Author(s):
Modern oncology has never been more precise. Advances in molecular diagnostics, targeted therapies, and immunotherapy enable clinicians to tailor treatment to a patient's tumor biology. Yet for all the sophistication in treating cancer itself, the psychological experience of cancer care often receives far less systematic attention.
"We've become experts at treating the hardware," said Douglas Flora, MD, LSSBB, FACCC, a medical oncologist and Executive Medical Director at St. Elizabeth Healthcare. "We're failing to support the software and the human mind that's processing this trauma. You can't reboot the system if you only fix half the machine."
The consequences of that gap are not abstract. Flora said roughly 40% of patients with cancer have a diagnosable psychiatric disorder.1 Depression, anxiety, and suicidal ideation, among other psychosocial sequelae, are common among patients with cancer, and when those symptoms go unrecognized or untreated, they can affect whether patients remain engaged in care.
"Hopelessness can set in with depression and anxiety," said Josh Myers, PhD, Co-Founder of Adjuvant Behavioral Health. "Patients start asking, 'Why even try?' They stop showing up for appointments."
In community oncology settings, missed appointments and treatment interruptions can ripple outward, affecting both clinical outcomes and day-to-day operations. The challenge for many community cancer programs is failing to recognize the importance of behavioral health. It is determining how to incorporate behavioral health services into an already complex care environment.
Dr. Flora argues that mental health care itself has not kept pace with the rest of medicine. "We're treating mental health with a blunt instrument," he said. "Trial and error medications, 15-minute checks to make sure you're okay for a refill." That mismatch is increasingly recognized across oncology. The question is no longer whether distress matters. The question is how to respond to distress in a practical, scalable way.
A Model Designed for Medical Settings
The Collaborative Care Model was developed to integrate behavioral health into medical care rather than operate as a separate referral pathway. In oncology, the approach centers on keeping the oncologist as the patient's primary physician while expanding the team around that relationship. Three roles anchor the model:
This structure allows a single psychiatric specialist to support many patients indirectly, extending behavioral health expertise across the oncology program without requiring an in-house psychiatry department. Even with a clear framework, however, implementation in real-world clinics requires coordination, staffing decisions, and workflow design.
What Implementation Looks Like in Practice
For most community oncology programs, implementation begins with a practical question: Who will carry the operational load?
"We want to do all of the heavy lifting," Dr. Myers said. "The oncology program is busy enough attempting to shrink and eliminate tumors."
In collaborative care partnerships, behavioral health organizations may assume much of the administrative responsibility, including patient consent, documentation, and care coordination. Oncology teams focus primarily on identifying patients who may benefit from support and introducing them to the program.
Communication typically occurs through existing clinical channels. "We're in…lockstep with the clinics," Dr. Myers said. "Communication often happens at the nurse or social work[er] level, and notes are shared through the EHR [electronic health record]." This approach allows behavioral health services to operate alongside oncology care without imposing a significant administrative burden on physicians.
Inside the clinic, implementation usually begins by examining current distress screening practices. Many oncology programs already use tools such as the PHQ-9 or the NCCN Distress Thermometer. What varies is what happens after those scores are recorded. For some cancer programs, distress screening has become routine documentation without a reliable pathway to follow-up care. Collaborative care changes that by linking distress identification to an operational response.
Cancer programs also need access to psychiatric consultation. In many settings, this access does not require a full-time psychiatrist. Even a limited weekly review of patient registries can provide clinical oversight and help extend behavioral health expertise across a larger patient population.
The care manager typically becomes the operational hub of the Collaborative Care Program. Rather than creating an entirely new role, many clinics outsource this responsibility to a partnership behavioral health company, such as Adjuvant. The care manager tracks screening results, maintains regular contact with patients, and helps ensure that symptoms are monitored over time.
Lessons From Early Implementation
The Center for Cancer and Blood Disorders, a multi-site oncology practice in Maryland, has implemented collaborative behavioral health services across several locations. Lindsey Bryant, the practice's Director of Value-Based Care, said one of the earliest lessons was the importance of staff education before launch. "We took the opportunity before launching to meet with the physicians, nurse practitioners, and medical assistants," Bryant said. "We explained what the program is and how it benefits patients."
