Depression and carcinoma of the pancreas

Exploring the Link Between Pancreatic Neuroendocrine Tumors and Depression: A Case Study

This case probes the potential temporal relationship between pancreatic neuroendocrine tumor (PNET) and depression. This patient has chronic symptoms of depression with no formal diagnosis until within a year of doctors suspecting her diagnosis of pancreatic cancer. An excisional biopsy confirmed a grade 1 neuroendocrine tumor (NET) in the pancreas, and postoperative psychiatric consultation confirmed continued elevated depression. This report presents an illustrative example of the ongoing research questions surrounding the relationship between the timing of a depression diagnosis and a PNET diagnosis. The depression-before-diagnosis relationship in pancreatic cancer patients is an observation that warrants further studies as depression could be a valuable early warning sign of pancreatic cancer.

Pancreatic cancer and depression

Pancreatic cancer is a highly devastating disease with high mortality rates. Even patients who undergo potential curative surgery have a high risk for recurrence. The incidence of depression and anxiety are higher in patients with cancer than the general population. However, patients with pancreatic cancer are at most of risk of both depression and anxiety and there seems to be a biological link. In some patients, depression seems to be a precursor to pancreatic cancer. In this article we discuss the biological link between depression anxiety and hepatobiliary malignancies and discuss treatment strategies.

Symptom Management in Pancreatic Cancer

OPINION STATEMENT

Despite extensive research that has identified new risk factors, genetic mutations, and therapeutic options, pancreatic ductal adenocarcinoma continues to be a leading cause of cancer related death. Patients with pancreatic cancer, along with their clinicians, must balance realistic hope alongside a life-threatening diagnosis. As the search for treatments to reduce the morbidity and mortality continues, symptom management and quality of life remain the focus of our efforts. In addition to side effects of cancer-directed therapy, patients are at risk for malnutrition, pain, and fatigue. These factors are often overlooked in practice, so a multidisciplinary team is critical in optimizing the care of patients.

Depression and quality of life in patients with breast cancer undergoing chemotherapy and monoclonal antibodies

Background

Depression is one of the major psychiatric morbidities in cancer patients. The purpose of our study was to evaluate the impact of depressive symptoms in the quality of life (QoL) of patients with breast cancer undergoing chemotherapy and monoclonal antibodies treatments.

Methods

Observational, cross-sectional study conducted between April and November 2016. To evaluate the QoL, the EORTC QLQ-C30 and QLQ-BR23 questionnaire were used. The patients were screened for depressive symptoms using the Hospital Anxiety and Depression Scale (HADS-D) and those with a positive HADS-D positive questionnaire were referenced to the Psychiatry and Mental Health Department for further assessment and follow-up.

Results

We included 45 female patients. Sixteen (35.6%) patients had a positive HADS-D questionnaire and depressive symptoms confirmed by a psychiatric physician. Of those patients, 7 (15.6%) had a major depressive episode confirmed by psychiatric interview. There was a significant association of depressive symptoms with the future perspectives scale (p = 0.022), breast symptoms scale (p = 0.011) and arm symptom scale (p = 0.005). Significant differences were found in the fatigue (p = 0.024), pain (p = 0.037) and dyspnea (p = 0.009) subscales being worse in patients with depressive symptoms. The association between having depressive symptoms or not was shown to be significant or marginally significant for the variables stage of the tumour (p = 0.057), presence of distant metastasis (p = 0.072) and previous diagnosis of depression (p = 0.011). The patients treated with regimens containing monoclonal antibodies presented better outcomes in various subscales of the EORTC QLQ-C30 and QLQ-B23 questionnaires than those patients treated with chemotherapy regimens without monoclonal antibodies.

Conclusions

Despite the small sample of our study, this study provided evidence that depressive symptoms in patients with breast cancer undergoing chemotherapy and monoclonal antibodies treatments detrimentally reduced various aspects of QoL.

Bridging clinic: The initial medical management of patients with newly diagnosed pancreatic cancer

Pancreatic cancer is the 11th most common cancer in the UK and has the worst prognosis of any tumour with minimal improvements in survival over recent decades. As most patients are either ineligible for surgery or may decline chemotherapy, the emphasis is on control of symptoms and management of complications such as poor nutritional status. The time period between informing the patient of their diagnosis and commencing cancer treatments presents a valuable opportunity to proactively identify and treat symptoms to optimise patients' overall well-being. The 'bridging clinic', delivered by a range of healthcare professionals from gastroenterologists to nurse practitioners, can provide this interface where patients are first informed of their diagnosis and second supportive therapies offered. In this article, we provide a structure for instituting such supportive therapies at the bridging clinic. The components of the clinic are summarised using the mnemonic INDASH (Information/Nutrition/Diabetes and Depression/Analgesia/Stenting/Hereditary) and each is discussed in detail below.

Psychoaffective repercussions of pain in cancer patients

PURPOSE

Pain often induces in cancer patient emotional disorders such as anxiety, depression and alteration of quality of life. The purpose of our work was to assess the impact of the intensity of pain and those characteristics on anxiety, depression state and quality of life of cancer patients.

MATERIAL AND METHODS

This is an analytical cross-sectional study including 106 cancer patients with pain. We evaluated four parameters: pain intensity by visual analogue scale, the presence of anxiety and of depression using the Hospital Anxiety and Depressive Scale, and the alteration of quality of life by 36-item Short-Form Health Survey.

RESULTS

Patients' average age was 55 years old. The sex ratio was 0.79. Pain intensity was low in 16%, moderate in 49.1% and intense in 34.9% of patients. The prevalence of anxiety and depression was 49.1% and 54% of patients, respectively. The independent factors correlated to the occurrence of anxiety were: pain intensity, bone localization, continuous progression, chronicity of pain, advanced stage, hospitalization at day hospital, the partial or no response to analgesic treatment. The independent factors correlated to the onset of depression were: intensity of pain, advanced stage of the disease, bone localization, step 2 or 3 of analgesic, and partial or no response to analgesic treatment.

