Keywords
breast cancer - India - medical oncology - psychiatry - psycho-oncology - psycho-oncology
service
Introduction
Breast cancer is presently the most diagnosed cancer and the fifth leading cause of
death worldwide.[1] In India, it is the most frequent cancer among women.[2] In the past three decades, remarkable advancements have been made in breast cancer
treatments, especially in the areas of surgery, radiotherapy, targeted systemic therapies,
genomics, and molecular biology that in turn has not only improved overall survival
(including disease-free survival) but has also resulted in better management of the
axilla, more acceptable cosmetic outcomes, and reduced treatment time and hospital
visits.[3] Due to enhanced survivorship and better cosmesis, patients often face minimization
of the subjective distress associated with the diagnosis. They often face comments
as “it's only breast cancer” and that “there is nothing much to worry about.”[4] However, objective data show, despite the medical advances, rates of psychological
morbidities is highest among patients with breast cancer as compared to all other
cancers.[5] Breast cancer treatments, although ensuring longer survivorship, affect nearly all
the key aspects of femininity including sexuality, physical identity, fertility, and
the ability to breastfeed.[4] The diagnosed person or the survivor deals with a plethora of issues including a
constant preoccupation about the relapse of cancer, body-image issues related to mastectomy,
lymphoedema and hair loss, anticipated problems in companionship, sexual intimacy,
reproduction, and parenting abilities, and even worries about passing the “cancer
gene” to their grown-up children.[3]
[6]
[7] Many of these concerns can be chronic and patients may continue to have anxiety
and depressive symptoms for years.[8]
[9] These symptoms are often colored by the patient's perception of the disease, their
illness experience, and the coping resources of the person. Interestingly studies
showed that the psychological symptoms are not associated with any biological prognostic
factors like tumor size, histology, number of axillary lymph nodes involved, or other
treatment-related factors, except for adjuvant chemotherapy which has been found to
increase the risk for either or both anxiety and depression.[8] The patient's concerns have a significant impact on the family members. The prevalence
of anxiety and depression in family/caregivers is similar to that of breast cancer
patients.[10] In India, caregiving is mostly performed by family members (both physical and psychological)
and in most cases, family members do not feel the need or have the means to seek professional
help.[11] Family caregivers of cancer patients often report significant anxiety or depressive
symptoms and these symptoms persist during the initial months and years following
the cancer diagnosis.[12] Therefore, there has been an increasing emphasis on the psychosocial care of breast
cancer patients, survivors, and caregivers. A recent study conducted in India points
out that both the patient and the caregiver seek structured counselling services for
patient–caregiver dyads, improved doctor–caregiver communication, and routine practice
of disclosure of cancer diagnosis.[13]
Psycho-oncology is a relatively recent area of specialization in India and not many
cancer centers in India have a psycho-oncology service accessible to patients, although
this is changing rapidly. One paper cites the lack of routine integration of psychosocial
care in cancer settings.[14] Most psycho-oncology studies conducted in India usually point to the need for the
development of psychosocial approaches for cancer that are suitable and acceptable
to patients. In this article, we report the types of mental health issues faced by
patients with breast cancer who were assessed by the psycho-oncology unit in a tertiary
cancer hospital in eastern India over 3 years starting from January 2018 and ending
in December 2020. The article also discusses a service delivery model that is suited
to low- and middle-income country settings.
Objectives
The main objective of the current study was to explore and describe the nature of
psycho-oncological services accessed by patients with breast cancer in a specialist
cancer center.
Materials and Methods
Study Design
The study follows a design of a retrospective case series for a period of 3 years
based on a contemporaneous electronic medical record of psychiatric assessments documented
for all the patients by the treating consultant psychiatrist after ethical clearance
for the institutional review board.
Setting
This study was conducted in a tertiary, philanthropic cancer care center serving eastern
Indian states and neighboring South Asian countries like Bangladesh, Nepal, and Bhutan.
Currently, the hospital has a capacity of 431 beds and caters to a large catchment
area.
Psycho-oncology Services
The study hospital has a well-functioning psycho-oncology service, developed since
the very beginning of the hospital's inception and currently maintained by two consultant
psychiatrists and clinical psychologists. The department has daily outpatient and
in-patient services and works consistently and routinely for patients reaching out
for psychological aid. The hospital's breast disease management protocol ensures optimal
access for patients, who at times come with ailments in the context of their cancer
diagnoses and at other times with a premorbid psychiatric illness that might affect
cancer treatment itself.
