Psychiatric illness delays diagnosis of esophageal cancer

Impact of Self-Reported Long-Term Mental Health Morbidity on Help-Seeking and Diagnostic Testing for Bowel-Related Cancer Symptoms: A Vignette Study

OBJECTIVE

To investigate if pre-existing mental health morbidity (MHM) might influence help-seeking and willingness to undergo diagnostic investigations for potential colorectal cancer (CRC) symptoms.

METHODS

An online vignette survey was completed by 1307 adults aged > 50 years recruited through Prolific, a UK panel provider. Participants self-reported any chronic physical or MHM. After having been presented with vignettes describing new onset symptoms (rectal bleeding or change in bowel habit), participants answered questions on symptom attribution and attitudes to investigations. Using multivariable logistic regression we examined the association between MHM and symptom attribution, intended help-seeking, and willingness to undergo investigations, controlling for socio-demographic factors and physical morbidities.

RESULTS

Self-reported MHM (reported by 14% of participants) was not associated with cancer symptom attribution (29% of participants with or without MHM mentioned cancer as a possible reason for rectal bleeding and 14% for change in bowel habit). Individuals with self-reported MHM were less likely to contact a GP if experiencing a change in bowel habit (19% vs. 39%; adjusted (a)OR = 0.34, 95% CI 0.19-0.60) and to mention rectal bleeding to their GP (83% vs. 89%, aOR = 0.49, 95% CI 0.26-0.94). Although most participants would be willing to undergo a colonoscopy for these high-risk symptoms, those with depression/anxiety were less willing (90% vs. 96%; aOR: 0.37, 95% CI 0.16-0.87).

CONCLUSIONS

Individuals with self-reported MHM are less likely to seek help and less willing to undergo investigations for high-risk symptoms. Targeted support, for example, through additional mental health nurses, might facilitate prompt cancer diagnosis for the large group of people with MHM.

Pulmonary Embolism Management Audit and Machine Learning Analysis of Delayed Anticoagulation in a Swiss Teaching Hospital

Background/Objectives: Diagnosing acute pulmonary embolism (PE) is challenging due to its wide range of symptoms and numerous differential diagnoses. Medical professionals must balance performing all essential examinations and avoiding unnecessary testing. This study aimed to retrospectively audit the diagnosis and treatment of acute PE at a Swiss public teaching hospital to determine the adherence to current guidelines and to identify the factors associated with the delayed initiation of anticoagulation in PE patients. Methods: In this retrospective observational cohort study, we included all adult patients hospitalized with PE at the Cantonal Hospital Baselland (KSBL) between November 2018 and October 2020, where the diagnosis was made within the first twelve hours of their arrival to the emergency department (ED). LASSO regression was employed to identify clinical characteristics associated with delayed anticoagulation initiation. Results: A total of 197 patients were included (mean age: 70 years, 54% female). The audit revealed that diagnostic workup was conducted according to guidelines in 57% of cases. Often, D-dimer levels were measured although not strictly necessary (70%). Pretest probability was assessed and documented using the Wells or Geneva score in only 3% of patients, and risk assessment via the Pulmonary Embolism Severity Index (PESI) score was documented in 21% of patients. The median time from ED arrival to CT scan was 120 min (IQR 89.5-210.5), and the median time to anticoagulation initiation was 193 min (IQR 145-277). Factors identified by LASSO associated with delayed anticoagulation included prolonged time from ED arrival to CT scan, the presence of distended jugular veins on examination, ED arrival in the morning, and presenting symptoms of weakness or tiredness. Complementary leg ultrasound was performed in 57% of patients, with 38% of these cases lacking prior clinical examination for deep vein thrombosis. The duration of the anticoagulation treatment was not specified in the discharge report for 17% of patients. A medical follow-up after discharge was recommended in 75% of the patients. Conclusions: In conclusion, while the management of PE at the KSBL generally adheres to high standards, there are areas for improvement, particularly in the morning performance, the use of a pretest probability assessment, D-dimer measurement, risk assessment via the PESI score, the performance of complementary leg ultrasounds, clarification of the anticoagulation duration, and follow-up management.

Dissecting the Prediagnostic Journey to Identify Opportunities for Early Detection of Esophageal Cancer: Findings From a High-Risk Area in Rural China

PURPOSE

Survival from esophageal cancer (EC) is poor, partly reflecting the delay in diagnosis. To inform the potential measures for downstaging the disease, we estimated diagnosis delay, that is, the length of interval from symptom-to-diagnosis (STD), and investigated its correlates among patients with EC in a high-risk resource-limited rural area in China.

METHODS

Patients newly diagnosed with EC (N = 411) were recruited in a secondary hospital in Henan province in China between August 1, 2018, and October 21, 2020. A face-to-face structured questionnaire was used to collect patient-level and health-seeking data from patients and/or proxies. Association between the length of STD interval and stage at diagnosis was examined using logistic regression. Correlates of the length of the STD interval were identified using negative binomial regression.

RESULTS

The median STD interval was 61 (IQR, 24-155) days, with the time from symptom onset to first health care contact representing 90.1% (IQR, 7.8%-100%) of its length. The odds of being diagnosed at stages III-IV increased by 3% (age- and sex-adjusted odds ratio, 1.03 [95% CI, 0.99 to 1.08]) for every 2-month increase in the STD interval. Higher awareness of EC risk factors was associated with shorter STD intervals (incidence rate ratio [95% CI] for awareness score ≥2 v ≤0: 0.65 [0.46 to 0.93]), whereas patients who first visited secondary or tertiary/cancer hospitals had much longer STD intervals than those who first visited a primary health care facility (1.69 [1.19 to 2.40]; 2.22 [1.24 to 3.97]).

CONCLUSION

The median length of the STD interval was 2 months, but with considerable interindividual variability. Improving EC awareness, coupled with effective referral pathways, may promote timely diagnosis of this disease.

Psychiatric disorders and the cancer diagnostic process in general practice: a combined questionnaire and register study exploring the patients' experiences in Denmark

OBJECTIVE

Patients with psychiatric disorders are at risk of experiencing suboptimal cancer diagnostics and treatment. This study investigates how this patient group perceives the cancer diagnostic process in general practice.

DESIGN

Cross-sectional study using questionnaire and register data.

SETTING

General practice in Denmark.

SUBJECTS

Patients diagnosed with cancer in late 2016 completed a questionnaire about their experiences with their general practitioner (GP) in the cancer diagnostic process (n = 3411). Information on pre-existing psychiatric disorders was obtained from register data on psychiatric hospital contacts and primary care treated psychiatric disorders through psychotropic medications. Logistic regression was used to analyse the association between psychiatric disorders and the patients' experiences.

