Management of Depression in Patients With Cancer: A Clinical Practice Guideline

The Impact of Chronic Diseases on Mental Health: An Overview and Recommendations for Care Programs

PURPOSE OF REVIEW

The current achievement of medical advancement is noteworthy; however, the occurrence of chronic diseases is increasing day by day, with a significant percentage of affected people are suffering from a mental health crisis. This article aims to present a thorough yet brief review of methods that can be employed to build the emotional wellness of chronic patients.

RECENT FINDINGS

The mental health care strategies include resilience-building, coping skills training, professional counseling, and lifestyle adaptations. Additionally, the article highlights the efficacy of several modern interventions, such as mindfulness-based therapies, cognitive behavioral therapy, eye movement desensitization, and recovery from stress therapy. The global burden of chronic illness emphasizes the pressing need to mitigate mental health problems among chronic patients. By providing actionable insights, our study clears the path for targeted interventions and holistic approaches for chronic disease patients. Moreover, the article suggests to policymakers and clinicians the need for collaboration and multifaceted interventions.

The Increasing Burden of Depression in Patients Undergoing Head and Neck Cancer Operations

OBJECTIVE

Depression remains prevalent in patients undergoing head and neck cancer (HNCA) operations. The present study aimed to assess the impact of depression on perioperative and readmission outcomes following HNCA resection.

METHODS

All elective hospitalizations involving HNCA resection were identified from the 2010-2019 Nationwide Readmissions Database. Patients were stratified by history of depression. To perform risk-adjustment in assessing perioperative and readmission outcomes, 3:1 nearest neighbor matching was performed. A subpopulation analysis was also conducted to assess interval development of depression in the postoperative period.

RESULTS

Of an estimated 133,018 patients undergoing HNCA operations, 8.9% (n = 11,855) had comorbid depression. Over the decade-long study period, the prevalence of depression in this population increased (7.8% in 2010 vs. 10.0% in 2019, NPTrend<0.001). Among 24,938 propensity matched patients, those with depression had similar incidence of in-hospital mortality (0.4 vs. 0.7%, p = 0.14) as well as perioperative medical (22.0 vs. 21.9%, p = 0.93) and surgical (10.2 vs. 10.3, p = 0.84) complications, though had higher rates of non-home discharge (16.9 vs. 13.5%, p < 0.001) and 30-day readmission (13.6 vs. 11.8%, p = 0.030). Predictors of depression in the postoperative period included primary coverage by Medicare or Medicaid as well as comorbid anxiety or drug use disorder.

CONCLUSION

The prevalence of depression in HNCA patients continues to increase. Although depression was not associated with increased in-hospital mortality and complications, it did impact rates of rehospitalization as well as non-routine discharge. Screening and therapeutic interventions addressing such postoperative events may serve to improve long-term clinical and financial outcomes in this at-risk population.

LEVEL OF EVIDENCE

3-Retrospective cohort study Laryngoscope, 133:3396-3402, 2023.

Suicide after a Diagnosis of Cancer: Follow-Up of 1.4 Million Individuals, 2009-2019

Background: The study explores whether Polish cancer patients face elevated suicide risk, emphasizing the vital need to comprehend and mitigate their unique mental health struggles. Methods: We conducted a cohort study based on Polish National Cancer Registry data (diagnosis in 2009-2019). Age-, sex-, and year-standardized mortality ratios (SMR) are presented with 95% confidence intervals (CIs) overall and by sex. Results: The study included 1.43 million individuals diagnosed with cancer. There were 830 suicide cases in this group. The overall SMR for suicide was 1.34 (95% CI 1.25-1.43). The highest risk of suicide death was observed in the first six months after diagnosis (SMR = 1.94, 1.69-2.21): cancers of the heart and pleura (19.15, 2.32-69.18), an unspecified site (3.99, 1.09-10.22), and the esophagus (3.34, 1.08-7.79). The highest overall risk of suicide after cancer diagnosis was observed in esophageal (2.94, 1.47-5.26), gastric (2.70, 2.00-3.57), cervical (2.20, 1.06-4.05), and head and neck cancers (2.06, 1.52-2.72). Conclusions: Patients with cancer face significantly higher suicide risk, peaking within six months post-diagnosis. Urgent integration of suicide risk screening and prevention into cancer care is crucial, supporting mental well-being and guiding proactive healthcare strategies.

