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. Author manuscript; available in PMC: 2021 Feb 1.
Published in final edited form as: Cancer. 2019 Oct 18;126(3):602–610. doi: 10.1002/cncr.32564

Is screening for psychosocial risk factors associated with mental health care in older adults with cancer undergoing surgery?

Kelly M Trevino 1, Christian Nelson 1, Rebecca Saracino 1, Beatriz Korc-Grodzicki 1, Saman Sarraf 1, Armin Shahrokni 1
PMCID: PMC6980247  NIHMSID: NIHMS1052311  PMID: 31626346

Abstract

Introduction.

Surgery is a notable stressor for older adults with cancer who are often medically and psychosocially complex. This study examined rates of pre-operative psychosocial risk factors in older adults with cancer undergoing elective surgery and the relationship between these risk factors and provision of mental health services during the post-operative hospitalization.

Methods.

Patients aged 75 years or older (n=1,211) referred to the Geriatrics Service at a comprehensive cancer center were enrolled. Patients underwent elective surgery with a length of stay of 3 days or longer and were followed for at least 30 days after surgery. A comprehensive geriatric assessment (CGA) was administered as part of routine pre-operative care. Bivariate relationships between demographic and surgical characteristics and the pre-operative CGA and receipt of mental health services during the post-operative hospitalization were examined. Characteristics with bivariate relationships significant at the p<.10 level were entered into a multivariable regression predicting post-operative mental health service use.

Results.

One-fifth of the total sample (20.6%) received post-operative mental health services. In multivariable analyses, high distress (p=.007) and poor social support (p=.02) were associated with greater likelihood of receipt of mental health services. Of patients with high distress and poor social support, only one-quarter (24.6–25.5%) received mental health care.

Conclusions.

Distressed older adults and those with low levels of support pre-operatively were more likely to receive mental health services after surgery. Yet, less than one-third of these patients received inpatient post-operative mental health care, indicating that barriers to translating screening into provision of psychosocial services remain.

Keywords: Neoplasms, Aged, Mental health, Operative, Referral consultation

Precis:

In older adult cancer patients undergoing elective surgery, pre-operative high distress and poor social support were associated with greater likelihood of receipt of mental health services during the post-operative hospitalization. However, only one-quarter of patients with high distress and low social support received mental health care post-operatively.

Introduction

Surgery is first-line treatment for many cancers common in older adults. While surgery is appropriate for many older adults, frail patients are at higher risk for surgical complications than non-frail patients.1,2 Further, comorbidities such as cardiovascular and pulmonary diseases can influence post-operative mortality and morbidity.3 Therefore, thorough assessment of risk factors for poor surgical outcomes in older adults with cancer is vital for patient-centered treatment planning. Psychosocial risk factors are common and important in the care of older adult surgical patients. Approximately three-quarters (73.4%) of older adult surgical patients endorse at least one psychosocial risk pre-operatively.4 Further, the presence of pre-operative psychosocial risk factors such as poor mental health and low social support are associated with poor post-operative outcomes including lower functional status,5,6 higher risk for surgical complications,4 greater symptom distress,7,8 and worse quality of life.6

In 2015, the American College of Surgeons Commission on Cancer required distress screening and provision of mental health services in cancer centers as a criterion for accreditation9 and extensive resources were allocated to distress screening protocols.10 Recommended distress screening tools include the Distress Thermometer,11 Generalized Anxiety Disorder-7 scale (GAD-7), and Patient Health Questionnaire-9 (PHQ-9).12 While these assessments capture difficult emotions, they do not reflect the complex psychosocial situation of many older adults.

The Comprehensive Geriatric Assessment (CGA) was developed to inform treatment planning for older adults with cancer through multi-dimensional assessment of domains relevant to older adults that may not be captured in routine clinical assessments.13,14 These domains include multiple psychosocial factors such as distress, depression, social support, and social activity that provide a more comprehensive evaluation of psychosocial needs than distress screening alone. In the context of surgical treatment, assessment of geriatric syndromes has been shown to predict surgical outcomes of older adults including post-operative complications,2,15,16 institutionalization,2,15 length of stay,2,15,16 and mortality.15 As a result, the American College of Surgeons, American Geriatric Society,17 and International Society of Geriatric Oncology18 recommend pre-operative administration of the CGA to identify high-risk patients and prevent adverse surgical outcomes.