CONCLUSION

The prevalence of anxiety and depression in our patients was slightly higher than those reported in the literature. The main factors correlated with the onset of depression and anxiety were: severe pain, bone location, and advanced stage of the disease.

Psychological Outcomes and Quality of Life in Relation to Pancreatectomy: A Systematic Review

This review aimed to inventory and analyze previous studies regarding quality of life (QoL) and psychological outcomes in relation to pancreatectomy. PubMed and PsycInfo databases were reviewed using the Preferred Reporting Items for Systematic review and Meta-Analysis guidelines. Thirteen studies were selected, 9 of which focused on the QoL after surgery. Quality of life significantly improved 3 to 6 months after surgery. Regarding the postoperative experience, one study reported high fear of recurrence of cancer, whereas another emphasized various expressions of patient needs. One study explained how strategy and ability to adapt are not related to the type, the cause, nor the physical condition, but are mainly influenced by the age and the subjective experience of the patients. A last study showed that depression did not affect survival rate after surgery. Our systematic review found only few studies regarding the psychological condition after pancreatectomy and highlights the need to describe and characterize the patients' psychological characteristics in this setting.

Pancreatic Cancer-Associated Depression: A Case Report and Review of the Literature

The prevalence of major depressive disorder (MDD) in pancreatic cancer (PC) has been reported up to 7 times higher than the general population. Despite repeated studies that show worse quality of life, survival outcomes, and treatment compliance in cancer patients with depression, baseline antidepressant use ranges from 15% to 27%. A meta-analysis of 6 prospective trials specific to PC estimates that 43% of patients with PC experience depression after diagnosis. This is especially alarming in patients with PC, who may experience a prodrome of symptoms including depression and loss of drive. In fact, this prodrome of symptoms may very well be due to an overexpression of indoleamine 2,3-dioxgenase, an enzyme in the kynurenine pathway that leads to serotonin depletion and the buildup of cytotoxic metabolites in the brain. In this literature review, we outline all previous studies pertinent to PC and depression, as well as the molecular underpinnings that may contribute to states of depression, and report on previous randomized control trials in cancer populations that investigate the use of antidepressants to treat depressive symptoms and improve quality of life both prophylactically and after the onset of major depressive disorder. In addition, we detail a case report outlining the precipitous decline in health in 1 patient with PC and depression.

Clinical Factors as a Component of the Personalized Treatment Approach to Advanced Pancreatic Cancer: a Systematic Literature Review

INTRODUCTION

Pancreatic cancer is often diagnosed at late stages, where disease is either locally advanced unresectable or metastatic. Despite advances, long-term survival is relatively non-existent.

DISCUSSION

This review article discusses clinical factors commonly encountered in practice that should be incorporated into the decision-making process to optimize patient outcomes, including performance status, nutrition and cachexia, pain, psychological distress, medical comorbidities, advanced age, and treatment selection.

CONCLUSION

Identification and optimization of these clinical factors could make a meaningful impact on the patient's quality of life.

Understanding the Pathophysiology of Psychological Distress and Pancreatic Cancer: A Systematic Review

BACKGROUND

Psychological distress is highly prevalent in patients with pancreatic cancer (PC), yet little is known about the pathophysiology underlying the relationship between these 2 diseases. Our aim was to systematically review the evidence examining the pathophysiological mechanisms of the association between PC and psychological distress.

METHODS

A systematic review of the literature was conducted using MEDLINE, Embase, PsychINFO, and CINAHL databases and reported according to the preferred reporting items for systematic reviews and meta-analyses guidelines. Studies examining the pathophysiological mechanisms between PC and psychological distress were included for analysis.

RESULTS

Eight studies were identified that fulfilled inclusion criteria. Four mechanisms were identified accounting for the possible relationship between psychological distress and PC, including (1) stress-induced β-adrenergic signaling, (2) interleukin-6-mediated effects, (3) kynurenine pathway upregulation, and (4) altered cerebral glucose metabolism.

CONCLUSIONS

The relationship between psychological distress and PC is complex, and our understanding of these mechanisms may have implications for holistic clinical management and oncological outcome. The evidence exploring the pathophysiology of this interaction is sparse, but most well established with regard to the stress-induced β-adrenergic signaling mechanism. Further studies in larger cohorts are required to elucidate the relationship between PC and psychological distress to be able to identify therapeutic targets for both conditions.

Implication of exercise interventions on sleep disturbance in patients with pancreatic cancer: a study protocol for a randomised controlled trial

Introduction and purpose

Patients with pancreatic cancer (PC) have long been known to have high rates of depression. Depression in patients with PC can be linked to sleep disturbance. The American College of Sports Medicine notes that physical exercise is safe for most patients with cancer and physical inactivity should be avoided. However, clinical impacts of exercise interventions (EIs) on patients with PC have been poorly investigated. We aim to prospectively examine the effect of EIs on sleep disturbance in patients with PC using actigraphy, which is an objective measurement of motor activity and sleep.

Methods and analysis

This trial is a non-double blind randomised controlled trial. Standard therapy for each patient with PC will be allowed. When registering study subjects, a thorough assessment of the nutritional status and the daily physical activities performed will be undertaken individually for each participant. Study subjects will be randomly assigned into two groups: (1) the EI and standard therapy group or (2) the standard therapy group. In the EI and standard therapy group, physical activities equal to or higher than walking for 60 min/day will be strongly recommended. The primary outcome measure is the sleep-related variable using actigraphy (activity index) at 12 weeks.

Ethics and dissemination

The trial received approval from the Institutional Review Board at Hyogo College of Medicine (approval no. 2769). Final data will be publicly announced. A report releasing the study findings will be submitted for publication to an appropriate peer-reviewed journal.