MAIN OUTCOME MEASURES

Patients' experiences, including cancer worry, feeling being taken seriously, and the perceived time between booking an appointment and the first GP consultation.[Box: see text].

RESULTS

A total of 13% of patients had an indication of a psychiatric disorder. This group more often perceived the time interval as too short between the first booking of a consultation and the first GP consultation. Patients with primary care treated psychiatric disorders were more likely to worry about cancer at the first presentation and to share this concern with their GP compared with patients without psychiatric disorders. We observed no statistically significant association between patients with psychiatric disorders and perceiving the waiting time to referral from general practice, being taken seriously, trust in the GP's abilities, and the patients' knowledge of the process following the GP referral.

CONCLUSION

The patients' experiences with the cancer diagnostic process in general practice did not vary largely between patients with and without psychiatric disorders. Worrying about cancer may be a particular concern for patients with primary care treated psychiatric disorders.

Impact of pre-existing mental health disorders on the receipt of guideline recommended cancer treatments: A systematic review

OBJECTIVE

Disparities in cancer outcomes for individuals with pre-existing mental health disorders have already been identified, particularly for cancer screening and mortality. We aimed to systematically review the influence on the time from cancer diagnosis to cancer treatment, treatment adherence, and differences in receipt of guideline recommended cancer treatment.

METHODS

We included international studies published in English from 1 January 1995 to 23 May 2022 by searching MEDLINE, Embase, and APA PsycInfo.

RESULTS

This review identified 29 studies with 27 being published in the past decade. Most studies focused on breast, non-small cell lung and colorectal cancer and were of high or medium quality as assessed by the Newcastle Ottawa Scale. All studies were from high-income countries, and mostly included patients enrolled in national health insurance systems. Five assessed the impact on treatment delay or adherence, and 25 focused on the receipt of guideline recommended treatment. 20/25 studies demonstrated evidence that patients with pre-existing mental health disorders were less likely to receive guideline recommended therapies such as surgery or radiotherapy. In addition, there was a greater likelihood of receiving less intensive or modified treatment including systemic therapy.

CONCLUSIONS

Across different cancer types and treatment modalities there is evidence of a clear disparity in the receipt of guideline recommended cancer treatment for patients with pre-existing mental health disorders. The effect of pre-existing mental health disorders on treatment delay or adherence is under-researched. Future research needs to include low- and middle-income countries as well as qualitative investigations to understand the reasons for disparities in cancer treatment.

Unplanned cancer presentation in patients with psychiatric disorders: A nationwide register-based cohort study in Denmark

Unplanned presentation in the cancer pathway is more common in patients with psychiatric disorders than in patients without. More knowledge about the risk factors for unplanned presentation could help target interventions to ensure earlier diagnosis of cancer in patients with psychiatric disorders. This study aims to estimate the association between patient characteristics (social characteristics and coexisting physical morbidity) and cancer diagnosis following unplanned presentation among cancer patients with psychiatric disorders. We conducted a population-based register study including patients diagnosed with cancer in 2014-2018 and also registered with at least one psychiatric disorder in the included Danish registers (n = 26,005). We used logistic regression to assess patient characteristics associated with an unplanned presentation. Almost one in four symptomatic patients (23.6 %) with pre-existing psychiatric disorders presented unplanned in the cancer trajectory. Unplanned presentation was most common for severe psychiatric disorders, e.g. organic disorders and schizophrenia. Old age, male sex, living alone, low education, physical comorbidity, and non-attendance in primary care were associated with increased odds of unplanned presentation. In conclusion, several characteristics of patients with pre-existing psychiatric disorders were associated with unplanned presentation in the cancer trajectory; for some groups more than 40 % had an unplanned presentation. This information could be used to design targeted interventions for patients with pre-existing psychiatric disorders to ensure earlier diagnosis of cancer in this population.

Routes to cancer diagnosis for patients with pre-existing psychiatric disorders: a nationwide register-based cohort study

Background

Poor cancer prognosis has been observed in patients with pre-existing psychiatric disorders. Therefore, we need better knowledge about the diagnosis of cancer in this patient group. The aim of the study was to describe the routes to cancer diagnosis in patients with pre-existing psychiatric disorders and to analyse how cancer type modified the routes.

Methods

A register-based cohort study was conducted by including patients diagnosed with incident cancer in 2014–2018 (n = 155,851). Information on pre-existing psychiatric disorders was obtained from register data on hospital contacts and prescription medication. Multinomial regression models with marginal means expressed as probabilities were used to assess the association between pre-existing psychiatric disorders and routes to diagnosis.

Results

Compared to patients with no psychiatric disorders, the population with a psychiatric disorder had an 8.0% lower probability of being diagnosed through cancer patient pathways initiated in primary care and a 7.6% higher probability of being diagnosed through unplanned admissions. Patients with pre-existing psychiatric disorders diagnosed with rectal, colon, pancreatic, liver or lung cancer and patients with schizophrenia and organic disorders were less often diagnosed through cancer patient pathways initiated in primary care.

Conclusion

Patients with pre-existing psychiatric disorders were less likely to be diagnosed through Cancer Patient Pathways from primary care. To some extent, this was more pronounced among patients with cancer types that often present with vague or unspecific symptoms and among patients with severe psychiatric disorders. Targeting the routes by which patients with psychiatric disorders are diagnosed, may be one way to improve the prognosis among this group of patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09598-x.

Barriers to cancer care for people with significant mental health difficulties: What healthcare staff say?

OBJECTIVES

Despite similar rates in cancer morbidity, patients with comorbid significant mental health difficulties (SMHD) experience higher mortality rates. This population has largely been neglected in cancer care research. Little is known about how to improve cancer outcomes for patients with SMHD. The aim of this research is to explore the views of healthcare professionals concerning the provision of cancer care to individuals with SMHD in an Irish context.

METHODS

Semi-structured interviews were conducted with healthcare professionals (n = 28) providing care to people with SMHD and cancer. This included oncology and psychiatry consultants (n = 10); clinical nurse specialists (n = 8); clinical psychologists (n = 6); and medical social workers (n = 4). Data were analysed using thematic analysis.

RESULTS

Four overarching themes were generated from the data highlighting the challenges associated with healthcare provision for this cohort. The themes were: Fragmentation of Care, Healthcare Providers' Understanding of SMHD, Complex Nature of Presentation, and Specialised Care Needs.

CONCLUSIONS

The findings contribute to advancing our understanding of cancer care provision for patients with SMHD. They identify important barriers and facilitators to cancer care provision for this population from the perspective of healthcare professionals in Ireland. These findings will help to shape future research and contribute to improving the quality-of-care for people with SMHD and cancer.

