Effects of stigma, anxiety and depression, and uncertainty in illness on quality of life in patients with prostate cancer: a cross-sectional analysis

PURPOSE

Although much work has been carried out on stigma, anxiety and depression, and quality of life(QoL) in cancer patients, far less work has been done to examine their associations. This study explores the effects of stigma, anxiety and depression, and uncertainty in illness on QoL in prostate cancer patients.

METHODS

A cross-sectional study surveyed levels of stigma, anxiety and depression, QoL, and uncertainty in illness in 263 people diagnosed with prostate cancer from the First Affiliated Hospital, Zhejiang University School of Medicine. The main study variables were analyzed by structural equation modeling.

RESULTS

Anxiety and depression were significantly negatively related to QoL, with a standardized regression coefficient (β=-0.312, S.E. =0.478, p < 0.05), which means that participants reporting higher levels of anxiety reported decreased levels of QoL. Stigma was positively related to anxiety and depression (β = 0.135, S.E. =0.203, p < 0.001) and uncertainty in illness (β = 0.126, S.E. =2.194, p < 0.05). Stigma has direct effects on QoL (β=-0.209, S.E. =1.655, p < 0.001), but in the presence of a third variable (anxiety and depression overall), direct effects are reduced, as indirect effects emerge through the variable anxiety and depression overall, with an indirect effect size of - 0.054.

CONCLUSIONS

Stigma impacts mental health, such as anxiety and depression, uncertainty in illness, and QoL. Health care professionals may help patients alleviate feelings of anxiety, depression, and uncertainty in illness to improve QoL outcomes.

Depression and anxiety during the year before death from cancer

OBJECTIVE

Previous studies of depression and anxiety during the year before death have reported different findings. We therefore aimed to study depression and anxiety in patients who had died from cancer and had previously attended cancer clinics.

METHODS

We analysed routine data on 4869 deceased patients who had completed the Hospital Anxiety and Depression Scale (HADS) as part of their routine cancer care. The HADS data were linked with demographic, cancer and mortality data from national registries. We used data from all HADS completed in the last year of life to investigate the relationships between mean depression (HADS-D) and anxiety (HADS-A) scores and the percentages of high scores (≥11 on each subscale) and time to death (Analysis 1). This analysis used multivariable linear regression with cubic splines and robust standard errors to allow for multiple HADS from the same patients. We also investigated within-patient changes in scores (Analysis 2) in a subset of patients who had completed more than one HADS.

RESULTS

In Analysis 1, modelled mean HADS-D scores increased by around 2.5 and the percentage of high HADS-D scores increased from 13% at six months before death to 30% at one month before death. Changes in HADS-A were smaller and occurred later. In Analysis 2, similar patterns were observed in individual patients' HADS scores.

CONCLUSION

Depression should be looked for and treated in patients with cancer and a prognosis of six months or less, in order to maximise the quality of patients' remaining life.

Integrated, cross-sectoral psycho-oncology (isPO): a new form of care for newly diagnosed cancer patients in Germany

Background

The annual incidence of new cancer cases has been increasing worldwide for many years, and is likely to continue to rise. In Germany, the number of new cancer cases is expected to increase by 20% until 2030. Half of all cancer patients experience significant emotional and psychosocial distress along the continuum of their disease, treatment, and aftercare, and also as long-term survivors. Consequently, in many countries, psycho-oncological programs have been developed to address this added burden at both the individual and population level. These programs promote the active engagement of patients in their cancer therapy, aftercare and survivorship planning and aim to improve the patients' quality of life.

In Germany, the “new form of care isPO” (“nFC-isPO”; integrated, cross-sectoral psycho-oncology/integrierte, sektorenübergreifende Psycho-Onkologie) is currently being developed, implemented and evaluated. This approach strives to accomplish the goals devised in the National Cancer Plan by providing psycho-oncological care to all cancer patients according to their individual healthcare needs. The term “new form of care" is defined by the Innovation Fund (IF) of Germany's Federal Joint Committee as “a structured and legally binding cooperation between different professional groups and/or institutions in medical and non-medical care”.

The nFC-isPO is part of the isPO project funded by the IF. It is implemented in four local cancer centres and is currently undergoing a continuous quality improvement process. As part of the isPO project the nFC-isPO is being evaluated by an independent institution: the Institute for Medical Sociology, Health Services Research, and Rehabilitation Science (IMVR), University of Cologne, Germany.

The four-year isPO project was selected by the IF to be eligible for funding because it meets the requirements of the federal government's National Cancer Plan (NCP), in particular, the “further development of the oncological care structures and quality assurance" in the psycho-oncological domain. An independent evaluation is required by the IF to verify if the new form of care leads to an improvement in cross-sectoral care and to explore its potential for permanent integration into the German health care system.

Methods

The nFC-isPO consists of six components: a concept of care (C1), care pathways (C2), a psycho-oncological care network (C3), a care process organization plan (C4), an IT-supported documentation and assistance system (C5) and a quality management system (C6). The two components concept of care (C1) and care pathways (C2) represent the isPO clinical care program, according to which the individual cancer patients are offered psycho-oncological services within a period of 12 months after program enrolment following the diagnosis of cancer. The remaining components (C3-C6) represent the formal-administrative aspects of the nFC-isPO that are intended to meet the legally binding requirements of patient care in the German health care system. With the aim of systematic development of the nFC-isPO while at the same time enabling the external evaluators to examine its quality, effectiveness and efficiency under conditions of routine care, the project partners took into consideration approaches from translational psycho-oncology, practice-based health care research and program theory. In order to develop a structured, population-based isPO care program, reference was made to a specific program theory, to the stepped-care approach, and also to evidence-based guideline recommendations.

Results

The basic version, nFC-isPO, was created over the first year after the start of the isPO project in October 2017, and has since been subject to a continuous quality improvement process. In 2019, the nFC-isPO was implemented at four local psycho-oncological care networks in the federal state North Rhine-Westphalia, in Germany. The legal basis of the implementation is a contract for "special care" with the German statutory health insurance funds according to state law (§ 140a SCB V; Social Code Book V for the statutory health insurance funds). Besides the accompanying external evaluation by the IMVR, the nFC-isPO is subjected to quarterly internal and cross-network quality assurance and improvement measures (internal evaluation) in order to ensure continuous quality improvement process. These quality management measures are developed and tested in the isPO project and are to be retained in order to ensure the sustainability of the quality of nFC-isPO for later dissemination into the German health care system.

Discussion

Demands on quality, effectiveness and cost-effectiveness of in the German health care system are increasing, whereas financial resources are declining, especially for psychosocial services. At the same time, knowledge about evidence-based screening, assessment and intervention in cancer patients and about the provision of psychosocial oncological services is growing continuously. Due to the legal framework of the statutory health insurance in Germany, it has taken years to put sound psycho-oncological findings from research into practice. Ensuring the adequate and sustainable financing of a needs-oriented, psycho-oncological care approach for all newly diagnosed cancer patients, as required by the NCP, may still require many additional years. The aim of the isPO project is to develop a new form of psycho-oncological care for the individual and the population suffering from cancer, and to provide those responsible for German health policy with a sound basis for decision-making on the timely dissemination of psycho-oncological services in the German health care system.