Duration of Service Assessed
The duration of the study was for three calendar years, from January 1, 2018 to December
31, 2020.
Collection of Data
The study hospital maintains an electronic health record system and the department
of psycho-oncology maintained contemporaneous health records electronically. Data
were collected from the existing health records. The electronic hospital management
system provided the demographic and clinical data for the patient and was supplemented
by manual documents of the hospital. Institutional ethics approval was obtained (EC/WV/TMC/49/20)
for the study.
Analysis of Data
All breast cancer patients who were assessed by the psycho-oncology department between
2018 to 2020 were included in the study. Simple descriptive statistics were used with
frequencies to describe the patients accessing psycho-oncology services. The continuous
variables (age and distance of the patient's home to the hospital) were checked for
normality with the Shapiro–Wilk test and Q–Q plots and an appropriate measure of central
tendency was used to describe the data. Since the results suggested that our data
were not normally distributed, we proceeded to use the median and the interquartile
range as descriptive parameters for the data.
Ethics
The present study was in accordance with the ethical standards of the institutional
ethical committee, national guidance on research ethics, and the 1964 Helsinki Declaration
and its later amendments.[15] The study was approved by the institutional ethics committee of Tata Medical Center,
Kolkata. In view of the retrospective nature of the study, a waiver of consent was
obtained from the institutional ethics committee of Tata Medical Center, Kolkata.
As per institutional policy (IEC Protocol Waiver No – EC/WV/TMC/49/20 on August 18,
2020).
Results
A total of 2,448 patients were treated by the breast onco-surgery team between the
years 2018 and 2020, out of which 338 patients reached out for psycho-oncology services
([Table 1]). Of 338 patients, 335 were females, while three of the patients were adult males
with breast cancer. The age of the patient and the distance of the patient's home
to the hospital were both continuous variables that were not normally distributed.
The age of patients ranged from 23 years to 76 years with a median age of 48.5 years
(interquartile range [IQR]: 41–57). They were mostly homemakers (n = 286, 84.6%), followed by government employees (n = 16, 4.7%). Four patients ran personal businesses (n = 4, 1.2%). The median distance between the hospital and their home was 56.3 km (IQR = 20.2–229.48
km) with the longest distance travelled by any patient being 1,583 km.
Table 1
Description of the data/sociodemographic details
|
Variable
|
|
n = 338
|
%
|
|
Age (in years) at presentation
|
|
Median = 48.50 (IQR: 41–57)
Maximum = 76
Minimum = 23
|
|
Gender
|
Female
|
335
|
99.1
|
|
Male
|
3
|
0.9
|
|
Marital status
|
Married
|
307
|
90.8
|
|
Single
|
21
|
6.2
|
|
Widow
|
10
|
3
|
|
Fund
|
Yes
|
47
|
13.9
|
|
No
|
291
|
86.1
|
|
Occupation
|
Homemaker
|
286
|
84.6
|
|
Business
|
4
|
1.2
|
|
Government job
|
16
|
4.7
|
|
Private job
|
6
|
1.8
|
|
Other
|
22
|
6.5
|
|
Retired
|
4
|
1.2
|
|
Distance (in kilometers)
|
|
Median = 56.30 (IQR: 20.20–229.48)
Maximum = 1,583
Minimum = 1
|
Abbreviation: IQR, interquartile range.
Of the 338 patients who accessed our service, 319 patients (94.4%) had a diagnosis
of invasive ductal carcinoma, whereas 9 patients (2.7%) had invasive lobular carcinoma.
Other carcinoma types (3% of all patients) included ductal carcinoma in situ, invasive
mammary carcinoma, and carcinomas of no special type/mixed type ([Table 2]). Among the patients who accessed psycho-oncology outpatient department, 171 (50.6%)
patients were at stage 2 cancer, 110 (32.5%) patients had stage 3 cancer, and 45 (13.3%)
patients were diagnosed to have stage 4 cancer. More than half of the patients (51.5%)
patients underwent mastectomy, while 34.9% of patients underwent breast-conserving
surgery. Among all the patients, 13.6% patients did not undergo any form of surgery
as they had distant metastasis. Almost three-fourths of the patients (73.4%) did not
have any distant metastasis. Most (88.8%) patients underwent some form of chemotherapy.
