The Impact of Preexisting Mental Health Disorders on the Diagnosis, Treatment, and Survival among Lung Cancer Patients in the U.S. Military Health System

Caring for Veterans With Depression and Cancer: An Overview for Civilian Nurse Clinicians

PURPOSE

Veterans put their lives on the line to serve our country, but their well-being is often threatened by multifaceted health issues related to military service, including elevated rates of lung cancer and depression. A significant percentage of Veterans have lost faith in mental health care or are unable to breach stigma-related barriers to seek and engage in this care. Veterans' lack of trust can be exacerbated by community mental health clinicians who have had little experience with Veterans and feel inadequately prepared to address their complex needs.

METHOD

The following databases were searched: PubMed, CINAHL Plus with Full Text, and Google Scholar; as well as the U.S. Department of Veterans Affairs website.

RESULTS

Results indicated that 50% of Veterans use civilian health care and perceive that civilian nurses lack knowledge of military culture and related trauma.

CONCLUSION

The current review offers civilian mental health professionals an overview of Veterans' unique issues and provides resources and practical suggestions for helping them overcome barriers to mental health care. [Journal of Psychosocial Nursing and Mental Health Services, 63(1), 13-22.].

All-cause mortality among United States military personnel: Findings from the Millennium Cohort Study, 2001-2021

PURPOSE

The goal of this study was to estimate all-cause mortality among Operations Enduring Freedom, Iraqi Freedom, and New Dawn era service members and veterans and to identify protective and risk factors for mortality.

METHODS

Using 20 years of longitudinal data from the Millennium Cohort Study (2001-2021), sequential Cox proportional hazard models were conducted to examine demographic, military, and health-related characteristics associated with all-cause mortality among service members and veterans.

RESULTS

Among 201,619 participants, 3806 (1.9 %) were deceased by the end of the observation period, with an age- and sex-adjusted incidence of 37.6 deaths per 100,000 person-years. Deployed service members had lower all-cause mortality risk than those who did not deploy. Personnel who experienced combat had higher mortality risk compared with those who did not in unadjusted models; this association was nonsignificant after accounting for health-related factors. Enlisted and Army personnel both had a higher mortality risk, while women and Hispanic individuals had a lower risk. Stressful life events, lower physical health related quality of life, problem drinking, and smoking were also associated with greater mortality risk.

CONCLUSION

These profiles may be useful for developing preventive education and intervention efforts in military and veteran populations to reduce premature mortality.

Incidence and Factors Associated With Mental Health Disorders in Patients With Rectal Cancer Post-Restorative Proctectomy

BACKGROUND

Most patients with rectal cancer experience bowel symptoms post-restorative proctectomy. The incidence of mental health disorders post-restorative proctectomy and its association with bowel symptoms are unknown.

OBJECTIVES

This study aimed 1) to describe the incidence of mental health disorders in patients who underwent restorative proctectomy for rectal cancer and 2) to study the association between incident mental health disorders and bowel dysfunction after surgery.

DESIGN

This retrospective cohort study used the Clinical Practice Research Datalink and Hospital Episode Statistics databases.

SETTINGS

The databases were based in the United Kingdom.

PATIENTS

All adult patients who underwent restorative proctectomy for a rectal neoplasm between 1998 and 2018 were included.

MAIN OUTCOME MEASURES

The primary outcome was an incident mental health disorder. The associations between bowel, sexual, and urinary dysfunctions and incident mental health disorders were studied using Cox proportional hazard regression models.

RESULTS

In total, 2197 patients who underwent restorative proctectomy were identified. Of 1858 patients without preoperative bowel, sexual, or urinary dysfunction, 1455 had no preoperative mental health disorders. In this cohort, 466 patients (32.0%) developed incident mental health disorders following restorative proctectomy during 6333 person-years of follow-up. On multivariate Cox regression, female sex (adjusted HR 1.30; 95% CI, 1.06-1.56), metastatic disease (adjusted HR 1.57; 95% CI, 1.14-2.15), incident bowel dysfunction (adjusted HR 1.41, 95% CI, 1.13-1.77), and urinary dysfunction (adjusted HR 1.57; 95% CI, 1.16-2.14) were found to be associated with developing incident mental health disorders post-restorative proctectomy.

LIMITATIONS

This study was limited by its observational study design and residual confounding.

CONCLUSIONS

Incident mental health disorders after restorative proctectomy for rectal cancer are common. The presence of bowel and urinary functional impairment significantly increases the risk of poor psychological outcomes among rectal cancer survivors.