Collaborative depression care sensitive to the needs of underserved patients with cancer: Feasibility, acceptability and outcomes

PURPOSE

A single-arm trial evaluated the feasibility, acceptability, and outcomes of COPE-D, a collaborative care intervention for underserved cancer patients with depression.

METHODS

Bilingual (Spanish and English) care managers provided counseling and/or medication management in consultation with physicians. Outcomes were treatment improvement (≥ 5-point reduction in PHQ-9), treatment response (≥ 50% reduction in PHQ-9), suicidal ideation resolution, and changes in depression (PHQ-9), anxiety (GAD-2), sleep disturbance (PSQI), global mental and physical health (PROMIS), social isolation (PROMIS), and qualitative feedback.

RESULTS

193 patients consented to participate. 165 initiated and 141 completed treatment, with 65% and 56% achieving treatment improvement and response, respectively. Outcomes did not differ by ethnicity (31% Hispanic), cancer stage (71% stages III-IV), income, or education. Suicidal ideation, depression, anxiety, sleep disturbance, and social isolation also improved. Qualitative feedback was largely positive.

CONCLUSION

COPE-D improved depression and quality of life among underserved patients, with acceptable retention rates.

Effect of Quality of Life on Radiation Adherence for Patients With Cervical Cancer in an Urban Safety Net Health System

PURPOSE

Outcomes for patients undergoing chemoradiation for cervical cancer are dependent on adherence to radiation therapy (RT). In other diseases, quality of life (QoL) is associated with treatment adherence, but the association between QoL and RT adherence for patients with cervical cancer remains unclear.

METHODS AND MATERIALS

This prospective study included patients undergoing RT for cervical cancer from 2017 to 2021 at an urban safety net hospital. The Functional Assessment of Cancer Therapy-Cervical Cancer Version 4 was used to assess QoL based on 5 subscales (physical, functional, social and emotional, and cervical-cancer specific). The survey was administered at radiation consult, then weekly during RT and at follow-up. Patient information was abstracted from the medical record. Radiation nonadherence was defined as missing ≥2 days of external beam RT. The Functional Assessment of Cancer Therapy-Cervical Cancer Version 4 total and subscale scores were compared between adherent and nonadherent patients. Multivariable logistic regression was performed to control for confounding variables.

RESULTS

Ninety-three patients were enrolled, completing 522 surveys. Median age at diagnosis was 46 years (interquartile range, 40-51); 76% of patients were Hispanic, and 12% were Black. Only 30% of patients were nonadherent with RT. A psychiatric comorbidity (P = .012) and symptomatic presentation (P = .027) were associated with decreased adherence. Baseline total QoL was higher in treatment-adherent than in nonadherent patients (median, 124.86; range, 48-160; 108.9, 46-150; P = .01). Higher baseline functional and physical subscale scores were associated with adherence (P < .05). Change from baseline to lowest score during treatment in the emotional subscale was also associated with patient adherence (P < .05). In multivariable analysis, higher baseline physical score, baseline total score, and change in emotional subscale score were associated with adherence (P < .05).

CONCLUSIONS

Poor QoL during chemoradiation for cervical cancer is associated with missed treatments. Physician assessment of a patient's well-being while they are undergoing RT is of utmost importance to improve adherence to treatment.

Management of Anxiety and Depression in Adult Survivors of Cancer: ASCO Guideline Update

PURPOSE

To update the American Society of Clinical Oncology guideline on the management of anxiety and depression in adult cancer survivors.

METHODS

A multidisciplinary expert panel convened to update the guideline. A systematic review of evidence published from 2013-2021 was conducted.

RESULTS

The evidence base consisted of 17 systematic reviews ± meta analyses (nine for psychosocial interventions, four for physical exercise, three for mindfulness-based stress reduction [MBSR], and one for pharmacologic interventions), and an additional 44 randomized controlled trials. Psychological, educational, and psychosocial interventions led to improvements in depression and anxiety. Evidence for pharmacologic management of depression and anxiety in cancer survivors was inconsistent. The lack of inclusion of survivors from minoritized groups was noted and identified as an important consideration to provide high-quality care for ethnic minority populations.