Screening for psychosocial risk factors independent of service provision does not improve patient outcomes.19–21 However, screening for psychosocial risk factors pre-operatively can inform post-operative care and discharge planning. However, little is known about the degree to which pre-operative assessment of psychosocial risk factors as assessed by the CGA is related to receipt of post-operative mental health services. In a sample of patients with gastrointestinal cancer undergoing surgery, patients who received a pre-operative assessment of anxiety and depression were more likely to seek mental health services in the three months following surgery than patients who were not assessed.22 However, the focus of this assessment was restricted to distress (i.e., anxiety and depression) and did not reflect the complex psychosocial situation of older adults with cancer. In addition, psychosocial services were assessed over the three months post-surgery, thereby capturing services received after patients were discharged from the hospital. The post-operative hospitalization provides a unique opportunity to initiate mental health services while barriers to care such as travel to the clinic are reduced. Further, mental health services provided during the post-operative hospitalization can inform discharge planning, ensuring patients’ mental health needs are adequately addressed after leaving the hospital.

The purpose of this study was to examine the prevalence of psychosocial risk factors in older adults with cancer undergoing elective surgery. Further, we examined the relationship between the presence of pre-operative psychosocial risk factors as assessed by the CGA and receipt of mental health services during the post-operative inpatient hospitalization. Informed by prior research, we hypothesized that over half of the sample would endorse a psychosocial risk factor and that the presence of a psychosocial risk factor pre-operatively would be associated with greater likelihood of receipt of post-operative mental health services.

Materials and Methods

Sample and procedures

This study is based on secondary analyses of existing data collected during routine clinical care. Patients referred to the Geriatrics Service at Memorial Sloan Kettering Cancer Center (MSK) complete a baseline assessment as part of routine clinical care. The assessment is administered using a feasible Electronic Rapid Fitness Assessment (eRFA) on a tablet in-clinic.23 The current analysis includes patients aged 75 years or older who were referred to the MSK Geriatrics Service for preoperative evaluation, underwent elective surgery with length of stay of 3 days or longer, and received at least 30 days of post-operative follow-up. All patients were co-managed by the geriatrics and surgical services for peri-operative care. The geriatrics service was the consultant and the surgical service was the primary treatment team. The geriatrics service provides the surgical team with recommendations based on their evaluation. The surgical team then makes referrals based on these recommendations, including for mental health services. The Institutional Review Board at Memorial Sloan Kettering Cancer Center approved this study.

Measures

Pre-operative Comprehensive Geriatric Assessment (CGA):

The Comprehensive Geriatric Assessment (CGA) was completed pre-operatively using the eRFA. The CGA is a multidimensional assessment that includes measures of physical health, functional status, and cognitive function (see supplemental material for a summary of CGA measures). Indicators of physical health assessed by the CGA include presence of four or more comorbid conditions (yes/no), significant unintentional weight loss (≥10 pounds), polypharmacy (taking five or more prescribe medications),24 falls in the past year (yes/no), and the Timed Up and Go test which is a measure of mobility (≥10 seconds indicates potential impairment).25,26 Functional status was assessed with the patient-reported Karnofsky Performance Status scale (KPS),27 the Katz Index of Activities of Daily Living scale (ADL),28–30 and the Instrumental Activities of Daily Living (iADL) scale.31,32 Patients were considered to have impaired KPS if the patient-rated KPS was 80 or lower. Those with at least one impairment in ADL or iADL were considered to have impaired ADL or iADL, respectively. The MiniCog was used to assess cognitive function (≤2 indicates possible cognitive impairment).33

Pre-operative Psychosocial Wellbeing:

