Psychological problems among cancer patients in relation to healthcare and societal costs: A systematic review.

BACKGROUND

Psychological problems such as symptoms of anxiety, symptoms of depression, psychological distress and fear of cancer recurrence are commonly reported in cancer patients. 1 , 2 , 3 In case of severe problems a psychiatric disorder may be present. Approximately 11‐19% of all cancer patients have a major depression disorder, anxiety disorder or adjustment disorder. 4 These psychological problems may, besides influencing a patients' health‐related quality of life, 5 also have economic consequences. 6

As previously hypothesized by Carlson and Bultz, 6 cancer patients with psychological problems may not only have increased mental healthcare use, they may also make more use of other domains of healthcare such as general practitioner (GP) visits or hospitalization. Patients with psychological problems are less likely to adhere to cancer treatment or lifestyle recommendations, which may affect their treatment effectiveness and in turn may increase healthcare use. 7 Also, cancer patients with psychological problems are at higher risk of developing comorbidities (e.g., diabetes and cardiovascular disease), 8 , 9 which may result in higher healthcare use. Besides higher healthcare use, psychological problems may also impact on economic losses by patients and their family themselves (e.g., out of pocket purchases or received informal care) 6 and economic losses in other sectors for example productivity losses due to absence from work (i.e., sick leave) or decreased work productivity. 10 , 11 Psychological problems among cancer patients are thus hypothesized to result in high economic costs from both a healthcare and societal perspective.

It is important to gain detailed insight into these economic consequences of psychological problems among cancer patients, as healthcare costs and other societal costs of cancer are already high, 12 and decisions have to be made on allocation of limited healthcare resources. Recently a systematic review (2018) 13 on 10 studies up to December 2017 investigated the relation between psychiatric disorders and healthcare costs among cancer patients. This systematic review revealed that psychiatric disorders are associated with increased healthcare use and costs across all phases of the cancer trajectory. This systematic review was, however, limited to studies from the United States and did not include studies on psychological symptoms or studies that investigated economic losses of patients, their family or other sectors (e.g., productivity losses). In addition, two systematic reviews investigated factors associated with return to work after cancer diagnosis among cancer patients. 14 , 15 However these two reviews did not specifically focus on the economic consequences of the association between psychological problems and return‐to‐work (i.e., the actual time absent from work).

No systematic review has, so far, focused on the association between psychological problems (including both psychological symptoms and psychiatric disorders) and all potentially related healthcare and societal resource use and costs among cancer patients. Therefore, the aim of this study was to systematically review associations between psychological problems (anxiety, depression, fear of cancer recurrence, distress, adjustment to cancer) and healthcare and societal related resource use and costs among cancer patients. Results are relevant both from the perspective of cancer patients and their families, as well as their employers (productivity), and the healthcare system with respect to reimbursement of psychological treatment for cancer patients.

METHODS

Literature search

Preferred reporting items for systematic reviews and meta‐analyses guidelines were used to conduct and describe this systematic review. 16 A comprehensive search was conducted in PubMed, Embase, and PsycINFO from inception up to 31 January 2021. Our search strategy included combinations of keywords, MeSH terms and synonyms which were adapted for each database search, related to three main topics: (1) cancer patients, (2) psychological problems (i.e., psychological symptoms including anxiety symptoms, depressive symptoms, distress and fear of cancer recurrence and psychiatric disorders including anxiety disorder, depression disorder and adjustment disorder) and (3) the use or costs of healthcare or societal resources (e.g., visits to the GP, medication use, inpatient costs, informal care costs, productivity losses).

A detailed description of the search strategy is available in Appendix 1 . An information specialist from the medical library provided advice on the literature search. Additionally, reference lists from included articles were manually searched and authors were asked for additional studies.

Study inclusion and exclusion criteria

Research studies were included if:

they investigated the association between psychological symptoms (i.e., symptoms of anxiety or depression, distress, or fear of cancer recurrence) or a psychiatric disorder (i.e., anxiety disorder, depression disorder or adjustment disorder) and the use or costs of healthcare or societal resources;

they included adult cancer patients (age ≥ 18 years) only; and

full text was available in English or Dutch.

