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Access to Psychosocial Oncology Services

Key findings

In 2017, 84% of cancer patients who had a referral date for nutrition therapy services saw a registered dietitian at a Regional Cancer Centre (RCC) in Ontario within 14 days of their referral. This is close to Cancer Care Ontario’s target of 85%. There is still, however, considerable variation in access across the province.

Measure:  Percentage of referred cancer patients seen within 14 days for registered dietitian services

 

Desired Direction:

 

An image of an arrow pointing upwards. This indicates that desired direction for this action is upwards.

 

As of this Report:

 

An image of a yellow box. This indicates that there is no time trend and this action is below but approaching target or has notable regional variation.

Fifty-eight percent (58%) of patients diagnosed with head and neck cancer in 2016 received registered dietitian services at a RCC, either before their treatment or within 14 days of receiving curative radiation and/or chemotherapy. This is less than Cancer Care Ontario’s target of 80%.

In 2017, 84% of cancer patients who had a referral date for social work services saw a social worker at a RCC in Ontario within 14 days of their referral. Similar to access to registered dietitian services, the provincial results are near Cancer Care Ontario’s target (85%), but notable regional variation remains.  

Access to psychiatry and psychology services across Ontario is affected by resource availability. There is significant regional variation in timely access to psychiatry and psychology services for cancer patients across the province.

What is psychosocial oncology?

Psychosocial oncology (PSO) is the interprofessional specialty concerned with understanding and treating the emotional, functional, practical, psychological, quality-of-life, social and spiritual impact that cancer has on patients and their families. PSO care spans from prevention, screening, diagnosis and treatment through survivorship and end-of-life care [1].

Specialized PSO providers include occupational therapists, physiotherapists, psychiatrists, psychologists, registered dietitians, speech language pathologists, spiritual care providers and social workers.

Measure:  Percentage of patients diagnosed with head and neck cancer seen by a registered dietitian prior to or within 2 weeks of beginning curative chemotherapy or radiation

 

Desired Direction:

 

An image of an arrow pointing upwards. This indicates that desired direction for this action is upwards.

 

As of this Report:

 

An image of an arrow pointing straight in a red box. This indicates that there has been no increase or decrease in performance over the previous periods identified and this action is well below targets.

Other disciplines that may be included in PSO programs include medical psychotherapists and mental health nurses.

How can we measure patient access to psychosocial oncology services?

The Psychosocial Oncology Program at Cancer Care Ontario supports timely access to high-quality PSO care to improve the quality of life of patients. The program has developed a measurement plan that evaluates the access to, and the effectiveness of, psychosocial support services for oncology patients across the province. The program is currently measuring access to registered dietitians for patients identified as having a need for nutritional intervention, access to social workers for patients referred to social work service, and the availability of timely access to psychiatry and psychology services.

To determine appropriate wait times for registered dietitians and social workers, an expert panel composed of PSO experts, registered dietitians, social workers, and patient and family advisors was convened. Based on expert consensus, the panel concluded that 85% of all cancer patients referred to registered dietitian or social work services should be seen within 2 weeks of referral to first consultation. The 85% target allows for delays due to circumstances in the clinic or those around patient preference (e.g., whether a patient would like to meet with a registered dietitian).

The Ambulatory Oncology Patient Satisfaction Survey (AOPSS) measures the patient experience regarding the information, communication and education domains. With growing work and interest related to the sexual health needs of patients, the Cancer System Quality Index (CSQI) highlights the AOPSS indicator related to the provision of sexual health information. For more information on the AOPSS, see Person-centred care and patient experience with outpatient cancer care.

Psychosocial services should be part of the team approach in the treatment of cancer.

Pat G., Patient/Family Advisor

Figure 1. Percentage of referred cancer patients seen within 14 days for registered dietitian services, by Regional Cancer Centre (RCC), 2017

More information regarding the methodology is available.

