Addressing the unseen burden in cancer care – Distress and treatment compliance

There has been substantial progress in the field of oncology in the past decade or so revolutionizing the way we understand and treat the disease now, as to how we did back say 20 or 30 years ago. While a great deal of our focus has mostly been on curing and controlling the cancer, another important aspect of cancer care is the psychological wellbeing of the patient. As an oncologist, I am sure everyone has seen the profound impact a cancer diagnosis creates on not only the patients but also their families and care givers. I must say that although frequently overlooked in clinical trials, this aspect remains as important for achieving optimal patient outcomes. The manuscript by Lavanya et al.,[1] “Distress in cancer patients and their compliance to treatment: A prospective study,” published in the Indian Journal of Cancer, offers a timely and important contribution to this subject, especially within the Indian context. The authors have rightly pointed out that distress in cancer patients is a global phenomenon. Various studies have shown that approximately 25–50% of cancer patients worldwide experience clinically significant distress with this figure being possibly higher in India up to 60–70%.[2,3] In their study, the authors have used the National Comprehensive Cancer Network (NCCN) Distress Thermometer (DT) and problem list which has been validated for its feasibility and utility in identifying distress across various cancer populations.[4-6] The study found that 19% of patients defaulted on treatment and that 70% of these were in the high-distress category, which reiterates the clinical implications of an unaddressed psychological burden. A recent systematic review and meta-analysis has similarly highlighted the reduced quality of life and poorer treatment adherence associated with psychological distress and resultant worse health outcomes in cancer patients.[7] Although the difference in mean distress scores between defaulters and compliant patients was not statistically significant (P = 0.663) in this study, it is important to note the timing of distress assessment as discussed by the authors. Measuring distress solely at the start of radiation may not fully capture the impact of the treatment-related toxicities, appearance of disease progression, or psychosocial interventions on the dynamics of a patient’s psychological distress. Longitudinal assessment of distress to better understand its relation to treatment adherence should perhaps be a key area of future research. We completely agree with the authors’ emphasis on frequent counselling for distressed patients. It is important to not only identify distress but also intervene actively and timely in order to mitigate its effects. However, there are multiple barriers to counseling, particularly in the Indian society. To cite a few examples, the social stigma attached to mental health issues, lack of awareness about availability of psychosocial support, logistical challenges resulting in loss of follow-up, and, at times, even a lack of prioritization or training among healthcare professionals.[8-10] Integration of psycho-oncology services into routine care must be considered as imperative as the treatment of the cancer itself.[11] This paper also points out the economic benefits of timely psychosocial care. Research indicates that addressing cancer patients’ distress can reduce healthcare costs by shifting from higher-cost emergency services to lower-cost nonemergent and preventive care.[12] Psychosocial interventions have also demonstrated efficacy in alleviating distress, fostering resilience, and improving the quality of life, with some studies even suggesting short-term survival benefits, particularly for group-delivered interventions.[7,13] In conclusion, Lavanya et al.’s study serves as a critical reminder that cancer care extends beyond just the drugs to cure or control cancer. Distress is a definite problem that can derail treatment compromising patient outcomes. While the study’s findings on the direct correlation between initial distress scores and compliance do warrant further longitudinal investigation, it does reinforce the need to proactively screen for distress, provide consistent counseling, and foster a supportive environment that addresses the holistic needs of our patients. As medical oncologists, we need to ensure that our patients get the support they need throughout their treatment for the best outcomes.