living with & beyond cancer – no health without …...dr asanga fernando @asangafern macmillan...

DELIVERING AN INTEGRATED SERVICE FOR CANCER PATIENTS.

– NO HEALTH WITHOUT MENTAL HEALTH

Dr Asanga Fernando @asangafern

Macmillan Consultant Liaison (Cancer) Psychiatrist & Clinical Director of simulation & clinical skills,

St George’s University Hospitals NHS

LEARNING OBJECTIVES

• Delivering Integrated services for Mental health and Cancer

• supporting the mental health needs of people living with and beyond cancer

• Our experience and my role as a Macmillan Consultant Liaison Psychiatrist

• Cancer Simulation and Education

• Interactive Discussion - what does good look like? What should we be

measuring?

THE RANGE – PSYCHOLOGICAL DISTRESS

Cancer Psychiatry 2019

NO HEALTH WITHOUT MENTAL HEALTH

• 25% within 1 year of Dx, 10% level 4 (NICE 2004)

• Poorer Functioning, QoL, Cancer specific probs (DHD)

• Adverse impact on carers, families

• Reduced adherence to cancer Rx

• Likely reduction in life expectancy

• Increased Cost (Naylor et al.2012) & length of stay


PATIENTS WITH EXISTING SMI

A STORY WITH AN UNHAPPY ENDING

TREATMENT OF PRE-EXISTING MH

• Cancer is over-represented in SMI population

• (Dalton et al 2002, Hung et al 2014) – Cancer incidence in MH units vsmatched gen pop – severe depression assoc with doubling of cancers.

• Particularly assoc with EtOH, substance misuse, smoking (also Lichtermann et al 2001)

• SMI complicates and delays access to cancer care

• Pt factors

• Neglect

• Suicidality

• Amotivation

• Psychomotor retardation

• Paranoia, persec. Delusions

• Systemic factors

• Access to smoking cessation,

• Screening – breast, cervical

• LT patients, prisoners, housebound.Cancer Psychiatry 2019

TREATMENT OF PRE-EXISTING MH

• Care driven by Multi-Agency approach

• Accompanying staff, transport, support workers, supported housing, social

• Thought Sx, Behavioural Sx, Cognitive Sx – cancer worsens all of these –think about how this is likely to impact upon engagement.

• Treatment decision making & Mental Capacity issues – commonplace.

• Delays to MH treatment:

• LT psychotherapy/ group

• Disruption of regular monitoring of risk, MSE by CMHT

• Hosp admission may lead to lapse in depot admin

• Surgery – may affect oral absorption

• Medication Interactions


CANCER PATIENTS WITH PSYCHIATRIC CO-MORBIDITY

DEPRESSION

• (Mitchell, A. J., Chan, M et al 2011) – 16.3%, (70 studies, 10,071 pts) (anxiety – 10.3%)

• (Massie, 2004) – varied, but up to 38% with Major depression

• Varies with Tumour type: Lung>Gynae>Breast>Colorectal>GU (Walker et al. 2014a)

• 73% patients receive no adequate, evidenced based Rx (Walker et al. 2014 b)

• Screening for depression doesn’t help with Rx? (Meijer et al. 2011)

• Undertreated by GPs

• Increases with severity of illness

• Sharpe et al (2004) 9%@ OPD, Rayner et al (2011) 36% advanced disease

• Elderly Ca patients - condition most associated with disability and morbidity

(Parpa et al. 2015)


F I G U R E 1 : B I O P S Y C H O S O C I A L F A C T O R S A S S O C I A T E D W I T H D E P R E S S I O N I N M E N W I T H

P R O S T A T E C A N C E R T A K E N F R O M : F E R V A H A , G . , I Z A R D , J . P . , T R I P P , D . A . , R A J A N , S . , L E O N G , D . P . , & S I E M E N S , D . R . ( 2 0 1 9 , J A N U A R Y ) . D E P R E S S I O N A N D P R O S T A T E C A N C E R : A

