Psychiatric morbidity and cervical cancer screening: a retrospective population-based case-cohort study

Barriers and facilitators for people with severe mental illness accessing cancer screening: A systematic review

OBJECTIVE

Evidence suggests that people with severe mental illness (PwSMI) are 2.1 times more likely to die from cancer before the age of 75, compared to people without Severe mental illness (SMI). Yet, cancer screening uptake is low among PwSMI. This mixed-methods systematic review aimed to identify the barriers and facilitators for PwSMI deciding to access and attend primary cancer screening of the cervix, breast and colon.

METHODS

Six electronic databases and two grey literature sources were searched, with 1017 records screened against inclusion criteria. Included papers were appraised and data synthesised using the constructs of Normalisation Process Theory.

RESULTS

Twenty papers met the inclusion criteria. Factors that impact upon uptake of PwSMI accessing cancer screening were found to include age, gender, race, and income. Common barriers to attending screening included poor communication from healthcare staff, stigmatising attitudes, and accessibility problems such as no access to transportation. While, facilitators included social support from friends, family, and healthcare providers.

CONCLUSIONS

Due to ease and privacy, colorectal screening was found to have fewer barriers when compared to cervical and breast screening. The review identified multiple barriers that can be addressed and targeted to support decision-making for cancer screening among PwSMI. The protocol was registered with PROSPERO (CRD42022331781).

Breast Cancer Screening Among Females With and Without Schizophrenia

Importance

Breast cancer screening with mammography is recommended in Ontario, Canada, for females 50 years or older. Females with schizophrenia are at higher risk of breast cancer, but in Ontario it is currently unknown whether breast cancer screening completion differs between those with vs without schizophrenia and whether primary care payment models are a factor.

Objective

To compare breast cancer screening completion within 2 years after the 50th birthday among females with and without schizophrenia, and to identify the association between breast cancer screening completion and different primary care payment models.

Design, Setting, and Participants

This case-control study analyzed Ontario-wide administrative data on females with and without schizophrenia who turned 50 years of age between January 1, 2010, and December 31, 2019. Those with schizophrenia (cases) were matched 1:10 to those without schizophrenia (controls) on local health integration network, income quintile, rural residence, birth dates, and weighted Aggregated Diagnosis Group score. Data analysis was performed from November 2021 to February 2023.

Exposures

Exposures were schizophrenia and primary care payment models.

Main Outcomes and Measures

Outcomes included breast cancer screening completion among cases and controls within 2 years after their 50th birthday and the association with receipt of care from primary care physicians enrolled in different primary care payment models, which were analyzed using logistic regression and reported as odds ratios (ORs) and 95% CIs.

Results

The study included 11 631 females with schizophrenia who turned 50 years of age during the study period and a matched cohort of 115 959 females without schizophrenia, for a total of 127 590 patients. Overall, 69.3% of cases and 77.1% of controls had a mammogram within 2 years after their 50th birthday. Cases had lower odds of breast cancer screening completion within 2 years after their 50th birthday (OR, 0.67; 95% CI, 0.64-0.70). Cases who received care from a primary care physician in a fee-for-service (OR, 0.57; 95% CI, 0.53-0.60) or enhanced fee-for-service (OR, 0.79; 95% CI, 0.75-0.82) payment model had lower odds of having a mammogram than cases whose physicians were paid under a Family Health Team model.

Conclusions and Relevance

This case-control study found that, in Ontario, Canada, breast cancer screening completion was lower among females with schizophrenia, and differences from those without schizophrenia may partially be explained by differences in primary care payment models. Widening the availability of team-based primary care for females with schizophrenia may play a role in increased breast cancer screening rates.

Mortality among patients with diffuse large B-cell lymphoma and mental disorders: a population-based study

BACKGROUND

Mental disorders have been reported in patients with diffuse large B-cell lymphoma (DLBCL), but studies examining their association with mortality are lacking.

METHODS

We conducted a population-based study using linked administrative health-care databases from Ontario, Canada. All patients with DLBCL 18 years of age or older treated with rituximab-based therapy between January 1, 2005, and December 31, 2017, were identified and followed until March 1, 2020. Mental disorders were defined as either preexisting or postdiagnosis (after lymphoma treatment initiation). Cox proportional hazards models were used to estimate the adjusted hazard ratio (HR) between mental disorders and 1-year and all-cause mortality while controlling for covariates.