CON LOS TRASTORNOS DE SALUD MENTAL EN PACIENTES CON CNCER DE RECTO POSTERIOR A PROCTECTOMA RESTAURADORA

ANTECEDENTES: La mayoría de los pacientes con cáncer de recto experimentan síntomas intestinales después de la proctectomía restauradora. Se desconoce la incidencia de trastornos de salud mental posteriores a la proctectomía restauradora y su asociación con síntomas intestinales.OBJETIVOS: Los objetivos de nuestro estudio son: a) describir la incidencia de trastornos de salud mental en pacientes sometidos a proctectomía restauradora por cáncer de recto; b) estudiar la asociación entre los trastornos de salud mental incidentes y la disfunción intestinal después de la cirugía.DISEÑO: Este fue un estudio de cohorte retrospectivo que utilizó las bases de datos Clinical Practice Research Datalink y Hospital Episode Statistics.ENTORNO CLÍNICO: Las bases de datos se basaron en el Reino Unido.PACIENTES: Se incluyeron todos los pacientes adultos que se sometieron a una proctectomía restauradora por una neoplasia rectal entre 1998 y 2018.PRINCIPALES MEDIDAS DE VALORACIÓN: El resultado primario fue un trastorno de salud mental incidente. Las asociaciones entre la disfunción intestinal, sexual y urinaria y los trastornos de salud mental incidentes se estudiaron utilizando modelos de regresión de riesgos proporcionales de Cox.RESULTADOS: En total, se identificaron 2.197 pacientes que se sometieron a proctectomía restauradora. De 1.858 pacientes sin disfunción intestinal, sexual o urinaria preoperatoria, 1.455 personas tampoco tenían trastornos de salud mental preoperatorios. En esta cohorte, 466 (32,0 %) pacientes desarrollaron trastornos de salud mental incidentes después de la PR durante 6333 años-persona de seguimiento. En la regresión multivariada de Cox, sexo femenino (HRa 1,30, IC 95% 1,06-1,56), enfermedad metastásica (HRa 1,57, IC 95% 1,14-2,15) e incidencia intestinal (HRa 1,41, IC del 95 %: 1,13 a 1,77) y la disfunción urinaria (aHR 1,57, IC del 95 %: 1,16 a 2,14) se asociaron con el desarrollo de trastornos de salud mental incidentes después de la proctectomía restauradora.LIMITACIONES: Este estudio estuvo limitado por el diseño del estudio observacional y la confusión residual.CONCLUSIÓN: Los trastornos de salud mental incidentes después de la proctectomía restauradora para el cáncer de recto son comunes. La presencia de deterioro funcional intestinal y urinario aumenta significativamente el riesgo de malos resultados psicológicos entre los sobrevivientes de cáncer de recto. (Traducción- Dr. Ingrid Melo ).

MilCanEpi: Increased Capability for Cancer Care Research in the Department of Defense

The Military Health System (MHS) of the US Department of Defense (DoD) provides comprehensive medical care to over nine million beneficiaries, including active-duty members, reservists, activated National Guard, military retirees, and their family members. The MHS generates an extensive database containing administrative claims and medical encounter data, while the DoD also maintains a cancer registry that collects information about the occurrence of cancer among its beneficiaries who receive care at military treatment facilities. Collating data from the two sources diminishes the limitations of using registry or medical claims data alone for cancer research and extends their usage. To facilitate cancer research using the unique military health resources, a computer interface linking the two databases has been developed, called Military Cancer Epidemiology, or MilCanEpi. The intent of this article is to provide an overview of the MilCanEpi data system, describing its components, structure, potential uses, and limitations.

Hematological and Other Cancers in People Using Clozapine: Analysis of Australian Spontaneous Reports Between 1995 and 2020

BACKGROUND

Recent observational study evidence suggests that clozapine, unlike other antipsychotics, may be associated with a small increased risk of hematological malignancy. This study described characteristics of hematological and other cancers in those taking clozapine reported to the Australian Therapeutic Goods Administration.

METHODS

We analyzed public case reports for "clozapine," "Clozaril," or "Clopine" from January 1995 to December 2020 classified as "neoplasm benign, malignant and unspecified" by the Australian Therapeutic Goods Administration. Data on age, sex, dose, clozapine start and cessation dates, Medical Dictionary for Regulatory Activities reaction terms, and date of cancer were extracted.

RESULTS

Overall, 384 spontaneous reports of cancers in people taking clozapine were analyzed. The mean age of patients was 53.9 years (SD, 11.4 years), and 224 (58.3%) were male. The most frequent cancers were hematological (n = 104 [27.1%]), lung (n = 50 [13.0%]), breast (n = 37 [9.6%]), and colorectal (n = 28 [7.3%]). The outcome was fatal for 33.9% of cancer reports. Lymphoma comprised 72.1% of all hematological cancers (mean patient age, 52.1 years; SD, 11.6 years). The median daily dose of clozapine at the time of hematological cancer report was 400 mg (interquartile range, 300-543.8 mg), and the median duration of clozapine use before hematological cancer diagnosis was 7.0 years (interquartile range, 2.8-13.2 years).

CONCLUSIONS

Lymphoma and other hematological cancers are overrepresented in spontaneous adverse event reports compared with other cancer types. Clinicians should be aware of the possible association with hematological cancers and monitor for and report any hematological cancers identified. Future studies should examine histology of lymphomas in people using clozapine and corresponding blood level of clozapine.