Report date: December 2017

Data source: Activity Level Reporting

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. See technical notes for detailed methodology and inclusions/exclusions

Figure 2. Percentage of head and neck cancer patients diagnosed from 2014 to 2016 seen by a registered dietitian at a Regional Cancer Centre (RCC) prior to beginning treatment or within 2 weeks of beginning curative radiation and/or systemic treatment

More information regarding the methodology is available.

Report date: December 2017

Data source: Activity Level Reporting

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. See technical notes for detailed methodology and inclusions/exclusions

Figure 3. Percentage of referred cancer patients seen within 14 days for social worker services by Regional Cancer Centre (RCC), 2017

More information regarding the methodology is available.

Report date: December 2017

Data source: Activity Level Reporting

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. See technical notes for detailed methodology and inclusions/exclusions

Figure 4. Specialized psychosocial oncology service by Regional Cancer Centre: psychiatry

 

Figure 5. Specialized psychosocial oncology service by Regional Cancer Centre: psychology

 

Figure 6. [Domain: Emotional Support] Percentage of questionnaire respondents who reported that they received enough information about possible changes in sexual activity, by type of cancer, fiscal year 2014/2015 to fiscal year 2016/2017

More information regarding the methodology is available.

Report date: December 2017

Data source: Ambulatory Oncology Patient Satisfaction Survey (AOPSS)

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. See technical notes for detailed methodology and inclusions/exclusions.
  2. † Values have been suppressed due to small cell counts.
  3. “Do not know” disease category may not match CSQI 2017 results due to the migration of data to a new system.

Figure 7. [Domain: Emotional Support] Percentage of questionnaire respondents who reported that they received enough information about possible changes in sexual activity, by gender, fiscal year 2016/2017

More information regarding the methodology is available.

Report date: December 2017

Data source: Ambulatory Oncology Patient Satisfaction Survey (AOPSS)

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. See technical notes for detailed methodology and inclusions/exclusions.

Data Table 1. Percentage of referred cancer patients seen within 14 days for registered dietitian services, by Regional Cancer Centre (RCC), 2017

RCC Percentage of referred cancer patients seen within 14 days for registered dietician services by Regional Cancer Centres of treatment in 2017 Total number of cancer patients who had their first consult with a dietitian within target (14 days) in 2017 Total number of new patients with valid referral and consult dates to a dietitian in 2017 Upper confidence interval in 2017 Lower confidence interval in 2017
Ontario 84.3 7734 9176 85.0 83.5
Windsor RCC 76.5 260 340 80.8 71.8
London RCP 86.3 670 776 88.7 83.9
Grand River RCC (Kitchener) 80.7 397 492 84.1 77.1
Juravinski (Hamilton) 73.2 552 754 76.3 70.0
Carlo Fidani (Peel) 95.9 1097 1144 97.0 94.7
UHN/PMH (Toronto) 84.8 790 932 87.0 82.4
Odette (Toronto Sunnybrook) 99.5 1183 1189 99.9 99.1
Stronach RCC (Newmarket) 86.2 307 356 89.7 82.5
MDRCC (Oshawa) 93.0 636 684 94.8 91.0
Southeastern RCC (Kingston) 64.3 223 347 69.2 59.1
Ottawa RCC 71.0 507 714 74.3 67.6
Simcoe-Muskoka RCC 92.7 659 711 94.5 90.7
North East (Sudbury) 48.2 253 525 52.4 43.8
Northwestern (Thunder Bay) 94.3 200 212 97.2 91.0

Report date: December 2017

Data source: Activity Level Reporting

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. See technical notes for detailed methodology and inclusions/exclusions

Data Table 2. Percentage of head and neck cancer patients diagnosed from 2014 to 2016 seen by a registered dietitian at a Regional Cancer Centre (RCC) prior to beginning treatment or within 2 weeks of beginning curative radiation and/or systemic treatment