Trial registration number

UMIN000029272; Pre-results.

Palliative Care in Pancreatic Cancer

BACKGROUND

Pancreatic cancer is a formidable health problem, representing the 10th most common malignancy in the United States and the 4th most common cause of all cancer deaths. The overall 5-year survival rate is 4%, making this disease a model tumor in which to address the specialized care issues of palliative medicine.

METHODS

General considerations in both medical decision-making and symptom management are reviewed. Treatment of patients with locally unresectable, recurrent, or metastatic disease is individualized, based on considerations that include patient age, patient wishes, family influence, insurance constraints, and geographic practice variations.

RESULTS

Success in managing progressive symptoms is needed to palliate patients with advanced pancreatic cancer. Common problems include biliary obstruction, depression, pain, intestinal obstruction, and fatigue.

CONCLUSIONS

Relief of pain and suffering associated with critical illness is required in managing patients with cancer. Pancreatic cancer is a model illness that mandates this need.

Palliative Care in Pancreatic Cancer

Background

Pancreatic cancer is a formidable health problem, representing the 10th most common malignancy in the United States and the 4th most common cause of all cancer deaths. The overall 5-year survival rate is 4%, making this disease a model tumor in which to address the specialized care issues of palliative medicine.

Methods

General considerations in both medical decision-making and symptom management are reviewed. Treatment of patients with locally unresectable, recurrent, or metastatic disease is individualized, based on considerations that include patient age, patient wishes, family influence, insurance constraints, and geographic practice variations.

Results

Success in managing progressive symptoms is needed to palliate patients with advanced pancreatic cancer. Common problems include biliary obstruction, depression, pain, intestinal obstruction, and fatigue.

Conclusions

Relief of pain and suffering associated with critical illness is required in managing patients with cancer. Pancreatic cancer is a model illness that mandates this need.

Pancreatic Cancer and Depression: A Narrative Review

Depression is a common concomitant of pancreatic cancer, and, because it often occurs before the cancer is diagnosed, its occurrence is likely to be intrinsic to the condition rather than a reaction to such a diagnosis. Because pancreatic cancer is associated with a very high mortality, its early detection is a key task. We therefore review relevant literature to determine whether the depression is prototypically distinctive and whether its identification might lead to earlier diagnosis of pancreatic cancer. We report on the epidemiology and prognosis of pancreatic cancer and on the prevalence, description, and possible mechanisms involved for the occurrence of any associated depressive state, before reviewing the comparative utility of depression in relation to other risk factors in aiding diagnosis. Published studies fail to identify any distinct depressive prototypic phenotype to depression associated with pancreatic cancer. Although it is a relatively common concomitant of pancreatic cancer, the utility of depression as a marker of the condition is not suggested from a key study evaluating its contribution in relation to other symptoms and risk factors.

Prevalence and predictive factors of depression and anxiety in patients with pancreatic cancer: a longitudinal study

OBJECTIVE

It is known that depression and anxiety occur more frequently in pancreatic cancer patients than in those with other malignancies. However, few studies have assessed depression and anxiety using reliable psychiatric diagnostic tools. The purpose of this study was to determine the prevalence of depression and anxiety among pancreatic cancer patients before and 1 month after the start of anticancer treatment using reliable psychiatric diagnostic tools, and to identify factors that predict their occurrence.

METHODS

Pancreatic cancer patients were consecutively recruited. Structured clinical interviews were used to determine the presence of affective disorders, anxiety disorders and adjustment disorders. Baseline interviews were performed prior to initiation of anticancer treatment, while follow-up interviews were performed 1 month after treatment was started. Medical, demographic and psychosocial backgrounds were also assessed as predictive factors.

RESULTS

One hundred and ten patients participated in the baseline interview and 91 in the follow-up interview. Depression and anxiety were observed in 15 patients (13.6%) at the baseline, and 15 patients (16.5%) at the follow-up. Lack of confidants was associated with depression and anxiety at the baseline. At the baseline, sadness, lower Karnofsky Performance Status and prior experience with the death of a family member due to cancer predicted newly diagnosed depression and anxiety at the follow-up.

CONCLUSION

A considerable percentage of pancreatic cancer patients experienced depression and anxiety. Multidimensional psychosocial predictive factors were found and optimal psychological care should incorporate early detection of sadness.

Pre-treatment effects of peripheral tumors on brain and behavior: neuroinflammatory mechanisms in humans and rodents

Cancer patients suffer high levels of affective and cognitive disturbances, which have been attributed to diagnosis-related distress, impairment of quality of life, and side effects of primary treatment. An inflammatory microenvironment is also a feature of the vast majority of solid tumors. However, the ability of tumor-associated biological processes to affect the central nervous system (CNS) has only recently been explored in the context of symptoms of depression and cognitive disturbances. In this review, we summarize the burgeoning evidence from rodent cancer models that solid tumors alter neurobiological pathways and subsequent behavioral processes with relevance to affective and cognitive disturbances reported in human cancer populations. We consider, in parallel, the evidence from human clinical cancer research demonstrating that affective and cognitive disturbances are common in some malignancies prior to diagnosis and treatment. We further consider the underlying neurobiological pathways, including altered neuroinflammation, tryptophan metabolism, prostaglandin synthesis and associated neuroanatomical changes, that are most strongly implicated in the rodent literature and supported by analogous evidence from human cancer populations. We focus on the implications of these findings for behavioral researchers and clinicians, with particular emphasis on methodological issues and areas of future research.

Cancer Mortality in People Treated with Antidepressants before Cancer Diagnosis: A Population Based Cohort Study

Background

Depression is common after a cancer diagnosis and is associated with an increased mortality, but it is unclear whether depression occurring before the cancer diagnosis affects cancer mortality. We aimed to study cancer mortality of people treated with antidepressants before cancer diagnosis.

