cancer.^1,2 Common concerns affecting a cancer survivor’s mental health may include social isolation, feelings of anxiety and depression, and fear of recurrence or, in some cases, death. Additionally, survivors can experience cancer treatment-related cognitive impairment. One study showed that 60% of breast cancer survivors who received chemotherapy or hormone therapies reported posttreatment cognitive difficulties with thinking, memory, and inattention.³ These and other mental health conditions have disabling effects on quality of life and may exacerbate preexisting health conditions and affect health care utilization among cancer survivors. For example, survivors with serious psychological distress more frequently utilize medical care and have lower odds of being up-to-date with preventive care and cancer screening.¹

ECONOMICS

Mental health conditions also have a substantial impact on the economic well-being of survivors and society at large. For instance, studies have reported that mental health disorders, including psychological distress and depression, are associated with considerable total health care costs by all service types (hospital, prescription drug, home health, ambulatory care, and long-term care).^4,5 Further, per person annual total costs associated with serious psychological distress among cancer survivors and society were $5482 in 2010 ($6127 in 2018 dollars).⁵ These direct medical expenditures were only a fraction of health care costs incurred by survivors. Nonmedical costs incurred by survivors and society are also substantial and include out-of-pocket expenses, productivity loss due to illness, productivity loss due to premature death, and intangible costs resulting from pain and suffering due to these conditions. When aggregated, these direct medical, nonmedical, and indirect costs together contribute billions of dollars in annual costs incurred by society. Because of the disabling nature of poor mental health, survivors may have employment difficulties. Of those who remain employed, more than 40% change their work schedule because of cancer.⁶ The combination of mental health issues, rising costs of medical care, and potential reduction in annual family income could increase the risk of medical financial hardship for survivors.⁷ Medical financial hardship includes material hardship (having difficulty paying for medical bills), psychological hardship (worrying about paying medical bills), and coping behavior (forgoing medical care or nonadherence to treatment because of cost).⁷ These conditions decrease survivors’ ability to cope effectively with the short- and long-term effects of cancer.

TRANSLATING RESEARCH INTO PRACTICE

To effectively detect and manage psychological distress among cancer patients, screening is recommended in all clinical settings and is required in facilities accredited by the American College of Surgeons Commission on Cancer. Medical providers that serve cancer survivors have limited knowledge of distress-screening guidelines, limited mental health discussions with their patients, and poor referral rates to psychosocial treatment when indicated. To address this issue, the CDC collaborated with the National Association of Chronic Disease Directors to develop innovative, interactive, continuing medical education training for medical providers, called the Provider Education for Mental Health Care of Cancer Survivors Training (www.cdc.gov/cancer/survivors/health-care-providers/mental-health-care-prov-ed.htm). This free, Web-based training was created to improve health care provider knowledge and communication about cancer survivors’ mental health needs and care, and to promote recommended distress screening. As a part of this training, medical providers can engage in role-play conversations with simulated cancer survivors to try different approaches to discussing mental health concerns identified through distress screening and make appropriate referrals when indicated. This training also allows providers to get personalized feedback and gain the confidence and skills to lead similar conversations in real life.

PROGRAMS AND PARTNERSHIPS

Between 2017 and 2019, 58 of 70 programs funded by the CDC’s National Comprehensive Cancer Control Program (NCCCP) produced objectives to address the social and emotional needs of cancer survivors (www.cdc.gov/cancer/ncccp). The NCCCP grantees focused on education efforts for the general public, policymakers, providers, and cancer survivors. The grantees are implementing evidence-based interventions to promote cancer prevention activities, such as increasing physical activity and decreasing or ceasing tobacco use and alcohol consumption. Several grantees implement evidence-informed interventions related to developing and sharing a formal survivorship plan that addresses the emotional and social needs of cancer survivors. Nearly 50% of the NCCCP grantees have implemented patient navigation programs to help facilitate care for cancer survivors with psychosocial needs associated with their diagnosis. Although most NCCCP grantees focus on cancer survivorship issues, a need exists to move toward policy, system, and environment change interventions that increase access to clinical preventive services, enable and promote healthy behaviors, and provide social and psychological support for cancer survivors.

Over the past decade, progress has been made in addressing mental health conditions among cancer survivors. More comprehensive, synergistic, and multilevel efforts are perhaps needed to address the complex needs faced by cancer survivors with mental health conditions.