RESULTS

We identified 10 299 patients with DLBCL. The median age of the cohort was 67 years; 46% of patients were female, and 28% had a preexisting mental disorder. At 1-year follow-up, 892 (9%) had a postdiagnosis mental disorder, and a total of 2008 (20%) patients died. Preexisting mental disorders were not associated with 1-year mortality (adjusted HR = 1.06, 95% confidence interval [CI] = 0.96 to 1.17, P = .25), but postdiagnosis disorders were (adjusted HR = 1.51, 95% CI = 1.26 to 1.82, P = .0001). During a median follow-up of 5.2 years, 2111 (22%) patients had a postdiagnosis mental disorder, and 4084 (40%) patients died. Both preexisting and postdiagnosis mental disorders were associated with worse all-cause mortality (preexisting adjusted HR = 1.12, 95% CI = 1.04 to 1.20, P = .0024; postdiagnosis adjusted HR = 1.63, 95% CI = 1.49 to 1.79, P < .0001).

CONCLUSIONS

Patients with DLBCL and mental disorders had worse short-term and long-term mortality, particularly those with postdiagnosis mental disorders. Further studies are needed to examine mental health service utilization and factors mediating the relationship between mental disorders and inferior mortality.

Overall and Cervical Cancer Survival in Patients With and Without Mental Disorders

Importance

Individuals with a mental disorder experience substantial health disparity and are less likely to participate in cervical screening and human papillomavirus vaccination. Additionally, this population may benefit less from tertiary cancer prevention.

Objective

To compare clinical characteristics and survival patterns between patients with cervical cancer with and without a preexisting diagnosis of a mental disorder at the time of cervical cancer diagnosis.

Design, Setting, and Participants

This cohort study obtained data from Swedish population-based (Swedish Cancer Register, Swedish Cause of Death Register, Swedish Total Population Register, Swedish Patient Register, and Swedish Longitudinal Integration Database for Health Insurance and Labor Market Studies) and quality registries (Swedish Quality Register of Gynecologic Cancer and Swedish National Cervical Screening Register) on patients with cervical cancer. Patients who were included in the analysis were identified using the Swedish Cancer Register and were diagnosed with cervical cancer between 1978 and 2018. The Swedish Patient Register was used to identify patients with mental disorders using codes from the International Classification of Diseases, Eighth Revision and Ninth Revision and the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. Because data on clinical characteristics at the time of cancer diagnosis were available for only for part of the study population, 2 patient groups were created: those with cervical cancer diagnosed from 2002 to 2016 and all patients diagnosed with cervical cancer (1978-2018). Data analyses were carried out between March and September 2022.

Exposure

Clinical diagnoses of a mental disorder, including substance abuse, psychotic disorders, depression, anxiety, stress-related disorders, attention-deficit/hyperactivity disorder, autism, and intellectual disability, prior to cervical cancer.

Main Outcomes and Measures

Death due to any cause or due to cervical cancer as ascertained from the Swedish Cause of Death Register.

Results

The sample included 20 177 females (mean [SD] age, 53.4 [17.7] years) diagnosed with cervical cancer from 1978 to 2018. In a subgroup of 6725 females (mean [SD] age, 52.2 [18.0] years) with cervical cancer diagnosed from 2002 to 2016, 893 (13.3%) had a preexisting diagnosis of a mental disorder. Compared with patients with no preexisting mental disorder diagnosis, those with a preexisting mental disorder had a higher risk of death due to any cause (hazard ratio [HR], 1.32; 95% CI, 1.17-1.48) and due to cervical cancer (HR, 1.23; 95% CI, 1.07-1.42). These risks were lower after adjustment for cancer characteristics at the time of cancer diagnosis (death due to any cause: HR, 1.19 [95% CI, 1.06-1.34] and death due to cervical cancer: HR, 1.12 [95% CI, 0.97-1.30]). Risk of death was higher for patients with substance abuse, psychotic disorders, or mental disorders requiring inpatient care. Among patients with cervical cancer diagnosed from 1978 to 2018, the estimated 5-year survival improved continuously during the study period regardless of preexisting diagnosis of a mental disorder status. For example, in 2018, the estimated 5-year overall survival proportion was 0.66 (95% CI, 0.60-0.71) and 0.74 (95% CI, 0.72-0.76) for patients with and without a preexisting diagnosis of a mental disorder, respectively.

Conclusions and Relevance

Findings of this cohort study suggest that patients with cervical cancer and a preexisting diagnosis of a mental disorder have worse overall and cervical cancer-specific survival than patients without a preexisting mental disorder diagnosis, which may be partly attributable to cancer and sociodemographic characteristics at diagnosis. Hence, individuals with mental disorders deserve special attention in the tertiary prevention of cervical cancer.

