Older Adults With Cancer, Mental Illness Less Likely to Receive Chemotherapy

Deborah Brauser

June 01, 2010

June 1, 2010 (New Orleans, Louisiana) — After receiving a diagnosis of cancer, older patients — especially women — with mental disorders are significantly less likely to undergo chemotherapy than those without mental illness, according to findings from a cohort trial from the Health and Retirement Study (HRS).

The results, which were presented here at the American Psychiatric Association (APA) 2010 Annual Meeting, also showed that although the odds of dying after a cancer diagnosis were significantly greater for men with a mental illness than without (odds ratio [OR], 2.91; 95% confidence interval [CI], 1.49 – 5.68), the odds were significantly lower for the women in this group than for those in the general population (OR, 0.36; 95% CI, 0.15 – 0.86).

"I think the number 1 takeaway is that although older adults with mental illness are well connected to primary care, they may not receive the same kind of cancer treatment and may need extra support and counseling to get there," principal investigator Simha Ravven, MD, resident at the Cambridge Health Alliance and fellow at Harvard Medical School in Cambridge, Massachusetts, told Medscape Psychiatry.

Chronic Mental Illness Challenging

Dr. Simha Ravven

"Numerous providers that I have worked with in the past in primary care and in psychiatry and in oncology have talked about the challenges of both screening and then treating people with chronic mental illness," said Dr. Ravven.

"For this study, we looked at this in context of a nationally representative study that examined both health and economic characteristics of older adults to see if cancer screening and treatment varied for those with prior mental illness, and if mortality after a cancer diagnosis differed," she added.

Records from 19,045 participants older than 51 years (women, n = 11,095; men, n = 7950) from the year 2000 cohort of the HRS surveys were evaluated. Of these, 13.97% had a history of mental illness.

Results showed that those with a history of mental illness were as likely to undergo clinical cancer screenings as were the general population.

"This included a breast exam, a Pap test, mammography, and a prostate exam in the prior 2 years," reported Dr. Ravven. "They were also more likely to have gotten non–cancer-related healthcare, such as a flu shot or a cholesterol test."

However, the participants with mental illness had lower odds of receiving chemotherapy after a recent cancer diagnosis compared with those without mental illness (OR, 0.33; 95% CI, 0.15 – 0.71; P = .0016).

"There are a lot of potential reasons for this," said Dr. Ravven. "The ones we heard most were that chemotherapy is a difficult and rigorous treatment protocol, so patients may be reluctant to start it, and a lot of providers may be concerned about treatment adherence in patients with mental illness."

She noted that it is also possible that the treatment differences could reflect some early diagnoses of certain cancers that do not include chemotherapy in their treatment protocol or diagnoses at a later stage with receipt of palliative rather than curative care.

When looking at women only, those with a history of mental illness and cancer also had significantly lower odds of receiving chemotherapy than those without the history (OR, 0.18; 95% CI, 0.06 – 0.59; P = .004). Among the men-only groups, there were no significant differences found.

There were also no significant differences found between all patients with and without mental illness for receipt of radiation, surgery, or biopsy.

Dr. Ravven said that her team plans to next look at the study information in greater detail, such as stage of cancer diagnosis and cancer site, and detailed information about psychiatric illness diagnosis and severity.

"Doing this could help us see who is at risk of not getting standard treatment and get a better sense of why — with the hope of intervening somewhere after screening to improve cancer treatment for people with mental illness," she explained.

Findings Not Surprising

"I thought this was an interesting study with interesting findings," APA scientific program committee member Ike Ahmed, MD, professor of psychiatry at John A. Burns School of Medicine at the University of Hawaii at Manoa, told Medscape Psychiatry.

"The question, however, is with their methodology and with how much can be generalized from their findings," added Dr. Ahmed, who was not involved with the study. "I think we can find some associations within this study but we don't really know what they mean."

He also noted concerns with how the investigators determined which of the elderly patients had mental illness. "They just asked each person if they have ever been treated for a mental illness. So they have no idea what that illness was or its severity. Plus, with questions from surveys, you don't know how reliable they are and how many are truthfully saying if they have mental illness or not."

That said, Dr. Ahmed commented that the findings were not a surprise to him. "Chemotherapy does involve a certain degree of commitment and forbearance to sustain it, and it does have all the side effects. So both from the standpoint of patients and of providers, it can be a challenging treatment."

When asked if, even with the study's limitations, this is something that clinicians should keep in mind, Dr. Ahmed answered, "Yes, definitely. The important key for providers, such as clinical oncologists or primary care doctors, is that this question involves both medical and psychiatric issues. So a psychiatric consultation might be appropriate if a person is having a hard time coping with the cancer or with the treatments.

"People with mental illness obviously suffer from significant medical problems, such as cancer, and possibly even higher rates of cancer because of certain habits that come with psychiatric problems, such as smoking or a substance abuse. And they should be able to get adequate treatment," he added.

Dr. Ahmed said that he hopes to see further analysis from this study, with a particular focus on the different types and severity of mental illness in this patient population. "This might help tease out more helpful information, such as differences in those with anxiety problems or in depression and how that might impact the findings."

This study was funded by the Doris Duke Charitable Foundation. The original HRS was sponsored by the National Institute on Aging. Dr. Ravven and Dr. Ahmed have disclosed no relevant financial relationships.

American Psychiatric Association (APA) 2010 Annual Meeting: Poster Abstract NR2-40. Presented May 24, 2010.


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