RECOMMENDATIONS

It is recommended to use a stepped-care model, that is, provide the most effective and least resource-intensive intervention based on symptom severity. All oncology patients should be offered education regarding depression and anxiety. For patients with moderate symptoms of depression, clinicians should offer cognitive behavior therapy (CBT), behavioral activation (BA), MBSR, structured physical activity, or empirically supported psychosocial interventions. For patients with moderate symptoms of anxiety, clinicians should offer CBT, BA, structured physical activity, acceptance and commitment therapy, or psychosocial interventions. For patients with severe symptoms of depression or anxiety, clinicians should offer cognitive therapy, BA, CBT, MBSR, or interpersonal therapy. Treating clinicians may offer a pharmacologic regimen for depression or anxiety for patients who do not have access to first-line treatment, prefer pharmacotherapy, have previously responded well to pharmacotherapy, or have not improved following first-line psychological or behavioral management.Additional information is available at www.asco.org/survivorship-guidelines.

Development and user testing of a patient decision aid for cancer patients considering treatment for anxiety or depression

BACKGROUND

Despite high rates of mental health disorders among cancer patients, uptake of referral to psycho-oncology services remains low. This study aims to develop and seek clinician and patient feedback on a patient decision aid (PDA) for cancer patients making decisions about treatment for anxiety and/or depression.

METHODS

Development was informed by the International Patient Decision Aid Standards and the Ottawa Decision Support Framework. Psycho-oncology professionals provided feedback on the clinical accuracy, acceptability, and usability of a prototype PDA. Cognitive interviews with 21 cancer patients/survivors assessed comprehensibility, acceptability, and usefulness. Interviews were thematically analysed using Framework Analysis.

RESULTS

Clinicians and patients strongly endorsed the PDA. Clinicians suggested minor amendments to improve clarity and increase engagement. Patient feedback focused on clarifying the purpose of the PDA and improving the clarity of the values clarification exercises (VCEs).

CONCLUSIONS

The PDA, the first of its kind for psycho-oncology, was acceptable to clinicians and patients. Valuable feedback was obtained for the revision of the PDA and VCEs.

Effectiveness and implementation of an electronic health record-integrated digital health intervention for managing depressive symptoms in ambulatory oncology: The My Well-Being Guide study rationale and protocol

BACKGROUND

Rates of clinically elevated depressive symptoms among ambulatory oncology patients are higher than in the general population and are associated with poorer health-related quality of life. Furthermore, a reduction in depressive symptoms may be associated with improved cancer survival. Several interventions have demonstrated efficacy in reducing oncologic depressive symptoms, including cognitive-behavioral stress management (CBSM). However, more work is needed to understand how to best implement CBSM into practice, such as through stepped-care approaches and digital health interventions linked to electronic health records (EHR). This manuscript presents the protocol of the My Well-Being Guide study, a pragmatic type 1 effectiveness-implementation hybrid study. This trial will test the effectiveness of My Well-Being Guide, a seven-week structured, CBSM-based digital health intervention designed to reduce depressive symptoms. This trial will also evaluate My Well-Being Guide's implementation across two health systems.

METHODS

The final sample (N = 4561) will be oncology patients at Northwestern Medicine or University of Miami Health System who are ≥18 years of age; have a cancer diagnosis; elevated depressive symptoms on the Patient-Reported Outcomes Measurement Information System Depression; and primary language is English or Spanish. Data collection will occur at baseline, and 2-, 6-, and 12-months post baseline. Outcome domains include depressive symptoms and implementation evaluation.

DISCUSSION

This study may provide valuable data on the effectiveness of our depressive symptom management digital health intervention linked to the EHR and the scalability of digital health interventions in general.

