Cancer research focuses on patients’ total health

Researchers in the Department of Research & Evaluation see patients as more than a collection of symptoms and possible medical solutions. They focus on the total health of each patient and are working to transform the entire care experience.

In 2022, that passion turned into publications on multiple fronts, including studies focused on improving the lives of patients with breast cancer.

“A person is not just their disease,” said Erin E. Hahn, PhD, MPH, a research scientist in the Division of Health Services Research & Implementation in Research & Evaluation. “Each one is a full, vibrant person who might be diagnosed with something that needs to be treated. And if you focus too narrowly only on the disease or care delivery, all these other things can go unaddressed.”

Recent research studies aimed at bettering the lives of breast cancer patients and breast cancer survivors included studies on:

  • screening breast cancer patients for depression;
  • whether exercise could help breast cancer survivors live longer; and
  • how these patients’ longevity was affected by chronic conditions such as diabetes, hypertension, and obesity.

“We are interested in holistic care, not just drug treatment,” said Reina Haque, PhD, MPH, a research scientist in the Division of Epidemiologic Research in Research & Evaluation. “We want to help the full person feel better both physically and emotionally.”

Increasing breast cancer survival

Dr. Haque focused on breast cancer patients’ longevity in 2 of her studies. One examined lifestyle factors that affect longevity among all breast cancer survivors, while the other assessed health conditions that may affect the longevity of women with advanced breast cancer.

When diagnosed at an early stage, breast cancer can be managed like a chronic condition. Early-stage breast cancer has 5-year survival rates near 99%, but the 5-year survival rate among women with metastatic breast cancer — breast cancer that has spread to other parts of the body — is only 29%, Dr. Haque said.

This difference can often impact the lives of women of color, who historically have not had their breast cancer diagnosed as early in the disease course as women who are white.

The first of Dr. Haque’s studies was published in October 2022 in Cancer Epidemiology, Biomarkers & Prevention.1 It found that the risk of death among women with metastatic breast cancer rises with increasing numbers of chronic conditions, such as diabetes, hypertension, and obesity.

“This study suggested that if we focus on managing chronic medical conditions in patients with metastatic breast cancer, we also may help reduce disparities in mortality,” said Dr. Haque, who was the senior author of the study.

“With advances in treatment, many women are living longer with metastatic breast cancer, but our findings showed that this is not being realized equally across racial and ethnic groups.”

Dr. Haque said the study gave researchers a glimpse into this issue, which will help identify potential ways to solve the disparities in breast cancer survival in the future.

Exercise and breast cancer survival

Dr. Haque also was a senior author of another study that showed that exercise significantly lowers risk of death for breast cancer survivors. While breast cancer survivors, like everyone else, are encouraged to exercise regularly, there had been little research previously on whether exercise helped these patients live longer.

The study was published in November 2022 in JAMA Network Open.2 It followed more than 300 breast cancer survivors for more than 7 years. Moderate physical activity was associated with a 60% lower chance of death in breast cancer survivors.

“One of the most important things we found was that a vigorous workout wasn’t necessary to increase longevity. Simply a brisk walk about 6 times a week helped,” Dr. Haque said.

She added, “What we learned from both studies is that the conditions that can affect long-term survival can have a behavioral component. So, treating the whole person is critically important.”

Living better with breast cancer

The essence of Dr. Hahn’s research into screening breast cancer patients for depression began while she was still in graduate school. She read a 2008 report on cancer care and how it often provides state-of-the-science biomedical treatment but fails to address the psychological and social problems associated with the illness.

“I had this realization … we need a more holistic approach,” she said.

That idea has inspired much of her work, as well as the study on implementing depression screening for breast cancer patients, which was published in January 2022 in JAMA.3

“We knew from previous research that breast cancer patients are at greater risk of depression than the general population, but implementing a successful depression screening program within an oncology department focused on beating cancer has been difficult,” Dr. Hahn said. “I knew if it can be done anywhere, it could be done here at Kaiser Permanente Southern California because we are an integrated system filled with dedicated people who can connect people to the resources they need — all within the same care network.”

Developing a successful screening program

To determine how depression screening could best be implemented, researchers separated medical oncology teams at different locations into 2 groups. In the first group, physicians and nurses received education about depression screening, regular feedback on their performance, feedback on their performance, and support in determining the best ways to add depression screening into their current workflow. In the second group — the control group — physicians and nurses received only education.

Researchers enrolled 1,436 members: 692 in the control group and 744 in the intervention group. The groups were similar in demographic and cancer characteristics.

Eighty percent of patients in the intervention group completed depression screening versus less than 1% in the control group.

Of the patients in the intervention group, 10% scored in the range indicating a need for referral to mental health services. Of those referred, 75% completed a visit with a mental health provider.

“Our study showed that building clinician support and feedback into the depression screening process for cancer patients can create a sustainable program that helps ensure our cancer patients get the mental health support that they need,” Dr. Hahn said.

The new screening initiative was subsequently built into the patient care and daily workflow of medical oncology teams throughout Kaiser Permanente Southern California.

“We have an incredible opportunity right now to be able to treat cancer, and also to make the lives of those living with cancer better,” said Dr. Hahn. “Our patients are living longer, fuller lives after cancer; and it is gratifying to be able to find ways to help them beyond the medicine.”

1Haque R et all. Cancer Epidemiol Biomarkers Prev. 2022;31:1935-43.
2Haque R et al. JAMA Netw Open. 2022;5(11):e2242660.
3Hahn EE et al. JAMA. 2022;327(1):41-49.