Methods and Findings

We conducted a population based cohort study of all adults diagnosed with cancer between January 2003 and December 2010 in Denmark (N = 201,662). We obtained information on cancer from the Danish Cancer Registry, on the day of death from the Danish Civil Registry, and on redeemed antidepressants from the Danish National Prescription Registry. Current users of antidepressants were defined as those who redeemed the latest prescription of antidepressant 0–4 months before cancer diagnosis (irrespective of earlier prescriptions), and former users as those who redeemed the latest prescription five or more months before cancer diagnosis. We estimated an all-cause one-year mortality rate ratio (MRR) and a conditional five-year MRR for patients who survived the first year after cancer diagnosis and confidence interval (CI) using a Cox proportional hazards regression model. Overall, 33,111 (16.4%) patients redeemed at least one antidepressant prescription in the three years before cancer diagnosis of whom 21,851 (10.8%) were current users at the time of cancer diagnosis. Current antidepressant users had a 32% higher one-year mortality (MRR = 1.32, 95% CI: 1.29–1.35) and a 22% higher conditional five-year mortality (MRR = 1.22, 95% CI: 1.17–1.26) if patients survived the first year after the cancer diagnosis than patients not redeeming antidepressants. The one-year mortality was particularly high for patients who initiated antidepressant treatment within four months before cancer diagnosis (MRR = 1.54, 95% CI: 1.47–1.61). Former users had no increased cancer mortality.

Conclusions

Initiation of antidepressive treatment prior to cancer diagnosis is common and is associated with an increased mortality.

Mood and anxiety disorders as early manifestations of medical illness: a systematic review

BACKGROUND

Affective disturbances involving alterations of mood, anxiety and irritability may be early symptoms of medical illnesses. The aim of this paper was to provide a systematic review of the literature with qualitative data synthesis.

METHODS

MEDLINE, PsycINFO, EMBASE, Cochrane, and ISI Web of Science were systematically searched from inception to February 2014. Search terms were 'prodrome/early symptom', combined using the Boolean 'AND' operator with 'anxiety/depression/mania/hypomania/irritability/irritable mood/hostility', combined with the Boolean 'AND' operator with 'medical illness/medical disorder'. PRISMA guidelines were followed.

RESULTS

A total of 21 studies met the inclusion criteria and were analyzed. Depression was found to be the most common affective prodrome of medical disorders and was consistently reported in Cushing's syndrome, hypothyroidism, hyperparathyroidism, pancreatic and lung cancer, myocardial infarction, Wilson's disease, and AIDS. Mania, anxiety and irritability were less frequent.

CONCLUSIONS

Physicians may not pursue medical workup of cases that appear to be psychiatric in nature. They should be alerted that disturbances in mood, anxiety and irritability may antedate the appearance of a medical disorder.

Prodromal depression in pancreatic cancer: Retrospective evaluation on ten patients

Objective:

Since the description by Yaskin in 1931, it has been observed that pancreatic cancer and depression are two clinical entities that share a high affinity. This observation relies on the higher incidence of depressive syndromes associated with pancreatic cancer than in any other type of digestive tumor, and on the possible occurrence of depressive symptoms several months before the diagnosis of cancer. We present here a series of cases whose screening returned positive for depression-related diagnoses in the months prior to revelation of the cancer.

Method:

We employed a structured psychiatric interview based on DSM–IV criteria (SCID–I). The diagnoses considered were major depressive episode, minor depressive episode, and subsyndromal depression. All subjects were free of psychiatric history.

Results:

Some 15 patients were initially included: 10 presented compatible criteria for a past depressive episode, 2 presented a major depressive episode, 4 met the diagnosis of minor depression, and 4 evidenced subsyndromal depression over the one-year period prior to cancer diagnosis.

Significance of results:

This series of cases is consistent with previous work on the subject that suggested an increased vulnerability to depressive events in the premorbid phase of pancreatic cancer. If the possibility of depressive syndromes constituting the early stages of neoplastic disease is a common idea, it is still impossible to determine the natural history of these two disorders and therefore their causal linkage.

Depression, cytokines, and pancreatic cancer

BACKGROUND

The aim of this study was to examine the relationships between cytokines, depression, and pancreatic cancer.

METHOD

A total of 75 individuals were recruited from two New York City hospitals (a cancer center and a psychiatric hospital) and composed of four subgroups: patients with adenocarcinoma of the pancreas who did (n = 17) and did not (n = 26) have a diagnosis of Major Depressive Episode (MDE), and healthy participants with (n = 7) and without (n = 25) MDE. All individuals completed a battery of self-report measures. Sera was assayed using Meso Scale Discovery techniques to measure the following pro-inflammatory and anti-inflammatory cytokines: IL-1beta, IL-2, IL-3, IL-4, IL-5, IL-6, IL-10, IL-12p70, IFN-gamma, TGF-beta, and TNF-alpha; we also calculated the IL-2/IL-4 ratio.

RESULTS

Pancreatic cancer patients had significantly higher levels of IL-6 and IL-10 and significantly lower TGF-beta levels than healthy participants. When the sample was divided into those with and without MDE, the groups only differed with regard to serum IL-6 levels. No significant cancer and depression interaction effect was observed. Severity of depressive symptoms was also significantly correlated with IL-6, rs = 0.28 and p = 0.02, whereas hopelessness was associated with IFN-alpha, rs  = 0.34 and p = 0.006. Pain, fatigue, and sleep disturbance were associated with several of the cytokines assayed including IL-1beta (pain intensity), IL-4 (pain intensity and overall sleep quality), IL-12p70 (pain intensity), and TGF-beta (fatigue intensity), but anxiety was not associated with any of the cytokines assayed.