Anxiety, Depression, and Stress Reaction/Adjustment Disorders and Their Associations with Healthcare Resource Utilization and Costs Among Newly Diagnosed Patients With Breast Cancer

Background: Breast cancer is the most common cancer among women in the United States. Newly diagnosed patients with breast cancer often experience anxiety, depression, and stress. However, the impact of psychological distress on healthcare resource utilization (HCRU) and costs has not been adequately assessed. Objectives: To evaluate the incidence and prevalence of anxiety, depression, and stress reaction/adjustment disorder among patients newly diagnosed with breast cancer, to examine HCRU and costs, and to assess the association of these psychiatric disorders with costs. Methods: This retrospective observational cohort study was conducted using a large US administrative claims database with an index date of newly diagnosed breast cancer. Demographics and comorbidities (including anxiety, depression, and stress reaction/adjustment disorder) were assessed using data collected 12 months before and after the index date. HCRU and costs were assessed using data collected 12 months after the index date. Generalized linear regressions were performed to examine the association between healthcare costs and anxiety, depression, and stress reaction/adjustment disorder. Results: Of 6392 patients with newly diagnosed breast cancer, 38.2% were diagnosed with psychiatric disorders including anxiety (27.7%), depression (21.9%), or stress reaction/adjustment disorder (6%). The incidence of these psychiatric disorders was 15% and the prevalence was 23.2%. Patients with anxiety, depression, or stress reaction/adjustment disorder had higher rates of several types of HCRU (P < .0001) and higher total all-cause costs compared with patients without these psychiatric disorders (P < .0001). Patients with incident anxiety, depression, or stress reaction/adjustment disorder incurred higher all-cause costs in the first year following breast cancer diagnosis than those with prevalent anxiety, depression, or stress reaction/adjustment disorder (P < .0003), or those without these psychiatric disorders (P < .0001). Discussion: Of patients with anxiety, depression, or stress reaction/adjustment disorder, those with incident psychiatric disorders had higher healthcare costs, suggesting that new-onset psychological distress may contribute to higher costs incurred by the payer. Timely treatment of psychiatric disorders in this population may improve clinical outcomes and reduce HCRU and costs. Conclusions: Anxiety, depression, and stress reaction/adjustment disorder were common among patients newly diagnosed with breast cancer and were associated with increased healthcare costs in the first year following breast cancer diagnosis.

Prevalence and associated factors of depression and anxiety among patients with cancer seeking treatment at the Butaro Cancer Center of Excellence in Rwanda

Background

Depression and anxiety are psychological and physiological disturbances persisting in cancer patients with high prevalence worldwide, particularly in low- and middle-income countries, due to complexities of determinants of health including biological, individual, socio-cultural, and treatment-related characteristics. Although depression and anxiety have an enormous impact on adherence, length of stay at the hospital, quality of life, and treatment outcomes, studies on psychiatric disorders remain limited. Thus, this study determined the prevalence and factors of depression and anxiety among patients with cancer in Rwanda.

Methods

A cross-sectional study was conducted among 425 patients with cancer from the Butaro Cancer Center of Excellence. We administered socio-demographic questionnaires and psychometric instruments. Bivariate logistic regressions were computed to identify significant factors to be exported into the multivariate logistic models. Then, odds ratios and their 95% confidence intervals were applied, and statistical significance at p < 0.05 were considered to confirm significant associations.

Results

The prevalence of depression and anxiety was 42.6 and 40.9%, respectively. Patients with cancer initiated to chemotherapy had a greater likelihood of being depressed [AOR = 2.06; 95% CI (1.11-3.79)] than those initiated to chemotherapy and counseling. Breast cancer was significantly associated with a greater risk of depression [AOR = 2.07, 95% CI (1.01-4.22)] than Hodgikins's Lymphoma cancer. Furthermore, patients with depression had greater odds of developing anxiety [AOR = 1.76, 95% CI (1.01-3.05)] than those with no depression. Those suffering from depression were almost two times more likely to experience anxiety [AOR = 1.76; 95% CI (1.01-3.05)] than their counterparts.

Conclusion

Our results revealed that depressive and anxious symptomatology is a health threat in clinical settings that requires enhancement of clinical monitoring and prioritization of mental health in cancer health facilities. Designing biopsychosocial interventions to address associated factors needs special attention to promote the health and wellbeing of patients with cancer.