As a part of the CGA, patients’ psychosocial wellbeing was assessed by evaluating distress level, depression, social support, and social activity limitation. This assessment is done as a routine care and as a part of a more comprehensive assessment of older adults with cancer during preoperative evaluation. As a result, we selected shorter yet still validated versions of instruments whenever possible to increase feasibility and minimize patient burden. Distress was assessed with the Distress Thermometer, a single item rating of distress from zero (no distress) to 10 (extreme distress).34–36 A cut-off of ≥4 demonstrated optimal sensitivity and specificity relative to validated measures of distress.37 Depression was assessed with the Geriatric Depression Scale-4, a four-item measure of depressive symptoms. Participants respond yes/no regarding their experience of each symptom over the past week. Endorsement of any item (i.e., a score of ≥1) suggests elevated depression).38 Social support was assessed by an abbreviated version of the Medical Outcome Study-Social Support Survey (MOS-SSS).39,40 The MOS-SSS version used in this study is a four-item scale assessing four social support domains evaluated in the original 18-item measure: emotional/informational, tangible, affectionate, and positive social interaction. Each item is rated from one to five with higher scores indicating better social support. The 4-item version demonstrates strong psychometric properties while reducing survey burden on participants.39 Social activity limitation was assessed with the Medical Outcome Study (MOS) Social Activity Survey, a three-item measure of the interference of a patient’s health condition with social activity. Each item is rated from one to five with higher scores indicating more health-related interference with social activity.41 A score of ≥8 indicates significant interference of social activity.

Post-operative Mental Health Care:

Receipt of post-operative mental health care was defined as any encounter by social work, psychology, and/or psychiatry with the patient and/or family during the post-operative hospital stay. This information was abstracted from the electronic medical record by trained study staff.

Other variables of interest:

Patient age and gender were extracted from the medical record. Surgical characteristics and surgical outcomes were also extracted from the medical record by trained staff and included number of hours in surgery, post-operative admission to the Intensive Care Unit (ICU; yes/no), major and minor adverse events defined by the Clavien-Dindo classification system (yes/no),42 hospital length of stay in days, and the American Society of Anesthesiologists Physical Status Classification System (ASA), a rating system used to describe a patient’s pre-operative physical health status.43

Statistical analyses

Bivariate analyses were performed to assess differences in sociodemographic characteristics, CGA factors, and surgical characteristics of those who received and did not receive mental health services during the postoperative hospitalization. Chi-square tests were used for categorical variables and paired t-tests for continuous variables. Variables that were different between the two groups (p<0.10) were then entered into a multivariable regression analysis predicting receipt of mental health services during the post-operative hospitalization. All statistical inferences were based on two-sided tests with p<0.05 considered statistically significant. In total, our dataset had <5% missing data in all variables. Multiple imputation was used to determine the missing values.

Results

A total of n=1,211 older adults with cancer were included in the analysis. Surgical procedures that were at least 5% of the cohort included colorectal surgery (n=216, 17.8%), pancreatectomy (n=134, 11.1%), hepatobiliary (n=116, 9.6%), modified or radical neck dissection (n=1169.6%), cystectomy (n=93, 7.7%), lung resection (n=77, 6.4%), orthopedic procedures (n=75, 6.2%), debulking (n=61, 5%), and gastrectomy (n=60, 5%). Across the entire sample, 250 (20.6%) patients received psychiatry, psychology, or social work consultation during their post-operative hospital stay, while 961 patients (79.4%) did not receive mental health services. Table 1 shows the sociodemographic and CGA characteristics of the total sample and of patients who received and did not receive mental health care. The median age of the sample was 80 years (range=75–100 years). In bivariate analyses, pre-operative psychosocial risk factors associated with greater likelihood of receipt of post-operative mental health services included low social support (p=.005), social activity interference (p<.001) and elevated distress and depression (p’s<.001).

Table 1.