Trial registration

The study was pre-registered at the German Clinical Trials Register (https://www.drks.de/DRKS00015326) under the following trial registration number: DRKS00015326; Date of registration: October 30, 2018.

What factors shape quality of life for women affected by gynaecological cancer in South, South East and East Asian countries? A critical review

Background

Gynaecological cancers are among the most prevalent cancers worldwide, with profound effects on the lives of women and their families. In this critical review, we explore the impacts of these cancers on quality of life (QOL) of women in Asian countries, and highlight areas for future inquiry.

Methods

A systematic search of the literature was conducted in six electronic databases: Web of Science, Scopus, Global Health (CAB Direct), PsycINFO (Ovid), EBMR (Ovid), and Medline (Ovid). Screening resulted in the inclusion of 53 relevant articles reporting on 48 studies.

Results

Most studies were conducted in high and upper-middle income countries in East Asia and used quantitative approaches. Women had predominantly been diagnosed with cervical or ovarian cancer, and most had completed treatment. Four key interrelated domains emerged as most relevant in shaping QOL of women affected by gynaecological cancer: support, including identified needs, sources and forms; mental health, covering psychological distress associated with cancer, risk and protective factors, and coping strategies; sexual function and sexuality, focused on physiological, emotional and relational changes caused by gynaecological cancers and treatments, and the impacts of these on women’s identities; and physical health, covering the physical conditions associated with gynaecological cancers and their impacts on women’s daily activities.

Conclusion

QOL of women affected by gynaecological cancer is shaped by their mental and physical health, support, and changes in sexual function and sexuality. The limited number of studies from lower- and middle-income countries in South and Southeast Asia highlights important knowledge gaps requiring future research.

Multiple factors shape the quality of life of women affected by gynaecological cancers in Asian countries as elsewhere. We identified 53 articles reporting on 48 studies, most conducted in high- and upper-middle income East Asian countries, with much less attention to women in lower income countries in South and Southeast Asia. Most studies used quantitative research methods to gain an understanding of the impact on women diagnosed with cervical or ovarian cancer who had completed treatment. Women’s quality of life was shaped by their mental and physical health, their support needs, and the changes they experienced in sexual function and sexuality.

Prevalence and determinants of anxiety and depression in long-term breast cancer survivors

BACKGROUND

There is a significant number of long-term breast cancer survivors in Germany. However, research on the psychological challenges of cancer survivors is limited. This analysis describes prevalence, development and determinants of depression and anxiety 5 to 6 years after diagnosis and identifies predictors for an increase of anxiety and depression over time.

METHODS

Data from 164 women was collected by survey and tumour documentation during post-operative hospital stay, 40 weeks and 5 to 6 years after diagnosis. Anxiety and depression were measured by the Hospital Anxiety and Depression Scale. Sankey-diagrams were created for visual presentation of prevalence over time. Logistic and linear regression models were calculated to identify determinants of anxiety and depression.

RESULTS

Respondents had higher levels of depression and anxiety 5 to 6 years than 40 weeks after the diagnosis. Lower vocational status and having children were associated with depression, surgery type was correlated with anxiety, and age, as well as comorbidities, were predictors for both anxiety and depression 5 to 6 years after diagnosis. An increase of depression over time was more likely when having children and comorbidities. An increase in anxiety was less likely after cancer recurrence.

CONCLUSIONS

Findings highlight that anxiety and depression are relevant burdens for breast cancer survivors in Germany. Several sociodemographic and clinical predictors are identified. There is need for psychosocial support after acute treatment and in the long-term. Research on psychological burdens of long-term breast cancer survivors in the identified vulnerable groups is needed.

An Algorithm to Stratify the Risk of Postoperative Emotional Distress in Cancer Patients with Advanced Metastatic Spinal Disease

Purpose

We wish (1) to assess what variables are significantly associated with postoperative emotional distress in patients with the metastatic spinal disease after surgery and (2) to develop and validate an algorithm to stratify patients at risk of postoperative emotional distress.

Patients and Methods

We retrospectively enrolled 171 patients with the metastatic spinal disease treated with surgery. Twelve potential variables were used to analyze postoperative emotional distress. Postoperative emotional well-being was measured using the Hospital Anxiety and Depression Scales (HADS). Significant variables were included in the algorithm and assigned scores based on odds ratios (ORs) from the multiple logistic regression analysis. The predictive performance of the risk algorithm was validated on the basis of discrimination and calibration.

Results

Twenty-six (15.20%) patients had a HADS of 19 points or more. Of all the 12 variables, age (P=0.06), marital status (P=0.02), primary cancer types (P=0.004), and physical well-being (P=0.006) were included in the algorithm. This algorithm ranged from 0 to 24. Higher scores represented higher rates of postoperative emotional distress. Patients were stratified into three risk groups: patients in the group A had scores of 0 to 9 and the rate of postoperative emotional distress was only 1.14%, patient in the group B had scores of 10 to 15 and the rate of postoperative emotional distress was 21.31%, and patient in the group C had scores of 16 to 24 and the rate of postoperative emotional distress was up to 54.55%. The area under the receiver operating characteristic curve (AUROC) for the algorithm was 0.84, and the correct classification rate was 81.3%.

Conclusion

Postoperative emotional distress is common in patients with the metastatic spinal disease after surgery. We propose and validate an algorithm that can be used as a potential screening tool to identify patients at high risk of postoperative emotional distress.

Hospital Anxiety and Depression Scale (HADS) accuracy in cancer patients

PURPOSE

The Hospital Anxiety and Depression Scale (HADS) is a self-report questionnaire designed to screen anxious and depressive states in patients in non-psychiatric settings. In spite of its large use, no agreement exists in literature on HADS accuracy in case finding. The present research addresses the issue of HADS accuracy in cancer patients, comparing its two subscales (HADS-A and HADS-D) against tools not in use in psychiatry, which are able to detect prolonged negative emotional states.

METHODS

2121 consecutive adult cancer inpatients were administered the HADS together with the State Anxiety subscale of State-Trait Anxiety Inventory and the Center for Epidemiologic Studies Scale on Depression. Receiver operating characteristic (ROC) curves were computed to identify a cut-off for anxious and depressive states in cancer patients. All indicators were computed together with their corresponding 95% confidence interval (95% CI).

RESULTS

Data of 1628 and 1035 participants were used to assess the accuracy in case finding of HADS-A and HADS-D, respectively. According to the ROC analysis, the optimal cut-off was > 9 units for the HADS-A and > 7 units for the HADS-D. The area under the ROC curve was 0.90 for HADS-A (95% CI 0.88-0.91) and 0.84 for HADS-D (95% CI 0.81-0.86).

CONCLUSIONS

This study suggested that risk scores of anxious and depressive states above specific HADS cut-offs are useful in identifying anxious and depressive states in cancer patients, and they may thus be applicable in clinical practice.

Identification of Anxiety and Depression Symptoms in Patients With Cancer: Comparison Between Short and Long Web-Based Questionnaires

Background

Physicians and nurses in cancer care easily fail to detect symptoms of psychological distress because of barriers such as lack of time, training on screening methods, and knowledge about how to diagnose anxiety and depression. National guidelines in several countries recommend routine screening for emotional distress in patients with cancer, but in many clinics, this is not implemented. By inventing screening methods that are time-efficient, such as digitalized and automatized screenings with short instruments, we can alleviate the burden on patients and staff.