Research Priorities for Interventions to Address Health Disparities in Lung Nodule Management: An Official American Thoracic Society Research Statement

Background: Lung nodules are common incidental findings, and timely evaluation is critical to ensure diagnosis of localized-stage and potentially curable lung cancers. Rates of guideline-concordant lung nodule evaluation are low, and the risk of delayed evaluation is higher for minoritized groups. Objectives: To summarize the existing evidence, identify knowledge gaps, and prioritize research questions related to interventions to reduce disparities in lung nodule evaluation. Methods: A multidisciplinary committee was convened to review the evidence and identify key knowledge gaps in four domains: 1) research methodology, 2) patient-level interventions, 3) clinician-level interventions, and 4) health system-level interventions. A modified Delphi approach was used to identify research priorities. Results: Key knowledge gaps included 1) a lack of standardized approaches to identify factors associated with lung nodule management disparities, 2) limited data evaluating the role of social determinants of health on disparities in lung nodule management, 3) a lack of certainty regarding the optimal strategy to improve patient-clinician communication and information transmission and/or retention, and 4) a paucity of information on the impact of patient navigators and culturally trained multidisciplinary teams. Conclusions: This statement outlines a research agenda intended to stimulate high-impact studies of interventions to mitigate disparities in lung nodule evaluation. Research questions were prioritized around the following domains: 1) need for methodologic guidelines for conducting research related to disparities in nodule management, 2) evaluating how social determinants of health influence lung nodule evaluation, 3) studying approaches to improve patient-clinician communication, and 4) evaluating the utility of patient navigators and culturally enriched multidisciplinary teams to reduce disparities.

Impact of pre-existing mental health disorders on the receipt of guideline recommended cancer treatments: A systematic review

OBJECTIVE

Disparities in cancer outcomes for individuals with pre-existing mental health disorders have already been identified, particularly for cancer screening and mortality. We aimed to systematically review the influence on the time from cancer diagnosis to cancer treatment, treatment adherence, and differences in receipt of guideline recommended cancer treatment.

METHODS

We included international studies published in English from 1 January 1995 to 23 May 2022 by searching MEDLINE, Embase, and APA PsycInfo.

RESULTS

This review identified 29 studies with 27 being published in the past decade. Most studies focused on breast, non-small cell lung and colorectal cancer and were of high or medium quality as assessed by the Newcastle Ottawa Scale. All studies were from high-income countries, and mostly included patients enrolled in national health insurance systems. Five assessed the impact on treatment delay or adherence, and 25 focused on the receipt of guideline recommended treatment. 20/25 studies demonstrated evidence that patients with pre-existing mental health disorders were less likely to receive guideline recommended therapies such as surgery or radiotherapy. In addition, there was a greater likelihood of receiving less intensive or modified treatment including systemic therapy.

CONCLUSIONS

Across different cancer types and treatment modalities there is evidence of a clear disparity in the receipt of guideline recommended cancer treatment for patients with pre-existing mental health disorders. The effect of pre-existing mental health disorders on treatment delay or adherence is under-researched. Future research needs to include low- and middle-income countries as well as qualitative investigations to understand the reasons for disparities in cancer treatment.

Preexisting psychological illness and its association with mortality in lung cancer patients with access to support resources

INTRODUCTION

Diagnosis of lung cancer often results in tremendous stress for most patients, especially in patients with underlying psychological illness. Psychosocial support (consultation with psychologist, psychotherapist, or social worker) referral is considered standard for quality cancer care; however, which patients utilize these resources and how these resources affect patient outcomes remain unclear.

OBJECTIVES

We aimed to identify which newly diagnosed lung cancer patients accessed available psychosocial resources and assessed how utilization of these resources correlated with treatment and survival outcomes.

METHODS

Data were collected from National Cancer Institute-designated cancer center at the University of New Mexico. We analyzed lung cancer registry and mortality data at the cancer center and bronchoscopy suite data to retrospectively identify patients diagnosed with lung cancer between 2012 and 2017. We used a logistic regression model to compare psychological support utilization at the cancer center between patients with and without history of psychiatric illness. We used a Cox proportional hazards model to identify individual risk factors for mortality.

RESULTS

Patients with a previous psychological diagnosis were 2.4 times more likely (odds ratio = 2.443; confidence interval [CI], 1.130-5.284) to utilize psychological resources than patients without a pre-cancer psychological diagnosis. Patients who received psychosocial intervention had a 120.4% higher hazard of dying than those who did not (hazard ratio = 2.204; 95% CI, 1.240-3.917). One-year survival probability among those who did not utilize resources was 62.65% (95% CI, 55.24%-71.06%) and 43.0% (95% CI, 31.61%-58.50%) among those who did. Patients with a previous psychiatric diagnosis were more likely to utilize psychosocial resources within 1 year of lung cancer diagnosis.

CONCLUSIONS

Patients with previous psychiatric illness are more likely to utilize psychosocial resources at the cancer center after a new diagnosis of lung cancer. Patients who utilize psychosocial interventions have higher 1-year mortality than those who do not.

Chronic Obstructive Pulmonary Disease and Lung Cancer: A Review for Clinicians

Chronic obstructive pulmonary disease (COPD) and lung cancer are common global causes of morbidity and mortality. Because both diseases share several predisposing risks, the 2 diseases may occur concurrently in susceptible individuals. The diagnosis of COPD has important implications for the diagnostic approach and treatment options if lesions concerning for lung cancer are identified during screening. Importantly, the presence of COPD has significant implications on prognosis and management of patients with lung cancer. In this monograph, we review the mechanistic linkage between lung cancer and COPD, the impact of lung cancer screening on patients at risk, and the implications of the presence of COPD on the approach to the diagnosis and treatment of lung cancer. This manuscript succinctly reviews the epidemiology and common pathogenetic factors for the concurrence of COPD and lung cancer. Importantly for the clinician, it summarizes the indications, benefits, and complications of lung cancer screening in patients with COPD, and the assessment of risk factors for patients with COPD undergoing consideration of various treatment options for lung cancer.