Relationship between demographic characteristics and pre-operative geriatric assessment variables and post-operative receipt of mental health care services; n (%)

Total sample N=1,211 No mental health care used N=961 (79.4%) Mental health care used N= 250 (20.6%) Beta P value
Demographic characteristics
 Age; mean (SD) 80.35 (4.35) 80.36 (4.3) 80.32 (4.4) −0.004 0.8
 Male 589 (48.6%) 478 (49.7%) 111 (44.4%) −0.043 0.12
 Non-Hispanic white 1035 (85.5%) 826 (86.0%) 209 (83.6%) −0.027 0.02
 Married 684 (56.5%) 566 (58.9%) 118 (47.2%) −0.094 0.02
 Living with family 882 (72.8%) 669 (69.6%) 153 (61.2%) −0.069 0.002
Physical health
 Comorbid conditions 664 (54.8%) 507 (52.8%) 157 (62.8%) 0.082 0.004
 Weight loss (≥10 pounds) 246 (20.3%) 182 (19.9%) 64 (27.5%) 0.074 0.01
 Fall in the past year 272 (22.5%) 198 (20.9%) 74 (29.7%) 0.086 0.003
 Impaired TUG 394 (32.5%) 281 (31.2%) 113 (48.5%) 0.147 <0.001
 Polypharmacy 485 (40.0%) 375 (42.8%) 110 (48.5%) 0.046 0.10
Functional status
 Impaired KPS 507 (41.9%) 360 (37.5%) 147 (59.0%) 0.176 <0.001
 Impaired ADL 632 (52.2%) 458 (47.8%) 174 (69.9%) 0.179 <0.001
 Impaired iADL 582 (48.1%) 418 (43.5%) 164 (65.9%) 0.181 <0.001
Cognitive function
 Impaired cognition 181 (14.9%) 138 (15.4%) 43 (18.5%) 0.034 0.2
Social function
 Poor social support 488 (40.3%) 368 (38.4%) 120 (48.2%) 0.081 0.005
 Social activity interference 636 (52.5%) 466 (48.5%) 170 (68.3%) 0.160 <0.001
Mental health
 Elevated distress 710 (58.6%) 529 (55.4%) 181 (72.7%) 0.142 <0.001
 Elevated depression 677 (55.9%) 510 (53.5%) 167 (68.2%) 0.119 <0.001
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Table 2 shows the surgical characteristics and outcomes of the total sample and by patients who received and did not receive mental health care. The median length of hospitalization was 7 days (range=3–150 days) and the median time in surgery was 195 minutes (range=25–914 minutes). In bivariate analyses, higher ASA classification was associated with greater likelihood of receipt of post-operative mental health services (p=.01). Further, longer hospitalizations (p<.001), longer time in surgery (p=.001), post-operative ICU admission (p<.001), and occurrence of minor (p=.02) and major (p<.001) adverse events were associated with greater likelihood of receipt of mental health services during the post-operative hospitalization.

Table 2.

Relationship between surgical characteristics and outcomes and post-operative receipt of mental health care services; n (%)

Total sample N=1,211 No mental health care use N=961 (79.4%) Mental health care used N= 250 (20.6%) Beta P value
ASA 0.087 0.01
 II 82 (6.8%) 71 (7.5%) 11 (4.5%)
 III 1015 (83.8%) 810 (85.4%) 205 (83.0%)
 IV 97 (8.0%) 66 (7.0%) 31 (12.5%)
 V 1 (.08%) 1 (0.1%) 0 (0)
Hospital length of stay (Days: Mean, SD) 8.68 (9.86) 7.31 (7.9) 13.9 (13.9) 0.273 0.001
Length of operation (Minutes: Mean, SD) 220 (147) 213 (139) 247 (174) 0.095 <0.001
Postoperative ICU admission 71 (5.9%) 39 (4.1%) 32 (12.8%) 0.151 <0.001
Minor adverse events reported 273 (22.5%) 194 (24.4%) 79 (31.6%) 0.070 0.02
Major adverse events reported 73 (6.0%) 42 (5.3%) 31 (12.4%) 0.119 <0.001
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In multivariable logistic regression analyses including variables with significant (p<.10) bivariate relationships with mental health service use, not being married (OR .59 [95% CI 0.35–0.99]; p=.05) and longer hospital length of stay (OR 1.08 [95% CI 1.05–1.11]; p<.001) were associated with greater likelihood of receipt of mental health services. Regarding CGA domains, only elevated distress (OR 1.72 [95% CI 1.16–2.56]; p=.007) and poor social support (OR 1.56 [95% CI 1.07–2.27]; p=.02) were associated with greater likelihood of receipt of mental health services after controlling for demographic characteristics, surgical characteristics and outcomes, and other CGA variables (see Table 3). The overall model fit was adjusted R2=.14, F(18,847)=8.90, p<.001.