Rehabilitation interventions for depression symptoms among cancer patients in Palestine: A systematic review

Background

Depression enhances the disease burden in patients with cancer. Psychological interventions and the rehabilitation of depression are required as a part of palliative care for cancer patients to improve their quality of life and mental health.The aim of the study was to review the literature about depression rehabilitation interventions among patients with cancer in Palestine.

Method

The electronic databases used: PubMed, Science Direct, Research Gate, and Google Scholar to search for systematic review articles for the review study.

Results

A total of 23 articles were reviewed, including five from Palestine and five from Arab and Islamic nations. Pharmacological and non-pharmacological interventions used to decrease symptoms of depression and enhance mental health among cancer patients represent the majority of interventions for depression rehabilitation in cancer patients. Interventions for depression rehabilitation among cancer patients in Palestine are only available from the perspective of palliative care, which also involves family education, managing the symptoms of cancer patients, and providing psychological support.

Conclusion

In Palestine, non-pharmacological interventions, such as psychological interventions, are the primary options for treating and recovering from symptoms of depression. The management of symptoms in cancer patients also has a favorable impact on mental health and recovery from depression. In Palestine, there is a need for improvement in palliative care, particularly interventions for depressive symptoms. The main reason Palestinian patients with cancer have such limited treatment and recovery options are because of Israeli occupation.

Effective maNagement of depression among patients witH cANCEr (ENHANCE): a protocol for a hybrid systematic review and network meta-analysis of randomised controlled trials of interventions for depressive symptoms

BACKGROUND

Depression is common among patients with cancer and is associated with lower treatment participation, lower satisfaction with care, poorer quality of life, greater symptom burden and higher healthcare costs. Various types of interventions (e.g. pharmacological, psychotherapy) are used for the treatment of depression. However, evidence for these among patients with cancer is limited. Furthermore, the relative effectiveness and acceptability of different approaches are unknown because a direct comparison between all available treatments has not been carried out. We will address this by conducting a network meta-analysis (NMA) of interventions for depression among people with cancer using a hybrid overview of reviews and systematic review methodology.

METHODS

We will search for and extract data from systematic reviews of randomised controlled trials (RCTs) of depression interventions for patients with cancer from inception, before performing a supplemental search for more recent RCTs. We will include RCTs comparing pharmacological, psychotherapy, exercise, combination therapy, collaborative care or complementary and alternative medicine interventions with pill placebo, no treatment, waitlist, treatment as usual or minimal treatment control groups, or directly in head-to-head trials, among adults who currently have cancer or have a history of any cancer and elevated depressive symptoms (scores above a cut-off on validated scales or meeting diagnostic criteria). Our primary outcomes will be change in depressive symptoms (standardised mean difference) and intervention acceptability (% who withdrew). Our secondary outcomes will be 6-month change in depressive symptoms, health-related quality of life, adverse events and mortality. We will independently screen for eligibility, extract data and assess risk of bias using the RoB 2 tool. We will use frequentist random-effects multivariate NMA in Stata, rankograms and surface under the cumulative ranking curves to synthesise evidence and obtain a ranking of intervention groups. We will explore heterogeneity and inconsistency using local and global measures and evaluate the credibility of results using the Confidence in NEtwork Meta-Analysis (CINeMA) framework.

DISCUSSION

Our findings will provide the best available evidence for managing depression among patients with cancer. Such information will help to inform clinical guidelines, evidence-based treatment decisions and future research by identifying gaps in the current literature.

SYSTEMATIC REVIEW REGISTRATION

Submitted to PROSPERO (record number: 290145), awaiting registration.

Understanding the basis of major depressive disorder in oncological patients: Biological links, clinical management, challenges, and lifestyle medicine

In recent years, the incidence of different types of cancer and patient survival have been rising, as well as their prevalence. The increase in survival in recent years exposes the patients to a set of stressful factors such as more rigorous follow-up and more aggressive therapeutic regimens that, added to the diagnosis of the disease itself, cause an increase in the incidence of depressive disorders. These alterations have important consequences for the patients, reducing their average survival and quality of life, and for these reasons, special emphasis has been placed on developing numerous screening tests and early recognition of depressive symptoms. Despite that cancer and major depressive disorder are complex and heterogeneous entities, they also share many critical pathophysiological mechanisms, aiding to explain this complex relationship from a biological perspective. Moreover, a growing body of evidence is supporting the relevant role of lifestyle habits in the prevention and management of both depression and cancer. Therefore, the present study aims to perform a thorough review of the intricate relationship between depression and cancer, with a special focus on its biological links, clinical management, challenges, and the central role of lifestyle medicine as adjunctive and preventive approaches to improve the quality of life of these patients.

