Cancer-Related Mortality in People With Mental Illness

Abstract

There is a 30% higher case fatality rate from cancer in psychiatric patients even though their incidence of cancer is no greater than in the general population. The reasons are unclear, but if increased cancer mortality were due to lifestyle only, cancer incidence should be similarly increased. Other hypotheses include delays in presentation, leading to more advanced staging at diagnosis, and difficulties in treatment access following diagnosis.Objective: To assess why psychiatric patients are no more likely than the general population to develop cancer but are more likely to die of it.Design, Setting, and Patients: A population-based record-linkage analysis compared psychiatric patients with the Western Australian population, using an inception cohort to calculate rates and hazard ratios. Mental health records were linked with cancer registrations and death records from January 1, 1988, to December 31, 2007, in Western Australia.Main Outcome Measures: Metastases, incidence, mortality, and access to cancer interventions.Results: There were 6586 new cancers in psychiatric patients. Cancer incidence was lower in psychiatric pa-tients than in the general population in both males (rate ratio = 0.86; 95% CI, 0.82-0.90) and females (rate ratio = 0.92; 95% CI, 0.88-0.96), although mortality was higher (males: rate ratio = 1.52; 95% CI, 1.45-1.60; females: rate ratio=1.29; 95% CI, 1.22-1.36). The proportion of cancer with metastases at presentation was significantly higher in psychiatric patients (7.1%; 95% CI, 6.5%-7.8%) than in the general population (6.1%; 95% CI, 6.0%-6.2%). Psychiatric patients had a reduced likelihood of surgery (hazard ratio = 0.81; 95% CI, 0.76-0.86), especially resection of colorectal, breast, and cervical cancers. They also received significantly less radiotherapy for breast, colorectal, and uterine cancers and fewer chemotherapy sessions.Conclusions: Although incidence is no higher than in the general population, psychiatric patients are more likely to have metastases at diagnosis and less likely to receive specialized interventions. This may explain their greater case fatality and highlights the need for improved cancer screening and detection.

Ethical Management of Patients with Cancer and Mental Illness

“…They are at increased risk for mortality due to many factors arising from their disability [11][12][13].…”

“…Several studies report a significantly higher rate of mortality in psychiatric patients overall compared to the general population [11][12][13], and one study has shown a higher rate of mortality for psychiatric patients with cancer even though the incidence of cancer in psychiatric patients is no greater than in the general population [11]. One possible explanation includes reduced access to screening [14,15], leading to delayed diagnosis and a more advanced stage at presentation.…”

“…One possible explanation includes reduced access to screening [14,15], leading to delayed diagnosis and a more advanced stage at presentation. In addition, people with mental illness have more limited access to cancer care and a lower likelihood of receiving specialized interventions [11].…”

Assessing Statewide All-Cause Future One-Year Mortality: Prospective Study With Implications for Quality of Life, Resource Utilization, and Medical Futility (Preprint)

“…When we focused the analysis on high-risk patients with dementia, given the increasing attention to mental illness of terminally ill patients 23,24 , we found a higher prevalence of dementia among high-risk elderly patients (2.24% vs. 0.17% in the low-risk cohort, P<0.001). About 40% of high-risk patients took medications for mental illness health conditions, which substantially higher than in the low-(6.5%) and intermediate-risk (27.3%) groups.…”

“…The prevalence of using antipsychotic medication was high in nursing homes, while the substantial use of conventional antipsychotics was common in acute and long-term inpatient settings 34 . Hence, these findings should give rise to more attention to mental illness of terminally ill patients, not only because of higher fatality rate from cancer in psychiatric patients 23 , but also because of great opportunities to improve end-of-life care for these vulnerable patients, given their loss of ability to communicate need and severe physical consequence 35 .…”