CONCLUSIONS

This study demonstrated an association between depression and IL-6, but not with other cytokines. Moreover, IL-6 was not significantly associated with other measures of psychological distress (anxiety and hopelessness) or with symptom distress (pain, fatigue, and sleep quality), although some cytokines assayed were associated with specific symptoms. The implications of these findings for the etiology and treatment of depression in pancreatic cancer patients are discussed.

Screening for depression, sleep-related disturbances, and anxiety in patients with adenocarcinoma of the pancreas: a preliminary study

Purpose. Screening for depression, sleep-related disturbances, and anxiety in patients with diagnosed adenocarcinoma of the pancreas. Materials and Methods. Patients were evaluated at initial consultation and subsequent visits at the multidisciplinary pancreatic cancer clinic at our University Cancer Center. Cross-sectional and longitudinal psychosocial distress was assessed utilizing Personal Health Questionnaire 9 (PHQ9) to screen for depression and monitor symptoms, the Penn State Worry Questionnaire (PSWQ) for generalized anxiety, and the University of Michigan Sleep Questionnaire to monitor sleep symptoms. Results. Twenty-two patients diagnosed with pancreatic cancer participated during the 6-month pilot study with longitudinal followup for thirteen patients. In this study, mild-to-moderate depressive symptoms, anxiety, and potential sleep problems were common. The main finding of the study was 23% of the patients who were part of this pilot project screened positive for moderately severe major depressive symptoms, likely anxiety disorder or a potential sleep disorder during the study. One patient screened positive for moderately severe depressive symptoms in longitudinal followup. Conclusions. Depression, anxiety, and sleep problems are evident in patients with pancreatic cancer. Prospective, longitudinal studies, with larger groups of patients, are needed to determine if these comorbid symptoms impact outcome and clinical course.

High level interleukin-6 in the medium of human pancreatic cancer cell culture suppresses production of neurotransmitters by PC12 cell line

It has been suggested that pancreatic cancer is associated with a greater prevalence of depression than many other cancers, but the mechanism accounting for this potential association has not yet been illustrated. In the present study, conditioned media (CM) from three pancreatic cancer cell lines and primary pancreatic cancer cells from two patients were added to culture system of differentiated pheochromocytoma cell line PC12. The release of dopamine (DA) and norepinephrine (NE) by PC12 was significantly inhibited after CM treatment (P < 0.05), similar to what happened after recombinant interleukin 6(IL-6) treatment. Furthermore, pretreatment with anti-IL-6 antibody significantly blocked the inhibitory effects of pancreatic cancer CM on DA and NE production (P < 0.05). We also demonstrated that tyrosine hydroxylase (TH), the rate-limiting enzyme for synthesis of catecholamine, was reduced after exposure to IL-6, which was accompanied by JAK-STAT3 pathway activation. Our results demonstrated that IL-6 in CM from pancreatic cancer down-regulated the production of DA and NE by PC12 cell. The possible underlying mechanisms might be decreasing TH production via activation of JAK-STAT3 signal transduction pathway. The present study might help to better understand the close relationship between pancreatic cancer and depression.

Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: a meta-analysis of 94 interview-based studies

BACKGROUND

Substantial uncertainty exists about prevalence of mood disorders in patients with cancer, including those in oncological, haematological, and palliative-care settings. We aimed to quantitatively summarise the prevalence of depression, anxiety, and adjustments disorders in these settings.

METHODS

We searched Medline, PsycINFO, Embase, and Web of Knowledge for studies that examined well-defined depression, anxiety, and adjustment disorder in adults with cancer in oncological, haematological, and palliative-care settings. We restricted studies to those using psychiatric interviews. Studies were reviewed in accordance with PRISMA guidelines and a proportion meta-analysis was done.

FINDINGS

We identified 24 studies with 4007 individuals across seven countries in palliative-care settings. Meta-analytical pooled prevalence of depression defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) criteria was 16·5% (95% CI 13·1-20·3), 14·3% (11·1-17·9) for DSM-defined major depression, and 9·6% (3·6-18·1) for DSM-defined minor depression. Prevalence of adjustment disorder alone was 15·4% (10·1-21·6) and of anxiety disorders 9·8% (6·8-13·2). Prevalence of all types of depression combined was of 24·6% (17·5-32·4), depression or adjustment disorder 24·7% (20·8-28·8), and all types of mood disorder 29·0% (10·1-52·9). We identified 70 studies with 10,071 individuals across 14 countries in oncological and haematological settings. Prevalence of depression by DSM or ICD criteria was 16·3% (13·4-19·5); for DSM-defined major depression it was 14·9% (12·2-17·7) and for DSM-defined minor depression 19·2% (9·1-31·9). Prevalence of adjustment disorder was 19·4% (14·5-24·8), anxiety 10·3% (5·1-17·0), and dysthymia 2·7% (1·7-4·0). Combination diagnoses were common; all types of depression occurred in 20·7% (12·9-29·8) of patients, depression or adjustment disorder in 31·6% (25·0-38·7), and any mood disorder in 38·2% (28·4-48·6). There were few consistent correlates of depression: there was no effect of age, sex, or clinical setting and inadequate data to examine cancer type and illness duration.

INTERPRETATION

Interview-defined depression and anxiety is less common in patients with cancer than previously thought, although some combination of mood disorders occurs in 30-40% of patients in hospital settings without a significant difference between palliative-care and non-palliative-care settings. Clinicians should remain vigilant for mood complications, not just depression.

FUNDING

None.

Pancreatic cancer and depression: myth and truth

BACKGROUND

Various studies reported remarkable high incidence rates of depression in cancer patients compared with the general population. Pancreatic cancer is still one of the malignancies with the worst prognosis and therefore it seems quite logical that it is one of the malignancies with the highest incidence rates of major depression.However, what about the scientific background of this relationship? Is depression in patients suffering from pancreatic cancer just due to the confrontation with a life threatening disease and its somatic symptoms or is depression in this particular group of patients a feature of pancreatic cancer per se?

