The effect of a severe psychiatric illness on colorectal cancer treatment and survival: A population-based retrospective cohort study

Abstract

Objectives To identify inequalities in cancer survival rates for patients with a history of severe psychiatric illness (SPI) compared to those with no history of mental illness and explore differences in the provision of recommended cancer treatment as a potential explanation. Design Population-based retrospective cohort study using linked cancer registry and administrative data at ICES. Setting The universal healthcare system in Ontario, Canada. Participants Colorectal cancer (CRC) patients diagnosed between April 1st, 2007 and December 31st, 2012. SPI history (schizophrenia, schizoaffective disorders, other psychotic disorders, bipolar disorders or major depressive disorders) was determined using hospitalization, emergency department, and psychiatrist visit data and categorized as ‘no history of mental illness, ‘outpatient SPI history’, and ‘inpatient SPI history’. Main outcome measures Cancer-specific survival, non-receipt of surgical resection, and non-receipt of adjuvant chemotherapy or radiation. Results 24,507 CRC patients were included; 482 (2.0%) had an outpatient SPI history and 258 (1.0%) had an inpatient SPI history. Individuals with an SPI history had significantly lower survival rates and were significantly less likely to receive guideline recommended treatment than CRC patients with no history of mental illness. The adjusted HR for cancer-specific death was 1.69 times higher for individuals with an inpatient SPI (95% CI 1.36–2.09) and 1.24 times higher for individuals with an outpatient SPI history (95% CI 1.04–1.48). Stage II and III CRC patients with an inpatient SPI history were 2.15 times less likely (95% CI 1.07–4.33) to receive potentially curative surgical resection and 2.07 times less likely (95% CI 1.72–2.50) to receive adjuvant radiation or chemotherapy. These findings were consistent across multiple sensitivity analyses. Conclusions Individuals with an SPI history experience inequalities in colorectal cancer care and survival within a universal healthcare system. Increasing advocacy and the availability of resources to support individuals with an SPI within the cancer system are warranted to reduce the potential for unnecessary harm.

Barriers to cancer care for people with significant mental health difficulties: What healthcare staff say?

“…35,36 Participants' comments in relation to difficulties distinguishing between psychiatric and cancer symptoms corroborate prior findings that diagnostic overshadowing, whereby patients' physical symptoms are incorrectly ascribed to their mental illness, 33 can occur in the case of cancer patients with SMHD. 10 Additionally, participants' reports regarding alterations in treatment and reduced opportunities for participation in clinical trials for patients with SMHD and cancer are consistent with previous findings that HCPs sometimes make decisions contrary to typical care standards due to SMHD-related stigma, 12,37 whereby patients are excluded from clinical trials due to staff's beliefs regarding patients' capacity to make medical decisions and provide consent, and due to difficulty communicating with patients. 10 It is possible that there is, at times, an outdated paternalistic model of care for people with SMHD 38 ; such paternalism may account for participants' reports that cancer patients with SMHD are often excluded from clinical trials.…”

Colorectal Cancer Survival in Multiple Sclerosis

“…8 In a Swedish study, survival following cancers of the upper and lower gastrointestinal tracts was higher in an MS cohort than in a non-MS cohort; 8 this surprising finding contrasts with those reported for persons with other serious chronic illnesses such as diabetes and psychiatric disorders. 9,10 Accurate prognostic information about cancer is critical to support therapeutic decision-making by persons with MS and their care providers. for all those aged ≥65 years and receiving home care or long-term care (i.e., nursing home).…”

Equity-Oriented Healthcare: What It Is and Why We Need It in Oncology

“…This includes, for example, people experiencing the often intersecting impacts of racism and other forms of discrimination, poverty, mental illness, substance use issues and related stigma, homelessness, and disability [ 2 , 3 ]. In addition to extensive co-morbidities, accelerated aging, and premature death [ 4 , 5 ], people who are marginalized experience higher cancer mortality and are diagnosed with advanced cancers more often than other people [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 ]. For example, people with severe mental illness have 92% higher odds of an advanced cancer at diagnosis than those without mental illness, while cancer-related deaths are two times higher among homeless adults and 1.7 times higher among individuals with severe mental illness compared to the general population [ 6 , 8 ].…”

“…In addition to extensive co-morbidities, accelerated aging, and premature death [ 4 , 5 ], people who are marginalized experience higher cancer mortality and are diagnosed with advanced cancers more often than other people [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 ]. For example, people with severe mental illness have 92% higher odds of an advanced cancer at diagnosis than those without mental illness, while cancer-related deaths are two times higher among homeless adults and 1.7 times higher among individuals with severe mental illness compared to the general population [ 6 , 8 ]. Such outcomes are linked to the compounding effects of stigma and discrimination, often unintentional, and other barriers, which create persistent inequities in access to care at all points in the cancer trajectory, preventing timely diagnosis and treatment, and further widening the health equity gap [ 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 ].…”

“…For example, people who experience poverty and unstable housing are significantly less likely to be seen by an oncologist after a cancer diagnosis and are significantly less likely to receive cancer treatment [ 21 ]. Similarly, individuals with severe mental illness (e.g., schizophrenia) are two times less likely to receive guideline-recommended cancer treatment [ 8 ]. In their work on cancer disparities among individuals with mental illness, Davis et al note that “differences in cancer care delivery from the point of diagnosis may explain the higher risk of death and may be a modifiable means of improving outcomes” [ 7 ] (p. 90).…”