The Impact of Dementia on Cancer Treatment Decision-Making, Cancer Treatment, and Mortality: A Mixed Studies Review

Dementia and cancer occur commonly in older adults. Yet, little is known about the effect of dementia on cancer treatment and outcomes in patients diagnosed with cancer, and no guidelines exist. We performed a mixed studies review to assess the current knowledge and gaps on the impact of dementia on cancer treatment decision-making, cancer treatment, and mortality. A search in PubMed, Medline, and PsycINFO identified 55 studies on older adults with a dementia diagnosis before a cancer diagnosis and/or comorbid cancer and dementia published in English from January 2004 to February 2020. We described variability using range in quantitative estimates, ie, odds ratios (ORs), hazard ratios (HRs), and risk ratios (RR) when appropriate and performed narrative review of qualitative data. Patients with dementia were more likely to receive no curative treatment (including hospice or palliative care) (OR, HR, and RR range = 0.40-4.4, n = 8), while less likely to receive chemotherapy (OR and HR range = 0.11-0.68, n = 8), radiation (OR range = 0.24-0.56, n = 2), and surgery (OR range = 0.30-1.3, n = 4). Older adults with cancer and dementia had higher mortality than those with cancer alone (HR and OR range = 0.92-5.8, n = 33). Summarized findings from qualitative studies consistently revealed that clinicians, caregivers, and patients tended to prefer less aggressive care and gave higher priority to quality of life over life expectancy for those with dementia. Current practices in treatment-decision making for patients with both cancer and dementia are inconsistent. There is an urgent need for treatment guidelines for this growing patient population that considers patient and caregiver perspectives.

Time to diagnosis of symptomatic gastric and oesophageal cancer in the Netherlands: Where is the room for improvement?

BACKGROUND

An efficient diagnostic pathway and early stage diagnosis for cancer patients is widely pursued. This study aims to chart the duration of the diagnostic pathway for patients with symptomatic oesophageal and gastric cancer, to identify factors associated with long duration and to assess the association of duration with tumour stage at diagnosis.

METHODS

This was a retrospective cohort study, using electronic health records of six routine primary care databases covering about 640,000 patients, partly linked to the Netherlands Cancer Registry. Symptomatic patients with oesophageal and gastric cancer (2010-2015) that presented in primary care were included. Duration of four diagnostic intervals was determined: patient interval; first symptoms to primary care consultation, primary care interval; consultation to referral, secondary care interval; referral to diagnosis, and the diagnostic interval; consultation to diagnosis. Characteristics associated with 'long duration' (≥P75 duration) were assessed using log-binomial regression. Median durations were stratified for tumour stages.

RESULTS

Among 312 symptomatic patients with upper gastrointestinal cancer, median durations were: patient interval: 29 days (interquartile interval 15-73), primary care interval: 12 days (interquartile interval 1-43), secondary care interval: 13 days (interquartile interval 6-29) and diagnostic interval: 31 days (11-74). Patient interval duration was comparable for patients with and without alarm symptoms. Absence of cancer-specific alarm symptoms was associated with 'long duration' of primary care interval and secondary care interval: relative risk 5.0 (95% confidence interval 2.7-9.1) and 2.1 (95% confidence interval 1.3-3.7), respectively. Median diagnostic interval duration for local stage disease was 51 days (interquartile interval 13-135) versus 27 days (interquartile interval 11-71) for advanced stage (p = 0.07).

CONCLUSION

In the diagnostic pathway of upper gastrointestinal cancers, the longest interval is the patient interval. Reducing time to diagnosis may be achieved by improving patients' awareness of alarm symptoms and by diagnostic strategies which better identify cancer patients despite low suspicion.

Decision-making factors for best supportive care alone and prognostic factors after best supportive care in non-small cell lung cancer patients

Among patients with non-small cell lung cancer (NSCLC), best supportive care (BSC) is well-known to improve patient's quality of life and prolong survival. This study aimed to clarify (1) the decision-making factors of BSC alone and (2) the prognostic factors after selection of no further anticancer therapies. We retrospectively reviewed the clinical data of patients with NSCLC between November 2004 and February 2014, who received BSC as only therapy and BSC after completion of anticancer therapies. One hundred eighteen patients received BSC alone. Among 860 patients treated with anticancer therapies, 236 were selected as control group, 160 of whom received BSC after anticancer therapy. The significant reasons for receiving BSC alone were: comorbidities of dementia, poor Eastern Cooperative Oncology Group performance status (ECOG-PS), patients' wishes, pulmonary comorbidities, wild type epidermal growth factor receptor (EGFR), relevant social background and psychiatric comorbidities. Poor prognostic factors at the start of BSC were poor ECOG-PS, presence of disseminated intravascular coagulation (DIC), and history of anticancer therapy. NSCLC patients with comorbidities, wild type EGFR, and relevant social background factors tended to receive BSC alone. Post-cancer therapy NSCLC patients and those with DIC and declining ECOG-PS have a shorter survival period from the start of BSC.

Comorbid chronic diseases and cancer diagnosis: disease-specific effects and underlying mechanisms

An earlier diagnosis is a key strategy for improving the outcomes of patients with cancer. However, achieving this goal can be challenging, particularly for the growing number of people with one or more chronic conditions (comorbidity/multimorbidity) at the time of diagnosis. Pre-existing chronic diseases might affect patient participation in cancer screening, help-seeking for new and/or changing symptoms and clinicians' decision-making on the use of diagnostic investigations. Evidence suggests, for example, that pre-existing pulmonary, cardiovascular, neurological and psychiatric conditions are all associated with a more advanced stage of cancer at diagnosis. By contrast, hypertension and certain gastrointestinal and musculoskeletal conditions might be associated with a more timely diagnosis. In this Review, we propose a comprehensive framework that encompasses the effects of disease-specific, patient-related and health-care-related factors on the diagnosis of cancer in individuals with pre-existing chronic illnesses. Several previously postulated aetiological mechanisms (including alternative explanations, competing demands and surveillance effects) are integrated with newly identified mechanisms, such as false reassurances, or patient concerns about appearing to be a hypochondriac. By considering specific effects of chronic diseases on diagnostic processes and outcomes, tailored early diagnosis initiatives can be developed to improve the outcomes of the large proportion of patients with cancer who have pre-existing chronic conditions.

Stage at diagnosis and survival in patients with cancer and a pre-existing mental illness: a meta-analysis

INTRODUCTION

Individuals with a pre-existing mental illness, especially those experiencing reduced social, occupational and functional capacity, are at risk for cancer care disparities. However, uncertainty surrounding the effect of a mental illness on cancer outcomes exists.