RCC Percentage of patients that saw a dietitian in 2014 Number of head and neck patients seen by a registered dietitian prior to beginning treatment or within 2 weeks of beginning curative radiation and/or systemic treatment in 2014 Number of patients diagnosed with head and neck cancer in the specified period and treated with sytemic/radiation within 12 months of diagnosis in 2014 Upper confidence interval in 2014 Lower confidence interval in 2014 Percentage of patients that saw a dietitian in 2015 Number of head and neck patients seen by a registered dietitian prior to beginning treatment or within 2 weeks of beginning curative radiation and/or systemic treatment in 2015 Number of patients diagnosed with head and neck cancer in the specified period and treated with sytemic/radiation within 12 months of diagnosis in 2015 Upper confidence interval in 2015 Lower confidence interval in 2015 Percentage of patients that saw a dietitian in 2016 (Jan. to Sept.) Number of head and neck patients seen by a registered dietitian prior to beginning treatment or within 2 weeks of beginning curative radiation and/or systemic treatment in 2016 (Jan. to Sept.) Number of patients diagnosed with head and neck cancer in the specified period and treated with sytemic/radiation within 12 months of diagnosis in 2016 (Jan. to Sept.) Upper confidence interval in 2016 (Jan. to Sept.) Lower confidence interval in 2016 (Jan. to Sept.)
Ontario 59.9 822 1373 62.4 57.2 56.1 754 1345 58.7 53.4 57.6 616 1070 60.5 54.6

Report date: December 2017

Data source: Activity Level Reporting

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. See technical notes for detailed methodology and inclusions/exclusions

Data Table 3. Percentage of referred cancer patients seen within 14 days for social worker services by Regional Cancer Centre (RCC), 2017

RCC Percentage of referred cancer patients seen within 14 days for social worker services by Regional Cancer Centre in 2017 Total number of cancer patients who had their first consult with a social worker within target (14 days) in 2017 Total number of new patients with valid referral and consult dates to a social worker in 2017 Upper confidence interval in 2017 Lower confidence interval in 2017
Ontario 84.4 8714 10327 85.1 83.7
Windsor RCC 71.2 324 455 75.3 66.9
London RCP 80.0 636 795 82.7 77.2
Grand River RCC (Kitchener) 92.3 441 478 94.6 89.8
Juravinski (Hamilton) 82.5 546 662 85.3 79.5
Carlo Fidani (Peel) 95.9 1252 1305 97.0 94.8
UHN/PMH (Toronto) 87.3 1378 1579 88.9 85.6
Odette (Toronto Sunnybrook) 99.4 1245 1252 99.8 99.0
Stronach RCC (Newmarket) 97.2 348 358 98.8 95.4
MDRCC (Oshawa) 94.4 571 605 96.1 92.5
Southeastern RCC (Kingston) 68.9 412 598 72.5 65.1
Ottawa RCC 59.5 710 1194 62.2 56.6
Simcoe-Muskoka RCC 83.1 338 407 86.6 79.3
North East (Sudbury) 73.9 317 429 77.9 69.6
Northwestern (Thunder Bay) 93.3 196 210 96.5 89.7

Report date: December 2017

Data source: Activity Level Reporting

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. See technical notes for detailed methodology and inclusions/exclusions

Data Table 4. Specialized psychosocial oncology service by Regional Cancer Centre: psychiatry

Regional Cancer Centre Windsor RCC London RCP Grand River RCC (Kitchener) Juravinski (Hamilton) Carlo Fidani (Peel) UHN/PMH (Toronto) Odette (Toronto Sunnybrook) Stronach RCC (Newmarket) MDRCC (Oshawa) Southeastern RCC (Kingston) Ottawa RCC Simcoe-Muskoka RCC North East (Sudbury) Northwestern (Thunder Bay)
Access to Psychiatrist No access Within host hospital On site On site Within host hospital On site On site On site On site Within host centre On site No access No access Within host hospital

