End of life breast cancer care in women with severe mental illnesses

Barriers and Facilitators to Breast Cancer Screening for Women With Severe Mental Illness

BACKGROUND

Women with severe mental illness (SMI) are diagnosed with breast cancer at later stages, with greater mortality rates than the general population. Although breast cancer screening is an acknowledged strategy for early breast cancer detection, women with SMI are 32% to 50% less likely to have regular mammography screenings, yet the specific factors related to the disparity in this population have not been determined.

AIM

The purpose of this study was to identify the barriers and facilitators toward breast cancer screening in women diagnosed with SMI.

METHOD

In collaboration with a community-based mental health services agency, women aged 40 and older, diagnosed with SMI, and treated at that agency, were identified and asked if they were willing to participate. Fifteen women agreed to be interviewed. An interpretive descriptive approach was utilized to analyze the qualitative data.

RESULTS

The themes elicited included barriers and facilitators to screening. Barriers found were: Psychiatric Symptoms, Fear, Distrust in the Health care System, and Not my Priority. Among the facilitators were Support, Good Health care Experiences, Make it Easy, Integrated Care, and Self-Care.

CONCLUSION

Unique to this study was the understanding by participants that physical health needed to be integrated into their mental health care services through direct support and education, primarily because the process of recovery from mental illness itself entailed the increasing ability for self-care, encompassing a focus on both mental and physical health needs and preventive care.

Do people with disabilities experience disparities in cancer care? A systematic review

BACKGROUND

Over 1.3 billion people, or 16% of the world's population, live with some form of disability. Recent studies have reported that people with disabilities (PwD) might not be receiving state-of-the-art treatment for cancer as their non-disabled peers; our objective was to systematically review this topic.

METHODS

A systematic review was undertaken to compare cancer outcomes and quality of cancer care between adults with and without disabilities (NIHR Prospero register ID number: CRD42022281506). A search of the literature was performed in July 2022 across five databases: EMBASE, Medline, Cochrane Library, Web of Science and CINAHL databases. Peer-reviewed quantitative research articles, published in English from 2000 to 2022, with interventional or observational study designs, comparing cancer outcomes between a sample of adult patients with disabilities and a sample without disabilities were included. Studies focused on cancer screening and not treatment were excluded, as well as editorials, commentaries, opinion papers, reviews, case reports, case series under 10 patients and conference abstracts. Studies were evaluated by one reviewer for risk of bias based on a set of criteria according to the SIGN 50 guidelines. A narrative synthesis was conducted according to the Cochrane SWiM guidelines, with tables summarizing study characteristics and outcomes. This research received no external funding.

RESULTS

Thirty-one studies were included in the systematic review. Compared to people without disabilities, PwD had worse cancer outcomes, in terms of poorer survival and higher overall and cancer-specific mortality. There was also evidence that PwD received poorer quality cancer care, including lower access to state-of-the-art care or curative-intent therapies, treatment delays, undertreatment or excessively invasive treatment, worse access to in-hospital services, less specialist healthcare utilization, less access to pain medications and inadequate end-of-life quality of care.

DISCUSSION

Limitations of this work include the exclusion of qualitative research, no assessment of publication bias, selection performed by only one reviewer, results from high-income countries only, no meta-analysis and a high risk of bias in 15% of included studies. In spite of these limitations, our results show that PwD often experience severe disparities in cancer care with less guideline-consistent care and higher mortality than people without disabilities. These findings raise urgent questions about how to ensure equitable care for PwD; in order to prevent avoidable morbidity and mortality, cancer care programs need to be evaluated and urgently improved, with specific training of clinical staff, more disability inclusive research, better communication and shared decision-making with patients and elimination of physical, social and cultural barriers.

Psychiatric Comorbidities and Outcomes in Palliative and End-of-Life Care: A Systematic Review

BACKGROUND

Although psychiatric comorbidities are common among individuals at end of life, their impact on outcomes is poorly understood.

METHODS

We conducted a systematic literature review of six databases following preferred reporting items for systematic reviews and meta-analyses guidelines and aimed at assessing the relationship between psychiatric comorbidities and outcomes in palliative and end-of-life care. Six databases were included in our search. This review is registered on PROSPERO (CRD42022335922).

RESULTS

Our search generated 7472 unique records. Eighty-eight full texts were reviewed for eligibility and 43 studies were included in the review. Clinically, psychiatric comorbidity was associated with poor quality of life, increased physical symptom burden, and low function. The impact of psychiatric comorbidity on health utilization varied, though many studies suggested that psychiatric comorbidity increased utilization of palliative care services. Quality of evidence was limited by lack of consistent approach to confounding variables as well as heterogeneity of the included studies.

CONCLUSION

Psychiatric comorbidity is associated with significant differences in care utilization and clinical outcome among patients at end of life. In particular, patients with psychiatric comorbidity and serious illness are at high risk of poor quality of life and high symptom burden. Our finding that psychiatric comorbidity is associated with increased utilization of palliative care likely reflects the complexity and clinical needs of patients with serious illness and mental health needs. These data suggest that greater integration of mental health and palliative care services may enhance quality-of-life among patients at end of life.

