The Global Challenges of Psycho-Oncology

In this video, Maya Bizri, MD, MPH, founding director of psycho-oncology at the American University of Beirut Medical Center, discusses systemic challenges to implementing mental health screenings for cancer patients in low- and middle-income countries. Bizri also outlines why U.S. methods and tools cannot just be directly extrapolated abroad.

The following is a transcript of her remarks:

My name is Dr. Bizri. I'm a psychiatrist by training. I've also specialized in psycho-oncology -- or psychosocial oncology, now it's called -- which is basically psychiatry for those patients that have had cancer at some point in their lives, whether they are patients that are undergoing treatment or cancer survivors.

And why that is important is because it's actually been shown that the mental health experience [during] your cancer experience, having depression or anxiety, will actually affect your clinical outcomes, so, your cancer prognosis.

There's a very high need globally for universal screening, and there's a consensus on that for universal screening of patients with cancer. The problem is how we translate that to global settings. What we mean by that is these are countries like Lebanon, where I practice, that do have chemotherapy, they have advances in biological therapies, but what we're missing out on is the psychosocial component.

GLOBOCAN has actually predicted that there'll be a 47% rise in cancer incidence by 2040. The largest burden of disease will actually be in the countries that are transitioning or low-human-development-index countries [as categorized] by WHO [World Health Organization], meaning low- and middle-income countries. The burden of disease will be higher in those countries. What makes the burden of disease more urgent in these countries is that the social determinants of health play a bigger role.

For any disease, there's an interplay between the psychological, physical, and social determinants of health, and that is more important in cancer care specifically. So when we talk about social determinants of health, we want to talk about access to care, employment, psychiatric well-being. And the role of financial toxicities -- financial toxicity meaning the toll that having cancer will take on your finances, which is up to 25% in any country, even in high-income countries, it's up to 25%, but it's even bigger in those [low- and middle-income] countries -- that's very important because it's the biggest factor that is directly associated with non-compliance.

So there are systemic healthcare service challenges, there are cultural patient-related challenges, and there are funding and resource allocation challenges.

I'll talk about the systems' healthcare challenges first. Every organization or institution you can think of calls for implementing a distress screening for unmet psychosocial needs. There's a problem with that. The problem is when you're screening for depression, distress, anxiety, what have you, in a patient with cancer, you want to take that and implement it in their culture and use a culturally validated screening tool.

It's not like chemotherapy, where you take the drug and you take it and you apply it. It's not a regimen, it's not a protocol. You have to develop these tools first and then translate them and have people that are trained that can implement them [and] to be able to detect them. That needs a lot of research, which needs a lot of funding, which needs a lot of specialized healthcare workforces.

There's also the cultural and patient-related challenges, meaning there is a lot of mental health stigma that is different from having the cancer stigma itself. There was a study in Lebanon, actually, that was very interesting and [it] showed that 81% of oncologists that were surveyed would prefer addressing the family first before telling the patient about their diagnosis. So you have that component, because there's a stigma around cancer.

As a global average, one out of four adults -- [this is not including] cancer -- one out of four adults will have at some point a mental health disorder, but only one out of 10 of those will actually seek help.

In many countries, mental health is not covered by insurances or by the government, in many low- and middle-income countries. So when you're talking about the financial toxicity to start with, patients will have difficulty really addressing psychosocial needs from a financial perspective, even if they do want to. What that means is you have a lot of non-compliance, non-adherence, and you have a loss of follow-up because the psychosocial component is not addressed.

I think we have to think of it from a different perspective when we talk about global health. Funding is one [issue] -- funding not just for programs, but funding for research around what we can do that is culturally sensitive and specific.

You know, I think in global health, we've gone beyond the system where we just take something that works here in the U.S. and equip it with money and send it out there. It doesn't work that way. So you have to really, when we talk about global health, we have to really think of a system that is capacity-building in the sense that [it] works with the infrastructure that is already present. So we can't talk about really having more mental health providers; we have to talk about training primary healthcare providers to do that work, even if it's not done here.

In the U.S. here, you have mid-tier providers, you have a lot of specialized [people], you have social workers, you have a social support system, you have financial coverage. These are things that are not present elsewhere. And access to care.

I'll talk about two things that I think are important when we think of low- and middle-income countries. One, we have to do the training at the level of community leaders, we have to do it [with] primary healthcare providers. The training is at a very basic level, and you can't talk about more advanced care because the infrastructures will take ages to get there.

And two, there's no way around it, we have to adopt telepsychiatry because of access challenges. Commuting is a big problem for patients. Patients cannot afford these long transportations, and I think we have to adopt telepsychiatry in low- and middle-income countries.

We usually don't think of that because we tend to think, "Oh, you know what? These are low- and middle-income countries. We're not going to apply telepsychiatry there." But I think it's a system that, well, you can't avoid it anymore. And I think it works perfectly, especially for psychiatry, where there is less procedural intervention, I would say. So, I think it lends itself to that platform very easily.

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