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Effect of a Community-Based Medical Oncology Depression Screening Program on Behavioral Health Referrals Among Patients With Breast CancerA Randomized Clinical Trial

Educational Objective
To understand the challenges of implementing psychosocial distress screening and management in oncology practices.
1 Credit CME
Key Points

Question  Does a depression screening program for patients with breast cancer treated in community oncology practices using tailored implementation science–guided strategies result in a greater proportion of referrals to behavioral health compared with an education-only strategy?

Findings  In this cluster randomized trial involving 1436 patients with breast cancer at 6 medical centers, a higher proportion of patients at sites randomized to the tailored strategies compared with the educational-only strategy had appropriate referral to behavioral health following screening, 7.9% vs 0.1%, respectively, a difference that was statistically significant.

Meaning  An implementation-strategy guided depression screening program compared with an educational-only strategy resulted in higher proportion of referrals to behavioral health among patients with breast cancer treated in a community setting.


Importance  Implementation of guideline-recommended depression screening in medical oncology remains challenging. Evidence suggests that multicomponent care pathways with algorithm-based referral and management are effective, yet implementation of sustainable programs remains limited and implementation-science guided approaches are understudied.

Objective  To evaluate the effectiveness of an implementation-strategy guided depression screening program for patients with breast cancer in a community setting.

Design, Setting, and Participants  A pragmatic cluster randomized clinical trial conducted within Kaiser Permanente Southern California (KPSC). The trial included 6 medical centers and 1436 patients diagnosed with new primary breast cancer who had a consultation with medical oncology between October 1, 2017, through September 30, 2018. Patients were followed up through study end date of May 31, 2019.

Interventions  Six medical centers in Southern California participated and were randomized 1:1 to tailored implementation strategies (intervention, 3 sites, n = 744 patients) or education-only (control, 3 sites, n = 692 patients) groups. The program consisted of screening with the 9-item Patient Health Questionnaire (PHQ-9) and algorithm-based scoring and referral to behavioral health services based on low, moderate, or high score. Clinical teams at tailored intervention sites received program education, audit, and feedback of performance data and implementation facilitation, and clinical workflows were adapted to suit local context. Education-only controls sites received program education.

Main Outcomes and Measures  The primary outcome was percent of eligible patients screened and referred (based on PHQ-9 score) at intervention vs control groups measured at the patient level. Secondary outcomes included outpatient health care utilization for behavioral health, primary care, oncology, urgent care, and emergency department.

Results  All 1436 eligible patients were randomized at the center level (mean age, 61.5 years; 99% women; 18% Asian, 17% Black, 26% Hispanic, and 37% White) and were followed up to the end of the study, insurance disenrollment, or death. Groups were similar in demographic and tumor characteristics. For the primary outcome, 7.9% (59 of 744) of patients at tailored sites were referred compared with 0.1% (1 of 692) at education-only sites (difference, 7.8%; 95% CI, 5.8%-9.8%). Referrals to a behavioral health clinician were completed by 44 of 59 patients treated at the intervention sites (75%) intervention sites vs 1 of 1 patient at the education-only sites (100%). In adjusted models patients at tailored sites had significantly fewer outpatient visits in medical oncology (rate ratio, 0.86; 95% CI, 0.86-0.89; P = .001), and no significant difference in utilization of primary care, urgent care, and emergency department visits.

Conclusions and Relevance  Among patients with breast cancer treated in community-based oncology practices, tailored strategies for implementation of routine depression screening compared with an education-only control group resulted in a greater proportion of referrals to behavioral care. Further research is needed to understand the clinical benefit and cost-effectiveness of this program.

Trial Registration  ClinicalTrials.gov Identifier: NCT02941614

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Corresponding Author: Erin E. Hahn, PhD, MPH, Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S Los Robles Ave, Pasadena, CA 91101 (erin.e.hahn@kp.org).

Accepted for Publication: December 1, 2021.

Author Contributions: Dr Hahn had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Hahn, Pounds, Lyons, Shen, La Cava, Brasfield, Gould.

Acquisition, analysis, or interpretation of data: Hahn, Munoz-Plaza, Lyons, Lee, Shen, Hong, Brasfield, Durna, Kwan, Beard, Ferreira, Padmanabhan, Gould.

Drafting of the manuscript: Hahn, Munoz-Plaza, Pounds, Lyons, Lee, Shen, Brasfield.

Critical revision of the manuscript for important intellectual content: Hahn, Munoz-Plaza, Lyons, Lee, Shen, Hong, La Cava, Brasfield, Durna, Kwan, Beard, Ferreira, Padmanabhan, Gould.

Statistical analysis: Hahn, Lee, Shen, Hong, Brasfield.

Obtained funding: Hahn, Lyons, Brasfield.

Administrative, technical, or material support: Pounds, Lyons, La Cava, Brasfield, Durna, Kwan, Beard.

Supervision: Hahn, Lyons, Shen, Brasfield, Ferreira, Gould.

Conflict of Interest Disclosures: None reported.

Funding/Support: This project was supported by grant 22OB-0029 from the Regents of the University of California, Research Grants Program Office, California Breast Cancer Research Program.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The opinions, findings, and conclusions herein are those of the author and do not necessarily represent those of the Regents of the University of California or any of its programs.

Data Sharing Statement: See Supplement 3.

Additional Contributions: We thank our Kaiser Permanente Southern California (KPSC) nursing teams and administrators for their support and involvement in the collection of study data and participation in study-related tasks including: Rosie Hong, MSN, RN, PHN; Raquel P. Valenzuela, MSN, RN; Keri Rosas; Olivia Robles, RN, BA, MSN, OCN; Elvia P. Cabrera, LCSW; Tyler Huynh, MPH; and Grace Coronado-King, LCSW, all affiliated with KPSC). No direct compensation was provided for their role on the study.

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