More than three-fourths of all patients (83.1%) were given radiation therapy, while
two-thirds of the patients (66.9%) received hormone therapy. More than half of all
patients (190 or 56.20%) presented with some form of medical comorbidity; of them,
59 (17.45%) patients had at least two comorbidities and 26 (7.69%) had more than two
comorbidities. Hypertension was the most common comorbidity reported in 123 (64.73%)
patients, followed by diabetes in 68 (35.78%) patients and hypothyroidism/hyperthyroidism
in 55 (28.94%) patients. Only 35 patients (10.35%) had both diabetes with hypertension.
Table 2
Cancer disease characteristics of our sample group
|
Variable
|
|
n = 338
|
%
|
|
Type of cancer
|
Invasive ductal carcinoma
|
319
|
94.4
|
|
Invasive lobular Carcinoma
|
9
|
2.7
|
|
Other
|
10
|
3.0
|
|
Stage of breast cancer
|
0
|
3
|
0.9
|
|
1
|
9
|
2.7
|
|
2
|
171
|
50.6
|
|
3
|
110
|
32.5
|
|
4
|
45
|
13.3
|
|
Estrogen receptor status
|
Positive
|
218
|
64.5
|
|
Negative
|
120
|
35.5
|
|
Progesterone receptor status
|
Positive
|
191
|
56.5
|
|
Negative
|
147
|
43.5
|
|
HER2 receptor status
|
Positive
|
79
|
23.4
|
|
Negative
|
233
|
68.9
|
|
Equivocal
|
26
|
7.7
|
|
Type of surgery
|
Breast-conserving surgery
|
118
|
34.9
|
|
Mastectomy
|
174
|
51.5
|
|
None
|
46
|
13.6
|
|
Chemotherapy
|
Yes
|
300
|
88.8
|
|
No
|
38
|
11.2
|
|
Radiotherapy
|
Yes
|
281
|
83.1
|
|
No
|
57
|
16.9
|
|
Trastuzumab therapy
|
Yes
|
44
|
13.0
|
|
No
|
294
|
87.0
|
|
Hormone therapy
|
Yes
|
226
|
66.9
|
|
No
|
112
|
33.1
|
|
Metastasis
|
Yes
|
90
|
26.6
|
|
No
|
248
|
73.4
|
|
Brain metastasis
|
Yes
|
20
|
5.9
|
|
No
|
318
|
94.1
|
|
Number of comorbidities
|
No comorbidities
|
148
|
43.8
|
|
Comorbidities
|
190
|
56.20
|
|
1
|
105
|
31.06
|
|
2
|
59
|
17.45
|
|
>2
|
26
|
7.69
|
|
Comorbidity types
|
Diabetes
|
68
|
35.78
|
|
Hypertension
|
123
|
64.73
|
|
Diabetes and hypertension
|
35
|
10.35
|
|
Hypo/hyperthyroidism
|
55
|
28.94
|
|
Electrolyte imbalance
|
2
|
1.05
|
|
Sepsis
|
1
|
0.52
|
|
COPD
|
5
|
2.63
|
|
Others
|
47
|
24.73
|
Abbreviations: COPD, chronic obstructive pulmonary disease; HER2, human epidermal
growth factor receptor 2.
Of all the breast cancer patients reviewed by psycho-oncology services, the most common
psychiatric diagnosis was depressive illness (n = 100, 29.6%), followed by adjustment disorders (n = 68, 20.1%) and anxiety (n = 66, 19.5%); next were major psychiatric disorders such as schizophrenia (n = 11, 3.3%), bipolar disorders (n = 14, 4.1%), organic mood or psychotic disorders (n = 9, 2.7%), and neuro-cognitive disorders (n = 3, 0.9%) ([Table 3]). Amongst the patients who were referred, 14.2% (n = 48) of the breast cancer patients did not have any psychiatric syndrome. There
was no report of completed suicide amongst the patients diagnosed with breast cancer
in the year for which the data were being analyzed. The number of treatment contacts
with psycho-oncology services varied and ranged from a single contact to 24 separate
contacts with mental health professionals, the median number of contacts being 2 (IQR = 1–4).
