Depression is a frequent and clinically important comorbidity across cancer types and treatment phases.1,2,3 Large systematic reviews and meta-analyses report prevalence estimates that vary by assessment method, cancer type, and treatment phase but commonly fall in the 15% to 25% range for clinically significant depressive disorder or symptoms.3,4 Depression in oncology is not only distressing; it is associated with worse symptom burden, poorer adherence to cancer treatments, increased hospitalizations, and reduced quality of life. These downstream effects make timely identification and effective treatment of depression a core component of comprehensive cancer care.4 Transcranial magnetic stimulation (TMS) expands the treatment options available to oncology clinicians by offering an effective, nonpharmacologic intervention for depression that avoids many of the barriers associated with systemic antidepressants.
Transcranial Magnetic Stimulation 101
TMS is a noninvasive outpatient treatment for depression that delivers brief, focused magnetic pulses through a coil placed on the scalp to modulate activity in the left dorsolateral prefrontal cortex, a region of the brain that regulates mood, motivation, and attention. TMS modulates mood-regulating cortical networks in ways that produce durable changes in circuit function, analogous in effect to antidepressant mechanisms but without systemic drug exposure.
TMS is not electroconvulsive therapy; it does not induce a generalized seizure and has a distinct and substantially more favorable adverse-effect profile. TMS is administered as a structured course of daily sessions (Monday-Friday), each lasting about 18 minutes, for approximately 5 to 7 consecutive weeks. This schedule parallels the rhythm of many radiation therapy protocols and allows oncology teams to integrate treatment planning and follow-up without disrupting cancer care. Sessions require no anesthesia, are conducted in an outpatient setting, and allow patients to resume normal activities immediately afterward. Treatment is delivered with the patient seated in a chair; the procedure is not painful, and patients can drive themselves to and from appointments without restrictions.
Evidence for Effectiveness in Treating Depression
Randomized clinical trials and large comparative studies demonstrate that modern TMS protocols produce clinically meaningful reductions in depressive symptoms for many patients with major depressive disorder, including those who have not responded to antidepressant medications. A large randomized noninferiority trial comparing intermittent theta-burst stimulation with conventional high-frequency repetitive TMS found comparable effectiveness with substantially shorter session times for TMS, expanding practical options for clinics and patients.5 Clinically meaningful improvement is often assessed after 10 to 15 sessions, allowing care teams to determine early whether the course is likely to be beneficial. Meta-analyses and systematic reviews continue to support TMS as an effective intervention for depression, with clinically relevant effect sizes and favorable safety profiles when standard screening and protocols are followed.
Safety and Special Considerations for Oncology Patients
The safety profile of TMS in oncology populations is supported by robust general evidence and can be thoughtfully applied within the context of cancer care. The following considerations highlight how TMS can be safely integrated for patients receiving oncology treatments, with attention to common clinical scenarios and comorbid conditions.
Expanding the Toolkit: New Approaches to Psychosocial Support
By Jennifer Bires, MSW, LCSW, OSW-C, FACCC
Cancer care has entered an era of extraordinary innovation. We can increasingly personalize treatment based on molecular profiles, predict response with greater precision, and extend survival in ways that would have seemed impossible only a generation ago. At the same time, emerging technologies, including artificial intelligence, are creating new opportunities to rethink how supportive care and mental health services are delivered, coordinated, and accessed.
Yet for many patients, the emotional and existential impact of cancer remains largely unchanged. Depression, anxiety, fear of recurrence, grief, uncertainty, changes in identity, questions about meaning, and distress related to mortality continue to shape the lived experience of cancer. For some, these concerns resolve with time and support. For others, they persist long after treatment ends or become barriers to engaging fully in care.
The next chapter of oncology should not only ask how we treat disease more effectively. It should ask how we help people live more fully through illness. Emerging interventions, TMS, psychedelic-assisted therapy, digital therapeutics, and AI-enabled models of psychosocial care, are generating interest because they offer what many patients and clinicians seek: additional pathways to address suffering when existing approaches have not been enough. These approaches may create new opportunities to improve mood, support meaning-making, strengthen coping, and increase access to care.