Objective

The aim of this study was to compare Web-based versions of the ultrashort electronic Visual Analogue Scale (eVAS) anxiety and eVAS depression and the short Hospital Anxiety and Depression Scale (HADS) with Web-based versions of the longer Montgomery Åsberg Depression Rating Scale-Self-report (MADRS-S) and the State Trait Anxiety Inventory- State (STAI-S) with regard to their ability to identify symptoms of anxiety and depression in patients with cancer.

Methods

Data were obtained from a consecutive sample of patients with newly diagnosed (<6 months) breast, prostate, or colorectal cancer or with recurrence of colorectal cancer (N=558). The patients were recruited at 4 hospitals in Sweden between April 2013 and September 2015, as part of an intervention study administered via the internet. All questionnaires were completed on the Web at the baseline assessment in the intervention study.

Results

The ultrashort and short Web-based-delivered eVAS anxiety, eVAS depression and HADS were found to have an excellent ability to discriminate between persons with and without clinical levels of symptoms of anxiety and depression compared with recommended cutoffs of the longer instruments MADRS-S and STAI-S (area under the curve: 0.88-0.94). Cutoffs of >6 on HADS anxiety and >7 hundredths (hs) on eVAS anxiety identified patients with anxiety symptoms with high accuracy. For HADS depression, at a cutoff of >5 and eVAS depression at a cutoff of >7 hs, the accuracy was very high likewise.

Conclusions

The use of the short and ultrashort tools, eVAS and HADS, may be a suitable initial method of Web-based screening in busy clinical settings. However, there are still a proportion of patients who lack access to the internet or the ability to use it. There is a need to find solutions for this group to find all the patients with psychological distress.

Agreement between a single-item measure of anxiety and depression and the Hospital Anxiety and Depression Scale: A cross-sectional study

Anxiety and depression can be heightened among individuals living with chronic diseases. Identifying these individuals is necessary for ensuring they are provided with adequate support. Traditional tools such as clinical interviews or symptom checklists are not always feasible to implement in practice. Robust single-item questions may be a useful alternative. This study aimed to measure agreement, sensitivity, specificity, positive predictive value and negative predictive value of a single-item question about anxiety and depression compared to the widely used Hospital Anxiety and Depression Scale (HADS). A cross-sectional survey of 2,811 people with cancer attending 19 treatment centres in Australia. Patients were approached in the waiting room prior to an outpatient clinic appointment and invited to complete a pen and paper survey. Participants completed the HADS as well as 2 single-items asking if they have felt anxious or depressed in the last week. The single-items for anxiety and depression each demonstrated moderate levels of sensitivity (0.78 for anxiety; 0.63 for depression) and specificity (0.75 for anxiety; 0.84 for depression) against the relevant HADS subscale. Positive predictive values were moderate (0.53 for anxiety and 0.52 for depression) while negative predictive values were high for both single-item questions (0.90 for anxiety and 0.89 for depression). The single-item measures of anxiety and depression may be useful to rule out individuals who do not require further psychological assessment or intervention for anxiety and depression. Further research is needed to explore whether these findings generalise to other chronic diseases.

ENdometrial cancer SURvivors' follow-up carE (ENSURE): Less is more? Evaluating patient satisfaction and cost-effectiveness of a reduced follow-up schedule: study protocol of a randomized controlled trial

Background

It has often been hypothesized that the frequency of follow-up visits for patients with early-stage endometrial cancer could be decreased. However, studies evaluating effects of a reduced follow-up schedule among this patient group are lacking. The aim of this study is to assess patient satisfaction and cost-effectiveness of a less frequent follow-up schedule compared to the schedule according to the Dutch guideline.

Methods

In this multicenter randomized controlled trial, patients diagnosed in the Netherlands with stage 1A and 1B low-risk endometrial cancer, for whom adjuvant radiotherapy is not indicated (n = 282), are randomized. Patients allocated to the intervention group receive four follow-up visits during three years. Patients allocated to the control group receive 10–13 follow-up visits during five years, according to the Dutch guideline. Patients are asked to fill out a questionnaire at baseline and after 6, 12, 36, and 60 months. Primary outcomes include patient satisfaction with follow-up care and cost-effectiveness. Secondary outcomes include healthcare use, adherence to schedule, health-related quality of life, fear of recurrence, anxiety and depression, information provision, recurrence, and survival. Linear regression analyses will be used to assess differences in patient satisfaction with follow-up care between intervention and control group.

Discussion

We anticipate that patients in the intervention arm have a similar satisfaction with follow-up care and overall outcomes, but lower healthcare use and costs than patients in the control arm. No differences are expected in quality-adjusted life-years and satisfaction, but the reduced schedule is expected to be cost-saving when implemented in the Netherlands.

Trial registration

ClinicalTrials.gov, NCT02413606. Registered on 10 April 2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2611-x) contains supplementary material, which is available to authorized users.

Initial evaluation of the validity and reliability of the culturally adapted Spanish CaSUN (S-CaSUN)

PURPOSE

There is a dearth of knowledge and limited research on the needs of Hispanic male cancer survivors (HMCSs). There is a clear need for the development of culturally and linguistically adapted needs assessment tools that are valid and reliable for use among the growing HMCS population. Thus, the purpose of this paper is to describe the field testing and psychometric evaluation of the translated and culturally adapted Spanish Cancer Survivor Unmet Needs Measure (S-CaSUN).

METHODS

Hispanic male cancer survivors (n = 84) completed the Spanish CaSUN (S-CaSUN), the Hospital Anxiety and Depression Scale (HADS), and the Functional Assessment of Cancer Therapy-General Population (FACT-GP). Construct validity of the S-CaSUN was assessed by correlation analysis among aforesaid measures. A test-retest procedure with 2-week delay was used to examine reproducibility with a participant subsample (n = 50). Cronbach's alpha was computed to assess internal consistency of the S-CaSUN.

RESULTS

Construct validity of the S-CaSUN was estimated by moderate correlation with the HADS anxiety (r = 0.55, P < 0.001) and depression scales (r = 0.60, P < 0.001) and the FACT-GP (r = - 0.62, P < 0.001). The test-retest correlation coefficient for the S-CaSUN was 0.78. Cronbach's alpha was 0.96. Field testing yielded a mean S-CaSUN score of 38.3 (SD = 26.2); all needs and positive change items were endorsed.

CONCLUSION

Findings from field testing and preliminary psychometric evaluation of the S-CaSUN provide initial evidence of validity and reliability of the measure and highlight the importance of going beyond translation when adapting measures to take culture, literacy, and language into consideration.

IMPLICATIONS FOR CANCER SURVIVORS

Reliable, culturally, and linguistically valid instruments facilitate identification of unique unmet needs of Hispanic cancer survivors that, in turn, can be addressed with evidence-based interventions. As cancer centers continue to develop survivorship programs, the S-CaSUN may be useful for a growing group of cancer survivors.

Development of anxiety, depression and health-related quality of life in oncology patients without initial symptoms according to the Hospital Anxiety and Depression Scale - a comparative study

BACKGROUND

Depression and anxiety are associated with decreased health-related quality of life (HRQoL). The knowledge about the development of anxiety, depression and HRQoL in cancer patients without depression or anxiety, that is initially scoring as non-cases (cutoff <8) according to the Hospital Anxiety and Depression Scale (HADS), is sparse. The objectives were: (1) to evaluate changes in anxiety, depression and HRQoL over 6 months in two independent cohorts of oncology patients initially scoring as non-cases by the HADS, (2) to compare stable non-case patients with the general population regarding HRQoL and (3) to explore the outcomes using >4 rather than >7 as cutoff on any of HADS subscales.