The relationship between prior psychiatric diagnosis and brain cancer diagnosis in the U.S. military health system

PURPOSE

Prior research suggested the increased likelihood of brain cancer diagnosis following certain psychiatric diagnoses. This association may result from detection bias or suggest an early sign for brain cancer. This study investigated whether psychiatric illness may be an early manifestation of brain cancer while considering potential effects of detection bias.

METHODS

This case-control study used the data from the Department of Defense's Central Cancer Registry and the Military Health System Data Repository. Four cancer-free controls and one negative-outcome control (cancers not associated with psychiatric illness) were matched to each brain cancer case diagnosed from 1998 to 2013 by age, sex, race, and military status. The groups were compared in the likelihood of having a pre-existing psychiatric diagnosis using conditional logistic regression.

RESULTS

We found a significant association of psychiatric illnesses with brain cancer (Odds Ratio (OR) = 2.63, 95% confidence interval (CI) = 2.18-3.16) and other cancers (OR = 1.80, 95% CI = 1.49-2.19), compared to non-cancer controls. The association was stronger for psychiatric diagnoses within three months before cancer (brain cancer: OR = 26.77, 95% CI = 15.40-46.53; other cancers: OR = 4.12, 95% CI = 1.96-8.65). The association with psychiatric disorders within 3 months were higher for small brain tumors (OR = 128.32, 95% CI = 17.28-952.92 compared to non-cancer controls) while the OR was 2.79 for other cancers (95% CI = 0.86-8.99 compared to non-cancer controls).

CONCLUSION

Our findings suggest an association between diagnosed psychiatric illnesses and subsequent brain cancer diagnosis, which may not be solely explained by detection bias. Psychiatric illness might be a sign for early detection of brain cancer beyond the potential effects of detection bias.

Cumulative burden of psychiatric disorders and self-harm across 26 adult cancers

Cancer is a life-altering event causing considerable psychological distress. However, information on the total burden of psychiatric disorders across all common adult cancers and therapy exposures has remained scarce. Here, we estimated the risk of self-harm after incident psychiatric disorder diagnosis in patients with cancer and the risk of unnatural deaths after self-harm in 459,542 individuals. Depression was the most common psychiatric disorder in patients with cancer. Patients who received chemotherapy, radiotherapy and surgery had the highest cumulative burden of psychiatric disorders. Patients treated with alkylating agent chemotherapeutics had the highest burden of psychiatric disorders, whereas those treated with kinase inhibitors had the lowest burden. All mental illnesses were associated with an increased risk of subsequent self-harm, where the highest risk was observed within 12 months of the mental illness diagnosis. Patients who harmed themselves were 6.8 times more likely to die of unnatural causes of death compared with controls within 12 months of self-harm (hazard ratio (HR), 6.8; 95% confidence interval (CI), 4.3-10.7). The risk of unnatural death after 12 months was markedly lower (HR, 2.0; 95% CI, 1.5-2.7). We provide an extensive knowledge base to help inform collaborative cancer-psychiatric care initiatives by prioritizing patients who are most at risk.

Palliative and high-intensity end-of-life care in schizophrenia patients with lung cancer: results from a French national population-based study

Schizophrenia is marked by inequities in cancer treatment and associated with high smoking rates. Lung cancer patients with schizophrenia may thus be at risk of receiving poorer end-of-life care compared to those without mental disorder. The objective was to compare end-of-life care delivered to patients with schizophrenia and lung cancer with patients without severe mental disorder. This population-based cohort study included all patients aged 15 and older who died from their terminal lung cancer in hospital in France (2014-2016). Schizophrenia patients and controls without severe mental disorder were selected and indicators of palliative care and high-intensity end-of-life care were compared. Multivariable generalized log-linear models were performed, adjusted for sex, age, year of death, social deprivation, time between cancer diagnosis and death, metastases, comorbidity, smoking addiction and hospital category. The analysis included 633 schizophrenia patients and 66,469 controls. The schizophrenia patients died 6 years earlier, had almost twice more frequently smoking addiction (38.1%), had more frequently chronic pulmonary disease (32.5%) and a shorter duration from cancer diagnosis to death. In multivariate analysis, they were found to have more and earlier palliative care (adjusted Odds Ratio 1.27 [1.03;1.56]; p = 0.04), and less high-intensity end-of-life care (e.g., chemotherapy 0.53 [0.41;0.70]; p < 0.0001; surgery 0.73 [0.59;0.90]; p < 0.01) than controls. Although the use and/or continuation of high-intensity end-of-life care is less important in schizophrenia patients with lung cancer, some findings suggest a loss of chance. Future studies should explore the expectations of patients with schizophrenia and lung cancer to define the optimal end-of-life care.