F O C U S E D R E V I E W F O R T H E C L I N I C I A N . I N U R O L O G I C O N C O L O G Y : S E M I N A R S A N D O R I G I N A L I N V E S T I G A T I O N S . E L S E V I E R


DEPRESSION & SUICIDALITY

• SMR 4-6.8 X age & sex matched population

• 2014 – 6122 deaths

• Men 45-59 (3x than women)

• Over 50% Hx Drug/EtOH misuse

• Burden – lung, UGI, Head and Neck (Robson et al. 2010; Robinson et al 2009)

• Head and Neck & Lung Ca >50% of Cancer suicides

• Comorbid loss of speech, tasting food, unable to seal mouth, disfigurement -risk factors.

• Consider:

• EtOH

• Economic factors

• Dynamic factors – esp pain, agitation

• Functioning


PSYCHIATRY OF CANCER TREATMENTS

TREATMENTS & PSYCHOLOGICAL IMPACT – PROSTATE CANCER

• Surgery (Prostatectomy)

• Incontinence

• Erectile dysfunction

• Decisional crisis/regret

• Radiotherapy

• Painful urinary frequency

• Bowel irritation/

Diarrhoea/Incontinence

• 6/12 post-radiotherapy, 16% severe

anxiety, 6% severe depression1,2

• Androgen Deprivation Therapy

• Loss of libido

• Weight redistribution

• Hot flashes

• Fatigue

• Cognitive Impairment – 50%3–5

• Specific newer agents with less cognitive

effect6

• Chemotherapy

1. Andreyev HJN, et al. The Lancet Oncology 2010;11(4):310-312; 2. Andreyev HJN, et al. The Lancet 2013;382(9910):2084-2092;

2. van Tol-Geerdink JJ, et al. Radiotherapy and Oncology 2011;98(2):203-206; 3. Gonzalez BD, et al. Journal of Clinical Oncology

2015;33(18):2021;

4. Cherrier MM, et al. Psycho‐Oncology 2009;18(3):237-247; 5. Nelson CJ, et al. Cancer 2008;113(5):1097-1106; 6. Sternberg CN, et

al. Lancet Oncol 2014;15(11):1263-8.

STEROIDS


END OF LIFE & SURVIVORSHIP

END OF LIFE CHALLENGES

• Desire for Hastened death:

• Strongly Associated with depression & with Sx burden, QoL

• Phys Sx such as fatigue increase DHD

• DHD is unstable over time

• If depression is present, Rx reduces DHD

• Non malignant disease have greater odds of DHD

• EoLC, opiates (opiate toxicity), falls, delirium, capacity, TEP, Advanced care planning

• Dynamic factors – pain, thirst, breathless, constipation, opiates

• MDT approach, effective psychiatric intervention can help improve QoL at the end of life

• Utilise Hospices


AN INTEGRATED SERVICE – WHAT DOES GOOD LOOK LIKE?

AND WHO SHOULD GET TO DECIDE?

CLINICAL INTEGRATION

• Example - Cancer Psychological Support (CaPS) team at St George’s.

• Co-located and embedded within Cancer services

• Multi-professional

• Ability to see carers

• Same electronic records as Oncology, Surgery, Primary care

• Rapid access to medication record

• Presence at MDTs

• Clinical integration also helps develop education, research and audit

• Patient group involvement

• Commissioning

• New ways of working

• Pathway approach

• Data and Outcomes – which ones matter? Are they important to patients? HR-QoL? Fxt?

• Education

A CANCER JOURNEY

• Diagnosis

• transfer of care

• Co-morbidity

Primary Care

• Surgery

• Chemotherapy

• Immunotherapy

• Radiotherapy

• Supportive

Secondary Care

(TREATMENT)

• Survivorship (Primary care)

• Transfer of Care

• End of Life care –Secondary care

• Hospice/ Comm pall

• Carers

Survivorship / End of Life

HEE funded Primary

Care Resource

Toolkit

Immunotherapy

SACT Communication

Surgery

CAMhELS, CAMhELS (int)

DNACPR (int)

CARERS

Primary care

INTEGRATION ACROSS THE PATHWAY

• HEE funded Transforming Primary Care Educational toolkit for people living with and beyond (developed by HEE, St George’s, TCST, Macmillan)

• Cancer Rehab

• Personalised Care

• Stratified Follow Up

• Cancer Care Reviews

• Psychological Support

• Bridging the gaps – Primary and Secondary care medications?