METHODS

The study group (SG) included 245 and the validation group (VG), a previous cohort, included 281 non-cases. Patients who were non-cases (HADS <8) at all completed assessments were categorized as stable non-cases (stable-NC); those who were doubtful/clinical cases (HADS >7) in at least one follow-up were categorized as unstable-NC. Questionnaires were completed at baseline, and after 1, 3 and 6 months. Age- and sex-matched EORTC QLQ-C30 data from the general population were used for HRQoL comparisons.

RESULTS

One hundred ninety-six (80%) SG and 244 (87%) VG patients were stable-NC and 49 (20%) SG and 37 (13%) VG patients were unstable-NC. SG and VG were similar in all outcomes. Anxiety, depression and HRQoL deteriorated over 6 months for unstable-NC (p < .05). HRQoL for stable-NC was comparable to that in the general population. If >4 had been used as cutoff, most unstable-NC (36/49 and 25/37, respectively) would have been identified at baseline.

CONCLUSIONS

Most non-cases are stable-NC with a high stable HRQoL, indicating no need for re-assessment. A minority develop anxiety or depression symptoms and impaired HRQoL; for these a cutoff >4 rather than >7 on HADS subscales may be useful for early detection.

Depressive spectrum disorders in cancer: prevalence, risk factors and screening for depression: a critical review

BACKGROUND

Although depression and mood-related disorders are common in persons with cancer, these conditions remain frequently overlooked in clinical practice. Negative consequences of depressive disorder spectrum have been reported (e.g. suicidal ideation, increase physical complications and somatic symptoms, negative influence on prognosis), indicating the need for routine screening, assessment and management.

METHODS

A search of the major databases (Medline, Embase, PsycLIT, PsycINFO, and the Cochrane Library) was conducted on the reviews and meta-analyses available in order to summarize relevant data concerning depressive disorders spectrum in terms of prevalence, risk factors, and screening and assessment among patients with cancer across the trajectory of the disease.

RESULTS

The data show a prevalence of depression and depressive disorders between 5% and 60% according to the different diagnostic criteria, the tools used in the studies (e.g. semi-structured psychiatric interview and psychometric questionnaires), as well as the stage and type of cancer. Furthermore, despite the significant health care resources devoted to cancer care and the importance of addressing depressive symptoms, assessment and management of depressive spectrum disorders in cancer patients remains suboptimal.

CONCLUSIONS

Routine screening and adequate assessment of depressive spectrum disorders is necessary in patients with cancer in order to effectively manage the multifaceted and complex consequences on cancer care.

Towards a new conceptualization of depression in older adult cancer patients: a review of the literature

OBJECTIVES

Identifying depression in older adults with cancer presents a set of unique challenges, as it combines the confounding influences of cancer and its treatment with the developmental changes associated with aging. This paper reviews the phenomenology of depression in older adults, and individuals diagnosed with cancer.

METHOD

PsychInfo, PubMed, Web of Science, and Google Scholar databases were searched for English-language studies addressing the phenomenology, symptoms, or assessment of depression in older adults and those with cancer.

RESULTS

The Diagnostic and Statistical Manual for Mental Disorders (DSM) criteria that appear to be relevant to both older adults and cancer patients are anhedonia, concentration difficulties, sleep disturbances, psychomotor retardation/agitation, and loss of energy. Possible alternative criteria that may be important considerations included constructs such as loss of purpose, loneliness, and irritability in older adults. Among cancer patients, tearfulness, social withdrawal, and not participating in treatment despite ability to do so were identified as potentially important symptoms.

CONCLUSIONS

Current DSM criteria may not adequately assess depression in older cancer patients and alternative criteria may be important to inform the understanding and identification of depression in this population. Enhancing diagnostic accuracy of depression is important as both the over-diagnosis and under-diagnosis is accompanied with significant costs. Thus, continued research exploring the phenomenology and identifying effective indicators of depression in older cancer patients is needed.

Validation of the distress and impact thermometer and the changes of mood during the first 6 months of treatment in gynecological cancer patients: a Kansai Clinical Oncology Group (KCOG)-G1103 prospective study

PURPOSE

To verify distress and impact thermometer (DIT) for screening emotional distress in gynecological cancer patients by Hospital Anxiety and Depression Scale total (HADS-T) as gold standard and to assess emotional changes by DIT and HADS-T.

METHODS

A prospective study was conducted in newly diagnosed gynecological cancer patients during the peri-treatment period after the cancer diagnosis followed by 6-month. We defined a HADS-T score of ≥11 as being indicative of emotional distress.

RESULTS

117 patients were enrolled between May 1, 2011 and March 31, 2012, and 95 were eligible. The median age was 54 years (range 31-77). (1) From the baseline to 3-month, distress (DIT-D) ≥4 with Impact (DIT-I) ≥2 exhibited sensitivity, specificity, positive predictive value (PPV), and negative predictive values (NPV) of 0.776 [95 % confidential interval (CI) 0.688, 0.850], 0.889 (95 % CI 0.824, 0.954), 0.868 (95 % CI 0.792, 0.949), and 0.808 (95 % CI 0.731, 0.886), respectively. (2) At 6-month, DIT-D ≥2 with DIT-I ≥1 exhibited sensitivity, specificity, PPV and NPV of 0.893 (95 % CI 0.778, 1), 0.825 (95 % CI 0.707, 0.942), 0.781 (95 % CI 0.638, 0.928), and 0.917 (95 % CI 0.826, 1). (3) At 6-month, the HADS-T, DIT-D, and DIT-I scores in individual patients were significantly reduced by a mean of 4.57 (p < 0.0001), 2.34 (p < 0.0001), and 1.10 (p = 0.0031), respectively, compared with those scores of baseline (Student's paired t test), but still remained high.

CONCLUSIONS

(1) On acute phase within 3-month setting, DIT; DIT-D ≥4 with DIT-I ≥2, is a reliable cut-off to screen emotional distress among gynecological cancer patients. (2) The patients' moods had improved, but not completely recovered at 6-month after the diagnosis.

Type D Personality in Gastric Cancer Survivors: Association With Poor Quality of Life, Overall Survival, and Mental Health

CONTEXT

The associations between Type D personality and poor quality of life, overall survival, and mental health in gastric cancer survivors.

OBJECTIVES

The aim of this research was to explore quality of life (QoL), mental health status, Type D personality, symptom duration, and emergency admissions of Chinese gastric cancer patients, as well as the relationship between these factors.

METHODS

Eight hundred thirty eligible Chinese patients newly diagnosed with gastric cancer between July 2009 and July 2011 were enrolled in this prospective study. Type D personality was measured with the 14-item Type D Personality Scale (DS14). Mental health status was measured with the Hospital Anxiety and Depression Scale. The QoL outcomes were assessed longitudinally using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 and Quality of Life Questionnaire-STO22 at baseline and six months after diagnosis.