METHODS

We conducted a systematic review and meta-analysis of observational studies using MEDLINE and PubMed from 1 January 2005 to 1 November 2018. Two reviewers evaluated citations for inclusion. Advanced stage was defined as regional, metastatic or according to a classification system. Cancer survival was defined as time survived from cancer diagnosis. Pooled ORs and HRs were presented. The Newcastle-Ottawa bias risk assessment scale was used. Random-effects models used the Mantel-Haenszel approach and the generic inverse variance method. Heterogeneity assessment was performed using I².

RESULTS

2381 citations were identified; 28 studies were included and 24 contributed to the meta-analysis. Many demonstrated methodological flaws, limiting interpretation and contributing to significant heterogeneity. Data source selection, definitions of a mental illness, outcomes and their measurement, and overadjustment for causal pathway variables influenced effect sizes. Pooled analyses suggested individuals with a pre-existing mental disorder have a higher odds of advanced stage cancer at diagnosis and are at risk of worse cancer survival. Individuals with more severe mental illness, such as schizophrenia, are at a greater risk for cancer disparities.

DISCUSSION

This review identified critical gaps in research investigating cancer stage at diagnosis and survival for individuals with pre-existing mental illness. High-quality research is necessary to support quality improvement for the care of psychiatric patients and their families during and following a cancer diagnosis.

Impact of serious mental illness on the treatment and mortality of older patients with locoregional high-grade (nonmetastatic) prostate cancer: retrospective cohort analysis of 49 985 SEER-Medicare patients diagnosed between 2006 and 2013

Background

The influence of serious mental illness (SMI) on the treatment and survival of patients with high‐grade prostate cancer is not well understood. We compared the initial cancer treatment and cancer‐specific mortality of SEER‐Medicare patients with locoregional high‐grade (nonmetastatic) prostate cancer with and without preexisting SMI.

Methods

We identified SEER‐Medicare patients who were 67 years of age or older diagnosed between 2006 and 2013 with locoregional high‐grade (nonmetastatic) prostate cancer. Preexisting SMI was identified by claims indicative of bipolar disorder, schizophrenia, and other psychotic disorder, during the 2 years before cancer diagnosis. We used multivariable binary logistic regression to examine associations between SMI and receipt of surgery or radiation concurrent with hormone therapy (definitive initial treatment) within 1 year after cancer diagnosis. We used Kaplan‐Meier survival curves, as well as Cox proportional hazards and competing risk models to evaluate unadjusted and adjusted associations between SMI and 5‐year cancer‐specific survival.

Results

Among 49 985 patients with locoregional high‐grade (nonmetastatic) prostate cancer, 523 (1.1%) had SMI and 49 462 (98.9%) had no SMI. Overall, SMI was associated with reduced odds of receiving surgery (OR = 0.66, 95% CI: 0.49‐0.89) or radiation concurrent with hormone therapy (OR = 0.81, 95% CI: 0.67‐0.98) as initial treatments in the year after cancer diagnosis. Additionally, SMI was associated with higher hazard of 5‐year cancer‐specific death (HR = 1.41, 95% CI: 1.06‐1.89) after accounting for competing risks of non‐cancer death.

Conclusion

Among SEER‐Medicare patients with locoregional high‐grade (nonmetastatic) prostate cancer, those with preexisting SMI—relative to those without these conditions—were less likely to receive definitive initial treatment in the year after diagnosis and had poorer cancer‐specific survival 5 years after diagnosis.

A systematic review of the prevalence of comorbid cancer and dementia and its implications for cancer-related care

OBJECTIVES

A comorbid diagnosis of cancer and dementia (cancer-dementia) may have unique implications for patient cancer-related experience. The objectives were to estimate prevalence of cancer-dementia and related experiences of people with dementia, their carers and cancer clinicians including cancer screening, diagnosis, treatment and palliative care.

METHOD

Databases were searched (CINAHL, Psychinfo, Medline, Embase, BNI) using key terms such as dementia, cancer and experience. Inclusion criteria were as follows: (a) English language, (b) published any time until early 2016, (c) diagnosis of cancer-dementia and (d) original articles that assessed prevalence and/or cancer-related experiences including screening, cancer treatment and survival. Due to variations in study design and outcomes, study data were synthesised narratively.

RESULTS

Forty-seven studies were included in the review with a mix of quantitative (n = 44) and qualitative (n = 3) methodologies. Thirty-four studies reported varied cancer-dementia prevalence rates (range 0.2%-45.6%); the others reported reduced likelihood of receiving: cancer screening, cancer staging information, cancer treatment with curative intent and pain management, compared to those with cancer only. The findings indicate poorer cancer-related clinical outcomes including late diagnosis and higher mortality rates in those with cancer-dementia despite greater health service use.

CONCLUSIONS

There is a dearth of good-quality evidence investigating the cancer-dementia prevalence and its implications for successful cancer treatment. Findings suggest that dementia is associated with poorer cancer outcomes although the reasons for this are not yet clear. Further research is needed to better understand the impact of cancer-dementia and enable patients, carers and clinicians to make informed cancer-related decisions.

Psychiatric disease in surgically treated colorectal cancer patients

BACKGROUND

Underlying psychiatric conditions may affect outcomes of surgical treatment for colorectal cancer (CRC) because of complex clinical presentation and treatment considerations. We hypothesized that patients with psychiatric illness (PSYCH) would have evidence of advanced disease at presentation, as manifested by higher rates of colorectal surgery performed in the presence of obstruction, perforation, and/or peritonitis (OPP-surgery).

MATERIALS AND METHODS

Using data from the 2007-2011 National Inpatient Sample, we identified patients with a diagnosis of CRC undergoing colorectal surgery. In addition to somatic comorbid conditions flagged in the National Inpatient Sample, we used the Clinical Classification Software to identify patients with PSYCH, including schizophrenia, delirium/dementia, developmental disorders, alcohol/substance abuse, and other psychiatric conditions. Our study outcome was OPP-surgery. In addition to descriptive analysis, we conducted multivariable logistic regression analysis to analyze the independent association between each of the PSYCH conditions and OPP-surgery, after adjusting for patient demographics and somatic comorbidities.

RESULTS

Our study population included 591,561 patients with CRC and undergoing colorectal cancer surgery, of whom 60.6% were aged 65 years or older, 49.4% were women, and 6.3% had five or more comorbid conditions. Then, 17.9% presented with PSYCH. The percent of patients undergoing OPP-surgery was 13.9% in the study population but was significantly higher for patients with schizophrenia (19.3%), delirium and dementia (18.5%), developmental disorders (19.7%), and alcohol/substance abuse (19.5%). In multivariable analysis, schizophrenia, delirium/dementia, and alcohol/substance abuse were each independently associated with increased rates of OPP-surgery.