Research studies were excluded if they:

presented descriptive statistics on the use or costs of healthcare or societal resources in a certain cancer population without investigating its association with (level of) psychological problems;

measured work ability or work performance instead of lost working hours;

measured return‐to‐work (yes/no) without insight on time absent from work;

measured return‐to‐work among cancer patients who were not of working age (i.e., included both patients of working age and those who were retired) or

were reviews

No limits were set for year of publication.

Selection process and quality assessment

After removing duplicates, two independent reviewers (F. E. Van Beek and L. M. A. Wijnhoven) screened all identified records based on title and abstract. Records that were not relevant based on the screening were excluded. Subsequently, the full‐text article of potentially relevant records were screened for eligibility using the inclusion and exclusion criteria. In case of disagreement, the full‐text article was discussed by the two reviewers, and when needed a third author (F. Jansen) was involved to meet consensus.

The quality of the included study was assessed with an 11‐item quality assessment scoring list based on Hayden et al. 17 and Drummond et al. 18 , 19 This list compromises four domains: study population, study attrition, data collection and data analysis. Each item was scored positive (“1”) or negative (“0”). In case information to evaluate an item was lacking, that item was scored negative as well. In case an item was not applicable, that item was scored as “not applicable (N/A).” A total score was calculated by summing the item scores, resulting in a score ranging from 0 (lowest quality) to 11 (highest quality). The quality assessment was conducted independently by two reviewers (F. E. Van Beek and L. M. A. Wijnhoven). In case of disagreement, the item was discussed by the two reviewers, and when needed a third author (F. Jansen) to meet consensus. In line with previous studies, 20 , 21 the article was rated “high quality” when an article was assigned at least 70% of the total score.

Data extraction

All studies eligible for inclusion were read thoroughly to extract data. For the data extraction a standardized collection form was used including: general information (first author, publication year, country), study design, study population (number of patients included, cancer site, relevant inclusion and exclusion criteria), psychological outcome and its measurement, use/costs outcomes and its measurement, and results (e.g., odds ratio, risk ratio, differences in mean). Based on the Dutch cost guideline of the National Healthcare Institute, 22 the use/cost outcome were, categorized into (1) healthcare use (e.g., medical specialist visits, length of hospital stay, medication use), (2) economic losses by patients and family (e.g., time expenses for providing informal care, travel costs, out of pocket payments) and (3) economic losses in other sectors (e.g., absenteeism from work). In addition, a fourth category was added in which healthcare use, losses by patients and family, and/or losses in other sectors were valued in monetary units. Based on the associations found in the literature, the four categories were further divided into subcategories including healthcare use (i.e., mental healthcare, supportive nonmental healthcare, primary care, oncology‐related healthcare, inpatient care, outpatient care, medication, and other healthcare use), economic losses by patient and family (i.e., complementary and alternatively medicine use (CAM), healthcare use of spouses, and lost work productivity of spouses), economic losses in other sectors (i.e., return‐to‐work) and losses in monetary units (i.e., mental healthcare, inpatient, outpatient, medication, total healthcare, absenteeism and presentisms (costs), out of pocket costs, and other costs) (Figure 1 ).

Statistical methods and level of scientific evidence

We used a best‐evidence synthesis to estimate the level of evidence for the investigated associations between psychological problems and healthcare use, economic losses by patients and family, economic losses in other sectors, and total costs, as used in previous studies. 20 , 21 , 23 The levels of evidence were (1) strong if an association was consistently supported by at least two high quality studies, (2) moderate if an association was consistently supported by at least one high‐quality study and at least one low‐quality study or if a factor was consistently supported by at least two low‐quality studies, and (3) inconclusive, if an association was supported by only one study, results were inconsistent or did not show an indication for a positive or negative association.

