Originally published as JCO Early Release 10.1200/JCO.2008.19.5990 on December 29 2008

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Predictors of Referral for Psychosocial Services: Recommendations From the Institute of Medicine Report—Cancer Care for the Whole Patient

Department of Psychiatry, Georgetown University, Washington, DC

This issue of Journal of Clinical Oncology includes a report of a study that seeks to identify predictors of referral for psychosocial care for patients being treated in an oncologic setting. The study by Ellis et al¹ compares referral patterns of patients with late-stage colorectal and lung cancer who were enrolled onto a study that assessed psychosocial functioning in patients with late-stage disease. The authors conducted a retrospective analysis to determine what patient-based characteristics predict referral for psychosocial evaluation and services. The study results indicated that younger age, being unmarried, and presence of depressive symptoms significantly predicted referral for additional services. Interestingly though, they found that fewer than 50% of patients who screened positive for depression were actually referred for psychosocial services. The study thus highlights the importance of psychosocial services for patients with cancer, which was recently addressed in the Institute of Medicine (IOM) report, Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs.²

Although there has been mounting evidence regarding the need for systematic evaluation and management of psychosocial needs of patients, the evidence is clear that most patients and their family members are not receiving these services. As a result of funding from the US Congress, the IOM established a committee to study the issue; in October 2007, the report was released. The report provides extensive information supporting the need for psychosocial services, the impact of psychosocial distress on a patient's ability to receive treatment, and the strong evidence of the effectiveness of a variety of interventions in helping to diminish psychosocial needs and distress. The report also developed a set of 10 recommendations, which call on providers, patients, family members, payors, researchers, and others to assure that appropriate psychosocial assessment and services are available for all patients with a diagnosis of cancer.

The evidence is clear that the majority of patients will have some level of psychosocial distress at some point during diagnosis, treatment, or survival related to cancer. Distress may be psychological—related to fears, coping skills, or interactions with family, friends, or health care providers, or it could be psychiatric, in that patients may experience a series of symptoms including disruptions in mood, increased anxiety, poor sleep, or poor concentration or memory. Or patients may have a host of social needs, including transportation, finances, employment, or housing. When these problems exist, patients may have difficulties tolerating cancer treatment and obtaining treatment or follow-up, or they may have significant difficulty functioning at work or at home. Moreover, numerous well-studied, reliable tools exist to accurately identify and assess these problems in the oncology treatment setting.

Furthermore, the report catalogs a vast literature that has demonstrated the effectiveness of a variety of interventions and services that can address psychosocial health needs. These services include information and education about illness and treatment; professional and peer-led individual and group counseling and psychotherapy; psychiatric treatment; help in managing disruptions in work, school, or family life; support with transportation, housing, and basic needs; and financial and legal assistance. There is strong and compelling evidence that these interventions can successfully address emotional, psychological, social, and cognitive issues.

However, the report also identified several barriers to receiving this care, which became the basis of many of the recommendations. Although the stigma of mental illness and psychological distress continues to play a role in determining whether patients seek assistance and oncology providers both identify and refer for treatment, other factors also play a role. Complicated reimbursement structures that separate mental health from physical health benefits may play a role. A lack of psychosocial professionals with experience in treating patients with cancer or other chronic medical illnesses is also important. The article by Ellis et al¹ presents data consistent with the findings of the IOM report, that screening of patients reveals a high rate of psychosocial need, but that screening alone does not predict referral or intervention. Even though presence of depressive symptoms predicted referral, 50% of patients with depression were not referred for psychosocial services. This study was conducted in Canada, where many of the economic barriers do not exist, yet referral and intervention were less than clinically indicated based on the level of distress and need.

Quality cancer care includes provision of appropriate psychosocial health care. The recommendations flow from this assertion, that the standard of care for provision of quality cancer care includes assessment and treatment for psychosocial issues. Further, the recommendations call on oncology providers to assure that such care is delivered by assuring adequate patient/physician communication, that a psychosocial needs assessment occurs, that appropriate referrals are made, and that there is evidence that patients receive the indicated psychosocial care. The recommendations also call on "patient education and advocacy organizations to educate patients and family members to expect and request, when necessary, cancer care that meets the standard for psychosocial care."² Payors are encouraged to work to address barriers for reimbursement in health benefits delivered; the National Cancer Institute and other federal agencies are tasked to conduct additional research that can support the strong evidence already in place and to create performance measures for psychosocial health services.

The report arose as a result of a number of professional and patient advocacy organizations' concerns that, despite the evidence, patients are not receiving the screening and interventions they need. Ellis et al¹ bring to light an important aspect of psychosocial care that helps us to better understand what patient factors predict referral. However, the IOM report tells another important side of this story: that the majority of patients will have some level of significant psychosocial distress that can interfere with an individual's ability to receive high-quality cancer care. Unless patients receive routine screening, they are likely not going to receive a full assessment and will not receive an intervention. In this study, even patients receiving an assessment and having positive symptoms were not necessarily identified by their clinician as needing further assessment or intervention. As the IOM report states, this is not an uncommon problem.

It now becomes the responsibility of the broader oncology community to assure that the recommendations from the report are implemented. The American Society of Clinical Oncology has worked with the American Psychosocial Oncology Society and others to develop a quality standard for psychosocial care, consistent with the report, to include in its set of quality standards. The National Comprehensive Cancer Network has published a guideline for psychosocial distress, which outlines a multidisciplinary approach to screening, intervention, and referral and follow-up.³ Professional, community, and patient advocacy organizations have begun to work on a variety of mechanisms to assure that these important recommendations are implemented. Ultimately though, as the report states: "All cancer care providers should ensure that every cancer patient within their practice receives care that meets the standard for psychosocial health care."² Moreover, the report also empowers consumers of cancer care: "All patients with cancer and their families should expect and receive cancer care that ensures the provision of appropriate psychosocial health services."

AUTHOR'S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest.

REFERENCES

1. Ellis J, Lin J, Walsh A, et al: Predictors of referral for specialized psychosocial oncology care in patients with metastatic cancer: The contributions of age, distress, and marital status. J Clin Oncol 27:699–705, 2009.[Abstract/Free Full Text]

2. Institute of Medicine. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press, 2007.

3. National Comprehensive Cancer Network. Distress Management. NCCN Clinical Practice Guidelines in Oncology V.1.2008. http://www.nccn.org/professionals/physician_gls/PDF/distress.pdf.

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