CAMHELS

W: www.gapssimulation.com E: [email protected]: @GAPSsimulation @asangafern

http://www.gapssimulation.com/

mailto:[email protected]

KNOWLEDGE BASED QUESTIONS

• 4 questions

• Total 74 responses

• Increased from 31% to 74%

• Highly Significant difference,

p=0.0001

0

0.5

1

1.5

2

2.5

3

3.5

Knowledge Based Questions

PRE POST

ATTITUDE BASED QUESTIONS

Have the participants

changed their views

towards mental co-

morbidity?

53.1

68.0

63.5

72.2 72.0

79.7

51.6

76.3 76.7

63.9

81.3

73.9

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Q5 Q6 Q7 Q8 Q9 Q10

Attitude Based Questions (%)

PRE POST

p=0.8 p=0.11 p=0.0001 p=0.01 p=0.061 p=0.013

CONFIDENCE BASED QUESTIONS

Questions

11 Risk assessment in suicidal patient

12 Screening for depression

13 Managing an agitated patient

14 Managing a patient at the end of life

15 Breaking bad news

66.6

73.8

67.9

73.2 72.9

81.883.8

79.2

85.8 85.0

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Q11 Q12 Q13 Q14 Q15

Confidence Based Questions

PRE POST

p=0.0001Highly statistically significant improvement in confidence for each stem, p=0.0001, paired t-test

QUALITATIVE FINDINGS

• Trainees Don’t actually get to practice Breaking

Bad News

• HCA’s don’t feel supported by Nurses

• All clinicians are scared to highlight difficulties with

co-morbidity unless they feel able to do anything

about it

• People highlight that there is less active treatment

of depression at the end of life

CAMHELS

• Better integration

between cancer, mental

health and EoLC

• EDUCATIONALLY

CLINICALLY

• RESEARCH

• SERVICE DESIGN

• Better Collaboration

internally and

internationally (Aus, SL)

CANCER

End of Life

Mental health

General Hospital Liaison Psychiatry

universal supportAenhanced supportB

specialist supportC

Patients & Carers

Comm. & Specialist Mental Health

V5.6

L O N D O N I N T E G R A T E D P A T H W A Y F O R C A N C E R P S Y C H O S O C I A L S U P P O R Th

os

pit

al

co

mm

un

ity

Community Palliative Care Services

N I C E L e v e l 3 & 4

Psycho-oncology team(incl. counselling, clinical psychology,

oncology psychiatry, psychotherapy etc)

Level 3/4specialists

4consultation

training & supervision

PE

RS

ON

AL

ISE

D C

AR

E

All hospital staffe.g. clinic, ward, administrative

N I C E L e v e l 1

as per NICE IOG 2004

HolisticNeedsPlan

Primary Care

GPs, primary care staff & ‘care navigator’ roles

CancerCarePlan

Level 2 assessment & first-line input

e.g. by Clinical Nurse Specialist

N I C E L e v e l 2

IAPT - Community Psychological Therapies

1

3

support for self-management

information resourcessocial prescribing

third sectorsocial care

digital

2

General Hospital Liaison Psychiatry

universal supportAenhanced supportB

specialist supportC

Patients & Carers

Comm. & Specialist Mental Health

V5.6

L O N D O N I N T E G R A T E D P A T H W A Y F O R C A N C E R P S Y C H O S O C I A L S U P P O R Th

os

pit

al

co

mm

un

ity

Community Palliative Care Services

N I C E L e v e l 3 & 4

Psycho-oncology team(incl. counselling, clinical psychology,

oncology psychiatry, psychotherapy etc)