CONCLUSIONS

Patients with PSYCH may have obstacles in receiving optimal care for CRC. Those with PSYCH diagnoses had significantly higher rates of OPP-surgery. Additional evaluation is required to further characterize the clinical implications of advanced disease presentation for patients with PSYCH diagnoses and colorectal cancer.

Diagnosis and treatment delays among elderly breast cancer patients with pre-existing mental illness

PURPOSE

This study aimed to compare diagnosis and treatment delays in elderly breast cancer patients with and without pre-existing mental illness.

METHODS

A retrospective cohort study was conducted using the Surveillance, Epidemiology and End Results-Medicare data including 16,636 women 68+ years, who were diagnosed with stage I-IIIa breast cancer in the United States from 2005 to 2007. Mental illness was identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes recorded on inpatient and outpatient claims during the 3 years prior to breast cancer diagnosis. Patients were classified as having no mental illness, anxiety, depression, anxiety and depression, or severe mental illness (bipolar disorder, schizophrenia, and other psychotic disorder). Multivariable binomial regression was used to assess the association between mental illness and delays of ≥60 and ≥90 days after adjustment for confounders.

RESULTS

Patients with comorbid anxiety and depression had an increased risk for diagnosis delay of ≥90 days from symptom recognition (RR 1.11; 95% CI 1.00, 1.23), and those with severe mental illness had an increased risk for initial treatment delay of ≥60 days from diagnosis (RR 1.36; 95% CI 1.06, 1.74). Patients with any mental illness experienced an increased risk for adjuvant chemotherapy delay of ≥90 days from last operation (RR 1.13; 95% CI 1.01, 1.26) and each category of mental illness, except depression, showed a non-significant trend for this association.

CONCLUSION

Breast cancer patients with mental illness should be closely managed by a cross-functional care team, including a psychiatrist, a primary care physician, and an oncologist, to ensure adequate care is received within an appropriate timeframe.

Waiting time for cancer treatment and mental health among patients with newly diagnosed esophageal or gastric cancer: a nationwide cohort study

Background

Except for overall survival, whether or not waiting time for treatment could influences other domains of cancer patients’ overall well-being is to a large extent unknown. Therefore, we performed this study to determine the effect of waiting time for cancer treatment on the mental health of patients with esophageal or gastric cancer.

Methods

Based on the Swedish National Quality Register for Esophageal and Gastric Cancers (NREV), we followed 7,080 patients diagnosed 2006–2012 from the time of treatment decision. Waiting time for treatment was defined as the interval between diagnosis and treatment decision, and was classified into quartiles. Mental disorders were identified by either clinical diagnosis through hospital visit or prescription of psychiatric medications. For patients without any mental disorder before treatment, the association between waiting time and subsequent onset of mental disorders was assessed by hazard ratios (HRs) with 95% confidence interval (CI), derived from multivariable-adjusted Cox model. For patients with a preexisting mental disorder, we compared the rate of psychiatric care by different waiting times, allowing for repeated events.

Results

Among 4,120 patients without any preexisting mental disorder, lower risk of new onset mental disorders was noted for patients with longer waiting times, i.e. 18–29 days (HR 0.86; 95% CI 0.74-1.00) and 30–60 days (HR 0.79; 95% CI 0.67-0.93) as compared with 9–17 days. Among 2,312 patients with preexisting mental disorders, longer waiting time was associated with more frequent psychiatric hospital care during the first year after treatment (37.5% higher rate per quartile increase in waiting time; p for trend = 0.0002). However, no such association was observed beyond one year nor for the prescription of psychiatric medications.

Conclusions

These data suggest that waiting time to treatment for esophageal or gastric cancer may have different mental health consequences for patients depending on their past psychiatric vulnerabilities. Our study sheds further light on the complexity of waiting time management, and calls for a comprehensive strategy that takes into account different domains of patient well-being in addition to the overall survival.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-3013-7) contains supplementary material, which is available to authorized users.

The Impact of Preexisting Mental Health Disorders on the Diagnosis, Treatment, and Survival among Lung Cancer Patients in the U.S. Military Health System

BACKGROUND

Higher cancer-related mortality has been observed among people with mental health disorders than in the general population. Both delay in diagnosis and inadequate treatment due to health care access have been found to explain the higher mortality. The U.S. Military Health System (MHS), in which all beneficiaries have equal access to health care, provides an ideal system to study this disparity where there are no or minimal barriers to health care access. This study assessed preexisting mental health disorders and stage at diagnosis, receipt of cancer treatment, and overall survival among patients with non-small cell lung cancer (NSCLC) in the U.S. MHS.

METHODS

The study used data from the linked database from the Department of Defense's Central Cancer Registry and the MHS Data Repository (MDR). The study subjects included 5,054 patients with histologically confirmed primary NSCLC diagnosed between 1998 and 2007.

RESULTS

Patients with a preexisting mental disorder did not present with more advanced disease at diagnosis than those without. There were no significant differences in receiving cancer treatments between the two groups. However, patients with a mental health disorder had a higher mortality than those without [adjusted HR, 1.11; 95% confidence interval (CI), 1.03-1.20].

CONCLUSIONS

Poor survival in NSCLC in patients with a preexisting mental health disorder is not necessarily associated with delay in diagnosis and/or inadequate cancer treatment.

IMPACT

This study contributes to the current understanding that health care access may not be sufficient to explain the poor survival among patients with NSCLC with preexisting mental health disorders. Cancer Epidemiol Biomarkers Prev; 25(12); 1564-71. ©2016 AACR.

Cancer and dementia: an exploratory study of the experience of cancer treatment in people with dementia

OBJECTIVE

Patients with comorbid cancer and dementia have poorer outcomes than those without dementia. We observe oncology teams managing patients with dementia and memory loss and explore these patients' needs and experiences of outpatient cancer services.

METHODS

A single site investigation of case study design to examine practices in four clinics using multi-methods of data collection: retrospective note review, observation, interviews, and recorded consultations. A framework analytic approach identifies themes within and across cases.

RESULTS

Thirty-three clinical encounters with patients with memory loss were observed. Ten consultations were audio-recorded and 16 individuals interviewed (n = 6 patients-carer dyads, n = 1 lone patient, and n = 5 staff). Medical records were reviewed for 338 cases. Cancer referrals did not document memory health, so clinicians rely on patient/carer disclosure to identify patients with memory problems. In practice, the problem often remains hidden. Treating teams who do become aware of memory difficulties are unsure how to support patients, but marked memory loss can limit treatment options and preclude radical intent. Carers are key facilitators of successful cancer consultations and management. Their support needs are largely unrecognized.