RESULTS

Identification and selection of studies

In total 4157 articles were yielded by PubMed, Embase and PsycINFO. Of these studies 272 were selected for full text review (Figure 2 ). In total 49 studies 1 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 fulfilled the eligibility criteria and were included in this systematic review. The majority of the studies focused on healthcare use ( n = 36) 24 , 25 , 27 , 28 , 29 , 31 , 33 , 34 , 35 , 37 , 38 , 39 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 51 , 53 , 54 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 64 , 67 , 69 , 70 , 71 , 72 followed by studies on costs in monetary units ( n = 13), 26 , 29 , 34 , 36 , 38 , 42 , 43 , 44 , 48 , 53 , 55 , 57 , 61 economic losses in other sectors ( n = 8) 30 , 32 , 40 , 49 , 63 , 65 , 66 , 68 and economic losses by patients and family ( n = 6). 28 , 29 , 50 , 52 , 64 , 69 Thirteen studies 28 , 29 , 34 , 38 , 42 , 43 , 44 , 48 , 53 , 57 , 61 , 69 focused on two or more of these categories (e.g., healthcare use and costs in monetary units), resulting in a total sum greater than 49 studies. In Tables 1–4 the characteristics of the included studies are presented according to healthcare use (Table 1 ), economic losses by patients and family (Table 2 ), economic losses in other sectors (Table 3 ) and costs in monetary units (Table 4 ).

In summary, all studies were published between 1972 and 2020, of which 24 studies 24 , 26 , 27 , 28 , 29 , 30 , 32 , 35 , 36 , 37 , 43 , 48 , 49 , 50 , 53 , 55 , 56 , 57 , 60 , 62 , 63 , 65 , 67 , 70 , 71 were published after December 2017. Most of the studies were conducted in the United States ( N = 27), 27 , 34 , 35 , 36 , 37 , 38 , 41 , 42 , 43 , 44 , 46 , 50 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 66 , 70 , 71 , 72 Netherlands ( N = 8), 26 , 29 , 30 , 39 , 45 , 67 , 68 Germany ( N = 3) 33 , 64 , 65 and Canada ( N = 3). 28 , 47 , 51 Studies were most often performed among mixed cancer patients ( N = 20) 27 , 28 , 29 , 33 , 36 , 37 , 38 , 41 , 44 , 47 , 50 , 53 , 54 , 61 , 62 , 63 , 64 , 66 , 68 , 70 and breast cancer patients ( N = 11). 32 , 34 , 38 , 45 , 49 , 52 , 59 , 60 , 63 , 65 , 71 Other studies were performed across a variety of other cancer patients: colorectal ( N = 5) 25 , 30 , 38 , 39 , 67 prostate cancer ( N = 2) 38 , 42 , lung cancer ( N = 3), 55 , 56 , 72 hepatocellular carcinoma ( N = 2), 48 , 57 head and neck cancer ( N = 2), 43 , 46 Gynecologic cancer ( N = 1) 31 , glioma cancer ( N = 1), 26 gastrointestinal cancer ( N = 1), 35 hematological malignancy ( N = 1) 40 and lymphoma ( N = 1) 24 patients. Sample sizes ranged from 42 to 50,147 patients.

Of all 49 studies, 34 studies 24 , 26 , 27 , 28 , 30 , 31 , 32 , 33 , 35 , 36 , 37 , 38 , 39 , 40 , 49 , 50 , 51 , 52 , 58 , 59 , 60 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 71 , 72 focused on psychological symptoms, 14 studies 25 , 34 , 41 , 42 , 43 , 44 , 46 , 48 , 53 , 54 , 55 , 56 , 57 , 61 focused on a psychiatric disorders and 1 study 29 on both. Focusing on psychological symptoms, 10 studies 31 , 32 , 33 , 39 , 40 , 45 , 58 , 64 , 66 , 72 investigated symptoms of anxiety as measured using the Hospital Anxiety and Depression Scale (HADS), General Anxiety Disorder‐7, State‐Trait Anxiety Inventory (STAI) or PROMIS Anxiety or Patient Health Questionnaire‐4 (PHQ‐4), 20 studies 26 , 27 , 29 , 32 , 33 , 35 , 36 , 39 , 40 , 45 , 49 , 50 , 51 , 58 , 59 , 63 , 65 , 67 , 70 , 72 investigated symptoms of depression as measured using the HADS, PHQ‐9, Center for Epidemiological Studies Depression Scale, Geriatric Depression Scale, PROMIS, Back Depression Inventory II or a study specific questionnaire, six studies 28 , 47 , 52 , 60 , 64 , 69 , 71 investigated fear of cancer recurrence measured with the Fear of Cancer Recurrence Inventory – Short Form, Concerns About Recurrence Scale or the Fear of Progression Questionnaire—Short Form (FoP‐Q‐SF), and 11 studies 24 , 30 , 33 , 37 , 38 , 50 , 52 , 58 , 62 , 67 , 70 investigated distress measured with the HADS, Impact of Event Scale, Distress Thermometer or Kessler Psychological Distress Scale (K10 and K6).

