Patients with Behavioral Health Disorders Less Likely to Have Surgery for Cancer

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Cancer patients with behavioral health disorders, such as substance abuse, eating disorders, and sleep disorders have a 7.76% increase in health care costs, a new study found.

A new study uncovered a significant trend: patients with behavioral health disorders are less likely to have surgery to remove cancerous tissues.1 More than that, patients with behavioral health disorders who did undergo surgery faced a greater probability of complications, extended hospital stays, and readmission within 90 days of surgery.

“Patients who had behavioral health disorders had a significantly lower likelihood to achieve an optimal outcome after surgery,” said investigator Tim Pawlik, MD, FACS, PhD, MPH, MTS, MBA, surgeon-in-chief of the Ohio State University Wexner Medical Center, in a press release.2 “This was associated with higher expenditures for their care and a worse prognosis, even after controlling for other clinical factors.”

Led by Erryk S. Katayama, BA, from the department of surgery at the Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, investigators collected Medicare data from 694,836 cancer patients with 6.7% (n = 46,719) who had a behavioral health disorder.1 Patients were diagnosed with either lung (45.3%), colorectal (28.3%), pancreatic (11.2%), liver (7.7%), esophageal (3.8%), and gastric (3.6%) cancer, between 2018 – 2021 and were identified through the Medicare Standard Analytic Files.

The primary outcome was to assess for the textbook outcome—a validated assessment of positive results during and after an operation. The textbook outcome included no complications, no extended hospital stays, no readmission within 90 days, and no postoperative mortality within 90 days after discharge.

Along with data on postoperative outcomes and in-hospital costs, investigators collected data on behavioral health disorders, such as substance abuse, eating disorders, or sleep disorders. They found 1 in 15 cancer patients in the Medicare system had ≥ 1 behavioral health disorder.

Not only can cancer worsen behavioral health disorders, but the team pointed out individuals with behavioral health disorders tend to have an increased cancer risk.

For instance, substance abuse increases the risk since activated inflammatory pathways expose individuals to environmental risk factors. Eating disorders, linked with poor nutrition and less physical activity, can increase the risk of gastrointestinal cancer. Additionally, people who have sleep disorders have impacted sleep quality and quality, both linked to a risk of cancer.

The data revealed for patients who underwent surgical resection (n = 161,197), 52.7% of patients achieved a post-operative textbook outcome. Behavioral health disorders were linked to worse surgical outcomes and greater odds of postoperative complications—and had particularly worse long-term post-operative survival median (no BHD: 46.6; 95% CI, 45.9 – 46.7 vs. BHD: 37.1; 95% CI, 35.6 – 38.7 months). The team found the same results for long-term post-operative survival after controlling for other clinical factors (hazard ratio [HR], 1.26; 95% CI, 1.22 – 1.32; P < .001).

Patients with a behavioral health disorder had greater odds of a complication (odds ratio [OR], 1.32; 95% confidence interval [CI], 1.26 – 1.39), prolonged hospital stay (OR, 1.36; 95% CI, 1.29 – 1.43), and 90-day readmission (OR, 1.57; 95% CI, 1.50 –1.65).

Patients with behavioral health disorders also were less likely to have surgery to remove cancerous tissues (no BHD: 23.4% vs. BHD: 20.3%; P <.001). Additionally, they had a 7.76% increase in health care costs (no BHD: $16,159 vs. BHD: $17,432; 95% CI, 6.67 – 8.87; P <.001).

The team highlighted multiple limitations, including only using Medicare data so findings may not be applied to a younger population and only using claims data so there was no disease stage, severity, or granular data. Additionally, they wrote how the number of people with behavioral health disorders could have been inaccurate if the high costs stopped them from seeking treatment, as well as analyzing a composite metric did not allow them to evaluate potential differences by subpopulations.

Investigators suggested interventions, such as psychiatry compensation programs with loan repayment, a collaborative care model, and continuing to use telehealth, to improve the care of cancer patients with behavioral health disorders.

“Knowing the important role that behavioral health disorders can play in the continuum of care of patients with cancer, health care providers can screen for these medical issues,” Pawlik said.2 “They can ask patients not only whether they have diabetes or hypertension, but more specifically screen for substance abuse, sleep disorders, and eating disorders.”


  1. Katayama, E, Woldesenbet, S, Munir, M, et al. Effect of Behavioral Health Disorders on Surgical Outcomes in Cancer Patients. Journal of the American College of Surgeons, 2024. DOI: 10.1097/XCS.0000000000000954
  2. Study Reveals the Impact of Behavioral Health Disorders on Cancer Surgery Outcomes. News Wise. February 15, 2024. Accessed February 28, 2024.