Management of Anxiety and Depression in Adult Cancer Survivors: ASCO Guidelines Update

Management of Anxiety and Depression in Adult Cancer Survivors: ASCO Guidelines Update

objective

Updated American Society of Clinical Oncology guidelines for the management of anxiety and depression in adult cancer survivors.

way

A multidisciplinary expert group meeting was convened to update the guidelines. A systematic review of evidence published between 2013 and 2021 was conducted.

outcome

The evidence base includes 17 systematic reviews ± meta-analyses (nine for psychosocial interventions, four for physical activity, three for mindfulness-based stress reduction [MBSR], and one for pharmacological interventions), and a further 44 randomised controlled trials. Psychological, educational, and psychosocial interventions may improve depression and anxiety. Evidence on pharmacological treatment of depression and anxiety in cancer survivors is inconsistent. The inadequate inclusion of minority survivors was noted and identified as an important consideration in providing high-quality care to minority populations.

suggestion

A stepwise model of care, in which the most effective intervention with minimal resource commitment is provided based on symptom severity, is recommended. All cancer patients should be educated about depression and anxiety. For patients with moderate depressive symptoms, clinicians should provide cognitive behavioral therapy (CBT), behavioral activation (BA), MBSR, structured physical activity, or experientially supported psychosocial interventions. For patients with moderate anxiety symptoms, clinicians should provide CBT, BA, structured physical activity, acceptance and commitment therapy, or psychosocial interventions. For patients with severe symptoms of depression or anxiety, clinicians should provide cognitive therapy, BA, CBT, MBSR, or interpersonal therapy. For patients who do not have access to first-line therapy, prefer pharmacotherapy, have previously responded well to pharmacotherapy, or have not improved after first-line psychological or behavioral management, the treating physician may offer pharmacological treatment options for depression or anxiety.

introduce

In 2023, the United States is expected to have 1,958,310 new cases of cancer. It is estimated that by 2040, the number of cancer patients and cancer survivors in the United States alone will reach about 26 million. The 5-year prevalence of all cancers worldwide is estimated at 50.5 million people. When it comes to caring for the growing number of cancer survivors, an aspect that is often overlooked is the psychological impact of cancer. The 12-month prevalence of any psychiatric disorder was significantly higher in cancer patients compared with control groups in the general population (odds ratio [OR], 1.28; 95% CI, 1.14 to 1.45). The psychological symptoms of cancer patients are not well understood and treated. These symptoms may be overlooked as a normal response to a cancer diagnosis, or interpreted as secondary to physical symptoms. To address this, the American Society of Clinical Oncology (ASCO) issued routine screening recommendations in July 2014 to guide referral and treatment using validated published measures.

Nonetheless, it remains critical to identify and treat cancer patients with comorbid psychiatric disorders, whether pre-existing or emerging. As previously guided, and reiterated here, stress, depression, and anxiety are pervasive and continue throughout the trajectory of life. Adults diagnosed with cancer reported higher levels of stress than healthy controls, with diagnosis and starting treatment being the most stressful moments. In the short term, stress co-changes with depression and anxiety symptoms, negative quality of life, physical symptoms, and treatment morbidity, while in the long term, data show that it is associated with cancer mortality.

The most common depressions in cancer patients are major depression and adjustment disorder, and data for other depressions are scarce. Depression is often associated with functional impairment, poor physical health, substance abuse, and poor quality of life, which in turn is influenced by impaired relationships, reduced physical activity (PA), and other factors. It is unclear how stressors in old age, such as comorbidities and partner loss, increase risk or severity. Depressive symptoms are exacerbated in patients with advanced stages of disease and/or a high symptom burden. Depression at diagnosis and throughout cancer development is co-associated with reduced adherence to treatment and follow-up care, increased inflammation, impaired immunity, and reduced survival.

In addition to depression, anxiety disorders are also common, with generalized anxiety disorder being the most common disorder in this population. Anxiety disorder is a condition that has not been given enough attention. Increased levels of anxiety predict non-adherence to recommended treatments, increased use and costs of medical care, and may even lead to cancer recurrence. For those who don't have cancer, depression and anxiety often go hand in hand. 30Notably, Arch et al found that 31% of cancer patients with anxiety disorders also had major depressive disorder (MDD).