RESULTS

The proportion of patients with symptom duration of more than one month and who were diagnosed after emergency admissions in the Type D group was significantly higher than that in the non-Type D personality group. At both of the time points, Type D patients reported statistically significant lower scores on role, emotional, cognitive, and social functioning (all Ps < 0.001) functional scales, global health status/QoL scales (P < 0.001), and worse symptom scores compared to patients without a Type D personality. During the six-month time frame, a higher percentage of patients in the Type D group demonstrated a considerable QoL deterioration. Clinically elevated levels of anxiety and depression were more prevalent in Type D than in non-Type D survivors (both Ps < 0.001). There was a statistically significant difference in three-year overall survival between the patients in the Type D group and the non-Type D personality group.

CONCLUSION

Type D personality is associated with poor QoL, three-year overall survival and mental health status among survivors of gastric cancer, even after adjustment of confounding background variables. The Type D personality group experienced increased levels of pain and fatigue compared to non-Type D patients. Type D personality might be a general vulnerability factor to screen for subgroups at risk of longer symptom duration and emergency admissions in clinical practice.

Type D personality is associated with delaying patients to medical assessment and poor quality of life among rectal cancer survivors

OBJECTIVE

The aim of this research was to explore quality of life (QoL), mental health status, type D personality, symptom duration, and emergency admissions of Chinese rectal cancer patients as well as the relationship between these factors.

METHODS

Type D personality was measured with the 14-item Type D Personality Scale (DS14). Mental health status was measured with the Hospital Anxiety and Depression Scale (HADS). The QoL outcomes were assessed longitudinally using the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-CR38 questionnaires at the baseline and 6 months after diagnosis.

RESULTS

Of the 852 survivors who responded (94 %), 187 (22 %) had a type D personality. The proportion of patients with duration of symptoms >1 month and being diagnosed after emergency admissions in type D group is significantly higher than that in non-type D group. At both of the time points, type D patients reported statistically significant lower scores on most of the functional scales, global health status/QoL scales, and worse symptom scores compared to patients without a type D personality. At the 6-month time point, a higher percentage of patients in the type D group demonstrated QoL deterioration. Clinically elevated levels of anxiety and depression were more prevalent in type D than in non-type D survivors.

CONCLUSIONS

Type D personality was associated with poor QoL and mental health status among survivors of rectal cancer, even after adjustment for confounding background variables. Type D personality might be a general vulnerability factor to screen for subgroups at risk for longer symptom duration and emergency admissions in clinical practice.

Anxiety and depression in long-term testicular germ cell tumor survivors

OBJECTIVE

Despite a good prognosis, the typically young age at diagnosis and physical sequelae may cause psychological distress in germ cell tumor survivors. We aimed to determine the frequency of anxiety and depression and analyze the impact of demographic and disease-related factors.

METHOD

We enrolled N=164 testicular germ cell tumor survivors receiving routine follow-up care at the University Cancer Center Hamburg and a specialized private practice (mean, 11.6 years after diagnosis). Patients completed the Generalized Anxiety Disorder Screener-7, the Patient Health Questionnaire-9 and the Memorial Symptom Assessment Scale-Short Form.

RESULTS

We found clinically significant anxiety present in 6.1% and depression present in 7.9% of survivors. A higher number of physical symptoms and having children were significantly associated with higher levels of both anxiety and depression in multivariate regression analyses controlling for age at diagnosis, cohabitation, socioeconomic status, time since diagnosis, metastatic disease and relapse. Younger age at diagnosis and shorter time since diagnosis were significantly associated with higher anxiety.

CONCLUSION

Although rates of clinically relevant anxiety and depression were comparably low, attention toward persisting physical symptoms and psychosocial needs related to a young age at diagnosis and having children will contribute to address potential long-term psychological distress in germ cell tumor survivors.

Effect of Relaxation With Guided Imagery on The Physical and Psychological Symptoms of Breast Cancer Patients Undergoing Chemotherapy

Background:

Breast cancer patients frequently experience psychological distress during the chemotherapy period.

Objectives:

This study aimed to evaluate the effect of relaxation with guided imagery on patients with breast cancer.

Patients and Methods:

A two-group, pretest-posttest, quasi-experimental design with a randomized controlled trial was conducted. Sixty-five breast cancer patients from one medical center in Taiwan were enrolled in the study. These patients were randomly assigned to the experimental group (n = 32) or to the control group (n = 33). Both groups received chemotherapy self-care education, but the experimental group also received relaxation with guided imagery training. The training on relaxation with guided imagery was conducted before chemotherapy, and the patients were supplied with a compact disc detailing the performance of relaxation with guided imagery for 20 minutes daily at home for 7 days after chemotherapy.

Results:

The experimental group showed significant decreases in insomnia (-0.34 ± 0.83, P < 0.05), pain (-0.28 ± 0.58, P < 0.05), anxiety (-3.56 ± 2.94, P < 0.00), and depression (-2.38 ± 2.70, P < 0.00) between the pretest and the posttest. Comparing the two groups, statistically significant differences were found in the overall symptom distress (B = 0.11, P < 0.05), insomnia (B = 0.50, P <0.05), depression (B = 0.38, P < 0.05), and numbness in physical symptoms (B = 0.38, P < 0.05), as well as in anxiety (B = 3.08, P < 0.00) and depression (B = 1.86, P < 0.00) in psychological distress. One week of relaxation with guided imagery can significantly improve the overall symptoms of distress, insomnia, depression, physical symptoms, and anxiety, and can decrease psychological distress.

Conclusions:

Relaxation with guided imagery had a positive effect on mediating anxiety and depression in breast cancer patients.

Patient-reported depression measures in cancer: a meta-review

The patient-reported depression measures that perform best in oncology settings have not yet been identified. We did a meta-review to integrate the findings of reviews of more than 50 depression measures used in adults with, or recovering from, any type of cancer. We searched Medline, PsycINFO, Embase, and grey literature from 1999 to 2014 to identify 19 reviews representing 372 primary studies. 11 reviews were rated as being of high quality (defined as meeting at least 20 criteria in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement). The Hospital Anxiety Depression Scale (HADS) was the most thoroughly evaluated measure, but was limited by cutpoint variability. The HADS had moderate screening utility indices and was least recommended in advanced cancer or palliative care. The Beck Depression Inventory was more generalisable across cancer types and disease stages, with good indices for screening and case finding. The Center for Epidemiologic Studies Depression Scale was the best-weighted measure in terms of responsiveness. This meta-review provides a comprehensive overview of the strengths and limitations of available depression measures. It can inform the choice of the best measure for specific settings and purposes.

Anxiety and depression among haematological cancer patients attending treatment centres: prevalence and predictors

BACKGROUND

This study aimed to: (1) estimate the prevalence of anxiety and/or depression among haematological cancer patients attending treatment centres; and (2) explore the demographic, disease and treatment characteristics associated with anxiety and/or depression.

METHODS

A cross-sectional study was conducted with outpatients from three haematology clinics in Australia. Patients with a confirmed diagnosis of haematological cancer were approached by a research assistant while waiting for their appointment and invited to participate in the survey. Participants completed the Hospital Anxiety and Depression Scale (HADS) and self-reported demographic, disease and treatment characteristics.