Impact of Psychiatric Comorbidities on Surgical Outcomes for Non-Small Cell Lung Cancer

BACKGROUND

Psychiatric comorbidities (PC) have been associated with poor surgical outcomes in several malignancies. However, the impact of PC on surgical outcomes for non-small cell lung cancer (NSCLC) remains largely unknown.

METHODS

NSCLC patients who underwent pulmonary resection at a single institution between 2006-2017 were included. Presence of preoperative PC was identified by documented diagnostic codes. Demographic, histopathologic, perioperative, and survival data were analyzed. Categorical variables were compared using chi-squared or Fisher's exact test. Overall and disease-free survival were analyzed using Kaplan-Meier method. Univariable and multivariable logistic regression analyses were performed for 30-day readmission.

RESULTS

Among 2907 patients, PC were present preoperatively in 180 (6%), including 130 (72%) anxiety, 52 (29%) depression, 28 (16%) adjustment disorder, 16 (9%) alcohol abuse, 8 (4%) sleep disorder, and 3 (2%) schizophrenia. Patients with PC were younger, with fewer cardiovascular complications. There were no differences in length of stay. However, PC led to increased 30-day readmission (12% vs 6%, p=0.004). Reasons for readmission did not differ between groups (p=0.679). Upon multivariable analysis, PC independently predicted 30-day readmission (OR: 2.00, p=0.005). Importantly, there were no differences in 30- or 90-day mortality (p=0.495 and 0.748, respectively), overall survival (p=0.439), or disease-free survival (p=0.924).

CONCLUSIONS

NSCLC patients with and without PC experienced similar perioperative and long-term outcomes, suggesting that individuals should not be denied surgical care on the basis of such comorbidities. However, further research should seek to identify reasons for increased risk of readmission for patients with PC and validate these findings in other settings.

Association of pre-existing mental illness with all-cause and cancer-specific mortality among Medicare beneficiaries with pancreatic cancer

BACKGROUND

Among patients with pancreatic cancer, the association of pre-existing mental illness with long-term outcomes remains unknown.

METHODS

Individuals diagnosed with pancreatic adenocarcinoma were identified in the SEER-Medicare database. Patients were classified as having mental illness if an ICD9/10CM code for anxiety, depression, bipolar disorder, schizophrenia or other psychotic disorder was recorded.

RESULTS

Among the 54,234 Medicare beneficiaries with pancreatic cancer, roughly 1 in 12 (n = 4793, 8.83%) individuals had a diagnosis of a mental illness. The majority (n = 4029, 84.1%) had anxiety or depression, while 16% (n = 764) had bipolar/schizophrenic disorders. On multivariable analysis, among patients with early stage cancer, individuals with pre-existing anxiety/depression and bipolar/schizophrenic disorders had 22% (OR 0.78, 95% CI 0.69-0.86) and 46% (OR 0.54, 95% CI 0.42-0.70) reduced odds, respectively, to undergo cancer-directed surgery. Furthermore, patients with a pre-existing history of bipolar/schizophrenic disorders had a 20% (HR 1.20, 95% CI 1.21-1.40) higher risk of all-cause mortality and 27% (HR 1.27, 95% CI 1.17-1.37) higher risk of pancreatic cancer-specific mortality compared to individuals without a history of mental illness.

CONCLUSION

One in twelve patients with pancreatic cancer had a pre-existing mental illness. Individuals with mental illness were more likely to have worse overall and cancer-specific long-term outcomes.

Early-Stage Non-Small Cell Lung Cancer Stereotactic Body Radiation Therapy (SBRT) Outcomes in an Equal Access Military Setting

Introduction Lung stereotactic body radiation therapy (SBRT) is a first-line treatment for early-stage lung cancer in non-surgical candidates or those who refuse surgery. We compared our institutional outcomes from a unique patient population with decreased barriers to care with a recently published prospective series. Materials and methods  We retrospectively reviewed all patients who received definitive lung SBRT at the Walter Reed National Military Medical Center from 2015 to 2020. All patients underwent a positron emission tomography-computed tomography (PET-CT) and all were presented at a multidisciplinary tumor board. Patients were treated on a Trubeam linear accelerator (LINAC)-based system with daily cone-beam CT. The results were qualitatively compared to outcomes from prospective studies including RTOG 0236 and RTOG 0618. Results A total of 105 patients with 114 lesions were included. Median age was 77 years and 54.7% had ≥ 40-pack year smoking history. 36.8% did not have pathologic confirmation. With a median follow-up of 24 months, three-year local control (LC), disease-free survival (DFS) and overall survival (OS) rates were 92.4%, 81.0%, and 80.0%, respectively. Rates of Grade 1 and 2 toxicity were 21.9% and 6.7% and no patients experienced Grade ≥ 3 toxicity. Conclusions In our military setting with universal coverage and routine multidisciplinary care, lung SBRT provides outcomes comparable to prospective studies conducted at high-volume academic centers. More than one-third of patients were treated empirically without pathologic confirmation of disease, demonstrating a difference between clinical trials and community practice. Further investigation is warranted to integrate multidisciplinary management and achieve equal access to care to bridge existing health disparities in the community setting.