The number of contacts was more (median 3.50, IQR = 1.75–9.25) for people with known
severe enduring mental illness. Based on the median score, the entire sample of patients
included in the study was divided into two groups (1–3 evaluations vs. >3 evaluations
by psycho-oncology). The chi-square test was used for exploring the association of
those with and without severe mental illnesses (e.g., schizophrenia, bipolar disorder,
etc.), the total number of evaluations by psycho-oncology (1–3 evaluations vs. >3
evaluations by psycho-oncology) was found to be statistically significant (p < 0.01). While some of the patients evaluated (16.3%) did not need any psychotropic
medications, almost half of the patients (48.52%) were managed with only one medication
for their symptoms. An almost equal percentage of patients (45.6%) also needed psychological
interventions in the form of psychoeducation, psychological support, coping strategies,
suggestion for lifestyle modifications including sleep hygiene techniques, or a combination
of these.
Table 3
Psycho-oncology factors and services
|
Variable
|
|
n = 338
|
%
|
|
Psychiatric diagnosis given
|
No psychiatric diagnosis
|
48
|
14.2
|
|
Delirium
|
8
|
2.4
|
|
Adjustment disorder
|
68
|
20.1
|
|
Depressive disorder
|
100
|
29.6
|
|
Anxiety disorder
|
66
|
19.5
|
|
Substance abuse
|
1
|
0.3
|
|
Schizophrenia
|
11
|
3.3
|
|
BPAD
|
14
|
4.1
|
|
Other psychotic disorder
|
5
|
1.5
|
|
Organic mood and psychotic disorder
|
9
|
2.7
|
|
Dementia
|
3
|
0.9
|
|
Number of medications
|
No psychotropic medication
|
55
|
16.3
|
|
Prescribed medications
|
283
|
83.7
|
|
1
|
164
|
48.52
|
|
2
|
99
|
29.28
|
|
>2
|
20
|
5.90
|
|
Type of medication
|
Sedative
|
93
|
32.86
|
|
Antidepressant
|
210
|
74.20
|
|
Mood stabilizer
|
26
|
9.18
|
|
Antipsychotics
|
66
|
23.32
|
|
Others
|
27
|
9.54
|
|
Psychological intervention
|
Yes
|
154
|
45.6
|
|
No
|
184
|
54.4
|
|
Number of visits
|
All patients (n = 338)
|
Median = 2 (IQR: 1–4)
Maximum = 24
Minimum = 1
|
|
|
SMD (n = 30)
|
Median = 3.50 (IQR: 1.75–9.25)
Maximum = 15
Minimum = 1
|
|
|
Previous psychiatric diagnosis (past history)
|
Yes
|
113
|
33.4
|
|
No
|
225
|
66.6
|
|
Family history of psychiatric diagnosis
|
Yes
|
44
|
13.0
|
|
No
|
294
|
87.0
|
Abbreviations: BPAD, bipolar affective disorder; IQR, interquartile range; SMD, severe
mental disorder.
Note: Severe mental disorders (schizophrenia, BPAD, other psychotic disorders).
Discussion
Studies in various parts of the world suggest that patients require individualized
treatment plans according to their needs.[16]
[17]
[18] In the current article, around half of the patients who accessed psycho-oncology
services presented in advanced stages (stage 3 or 4), while others presented in earlier
stages. The majority of the patients received curative surgery, radiation therapy,
and/or chemotherapy based on the weekly multidisciplinary group discussions. The common
reasons for referral to psycho-oncology from the perspective of the oncologist were
low mood, fragmented sleep, restlessness, and being agitated or expressing suicidal
thoughts. It was rare that a syndromic psychiatric diagnosis was mentioned in the
referral. Of the patients who were referred, most were diagnosed with depressive disorder
(n = 100, 29.6%), followed by adjustment disorders (n = 68, 20.1%) and anxiety disorders (n = 66, 19.5%). European and American guidelines stress the need for the incorporation
of psychological interventions in breast cancer services.[19]
[20] Even with significant improvement in the outcome of breast cancer over the last
few decades, a survey conducted in 32 countries in Europe showed that only one-third
of the countries had documented requirements and specific indicators for psychosocial
interventions, resources they require, and educational requirements.[19] The role of psychosocial support remains crucial in treatment. “The SARS-CoV-2 pandemic
had affected cancer care and service delivery around the world and we published the
impact of the pandemic on psycho-oncology services separately.”[21]
A recent review[22] covering several studies around the globe, including India, concluded the prevalence
of depression in breast cancer to be around 32%. The higher rates of psychiatric morbidity
reported in this audit were perhaps because we only evaluated patients who were referred.