RESULTS

Questionnaires from 304 participants were returned. Twenty-seven percent of patients reported anxiety and 17% reported depression. Specifically, 15% reported anxiety without depression, 5% reported depression without anxiety, and 12% reported comorbid anxiety and depression. Participants who had to relocate to receive treatment had almost three times the odds of reporting anxiety and/or depression compared to those who did not have to move. Former smokers also had significantly higher odds of reporting anxiety and/or depression.

LIMITATIONS

The HADS is likely to have produced some false positives and false negatives when compared with gold standard structured clinical interviews for assessing psychological morbidity.

CONCLUSIONS

Approximately 20% of haematological cancer patients attending outpatient clinics may experience clinically significant levels of anxiety and/or depression. Providing additional tailored support to patients who have had to relocate for treatment, and to former smokers, may help to reduce anxiety and depression among these subgroups.

Agreement between HADS classifications and single-item screening questions for anxiety and depression: a cross-sectional survey of cancer patients

BACKGROUND

We assessed agreement between reported anxiety and depression levels of cancer patients using (i) single self-report items and (ii) the Hospital Anxiety and Depression Scale (HADS). We also explored whether anxiety and depression assessment by (i) single self-report items or (ii) the HADS was most strongly associated with a preference to be offered professional assistance. The proportion of patients indicating that they would accept (or were currently using) professional support if they were experiencing anxiety or depression was also examined.

PATIENTS AND METHODS

A consecutive sample of cancer patients undergoing radiotherapy at four metropolitan public hospitals in Australia completed a touch screen computer survey. A consecutive subsample of patients attending three of these treatment centres answered additional questions about psychological support preferences.

RESULTS

Of 304 respondents, 54% [95% confidence interval (CI) 48% to 60%] perceived that they were currently experiencing mild to severe anxiety and depression. 22% (95% CI 18% to 27%) indicated a preference to be offered professional help. There was moderate agreement between the HADS and single-item responses for categorisation of anxiety and depression. Patient-perceived mild to severe anxiety and depression levels appeared to be the best measure for identifying those with a preference to be offered professional assistance. Of a subsample of 193 respondents, 89% (95% CI 84% to 93%) indicated that if they were experiencing anxiety or depression, they would accept (or were currently using) professional support.

CONCLUSIONS

Single-item screening in a cancer care setting may not adequately capture clinical anxiety and depression. However, single-items assessing patients' perceived levels of anxiety and depression are useful indicators of whether patients want to be offered, and are likely to accept, psychosocial care.

Living with the physical and mental consequences of an ostomy: a study among 1-10-year rectal cancer survivors from the population-based PROFILES registry

BACKGROUND

This study examined the physical and mental consequences of an ostomy among 1-10-year rectal cancer survivors.

METHODS

Patients with rectal cancer diagnosed from 2000 to 2009, as registered in the population-based Eindhoven Cancer Registry, received a questionnaire on quality of life (QOL; EORTC QLQ-C30), disease-specific health status (EORTC QLQ-CR38), depression and anxiety (HADS), illness perceptions (Brief Illness Perception Questionnaire), and health care utilization; 76% (n = 1019) responded.

RESULTS

A total of 408 (43%) rectal cancer survivors had an ostomy at survey and they reported a statistically significant and clinically relevant lower physical, role, and social functioning, and global health status/QOL but fewer problems with constipation and diarrhea compared with those without an ostomy. Also, they had a significantly worse body image, more male sexual problems, and fewer gastrointestinal problems although these differences were not clinically relevant. No differences regarding the prevalence of symptoms of anxiety and depression were found. Survivors with an ostomy believed that their illness have significantly more serious consequences, will last longer (clinically relevant), and were more concerned about their illness compared with those without an ostomy. Survivors with an ostomy visited their medical specialist, but not their general practitioner, significantly more often. Also, they more often received additional support after cancer treatment.

CONCLUSIONS

Rectal cancer survivors with an ostomy have a lower QOL, worse illness perceptions, and a higher health care consumption compared with those without an ostomy 1-10 years after diagnosis.

Patient and health professional's perceived barriers to the delivery of psychosocial care to adults with cancer: a systematic review

OBJECTIVE

To explore the barriers experienced and perceived by health professionals and patients in the delivery of psychosocial care to adults with cancer.

METHODS

Systematic searches were undertaken using the PsychInfo, Medline and CINAHL electronic databases, up to October 2013. Research reporting health professional or patient experiences and perceptions of barriers to psychosocial care are included in the review. The systematic review includes studies that have non-experimental, exploratory and observational designs, as is appropriate to answer the review question. Included studies were critically appraised. The results of individual quantitative studies were aggregated. Qualitative content analysis was used to analyse the qualitative results.

RESULTS

Twenty-five papers met the pre-specified inclusion criteria for the final review. The most commonly perceived barrier for patients relates to receiving adequate support from elsewhere and a lack of perceived need for psychosocial care. Health professionals report barriers at an organisational level most frequently followed by cultural and then individual clinician-related barriers.

CONCLUSIONS

Barriers exist on a variety of levels. People with cancer need clear appropriate information and communication about psychosocial services, including information about the role of psychosocial care in addition to existing supports. Interventions that target the complex interplay of individual, organisational and cultural factors need to be developed. Strategies that improve health professional communication skills, identify clear referral pathways, improve acceptability of interventions and clearly identify the need for services could address many of the barriers identified in this review.

Comparison of the hospital anxiety and depression scale and the center for epidemiological studies depression scale for detecting depression in women with breast or gynecologic cancer

OBJECTIVE

Depression is common in cancer patients but frequently undetected. Consensus regarding validity and optimal thresholds of screening measures is lacking. We investigated the validity of the Hospital Anxiety and Depression Scale (HADS-D) and Center for Epidemiological Studies Depression Scale (CES-D) relative to a referent diagnostic standard in women with breast or gynecologic cancer.

METHOD

Participants were 100 patients who completed the CES-D and HADS-D within a larger study. The Mini International Neuropsychiatric Interview was the criterion standard. Sensitivity, specificity, predictive values and likelihood ratios for various thresholds were calculated using receiver operating characteristics. Participants were assigned to two diagnostic groups: 'major depressive disorder' or 'any depressive disorder'.

RESULTS

Separate analyses were conducted whereby participants found to be receiving depression/anxiety treatment at the time of validation (n=28) were excluded. Both measures had good internal consistency and criterion validity. There were no statistical differences in global accuracy between the measures for detecting either group. For optimal sensitivity and specificity in both groups, generally recommended thresholds were lowered for the HADS-D. For the CES-D, the threshold was lowered for 'any depressive disorder' and raised for 'major depressive disorder'. Negative predictive values associated with our recommended cutoffs were excellent, but positive predictive values were poor.

CONCLUSIONS

The HADS-D and CES-D have acceptable properties and are equivalent for detecting depression in this population. Depending on the purpose of screening, the CES-D may be more suitable for identifying major depression. Threshold choice may have serious implications for screening program effectiveness, and the use of generally recommended thresholds should be cautious.

Psychodynamic interventions in cancer care I: psychometric results of a randomized controlled trial

OBJECTIVE

This study aimed to assess the effectiveness of psychodynamic interventions in cancer care.

METHODS

Between 2006 and 2009, each consecutive outpatient of the Oncology Center of the University Hospital of Lausanne was invited to participate in a trial evaluating the effects of psychological support. Accepting patients were randomly assigned to an immediate intervention or a delayed intervention [4-month waiting list]. Patients who declined support were asked to participate in an observational group [OG]. Socio-demographic and medical data, anxiety, and depression [HADS], psychological distress [SCL-90], alexithymia [TAS] and quality of life [EORTC] were recorded at baseline, and at 1, 4, 8, and 12-months follow-up.

