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Cancer care providers need to proactively address patients' psychological and social needs

October 24, 2007

WASHINGTON -- Cancer therapies save and prolong many lives, but they and the tumors they target also can exact a debilitating toll on patients' mental and emotional and cause health problems that typically are not dealt with during oncology treatment. Cancer care that focuses solely on eradicating tumors without addressing the patient's general well-being can increase patients' suffering, may compromise their ability to follow through on treatment, and falls short of achieving quality care, says a new report from the Institute of Medicine.

The report proposes a new standard of care under which all oncology care providers would systematically screen patients for distress and other problems; connect patients with health care or service providers who have resources to tackle these issues and coordinate care with these professionals; and periodically re-evaluate patients to determine if any changes in care are needed.

To achieve this standard, the report recommends an evidence-based model for ensuring that psychosocial health services are an integral part of cancer care and provides strategies for implementing this model in settings with varying levels of resources. The vision laid out in the report could apply to the care of other serious chronic illnesses as well, noted the authoring committee.

"Killing cancer cells is important, but it's not enough to ensure that the adverse effects of patients' therapies don't undermine their gains," said committee chair Nancy E. Adler, vice chair, department of psychiatry, and director, Center for Health and Community, University of California, San Francisco. "This report provides an action plan for overcoming the barriers to psychosocial health services that patients need to be as healthy and whole as possible during and after cancer treatment."

Many of the services and resources already exist, often at no cost to patients, but oncology providers are not proactively identifying patients' needs and helping them find and use these resources, the committee noted. Because many of these services are free or are reimbursable through health insurance providers and programs, the creation of new benefits or payment mechanisms would not be necessary for the most part, the report says.

Cancer patients' psychosocial needs range from information about their therapies and the potential physical side effects, to treatment for depression, stress, or other mental and emotional conditions; assistance with daily activities that they can no longer perform independently; and assistance with transportation, prosthetics, medications, and other supplies they cannot afford or to which they do not have ready access. The report lists multiple resources of free services and information available to cancer patients and their families.

The committee acknowledged that currently there are not enough psychosocial services and resources to meet the needs of all patients and that cancer care providers can only partially resolve some problems, such as lack of health insurance or poverty. However, this should not preclude attempts to remedy as many psychosocial problems as possible.

Because individual clinical practices vary by their setting and patient population as well as by available resources, they will also vary in how they implement the proposed standard of care. The report offers examples of how some large and small practices deliver this care successfully and suggests ways that even providers with limited resources could do so.

"Many cancer care providers may be surprised at the array of psychosocial health services available nationwide at no cost to patients," said committee member Patricia Ganz, director, cancer prevention and control research, Jonsson Comprehensive Cancer Center, University of California, Los Angeles. "Our report also provides practical guidance to providers about how they can design their practices to better address their patients' needs."

The policies and practices of many health insurance purchasers and payers support the delivery of psychosocial health care, but they are not delivering this care uniformly, the committee concluded. Not all insurance plans fully use available mechanisms to compensate providers for assessments and interventions to develop tailored care plans, help patients manage their illnesses, and coordinate their care with other providers.

Group purchasers -- Medicare, Medicaid, and employers -- and health insurance plans should assess how psychosocial care is addressed in their agreements with each other and with health care providers and determine the adequacy of payment rates, the report says. They may find, for example, that interventions are currently covered in their payment and reimbursement mechanisms. However, mechanisms may need to be developed for reimbursing higher-than-average levels of care coordination.

Multiple organizations could significantly influence cancer care providers' adherence to the proposed standard of care. The National Cancer Institute, as the nation's leader in developing better approaches to cancer care, could include requirements for addressing psychosocial health needs in its protocols, standards, and programs. Standard-setting organizations such as the National Comprehensive Cancer Network -- an alliance of 20 leading cancer centers in the United States -- and the American College of Surgeons' Commission on Cancer could incorporate the report's recommended standard and its components into their own standards.

The National Academies