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by Edward Winstead
Many people who are being treated for cancer experience symptoms of depression, pain, and fatigue. But scientists are still studying how best to manage these symptoms in people with cancer.
One approach is to integrate the assessment and treatment of symptoms as a part of routine cancer care. With this approach, people who need support are offered weekly cognitive behavioral therapy sessions from a trained counselor and/or medicine for their symptoms provided by their medical teams.
The strategy, called integrated screening and stepped collaborative care, has now shown promise in a large clinical trial involving people with different types and stages of cancer.
In the NCI-supported study, participants were randomly assigned to receive integrated screening and stepped collaborative care or standard care, which consisted of referring patients to health care providers for treatment.
The stepped collaborative care group had a greater improvement in health-related quality of life, including their emotional, physical, and functional well-being, during the first 6 months of treatment, according to results published March 12 in The Lancet.
The improvement was maintained for up to a year. In addition, participants who received stepped collaborative care also reported reductions in the three most common symptoms.
“Our results highlight the importance of integrating screening and treatment with routine cancer care and offering this at no cost to patients,” said the trial’s lead researcher, Jennifer Steel, Ph.D., a clinical health psychologist at the University of Pittsburgh Medical Center (UPMC).
“We need to revisit our current approach of screening patients for symptoms and referring them for treatment,” Dr. Steel said. “Our hope is that this research could lead to a shift in care that improves patient quality of life.”
Getting started with treatment for symptoms
The study occurred during the pandemic, and the stepped collaborative care intervention was delivered via telehealth. The trained counselors worked closely with the cancer care team to manage people’s symptoms.
With standard care, people being treated for cancer are screened for symptoms of depression, pain, and fatigue. Those who need treatment for these symptoms are referred to a specialist within or outside their health care facilities. Patients then follow up to arrange an appointment and may be responsible for some or all the treatment costs.
But this approach often fails to give people the full support they need, the researchers noted. Just getting started can be a challenge. By contrast, offering patients an integrated approach to screening for the symptoms and automated referral to receive stepped collaborative care increases the likelihood that they will begin treatment, Dr. Steel said.
In the trial, about 75% of the patients who were offered support began treatment with a trained counselor, compared with only about 4% of the patients in the standard treatment group.
Some of the participants in the stepped collaborative group said they were willing to try the therapy because it was free and part of their routine cancer care.
Being invited to participate in therapy was “helpful,” one participant said. The counselor “walks you through the process and knows your doctor,” the person added. “That makes you feel comfortable because you’re already scared to death.”
Another participant said, “Being reached out to absolutely influenced my decision” to receive treatment.
Reducing the use of health care resources
The trial included 459 people being treated for cancer who had certain levels of depression, pain, or fatigue (or all of these). They were treated at one of 29 cancer outpatient clinics affiliated with UPMC. The vast majority of participants were White and over age 60.
The researchers randomly assigned participants to receive stepped collaborative care or standard care, which included referring patients who showed evidence of depression, pain, or fatigue on screening to a health care professional.
In the stepped collaborative care group, participants were contacted to begin cognitive behavioral therapy for an hour once a week through telehealth. Patients received 8 to 12 sessions initially but could continue therapy for up to 6 months if needed. Medicine for depression, pain, and fatigue was also available if the patient preferred or did not respond to cognitive behavioral therapy.
After a median follow-up of 6 months, people in the stepped collaborative care group had clinically meaningful improvements in emotional, functional, and physical well-being, whereas those in the standard treatment group didn’t. The improvements lasted up to 1 year, which is how long the participants were followed.
In addition, people in the stepped collaborative care group had fewer emergency room visits, fewer hospital readmissions within 90 days, and shorter hospital stays than the standard care group.
Dr. Steel noted that reducing the use of health care resources might be important for patients. Fewer hospitalizations and emergency room visits “could lower cancer care costs to the patient, as well as stress associated with those visits for both the patient and the family,” she said.
“The trial highlights what can be achieved using telehealth,” said Paige A. Green, Ph.D., a health psychologist and behavioral medicine researcher in NCI’s Division of Cancer Control and Population Sciences who was not involved in the trial.
Dr. Green called the findings “promising” but noted that the trial had limitations, such as a study population that was more than 90% White.
“The lack of meaningful inclusion of patient populations that are often underrepresented in cancer research might limit the relevance of the study findings to those groups,” said Dr. Green.
How is cognitive behavior therapy used to manage symptoms?
The trial participants who underwent cognitive behavioral therapy were taught strategies to deal with their symptoms, including relaxation techniques and ways to alter core beliefs about themselves and their environment.
Participants who were experiencing pain and fatigue were taught strategies to positively affect their thinking, improve sleep hygiene, and increase physical activity.
With stepped care, health care providers continually monitor a person’s response to treatment until the symptoms are adequately addressed.
“If the person were not responding, the providers could ‘step up’ the care by increasing the frequency or the intensity of the treatment they were providing or by trying another treatment approach,” Dr. Steel explained.
Cost savings from stepped collaborative care
According to the researchers, if health care systems offered an integrated screening and treatment program at no cost to the patient, such systems would save about $16,000 per patient per year. Their estimate was based on the savings from shorter hospital stays, fewer emergency room visits, and fewer 90-day readmissions.
“This study is an important contribution” to the data on stepped collaborative care as part of cancer treatment, said Barbara L. Andersen, Ph.D., a clinical psychologist who studies biobehavioral aspects of cancer at The Ohio State University.
“The inclusion of cost data, I hope, will significantly strengthen the case for [providing] psychological care for patients in need,” added Dr. Andersen, who is also a member of an expert panel on the management of anxiety and depression in adult survivors of cancer.
For some participants in the trial, receiving mental health support at no cost played a role in their decisions to try cognitive behavioral therapy. One participant said cost was “a very big factor.”
“Seniors my age are on a budget,” the person explained. The cost of talking with a therapist on the phone “is the number one thing that anybody’s going to look at, especially if they’re 65 or older.”
Testing stepped collaborative care in up to 100 cancer clinics
For the study, Dr. Steel and her colleagues screened nearly 1,600 patients. Only 481 (30%) did not report any of the three symptoms targeted by the intervention.
Susanne Oksbjerg Dalton, Ph.D., and Christoffer Johansen, M.D., Ph.D., of Copenhagen University wrote in an accompanying editorial that the finding highlights the need to scale up collaborative care for nearly all people with cancer.
“Such a high symptom prevalence in patients treated for cancer seems overwhelming, but this underpins the negative effect of treatment on patient quality of life,” they wrote.
Dr. Steel and her colleagues are planning to develop a training institute to prepare mental health professionals to deliver the intervention. They are also planning a clinical trial to evaluate the new approach in nearly 100 clinics at UPMC Hillman Cancer Center.