Quality assessment of clinical practice guidelines on psychological distress of cancer patients using the AGREE II instrument

Objective

This study aimed to assess the quality of the clinical practice guidelines on psychological distress among cancer patients and provide users with recommendations for coping with psychological distress.

Methods

A systematic search of relevant clinical practice guidelines was undertaken to identify and select the clinical practice guidelines related to psychological distress among cancer patients. Literature databases were searched in PubMed, Web of Science, Excerpta Medica Database, the Cumulative Index to Nursing &amp; Allied Health Literature, China Biology Medicine, China National Knowledge Infrastructure, WanFang and Weipu Journal Database. The guideline databases include Yimaitong Guidelines Network, National Guideline Clearinghouse, National Institute for Health and Clinical Excellence, American Society of Clinical Oncology (ASCO), New Zealand Guidelines Group, Scottish Intercollegiate GuidelinesNetwork, American Psychological Association, Registered Nurses’ Association of Ontario and Cancer Care Ontario (CCO). Four independent reviewers assessed the eligible guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.

Results

Six clinical practice guidelines were included and assessed for critical evaluation. The median score for the scope and purpose domain was 71.5% (IQR 64%-77.25%), the stakeholder involvement domain was 65% (IQR 47.5%-74.5%), the rigour of the development domain was 61.5% (IQR 45.5%-85.25%), the clarity of the presentation domain was 91% (IQR 72.25%-94.5%), the applicability domain was 70% (IQR 33%-78.75%), and the editorial independence domain was 48.84% (IQR 61.75%-95%). Four guidelines (ASCO, 2014; Canadian Association of Psychosocial Oncology, 2015; NCCN, 2020, and CCO, 2016) were classified as “recommended,” and the remaining (European Palliative Care Research Collaborative and Chinese Psychosocial Oncology Society) were “recommended with modifications,” especially in the domains of Stakeholder involvement, rigour of development, and applicability. The inter-rater consistency of each domain showed moderate level (0.52–0.90) analyzing by intraclass correlation.

Conclusions

The clinical practice guidelines on psychological distress among cancer patients varied in quality, and there were discrepancies in terms of the recommendations and recommendation grades. These findings could contribute to improving the quality of clinical practice guidelines on psychological distress, and enable the development and implementation of evidence-based guidelines for cancer patients.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO, identifier CRD42020209204.

The Role of the Psycho-Oncologist during the COVID-19 Pandemic: A Clinical Breast Cancer Case Report

The 2019 coronavirus pandemic (COVID-19) has been very stressful, but more so for those with cancer. Patients with cancer experienced more pandemic-related stress and psychological distress than those without a cancer diagnosis. This case report, about a breast cancer patient, is presented in order to emphasize (1) the importance of the management of psychological care in oncology, (2) the need for a thorough understanding of the efficacy of the role of the psycho-oncologist and related interventions in a breast care unit for the health of both patients and professionals to improve clinical outcomes, and (3) the emerging health concerns of breast cancer patients in the context of the COVID-19 pandemic.