Level 3/4specialists

4

PE

RS

ON

AL

ISE

D C

AR

E

All hospital staffe.g. clinic, ward, administrative

N I C E L e v e l 1

as per NICE IOG 2004

HolisticNeedsPlan

Primary Care

GPs, primary care staff & ‘care navigator’ roles

CancerCarePlan

Level 2 assessment & first-line input

e.g. by Clinical Nurse Specialist

N I C E L e v e l 2

IAPT - Community Psychological Therapies

1

3

support for self-management

information resourcessocial prescribing

third sectorsocial care

digital

2

all Level 1 care, plus:

Level 2

• assessment of significant distress & psychological issues identified in HNA or routine cancer care

• first-line psychological interventions to enhance self-management e.g. relaxation, worry tree, structured problem-solving, motivational interviewing

• consultation and advice from specialist service (e.g. Level 3-4 psycho-oncology service to guide Level 2 input)

• signposts/refers to specific cancer psychological care resources e.g. structured support groups

Community

• Primary Care-level 2 support from a trained primary care nurse/other professional

• IAPT Step 2 : low-intensity interventions, e.g. guided self-help for anxiety or depression, psycho-educational groups, computerised CBT (non-cancer specific)

Healthcare system

• underlying principle: how to prevent distress and promote adjustment• prompt, efficient, reliable systems e.g. for appointments and reporting• effective communication between staff/services across the pathway

Level 1 care – All

• compassionate communication• active listening• timely information, advice and links with social care e.g regarding

employment, finances, benefits etc• facilitating access to peer support, open groups, online forums, • third sector organisations• social prescribing• digital resources

Keyworker – e.g. clinical nurse specialist

• meets person at diagnosis to establish a reliable relationship• develops a holistic understanding of the impact of cancer on the person• maintains a reliable single point of contact throughout• guides the person in effective self-management• identifies needs, signposts to specific resources and reviews impact• advocates psychosocial perspective in MDT

Personalised care

• HNA – holistic needs assessment and care plan, at key points in pathway

• EOT – end of treatment review, includes HNA and treatment summary (TS)

• HWBE – health & wellbeing event• CCR – cancer care review in primary care

all Level 1&2 care, plus:

• specialist clinical assessment of distress & mental health in the context of cancer

• developing a comprehensive biopsychosocial psychological formulation or multidimensional diagnostic profile

Level 3

• assess and deliver interventions with complex presentations that include cancer and psychosocial factors

• psychological interventions e.g. counselling, solution-focused therapy, focused on cancer-related difficulties

• IAPT Step 3: High-intensity unidisciplinaryinterventions (non-cancer specific) e.g. CBT, counselling for depression.

Level 4

• embedded within cancer MDT input• assess and intervene with complex

psychological, psychotherapeutic or pharmacological interventions

• management of non-acute risk• enabling effective liaison of mental health &

related services to cancer MDT

universal supportA enhanced supportBspecialist supportC

Level 1 > 2

All staff to request or implement Level 2 input when:

• HNA or other screening identifies heightened distress (e.g. DT>5,

GAD/PHQ>9)

• patient or carer self-identify poor coping or psychological issues

that affect function

• clinical impression of persistent significant distress in clinical

encounters

• clinician concerns about difficulties with decisions, adherence,

treatments.

• When there is clinical evidence of significant concerns relating

to treatment, mental health or risk, direct referral to Level 3/4

would be appropriate.

1

Referral Criteria (i)

Acute/Hospital Context

Level 2 > Psycho-oncology

Clinical judgement, taking into account:

• Keyworker observes pattern of poor psychological adjustment

over time

• Level 2 assessment identifies significant severity, persistence and

functional impact of distress, and background complexities/

vulnerabilities e.g. trauma, multiple losses, relevant mental

health history

• Level 2 input (e.g. ‘worry tree’, sleep hygiene) has not proved

sufficient

• Holistic care requires multiprofessional coordination

(hospital/mental health) and/or multidisciplinary input (e.g.

psychosexual rehabilitation)

2

GP > Psycho-oncology


• undergoing active cancer tests & treatments, or

unstable/advancing/progressive disease

• significant cancer /treatment consequences (e.g. epilepsy,

GvHD, neutropenia, dysphagia), requiring multidisciplinary

input.

