oncologists, medical oncologists), and care is often not well coordinated. Fragmentation of care is an added psychological burden; the patient is not given care by a single, trusted physician. In addition, the outpatient offices and clinics are extremely busy; the length of time doctors can spend with patients is often limited; and the opportunity to bring up psychosocial problems may be lost. Receiving adequate information and the ability to ask questions in a comfortable way are basic needs for addressing psychosocial concerns. Breast cancer care occurs primarily in private office-based practices that routinely do not employ psychosocial professionals.

Another barrier is the lack or inadequacy of health insurance coverage. An estimated 5 percent of women ages 25 to 64 with breast cancer are uninsured, or, if patients are insured, there is coverage of mental health services with lower reimbursement levels or placement of mental health services in behavioral health contracts, separate from medical coverage (see Chapter 6). Still other barriers are the reluctance to discuss psychosocial concerns with the busy oncologist provider; the stigma associated with seeking or using mental health services; physicians’ failure to ask patients about distressing emotional symptoms; and the lack of simple, rapid instruments for screening for psychosocial distress. All are barriers to the symptoms receiving appropriate recognition, diagnosis, and treatment by supportive and psychosocial services. Also, primary oncology teams in outpatient offices are often not familiar with clinical practice guidelines for managing psychosocial distress; they often work in environments that do not provide psychosocial services onsite; and they often are not aware of the psychosocial resources in their local communities. The situation is complicated additionally by the paucity in many communities of identified professionals with skills in managing psychosocial and mental health issues in patients with cancer. As part of an initiative to help locate appropriate professionals, the American Psychosocial Oncology Society (APOS) now provides a directory online (www.apos-society.org) and a toll-free help line for patients and families (1-866-APOS-4-HELP). Overcoming barriers to appropriate use of psychosocial services will require advocacy, monitoring of psychosocial services through quality assurance programs to ensure compliance with standards of care, physician education, training in communication skills, and research relative to identifying and overcoming barriers.

REFERENCES

AAFP (American Academy of Family Physicians). 2002. Cancer: After Treatment. [Online]. Available: http://familydoctor.org/723.xml [accessed April 27, 2005].

AAMC (American Association of Medical Colleges). 2005. AAMC Launches Chronic Care Initiative. [Online]. Available: http://www.aamc.org/newsroom/pressrel/2005/050428.htm [accessed May 2, 2005].



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