CONCLUSIONS

Training that educates cancer teams on how to identify and support individuals with memory problems before and during treatment and recognize the carer role may facilitate complex cancer care and help reduce inequalities of outcomes.

Does the Presence of a Major Psychiatric Disorder Affect Tolerance and Outcomes in Men With Prostate Cancer Receiving Radiation Therapy?

Prior studies have suggested that men with prostate cancer and psychiatric disorders (+Psy) have worse outcomes compared with those without (-Psy), particularly due to delayed diagnosis or reduced access to definitive treatment. In the current study, the toxicity and outcomes of men who were primarily diagnosed through prostate-specific antigen screening and who underwent definitive treatment with external beam radiation was investigated. The charts of 469 men diagnosed with prostate cancer from 2003 to 2010 were reviewed. The presence of +Psy was based on a Diagnostic and Statistical Manual of Mental Disorders-Fourth edition diagnosis of posttraumatic stress disorder, depression, schizophrenia, bipolar disorder, and/or generalized anxiety disorder. Kaplan-Meier analysis was used to analyze biochemical control, distant control, prostate cancer-specific survival, and overall survival. One hundred patients (21.3%) were identified as +Psy. At a median follow-up of 73 months, there were no differences regarding 6-year biochemical control (79.8% -Psy vs. 80.4% +Psy, p = .50) or 6-year distant metastatic-free survival (96.4% -Psy vs. 98.0% +Psy, p = .36). There were also no differences regarding the 6-year prostate cancer-specific survival (98.4% -Psy vs. 99.0% +Psy, p = .45) or 6-year overall survival (80.2% -Psy vs. 82.2% +Psy, p = .35). Short- and long-term genitourinary and gastrointestinal toxicities were similar between the groups. On multivariate analyses with propensity score adjustment, +Psy was not a significant predictor for toxicity, biochemical recurrence, or survival. The presence of +Psy was not associated with higher toxicity or worse clinical outcomes, suggesting that effective removal of screening and treatment barriers may reduce the survival disparities of these patients.

Differences in cancer stage, treatment and in-hospital mortality between patients with and without schizophrenia: retrospective matched-pair cohort study

BACKGROUND

Healthcare access and outcomes in cancer patients with schizophrenia remain unclear.

AIMS

To investigate the likelihood of early diagnosis and treatment in patients with schizophrenia who have cancer and their prognosis.

METHOD

A retrospective matched-pair cohort of gastrointestinal cancer patients was identified using a national in-patient database in Japan. Multivariable ordinal/binary logistic regressions was modelled to compare cancer stage at admission, invasive treatments and 30-day in-hospital mortality between patients with schizophrenia (n = 2495) and those without psychiatric disorders (n = 9980).

RESULTS

The case group had a higher proportion of stage IV cancer (33.9% v. 18.1%), a lower proportion of invasive treatment (56.5% v. 70.2%, odds ratio (OR) = 0.77, 95% CI 0.69-0.85) and higher in-hospital mortality (4.2% v. 1.8%, OR = 1.35, 95% CI 1.04-1.75).

CONCLUSIONS

Patients with schizophrenia who had gastrointestinal cancer had more advanced cancer, a lower likelihood of invasive treatment and higher in-hospital mortality than those without psychiatric disorders.

Why do psychiatric patients have higher cancer mortality rates when cancer incidence is the same or lower?

OBJECTIVE

Studies of overall cancer incidence and mortality in psychiatric patients have had mixed results. Some have reported lower than expected cancer incidence or mortality, while others have found no association or an increased risk depending on sample, psychiatric diagnosis, cancer site and methodology. Few studies have compared cancer incidence and mortality using the same population and methodology.

METHOD

A population-based record-linkage analysis to compare cancer incidence and mortality in psychiatric patients with that for the general Queensland population, using an historical cohort to calculate age- and sex-standardised rate ratios and hazard ratios. Mental health records were linked with cancer registrations and death records from 2002 to 2007.

RESULTS

There were 89,992 new cancer cases, of which 3349 occurred in people with mental illness. Cancer incidence was the same as the general population for most psychiatric disorders. Rates were actually lower for dementia (hazard ratio = 0.77; 95% confidence interval = [0.67, 0.88]) and schizophrenia (hazard ratio = 0.84; 95% confidence interval = [0.72, 0.98]). By contrast, mortality was increased in psychiatric patients (hazard ratio = 2.27; 95% confidence interval = [2.15, 2.39]) with elevated hazard ratios for all the main psychiatric diagnoses.

CONCLUSIONS

Lifestyle, such as alcohol or tobacco use, would not explain our findings that people with mental illness are no more likely than the general population to develop cancer but more likely to die of it. Other factors may be the difficulty in differentiating medically explained and unexplained symptoms, greater case fatality or inequity in access to specialist procedures. The study highlights the need for improved cancer screening, detection and intervention in this population.

Psychiatric Illness is a Disparity in the Surgical Management of Rectal Cancer

BACKGROUND

Psychiatric disorders are common in the US and represent a major health disparity but little is known about their impact on surgical management and outcomes in cancer.

OBJECTIVE

The aim of this study was to determine whether rectal cancer patients with psychiatric diagnoses have fewer sphincter-preserving procedures and higher postoperative complications.

METHODS

Overall, 23,914 patients from the Nationwide Inpatient Sample (NIS) who underwent surgery for rectal cancer from 2004 to 2011 were identified. Patients with comorbid common psychiatric diagnoses were identified by International Classification of Diseases, Ninth Revision (ICD-9) codes. Main outcomes were measured by operation performed, length of stay (LOS), postoperative complications, and discharge disposition.

RESULTS

Twenty percent of patients had a psychiatric diagnosis, with substance use being the most common psychiatric disorder (63 %). Patients with psychiatric diagnoses were more likely to be younger, White, have lower income, and have Medicaid insurance (p < 0.001) than those without. In a logistic regression model, patients with any psychiatric diagnosis were less likely to have sphincter-sparing surgery, controlling for patient sociodemographics, Charlson score, hospital procedure volume, and year (odds ratio 0.77; 95 % CI 0.72-0.83). LOS and postoperative complications were similar among the cohorts. Patients with psychiatric disorders were more likely to have home health care at discharge (p < 0.001).

CONCLUSIONS

Fewer sphincter-sparing procedures were performed on rectal cancer patients with psychiatric diagnoses. However, no significant differences in postoperative complications were observed.