Association of Mental Health Treatment With Outcomes for US Veterans Diagnosed With Non-Small Cell Lung Cancer

Importance

Preexisting mental health disorders (MHDs) are associated with increased mortality in people diagnosed with cancer, yet few data exist on the efficacy of interventions to mitigate this disparity.

Objective

To evaluate the association of participation in mental health treatment programs (MHTPs), housing support programs, or employment support programs with stage at cancer diagnosis, receipt of stage-appropriate treatment, and mortality among patients with a preexisting MHD.

Design, Setting, and Participants

This retrospective, population-based cohort study included 55 315 veterans in the Veterans Affairs Central Cancer Registry (VACCR) who had newly diagnosed non-small cell lung cancer (NSCLC) from September 30, 2000, to December 31, 2011. Data were analyzed from January 15, 2017, to March 17, 2020.

Exposures

Mental health disorders, including schizophrenia, bipolar disorder, depressive disorder, posttraumatic stress disorder, and substance use disorder.

Main Outcomes and Measures

Stage at cancer diagnosis, receipt of stage-appropriate cancer treatment, all-cause mortality, and lung cancer-specific mortality.

Results

Of 55 315 veterans with a new diagnosis of NSCLC included in the analysis (98.1% men; mean [SD] age, 68.1 [9.8] years), 18 229 had a preexisting MHD, among whom participation in MHTPs was associated with a lower likelihood of being diagnosed in a late stage (odds ratio [OR], 0.62; 95% CI, 0.58-0.66; P < .001), a higher likelihood of receiving stage-appropriate treatment (OR, 1.55; 95% CI, 1.26-1.89; P < .001), lower all-cause mortality (adjusted hazard ratio [AHR], 0.74; 95% CI, 0.72-0.77; P < .001), and lower lung cancer-specific mortality (AHR, 0.77; 95% CI, 0.74-0.80; P < .001). Likewise, participation in housing and employment support programs was associated with similar improvements in all outcomes described above.

Conclusions and Relevance

In veterans with preexisting MHDs diagnosed with NSCLC, participation in MHTPs and housing and employment support programs was associated with improved lung cancer-related outcomes. This study might be the first to demonstrate significant improvement in cancer mortality for patients with MHDs who participate in MHTPs, housing support programs, or employment support programs. This work supports substantial literature that investment in mental health and social needs can improve health outcomes and highlights the importance of further research to identify, evaluate, and implement interventions to improve outcomes for patients with MHDs who are diagnosed with cancer.

The effect of a severe psychiatric illness on colorectal cancer treatment and survival: A population-based retrospective cohort study

OBJECTIVES

To identify inequalities in cancer survival rates for patients with a history of severe psychiatric illness (SPI) compared to those with no history of mental illness and explore differences in the provision of recommended cancer treatment as a potential explanation.

DESIGN

Population-based retrospective cohort study using linked cancer registry and administrative data at ICES.

SETTING

The universal healthcare system in Ontario, Canada.

PARTICIPANTS

Colorectal cancer (CRC) patients diagnosed between April 1st, 2007 and December 31st, 2012. SPI history (schizophrenia, schizoaffective disorders, other psychotic disorders, bipolar disorders or major depressive disorders) was determined using hospitalization, emergency department, and psychiatrist visit data and categorized as 'no history of mental illness, 'outpatient SPI history', and 'inpatient SPI history'.

MAIN OUTCOME MEASURES

Cancer-specific survival, non-receipt of surgical resection, and non-receipt of adjuvant chemotherapy or radiation.

RESULTS

24,507 CRC patients were included; 482 (2.0%) had an outpatient SPI history and 258 (1.0%) had an inpatient SPI history. Individuals with an SPI history had significantly lower survival rates and were significantly less likely to receive guideline recommended treatment than CRC patients with no history of mental illness. The adjusted HR for cancer-specific death was 1.69 times higher for individuals with an inpatient SPI (95% CI 1.36-2.09) and 1.24 times higher for individuals with an outpatient SPI history (95% CI 1.04-1.48). Stage II and III CRC patients with an inpatient SPI history were 2.15 times less likely (95% CI 1.07-4.33) to receive potentially curative surgical resection and 2.07 times less likely (95% CI 1.72-2.50) to receive adjuvant radiation or chemotherapy. These findings were consistent across multiple sensitivity analyses.

CONCLUSIONS

Individuals with an SPI history experience inequalities in colorectal cancer care and survival within a universal healthcare system. Increasing advocacy and the availability of resources to support individuals with an SPI within the cancer system are warranted to reduce the potential for unnecessary harm.

An Overview of Treating People with Comorbid Dementia: Implications for Cancer Care

With increasing prevalence of both cancer and dementia in the UK, due to an ageing population, oncology healthcare professionals will experience higher numbers of people with both conditions. As dementia is highly heterogeneous and symptoms vary from individual to individual, it presents specific challenges for healthcare professionals, people with dementia and caregivers alike. This overview will describe current theories that explain the association between cancer and dementia, report prevalence rates and highlight the evidence on the impact of having a diagnosis of dementia on outcomes along the cancer pathway from cancer symptom detection to cancer treatment outcomes. It suggests that although prevalence rates of cancer and dementia are typically lower than other comorbidities, people with cancer and dementia have poorer cancer-related outcomes. This includes later stage cancer diagnoses, fewer cancer treatment options and an increased risk of death compared with people who have cancer alone or other comorbid conditions. Considerations for cancer treatment decision making and management are proposed to improve patient experience for this group.