Table 3.

Relationship between pre-operative geriatric assessment variables, surgical characteristics and outcomes and post-operative receipt of mental health care services

Odds ratio 95% CI P value
Demographic characteristics
 Marital status 0.59 0.35–0.99 0.05
 Non-Hispanic white 0.82 0.48–1.39 0.46
 Living with family 1.48 0.85–2.58 0.17
Surgical characteristics/outcomes
 Hospital length of stay 1.08 1.05–1.11 <0.001
 ASA 1.46 0.92–2.32 0.11
 Major adverse events reported 0.78 0.37–1.65 0.51
 Postoperative ICU admission 1.70 0.82–3.51 0.15
 Length of operation 1.00 0.99–1.001 0.85
 Minor adverse events reported 1.06 0.71–1.58 0.78
Geriatric assessment variables
 Elevated distress 1.72 1.16–2.56 .007
 Poor social support 1.56 1.07–2.27 .02
 Impaired iADL 1.49 0.94–2.36 .09
 Comorbid conditions 1.34 0.93–1.95 .12
 Impaired ADL 1.47 0.94–2.30 .09
 Impaired KPS 0.85 0.54–1.35 .49
 Falls in the past year 1.14 0.75–1.72 .55
 Impaired Timed up and Go 1.05 0.69–1.58 .83
 Social activity interference 1.11 0.71–1.73 .64
 Weight loss 1.22 0.80–1.86 .35
 Elevated depression 1.10 0.73–1.64 .65
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Note. Marital status: No=0, Yes=1; Non-Hispanic white: No=0, Yes=1; Living with family; No=0, Yes=1; Major adverse events: No=0, Yes=1; Postoperative ICU admission: No=0, Yes=1; Minor adverse events: No=0, Yes=1; Elevated distress: DT<4=0; DT≥4=1; Poor social support: No=0, Yes=1; Impaired iADL: No=0, Yes=1; Comorbid conditions: No=0, Yes=1; Impaired ADL: No=0, Yes=1; Impaired KPS: No=0, Yes=1; Fall in the past year: No=0, Yes=1; Impaired TUG: <10 seconds=0, ≥10 seconds=1; Social activity interference: No=0, Yes=1; Weight loss: <10 pounds=0, ≥10 pounds=1; Elevated depression: GDS<1=0; GDS≥1=1.

The prevalence of mental health service use among patients with impairments on CGA variables was also examined (see Figure 1). Across CGA domains, 22.7–29% of patients with pre-operative impairments on these indicators received mental health services after surgery. For pre-operative CGA variables significantly associated with mental health service use in multi-variable analyses, 25.5% of patients with elevated distress and 24.6% of patients with poor social support received mental health services during the post-operative hospitalization. Depression was not significantly associated with the receipt of mental health services. However, of patients with elevated depression pre-operatively, 24.7% received mental health services during the post-operative hospitalization.

Figure 1.

Figure 1.