Of the 14 studies 25 , 34 , 41 , 42 , 43 , 44 , 46 , 48 , 53 , 54 , 55 , 56 , 57 , 61 that investigated psychiatric disorders one study used a psychiatric interview (i.e., The Structured Clinical Interview) to investigate the presence of a depression disorder. In all other studies, the psychiatric disorder was retrieved from medical files: two studies 29 , 43 focused on adjustment disorder, three studies 29 , 43 , 53 on anxiety disorder, 13 studies 25 , 29 , 41 , 42 , 43 , 44 , 46 , 53 , 54 , 55 , 56 , 57 , 61 on depression disorder, and two 34 , 48 on presence of any psychiatric disorders (i.e., a combination of anxiety disorder and/or depression disorder and/or adjustment disorder).

Quality assessment

Thirty‐seven of the 49 studies were of high methodological quality as demonstrated in Appendix B . Most of the studies (19/25) scored negative on the item “patients who want to participate in study (participation rate)” due to a participation rate lower than 80%, a missing baseline participating rate or a selective non‐response. Half of the included articles (25/49) did not meet the criteria for sufficient reporting of baseline descriptives, in particular, time since diagnosis, tumor stage, and/or treatment were often not reported. Almost all studies (42/49) used multivariate analyses and included more than 100 patients (47/49).

Psychological problems in relation to healthcare use

Table 5 provides an overview of the results regarding type of psychological problem (i.e., anxiety symptoms, depressive symptoms, distress, fear of cancer recurrence, anxiety disorder, depression disorder, adjustment disorder or any psychiatric disorder) and type of healthcare use (i.e., mental, supportive nonmental, primary, oncology‐related, inpatient, outpatient, and medicine and other healthcare use). Thirty six studies 24 , 25 , 27 , 28 , 29 , 31 , 33 , 34 , 35 , 37 , 38 , 39 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 51 , 53 , 54 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 64 , 67 , 69 , 70 , 71 , 72 investigated 48 associations in total of which six showed a strong evidence two a moderate evidence and 40 showed inconclusive evidence.

We found strong evidence that a depression disorder was positively associated with increased mental healthcare use. 29 , 41 Also, there was strong evidence that fear of cancer recurrence was positively associated with more use of primary care (i.e., GP. 60 , 69 In addition, strong evidence was found for a positive association between depression disorder and increased inpatient healthcare use (e.g., hospitalization, inpatient healthcare use and intensive care admission) as nine studies 25 , 42 , 43 , 44 , 46 , 53 , 54 , 56 found a positive association and three studies 46 , 56 , 61 found no association. The same holds for anxiety disorder and increased inpatient healthcare use. 43 , 53 Anxiety disorder 43 , 53 and depression 25 , 38 , 42 , 43 , 44 , 53 , 54 , 57 disorder were both found to be positively associated with increased outpatient care use (i.e., emergency department visits, ambulatory visits or general outpatient care use.