Comorbidity and stage at diagnosis among lung cancer patients in the US military health system

PURPOSE

We investigated the association between comorbidities and stage at diagnosis among NSCLC patients in the US Military Health System (MHS), which provides universal health care to its beneficiaries.

METHODS

The linked data from the Department of Defense's Central Cancer Registry (CCR) and the MHS Data Repository (MDR) were used. The study included 4768 patients with histologically confirmed primary NSCLC. Comorbid conditions were extracted from the MDR data. Comorbid conditions were those included in the Charlson Comorbidity Index (CCI) and were defined as a diagnosis during a 3-year time frame prior to the NSCLC diagnosis. Multivariable logistic regression was performed to estimate odds ratios (ORs) and 95% confidence intervals (95% CI) of late stage (stages III and IV) versus early stage (stages I and II) in relation to pre-existing comorbidities.

RESULTS

Compared to patients with no comorbidities, those with prior comorbidities tended to be less likely to have lung cancer diagnosed at late stage. When specific comorbidities were analyzed, decreased odds of being diagnosed at late stage were observed among those with chronic obstructive pulmonary disease (COPD) (adjusted OR 0.78, 95% CI 0.68 to 0.90). In contrast, patients with a congestive heart failure or a liver cirrhosis/chronic hepatitis had an increased likelihood of being diagnosed at late stage (adjusted OR 1.30, 95% CI 1.00 to 1.69 and adjusted OR 1.87, 95% CI 1.24 to 2.82, respectively).

CONCLUSIONS

Among NSCLC patients in an equal access health system, the likelihood of late stage at diagnosis differed by specific comorbid diseases.

Stage at diagnosis and survival in patients with cancer and a pre-existing mental illness: a meta-analysis

INTRODUCTION

Individuals with a pre-existing mental illness, especially those experiencing reduced social, occupational and functional capacity, are at risk for cancer care disparities. However, uncertainty surrounding the effect of a mental illness on cancer outcomes exists.

METHODS

We conducted a systematic review and meta-analysis of observational studies using MEDLINE and PubMed from 1 January 2005 to 1 November 2018. Two reviewers evaluated citations for inclusion. Advanced stage was defined as regional, metastatic or according to a classification system. Cancer survival was defined as time survived from cancer diagnosis. Pooled ORs and HRs were presented. The Newcastle-Ottawa bias risk assessment scale was used. Random-effects models used the Mantel-Haenszel approach and the generic inverse variance method. Heterogeneity assessment was performed using I².

RESULTS

2381 citations were identified; 28 studies were included and 24 contributed to the meta-analysis. Many demonstrated methodological flaws, limiting interpretation and contributing to significant heterogeneity. Data source selection, definitions of a mental illness, outcomes and their measurement, and overadjustment for causal pathway variables influenced effect sizes. Pooled analyses suggested individuals with a pre-existing mental disorder have a higher odds of advanced stage cancer at diagnosis and are at risk of worse cancer survival. Individuals with more severe mental illness, such as schizophrenia, are at a greater risk for cancer disparities.

DISCUSSION

This review identified critical gaps in research investigating cancer stage at diagnosis and survival for individuals with pre-existing mental illness. High-quality research is necessary to support quality improvement for the care of psychiatric patients and their families during and following a cancer diagnosis.

Relationship between preexisting mental disorders and prognosis of gynecologic cancers: A case-control study

AIM

Cancer treatment involves long-term therapy and follow-up, with mental disorders (MD) often affecting the treatment process. Hence, in this study, we retrospectively analyze cases involving gynecologic cancer with MD and clarify the relationship between psychosis and cancer prognosis.

METHODS

Patients with both gynecologic cancer and MD from January 2003 to August 2016 were recruited in this study. Cases were limited to those whose MD had been diagnosed before their cancer. Control patients without MD were also analyzed. Both cases and controls were adjusted for age, cancer type, and cancer stage.

RESULTS

A total of 54 patients with gynecologic cancer and MD, as well as 108 controls without MD, were included. The median age of the patients was 52 years. Details regarding cancer type were as follows: 11 ovarian cancers, 26 uterine corpus cancers and 17 cervical cancers. Among these, 25 schizophrenia cases, 15 depressive disorders, 4 bipolar disorders and 10 other MD were recorded. No significant differences in the 5-year survival rate were found between patients and controls. In advanced-stage cervical cancer, however, the prognosis was significantly poor given the low rate of initial treatment completion. Moreover, patients with advanced-stage cervical cancer had significantly lower chemotherapy completion rates compared to those with other gynecologic malignancies.

CONCLUSION

Mental disorders do not affect the prognosis of gynecologic cancers, except for advanced cervical cancer. Accordingly, improving the low rate of initial treatment completion seems to be a focal point for better prognosis in advanced cervical cancer.