At the same time, innovation should not outpace implementation. Historically, new mental health interventions have rarely been developed with oncology populations in mind from the outset. Cancer brings unique realities, including symptom burden, uncertainty, caregiver demands, treatment schedules, medical complexity, and limited bandwidth for additional appointments. This is particularly important, as many emerging approaches carry their own burdens. TMS often requires repeated visits over multiple weeks. Psychedelic-assisted therapy models may involve preparation, treatment, and integration over extended periods. Even digital tools require onboarding, engagement, and trust.
Cancer centers have an opportunity to begin designing systems that enable innovation. That means evaluating these approaches directly in oncology populations, building coordinated referral pathways, reducing logistical burdens, and preparing clinicians to discuss emerging options in language that patients can understand and trust.
Jennifer Bires, MSW, LCSW, OSW-C, FACCC, is Executive Director of Life with Cancer and Patient Experience at Inova Schar Cancer Institute in Fairfax, Virginia.
General Safety
Safety data from large TMS programs and guideline statements indicate that TMS is well tolerated in most adults when contraindications (notably a history of epilepsy or certain intracranial conditions) are respected and when device-specific screening is performed. Adverse events are most often mild and transient (scalp discomfort, headache); serious adverse events, such as prolonged seizure, are rare under guideline-based practice.6,7 Serious complications are uncommon.8 TMS does not interfere with diagnostic imaging or radiation therapy planning, allowing patients to continue their oncology treatments without modification. These general safety findings provide the foundation for oncology-specific considerations when evaluating TMS for patients receiving cancer care.
Implanted Devices and Ports
Central venous ports are not considered contraindications to TMS. Modern cardiac devices are also not absolute contraindications, but they require device-specific review and coordination with cardiology or the device manufacturer to confirm safe parameters before treatment.
Drug Interactions and Polypharmacy
TMS has no direct pharmacokinetic interactions with chemotherapy or targeted oncology agents because it is a localized, nonpharmacologic intervention. This makes TMS an attractive option when clinicians are concerned about drug-drug interactions, cumulative adverse effects, or the additive burden of systemic psychotropic medications. TMS can be delivered safely during chemotherapy or immunotherapy cycles, as it does not affect systemic treatment schedules, hematologic parameters, or infusion timing.
Pregnancy and Medication-Limited Patients
For pregnant patients or those for whom additional systemic antidepressants are undesirable, TMS offers a nonpharmacologic alternative that avoids fetal drug exposure and systemic adverse effects. Published case series and clinical experience support the use of TMS in pregnancy when coordinated with obstetric care, although randomized data in pregnancy are limited, and individualized risk–benefit discussions are essential.9
Brain Tumors and Intracranial Disease
Clinical teams generally avoid TMS in patients with primary brain tumors or brain metastases, and major international safety guidelines for TMS support this caution. These guidelines do not list brain tumors as an absolute contraindication, but they consistently identify intracranial lesions that may alter cortical excitability or seizure threshold as conditions requiring extreme caution or specialist consultation.10
Why TMS May Be Uniquely Suited to Many Oncology Patients
TMS offers several practical and clinical advantages that align well with the complex needs of patients undergoing cancer treatment, particularly when treatment burden, medication exposure, and care coordination are key considerations:
- Medication-sparing option. TMS can be particularly valuable when clinicians and patients prefer to avoid adding systemic antidepressants because of adverse effects, interactions, or patient preference.
- Faster clinical response for some patients. Modern TMS protocols, including accelerated and theta-burst approaches, can produce measurable symptom improvement on a timeline that rivals or shortens the weeks often required for antidepressant titration.
- No pharmacologic interactions. Because TMS acts locally on brain circuits rather than systemically, it avoids the drug–drug interactions that complicate many oncology treatment regimens.
- Feasible with many implanted devices. Central venous ports do not preclude TMS, and some cardiac devices can be used safely with device-specific review and coordination.
Who to Consider Referring for TMS
TMS is delivered in specialized psychiatric or behavioral health clinics by trained technicians under physician supervision, and oncology referrals typically include the diagnosis, current medications, and details of any implanted devices. Cancer programs looking to offer this treatment should consider:
- Patients with moderate to severe major depressive disorder who have not responded to adequate trials of psychotherapy and/or antidepressant medication
- Patients whose depressive symptoms are impairing cancer treatment adherence, symptom management, and/or quality of life
- Pregnant patients or those with contraindications or intolerance to additional systemic antidepressants.