In 2023, 2 million new cases of cancer are expected to be diagnosed. The number of people suffering from depression or anxiety can be estimated by taking into account the prevalence in studies using symptom reporting versus diagnostic interviews, which reported lower prevalence. The prevalence of depression was at least twice as high in unipolar mood disorder in patients with cancer compared with controls (major depression: OR, 2.07; 95% CI, 1.71 to 2.51; dysthymic disorder: OR, 2.93; 95% CI, 2.13 to 4.02). 4Using a self-report tool with specific cut-off points (e.g., Patient Health Questionnaire-9 ≥ 10), moderate to severe depressive symptom incidence ranged from 13% to 27%. 32 - 35 When diagnostic criteria for MDD are used, the prevalence is 14.3%. Looking at these estimates more broadly, the World Health Organization estimates that, overall, 4.4% of the world's population suffers from depression, which is significantly lower than cancer patients. A conservative estimate (14.3%) of the number of patients with newly diagnosed cancer with MDD in 2023 is approximately 286,000 adults.

For anxiety disorders, studies using self-report tools with specified cut-off points (e.g., Hospital Anxiety and Depression Scale≥8) found prevalence estimated to be between 4% and 48%. In studies using diagnostic interviews, the prevalence was about 10%. In comparison, the World Health Organization estimates that anxiety disorders affect 3.6% of the global population. Similarly, a conservative estimate (10%) of the number of new cases with comorbid anxiety disorders is 200,000.

In addition to the psychological, behavioral, and biological disturbances caused by post-cancer depression and anxiety, people with untreated depression may be at risk. Clinical depression does not resolve, and patients remain at risk of self-harm and/or suicide. An 85% higher risk of self-harm and/or suicide has been reported than in the general population (standardised mortality rate of 1.85; 95% CI, 1.55 to 2.20), with the highest risk in the first 12 months after cancer diagnosis, emphasizing the importance of screening newly diagnosed patients.

The purpose of this guideline update is to collect and examine evidence published since the publication of the guidelines by Andersen et al. in 2014. The 2014 guidelines, adapted from the Canadian Practice Guidelines for Screening, Assessment and Care for Psychosocial Distress (Depression, Anxiety) in Adults with Cancer, address three research questions: What is the best interventions for screening, assessment, and psychosocial support care for adults with cancer diagnosed with symptoms of depression and/or anxiety? As screening and assessment of depression and anxiety continued to improve, the reconvened panel revised the study question to focus solely on management and treatment. Readers are encouraged to review ASCO's 2014 recommendations on screening and assessment (see also Appendix Table A1), which the Panel believes remain relevant. Of particular note is that if a patient is considered to be at risk of harming himself and/or others through screening and further evaluation, clinicians should refer him or her to a licensed mental health professional for urgent evaluation and interventions should be implemented to reduce the risk of harm to themselves and/or others (Figure 1).

Management of Anxiety and Depression in Adult Cancer Survivors: ASCO Guidelines Update

Guiding questions

What are the recommended treatments for anxiety and/or depression in adult (≥ age 18) cancer survivors?

Target Population

Adult cancer survivors, defined as those with anxiety and/or depression at any time from the time of diagnosis to the time thereafter.

Target audience

Health care providers include oncologists, psychologists, psychiatrists, psychosocial and rehabilitation professionals, integrative medicine practitioners, primary care providers, social workers, nurses, and others involved in providing care to cancer survivors and their family members and caregivers.

way

After specifying the questions and search parameters, a systematic review of the relevant literature was conducted, and an expert group was convened to develop updated clinical practice guideline recommendations based on the results of the review and other considerations.

suggestion

Please refer to ASCO's 2014 recommendations on screening and assessment (also available in Appendix Table A1 [online only]).

General Management Principles

Recommendation 1.1.

Information about depression and anxiety should be provided to all cancer patients and their caregivers, families, or trusted confidants. They should also be provided with resources, such as contact information for healthcare providers, for further evaluation and treatment within or outside the facility (type: evidence-based; The pros outweigh the cons; Quality of the evidence: moderate; Recommended Strength: Strong).

