Kelly E. Irwin

Early palliative care and metastatic non-small cell lung cancer Potential mechanisms of prolonged survival

Patients with advanced cancer experience a significant burden of physical symptoms and psychological distress at the end of life, and many elect to receive aggressive cancer-directed therapy. The goal of palliative care is to relieve suffering and promote quality of life (QOL) for patients and families. Traditionally, both the public and medical community have conceptualized the need for patients to make a choice between pursuing curative therapy or receiving palliative care. However, practice guidelines from the World Health Organization and leadership from the oncology and palliative care communities advocate a different model of palliative care that is introduced from the point of diagnosis of life-threatening illness. Early palliative care has been shown to provide benefits in QOL, mood, and health care utilization. Additionally, preliminary research has suggested that in contrast to fears about palliative care hastening death, referral to palliative care earlier in the course of illness may have the potential to lengthen survival, particularly in patients with advanced nonsmall-cell lung cancer. This review summarizes the literature on potential survival benefits of palliative care and presents a model of how early integrated palliative care could potentially influence survival in patients with advanced cancer.

Cancer care for individuals with schizophrenia.

Individuals with schizophrenia are a vulnerable population that has been relatively neglected in health disparities research. Despite having an equivalent risk of developing most cancers, patients with schizophrenia are more likely to die of cancer than the general population. Cancer care disparities are likely the result of patient‐, provider‐, and systems‐level factors and influenced by the pervasive stigma of mental illness. Individuals with schizophrenia have higher rates of health behaviors linked with cancer mortality including cigarette smoking. They also have significant medical comorbidity, are less likely to have up‐to‐date cancer screening, and may present at more advanced stages of illness. Patients with schizophrenia may be less likely to receive chemotherapy or radiotherapy, have more postoperative complications, and have less access to palliative care. However, opportunities exist for the interdisciplinary team, including medical, surgical, and radiation oncologists; psychiatrists; and primary care physicians, to intervene throughout the continuum of cancer care to promote survival and quality of life. This review summarizes data on overall and cancer‐specific mortality for individuals with schizophrenia and reviews specific disparities across the cancer care continuum of screening, diagnosis, treatment, and end‐of‐life care. Using a case, the authors illustrate clinical challenges for this population including communication, informed consent, and risk of suicide, and provide suggestions for care. Finally, recommendations for research to address the disparities in cancer care for individuals with schizophrenia are discussed. Despite significant challenges, with collaboration between oncology and mental health teams, individuals with schizophrenia can receive high‐quality cancer care. Cancer 2014;120:323–334.

Processes of Discontinuing Chemotherapy for Metastatic Non–Small-Cell Lung Cancer at the End of Life

PURPOSE Administration of chemotherapy close to death is widely recognized as poor-quality care. Prior research has focused on predictors and outcomes of chemotherapy administration at the end of life. This study describes processes of chemotherapy discontinuation and examines their relationships with timing before death, hospice referral, and hospital death. PATIENTS AND METHODS We reviewed health records of a prospective cohort of 151 patients with newly diagnosed metastatic non-small-cell lung cancer who participated in a trial of early palliative care. Chemotherapy treatments during final regimen were qualitatively analyzed to identify categories of discontinuation processes. We then quantitatively compared predictors and outcomes of the process categories. RESULTS A total of 144 patients died, with 81 and 48 receiving intravenous (IV) and oral chemotherapies as their final regimen, respectively. Five processes were identified for IV chemotherapy: definitive decisions (19.7%), deferred decisions or breaks (22.2%), disruptions for radiation therapy (22.2%), disruptions resulting from hospitalization (27.2%), and no decisions (8.6%). The five processes occurred at significantly different times before death and, except for definitive decisions, ultimate decisions for no further chemotherapy and referral to hospice were often made months later. Among patients receiving oral chemotherapy, 83.3% (40 of 48) were switched from IV to oral delivery as their final regimen, sometimes concurrent with or even after hospice referral. CONCLUSION Date of last chemotherapy is not a proxy for when a decision to stop treatment is made. Patients with metastatic non-small-cell lung cancer stop their final chemotherapy regimen via different processes, which significantly vary in time before death and subsequent end-of-life care.