• Frequent and/or ongoing hospital contact for cancer care

• Psychosocial factors impacting adversely on:

- accessing cancer tests/treatment adherence

-decision-making (e.g treatment decisions )

-health self-management (e.g medication adherence_ -

-cancer rehab

• requires multiprofessional coordination with cancer mdt and

other services (e.g. mental health) and/or multidisciplinary

input (e.g. psychosexual rehabilitation)

• Usually seen for up to 12-18 months after End Of Treatment

3

Referral Criteria (ii)

Primary / Community Context

GP > IAPT


• Meets general criteria for IAPT g mild/moderate anxiety

and/or depression

• Medically stable/cancer remission/cancer ‘in the

background’

• Few hospital cancer-related contacts/routine follow up

• Nil or mild/well-managed physical consequences of

treatment

• link to pre-existing issues, e.g. previous anxiety disorder

re-activated by cancer uncertainty

• unidisciplinary input sufficient

• No acute mental health risk concerns

Psycho-oncology teams leading service coordination and sharing expertise across the pathway

Psycho-oncology teams will :

• Across the whole pathway, coordinate and collaborate with other enhanced & specialist

services (e.g. general hospital liaison psychiatry, community and specialist mental health,

palliative care, primary care, IAPT, third-sector providers and others) to ensure the

delivery of personalised care with a safe, individualised, comprehensive and clear plan.

• provide consultation, expert advice and training on cancer and psychological issues to a

range of professionals across the whole pathway

The aim of this function overall will be to ensure:

• patients are offered all relevant choices

• all people with pre-existing SMI have optimal cancer treatment

• GPs , primary care staff and cancer MDTs are offered clear and reliable advice on how

cancer care and mental health / psychological care will be coordinated

4

Referral Criteria (iii)

CONCLUSIONS

• Delivering Integrated services for Mental health and Cancer

• supporting the mental health needs of people living with and beyond cancer

• Our experience and my role as a Macmillan Consultant Liaison Psychiatrist

• Cancer Simulation and Education

• Interactive Discussion - what does good look like? What should we be

measuring?

REFERENCES

• Naylor, C., Parsonage, M., McDaid, D., Knapp, M., Fossey, M., & Galea, A. (2012). The Kings Fund. Long term conditions and mental health. The cost of comorbidities.

• Dalton, S. O., Mellemkjær, L., Olsen, J. H., Mortensen, P. B., & Johansen, C. (2002). Depression and cancer risk: a register-based study of patients hospitalized with affective disorders, Denmark, 1969–1993. American journal of epidemiology, 155(12), 1088-1095.

• Hung, Y. N., Yang, S. Y., Huang, M. C., Lin, S. K., Chen, K. Y., Kuo, C. J., & Chen, Y. Y. (2014). Cancer incidence in people with affective disorder: nationwide cohort study in Taiwan, 1997–2010. The British Journal of Psychiatry, 205(3), 183-188.

• Lichtermann, D., Ekelund, J., Pukkala, E., Tanskanen, A., & Lönnqvist, J. (2001). Incidence of cancer among persons with schizophrenia and their relatives. Archives of general psychiatry, 58(6), 573-578.

• Mitchell AJ, et al. The lancet oncology 2011;12(2):160–174

• Massie MJ. J Natl Cancer Inst Monogr 2004;32:57–71

• Walker J, et al. The Lancet Psychiatry 2014;1(5):343–350

• Sharpe, M., Walker, J., Hansen, C. H., Martin, P., Symeonides, S., Gourley, C., ... & Murray, G. (2014). Integrated collaborative care for comorbid major depression in patients with cancer (SMaRT Oncology-2): a multicentre randomised controlled effectiveness trial. The Lancet, 384(9948), 1099-1108.