Recommendation 1.2.

Clinicians should adopt a stepwise model of care, in which the most effective and least resource-intensive intervention is selected based on symptom severity when choosing a treatment for anxiety and/or depression. Other variables that may influence the choice of treatment include:

• History of psychiatric illness, i.e., prior diagnosis, with or without treatment

•History of drug use

• Prior mental health treatment response

• Functional abilities and/or limitations related to self-care, daily activities, and/or mobility

• Recurrent or advanced cancer

• Have other chronic medical conditions (such as heart disease)

• Members of socially and/or economically marginalized groups (e.g., Black, low socioeconomic status)

(Type: Evidence-based; The benefits outweigh the harms; Quality of the evidence: moderate; Recommended Strength: Strong)

Recommendation 1.3.

Psychological and psychosocial interventions provided by mental health practitioners should be derived from manual, empirically supported treatments. The evidence-based treatment manual should detail the content, structure, mode of delivery, number of sessions, duration of treatment, and related topics. Linguistic, cultural, and socio-ecological contexts need to guide any treatment customization (type: evidence-based; The pros outweigh the cons; Quality of the evidence: moderate; Recommended intensity: moderate).

Recommendation 1.4.

When referring for further evaluation or psychological care, clinicians should make every effort to reduce barriers and facilitate patient follow-up. It is crucial to determine a follow-up to the first appointment, as well as to identify any obstacles that may arise from the patient. Thereafter, it can also be helpful to determine patient satisfaction and assist in addressing any new and/or persistent barriers (type: informal consensus; The pros outweigh the cons; Quality of the evidence: insufficient; Recommended intensity: moderate).

Recommendation 1.5.

Treatment of depressive symptoms should be prioritized in patients with co-existing symptoms of depression and anxiety. Alternatively, a unified regimen of treatment (i.e., combined with cognitive behavioural therapy [CBT] for depression and anxiety) (type: evidence-based; The pros outweigh the cons; Quality of the evidence: high; Recommended Strength: Strong).

Recommendation 1.6.

For patients referred for psychotherapy, a mental health professional should regularly assess response to treatment (e.g., before, 4 weeks, 8 weeks, and at the end of treatment). (Type: Evidence-based; The benefits outweigh the harms; Quality of the evidence: moderate; Recommended Strength: Strong).

Recommendation 1.7.

If pharmacotherapy is used, the treating physician should assess the patient's degree of symptom relief, side effects and adverse events, and satisfaction using standardized validation tools at regular intervals (e.g., 4 and 8 weeks). If symptoms stabilize or worsen, the treating physician should reassess the plan and make modifications (Type: Informal Consensus; The pros outweigh the cons; Quality of the evidence: insufficient; Recommended Strength: Strong).

Recommendation 1.8.

If, after 8 weeks of treatment for depression and/or anxiety, there is little improvement in symptoms despite good adherence, the treating physician should adjust the treatment regimen (eg, adding a psychological or pharmacological intervention to a single treatment; If it is medication, change the medication; In the case of group therapy, refer to individual therapy). The same considerations may apply if the patient has low satisfaction with treatment and/or has a treatment barrier (type: informal consensus; The pros outweigh the cons; Quality of the evidence: insufficient; Recommended intensity: moderate).

Authors' note: Current evidence supports recommended treatment interventions for depression and anxiety as an effective treatment option. However, it is acknowledged that the availability of mental health services, ease of access, and the timing and cost of service delivery are important considerations, which can vary depending on the treatment setting. The choice of interventions offered to patients should be based on shared decision-making, taking into account availability, accessibility, patient preference, likelihood of adherence, and cost.

Treatment and care options for depressive symptoms

Recommendation 2.1.

For patients with moderate to severe depressive symptoms, culturally and linguistically appropriate information should be provided to the patient and his/her designated caregiver, family member, or trusted confidant. Information may include the following: common (frequency) of depression, common psychological, behavioral, and vegetative symptoms, signs of worsening symptoms, and indications to contact your health care team (provide contact information). (Type: Evidence-based; The pros outweigh the cons; Quality of the evidence: moderate; Recommended Strength: Strong).