 

Data Table 5. Specialized psychosocial oncology service by Regional Cancer Centre: psychology

Regional Cancer Centre Windsor RCC London RCP Grand River RCC (Kitchener) Juravinski (Hamilton) Carlo Fidani (Peel) UHN/PMH (Toronto) Odette (Toronto Sunnybrook) Stronach RCC (Newmarket) MDRCC (Oshawa) Southeastern RCC (Kingston) Ottawa RCC Simcoe-Muskoka RCC North East (Sudbury) Northwestern (Thunder Bay)
Access to Psychologist No access Within Community No access No access No access On site On site No access No access No access On site No access On site Within host hospital

 

Data Table 6. [Domain: Emotional Support] Percentage of questionnaire respondents who reported that they received enough information about possible changes in sexual activity, by type of cancer, fiscal year 2014/2015 to fiscal year 2016/2017

Type of cancer Percentage of positive responses in fiscal year 2014/2015 Number of positive responses in fiscal year 2014/2015 Total number of responses in fiscal year 2014/2015 Lower confidence interval in fiscal year 2014/2015 Upper confidence interval in fiscal year 2014/2015 Percentage of positive responses in fiscal year 2015/2016 Number of positive responses in fiscal year 2015/2016 Total number of responses in fiscal year 2015/2016 Lower confidence interval in fiscal year 2015/2016 Upper confidence interval in fiscal year 2015/2016 Percentage of positive responses in fiscal year 2016/2017 Number of positive responses in fiscal year 2016/2017 Total number of responses in fiscal year 2016/2017 Lower confidence interval in fiscal year 2016/2017 Upper confidence interval in fiscal year 2016/2017
All disease 45.7 44.1 47.3 46.7 1723 3693 45.0 48.3 49.3 47.6 51.1
Brain 33.3 21 63 21.7 45.0 40.9 29 71 29.4 52.3 45.7 16 35 29.2 62.2
Breast 42.4 415 979 39.3 45.5 42.6 443 1039 39.6 45.7 44.4 369 831 41.0 47.8
Cervix/uterine/ovarian 50.7 106 209 43.9 57.5 44.2 96 217 37.6 50.9 54.6 100 183 47.4 61.9
Colorectal/bowel 50.9 191 375 45.9 56.0 53.1 163 307 47.5 58.7 46.3 126 272 40.4 52.3
Head/neck 32.8 43 131 24.8 40.9 41.5 44 106 32.1 50.9 34.7 25 72 23.7 45.7
Hematology (blood) 33.8 49 145 26.1 41.5 34.6 66 191 27.8 41.3 46.8 81 173 39.4 54.3
Kidney/bladder 43.4 23 53 30.1 56.7 46.4 32 69 34.6 58.2 41.9 26 62 29.7 54.2
Lung 44.9 149 332 39.5 50.2 40.2 138 343 35.0 45.4 48.6 155 319 43.1 54.1
Lymphoma 41.4 140 338 36.2 46.7 45.5 146 321 40.0 50.9 49.6 131 264 43.6 55.7
Melanoma 34.8 32 92 25.1 44.5 35.5 33 93 25.8 45.2 35.4 28 79 24.9 46.0
Prostate/testicular 65.9 364 552 62.0 69.9 68.1 385 565 64.3 72.0 68.4 336 491 64.3 72.5
Sarcoma 37.5 12 32 20.7 54.3 40.0 14 35 23.8 56.2 52.9 9 17 29.2 76.7
Stomach 38.0 19 50 24.6 51.5 36.8 14 38 21.5 52.2 32.6 14 43 18.6 46.6
Other 35.3 104 295 29.8 40.7 40.3 120 298 34.7 45.8 44.4 107 241 38.1 50.7
Do not know 14.3 0.0 40.2 0.0 0 0 0.0 0.0 31.3 8.5 54.0

Report date: December 2017

Data source: Ambulatory Oncology Patient Satisfaction Survey (AOPSS)

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. See technical notes for detailed methodology and inclusions/exclusions.
  2. † Values have been suppressed due to small cell counts.
  3. “Do not know” disease category may not match CSQI 2017 results due to the migration of data to a new system.