All patients are assessed by the breast surgery or medical oncology teams and referred
to psycho-oncology as per accepted disease management guidelines when suspected to
have psychological or psychiatric morbidity. Some patients diagnosed with syndromic
psychiatric morbidity needed pharmacological management. Depression in breast cancer
is associated with increased morbidity, suicidality, and longer hospital stays for
treatment.[23] Depression can result in poorer adherence to cancer-specific treatments[24] and that may indirectly increase the risk for mortality. Antidepressants including
selective-serotonin reuptake inhibitors are recommended for managing syndromic depression
and these are effective in this group of patients.[25] The majority of patients treated by us were managed with a single psychotropic combined
with psychological interventions. Only around one-third of the assessed patients needed
more than one psychotropic medication. This was mostly due to the use of nonsedative
antidepressants like Venlafaxine, with less propensity to interfere with the metabolism
of Tamoxifen,[26] but occasionally requiring additional short-term low-dose benzodiazepines for fragmented
sleep. Overall, avoiding polypharmacy is recommended.
Psychological interventions were initiated for almost half of the patients seeking
help, which is often the preferred mode of intervention for the management of issues
related to coping with a cancer diagnosis and related predicaments like procedural
anxiety, body-image issues, fear of recurrence, and psychological distress at the
end of life. Psycho-education about possible symptoms, treatment needed, and behavioral
and lifestyle interventions such as sleep hygiene were used frequently. Lifestyle
interventions empower the patient and their relatives to initiate simple changes that
may help them navigate through complex treatment processes when the psychological
distress is transient.[27]
[28] Psycho-educational approaches, on the other hand, attempt to address realistic concerns
by instilling a sense of control within transiently distressed patients; people with
more serious psychological issues may need more specific psychological interventions.[29] As evident from our data, psychological interventions are brief as many patients
accessed the service for a few sessions only. The people who came for repeated consultations
usually had a pre-existing mental illness. The study emphasizes the need for an integrated
psycho-oncology service model. This can improve access to mental health care in resource-poor
low and middle-income countries like India.[30]
[31]
The typical referrals of patients with breast cancer patients managed by psycho-oncology
services are represented in [Table 4].
Table 4
Typical presentation and psycho-oncology management of patients with breast cancer
|
Demographic and clinical profile
|
Psychological issues
|
Usual reason for referral and treatment goals
|
Interventions offered by psycho-oncology services
|
|
40–65-year-old lady, recently diagnosed with breast cancer, presenting with episodes
of palpitation, breathlessness, feelings of impending doom whenever entering the hospital
or day-care to receive chemotherapy.
|
Adjustment disorder with panic attacks
|
Reason: difficulty to accept the diagnosis, distress
Goal: assist in adaptation
|
Psychological intervention addressing anticipatory anxiety, catastrophization and
coping.
If required, antidepressants with or without (for a short duration) benzodiazepines
|
|
40–60-year-old lady with breast cancer undergoing adjuvant chemotherapy and awaiting
surgery with worries about the side effects of chemotherapy, surgery, outcome, and
implication on her family especially children
|
Anxiety
|
Reason: anxiety about cancer and predicaments
Goal: address anxiety and improve coping
|
Psychological intervention to address anxiety, relaxation techniques, psychological
support
If required, add antidepressants like Citalopram, Venlafaxine
|
|
45–65-year-old lady postsurgery for breast cancer with low mood, crying spells, terminal
insomnia, diurnal variation of mood, anhedonia, decreased appetite
|
Depression
|
Reason: depressed mood, decreased motivation for treatment, suicidal risk
Goal: assessment of depressive cognition and risk of suicide
|
Pharmacological (SSRI/TCA) and nonpharmacological intervention (cognitive behavioral
techniques) for depression.