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.

Mortality from cancer in people with severe mental disorders in Emilia Romagna Region, Italy

Objective

To examine cancer‐related mortality in patients with severe mental disorders (SMI) in the Emilia Romagna (ER) Region, Northern Italy, during the period 2008–2017 and compare it with the regional population.

Methods

We used the ER Regional Mental Health Registry identifying all patients aged ≥18 years who had received an ICD‐9CM system diagnosis of SMI (i.e., schizophrenia or other functional psychosis, mania, or bipolar affective disorders) during a 10‐year period (2008–2017). Information on deaths (date and causes of death) were retrieved through the Regional Cause of Death Registry. Comparisons were made with the deaths and cause of deaths of the regional population over the same period.

Results

Amongst 12,385 patients suffering from SMI (64.1% schizophrenia spectrum and 36.9% bipolar spectrum disorders), 24% (range 21%–29%) died of cancer. In comparison with the general regional population, the mortality for cancer was about 50% higher among patients with SMI, irrespective if affected by schizophrenia or bipolar disorders. As for the site‐specific cancers, significant excesses were reported for stomach, central nervous system, respiratory, and pancreas cancer with a variability according to psychiatric diagnosis and gender.

Conclusions

Patients suffering from SMI had higher mortality risk than the regional population with some differences according to cancer type, gender, and psychiatric diagnosis. Proper cancer preventive and treatment interventions, including more effective risk modification strategies (e.g., smoking cessation, dietary habits) and screening for cancer, should be part of the agenda of all mental health departments in conjunction with other health care organizations, including psycho‐oncology.

Cancer and schizophrenia

PURPOSE OF REVIEW

On the basis of articles published in 2018, 2019 and 2020, the first aim of this review is to present estimates of incidence rates and excess mortality of overall cancer and organ-specific cancers for patients with schizophrenia compared with the general population.The second aim is to explore if underdiagnosis and undertreatment can explain - at least partly - the increased mortality of cancer in patients with schizophrenia compared with the general population.

RECENT FINDINGS

Patients diagnosed with schizophrenia have an approximately 50% increased risk of death by cancer compared to age and sex-matched people in the general population. Studies have confirmed an increased mortality from breast, lung and colon cancer in patients with schizophrenia.Analyses of incidence of cancer revealed contradicting results, with some studies showing no increase in incidence and others a modestly increased incidence in overall cancer. Studies of incidence of specific types of cancers showed modestly increased risk of pancreas, oesophagus, breast cancer and contradicting results regarding lung cancer.In studies identified that compared to the general population, patients with schizophrenia were at an increased risk of not being diagnosed or treated for cancer before death of cancer. In addition, patients with schizophrenia had lower chances of getting optimal treatment for colon cancer after diagnosis.

SUMMARY

This review indicates that patients with schizophrenia are at increased risk of dying of cancer and of several specific types of cancer. This increased mortality can be reduced if the price of tobacco is increased, if smoking cessation programmes are offered systematically, screening programs better implemented in this highly vulnerable group, and if procedures to facilitate access to early diagnosis and effective treatment are implemented.

Cervical cancer among Swedish women with drug use disorders: A nationwide epidemiological study

BACKGROUND/AIM

Cervical cancer incidence and mortality has decreased after introduction of national screening in Sweden, but women with drug use disorders (DUD) are less likely to participate in screening programs. We aimed to investigate cervical cancer incidence and mortality among women with DUD compared to the general female population in Sweden.

METHODS

We conducted a cohort study based on Swedish national register data for the period January 1997-December 2015. Data was collected for 3,838,248 women aged 15-75 years of whom 50,858 had DUD. Adjusted hazard ratios (HRs) for incident and fatal cervical cancer were calculated for women with and without DUD using Cox regression analysis.

RESULTS

DUD was significantly associated with incident cervical cancer (HR = 1.39, 95% confidence interval [CI] 1.39-1.61), but not fatal cervical cancer (HR = 1.25, 95% CI: 0.91-1.71), after adjusting for age, educational attainment, social welfare, region of residence, marital status and HIV infection.

CONCLUSION

Women with DUD were thus identified as a risk group for incident cervical cancer, which calls for attention from clinicians and policy makers. It is possible that non-attendance in cancer screening and other healthcare seeking barriers may affect the risk of incident cervical cancer among women with DUD but more research on this topic is needed.