Those conversations helped ensure that clinicians and staff understood how the program would operate before patients were introduced to it. Bryant also found that the physical presence of behavioral health personnel within the clinic increased patient engagement. "Having the therapist in the clinic talking to the patient about the program has made all the difference," Bryant said.
Programs that rely solely on phone outreach can appear to patients as an outside service rather than part of their oncology care. Bryant said that when a behavioral health navigator is physically present in the clinic and visible as part of the practice, that perception changes. At her practice, nearly 70% of referred patients agreed to enroll, a figure Bryant described as high for programs of this kind. Frontline staff also play a major role in identifying patients who may need support. "Patients will tell staff things that they may not tell their physician," Bryant said.
When staff members understand the behavioral health program and how to connect patients with these services, those conversations can become opportunities for intervention. Bryant said staff buy-in turned out to be at least as important as physician buy-in because medical assistants, nurses, and front desk staff interact with patients throughout the day and often become the first to recognize distress.
Implementation, however, rarely follows a single template. Bryant noted that each clinic location requires adjustments to accommodate existing workflows and physical space.
"The behavioral health navigator has to be extremely flexible," she said. "It takes a unique personality to adapt to the different clinic flows."
Most community oncology programs have limited square footage, and finding a place for a behavioral health navigator to work can be a genuine logistical challenge. The navigator needs to speak with patients as they come out of exam rooms, pull them into a private space for a brief conversation, and adapt as rooms turn over. The Center for Cancer and Blood Disorders is still refining how to manage those realities across multiple sites.
Bryant's view of the early results is measured but optimistic. "I think it shows that these services are important to patients," she said, "and how we're approaching it, with the navigator there in the clinic, is working."
The Workflow Problem
Fred Ashbury, PhD, FMASCC, Chief Scientific Officer and Co-Founder of VieCure, approaches the implementation challenge as both a clinical and operational problem. He argues that behavioral health integration succeeds or fails based largely on whether it fits into the oncologist's existing workflow. "The more I ask you to do outside your workflow, the less likely you are to do it," Dr. Ashbury said. "If it's hard to do—even if you know it's the right thing to do for the patient—the chances that you'll do that task are reduced."
Community oncology programs already use validated screening tools. The problem is not that oncologists refuse to screen. The problem is that a poor score on a distress assessment often triggers a question the oncologist cannot easily answer alone: What do I do now? Oncologists are not trained as mental health specialists, and the next steps often involve manual processes, external referrals, and disconnected systems. In some communities, behavioral health specialists may also be difficult to access.
Dr. Ashbury said those barriers can be reduced when behavioral health prompts are embedded directly into the oncology EHR workflow rather than requiring a separate login or secondary system. When a patient scores poorly on a distress screener, the goal is for the clinician to see not just the problem, but also a clear intervention pathway.
The same principle applies to communication between oncology and behavioral health teams. "You're controlling what you're good at, which is cancer care, and letting the behavioral health teams focus on their specialty to mitigate problems and improve outcomes through better therapy adherence," Dr. Ashbury said.
Dr. Ashbury also emphasized the importance of keeping the patient's full therapeutic plan visible across both sides of care. Medication interactions between oncology treatments and antidepressants or anxiolytics can be clinically significant. Systems that run contraindication checks and maintain a shared plan can reduce risk and minimize manual work for clinical staff.
For Dr. Ashbury, the central measure of success is straightforward: "Success looks like the collaboration actively occurs across professionals in workflow, and technology is the vehicle."
Education, Not Just Referral
If staffing and workflow are central to implementation, education may be the factor that determines whether patients participate. Dr. Myers said the largest source of resistance is not usually the institution. It is the patient.
"The pushback is from the patient," Dr. Myers said. Many patients initially do not see behavioral health care as relevant to their cancer treatment. "They'll say, 'I have cancer, I don't have depression.'"
That response points to one of the most underdiscussed aspects of implementation: patient education. Clinicians and staff may understand the value of behavioral health support, but patients may interpret anxiety, panic, insomnia, or hopelessness as simply part of having cancer. "We want them to understand that mental health care is cancer care," Myers said. "It's all part of the kit that the oncologist is using to treat you."
That message appears to be most effective when reinforced consistently by physicians, nurses, staff, and care coordinators. When behavioral health is framed as a routine part of oncology care rather than an outside referral, participation improves.
The Case for Integration
For practice leaders, the case for collaborative care is not only clinical. It is operational and financial as well.