Recommendation 2.2.

For patients with moderate depressive symptoms, clinicians should provide individual or group therapy with any of the following treatment options:

• Cognitive therapy or CBT

• Behavioral Activation (BA)

• Organized physical activity and exercise

• Mindfulness-Based Stress Reduction (MBSR)

•Psychosocial interventions using experientially supported components (e.g., relaxation, problem-solving).

(Type: Evidence-based; The benefits outweigh the harms; Quality of the evidence: moderate; Recommended Strength: Strong).

Recommendation 2.3.

For patients with major depressive symptoms, clinicians should individualize treatment with any of the following treatment options:

• Cognitive therapy or CBT

• Bachelor of Arts

• Mindfulness stress reduction

• Interpersonal Therapy

(Type: Evidence-based; The benefits outweigh the harms; Quality of the evidence: moderate; Recommended Strength: Strong).

Recommendation 2.4.

The treating physician may offer a pharmacological regimen for patients who are unable to obtain first-line therapy, who have expressed a preference for pharmacotherapy, or who do not improve with first-line psychological or behavioral management. Pharmacotherapy should also be considered in patients with a history of response to pharmacotherapy, severe symptoms, or features of psychosis (type: evidence-based; The pros outweigh the cons; Quality of the evidence: low; Recommended Intensity: Weak).

Declaration of Conformity.

Despite the limitations and weak evidence for pharmacotherapy, there are empirical benefits that demonstrate some alternatives.

Treatment and care options for anxiety symptoms

Recommendation 3.1.

For patients with moderate to severe anxiety symptoms, culturally and linguistically appropriate information should be provided to the patient and his/her designated caregiver, family member, or trusted confidant. Information may include the following: commonality (frequency) of stress and anxiety, psychological, behavioral, and cognitive symptoms, signs of worsening symptoms, and health care team contact information (type: evidence-based; The pros outweigh the cons; Quality of the evidence: moderate; Recommended Strength: Strong).

Recommendation 3.2.

For patients with moderate anxiety symptoms, clinicians should provide individual or group therapy with any of the following treatment options:

• Cognitive-behavioral therapy

• Bachelor of Arts

• Organized physical activity and exercise

• Psychosocial interventions with evidence-based support (e.g. relaxation, problem-solving)

(Type: Evidence-based; The benefits outweigh the harms; Quality of the evidence: moderate; Recommended Strength: Strong).

Recommendation 3.3.

For patients with severe anxiety symptoms, clinicians should provide individualized treatment with one of the following treatment regimens:

• Cognitive-behavioral therapy

• Bachelor of Arts

• Mindfulness stress reduction

• Interpersonal Therapy

(Type: Evidence-based; The benefits outweigh the harms; Quality of the evidence: moderate; Recommended Strength: Strong).

Recommendation 3.4.

For patients who do not have access to first-line therapy, who express a preference for pharmacotherapy, or who do not improve with first-line psychological or behavioral management, the treating physician may offer an anxiety medication regimen (type: evidence-based; The benefits outweigh the harms; Quality of the evidence: low; Recommended Intensity: Weak).

suggestion

Clinical problems

What treatments are recommended for anxiety and/or depression in adult cancer survivors?

General Management Principles

Recommendation 1.1.

Information about depression and anxiety should be provided to all patients with oncology and to the patient's designated caregivers, family members, or trusted close friends. They should also be provided with resources, such as the provider's contact information, for further evaluation and treatment within or outside the facility, if available (Type: evidence-based; The pros outweigh the cons; Quality of the evidence: moderate; Recommended Strength: Strong).

Declaration of Conformity.

Recommendation 1.2.

When choosing a treatment for anxiety and/or depression, clinicians should adopt a stepwise model of care, i.e., selecting the most effective and least resource-intensive intervention based on symptom severity. Other variables that may influence the choice of treatment include:

History of psychiatric illness, i.e., prior diagnosis, with or without treatment

History of substance abuse

Response to prior mental health treatment

Functional abilities and/or limitations related to self-care, daily activities, and/or mobility

Recurrent or advanced cancer

Presence of other chronic medical conditions (e.g., heart disease)

Members of socially and/or economically marginalized groups (e.g., Black, low socioeconomic status)

(Type: Evidence-based; The benefits outweigh the harms; Quality of the evidence: moderate; Recommended Strength: Strong).

