A Collaborative Care Model Recognizes That the Oncology Patient’s Journey Does Not End At Remission

Earon Lehning, LCSW, Senior Collaborative Care Therapist, Rochester Regional Health – Lipson Cancer Institute at Association of Community Cancer Centers, joins Pharmacy Times to discuss the merits of a billable collaborative care model for which treating patients with cancer. Lehning discusses the model, adapted from one from the University of Washington, and the importance of offering patient care after remission, which includes mental health services. She presented on the model in a session the Association of Community Cancer Centers (ACCC) 40th 2023 National Oncology Conference in Austin, TX, from November 4 to 6, 2023.

Pharmacy Times Staff: Does emotional health impact other aspects of active treatment/survivorship (i.e., medication adherence; treatment outcomes; lifestyle; employment)?

Earon Lehning, LCSW: Yes, individual mood absolutely affects quality of life, treatment outcomes, and many aspects of people's treatments both during active treatment and in survivorship. We know that depression alone affects at least 10% of patients with cancer, and we know that depression is associated with worsening anxiety, higher measures of pain, fatigue, it impacts daily functioning, and it impacts individuals’ adherence to treatment regimens, and even as far as impacting some individuals’ will to continue living. We may even have individuals who may be struggling with suicidal ideation.

Pharmacy Times Staff: Your health center’s cancer program will begin to embed counseling services into oncology/palliative care. While both aim to improve quality of life for the patient, how do they differ?

Earon Lehning, LCSW: I think that they go hand-in-hand. Palliative care and counseling—therapy services—both aim to improve quality of life. Palliative care, focuses on things like pain, difficulty breathing, but it is the whole picture as well and therapy can really complement that. Maybe a therapist is able to teach some breathing techniques that might help an individual work through some of the pain that they're having, or even just for breathing in general, counseling—or even the palliative care team—might be able to help patients work through some of the cultural issues that might come up. When we think about palliative care, we think about pain management, and not every culture has a goal of reducing pain or getting rid of pain. Some cultures find that valuable or find meaning in it, so even working through those aspects of treatment, the 2 can really complement each other.

Pharmacy Times Staff: How does earlier counseling intervention support patients in oncology/palliative care?

Earon Lehning, LCSW: I'm coming from more of the oncology perspective than the palliative care perspective, but we had a social work team that was able to address a lot of the psychosocial concerns of our patients. What we were seeing was that a lot of times our patients were struggling with symptoms of depression and anxiety, other mood concerns. You know, just grieving some of the life changes and impacts on their body. Sometimes by the time we got to that point we were more in a reactive state than a preventative state, and the goal was really to be able to catch things early on and address them before they became an issue that impacted an individual's quality of life, their care, or anything like that.

Pharmacy Times Staff: What does concurrent counseling and oncology/palliative care look like in the context of the patient care journey?

Earon Lehning, LCSW: What typically happens is—there's multiple ways that a referral can come to our collaborative care team—once we receive a referral, we reach out to the patient and do an assessment. We screen for symptoms of depression, anxiety, or other concerns that might be going on, and then we develop individual treatment plans with patients based on those needs. Sometimes we're addressing anxiety, anxiety around treatments, anxiety around medications, anxiety for going to a radiation treatment where it might be claustrophobic…sometimes there's anxiety around decision-making or involving family members or our caregivers. We also follow through with the people we work with who are in survivorship, and that's a whole other a whole other aspect of what we work with. It might be body image issues, ongoing pain issues, concerns around sexuality or sexual function, anxiety around reoccurrence, survivor's guilt…there's multiple things that come up, that unfortunately, the journey for a cancer patient doesn't end when the disease is in remission.

Pharmacy Times Staff: It seems that when a patient overcomes cancer, there is a little discourse about what happens next.

Earon Lehning, LCSW: That's a common theme I hear, people will tell me “Everyone's happy for me and they want to know why I'm not celebrating. But for me, I just went through 3 years of, of treatment. It's in remission…there's no evidence of disease right now, but what does that mean for me 5 years from now and how do I continue living life after my whole perspective on on this terrible thing that happened to me?”

You know, none of us expect cancer to happen to us, it's something that happens to everyone else. That's a big struggle for people as they move forward past the acute medical phase of the disease.

Pharmacy Times Staff: How can pharmacist/psychiatrists support active patients and survivors as part of a collaborative care team?

Earon Lehning, LCSW: I think that the pharmacist does play an important role in patient care. Maybe the pharmacist is talking to a patient and sees them struggling and encourages them to follow up with their providers about options for support. There's multiple situations where we have individuals, for example, who are taking hormone therapies after breast cancer diagnosis and treatment. Sometimes that can impact patients mood, so that might be something that a pharmacist might catch knowing what medications an individual is on, and maybe seeing the patient struggle and recognizing that maybe that might be 1 of the causes.

Or things like catching medication interactions…I recently was working with an individual who needed radiation in his head and neck region and the medication he was taking for depression lowered his seizure threshold. The pharmacist was able to catch that the 2 of those things together would not be a good thing, so we didn't have a problem because it was caught. Those are the types of things that are absolutely vital, and that the more eyes we have on a patient looking at the whole picture, the better care we can provide.

Pharmacy Times Staff: How can more community clinics implement a collaborative care model to support emotional health during treatment and survivorship?

Earon Lehning, LCSW: The collaborative care model that we're working with was developed by the AIMS Center out of the University of Washington. So, if a center is interested in using that model, they could certainly reach out to the AIMS Center and work with them to implement the program within their own department. It’s an evidence-based model, it's a billable model, which is important for ongoing support for the organization as a whole. It's a model that our social work team developed. The AIMS Center used it with primary care, and we adopted it to individuals with cancer. Most social work teams would be super excited to be able to implement something that is financially sustainable and further reaches the needs of our patients.

Pharmacy Times Staff: What are some of the largest patient-related benefits associated with this model?

Earon Lehning, LCSW: I think that 1 of the biggest benefits I've seen as just the normalization of the struggle for people. I can't tell you how many times I've met with patients who think that they're the only 1 that feels this way about whatever the issue is. You know, we don't talk about the internal battle that cancer is and the ongoing struggle and all the pieces of that. Just to normalize that is super impactful for our patients.