Moderate evidence (one high and one low‐quality study) 34 , 48 was found for the association between any psychiatric disorder and inpatient care use (i.e., prolonged hospitalization or increased length of hospitalization). Moderate evidence was also found for the association between depression disorder and increased medication (i.e., number of prescriptions). 25 , 44

Inconclusive evidence was found for many ( n = 40) of the studied associations. Remarkable, however, were the negative associations found with regard to oncology related healthcare and psychological symptoms (i.e., depressive symptoms and fear of cancer recurrence) as these were the only examples of all healthcare use associations, in which studies demonstrated that the psychological symptoms were associated with decreased healthcare use (i.e., oncology‐related visits, mammography screening and other screening practices). 51 , 69

Psychological problems in relation to economic losses by patients and family

Six studies 28 , 29 , 50 , 52 , 64 , 69 investigated in total 10 associations between psychological problems and economic losses by patients and family, namely use of CAM ( n = 4), 28 , 29 , 64 , 69 healthcare use by spouses ( n = 2) 50 , 52 and lost work productivity of spouses ( n = 1) 52 (Table 6 ). Inconclusive evidence was found for all of the 10 investigated associations, of which eight due to the fact that only one study investigated the association. The association between fear of cancer recurrence and CAM use was investigated in three studies of which one study 69 found a positive association with increased number of CAM but no association with use of CAM (yes/no) among breast cancer patients, and two studies 28 , 64 found no association at all among a mixed cancer population.

Psychological problems in relation to losses in other sectors

Eight studies 30 , 32 , 40 , 49 , 63 , 65 , 66 , 68 investigated in total three associations between psychological problems and losses in other sectors, all of them focused on return to work (Table 7 ). Strong evidence was found that symptoms of anxiety and depression were negatively associated with return to work , indicating that patients with symptoms did not or returned later to work than patients without symptoms or with less symptoms. Three studies found a negative association between anxiety symptoms and return to work at 9, 12 and 24 months after cancer diagnosis among mixed, breast and hematological cancer patients , respectively. 32 , 40 , 66 Six studies found a negative association between depressive symptoms and return‐to‐work at 6, 12, 15, 18 and 24 months after diagnosis also among mixed, breast and hematological cancer patients. 32 , 40 , 49 , 63 , 65 , 68 One study 32 among breast cancer patients compared return‐to‐work among three groups of patients (no symptoms of depression, moderate symptoms of depression and severe symptoms of depression), which found that patients with severe symptoms of depression did return to work later than patients with low symptoms of depression, whereas no such difference was found in comparison to patients with moderate symptoms of depression. Inconclusive evidence was found on the association between distress and return‐to‐work among colorectal cancer patients. 65

Psychological problems in relation to losses in monetary units

Thirteen studies 26 , 29 , 34 , 36 , 38 , 42 , 43 , 44 , 48 , 53 , 55 , 57 , 61 investigated 33 associations in total between psychological problems and costs in monetary units (i.e., mental, inpatient, outpatient medicine total healthcare, productivity losses and out of pocket costs) (Table 8 ), of which four showed a strong association and 29 showed inconclusive evidence. There was strong evidence that a depression disorder was positively associated with inpatient, outpatient and total healthcare costs. Three high quality studies found a positive association between a depression disorder and inpatients costs among mixed cancer patients. 53 , 57 , 65 Three high‐quality studies 53 , 55 , 61 also found a positive association between depression disorder and outpatient costs among mixed cancer patients, whereas one high quality study 57 found no association among multiple myeloma patients. Six high‐quality studies 43 , 44 , 53 , 55 , 57 , 61 found a positive association between a depression disorder and total healthcare costs among head and neck ( N = 1), multiple myeloma ( N = 1) and mixed ( N = 4) cancer patients. One additional study 42 among prostate cancer patients reported a positive association between post‐treatment depression disorder and total healthcare costs in year two and three following diagnosis, whereas no such association was found in the same study with total healthcare costs in the year following diagnosis or year four and five post diagnosis. Furthermore, there was strong evidence that an anxiety disorder was positively associated with total healthcare costs 43 , 53 among mixed cancer patients. Inconclusive or limited evidence was found for all 29 other investigated associations.