Recommendation 1.3

Psychological and psychosocial interventions provided by mental health practitioners should be derived from manual, empirically supported treatments. The evidence-based treatment manual should detail the content, structure, mode of delivery, number of sessions, duration of treatment, and related topics. Linguistic, cultural, and socio-ecological contexts need to guide any treatment customization (type: evidence-based; The pros outweigh the cons; Quality of the evidence: moderate; Recommended intensity: moderate).

Recommendation 1.4

When referring for further evaluation or psychological care, clinicians should make every effort to reduce barriers and facilitate patient follow-up. It is crucial to determine a follow-up to the first appointment, as well as to identify any obstacles that may arise from the patient. Thereafter, it can also be helpful to determine patient satisfaction and assist in addressing any new and/or persistent barriers (type: informal consensus; The pros outweigh the cons; Quality of the evidence: insufficient; Recommended intensity: moderate).

Recommendation 1.5

For patients with co-existing symptoms of depression and anxiety, priority should be given to treatment of depressive symptoms, or a unified regimen (i.e., a combination of CBT treatment for depression and anxiety) (type: evidence-based; The pros outweigh the cons; Quality of the evidence: high; Recommended Strength: Strong).

Recommendation 1.6

For patients referred for psychotherapy, a mental health professional should regularly assess response to treatment (e.g., before, 4 weeks, 8 weeks, and at the end of treatment). (Type: Evidence-based; The benefits outweigh the harms; Quality of the evidence: moderate; Recommended Strength: Strong).

Recommendation 1.7

If pharmacotherapy is used, the treating physician should assess the patient's degree of symptom relief, side effects and adverse events, and satisfaction using standardized validation tools at regular intervals (e.g., 4 and 8 weeks). If symptoms stabilize or worsen, the treating physician should reassess the plan and make modifications (Type: Informal Consensus; The pros outweigh the cons; Quality of the evidence: insufficient; Recommended Strength: Strong).

Recommendation 1.8

If, after 8 weeks of treatment for depression and/or anxiety, there is little improvement in symptoms despite good adherence, the treating physician should adjust the treatment regimen (eg, adding a psychological or pharmacological intervention to a single treatment; If it is medication, change the medication; In the case of group therapy, refer to individual therapy). The same considerations may apply if the patient has low satisfaction with treatment and/or has a treatment barrier (type: informal consensus; The pros outweigh the cons; Quality of the evidence: insufficient; Recommended intensity: moderate).

Treatment and care options for depressive symptoms

Recommendation 2.1.

For patients with moderate to severe depressive symptoms, culturally and linguistically appropriate information should be provided to the patient and his/her designated caregiver, family member, or trusted confidant. Information may include the following: common (frequency) of depression, common psychological, behavioral, and vegetative symptoms, signs of worsening symptoms, and indications to contact your health care team (provide contact information). (Type: Evidence-based; The pros outweigh the cons; Quality of the evidence: moderate; Recommended Strength: Strong).

Recommendation 2.2.

For patients with moderate depressive symptoms, clinicians should provide individual or group therapy with any of the following treatment options:

Cognitive therapy or CBT

Bachelor of Arts

Structured PA and exercise

Mindfulness-Based Stress Reduction (MBSR)

Psychosocial interventions using empirically supported components (e.g., relaxation, problem-solving).

(Type: Evidence-based; The benefits outweigh the harms; Quality of the evidence: moderate; Recommended Strength: Strong).

Recommendation 2.3.

For patients with major depressive symptoms, clinicians should individualize treatment with any of the following treatment options:

Cognitive therapy or CBT

Bachelor of Arts

Rehabilitation from decompression sickness

Interpersonal therapy

(Type: Evidence-based; The benefits outweigh the harms; Quality of the evidence: moderate; Recommended Strength: Strong).

Recommendation 2.4.