Predictors of Disruptions in Breast Cancer Care for Individuals with Schizophrenia

BACKGROUND Patients with schizophrenia experience markedly increased breast cancer mortality, yet reasons for this disparity are poorly understood. We sought to characterize disruptions in breast cancer care for patients with schizophrenia and identify modifiable predictors of those disruptions. MATERIALS AND METHODS We performed a medical record review of 95 patients with schizophrenia and breast cancer treated at an academic cancer center between 1993 and 2015. We defined cancer care disruptions as processes that interfere with guideline-concordant cancer care, including delays to diagnosis or treatment, deviations from stage-appropriate treatment, and interruptions in treatment. We hypothesized that lack of psychiatric treatment at cancer diagnosis would be associated with care disruptions. RESULTS Half of patients with schizophrenia experienced at least one breast cancer care disruption. Deviations in stage-appropriate treatment were associated with breast cancer recurrence at 5 years (p = .045). Patients without a documented psychiatrist experienced more delays (p = .016), without documented antipsychotic medication experienced more deviations (p = .007), and with psychiatric hospitalizations after cancer diagnosis experienced more interruptions (p < .0001). Independent of stage, age, and documented primary care physician, lack of documented antipsychotic medication (odds ratio [OR] = 4.97, 95% confidence interval [CI] = 1.90, 12.98) and psychiatric care (OR = 4.56, 95% CI = 1.37, 15.15) predicted cancer care disruptions. CONCLUSION Disruptions in breast cancer care are common for patients with schizophrenia and are associated with adverse outcomes, including cancer recurrence. Access to psychiatric treatment at cancer diagnosis may protect against critical disruptions in cancer care for this underserved population. IMPLICATIONS FOR PRACTICE Disruptions in breast cancer care are common for patients with schizophrenia, yet access to mental health treatment is rarely integrated into cancer care. When oncologists documented a treating psychiatrist and antipsychotic medication, patients had fewer disruptions in breast cancer care after adjusting for age, cancer stage, and access to primary care. Addressing psychiatric comorbidity at breast cancer diagnosis may increase the likelihood that patients with schizophrenia receive timely, stage-appropriate cancer treatment. Comanagement of schizophrenia and breast cancer at cancer diagnosis may be one key strategy to decrease inequities in cancer treatment and improve cancer survival in this underserved population.

Use of Antidepressant Medications Moderates the Relationship Between Depressive Symptoms and Hospital Length of Stay in Patients with Advanced Cancer

Patients with cancer often experience depression, which can influence treatment outcomes and quality of life. This article evaluates associations among depressive symptoms, use of antidepressants, and hospital length of stay in patients with advanced cancer.

The Patients We Have to See

A psychiatrist and health services researcher, specializing in serious mental illness and cancer, discusses the need for the integration of mental health care and cancer care to promote equity in patient care.

Case 30-2016

Dr. Daniel J. Daunis (Psychiatry): A 63-year-old woman with bipolar disorder, worsening depression, and multiple other medical conditions, including lung cancer and breast cancer, was admitted to the inpatient psychiatry service of this hospital for electroconvulsive therapy (ECT). The patient had a long-standing history of bipolar disorder, including depressive episodes, which were characterized by low motivation, low energy, a feeling of hopelessness, agoraphobia, and suicidal ideation without suicide attempts, and brief episodes, each lasting for 2 to 3 weeks, of hypomania and mania with irritable or elevated mood, labile affect, pressured speech, and a decreased need for sleep. Twelve years before this admission, she had received a diagnosis of stage IIA estrogen-receptor–positive and progesterone-receptor–positive, HER2/neu-negative invasive ductal carcinoma of the left breast, with lymphatic-vessel invasion and isolated tumor cells in 2 of 2 lymph nodes. The patient underwent lumpectomy and adjuvant wholebreast radiation therapy. Follow-up therapy included four cycles of doxorubicin and cyclophosphamide chemotherapy and a 5-year course of tamoxifen. She had also been hospitalized three times for mania with psychotic features, including paranoia and visual hallucinations; her most recent hospitalization for mania occurred during her treatment for breast cancer, 11 years before this admission for ECT. She also had attention deficit–hyperactivity disorder (ADHD). Over the years, she had been treated with lithium, stimulants, atypical antipsychotic agents, and multiple classes of antidepressants. Six years before this admission, the patient discontinued primary care follow-up, and shortly thereafter she discontinued psychiatric care. Two years before this admission, a diagnosis of stage II non–small-cell carcinoma of the right lung was made. At the time of the diagnosis, she was referred to a psychiatrist at the cancer center of this hospital. Her medications were adjusted, and her depression abated. She underwent a right upper lobectomy and received adjuvant chemotherapy. From the Departments of Psychiatry (K.E.I., O.F.), Radiation Oncology (A.G.T.), Radiology (P.E.F.), and Pathology (T.M.G.) and the Division of Medical Oncology (J.P.), Massachusetts General Hospital, and the Departments of Psychiatry (K.E.I., O.F.), Medicine (J.P.), Radiation Oncology (A.G.T.), Radiology (P.E.F.), and Pathology (T.M.G.), Harvard Medical School — both in Boston.