Data Table 7. [Domain: Emotional Support] Percentage of questionnaire respondents who reported that they received enough information about possible changes in sexual activity, by gender, fiscal year 2016/2017

Gender Percentage of positive responses in fiscal year 2016/2017 Number of positive responses in fiscal year 2016/2017 Total number of positive responses in fiscal year 2016/2017 Lower confidence interval in fiscal year 2016/2017 Upper confidence interval in fiscal year 2016/2017 Overall p-value in fiscal year 2016/20147
Male 53.0 855 1614 50.5 55.4 <0.0001
Female 45.5 769 1689 43.2 47.9 <0.0001

Report date: December 2017

Data source: Ambulatory Oncology Patient Satisfaction Survey (AOPSS)

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. See technical notes for detailed methodology and inclusions/exclusions.

What do the results show?

Most cancer patients referred for registered dietitian services are seen within 14 days of referral, but fewer head and neck cancer patients are seen either before their treatment or within the target of 14 days (Figures 1 and 2).

  • In 2017, 84% of referred cancer patients saw a registered dietitian within 14 days, nearly meeting Cancer Care Ontario’s target of 85%.
  • There are regional differences in the wait time data for registered dietitians. Some reasons for this could include different staffing ratios and different models of service delivery. The Psychosocial Oncology Program will work with stakeholders at many levels, including a CCO-sponsored Community of Practice for Registered Dietitians, to address and resolve these issues.
  • Fifty-eight percent (58%) of head and neck cancer patients saw a registered dietitian prior to or within 2 weeks of curative chemotherapy or radiation treatment in 2016. This has remained below Cancer Care Ontario’s target of 80% over the last 3 years, and it is relatively unchanged over that period.
  • Cancer Care Ontario is working with multiple stakeholders to identify possible barriers to head and neck patients receiving timely registered dietitian services.
  • The Psychosocial Oncology Program will work with stakeholders at many levels, including a CCO-sponsored Community of Practice for Registered Dietitians to address and resolve these issues.

Most cancer patients referred for social work services are seen within 14 days of referral (Figure 3). Access to psychiatry and psychology services varies significantly across the province (Figures 4 and 5).

Measure:  Percentage of referred cancer patients seen within 14 days for social work services

 

Desired Direction:

 

An image of an arrow pointing upwards. This indicates that desired direction for this action is upwards.

 

As of this Report:

 

An image of a yellow box. This indicates that there is no time trend and this action is below but approaching target or has notable regional variation.

  • In 2017, 84% of cancer patients who had a referral date for social work services saw a social worker at a RCC in Ontario within 14 days of their referral.
  • Access to social workers varies considerably between cancer centres across the province. This could be due to different staffing ratios and different models of service delivery. The Psychosocial Oncology Program will work with stakeholders at many levels, including a CCO-sponsored Community of Practice for Depression and Anxiety to address and resolve these issues.
  • Figures 4 and 5 highlight the regional availability of timely services from psychiatry and psychology. To be included on the map as a psychiatrist or psychologist in the community, the practitioner would have to have expertise in cancer, a partnership relationship with the cancer centre and timely availability.
  • Of the 14 RCCs, 3 have no access to psychiatry within either the cancer centre or the hospital.
  • For psychology, there is even less access across the province: 8 of 14 cancer centres have no access to psychologists.
  • RCCs report that patient need frequently exceeds resources, and that patient access to specialized psychosocial services can be affected as a result.

About half of AOPSS respondents found they had enough information about changes in sexual activity (Figures 6 and 7).

