Inequalities in Lung Cancer Care of Elderly Patients With Schizophrenia

Abstract

Objective Cancer mortality is higher in individuals with schizophrenia, a finding that may be due, in part, to inequalities in care. We evaluated gaps in lung cancer diagnosis, treatment, and survival among elderly individuals with schizophrenia. Methods The Surveillance, Epidemiology, and End Results (SEER) database linked to Medicare records was used to identify primary non-small cell lung cancer (NSCLC) patients ≥66 years of age. Lung cancer stage, diagnostic evaluation, and rates of stage-appropriate treatment were compared among patients with and without schizophrenia using unadjusted and multiple regression analyses. Survival was compared among groups using Kaplan-Meier methods. Results Of the 96,702 NSCLC patients in SEER, 1,303 (1.3%) had schizophrenia. In comparison to the general population, patients with schizophrenia were less likely to present with late-stage disease after controlling for age, sex, marital status, race/ethnicity, income, histology, and comorbidities (odds ratio [OR]: 0.82; 95% confidence interval [CI]: 0.73-0.93) and were less likely to undergo appropriate evaluation (p<0.050 for all comparisons). Adjusting for similar factors, patients with schizophrenia were also less likely to receive stage-appropriate treatment (OR: 0.50, 95% CI: 0.43-0.58). Survival was decreased among patients with schizophrenia (mean survival 22.3 vs. 26.3 months, p=0.002), however no differences were observed after controlling for treatment received (p=0.4). Conclusions Elderly patients with schizophrenia present with earlier stages of lung cancer, but are less likely to undergo diagnostic evaluation or to receive stage appropriate treatment, resulting in poorer outcomes. Efforts to increase treatment rates for elderly patients with schizophrenia may lead to improved survival in this group.

Cancer survival in the context of mental illness: a national cohort study

“…Where all cancers and/or all mental illnesses are examined together, the different stage distribution for different cancers and mental illnesses may be obscured, resulting in no apparent relationship (for example [7]). Differences in findings for the same mental illness diagnosis (e.g., schizophrenia) are likely to relate to the cancer and the health system setting -for example, the finding of earlier lung cancer diagnosis in Medicare patients with schizophrenia than others [20] suggests that these patients undergo a high degree of surveillance of the type likely to pick up lung cancer (likely chest x-rays) in the Medicare system.…”

“…Other studies which have examined the role of cancer stage at diagnosis in survival disparities for people with history of mental illness have produced conflicting findings, with some studies finding that mental illnesses are associated with late diagnosis [10], while others finding an association with early diagnosis [20], or no association [7]. Preexisting illness (including mental illness) can influence the stage at which cancers are diagnosed in a variety of ways, sometimes overshadowing cancer symptoms resulting in late diagnosis, but in other cases leading to increased surveillance resulting in earlier cancer diagnosis, depending on factors such as the severity of the illness, the type of cancer and the health system context [21].…”

Cancer screening, prevention, and treatment in people with mental illness

“…A study of Surveillance, Epidemiology and End Results‐Medicare‐linked data showed that individuals with mental illness (defined as mood disorders, psychotic disorders, dementia, substance abuse and dependence disorders, and other) and colon cancer are more likely to have unstaged colon cancer or a diagnosis of colon cancer at autopsy . Another Surveillance, Epidemiology and End Results‐Medicare analysis revealed that patients with schizophrenia and nonsmall cell lung cancer are less likely to have appropriate evaluation . A study of Swedish adults with schizophrenia who died of cancer showed that those individuals were less likely to have a cancer diagnosis before death .…”

Updates in Psychosomatic Medicine: 2014

“…The articles were Updates in Psychosomatic Medicine related to 15 subspecialties: cardiac psychiatry, [4][5][6][7][8][9] collaborative care/integrated behavioral health, 10,11 emergency psychiatry, 12,13 HIV psychiatry, [14][15][16][17][18][19][20] neuropsychiatry, 21-31 pediatric psychosomatic medicine, 32-36 psychodermatology, [37][38][39][40][41][42][43][44][45] psychonephrology, 46-55 psycho-oncology and palliative care, [56][57][58][59][60][61][62][63][64] serious mental illness, [65][66][67][68][69][70][71][72] somatic symptom disorders, 73 suicide, 74-78 transplant psychiatry, [79][80][81][82][83][84]…”