Disparity of end-of-life care in cancer patients with and without schizophrenia: A nationwide population-based cohort study

BACKGROUND

Cancer patients with schizophrenia may face disparities in end-of life care, and it is unclear whether schizophrenia affects their medical care and treatment.

METHODS

We conducted a nationwide population-based cohort study based on the National Health Insurance Research Database of Taiwan. The study population included patients >20years old who were newly diagnosed as having one of six common cancers between 2000 and 2012 (schizophrenia cohort: 1911 patients with both cancer and schizophrenia; non-schizophrenia cohort: 7644 cancer patients without schizophrenia). We used a multiple logistic regression model to analyze the differences in medical treatment between the two cohorts in the final 1 and 3months of life.

RESULTS

In the 1month before death, there was higher intensive care unit utilization in the schizophrenia group [odd ratio (OR)=1.21, 95% confidence interval (CI)=1.07-1.36] and no significant differences between the groups in-hospital stay length or hospice care. The schizophrenia patients received less chemotherapy (OR=0.60, 95% CI=0.55-0.66) but more invasive interventions, such as cardiopulmonary resuscitation (OR=1.34, 95% CI=1.15-1.57). Advanced diagnostic examinations, such as computed tomography/magnetic resonance imaging/sonography (OR=0.80, 95% CI=0.71-0.89), were used less often for the schizophrenia patients. The 1- and 3-month prior to death results were similar.

CONCLUSION

End-of-life cancer patients with schizophrenia underwent more frequent invasive treatments but less chemotherapy and examinations. Treatment plans/advance directives should be discussed with patients/families early to enhance end-of-life care quality and reduce health care disparities caused by schizophrenia.

Do Future Limitation Perspective in Cancer Patients Predict Fear of Cancer Recurrence, Mental Distress, and the Ventromedial Prefrontal Cortex Activity?

Life-threatening diseases (e.g., cancer) affect people's future time perspective (FTP) and affect their mental health. When one's lifetime is perceived as running out, the individual possesses a future limitation perspective (FLP), which is one of factors in FTP. In this study, we explored the structural relationship between FLP, fear of cancer recurrence (FCR), mental health status (MHS), and brain activity in patients with cancer. Cancer patients were divided into two groups using the FTP scale and Feelings About Life Scale: a strong FLP group (S-FLP) and a weak FLP group (W-FLP). For these groups, we measured cancer patients' MHS using the Symptom Checklist (SCL-90) and FCR using the Cancer Acceptance Scale; brain activity was measured using resting-state functional magnetic resonance imaging (rs-fMRI). Behavioral results showed that the S-FLP group had higher mental symptoms and FCR scores than did the W-FLP group. Neuroimaging results revealed that spontaneous brain activity in the ventromedial prefrontal cortex (vmPFC) was stronger in the W-FLP group than in the S-FLP group. Moreover, brain activity in the vmPFC negatively correlated with FLP, FCR, and SCL-90 scores only in the S-FLP group, and the model constructed further indicated that FCR and SCL-90 scores fully mediated the relationship between FLP and vmPFC activities. These findings suggested that a strong FLP might lead to mental disorders and greater FCR, which might change the spontaneous activity of the vmPFC in cancer patients.

Psychiatric disease in surgically treated colorectal cancer patients

BACKGROUND

Underlying psychiatric conditions may affect outcomes of surgical treatment for colorectal cancer (CRC) because of complex clinical presentation and treatment considerations. We hypothesized that patients with psychiatric illness (PSYCH) would have evidence of advanced disease at presentation, as manifested by higher rates of colorectal surgery performed in the presence of obstruction, perforation, and/or peritonitis (OPP-surgery).

MATERIALS AND METHODS

Using data from the 2007-2011 National Inpatient Sample, we identified patients with a diagnosis of CRC undergoing colorectal surgery. In addition to somatic comorbid conditions flagged in the National Inpatient Sample, we used the Clinical Classification Software to identify patients with PSYCH, including schizophrenia, delirium/dementia, developmental disorders, alcohol/substance abuse, and other psychiatric conditions. Our study outcome was OPP-surgery. In addition to descriptive analysis, we conducted multivariable logistic regression analysis to analyze the independent association between each of the PSYCH conditions and OPP-surgery, after adjusting for patient demographics and somatic comorbidities.

RESULTS

Our study population included 591,561 patients with CRC and undergoing colorectal cancer surgery, of whom 60.6% were aged 65 years or older, 49.4% were women, and 6.3% had five or more comorbid conditions. Then, 17.9% presented with PSYCH. The percent of patients undergoing OPP-surgery was 13.9% in the study population but was significantly higher for patients with schizophrenia (19.3%), delirium and dementia (18.5%), developmental disorders (19.7%), and alcohol/substance abuse (19.5%). In multivariable analysis, schizophrenia, delirium/dementia, and alcohol/substance abuse were each independently associated with increased rates of OPP-surgery.

CONCLUSIONS

Patients with PSYCH may have obstacles in receiving optimal care for CRC. Those with PSYCH diagnoses had significantly higher rates of OPP-surgery. Additional evaluation is required to further characterize the clinical implications of advanced disease presentation for patients with PSYCH diagnoses and colorectal cancer.