  • Forty-nine percent (49%) of respondents stated they received enough information about possible changes in sexual activity. This varied by type of cancer, ranging from 33% of patients diagnosed with stomach cancer stating their information on sexual activity was sufficient to 68% of prostate/testicular cancer patients (Figure 6).
  • A higher percentage of males (53%) than females (46%) stated they received enough information about possible changes in their sexual activity (Figure 7).

Why is this important to patient care?

Timely access to specialized registered dietitian services improves patient outcomes.

  • Early nutritional intervention is important for head and neck cancer patients undergoing radiation therapy or concurrent chemotherapy/radiation. This allows registered dietitians to be proactive in supporting a patient’s nutritional needs.
  • Guidelines developed by CCO’s Program in Evidence-Based Care (PEBC) indicate that registered dietitians should be key members of the core healthcare team, which collectively is “responsible for the assessment, treatment, planning, management, survivorship and rehabilitation” of head and neck cancer patients [1].
  • In a recent study, researchers found that 36% of head and neck patients are malnourished before treatment. This is associated with fatigue, appetite loss, nausea and vomiting [2].
  • Early nutrition intervention for head and neck cancer patients prior to receiving radiation and/or chemotherapy treatment is associated with minimizing weight loss, deterioration in nutritional status and reducing symptoms (such as anorexia, nausea, vomiting, dry mouth and taste distortion). It is also linked to increasing energy and protein intake, quality-of-life measures, performance status and physical functioning [2–4].
  • Weight loss is significantly associated with deterioration in the quality of life, physical and social functioning, social eating and social contact [5].

Cancer patients frequently have dietary, emotional, functional, occupational and physical concerns related to their treatment and resulting symptoms.

  • Social work has a unique role that can support the emotional, functional, psychological, social and spiritual concerns that patients have about cancer. It can also play a very important role in supporting patients and their families to address the financial burden that can occur while a person is undergoing or recovering from treatment [6]
  • Emotional distress is common in the cancer experience and sometimes is a consequence of cancer treatment [7]. Estimates suggest about 25% of cancer patients will suffer from clinically significant depressive symptoms, and these may affect adherence to cancer treatment, physical health outcomes and quality of life; they also are a major factor associated with suicide in cancer patients [8–12]. Other outcomes of concern include anxiety (including extreme recurrence fears), relationship problems, body image disturbances, sexual dysfunction and problems with substance abuse and addiction [3, 13].
  • Having prompt access to specialized psychiatry and psychology services can reduce suffering, improve quality of life, reduce the likelihood of suicide and treatment non-adherence, and possibly improve health outcomes for patients [6, 14].

Access to sexual health information and resources can improve patient quality of life.

  • The diagnosis and treatment of cancer often is associated with significant sexual dysfunction [10]. Sexuality may be affected by changes in appearance, physical side effects (e.g., pain, erectile dysfunction or vaginal dryness), and emotional and relationship changes that occur because of treatment or the diagnosis itself. Across disease sites, estimates of sexual dysfunction after cancer treatment range from 40% to 100% [10].
  • CCO’s PEBC recently released a guideline on sexual health that provides guidance on effective strategies and interventions to manage sexual function side effects as a result of cancer diagnosis and treatment. A corresponding patient guide has been developed by the Patient Education Program at CCO. Additionally, the Psychosocial Oncology Program maintains a Sexual Health in Cancer Community of Practice.
  • The Patient Education Program continues to evaluate the quality and quantity of information that patients receive about sexuality to inform potential quality improvement initiatives. Historically, sexual health concerns have not been explicitly addressed by clinicians, but there is a growing awareness of the importance of identifying sexual health issues and supporting people with sexual health information, education and psychosocial support to enhance their quality of life.