RESULTS

Of the 1973 approached patients, 1057 were excluded, 530 refused, and 386 were included with 196 of them participating in the OG. Of the patients in the intervention group [IG] [N = 190], 94 were randomized to the immediate intervention and 96 to the delayed intervention group (dIG). IG patients were younger, predominantly female, and had more psychological symptoms compared with those in the OG. Although patients of the IG and OG showed significant improvement in quality of life from baseline to 12-months follow-up, other outcomes [anxiety, depression, psychological distress, and alexithymia] remained unchanged.

CONCLUSIONS

The intervention was not effective with regards to psychometric outcome. The results have to be interpreted in light of the study design [untargeted intervention], the low levels of psychiatric symptoms, dropout of symptomatic patients, and the high prevalence of alexithymia.

Problems in cross-cultural use of the hospital anxiety and depression scale: "no butterflies in the desert"

Objective

The Hospital Anxiety and Depression Scale (HADS) is widely used to screen for anxiety and depression. A large literature is citable in support of its validity, but difficulties are increasingly being identified, such as inexplicably discrepant optimal cutpoints and inconsistent factor-structures. This article examines whether these problems could be due to the construction of the HADS that poses difficulties for translation and cross-cultural use.

Methods

Authors’ awareness of difficulties translating the HADS were identified by examining 20% of studies using the HADS, obtained by a systematic literature search in Pubmed and PsycINFO in May 2012. Reports of use of translations and validation studies were recorded for papers from non-English speaking countries. Narrative and systematic reviews were examined for how authors dealt with different translations.

Results

Of 417 papers from non-English speaking countries, only 45% indicated whether a translation was used. Studies validating translations were cited in 54%. Seventeen reviews, incorporating data from diverse translated versions, were examined. Only seven mentioned issues of language and culture, and none indicated insurmountable problems in integrating results from different translations.

Conclusion

Initial decisions concerning item content and response options likely leave the HADS difficult to translate, but we failed to find an acknowledgment of problems in articles involving its translation and cross-cultural use. Investigators’ lack of awareness of these issues can lead to anomalous results and difficulties in interpretation and integration of these results. Reviews tend to overlook these issues and most reviews indiscriminately integrate results from studies performed in different countries. Cross-culturally valid, but literally translated versions of the HADS may not be attainable, and specific cutpoints may not be valid across cultures and language. Claims about rates of anxiety and depression based on integrating cross-cultural data or using the same cutpoint across languages and culture should be subject to critical scrutiny.

Profile and predictors of global distress: can the DT guide nursing practice in prostate cancer?

OBJECTIVE

This study examines the ability of the distress thermometer to accurately identify patients with higher symptoms, unmet needs and psychological morbidity.

METHODS

Baseline data collected as part of a randomized controlled trial evaluating a nurse-led supportive care intervention for men with prostate cancer commencing radiotherapy at a specialist cancer hospital in Melbourne, Australia. Measures assessed global distress (DT), anxious and depressive symptomatology (HADS), prostate-cancer specific quality of life (EPIC-26), unmet supportive care needs (SCNS-SF34R) and cancer treatment-related concerns (CATS). Following descriptive and correlational analysis, hierarchical multiple regression was employed to examine the contribution of variable sets to explaining variance in DT scores.

RESULTS

Less than 20% of men reported DT scores of 4 or higher, indicating overall low distress. The DT accurately identified almost all men reporting HADS score indicative of anxious or depressive symptomatology, suggesting it accurately identifies psychological morbidity. Importantly, the DT identified a further group of distressed men, not identified by HADS, whose distress related to unmet needs and prostate cancer-specific issues, indicating the DT is superior in identifying other forms of distress. While the hierarchical multiple regression confirmed anxious and depressive symptomatology as the best predictor of distress score, many other scales are also good predictors of DT scores, supporting the argument that distress is multi-determined.

SIGNIFICANCE OF RESULTS

Nurses can be confident that the DT accurately identifies patients with psychological morbidity and importantly identifies other patients with distress who may require intervention. A distress score of 4 or higher identified participants with higher physical symptomatology, higher unmet needs, more concerns about treatment and poorer quality of life. The low prevalence of distress reaching cut off scores suggests nurses would not be overwhelmed by the outcomes of screening and could use the score to prioritise the patients who need greater attention at entry to radiotherapy services.

Prevalence and Predictors of the Short-Term Trajectory of Anxiety and Depression in the First Year After a Cancer Diagnosis: A Population-Based Longitudinal Study

Purpose

Few studies have examined psychological adjustment for cancer survivors in late treatment and early survivorship stages. Our study investigated the prevalence and short-term trajectories of anxiety, depression, and comorbid anxiety-depression among adult cancer survivors, and identified the individual, disease, health behavior, psychological, and social predictors of chronic and late psychological morbidity.

Methods

A heterogeneous sample of adult cancer survivors was recruited from two state-based cancer registries. A total of 1,154 survivors completed self-report questionnaires at 6 (Time 1) and 12 months (Time 2) postdiagnosis. Anxiety and depression were assessed by the Hospital Anxiety and Depression Scale with cases identified by a subscale cutoff score ≥ 8. Logistic regression analyses identified Time 1 characteristics associated with anxiety and/or depression at Time 2.

Results

The point prevalence of anxiety (Time 1, 22%; Time 2, 21%), depression (13% at both timepoints) and comorbid anxiety-depression (9% at both timepoints) was similar at 6 and 12 months postdiagnosis. The most prevalent Time 1 to Time 2 trajectory was noncase for anxiety (70%), depression (82%), and comorbid anxiety-depression (87%). While psychological morbidity at Time 1 was the strongest predictor of psychological morbidity at Time 2, being diagnosed with lung cancer and health risk behaviors (smoking, insufficient physical activity) were also strong predictors.

Conclusion

Targeted psychological screening of vulnerable survivors and early intervention may prevent the onset and/or reduce the severity of psychological morbidity in early survivorship. Trials of risk reduction interventions targeting psychological functioning and health risk behaviors seem warranted.

Depression and anxiety in long-term cancer survivors compared with spouses and healthy controls: a systematic review and meta-analysis

BACKGROUND

Cancer survival has improved in the past 20 years, affecting the long-term risk of mood disorders. We assessed whether depression and anxiety are more common in long-term survivors of cancer compared with their spouses and with healthy controls.

METHODS

We systematically searched Medline, PsycINFO, Embase, Science Direct, Ingenta Select, Ovid, and Wiley Interscience for reports about the prevalence of mood disorders in patients diagnosed with cancer at least 2 years previously. We also searched the records of the International Psycho-oncology Society and for reports that cited relevant references. Three investigators independently extracted primary data. We did a random-effects meta-analysis of the prevalences of depression and anxiety in cancer patients compared with spouses and healthy controls.