DISCUSSION

Several studies provide evidence of depression to precede the diagnosis of pancreatic cancer and some studies even blame it for its detrimental influence on survival. The immense impact of emotional distress on quality of life of cancer patients enhances the need for its early diagnosis and adequate treatment. Knowledge about underlying pathophysiological mechanisms is required to provide the optimal therapy.

SUMMARY

A review of the literature on this issue should reveal which are the facts and what is myth.

Symptom indicator of severity of depression in cancer patients: a comparison of the DSM-IV criteria with alternative diagnostic criteria

OBJECTIVE

The objective of this study was to explore the performances of several diagnostic criteria items for judging the severity of major depression among cancer patients.

METHOD

Using modern item response theory, we examined the performances of the diagnostic criteria outlined by the DSM-IV and two sets of conceptual diagnostic criteria (the Endicott and the Cavanaugh criteria) in a series of 728 cancer patients who had been diagnosed with major depression using an inclusive approach.

RESULTS

While all the DSM-IV diagnostic criteria, including feelings of worthlessness and suicidal ideation, had a low ability for discriminating the severity of depression, two proposed items (not participating in medical care and social withdrawal) appeared to be good markers of moderately severe major depressive disorder among cancer patients. In addition, the items "fearfulness or depressed appearance in face or body posture" and "brooding, self-pity or pessimism" may be good markers for mild major depressive disorders, while the item "cannot be cheered up, doesn't smile, no response to good news or funny situations" may be a good marker for severe major depressive disorder.

CONCLUSIONS

The findings of the present study suggest that alternative criteria may have utility in diagnosing depression severity in cancer patients.

Requestioning depression in patients with cancer: Contribution of somatic and affective symptoms to Beck's Depression Inventory

BACKGROUND

Depressive symptoms are a major complaint reported by cancer patients. Somatic and affective symptoms can contribute to depression.

PATIENTS AND METHODS

We investigated the prevalence of somatic and affective depressive symptoms with the Beck Depression Inventory (BDI) in 213 hospitalized cancer patients prior to the start of chemotherapy.

RESULTS

Seventeen of 213 patients (8%) were screened positive for major depression; 40 (19%) had mild to moderate depressive symptoms. The corresponding figures for somatic and affective symptoms were 33.3% and 2.8% in the patients with major depression and 23.0% and 8.0% in those with mild to moderate depressive symptoms. Female patients, patients with solid tumour and those with functional limitations had significantly higher mean scores. All differences were related to higher scores in somatic and not in affective items.

CONCLUSIONS

Most alterations in the BDI in cancer patients are related to somatic and not to affective symptoms and may be attributed not to depression but to severity of the underlying disease.

Interleukin-6 levels and HPA axis activation in breast cancer patients with major depressive disorder

An association or a casual link has been proposed between the neuroendocrinological and neuroimmunological changes attributed to either depression or cancer. This study investigated whether breast cancer patients with and without major depression exhibit plasma interleukin-6 abnormalities and dexamethasone suppression test results. Four groups, each consisting of 30 women (1--healthy women, 2--patients with major depression, 3--breast cancer patients without major depression, 4--breast cancer patients with major depression), were compared to each other. Psychiatric evaluations were made by structured clinical interview for DSM-IV. Severity of depression was measured with the Hamilton Depression Rating Scale. Plasma levels of interleukin-6 were measured. A dexamethasone suppression test was applied. Breast cancer patients with major depression had markedly higher plasma levels of interleukin-6 than the other group. All breast cancer patients with depression had abnormal dexamethasone suppression test results. These findings suggest a hypothalamo-pituitary-adrenal axis activation and plasma levels of interleukin-6 and plasma interleukin-6 elevation and plasma levels if interleukin-6 and plasma levels of post cortisol concentrations. Evidence for a casual link or association of major depression with immune and endocrinological activation needs to be investigated further.

Assessment of physical etiologies for mood and anxiety disorders in structured diagnostic interviews

BACKGROUND

Structured diagnostic inter- views include items that evaluate physical etiologies for mood and anxiety disorders. The objective of this article was to assess the impact of such items.

METHOD

A mental health survey in Canada collected data from n = 36,984 household residents. The lifetime prevalence of mood and anxiety disorders was calculated with and without exclusions due to physical causes.

RESULTS

Approximately 10% of subjects with a lifetime depressive disorder reported that all of their episodes were due to one or more physical cause. Many of the reported etiologies were implausible given the DSM-IV requirement that the disturbance be a "direct physiological consequence" of the physical cause. The results were similar for manic episodes and anxiety disorders.

CONCLUSIONS

Structured diagnostic interviews assess physical etiologies in ways that are subject to inconsistency and inaccuracy. Physical etiology items may bias estimates by introducing etiological opinions into the assessment of disorder frequency.

Effect of depression on all-cause mortality in adults with cancer and differential effects by cancer site

OBJECTIVE

The objective of this study was to compare the effect of depression on the risk of death in adults with and without cancer and by specific cancer site among those with cancer.

RESEARCH DESIGN AND METHODS

We analyzed data on 10,025 participants in the population-based National Health and Nutrition Examination Survey (NHANES) 1 Epidemiologic Follow-up Study. Four groups were created based on cancer and depression status in 1982: (a) no cancer, no depression (reference group; no CA, no DEP); (b) depression but no cancer (DEP, no CA); (c) cancer but no depression (CA, no DEP); and (d) cancer and depression (CA+DEP). Six CA sites were defined: lung, breast, gastrointestinal (GI), genitourinary (GU), skin and other. Cox proportional models were used to calculate adjusted hazard for death for each group compared with the reference group and by cancer site.