The treating physician may offer a pharmacological regimen for patients who are unable to obtain first-line therapy, who have expressed a preference for pharmacotherapy, or who do not improve with first-line psychological or behavioral management. Pharmacotherapy should also be considered in patients with a history of response to pharmacotherapy, severe symptoms, or features of psychosis (type: evidence-based; The pros outweigh the cons; Quality of the evidence: low; Recommended Intensity: Weak).

Qualifying Statement. Despite the limitations and weak evidence for pharmacotherapy, empirically there is some evidence of benefit sufficient as an alternative.

Treatment and care options for anxiety symptoms

Recommendation 3.1.

For patients with moderate to severe anxiety symptoms, culturally and linguistically appropriate information should be provided to the patient and his/her designated caregiver, family member, or trusted confidant. Information may include the following: commonality (frequency) of stress and anxiety, psychological, behavioral, and cognitive symptoms, signs of worsening symptoms, and health care team contact information (type: evidence-based; The pros outweigh the cons; Quality of the evidence: moderate; Recommended Strength: Strong).

Recommendation 3.2.

For patients with moderate anxiety symptoms, clinicians should provide individual or group therapy with any of the following treatment options:

Cognitive-behavioral therapy

Bachelor of Arts

Structured PA and exercise

Psychosocial interventions with evidence-based support (e.g., relaxation, problem-solving)

(Type: Evidence-based; The benefits outweigh the harms; Quality of the evidence: moderate; Recommended Strength: Strong).

Recommendation 3.3.

For patients with severe anxiety symptoms, clinicians should provide individualized treatment with one of the following treatment regimens:

Cognitive-behavioral therapy

Bachelor of Arts

Rehabilitation from decompression sickness

Interpersonal therapy

(Type: Evidence-based; The benefits outweigh the harms; Quality of the evidence: moderate; Recommended Strength: Strong).

Recommendation 3.4.

For patients who do not have access to first-line therapy, who express a preference for pharmacotherapy, or who do not improve with first-line psychological or behavioral management, the treating physician may offer an anxiety medication regimen (type: evidence-based; The benefits outweigh the harms; Quality of the evidence: low; Recommended Intensity: Weak).

discuss

This guideline continues the 2014 guideline, which emphasized screening and recommended measures to assess symptoms of depression and anxiety, reaffirming the importance of screening for mental health conditions and preparing oncology and mental health professionals for the next steps when symptom exacerbation is detected—specifically, conducting further evaluation to determine the severity of symptoms, referral for treatment if necessary, and choosing empirically supported treatments. Since the 2014 guidelines, screening has become a goal of care, but its principles and procedures have yet to be fully implemented. The panel recognized that in some cases, screening for psychological symptoms is still only ideal, but people have made great strides in achieving this standard of care, and since 2015, cancer centers have included distress screening as a standard of accreditation when they seek accreditation from the Cancer Board. As for management, our systematic review showed strong results in reducing symptoms with CBT and BA. This contrasts with the limited, low-quality evidence for pharmacological treatments.

As highlighted in the 2014 ASCO Guidelines, the following topics remain important in this update. Education: Many hospitals or centers provide information about cancer treatment for patients, including surgery, chemotherapy, immunotherapy, and related topics. We recommend that general (level 1) materials on coping with stress and treating anxiety and depression should also be provided on a regular basis. For individuals with exacerbated symptoms, it is essential to confirm and normalize the patient's experience, providing information including common signs and symptoms of anxiety and/or depression, the type of treatment used, and the route of treatment. Timing of screening: While this is not the focus of this updated review, it is recognized that how and when to screen cancer patients and survivors is an important determinant of timely management of anxiety and depression. The period between diagnosis and initiation of treatment is an important time for the first screening, as one-third of patients report experiencing severe psychological distress during this period. However, the demand has remained since then; Many of the interventions reviewed were delivered after completion of treatment for the primary tumor. Risk correlation: Anxiety and depression symptoms and disorders are not randomly distributed. Correlation with exacerbations of symptoms includes current or prior psychiatric illness, other chronic medical conditions, adverse social health determinants, and poor functional status. Graded care: As with the previous edition, this guideline defines the levels of screening follow-up for tailored, efficient, and cost-effective patient care.