Geriatric assessment findings independently associated with clinical depression in 1092 older patients with cancer: the ELCAPA Cohort Study

OBJECTIVE

We aim to assess the prevalence and associated factors of clinical depression in older patients with cancer.

METHODS

We studied a prospective cohort of cancer patients aged ≥ 70 years and referred to geriatric oncology clinics between 2007 and 2012. A multidimensional geriatric assessment was performed before choosing the cancer-treatment strategy. Clinical depression was diagnosed by senior geriatricians by a semi-structured interview. It encompassed criteria of the Diagnostic and Statistical Manual of Mental Disorders (fourth edition) and of the International Classification of Diseases (10th edition). Multivariate logistic regression was performed.

RESULTS

Of 1121 consecutive patients, 1092 had available data (mean age, 80.4 years; women, 48.8%; metastases, 51.3%; cancer location: colorectal 21.1%, breast 16.8%, kidney, bladder or urinary tract 14.0%, and prostate 11.4%). The overall prevalence of clinical depression was 28.4% (95% confidence interval, 25.7-31.2). Factors independently associated with clinical depression by multivariate analysis adjusting for all following factors plus gender, and metastasis were impaired mobility (adjusted odds ratio [aOR], 2.35; 1.59-3.46), impaired functional status defined as Eastern Cooperative Oncology Group Performance Status ≥ 2 (aOR, 2.39; 1.66-3.43) or as activities of daily living < 6 (aOR, 2.43; 1.73-3.41), inpatient status (aOR, 1.68; 1.20-2.37), inadequate social support (aOR, 1.66; 1.16-2.37), cognitive impairment (aOR, 1.76; 1.24-2.49), polypharmacy defined as five or more non-antidepressant drugs (aOR, 1.65; 1.14-2.38), multimorbidity (aOR additional CIRS-G point , 1.08; 1.04-1.12), and cancer-related pain (aOR, 1.76; 1.26-2.46).

CONCLUSION

In older patients with as-yet untreated cancer at various sites and stages, clinical depression was highly prevalent. Clinical depression was independently associated with several geriatric assessment findings (impaired mobility and function, inadequate social support, cognitive impairment, polypharmacy, and multimorbidity) independently from gender, tumor site, and metastatic status.

The effect of pre-existing mental health comorbidities on the stage at diagnosis and timeliness of care of solid tumor malignances in a Veterans Affairs (VA) medical center

There are limited data on the impact of mental health comorbidities (MHC) on stage at diagnosis and timeliness of cancer care. Axis I MHC affect approximately 30% of Veterans receiving care within the Veterans Affairs (VA) system. The purpose of this study was to compare stage at diagnosis and timeliness of care of solid tumor malignancies among Veterans with and without MHC. We performed a retrospective analysis of 408 charts of Veterans with colorectal, urothelial, and head/neck cancer diagnosed and treated at VA Connecticut Health Care System (VACHS) between 2008 and 2011. We collected demographic data, stage at diagnosis, medical and mental health co-morbidities, treatments received, key time intervals, and number of appointments missed. The study was powered to assess for stage migration of 15–20% from Stage I/II to Stage III/IV. There was no significant change in stage distribution for patients with and without MHC in the entire study group (p = 0.9442) and in each individual tumor type. There were no significant differences in the time intervals from onset of symptoms to initiation of treatment between patients with and without MHC (p = 0.1135, 0.2042 and 0.2352, respectively). We conclude that at VACHS, stage at diagnosis for patients with colorectal, urothelial and head and neck cancers did not differ significantly between patients with and without MHC. Patients with MHC did not experience significant delays in care. Our study indicates that in a medical system in which mental health is integrated into routine care, patients with Axis I MHC do not experience delays in cancer care.

Breast cancer screening in women with mental illness: comparative meta-analysis of mammography uptake

BACKGROUND

There is a higher mortality rate due to cancer in people with mental illness and previous work suggests suboptimal medical care in this population. It remains unclear if this extends to breast cancer population screening.

AIMS

To conduct a systematic review and meta-analysis to establish if women with a mental health condition are less likely to receive mammography screening compared with those without mental ill health.

METHOD

Major electronic databases were searched from inception until February 2014. We calculated odds ratios (OR) with a random effects meta-analysis comparing mammography screening rates among women with and without a mental illness. Results were stratified according to primary diagnosis including any mental illness, mood disorders, depression, severe mental illness (SMI), distress and anxiety.

RESULTS

We identified 24 publications reporting breast cancer screening practices in women with mental illness (n = 715,705). An additional 5 studies investigating screening for those with distress (n = 21,491) but no diagnosis of mental disorder were identified. The pooled meta-analysis showed significantly reduced rates of mammography screening in women with mental illness (OR = 0.71, 95% CI 0.66-0.77), mood disorders (OR = 0.83, 95% CI 0.76-0.90) and particularly SMI (OR = 0.54, 95% CI 0.45-0.65). No disparity was evident among women with distress alone.

CONCLUSIONS

Rates of mammography screening are lower in women with mental illness, particularly women with SMI, and this is not explained by the presence of emotional distress. Disparities in medical care due to mental illness clearly extend into preventive population screening.

Cancer mortality among psychiatric patients treated in a community-based system of care: a 25-year case register study

PURPOSE

Cancer mortality data allow assessing, at the same time, the risk of developing the disease and the quality of care provided to patients after the oncologic diagnosis. This study explores the risk of death caused by a single tumor site in a psychiatric population treated in a community-based psychiatric service.

METHODS

All patients with an ICD-10 psychiatric diagnosis, seeking care in 1982-2006 (25 years), were included. Data were drawn from the South Verona Psychiatric Case Register (PCR). Mortality and cause of death were ascertained using different procedures and sources. Standardized mortality ratios (SMRs) were used to compare the observed number of deaths with the expected number using as reference a population in the Veneto region.

RESULTS

Having been admitted to the hospital (SMR = 1.32), having a short interval from registration (1.52), having a diagnosis of alcoholism (2.03), and being a middle-aged male (1.83) were factors showing an increased risk of death from cancer. Increased SMRs were found for cancer of the oral cavity (22.93), lymphoma, leukemias, Hodgkin's lymphoma (8.01), and central nervous system (CNS) and cranial nerve tumors (4.75). The SMR decreased for stomach tumors (0.49). Patients with alcoholism (5.90 for larynx), affective disorders (20.00 for lymphomas), and personality disorders (28.00 for SNC) were found to be exposed to a high risk of cancer death in specific sites.