FINDINGS

Our search returned 144 results, 43 were included in the main analysis: for comparisons with healthy controls, 16 assessed depression and ten assessed anxiety; of the comparisons with spouses, 12 assessed depression and five assessed anxiety. The prevalence of depression was 11·6% (95% CI 7·7-16·2) in the pooled sample of 51 381 cancer survivors and 10·2% (8·0-12·6) in 217 630 healthy controls (pooled relative risk [RR] 1·11, 95% CI 0·96-1·27; p=0·17). The prevalence of anxiety was 17·9% (95% CI 12·8-23·6) in 48 964 cancer survivors and 13·9% (9·8-18·5) in 226 467 healthy controls (RR 1·27, 95% CI 1·08-1·50; p=0·0039). Neither the prevalence of depression (26·7% vs 26·3%; RR 1·01, 95% CI 0·86-1·20; p=0·88) nor the prevalence of anxiety (28·0% vs 40·1%; RR 0·71, 95% CI 0·44-1·14; p=0·16) differed significantly between cancer patients and their spouses.

INTERPRETATION

Our findings suggest that anxiety, rather than depression, is most likely to be a problem in long-term cancer survivors and spouses compared with healthy controls. Efforts should be made to improve recognition and treatment of anxiety in long-term cancer survivors and their spouses.

FUNDING

None.

Psychological distress in cancer patients undergoing radiation therapy treatment

PURPOSE

The objective of this study was to examine the likely presence of, and factors associated with, anxiety, depression and overall psychological distress in cancer outpatients undergoing radiation therapy treatment in Sydney, Australia.

METHODS

A touchscreen computer survey was conducted in four radiation therapy treatment centre waiting rooms. Patients waiting to receive treatment completed the survey which included questions about demographic and disease characteristics, survey acceptability and the Hospital Anxiety and Depression Scale (HADS).

RESULTS

A total of 454 patients (70 %) completed the touchscreen computer survey. The likely presence of anxiety (HADS-A ≥11), depression (HADS-D ≥11) and overall psychological distress (HADS-T ≥15) was 15, 5.7 and 22 %, respectively. Cancer type was found to be associated with each HADS screening category. The majority of patients reported high survey acceptability and willingness to complete similar touchscreen computer surveys in the treatment centre waiting room on additional occasions.

CONCLUSIONS

As radiotherapy patients frequently attend the radiation oncology department, routine screening and intervention for elevated levels of psychological distress in this setting appears to be feasible. High survey completion rates and high patient-rated acceptability support this approach to screening. The likely presence of psychological distress is reported for this sample; however, the selection of HADS threshold scores is likely to have influenced the reported rates. Further research is needed to identify how cancer type impacts on likely caseness across the different HADS classifications examined.

Walking a mile in their shoes: anxiety and depression among partners and caregivers of cancer survivors at 6 and 12 months post-diagnosis

PURPOSE

This study aims to examine the prevalence of psychosocial variables associated with anxiety and depression among partners and caregivers of cancer survivors, compare prevalence with community norms and report differences across cancer diagnosis.

METHODS

A prospective survey of partners and caregivers was undertaken to assess anxiety and depression and potential psychosocial variables associated with these outcomes at 6 and 12 months post-survivor diagnosis (N = 436).

RESULTS

Although the proportion of anxious participants decreased over time (p = 0.01), the percentage of those depressed remained stable (p = 0.68). Most participants who were depressed were also anxious. To a certain extent, the prevalence of anxiety and depression exceeded community norms and varied across cancer types. Partners and caregivers particularly vulnerable included those of lung, haematological or head and neck survivors. High use of avoidant coping and interference in regular activities were associated with both anxiety and depression across time points. Of the different types of support measured, only lower emotional/informational support was associated with anxiety and depression at 6 months, whereas lower positive social interaction was associated with depression at 12 months. Additional variables associated with anxiety and depression at 12 months included higher unmet needs and involvement in personal and medical tasks, respectively.

CONCLUSIONS

Even at 12 months post-survivor diagnosis, almost a third of participants reported anxiety, a result partially predicted by high use of avoidant coping and interference in regular activities. Understanding variables associated with partners' and caregivers' anxiety and depression can lead to optimal referral to supportive care services and inform the tailoring of interventions to address those variables contributing to anxiety and depression at particular time points.

How does the Distress Thermometer compare to the Hospital Anxiety and Depression Scale for detecting possible cases of psychological morbidity among cancer survivors?

PURPOSE

Use of the Distress Thermometer (DT) as a screening tool is increasing across the cancer trajectory. This study examined the accuracy and optimal cut-off score of the DT compared to the Hospital Anxiety and Depression Scale (HADS) for detecting possible cases of psychological morbidity among adults in early survivorship.

METHODS

This study is a cross-sectional survey of 1,323 adult cancer survivors recruited from two state-based cancer registries in Australia. Participants completed the DT and the HADS at 6 months post-diagnosis.

RESULTS

Compared to the HADS subscale threshold ≥8, the DT performed well in discriminating between cases and non-cases of anxiety, depression and comorbid anxiety-depression with an area under the curve of 0.85, 0.84 and 0.87, respectively. A DT cut-off score of ≥2 was best for clinical use (sensitivity, 87-95 %; specificity, 60-68 %), ≥4 was best for research use (sensitivity, 67-82 %; specificity, 81-88 %) and ≥3 was the best balance between sensitivity (77-88 %) and specificity (72-79 %) for detecting cases of anxiety, depression and comorbid anxiety-depression. The DT demonstrated a high level of precision in identifying non-cases of psychological morbidity at all possible thresholds (negative predictive value, 77-99 %).

CONCLUSIONS

The recommended DT cut-off score of ≥4 was not supported for universal use among recent cancer survivors. The optimal DT threshold depends upon whether the tool is being used in the clinical or research setting. The DT may best serve to initially identify non-cases as part of a two-stage screening process. The performance of the DT against 'gold standard' clinical interview should be evaluated with cancer survivors.

Cancer patients' willingness to answer survey questions about life expectancy

Purpose

This study aimed to determine the proportion and characteristics of radiation oncology outpatients who were willing to answer questions about their life expectancy.

Methods

A cross-sectional patient self-report survey was conducted using touch screen computers in Australian radiation oncology treatment centers. The primary outcome was the respondent’s willingness to complete a survey subsection about life expectancy. Demographic and disease characteristics were also collected, and level of anxiety and depression was assessed using the Hospital Anxiety and Depression Scale.

Results

Of the 469 oncology outpatients who completed the survey, 327 (70 %; 95 % CI, 65 %, 74 %) indicated that they were willing to answer questions about life expectancy. Being female (p < 0.001), older (p < 0.05), born in Asia (p < 0.05), and being diagnosed with cancer types other than breast and prostate cancer (p < 0.01) were associated with lower odds of answering life expectancy questions.

Conclusions

The opportunity to opt-out of survey questions about sensitive issues such as life expectancy is a feasible method for accessing important information about patient preferences while minimizing burden. Further research may be needed to improve acceptability of life expectancy research to some patient groups.

Psychosocial care in cancer

Psychosocial care for cancer patients historically has been overlooked as an aspect of quality clinical care. However, several organizations have recently made strong recommendations for inclusion of psychosocial care across the continuum of treatment, from diagnosis, through treatment, into survivorship, and in the palliative stages of care. The evidence base for screening, diagnosis, and effective treatment of psychosocial issues in the context of cancer care is growing. Recent highly relevant research covering major topics in psycho-oncology, including distress, delivery of care, psychoneuroimmunology, and cognitive deficits related to cancer, is reviewed in this article.