Depression is common among people with likely incurable cancer – understandably so. But studies have shown that it can be treated, and if the goal is for individuals to be able to engage as much as possible with family, friends, hobbies or whatever gives them joy and purpose in whatever amount of time they have, then treating depression becomes imperative.
That's not so easy, though, as patients may face a shortage of mental health workers, difficulties with transportation and continuing stigma around mental health issues.
Evan Graboyes, M.D., a head and neck surgical oncologist and director of Survivorship and Cancer Outcomes Research at MUSC Hollings Cancer Center, and Jennifer Dahne, Ph.D., a licensed clinical psychologist and leader of the Behavioral Health Innovations Lab at Hollings, have teamed up to create a new model of care delivery to reach out to this specific group of patients proactively and provide timely and tailored mental health treatment.
Together, they have received a $3.1 million grant from the National Cancer Institute (NCI) to test their model in a clinical trial through the Hollings Cancer Network. The grant from the NCI builds upon a smaller pilot project funded by Hollings to develop the idea.
Depression among cancer survivors
There are more and more people who now experience cancer as a chronic disease that is managed with treatments over the course of many, many years. There's a lot we don't know about this growing yet understudied subpopulation of cancer survivors. However, we do know that depression is one of the most important toxicities experienced by this group of people who are on therapies for a long time."
Evan Graboyes, M.D., head and neck surgical oncologist and director of Survivorship and Cancer Outcomes Research at MUSC Hollings Cancer Center
This group includes people whose cancer was already advanced at the time they were diagnosed or whose cancer became advanced or metastasized after initial treatment. With modern therapies, their cancer can be controlled, perhaps for years, but doctors can't completely eradicate it.
In fact, up to half of people with likely incurable cancer report depressive symptoms. That can lead to reduced quality of life, lower adherence to recommended treatments and higher suicidal ideation.
Proactive depression treatment
Graboyes and Dahne want to get proven treatments for depression to this patient group more quickly and in a more accessible way.
Waiting for a patient's next appointment to then screen for depression and make a referral isn't the most effective way, Graboyes said. And setting up a series of appointments at specific recurring intervals isn't necessarily helpful for this group, as their depression may come and go.
Instead, Dahne and Graboyes envision a system where the patient in need is automatically identified through the electronic health record and prompted to enroll in a remote depression treatment program that they can access on an as-needed basis.
In her own research and clinical care, Dahne developed a mobile app-based treatment called "Moodivate" that delivers a form of therapy called behavioral activation. She's now wrapping up a study of its effectiveness in more than 600 people identified through primary care who used the app to treat depression.
With input from an advisory group of patients with cancer, Dahne and Graboyes adapted the Moodivate app to fit the unique needs of cancer survivors and preliminarily evaluated the intervention with 30 patients. In the pilot, the researchers saw a level of adherence so high that it shocked Dahne.
"We followed everyone weekly for four weeks. They had to do an assessment every single week, and we had almost 100% retention," she said. "I have never experienced that type of engagement from participants in my trials."
Behavioral activation
"The idea behind behavioral activation is that depression is caused by essentially dropping out of life," Dahne said. "You stop engaging with the things that used to bring you pleasure and joy and that were important to you.
"That makes a lot of sense with cancer survivors, particularly those who are living with likely incurable cancer. The options of things that you can do narrows as you get sicker. It makes sense that your mood would worsen because of that," she said.
Behavioral activation doesn't mandate the same specific actions from every participant. Instead, people are asked to think about what is most important to them. If being a good parent or grandparent is a key value, for example, what can they do on a daily basis to live a life that is well-aligned with that value?
"What are concrete activities that are observable, measurable and the very smallest piece possible that you can schedule and complete to live a value-driven life?" Dahne said. "And then the bread and butter of the treatment becomes scheduling in and completing those activities. And as you engage more in activities that are important to you and are enjoyable to you, then depression improves."
Having treatment reminders at their fingertips can help people to access care when they need it, even if they live in rural areas without mental health providers or if mental health providers don't have any open appointment slots.
The majority of Americans, regardless of income, education or geography, have smartphones, making this type of virtual therapy accessible to most people. As a result, Graboyes argues, evidence-based mental health treatment offered via a smartphone platform can actually improve health equity and diminish disparities in access to care and outcomes.
"With trials that are done remotely, we reach out to those patients who are potentially most medically vulnerable. It's a way that we can reach those in greatest need, as opposed to the ones who are capable of traveling, who may not be the ones who actually need help the most," Graboyes said.
Scaling up to reach more people
In addition to testing how well this therapy works, the researchers will be developing a natural language processing model to identify the patients who should be invited to participate in this therapy.
Electronic health records are great for targeting patients within very specific, concrete parameters. For example, the system can be set up to send messages about colonoscopy screening to patients as they reach their 45th birthdays, the age at which colonoscopies are recommended to begin.
But the determination that someone is living with likely incurable cancer is more subtle. It can be found in the provider notes and pathology, or blood test and radiology reports, if you know what you're looking for.
During the pilot, the researchers manually reviewed charts to find people to invite. But it's impractical and a poor use of resources to have a surgeon reviewing charts, Dahne pointed out, especially if the hope is that this type of program could be scaled up to reach thousands of patients.
Instead, they want to train a natural language processing model to be able to pick out the same patients that a human reviewer would choose.
If successful, this would have benefits beyond this particular study. It could be used by Hollings and other cancer centers to understand more fully how many people are living with likely incurable cancer and to offer other survivorship resources.
"This is just the first step," Dahne said. "We hope that other types of digital interventions that address other mental health or cancer survivorship needs could be inserted into this same paradigm."
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