Dr. Ashbury noted that when nurses spend unstructured time trying to support distressed patients without formal behavioral health support, they are pulled away from the clinical work they were trained to do. He also pointed to a broader pattern: patients who are not receiving adequate mental health support are more likely to disengage from treatment, delay reporting symptoms, and interrupt care. "If you manage psychosocial sequelae well, people participate in their treatment," Ashbury said. "When you don't manage them well, they don't."
Dr. Myers said programs may also see a modest net revenue benefit per enrolled patient, depending on geography and program structure. Still, the more durable argument is not revenue capture; it is that behavioral health support can protect treatment adherence, reduce avoidable disruption, and allow staff to work closer to the top of their roles.
Proactive Care, Not Just Crisis Response
One of the most important advantages of a more integrated care model is that it enables the behavioral health team to shift from reactive to proactive care. Dr. Ashbury described a patient who finishes treatment, rings the bell, and leaves the clinic feeling relieved. Three months later, that same patient returns for follow-up imaging and faces a familiar source of anxiety: what if the cancer has come back?
In a fully integrated system, the behavioral health team can see that appointment coming and reach out before distress becomes a crisis. The same logic applies at diagnosis, at treatment transitions, and at disease progression. These are moments when patients may be too overwhelmed to fully process what they are being told, even when they appear outwardly engaged.
That kind of anticipatory support is difficult to provide in a fragmented referral model. It becomes more feasible when behavioral health clinicians have access to the same treatment timeline and care plan as the oncology team.
Early Evidence and Remaining Questions
Adjuvant Behavioral Health reported 2025 outcomes data showing improvement in distress scores among patients with longitudinal NCCN Distress Thermometer measurements.3 Among those patients, 43% demonstrated improvement, 62% experienced a clinically meaningful reduction of at least 2 points from their highest to lowest distress level, and the average peak-to-relief improvement was 2.8 points across 12.8 measurements per patient.3 The organization also reported a patient satisfaction score of 4.9 out of 5.3
These data come from a single organization at an early stage of scale and should be interpreted accordingly. Still, they suggest the potential value of combining standardized measurement with ongoing patient contact.
Dr. Flora also pointed to a large study published in Nature examining the genetic architecture of psychiatric diagnoses across more than one million people, arguing that psychiatry is beginning to move toward a more biologically grounded understanding of mental illness.2 For oncology clinicians accustomed to biomarker-driven care, that scientific shift may help make behavioral health integration feel less peripheral and more aligned with the direction of modern medicine.
Conclusion: From Recognition to Action
The conversation in oncology has shifted. Distress is no longer viewed simply as an unfortunate byproduct of cancer treatment. Increasingly, distress is recognized as a clinical issue that can influence whether patients remain engaged in care. The evidence base for the Collaborative Care Model exists. The staffing model is adaptable. Technology can reduce workflow friction. Early implementation experience offers practical lessons about what works and what needs refinement.
What remains is the work of translating those elements into routine practice. As Dr. Flora put it, "The chemo is the easy part. The mental health, the anguish, the existential dread are where the art of oncology is really practiced." For community oncology programs, the challenge is no longer whether behavioral health matters; it is whether they can address it. It is how intentionally they choose to build behavioral health into care.
Fred Ashbury, PhD, FMASCC, is the Chief Scientific Officer and Co-Founder of VieCure, and Professor of Internal Medicine and Medical Oncology at The Ohio State University. Lindsey Bryant is the Director of Value-Based Care at The Center for Cancer and Blood Disorders, a multi-site community oncology practice serving the state of Maryland. Douglas Flora, MD, LSSBB, FACCC, is a medical oncologist and Executive Medical Director at St. Elizabeth Healthcare. He is the author of Rebooting Cancer Care: Can AI Make Care More Human Again? and a national voice on integrating precision medicine and behavioral health in oncology. He is also ACCC President-Elect. Josh Myers, PhD, is a Co-Founder of Adjuvant Behavioral Health, a collaborative care behavioral health organization serving community oncology practices.
References
Understanding both the benefits to be had from offering BsAb therapy to its community and the scope of this undertaking, Vanderbilt-Ingram Cancer Center took a novel approach with its APP-led BsAb step-up dosing clinic, which won the program a 2026 ACCC Innovator Award.