• Meijer, A., Roseman, M., Milette, K., Coyne, J. C., Stefanek, M. E., Ziegelstein, R. C., ... & de Jonge, P. (2011). Depression screening and patient outcomes in cancer: a systematic review. PLoS One, 6(11), e27181.

• Strong, V., Sharpe, M., Cull, A., Maguire, P., House, A., & Ramirez, A. (2004). Can oncology nurses treat depression? A pilot project. Journal of advanced nursing, 46(5), 542-548.

• Rayner, L., Lee, W., Price, A., Monroe, B., Sykes, N., Hansford, P., ... & Hotopf, M. (2011). The clinical epidemiology of depression in palliative care and the predictive value of somatic symptoms: cross-sectional survey with four-week follow-up. Palliative Medicine, 25(3), 229-241.

• Parpa, E., Tsilika, E., Gennimata, V., & Mystakidou, K. (2015). Elderly cancer patients’ psychopathology: a systematic review: aging and mental health. Archives of gerontology and geriatrics, 60(1), 9-15.


REFERENCES

• Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta psychiatrica scandinavica, 67(6), 361-370.

• Zung, W. W. (1965). A self-rating depression scale. Archives of general psychiatry, 12(1), 63-70.

• Walker, J., Postma, K., McHugh, G. S., Rush, R., Coyle, B., Strong, V., & Sharpe, M. (2007). Performance of the Hospital Anxiety and Depression Scale as a screening tool for major depressive disorder in cancer patients. Journal of psychosomatic research, 63(1), 83-91.

• Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ‐9: validity of a brief depression severity measure. Journal of general internal medicine, 16(9), 606-613.

• Lloyd-Williams, M., Friedman, T., & Rudd, N. (2000). Criterion validation of the Edinburgh Postnatal Depression Scale as a screening tool for depression in patients with advanced metastatic cancer. Journal of pain and symptom management, 20(4), 259-265.

• Pitman, A., Suleman, S., Hyde, N., & Hodgkiss, A. (2018). Depression and anxiety in patients with cancer. Bmj, 361, k1415.

• Breitbart, W., Rosenfeld, B., Tobias, K., Pessin, H., Ku, G. Y., Yuan, J., & Wolchok, J. (2014). Depression, cytokines, and pancreatic cancer. Psycho‐oncology, 23(3), 339-345.

• Delattre, J. Y., Krol, G., Thaler, H. T., & Posner, J. B. (1988). Distribution of brain metastases. Archives of neurology, 45(7), 741-744.

• Darnell, R., Darnell, R. B., & Posner, J. B. (2011). Paraneoplastic syndromes (Vol. 79). OUP USA.

• Robinson, D., Renshaw, C., Okello, C., Møller, H., & Davies, E. A. (2009). Suicide in cancer patients in South East England from 1996 to 2005: a population-based study. British journal of cancer, 101(1), 198.

• Robson, A., Scrutton, F., Wilkinson, L., & MacLeod, F. (2010). The risk of suicide in cancer patients: a review of the literature. Psycho‐oncology, 19(12), 1250-1258.

• Warrington, T. P., & Bostwick, J. M. (2006, October). Psychiatric adverse effects of corticosteroids. In Mayo Clinic Proceedings (Vol. 81, No. 10, pp. 1361-1367). Elsevier.

• Hodgkiss, A. (2016). Biological psychiatry of cancer and cancer treatment. Oxford University Press.


DELIVERING AN INTEGRATED SERVICE FOR CANCER PATIENTS.

– NO HEALTH WITHOUT MENTAL HEALTH

Dr Asanga Fernando @asangafern

Macmillan Consultant Liaison (Cancer) Psychiatrist & Clinical Director of simulation & clinical skills,

St George’s University Hospitals NHS

living with & beyond cancer – no health without …...dr asanga fernando @asangafern macmillan...

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