RESULTS

Over 8 years (78,433 person-years of follow-up), 1925 deaths were documented. The mortality rate per 1000 person-years of follow-up was highest in the CA+DEP group. Compared to the reference group, the hazard ratios (HRs) for all-cause mortality were as follows: CA, no DEP: 1.43 [95% confidence interval (95% CI)=1.23-1.67]; DEP, no CA: 1.44 (95% CI=1.28-1.63); CA+DEP: 1.87 (95% CI=1.49-2.34). HRs for depression by site were as follows: lung: 1.30 (95% CI=0.49-3.99); breast: 1.27 (95% CI=0.58-2.79); GI: 1.47 (95% CI=0.58-3.75); GU: 0.93 (95% CI=0.50-1.74); skin: 1.07 (95% CI=0.67-1.69); other: 2.13 (95% CI=0.55-8.25).

CONCLUSION

The coexistence of cancer and depression is associated with a significantly increased risk of death, and the effect of depression on the risk of death differs by cancer site.

Long-term medical conditions and major depression: strength of association for specific conditions in the general population

BACKGROUND

The prevalence of major depression (MD) in persons with nonpsychiatric medical conditions is an indicator of clinical need in those groups, an indicator of the feasibility of screening and case-finding efforts, and a source of etiologic hypotheses. This analysis explores the prevalence of MD in the general population in relation to various long-term medical conditions.

METHODS

We used a dataset from a large-scale Canadian national health survey, the Canadian Community Health Survey (CCHS). The sample consisted of 115 071 subjects aged 18 years and over, randomly sampled from the Canadian population. The survey interview recorded self-reported diagnoses of various long-term medical conditions and employed a brief predictive interview for MD, the Composite International Diagnostic Interview Short Form for Major Depression. Logistic regression was used to adjust estimates of association for age and sex.

RESULTS

The conditions most strongly associated with MD were chronic fatigue syndrome (adjusted odds ratio [AOR] 7.2) and fibromyalgia (AOR 3.4). The conditions least strongly associated were hypertension (AOR 1.2), diabetes, heart disease, and thyroid disease (AOR 1.4 in each case). We found associations with various gastrointestinal, neurologic, and respiratory conditions.

CONCLUSIONS

A diverse set of long-term medical conditions are associated with MD, although previous studies might have lacked power to detect some of these associations. The strength of association in prevalence data, however, varies across specific conditions.

Relationship between depression and pancreatic cancer in the general population

OBJECTIVE

Prior research suggesting a relationship between pancreatic cancer and depression conducted on clinical populations has been subject to recall bias. We reexamined this association using longitudinal population-based data.

METHODS

This was a retrospective cohort study using longitudinal insurance claims data.

RESULTS

Men with mental disorders were more likely to develop pancreatic cancer than those without psychiatric claims (odds ratio 2.4, confidence interval 1.15-4.78). Depression more commonly preceded pancreatic cancer than it did other gastrointestinal malignancies (odds ratio 4.6, confidence interval 1.07-19.4) or all other cancers (odds ratio 4.1, confidence interval 1.05-16.0).

CONCLUSIONS

Depression and pancreatic cancer are associated in the general population.

Somatic symptoms for diagnosing major depression in cancer patients

Diagnosing depression in cancer patients has been challenging because the diagnostic criteria include somatic symptoms frequently attributed to the cancer itself or its treatment. However, few studies have explored how to appropriately deal with individual somatic symptoms. The authors used data from 220 cancer patients with major depression to examine the intercorrelations among the DSM-IV somatic and nonsomatic symptom criteria as well as whether the presence of an individual somatic symptom could discriminate the severity of major depression. Appetite changes and a diminished ability to think were positively associated with anhedonia. Sleep disturbance and fatigue were not significantly associated with nonsomatic symptoms. These associations were consistent after adjusting for physical functioning and pain. Only patients with appetite changes showed a higher severity of depression. These results suggest that individual somatic symptoms differ in nature and that appetite-related symptoms and a diminished ability to think may be useful for diagnosing depression in cancer patients, whereas sleep disturbances and fatigue may not be as useful.

Biobehavioral outcomes following psychological interventions for cancer patients

Psychological interventions for adult cancer patients have primarily focused on reducing stress and enhancing quality of life. However, there has been expanded focus on biobehavioral outcomes--health behaviors, compliance, biologic responses, and disease outcomes--consistent with the Biobehavioral Model of cancer stress and disease course. The author reviewed this expanded focus in quasiexperimental and experimental studies of psychological interventions, provided methodologic detail, summarized findings, and highlighted novel contributions. A final section discussed methodologic issues, research directions, and challenges for the coming decade.

Biobehavioral outcomes following psychological interventions for cancer patients

Psychological interventions for adult cancer patients have primarily focused on reducing stress and enhancing quality of life. However, there has been expanded focus on biobehavioral outcomes--health behaviors, compliance, biologic responses, and disease outcomes--consistent with the Biobehavioral Model of cancer stress and disease course. The author reviewed this expanded focus in quasiexperimental and experimental studies of psychological interventions, provided methodologic detail, summarized findings, and highlighted novel contributions. A final section discussed methodologic issues, research directions, and challenges for the coming decade.

Assessment of depression among cancer patients: the role of pain, cancer type and treatment

One hundred consecutive cancer patients were assessed using two structured methods for assessing major depressive disorder-Structured Clinical Interview for DSM III-R (SCID) and Endicott criteria-and using a depression rating scale-Hamilton Depression Rating Scale (HAMD). Forty-nine percent of patients were depressed using SCID (DSM III-R criteria), whereas 29% of patients were depressed using Endicott criteria. Twenty-eight percent of patients were depressed using both criteria. Age and sex did not have any influence on the assessment of major depression. Both the structured interview and the rating scale were able to identify suicide ideation. Depressed patients were not shown to have more lifetime depression than non-depressed patients using both structured methods. Patients who were depressed using both assessments of depression had more metastasis and pain than non-depressed patients.