CONCLUSIONS

Psychiatric patients showed different patterns of site-specific cancer mortality when compared with the general population. The 20-fold higher risk of dying from hematological neoplasms needs further investigation. Chronic use of phenothiazines could be involved in the relative protection from stomach and prostate cancer found in psychiatric patients.

The influence of health disparities on targeting cancer prevention efforts

Despite the advances in cancer medicine and the resultant 20% decline in cancer death rates for Americans since 1991, there remain distinct cancer health disparities among African Americans, Hispanics, Native Americans, and the those living in poverty. Minorities and the poor continue to bear the disproportionate burden of cancer, especially in terms of stage at diagnosis, incidence, and mortality. Cancer health disparities are persistent reminders that state-of-the-art cancer prevention, diagnosis, and treatment are not equally effective for and accessible to all Americans. The cancer prevention model must take into account the phenotype of accelerated aging associated with health disparities as well as the important interplay of biological and sociocultural factors that lead to disparate health outcomes. The building blocks of this prevention model will include interdisciplinary prevention modalities that encourage partnerships across medical and nonmedical entities, community-based participatory research, development of ethnically and racially diverse research cohorts, and full actualization of the prevention benefits outlined in the 2010 Patient Protection and Affordable Care Act. However, the most essential facet should be a thoughtful integration of cancer prevention and screening into prevention, screening, and disease management activities for hypertension and diabetes mellitus because these chronic medical illnesses have a substantial prevalence in populations at risk for cancer disparities and cause considerable comorbidity and likely complicate effective treatment and contribute to disproportionate cancer death rates.

Prevalence and correlates of potentially undetected dementia among residents of institutional care facilities in Ontario, Canada, 2009-2011

OBJECTIVES

This study aims to determine the prevalence of potentially undetected dementia among institutional care facility residents in Ontario, Canada, and to identify factors associated with undetection.

METHODS

We utilized a population-based secondary data analysis approach, pertaining to data from the Canadian Institute for Health Information's Continuing Care Reporting System, 2009-2011. Potentially undetected dementia was defined as having severely impaired cognitive function and requiring extensive assistance on activity of daily living (ADL) but no records of dementia diagnoses. Cognitive function was measured by the Cognitive Performance Scale (CPS), 0 (intact) to 6 (very severe impairment), and ADL by a hierarchy scale, 0 (independent) to 6 (total dependence).

RESULTS

Of the 242,957 residents who had no records of dementia diagnoses, 11.6% (n = 28,078) had a CPS score ≥4 (severe impairment or higher) and ADL score ≥3 (required extensive assistance or more). Data from 11,614 demented residents with corresponding CPS and ADL scores were used for comparison. Residents without dementia diagnosis were younger (77 vs. 84 years), more likely to have never married (20% vs. 6%), and have longer admission (4 vs. 2.8 years). The most significant factors for no diagnoses were never married (adjusted odds ratio = 2.1, 95% confidence interval [CI] = 1.91-2.29), admitted to hospital-based facilities (adjusted odds ratio = 1.58, 95% CI = 1.48-1.69), presence of schizophrenia (adjusted odds ratio = 1.43, 95% CI = 1.22-1.69), depression (adjusted odds ratio = 1.23, 95% CI = 1.16-1.29), and diabetes mellitus (adjusted odds ratio = 1.32, 95% CI = 1.26-1.40).

CONCLUSIONS

A large number of residents who had poor cognitive function and inadequate ADL ability did not have dementia diagnoses on record. Social and comorbid conditions were contributing factors to potentially undetected dementia.

Gender differences in the association between depressive mood and mortality: a 12-year follow-up population-based study

BACKGROUND

Depressive mood has been associated with all-cause mortality in both men and women. This study aimed at exploring gender differences in the association between depressive mood and specific causes of mortality as well as factors that may account for it, including education, marital status, social support, health behaviors, and chronic diseases.

METHODS

A population-based survey including 6043 subjects (2892 men and 3151 women) was conducted in 1996 in the north-east of France with a questionnaire covering education, marital status, social support, health behaviors (smoking status, alcohol consumption, body mass index), and chronic diseases. Depressive mood was measured using the Duke Health Profile questionnaire. Cox regression models were used to examine its association with subsequent natural all-cause mortality, and cardiovascular and cancer mortality.

RESULTS

During a follow-up of 12.5 years, 406 men and 303 women died from a natural cause. Adjusting for all covariates, depressive mood predicted natural mortality in both men [Hazard Ratio (HR)=1.30; 95% confidence interval (CI): 1.00-1.69] and women (HR=1.37; 95% CI: 1.06-1.77). However, this association was significant for cardiovascular mortality in men (HR=1.63; 95% CI: 1.00-2.65) whereas it was significant for cancer mortality in women (HR=1.71; 95% CI: 1.11-2.64).

LIMITATIONS

Baseline data were self-reported and the response rate was low.

DISCUSSION

Preventive strategies aiming at reducing the increased mortality associated with depressive mood should take gender into account. Depressed men may warrant a better screening for cardiovascular risk factors and diseases, whereas depressed women may benefit from better cancer prevention measures.

Prognostic factors for the survival of patients with esophageal cancer in Northern Iran

BACKGROUND

Esophageal cancer is the 8(th) most common cancer and the 6(th) leading cause of cancer-related death, worldwide. In Iran, the high incidence rates of this type of cancer have been reported from the Caspian Sea region. This study aimed at assessing the factors affecting survival of patients with esophageal cancer in neighbor provinces around Caspian Sea using parametric and semi-parametric models with univariate gamma frailty model.

METHODS

In this study, we performed a prospective review of 359 patients presenting with esophageal cancer from 1990 to 1991. The data were obtained using the Cancer Registry information existed in Babol research center in Iran. Study participants were followed-up until 2006 for a period of 15 years. Hazard ratio was used to interpret the risk of death. The Akaike Information Criterion (AIC) was considered as a criterion to select the best model(s).

RESULTS

Of the 359 patients, 225 (62.7%) were male with a mean age of 60.0 years and 134 (37.3%) were female with a mean age of 55.3 at the time of diagnosis. 1- , 3- and 5-year survival rates after diagnosis were 23%, 15% and 13% , respectively. Comparison between Cox and parametric models of AIC showed that the overall fitting was improved under parametric models. Among parametric models, the log-logistic model with gamma frailty provided better performance than other models. Using this model, we found that gender (p=0.012) and family history of cancer (p= 0.003) were significant predictors.

CONCLUSIONS

Since the proportionality assumption of the Cox model was not held (p = 0.01), the Cox regression model was not an appropriate choice for analyzing our data. According to our findings, log logistic model with gamma frailty could be considered as a useful statistical model in survival analysis of patients with esophageal cancer rather than Cox and log-normal models.