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Percentage of patients with pre-operative geriatric assessment impairments who received post-operative mental health care

Discussion

This study examined the prevalence of pre-operative psychosocial risk factors in older adults with cancer and the relationship between these risk factors and receipt of mental health services during the post-operative hospitalization. Consistent with our hypotheses, psychosocial risk factors were common with up to half of the sample endorsing poor social function and over half endorsing elevated distress. After controlling for demographic characteristics, surgical characteristics and outcomes, and other geriatric assessment domains (e.g., comorbidities, impaired ADL/iADL), elevated distress and poor social support were associated with post-operative receipt of psychosocial services. However, only one-quarter of patients with elevated distress and poor social support pre-operatively received mental health services during the post-operative hospitalization. These findings highlight the long-standing challenge noted by the Institute of Medicine report, Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs44 of ensuring that patients with the greatest need for psychosocial services are provided with those services.

Consistent with prior research,4 over half of the sample endorsed at least one psychosocial risk factor. A cancer diagnosis and preparation for surgery are stressful events that likely strain older adults and their families. In the context of research indicating that pre-operative psychosocial risk factors are associated with poor surgical outcomes in cancer patients,4,5 the high rates of psychosocial risk factors in this particularly vulnerable population are concerning and point to a potential area of unmet need with negative implications for patients’ physical and emotional recovery from surgery.

Elevated distress was a psychosocial risk factor significantly associated with the receipt of post-operative mental health services. This finding is notable given that pre-operative distress has been associated with greater nausea, discomfort, fatigue, and pain post-surgically in cancer patients.45,46 Although the causal relationship between distress and these symptoms is not entirely clear, research suggests that the impact of distress on immune system function may be a factor.47–49 Given the high rates of elevated distress in this study, peri-operative treatment of distress symptoms may improve the mental health and post-operative recovery of a large proportion of older adults.

Poor social support was also associated with the receipt of mental health services post-operatively. Social support is often a vital component of successful recovery from surgery.50 Patients recovering from surgery may need assistance with medication adherence, dressing changes, completion of ADLs and iADLS, communication with the healthcare team, and transportation to follow-up appointments. Due to the potential negative impact of poor social support on recovery, surgical teams may be more likely to refer patients for mental health services to ensure social support needs are met prior to discharge.

Despite the statistically significant relationships between distress and social support and receipt of mental health services, three-quarters of patients with elevated distress and poor social support, respectively, did not receive post-operative mental health services. It is important to note that the CGA results analyzed in this study do not automatically trigger referrals for mental health services. The CGA is completed by the Geriatrics Service which then provides recommendations to the primary treatment team. Referrals to mental health services are not triggered automatically by the CGA and it is unclear in this study whether referrals were not made or patients refused mental health services that were offered. Further, data on the reasons for post-operative mental health referrals, the provider making these referrals, and the discipline providing mental health services (i.e., psychology, psychiatry, social work) are not available. Research examining the process of post-operative mental health referrals is necessary to identify gaps that interfere with service provision. Regardless, these findings indicate that psychosocial screening often fails to translate into improved care. Processes are clearly needed to bridge the gap between screening and the provision of mental health services that will benefit patients.

The low rates of mental health service use post-operatively in this study may reflect the challenges associated with integrating multiple teams into patient care, such as clear communication and distribution of tasks. Strategies for improving this coordination may increase provision of mental health services for patients undergoing evaluation by multiple clinical services. Potential strategies include clear delineation of responsibilities among medical and psychosocial oncology providers and triage algorithms that match patient needs with the psychosocial provider best equipped to meet those needs (e.g., psychologist, psychiatrist, social worker). Research evaluating the impact of such triage algorithms on rates of unmet psychosocial needs and patient outcomes will inform integration of these processes into clinical care.