Breast Cancer Care Pathways for Women with Preexisting Severe Mental Disorders: Evidence of Disparities in France?

The excess cancer mortality in persons with severe mental illness (SMI) has been well documented, and research suggests that it may be influenced by care-related factors. Our objective was to assess breast cancer care pathways in women with SMI in France, using an exhaustive population-based data-linkage study with a matched case-control design. The cases were 1346 women with incident breast cancer in 2013/2014 and preexisting SMI who were matched with three controls without SMI presenting similar demographics, initial breast cancer type, and year of incidence. We compared cancer care pathways and their quality for cases and controls, using a consensual set of indicators covering diagnosis, treatment, follow-up, and mortality (until 2017). After adjusting for covariates, cases had lower odds to undergo the main diagnostic tests, lumpectomy, adjuvant chemotherapy, and radiotherapy, as well as hormone therapy, but higher odds for mastectomy. Suboptimal quality in cancer pathways was observed for both groups, but to a higher extent for cases, especially for not receiving timely care after diagnosis and post-treatment follow-up. Breast cancer mortality, considering competing risks of deaths, was significantly elevated in women with SMI. These findings highlight disparities in cancer care pathways for individuals with SMI, as well as specific aspects of the care continuum which could benefit from targeted actions to reach equity of outcomes.

NDIS Participants with Psychosocial Disabilities and Life-Limiting Diagnoses: A Scoping Review

This research aimed to map evidence about system supports and gaps for Australians with psychosocial disabilities and life-limiting diagnoses. A scoping review of available policy documents, academic, and grey literature was completed to discover key characteristics of this concept and provide context around the phenomenon. Our focus was on Australia's National Disability Insurance Scheme (NDIS), a key reform providing support to the disability population nationally. No peer-reviewed or grey literature was retrieved on the phenomena. Therefore, three lines of enquiry were developed: experiences of NDIS participants living with psychosocial disabilities; the death, dying, and palliative care supports and experiences of NDIS participants of any disability type; and the experiences for people living with severe and persistent mental illness (SPMI) and life-limiting diagnoses. Five themes were identified: (1) the person; (2) advocacy; (3) informal supports; (4) formal supports; and (5) existing research. NDIS participants living with SPMI and their informal and formal support systems are still struggling to navigate the NDIS. While there are no specific publications about their end-of-life experiences, people with SPMI often experience poor end-of-life outcomes. Rigorous research into their death, dying, and palliative care experiences is needed to inform improved support to them, including their end-of-life care.

Intensive end-of-life care in acute leukemia from a French national hospital database study (2017–2018)

Background

A better understanding of how the care of acute leukemia patients is managed in the last days of life would help clinicians and health policy makers improve the quality of end-of-life care. This study aimed: (i) to describe the intensity of end-of-life care among patients with acute leukemia who died in the hospital (2017–2018) and (ii) to identify the factors associated with the intensity of end-of-life care.

Methods

This was a retrospective cohort study of decedents based on data from the French national hospital database. The population included patients with acute leukemia who died during a hospital stay between 2017 and 2018, in a palliative care situation (code palliative care Z515 and-or being in a inpatient palliative care support bed during the 3 months preceding death). Intensity end-of-life care was assessed using two endpoints: High intensive end-of-life (HI-EOL: intensive care unit admission, emergency department admission, acute care hospitalization, intravenous chemotherapy) care and most invasive end-of-life (MI-EOL: orotracheal intubation, mechanical ventilation, artificial feeding, cardiopulmonary resuscitation, gastrostomy, or hemodialysis) care.

Results

A total of 3658 patients were included. In the last 30 days of life, 63 and 13% of the patients received HI-EOL care and MI-EOL care, respectively. Being younger, having comorbidities, being care managed in a specialized hospital, and a lower time in a palliative care structure were the main factors associated with HI-EOL.

Conclusions

A large majority of French young adults and adults with acute leukemia who died at the hospital experienced high intensity end-of-life care. Identification of factors associated with high-intensity end-of-life care, such as the access to palliative care and specialized cancer center care management, may help to improve end-of-life care quality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00937-0.

Gynecological Health Concerns in Women with Schizophrenia and Related Disorders: A Narrative Review of Recent Studies

Sex and age are important factors influencing physical and mental health in schizophrenia. Our goal was to review the recent literature for associations between gynecological conditions and psychotic illness and to propose integrated strategies for their management in order to improve overall health outcomes in women. We addressed the following questions: What are the prevalence and risk factors of gynecological disorders in women with schizophrenia or delusional disorder (DD)? What are the rates of uptake of gynecological cancer screening and mortality in this population? What role does menopause play? We found an increased incidence of breast cancer in women with schizophrenia. Other gynecological comorbidities were less frequent, but the field has been understudied. Low rates of breast and cervical cancer screening characterize women with schizophrenia. Menopause, because of endocrine changes, aging effects, and resultant comorbidity is associated with high rates of aggressive breast cancer in this population. Uterine and ovarian cancers have been less investigated. Psychosocial determinants of health play an important role in cancer survival. The findings lead to the recommendation that primary care, psychiatry, gynecology, oncology, and endocrinology collaborate in early case finding, in research into etiological links, and in improvement of prevention and treatment.