Mood and anxiety syndromes in emergency psychiatry

Mood and anxiety disorders are common in the general population and in the emergency setting. As psychiatric emergency care moves from the realm of triage and referral to a more definitive initiation of treatment, clinicians must approach the assessment and initial management of patients with mood and anxiety disorder in a rational and safe way. In the ED, the next step in assessing patients with mood or anxiety symptoms, after any immediate safety concerns are addressed, is to rule out medical or substance-induced causes. Treatment of these patients is directed at the underlying condition. When a primary psychiatric diagnosis is made, initial management, including definitive pharmacologic or psychotherapeutic intervention, can be started in the ED.

[Therapy of pancreatic adenocarcinoma]

BACKGROUND

Despite significant advances in the areas of epidemiology, risk factors, molecular genetics and diagnosis pancreatic carcinoma is characterized by a dismal prognosis and ranks 5th among malignancy-associated deaths. This article attempts to critically review the current literature and analyze therapeutic recommendations based on published evidence. Therapeutic options are based on the stage of the disease.

SURGICAL TREATMENT

Surgical resection with curative intention is feasible only in a minority of patients presenting with locally confined tumor disease. RADIO- AND CHEMOTHERAPY: Adjuvant combined radiochemotherapy might potentially improve survival and can also be considered in unresectable, locally advanced disease. The role of chemotherapy in advanced disease is exclusively palliative. Up to now, no chemotherapeutic regimen has demonstrated convincing impact on survival. Newer substances, such as gemcitabine, appear to be of some value in respect to quality of life. Best supportive care oriented at clinical symptoms remains a cornerstone in the therapeutic concept of patients with pancreatic carcinoma.

CONCLUSION

Development of innovative therapeutic strategies is therefore mandatory.

Vagaries of clinical presentation of pancreatic and biliary tract cancer

Pancreatic and biliary carcinomas remain a challenge to clinicians and investigators, as diagnosis is rarely achieved while the tumor is still in a curative stage. Clinical symptoms and signs of these neoplasias are non-specific and heterogeneous. We review the clinical presentation of these tumors, with an emphasis on their pathophysiology and relationship with survival. Abdominal pain is the most common presenting complaint in pancreatic and biliary tract carcinomas, regardless of their size; although severe back pain usually indicates neural compromise, and is associated with a short survival. Jaundice may also be an early sign, in fact, pancreatic tumors that present as painless jaundice have been ascribed, a relatively more favorable prognosis. Weight loss is a common finding in most patients, being usually associated with malabsorption. These neoplasias may also present as diabetes, as an acute pancreatitis episode, with venous thrombosis or malignant thrombophlebitis, as a gastrointestinal hemorrhage, with mental disturbances, or skin manifestations.

Anxiety symptoms and panic attacks preceding pancreatic cancer diagnosis

Cancer of the pancreas is a highly malignant disease with a very poor prognosis. Depression and anxiety occur more frequently in cancer of the pancreas than they do in other forms of intra-abdominal malignancies and other cancers in general. Yet, the etiology of psychiatric symptoms in patients with cancer of the pancreas may not be traced solely to poor prognosis, pain, or existential issues related to death and dying. In as many as half of patients that go on to be diagnosed with the disease, symptoms of depression and anxiety precede knowledge of the diagnosis. This observation has raised speculation that mood and anxiety syndromes are related to disruption in one of the physiologic functions of the pancreas. In this paper, we present a patient who had no prior psychiatric history and developed panic attacks just prior to diagnosis of her cancer. To our knowledge, this is the first report in the literature where panic attacks, not simply anxiety, presented prior to a pancreatic cancer diagnosis. Her symptoms resolved following resection of the tumor. Implications of such phenomena for the diagnosis and treatment of anxiety and depression in pancreas cancer are discussed.

Long-term medical conditions and major depression in the Canadian population

OBJECTIVES

To evaluate associations between long-term medical conditions and major depression in the Canadian population, and to examine the impact of these conditions on health care service use and disability.

METHODS

Data from the first wave of the Canadian National Population Health Survey (NPHS) were used. The NPHS used a probability sample of 17,626 Canadians and included questions about long-term medical conditions, health care service use, and disability and a brief predictor of major depression. Contingency tables and graphical techniques were used to evaluate associations between the variables of interest.

RESULTS

Various chronic medical conditions were associated with an elevated prevalence of major depression. There was no evidence that subjects with major depression and comorbid medical conditions were more likely to be admitted to hospital or to be high users of physician services. However, major depression comorbid with chronic medical conditions was associated with a greater than expected extent of activity limitations.

CONCLUSIONS

Chronic illness may increase the risk of depression or the duration of depressive episodes; either effect could lead to an increased prevalence. Alternatively, major depression may predispose individuals to certain chronic illnesses. Comorbid major depression and chronic medical conditions are associated with a considerable burden of disability in the Canadian population but not excessive use of physician services.

Assessment and treatment of depression in the cancer patient

The prevalence, diagnosis, and treatment of depression in the cancer patient are reviewed. Although frequently encountered in the cancer patient population, depression often remains undiagnosed and untreated. This carries grave consequences in that depressed cancer patients experience a poorer quality of life, are less compliant with medical care, have longer hospital stays, and have higher mortality rates. Diagnostic assessment of depression in the cancer patient raises difficulties both upon phenomenological and etiological grounds. In particular, the presence of neurovegetative symptoms which may be secondary to either cancer or depression may cloud the diagnostic picture. Due to the serious consequences of unrecognized depression, a more sensitive inclusive approach to diagnosis is recommended in the clinical setting. Finally, the limited data regarding treatment of depression in patients with cancer is reviewed. This includes a discussion of both psychosocial and pharmacological interventions which are shown to alleviate depression, improve quality of life measures, improve immune function, and lengthen survival time.