Additional characteristics of the post-operative hospitalization may also account for the low prevalence of mental health service use. Patients may feel too ill following surgery to engage in mental health services and may refuse services that are offered. Further, the post-operative hospitalization is a truncated time during which numerous aspects of the patient’s physical health must be monitored and addressed. Discharge planning is often complex for older adults due to their wide-ranging needs (e.g., safety modifications to the home setting, coordination of care across multiple disciplines, medication reconciliation). Designing mental health services to be easily integrated into post-surgical care may improve rates of mental health service use. For example, short targeted sessions that focus on a well-defined goal and include discussions of post-discharge mental health services may improve older adults’ mental health while remaining feasible in an inpatient setting. Post-operative delirium is an additional factor that may influence patients’ ability to utilize mental health services. Approximately 15–17% of older adults who undergo surgery for cancer experience postoperative delirium;51,52 older adults are at significantly increased risk for delirium relative to younger patients.51–53 Pre-operative assessment of delirium risk factors (e.g., cognitive dysfunction, medical comorbidities, pain) and implementation of preventive interventions followed by assessment and treatment of post-operative delirium is a vital component of the medical care of these patients53 and may also facilitate patients’ ability to engaged in needed mental health services post-operatively.

Strengths of this study include collection of data before and after surgery during routine clinical care rather than in the context of a controlled research project. As a result, this study captures rates of pre-operative psychosocial risk factors and their relationship to post-operative mental health care within a clinical setting. However, our study is not without limitations. The current sample was restricted to patients referred to the Geriatrics Service for consultation with a specialist, precluding comparison of patients who were and were not referred to Geriatrics and limiting the representativeness of the sample. However, patients referred to the Geriatrics Service are likely more medically and psychosocially complex than the general population of older adults undergoing surgery for cancer. Due to this complexity, these are also the patients likely to be in greatest need of psychosocial services.

This study was conducted at a single comprehensive care center in an urban setting with a largely white sample, limiting the generalizability of these findings to other populations and settings. Further, mental health services may be more available in this setting than at smaller hospitals and cancer centers and examination of these relationships in more underserved populations is warranted. In settings with limited psychosocial services, the number of older adults with pre-operative psychosocial risk factors may overwhelm available resources and be a barrier to adequate psychosocial care. Strategies for increasing the availability of psychosocial services include hiring additional psychosocial providers within the institution, integrating general practitioners in the psychosocial care of older adult surgical patients, and enhancing the ability of patients’ personal support networks to meet their psychosocial needs. Wide use of all available resources including patients’ family members, community-based social services, staff at assisted living and long-term care facilities, and general practitioners will help ensure patients’ psychosocial needs are met. Further, use of non-psychiatric resources may reduce the stigma toward mental health service endorsed by many older adults and facilitate engagement in interventions for unmet psychosocial needs.54,55 Services provided to a particular patient likely depend on availability and patient preference. Assessing patient preference for available resources and including patients in treatment planning is vital to ensuring patients utilize all resources available to meet their psychosocial needs.56 Finally, the assessment of mental health service use in this study was restricted to the post-surgical hospitalization. Patients may have received outpatient mental health services post-discharge. However, for older adults with pre-operative psychosocial risk factors, the post-operative hospitalization may be an opportune time to initiate mental health services due to the absence of treatment barriers such as travel to the mental health clinic. Future research that tracks the psychosocial care paths of older adults undergoing cancer surgery including assessment of who provides which services, the frequency and duration of services, and the criteria used to inform service provision will identify gaps in care that can be addressed to reduce unmet psychosocial needs in this population.

Conclusion

This study indicates that many older adults undergoing elective cancer surgery endorse psychosocial risk factors. However, few receive post-operative mental health services, even when pre-operative information on these risk factors is available. While restricted to a single institution, this study identifies an important gap in older adult patient care during surgical treatment, a pivotal point in treatment that can influence patients’ long-term well-being. Implementation of strategies to better connect pre-operative assessment of psychosocial risk factors to post-operative services is vital to maximizing older adult function and quality of life post-surgery.

Supplementary Material

Supp TableS1

Funding:

National Institute on Aging and American Federation for Aging Research (K23AG048632, Trevino); Beatriz and Samuel Seaver Foundation (Shahrokni), the Memorial Sloan Kettering Cancer and Aging Program (Korc-Grodzicki), and National Institutes of Health/National Cancer Institute Cancer Center Support Grant P30 CA008748 (Thompson) and R25 CA020449 (Wolchok).

Footnotes

Conflicts: The authors have no conflicts to disclose.

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