DISCUSSION

The aim of this systematic review was to investigate associations between psychological problems and healthcare and societal related resource use and costs among cancer patients. In total 49 studies were included in this systematic review which investigated 94 different associations between psychological problems and healthcare or societal resource use or costs: 48 for healthcare use, 10 for economic losses of patients and their family, three on other losses such as return to work and 33 for total costs as measured in monetary units. For 14 of these 94 associations, moderate or strong evidence was found. Fear of cancer recurrence, having an anxiety disorder, having a depression disorder and having any psychiatric disorder were associated with higher healthcare use on at least one healthcare subcategory (i.e., mental, primary, inpatient or outpatient healthcare). Anxiety symptoms and depression symptoms were associated with reduced return to work, presence of an anxiety disorder was associated with higher total healthcare costs; and presence of a depression disorder was associated with higher inpatient, outpatient and total healthcare costs. For all other 80 investigated associations inconclusive evidence was found, mostly due to limited studies or inconsistent evidence.

This study confirms the hypothesis made by Carlson and Bultz 6 that cancer patients with psychological problems may not only have increased mental healthcare use but also make more use of other domains of healthcare. We found strong evidence that fear of cancer recurrence was positively associated with increased primary healthcare use. Inconclusive evidence was found for symptoms of anxiety, symptoms of depression, distress and fear of cancer recurrence in relation to all other healthcare use categories, often due to inconsistent findings. However, strong evidence was found that both anxiety disorder and depression disorder were associated with increased inpatient and outpatient healthcare use. In addition, evidence was found for an association between depression disorder and increased mental healthcare use and any type of psychiatric disorder (including anxiety and depression disorder) and inpatient care use. This discrepancy in findings between healthcare use and symptoms of anxiety and depression versus anxiety and depression disorder may be caused by a dose‐response relationship; that is, anxiety or depression problems may only result in higher healthcare use when the problem exceeds a certain threshold. However, it may also be that the association between symptoms of anxiety or depression and healthcare use only exists in certain groups of cancer patients or with specific healthcare use categories. This might explain why in a previous study among 4,020 mixed cancer patients no associations were found between anxiety and depressive symptoms and increased healthcare use, 33 whereas in another study among 3957 colorectal cancer patients this association was found to be significant. 39

In contrast to the hypothesis of Carlson and Bultz, 6 the only healthcare use category which showed, evidence (although inconclusive) of a negative association with psychological problems was oncology‐related care. So far, five studies have investigated the association between symptoms of depression or fear of cancer recurrence and use of oncology related care of which two studies found lower oncology‐related care use among patients with psychological symptoms. 39 , 51 , 69 In four studies, however, also evidence was also found for no or a positive association 39 , 51 , 60 , 71 (some studies found evidence for both a negative association and absence of an association). An explanation may be that patients with higher symptoms of depression or fear of cancer recurrence have a more avoidant coping style 73 which may limit the uptake of specific types of oncology‐related care. Further research is however needed to unravel this association.

With regard to economic losses of patient and family we found inconclusive evidence for all associations, mostly due to limited studies (i.e., eight of the 10 associations were investigated by only one study). Only two studies have investigated the association between psychological problems among breast cancer and mixed cancer patients and healthcare use and productivity losses among their spouses.

With regard to economic losses in other sectors, we found strong evidence that anxiety and depressive symptoms are negatively associated with return‐to‐work. These results are in line with the hypothesis of Carlson and Bultz that the economic consequences of psychological problems among cancer patients are larger than the economic costs of (mental) healthcare only. 6 In our systematic review, we only included articles which measured return‐to‐work with insight on time absent from work. Studies that investigated the association but without a clear timeframe for returning to work were excluded as the association between psychological problems and return‐to‐work in these studies may have been biased by time since diagnosis. 74 , 75 , 76 Remarkable, however, was that no study included in our systematic review investigated the association between psychiatric disorders and return‐to‐work. We hypothesize, however, that in line with the results on psychological symptoms and return‐to‐work, psychiatric disorders are also negatively associated with return to work.

With regard to losses in monetary units, strong evidence showed that depression disorder was positively associated with more inpatient care costs, outpatient care costs and total care costs. Anxiety disorder was also found to be positively associated with more inpatient care costs. Evidence on all other 26 associations was limited or inconclusive. Further research is needed to explore these associations and take possible moderators or mediators (e.g., coping style, social support) into account. For example, studies have demonstrated that cancer patients with psychological problems are more likely to develop comorbidities and are less likely to adhere to cancer treatment or lifestyle recommendations which may result in higher costs. 7 However, comorbidities may also lead to more psychological problems. The pathway via which psychological problems affect healthcare and societal resource use and costs, or the reverse , is thus not yet completely understood. Further research is needed on third variables such as coping style, and social support.