Next steps

  • The Psychosocial Oncology Program is working with regional partners to implement the newly released Psychosocial Oncology Service Delivery Framework Recommendations. The recommendations address the components and providers of service for high-quality and equitable PSO services within a Regional Cancer Program (RCP). It also articulates the relationships and important linkages between PSO and other programs and services within RCPs.
  • The goal is to ensure the range of necessary PSO services are provided consistently and in a timely fashion to all cancer patients and their families who require them. This will be done through the regional adoption of evidence-based guidelines and support for sexual health, nutrition therapy, and depression and anxiety communities of practice that create a forum for collaboration, knowledge transfer and professional development.
  • The program will also continue to develop a comprehensive measurement plan and quality indicators (beyond wait times) to improve access. This includes measuring the availability of occupational therapy, physiotherapy and speech language therapy, as well as other rehabilitation programs (such as the availability of services for group programing or services that treat lymphedema).

Find out more

For more information about the Psychosocial Oncology Program, visit the CCO website.

Notes

  1. Gilbert R, Devries-Aboud M, Winquist E, Waldron J, McQuestion M; the Head and Neck Disease Site Group. The management of head and neck cancer in Ontario:organizational and clinical practice guideline recommendations [Internet]. Toronto: Cancer Care Ontario; 2009. Available from here.
  2. Capuano G, Gentile PC, Bianciardi F, Tosti M, Palladino A, Di Palma M. Prevalence and influence of malnutrition on quality of life and performance status in patients with locally advanced head and neck cancer before treatment. Support Care Cancer. 2010;18:433–437.
  3. Isenring EA, Capra S, Bauer JD. Nutrition intervention is beneficial in oncology outpatients receiving radiotherapy to the gastrointestinal or head and neck area. Br J Cancer. 2004;91:447–452. doi:10.1038/sj.bjc.6601962
  4. Ravasco P, Monteiro-Grillo I, Marque Vidal P, Camilo ME. Impact of nutrition on outcome: a prospective randomized controlled trial in patients with head and neck cancer undergoing radiotherapy. Head Neck. 2008;27(8):659–68.
  5. Langius JAE, van Dijk AM, Doornaert P, Kruizenga HM, Langendijk JA, Leemans CR, et al. More than 10% weight loss in head and neck cancer patients during radiotherapy is independently associated with deterioration in quality of life. Nutr Cancer. 2013;65(1):76–83. doi: 10.1080/01635581.2013.741749
  6. Nelson C. The financial hardship of cancer in Canada: a literature review. Manitoba: Canadian Cancer Society; 2010.
  7. Carlson LE, Waller A, Mitchell AJ. Screening for distress and unmet needs in patients with cancer: review and recommendations. J Clin Oncol. 2012;30(11):1160–77.
  8. Walker J, Holm Hansen C, Martin P, Sawhney A, Thekkumpurath P, Beale C, et al. Prevalence of depression in adults with cancer: a systematic review. Ann Oncol. 2013;24(4):895–900.
  9. DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med. 2000;160(14):2101–7.
  10. Carlson LE, Bultz BD. Benefits of psychosocial oncology care: improved quality of life and medical cost offset. Health Qual Life Outcomes. 2003;1:8.
  11. Chen ML, Chang HK. Physical symptom profiles of depressed and nondepressed patients with cancer. Palliat Med. 2004;18(8):712–8.
  12. Russ TC, Stamatakis E, Hamer M, Starr JM, Kivimäki M, Batty GD. Association between psychological distress and mortality: individual participant pooled analysis of 10 prospective cohort studies. BMJ. 2012;345. doi: Available from here.
  13. Howell D, Keshavarz H, Esplen MJ, Hack T, Hamel M, Howes J, et al. Pan-Canadian practice guideline: screening, assessment and management of psychosocial distress, depression and anxiety in adults with cancer. Version 2, 2015. Toronto: The Canadian Partnership Against Cancer and the Canadian Association of Psychosocial Oncology; July 2015.
  14. Breitbart WS, Alici Y. Psycho-oncology. Harv Rev Psychiatry. 2009;17(6):361–76.