Case 30-2016: A 63-Year-Old Woman with Bipolar Disorder, Cancer, and Worsening Depression

Dr. Daniel J. Daunis (Psychiatry): A 63-year-old woman with bipolar disorder, worsening depression, and multiple other medical conditions, including lung cancer and breast cancer, was admitted to the inpatient psychiatry service of this hospital for electroconvulsive therapy (ECT). The patient had a long-standing history of bipolar disorder, including depressive episodes, which were characterized by low motivation, low energy, a feeling of hopelessness, agoraphobia, and suicidal ideation without suicide attempts, and brief episodes, each lasting for 2 to 3 weeks, of hypomania and mania with irritable or elevated mood, labile affect, pressured speech, and a decreased need for sleep. Twelve years before this admission, she had received a diagnosis of stage IIA estrogen-receptor–positive and progesterone-receptor–positive, HER2/neu-negative invasive ductal carcinoma of the left breast, with lymphatic-vessel invasion and isolated tumor cells in 2 of 2 lymph nodes. The patient underwent lumpectomy and adjuvant wholebreast radiation therapy. Follow-up therapy included four cycles of doxorubicin and cyclophosphamide chemotherapy and a 5-year course of tamoxifen. She had also been hospitalized three times for mania with psychotic features, including paranoia and visual hallucinations; her most recent hospitalization for mania occurred during her treatment for breast cancer, 11 years before this admission for ECT. She also had attention deficit–hyperactivity disorder (ADHD). Over the years, she had been treated with lithium, stimulants, atypical antipsychotic agents, and multiple classes of antidepressants. Six years before this admission, the patient discontinued primary care follow-up, and shortly thereafter she discontinued psychiatric care. Two years before this admission, a diagnosis of stage II non–small-cell carcinoma of the right lung was made. At the time of the diagnosis, she was referred to a psychiatrist at the cancer center of this hospital. Her medications were adjusted, and her depression abated. She underwent a right upper lobectomy and received adjuvant chemotherapy. From the Departments of Psychiatry (K.E.I., O.F.), Radiation Oncology (A.G.T.), Radiology (P.E.F.), and Pathology (T.M.G.) and the Division of Medical Oncology (J.P.), Massachusetts General Hospital, and the Departments of Psychiatry (K.E.I., O.F.), Medicine (J.P.), Radiation Oncology (A.G.T.), Radiology (P.E.F.), and Pathology (T.M.G.), Harvard Medical School — both in Boston.

CASE RECORDS of the MASSACHUSETTS GENERAL HOSPITAL. Case 30-2016. A 63-Year-Old Woman with Bipolar Disorder, Cancer, and Worsening Depression.

Dr. Daniel J. Daunis (Psychiatry): A 63-year-old woman with bipolar disorder, worsening depression, and multiple other medical conditions, including lung cancer and breast cancer, was admitted to the inpatient psychiatry service of this hospital for electroconvulsive therapy (ECT). The patient had a long-standing history of bipolar disorder, including depressive episodes, which were characterized by low motivation, low energy, a feeling of hopelessness, agoraphobia, and suicidal ideation without suicide attempts, and brief episodes, each lasting for 2 to 3 weeks, of hypomania and mania with irritable or elevated mood, labile affect, pressured speech, and a decreased need for sleep. Twelve years before this admission, she had received a diagnosis of stage IIA estrogen-receptor–positive and progesterone-receptor–positive, HER2/neu-negative invasive ductal carcinoma of the left breast, with lymphatic-vessel invasion and isolated tumor cells in 2 of 2 lymph nodes. The patient underwent lumpectomy and adjuvant wholebreast radiation therapy. Follow-up therapy included four cycles of doxorubicin and cyclophosphamide chemotherapy and a 5-year course of tamoxifen. She had also been hospitalized three times for mania with psychotic features, including paranoia and visual hallucinations; her most recent hospitalization for mania occurred during her treatment for breast cancer, 11 years before this admission for ECT. She also had attention deficit–hyperactivity disorder (ADHD). Over the years, she had been treated with lithium, stimulants, atypical antipsychotic agents, and multiple classes of antidepressants. Six years before this admission, the patient discontinued primary care follow-up, and shortly thereafter she discontinued psychiatric care. Two years before this admission, a diagnosis of stage II non–small-cell carcinoma of the right lung was made. At the time of the diagnosis, she was referred to a psychiatrist at the cancer center of this hospital. Her medications were adjusted, and her depression abated. She underwent a right upper lobectomy and received adjuvant chemotherapy. From the Departments of Psychiatry (K.E.I., O.F.), Radiation Oncology (A.G.T.), Radiology (P.E.F.), and Pathology (T.M.G.) and the Division of Medical Oncology (J.P.), Massachusetts General Hospital, and the Departments of Psychiatry (K.E.I., O.F.), Medicine (J.P.), Radiation Oncology (A.G.T.), Radiology (P.E.F.), and Pathology (T.M.G.), Harvard Medical School — both in Boston.