It is important to note that the particular focus on depression and anxiety in cancer is still relatively new, and this follows decades of RCTs that have studied psychological and psychosocial interventions that focus on reducing stress and enhancing coping skills, and sometimes improving health behaviour or adherence. Psychological screening was minimal at the time of trial inclusion, and the majority of study participants (60% to 70%) may have no or few symptoms of generalized anxiety or major depression, which were often excluded from the trial. Even so, some trials that had a positive effect on other dimensions (i.e. anxiety or depression was not the primary outcome) were found to be effective in treating adults with depression. Against this backdrop, today's focus on cancer survivors with the greatest psychological needs is a major step forward. For them, the main emotional, cognitive, and behavioral disrupting factor is depression. RCT researchers recognise this as 95% of the studies reviewed focused on depression or comorbid with anxiety. We continue to recommend treating depression with validated cognitive and/or behavioral therapies first, or considering a unified treatment regimen for mood disorders across diagnoses.

Regarding treatment recommendations, this systematic review can confirm previous recommendations and refer to new therapies for which there is promising evidence. Previous guidelines listed CBT and BA as recommended treatments. This review suggests that these treatments remain the preferred first-line treatments and adds support for the use of components alone or in combination, such as problem-solving. The effects of CBT and BA on depression and anxiety are powerful and are universally applicable to gender, age, site of disease, time to cancer trajectory, and patients from the United States, English-speaking countries, Europe, and Asia, all of which are consistent with the results of large-scale population testing in the United States. In relation to the cost of treatment, the evidence also confirms multiple delivery methods, including via app, virtual, phone, etc.

Unlike previous guidelines, pharmacotherapy is not recommended as first-line therapy, either alone or in combination. The evidence is not convincing, as concluded by the 2018 Cochrane review, which was ineffective in patients with cancer on the treatment of MDD with antidepressants over a period of 6 to 12 weeks, and this interval was sufficient to detect an effect in pharmacological trials. The data supplemented with an overview of two studies reporting a positive effect at day 3, a finding with unclear consequences, and the sample size of the other studies was just within the cut-off for inclusion in the systematic review (N = 40). When mental health resources are not available or rare, physicians may consider opting for pharmacotherapy for patients who have responded well to depression or anxiety medication in the past, patients with severe neuroautonomic or agitated depression symptoms, depressed patients with psychotic or catatonic features, and/or patient preference. Two rigorous studies99,107 from the UK both described a 10-course multi-component BT treatment for MDD that achieved depression relief and other benefits while also providing pharmacological management compared to pharmacological studies alone.

The mental health crisis is a pervasive problem that affects people with all diseases, including cancer. Cancer patients with depression and/or anxiety do not have access to psychotherapy, which can be attributed to organizational and workforce barriers, such as a shortage of mental health professionals, and a limited referral network for the treatment of depression and anxiety. The choice of interventions for patients facing such barriers should be based on shared decision-making, taking into account availability, accessibility, patient preference, likelihood of adverse events, adherence, and cost.

Care needs to be taken to assess mental health regularly after the initial diagnosis. Finding significant pre- and post-treatment effects is necessary, but is often insufficient to confirm the effect of treatment in patients with depression or anxiety. Adequate time and repeat follow-up is required, particularly for conditions such as MDD that are known not to improve or worsen after improvement. In addition, the use of theoretically relevant process measures – assessments conducted during the course of treatment, providing confirmatory evidence that the intervention alters relevant aspects of the disease (e.g., exercise interventions altering daily sedentary behavior) and/or patient engagement and/or use of the intervention (e.g., using prescribed relaxation measures) – enables the investigators to identify effective measures. To assess changes more broadly, other measures (e.g., cancer-specific stress, coping strategies, days of sick leave, dose of cancer treatment received) may be used.

Several factors are known to increase suicide risk in cancer patients, including older age at diagnosis, lower education, unpartnered, living in rural or sparsely populated areas, psychological comorbidities, hopelessness, terminal cancer, and poor performance status. Crisis response plans should be implemented readily available as short, practical strategies to reduce short-term suicide risk. Institutional management and referral policies should be followed for any patient with acute suicidal tendencies.