Suicidal risk assessment and management
|
|
30–50-year-old lady postsurgery, postchemotherapy being upset with mastectomy and
hair loss, presenting with interpersonal issues with her husband along with a feeling
of estrangement in marital relationship
|
Body-image issues, marital discord
|
Reason: feelings of loss of physical identity, social stigma, and marital disharmony
Goal: address body image concerns, empowering her, and improving communication within
the marital dyad
|
Psychological interventions addressing body image and sexuality-related concerns,
helping the partners to express their feelings and distress about cancer and the relationship,
encourage dyadic coping
|
|
25–40-year-old married lady with living daughter presenting with known HBOC (hereditary
breast and ovarian cancer) and anxiety related to need for ovary removal early in
life, implication on perceived femininity, the implication of hereditary cancer on
her daughter and unmarried cousins
|
Anxiety in the context of hereditary cancer
|
Reason: worries about risk reduction surgery; worries about passing the gene to offspring
and social implication
Goal: psycho-education, psychological support
|
Psychological support with validation of her concerns, allowing her to evaluate the
pros and cons of the diagnosis, the chance of prevention of early cancer-related fatality
in her and multiple family members by screening or risk-reducing surgery
|
|
50–70-year-old lady with metastatic breast cancer, currently undergoing end-of-life
care under the department of palliative medicine, presents with being tearful, expressing
remorse about multiple decisions she took in her life, with fragmented sleep.
|
Anticipatory grief
|
Reason: low mood, being upset since their transition from curative to palliative
Goal: providing support
|
Pharmacological intervention for adequate control of physical symptoms like pain,
and fragmented sleep.
Psychological intervention to address the feeling of devastation, anticipatory grief,
and abandonment. Arrange a meeting with close ones, helping to sort out things that
she finds important, helping to find meaning and peace.
|
|
20–60-year-old family member of index breast cancer patient presenting with worries,
low mood, and fragmented sleep since index patient received the diagnosis of cancer
|
Anxiety and depressive reaction in relatives
|
Reason: anxiety about treatment outcome, implication on family, relationship
Goal: address anxiety and help to cope
|
Psychological intervention for anxiety, encouraging lifestyle modification, sleep
hygiene, providing support.
If required, add antidepressants like Mirtazapine, SSRIs
|
Abbreviations: SSRI, selective-serotonin reuptake inhibitor; TCA, tricyclic antidepressant.
Service delivery model for psycho-oncology services for women with breast cancer in
low- and middle-income countries:
Therefore, an integrated hospital-based psycho-oncology service for patients with
cancer is proposed. It is necessary that clinicians treating women with breast cancer
are initially sensitized about the magnitude of the problems and made aware of early
warning signs of mental health difficulties that warrant a referral. The institutional
breast cancer treatment protocol practiced included specific pointers for such a referral.
The psycho-oncology services are offered for both out-patients and hospitalized patients
and are almost always started on the day of referral. The psycho-oncology team used
pharmacological and nonpharmacological methods of treatments delivered by consultant
psychiatrists and clinical psychologists. The typical patient profiles and interventions
offered are discussed in [Table 4].
Strengths and Limitations
All patients were reviewed by consultant psychiatrists as per the International Classification
of Diseases 10 Revision. The psycho-oncology services were provided in the same hospital,
available every day of the week, and most patients are seen on the same day of the
referral whenever possible. The nature of the services was comprehensive for both
outpatients and inpatients. Despite being a single-center study, this center caters
to a wide geographical region in India and surrounding countries, and thus provides
a large catchment area. Additionally, the robust electronic hospital management system
resulted in thorough and consistent patient records. This emphasizes the role of an
integrated service model in low- and middle-income countries.
The article presented data on those women with breast cancer who accessed psycho-oncology
services. This article cannot comment on the patients with breast cancer who did not
attend psychiatry consultations or the overall prevalence of psychiatric morbidity
in women with breast cancer. The data are presented using simple descriptive statistics
and further associations were not presented as the study was originally not powered
for multiple testing and there were no a priori hypotheses. Also, for some patients,
the stage of cancer progressed over time. Hence testing for associations was avoided.
Conclusion
This study showed that a significant number of women with breast cancer access psycho-oncology
services, of whom around half of the patients had anxiety or depressive illnesses,
one-fifth had stress-related adjustment disorders and only a minority (10%) had major
psychiatric disorders like schizophrenia or bipolar affective disorder. The availability
of integrated psycho-oncology services in the cancer center improved the access to
mental health care for patients who wanted to seek help. This article attempts to
highlight the importance and need for a psycho-oncology service model managing common
psychiatric comorbidities in the present health care milieu.
Statement: all authors have participated in the write up of the article and approved
the submitted version of the manuscript. All the authors fulfil the authorship criteria
and declare that the manuscript represents honest work. The contents of this manuscript
have not been copyrighted or published previously and are not under consideration
for publication elsewhere. In addition, this manuscript will not be copyrighted, submitted,
or published elsewhere while acceptance by “Indian Journal of Medical and Paediatric
Oncology” is under consideration.