Key Takeaways for Oncology Practice
- Depression is common in cancer populations and warrants active screening and treatment.
- TMS is covered by most insurers for treatment-resistant major depressive disorder when standard criteria are met, which makes referral feasible for many patients.
- TMS is an effective, noninvasive option for many patients with depression, including those who cannot or prefer not to take additional medications.
- Safety is well established when guideline-based screening is used; ports do not preclude TMS, and some cardiac devices require device-specific review.
- Oncology clinicians should screen, document, and coordinate referrals rather than attempting to deliver TMS within oncology clinics unless specialized training and equipment are available.
Jeffrey Kendall, PsyD, LP, FACCC, is an experienced clinical psychologist and health care leader with nationally recognized expertise in psychosocial oncology. He is currently Director of Therapy Services at Sonder Behavioral Health and Wellness in the Greater Minneapolis-St. Paul area. Sarah Jax, RN, MA, CNP, AOCNP, is an experienced Advanced Oncology Certified Nurse Practitioner at Park Nicollet Frauenshuh Cancer Center in Saint Louis Park, Minnesota. Sara Schilplin, PsyD, LP, is Co-Founder and Chief Marketing Officer at Sonder Behavioral Health and Wellness in Minnetonka, Minnesota. Anna Schupp, PsyD, LP, is Co-Founder and Chief Clinical Officer at Sonder Behavioral Health and Wellness in Minnetonka, Minnesota.
References
- Kendall J, Clayton S, Hamann H. Oncology distress screening: distress prevalence, new standards, and implementation. Oncol Issues. 2012;27(6):22-28. https://cdn.sanity.io/files/0vv8moc6/accc-cancer/8bc3ac638f12d8c00043c44f7d7afb6819a9f565.pdf/v27-n6-oncology-distress-screening.pdf
- Funk R, Cisneros C, Williams RC, Kendall J, Hamann HA. What happens after distress screening? Patterns of supportive care service utilization among oncology patients identified through a systematic screening protocol. Support Care Cancer. 2016;24(7):2861-2868. doi:10.1007/s00520-016-3099-0
- Krebber AMH, Buffart LM, Kleijn G, et al. Prevalence of depression in cancer patients: a meta-analysis of diagnostic interviews and self-report instruments. Psychooncology. 2014;23(2):121-130. doi:10.1002/pon.3409
- Mitchell AJ, Chan M, Bhatti H, et al. Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: a meta-analysis of 94 interview-based studies. Lancet Oncol. 2011;12(2):160-174. doi:10.1016/S1470-2045(11)70002-X
- Blumberger DM, Vila-Rodriguez F, Thorpe KE, et al. Effectiveness of theta burst versus high-frequency repetitive transcranial magnetic stimulation in patients with depression (THREE-D): a randomised non-inferiority trial. Lancet. 2018;391(10131):1683-1692. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30295-2/abstract
- Vida RG, Sághy E, Bella R, et al. Efficacy of repetitive transcranial magnetic stimulation adjunctive therapy for major depressive disorder after two antidepressant treatment failures: Meta-analysis of randomized sham-controlled trials. BMC Psychiatry. 2023;23(1):545. doi:10.1186/s12888-023-05033-y
- Sabé M, Hyde J, Cramer C, et al. Transcranial magnetic stimulation and transcranial direct current stimulation across mental disorders: a systematic review and dose-response meta-analysis. JAMA Netw Open. 2024;7(5):e2412616. doi:10.1001/jamanetworkopen.2024.12616
- Rossi S, Hallett M, Rossini PM, Pascual-Leone A; The Safety of TMS Consensus Group. Safety, ethical considerations, and application guidelines for the use of transcranial magnetic stimulation in clinical practice and research. Clin Neurophysiol. 2009;120(12):2008-2039. doi:10.1016/j.clinph.2009.08.016
- Tendler A, Roth Y, Hanlon CA. “Can we deliver TMS to patients with implanted devices?” A practical summary of the recent safety recommendations. J Clin Psychiatry. 2023;84(4):23l14857. doi:10.4088/JCP.23l14857
- Kim DR, Wang E, McGeehan B, et al. Randomized controlled trial of transcranial magnetic stimulation in pregnant women with major depressive disorder. Brain Stimul. 2019;12(1):96-102. doi:10.1016/j.brs.2018.09.005