Limitations of the study and future research directions

This systematic literature review provides an opportunity to consider widely recently used study designs and methods. Early study design decisions may undermine the reliability and validity of a study because they reduce the likelihood of detecting reliable and effective effects. In RCTs, patient screening is critical (only one-third of studies are used) and has the potential benefit of reducing sample size. Regarding the latter, many studies (one-third) started with baseline group differences, a situation that is unlikely to occur at the time of intra-stratum randomization, as variables potentially relevant to outcomes can reduce interfering subject variance. Other decisions may reduce statistical power, such as often small sample sizes, insufficient sample sizes to detect effects between active treatments, or decreasing sample sizes over time. Data loss threatens the reliability and validity of research results. As previously mentioned, high mortality rates may occur in trial and/or palliative care settings recruiting patients with advanced disease. In addition to the latter, the most common source of bias in RCTs is churn.

There are several key points to reflect on regarding future research and clinical directions. Given the reliability and generalizability of the effects of CBT, no further argument would make a significant contribution to the literature, either for cancer patients or non-cancer patients. There is a need to conduct and disseminate studies on the acceptance of treatment guidelines by oncology providers and community settings. After screening, several action steps need to be taken, such as further evaluation to clarify the issue and determine if treatment is needed, identifying a mental health provider for referral, etc. The road after that may not be easy. As mentioned earlier, people with depressive symptoms often lack the motivation needed to follow referrals and/or adhere to treatment recommendations. The same is true for people with anxiety disorders. With this in mind, the panel recommends that mental health professionals or other members of the clinical team follow up with patients and providers to ensure a successful transition to psychotherapy. It is a myth that screening takes a long time. On the contrary, efforts beyond that take a lot of time and resources, and if they are not provided, they will cause the greatest loss to the patient.

Health Difference

Although the ASCO Clinical Practice Guidelines represent expert recommendations on best practices in disease management to provide the highest level of cancer treatment, it is important to note that many patients from socially or economically marginalized communities have limited access to health care and may not be able to access treatment that meets the guidelines. Members of socially and economically marginalized groups are defined as facing structural and systemic inequalities caused by discriminatory, sexist, racist, homophobic, and classist socio-cultural norms and government policies. Factors such as race and ethnicity, age, socioeconomic status, sexual orientation and gender identity, geographic location, and access to medical and mental health insurance all affect cancer treatment outcomes. Racial and ethnic disparities in health care are a significant contributor to this problem in the United States. Cancer patients of racial and/or ethnic minorities are more likely to have comorbidities, face more substantial barriers to receiving treatment, are more likely to be uninsured, and are at greater risk of receiving piecemeal or inferior treatment than other Americans.

According to the American Association for Cancer Research's 2022 Progress Report on Cancer Disparities, racial and ethnic minorities, as well as other underserved populations, bear a disproportionate burden of cancer and adverse effects of cancer treatment, including physical, emotional, psychosocial, and economic challenges. Breast, prostate, or colorectal cancer studies have found that black survivors consistently have poorer quality of life and physical and mental health than white cancer survivors. Even after taking into account sociodemographic and psychosocial factors, mental health disparities among survivors persist. In addition to racial and ethnic minorities, cancer survivors who identify as sexual minorities have a two- to three-fold higher risk of depression and/or poor mental health than heterosexuals of all races. This gap widens further among survivors who also come from racial or ethnic minorities, highlighting the impact of intersectionality on cancer health disparities.

In the context of this clinical practice guideline, these disparities in access to care should be taken into account, and healthcare providers should strive to provide the highest level of cancer treatment to these under-resourced populations. In addition, stakeholders should work towards health equity, ensure equitable access to high-quality cancer care and research, and address structural barriers to maintaining health inequities. At the institutional level, it is critical to document the patient's descriptive characteristics (e.g., race and ethnicity, gender identity, socioeconomic status). It is well known that social determinants of health, such as these, co-change with adverse cancer and mental health outcomes. Collecting such data will enable agencies to monitor their status in achieving timely and equitable cancer treatment and mental health coverage for all.

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