3 QUESTIONS ON . . . Helping Cancer Patients Who Have Depression & Anxiety

Linda E. Carlson, PhD, RPsych: Linda E. Carlson, PhD, RPsychAmong cancer survivors and people living with cancer at any stage, rates of depression and anxiety are high. Across multiple reviews, data suggests that as many as one in five to one in four people experience symptoms of either of these two mental health conditions. With growing recognition of the prevalence of these mental health comorbidities, ASCO published a recent guideline on the psychosocial, behavioral, and psychopharmacologic treatment approaches for both depression and anxiety in cancer survivors (J Clin Oncol 2023; doi: 10.1200/jco.23.00293). Now the organization has published a companion guideline with the collaboration of the Society for Integrative Oncology (SIO) that focuses on using integrative therapies for these mental health issues (J Clin Oncol 2023; doi: 10.1200/JCO.23.00857). The new guideline cites SIO's definition of integrative oncology as “a patient-centered, evidence-informed field of cancer care that uses mind and body practices, natural products, and/or lifestyle modifications from different traditions alongside conventional cancer treatments.” The guideline authors also note that the preferred terminology for such therapeutic techniques is “integrative therapies” to “emphasize the point that for optimal patient-centered care, they are intended to be fully integrated into routine oncology practice,” according to the paper. In an interview, the guideline's lead author, Linda E. Carlson, PhD, RPsych, SIO Immediate-Past President, elaborated on some of the key recommendations in the guideline and the hope it will be used by practicing oncologists. Carlson is also the Enbridge Research Chair in Psychosocial Oncology and Professor in the Department of Oncology in the Cumming School of Medicine at the University of Calgary. 1 Why did ASCO publish this guideline now? “People with cancer suffer from high levels of anxiety and depression across the disease trajectory, and effective nonpharmacological treatments for these symptoms are needed. More than 50 percent of people with cancer worldwide use integrative therapies. The evidence base has grown to the extent that sufficient evidence now exists to provide evidence-based guidance on their use. “Given the high usage of integrative therapies by people diagnosed with cancer and the growing evidence base to support their use in this context, the SIO and ASCO felt it was timely to critically review the current evidence and produce recommendations on the use of integrative therapies for treating anxiety and depression symptoms in people with cancer across the disease trajectory. “ASCO has published guidelines on screening, assessment, and conventional treatments for anxiety and depression in people with cancer previously, which was also recently updated. It is considered a companion document to go with the [new] integrative therapies guideline.” 2 What are some of the recommendations in the guideline? “The strongest recommendation in the guideline across both anxiety and depression symptoms is that mindfulness-based interventions should be offered to people with cancer both during active treatment and post-treatment. The next strongest recommendation is that yoga may be offered to people with cancer for both anxiety and depression symptom reduction across the treatment trajectory. “During cancer treatments such as surgery, chemotherapy, or radiation therapy, [activities such as] music therapy, relaxation therapies, and reflexology may be offered to reduce both anxiety and depression symptoms in people with cancer, while hypnosis and lavender essential oil inhalation may be recommended to help specifically with anxiety symptoms during diagnostic and treatment procedures. “Finally, tai chi or qigong programs may be considered to help alleviate symptoms of both depression and anxiety post-treatment, and reflexology may be recommended for anxiety. Acupuncture may also be considered for women with breast cancer to reduce anxiety symptoms post-treatment.” 3 What should practicing oncologists and cancer care providers know about the new guideline? “Because over half of all people with cancer use integrative therapies, an evidence-based guideline to help health care providers give sound advice on their use was sorely needed, both to improve outcomes for people who can benefit from these therapies and avoid harm from unproven alternative treatments. “There are useful supplemental materials, including treatment algorithms and summary tables, that health care providers can use to make treatment recommendations and guide patients to safe and effective integrative therapies. Health care providers can also use them to advocate for the inclusion of these therapies in their treatment centers. “Many popular therapies, such as massage, light therapy, energy therapies, natural health products/dietary supplements, and psychedelics/psilocybin-assisted therapy, did not have enough evidence from randomized controlled trials to make conclusive recommendations. This does not mean they cannot be helpful, but more research is needed in these areas. We also need more research on diverse types of cancer, more advanced cancers, and marginalized groups of people with cancer. “Many patients suffer from debilitating anxiety and depression, which can be managed with a variety of integrative therapies, as detailed in the recommendations. Clinicians are encouraged to refer to and advocate for cancer centers to provide access—through insurance reimbursement or publicly funded health care—to the many evidence-based therapies highlighted in this guideline.”

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