Early interventions for depression tied to better cancer survival

Depression may be an overlooked factor in cancer outcomes, according to a large SEER-Medicare analysis of more than 265,000 adults with six common cancers. Researchers found that patients with major depressive disorder had a higher risk of dying from their cancer, while those who received psychotherapy within four weeks of their cancer diagnosis had a 21% lower risk of cancer-specific mortality. Only 3% of patients with depression received psychotherapy in that early window, however.

Results were presented at the American Society for Radiation Oncology (ASTRO) Annual Meeting.

“Depression can be easy to miss in cancer care because symptoms such as fatigue, difficulty concentrating and loss of interest often overlap with the effects of cancer or its treatment,” said Edmund M. Qiao, MD, lead study author and a radiation oncology resident at the University of California San Diego.

“But when depression goes unrecognized or untreated, it can add another layer of difficulty at a time when patients need support the most. Our findings suggest that earlier screening and referral for psychotherapy could help address an important gap in comprehensive cancer care.”

Depression is common among people with cancer, but mental health services are not always integrated into oncology care. For the current study, researchers sought to understand whether depression itself was associated with cancer mortality and whether outcomes differed according to the type and timing of mental health treatment. The retrospective analysis examined two common approaches to treating depression: psychotherapy and antidepressant medication.

Researchers analyzed records from 265,639 Medicare beneficiaries age 66 or older who were diagnosed from 2010–2017 with breast, colorectal, prostate, bladder, kidney or non-small cell lung cancer (NSCLC). More than one in five patients (22%) also had a diagnosis of major depressive disorder.

Psychotherapy was identified through Medicare procedure codes, while pharmacotherapy was identified through Medicare Part D claims for antidepressant medications. Researchers evaluated treatment within four weeks of cancer diagnosis, with additional analyses at eight and 12 weeks.

Patients with both cancer and depression had an 11% higher risk of cancer-specific mortality than those without depression. One year after diagnosis, 29% of patients with depression had died from their cancer, compared with 21% of patients without depression. At five years, cancer-specific mortality was 43% for patients with depression, compared with 35% for those without it.

Psychotherapy soon after cancer diagnosis showed the strongest association with lower cancer mortality among patients with depression. Patients who received psychotherapy within four weeks had a 21% lower risk of cancer-specific mortality in adjusted analyses using propensity score weighting. There were smaller reductions associated with psychotherapy at eight weeks (13% lower risk) and 12 weeks (12% lower risk).

“Patients who connected with psychotherapy earlier tended to have better outcomes than those who did not receive it during that period,” Qiao said. “For oncology providers, these findings support identifying patients who may need mental health care and connecting them with appropriate services as early as possible.”

Five-year cancer-specific mortality was 31% among patients who received psychotherapy and 44% among those who did not. In this large patient cohort, however, only 3% of patients with depression had a psychotherapy session within four weeks of their cancer diagnosis, rising to just 4.6% by 12 weeks.

Medication was used much more often than psychotherapy, by 32.5% of patients within four weeks of their cancer diagnosis. It was not associated with lower cancer-specific mortality at any of the measured time points when the researchers analyzed the cohort without accounting for specific cancer type, however.

Researchers also examined associations between mental health, treatment and cancer-specific mortality for each of the six cancer types. Depression was most common among patients with NSCLC (27%) and least common among those with prostate cancer (13%). It was significantly associated with higher cancer-specific mortality in every cancer group, with the strongest association seen in prostate cancer.

The association between psychotherapy and cancer-specific mortality varied by cancer type, reaching statistical significance for prostate, breast and kidney cancer. Pharmacotherapy was significantly associated with lower cancer-specific mortality among patients with prostate cancer.

The differences across cancer types suggest that the relationship between mental health and cancer outcomes may be more nuanced than a single approach to depression management can capture, Qiao said.

“In the general population, psychotherapy and medication can both be effective ways to manage depression,” he said. “But cancer care adds context. A patient’s cancer type, prognosis and treatment course may influence both their mental health needs and which interventions are most helpful.”

Because the study was retrospective, it cannot establish that psychotherapy caused the reduction in cancer mortality. Although the researchers used statistical methods to account for measured differences between patients who did and did not receive mental health treatment, unmeasured factors could have influenced both access to psychotherapy and cancer outcomes.

The analysis also was limited to Medicare beneficiaries, and future research is needed to examine whether similar patterns are seen in younger patients.

“Cancer care has become increasingly personalized, but mental health care in oncology often remains generalized,” Qiao said. “These findings suggest we need to think more carefully about how depression may affect different types of cancer and how we can work with patients to create individualized support plans early in their care.”

“Depression is common among people facing cancer, but it is often underrecognized and undertreated,” said ASTRO expert Fumiko Chino, MD, a radiation oncologist at The University of Texas MD Anderson Cancer Center in Houston.

“This study shows that timely treatment for depression is associated with better cancer survival. Patients who received treatment within one month of diagnosis had a lower risk of cancer death; it also shows that psychotherapy may potentially be underutilized given larger benefits over medication. Tailored and appropriate screening and referral for mental health care is an essential part of lifesaving oncology care.”

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Sadie Harley

BSc Life Sciences & Ecology. Microbiology lab background with pharmaceutical news experience in oil, gas, and renewable industries.

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Andrew Zinin

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