STUDY LIMITATIONS

A strength of this study is that it focused on different psychological symptoms and disorders as well as different types of healthcare and societal costs. Also, in contrast to a previous systematic review, 13 the methodological quality of the included studies was investigated. Furthermore, we used the Dutch guidelines to define economic outcome categories. However, we acknowledge that this framework may not be suitable for all countries, as in some countries, for example, the healthcare costs are paid directly by the patient (without insurance). In those countries healthcare resource use may need to be categorized as “economic losses by patients and their family” instead of the category on “healthcare use.” A limitation is that vote counting was used to summarize the findings of the included studies. The absence of an association in some of the included studies may have been the consequence of limited power rather than an actual absence of an association. Meta‐analyses can solve this problem. However, we did not perform meta‐analyses, as studies were very heterogeneous in study population, psychological problem, cost category investigated, as well as measurements instruments. Our aim was to provide an overview on all economic consequences investigated in relation to psychological problems among cancer patients and a summarized direction of an association instead of the magnitude of the association. Finally, a limitation of this study is that based on the included studies we cannot draw conclusions on the causality of psychological problems and healthcare, societal resource use and costs among cancer patients as almost all studies had a cross‐sectional design.

CLINICAL IMPLICATIONS

Results of this systematic review indicate that the economic consequences of psychological problems among cancer patients are beyond mental healthcare costs only. Psychological problems among cancer patients also impact societal costs such as losses due to delayed return to work. This information is important to consider when building a business case for the reimbursement of psychological treatment for cancer patients. Based on the results of this systematic review we claim that treating psychological problems in general among cancer patients may not only improve psychological well‐being among cancer patients but also lead to medical cost offset and improved return‐to‐work. Two previous reviews 77 , 78 and later published studies 79 , 80 , 81 showed evidence that psychological treatment for patients with cancer is not only effective, but may also be cost saving. Several other studies are ongoing, 82 , 83 including one study on the effectiveness, cost‐utility and budget impact of psychological treatment among cancer patients with an adjustment disorder, 84 which, as also shown in this systematic review, is still an understudied population.

CONCLUSIONS

Psychological problems in cancer patients are associated with increased healthcare use, healthcare costs and economic losses, especially for (symptoms of) anxiety and depression disorder, and fear of cancer recurrence. Future research is needed on psychological problems in relation to understudied healthcare use or costs categories , productivity losses of patients and their caregivers, and informal care costs.

CONFLICT OF INTEREST

All authors declare that they have no conflicts of interest.

AUTHOR CONTRIBUTIONS

F. E. Van Beek: conceptualization; methodology; investigation; writing Original Draft. L. M. A. Wijnhoven: conceptualization; investigation; writing ‐ Review Editing. Karen Holtmaat: writing ‐ Review Editing. José A. E. Custers: writing ‐ Review Editing. Judith B. Prins: writing ‐ Review Editing. Irma M. Verdonck‐de Leeuw: conceptualization; writing ‐ Review Editing; supervision; funding Acquisition. F. Jansen: conceptualization; methodology; investigation; writing ‐ Review Editing; supervision.

Supporting information

Supplementary Material

Click here for additional data file.

Supplementary Material

Click here for additional data file.

ACKNOWLEDGEMENTS

This research was funded by a ZonMw, The Netherlands Organisation for Health (grant number: 856001005). The funding source had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.

Van Beek FE, Wijnhoven LMA, Holtmaat K, et al. Psychological problems among cancer patients in relation to healthcare and societal costs: a systematic review. Psychooncology. 2021;30(11):1801‐1835. 10.1002/pon.5753

DATA AVAILABILITY STATEMENT

The data that support the findings of this systematic review are all presented in Tables 1–4 .

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Associated Data

Supplementary Materials

Supplementary Material

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Supplementary Material

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Data Availability Statement

The data that support the findings of this systematic review are all presented in Tables 1–4 .