Screening for Distress and Health Outcomes in Head and Neck Cancer

Head and neck cancers (HNC) have higher rates of emotional distress than other cancer types and the general population. This paper compares the prevalence of emotional distress in HNC across various distress screening measures and examines whether significant distress or distress screening are associated with cancer-related survival. A retrospective observational cohort design was employed, with data collected from the Distress Assessment and Response Tool (DART) and linkages to administrative databases from 2010 to 2016. Descriptive and prevalence data were reported using multiple concurrently administered distress tools, including the Patient Health Questionaire-9 (PHQ-9), Generalized Anxiety Disorders-7 (GAD-7), Edmonton Symptom Assessment Scale-revised (ESAS-r), and MD Anderson Symptom Index-Head and Neck module (MDASI-HN). Across measures, 7.8 to 28.1% of the sample reported clinically significant emotional distress, with PHQ-9 and GAD-7 identifying lowest prevalence of moderate/severe distress, and the ultrashort distress screens within ESAS-r and MDASI-HN performing equivalently. Cox hazards models were used in univariate and multivariate survival analyses. ESAS depression (≥4), but not anxiety, was associated with increased risk of cancer-related mortality and patient completion of DART was associated with greater cancer-related survival. The findings underscore the importance of implementing routine distress screening for HNC populations and the utility of ultra-brief screening measures.

Cumulative burden of psychiatric disorders and self-harm across 26 adult cancers

Cancer is a life-altering event causing considerable psychological distress. However, information on the total burden of psychiatric disorders across all common adult cancers and therapy exposures has remained scarce. Here, we estimated the risk of self-harm after incident psychiatric disorder diagnosis in patients with cancer and the risk of unnatural deaths after self-harm in 459,542 individuals. Depression was the most common psychiatric disorder in patients with cancer. Patients who received chemotherapy, radiotherapy and surgery had the highest cumulative burden of psychiatric disorders. Patients treated with alkylating agent chemotherapeutics had the highest burden of psychiatric disorders, whereas those treated with kinase inhibitors had the lowest burden. All mental illnesses were associated with an increased risk of subsequent self-harm, where the highest risk was observed within 12 months of the mental illness diagnosis. Patients who harmed themselves were 6.8 times more likely to die of unnatural causes of death compared with controls within 12 months of self-harm (hazard ratio (HR), 6.8; 95% confidence interval (CI), 4.3-10.7). The risk of unnatural death after 12 months was markedly lower (HR, 2.0; 95% CI, 1.5-2.7). We provide an extensive knowledge base to help inform collaborative cancer-psychiatric care initiatives by prioritizing patients who are most at risk.

Depression and Long-Term Prescription Opioid Use and Opioid Use Disorder: Implications for Pain Management in Cancer

OPINION STATEMENT

Preventing depression in cancer patients on long-term opioid therapy should begin with depression screening before opioid initiation and repeated screening during treatment. In weighing the high morbidity of depression and opioid use disorder in patients with chronic cancer pain against a dearth of evidence-based therapies studied in this population, patients and clinicians are left to choose among imperfect but necessary treatment options. When possible, we advise engaging psychiatric and pain/palliative specialists through collaborative care models and recommending mindfulness and psychotherapy to all patients with significant depression alongside cancer pain. Medications for depression should be reserved for moderate to severe symptoms. We recommend escitalopram/citalopram or sertraline among selective serotonin reuptake inhibitors (SSRIs), or the serotonin and norepinephrine reuptake inhibitors (SNRIs) duloxetine, venlafaxine, or desvenlafaxine if patients have a significant component of neuropathic pain or fibromyalgia. Tricyclic antidepressants (TCAs) (consider nortriptyline or desipramine, which have better anticholinergic profiles) should be considered for patients who do not respond to or tolerate SSRI/SNRIs. Existing evidence is inadequate to definitively recommend methylphenidate or novel agents, such as ketamine or psilocybin, as adjunctive treatments for cancer-related depression and pain. Physicians who treat patients with cancer pain should utilize universal precautions to limit the risk of non-medical opioid use (non-medical opioid use). Patients should be screened for non-medical opioid use behaviors at initial consultation and at regular intervals during treatment using a non-judgmental approach that reduces stigma. Co-management with an addiction specialist may be indicated for patients at high risk of non-medical opioid use and opioid use disorder. Buprenorphine and methadone are indicated for the treatment of opioid use disorder, and while they have not been systematically studied for treatment of opioid use disorder in patients with cancer pain, they do provide analgesia for cancer pain. While an interdisciplinary team approach to manage psychological stress may be beneficial, this may not be possible for patients treated outside of comprehensive cancer centers.

Promise unfulfilled: Implementing web‐based psychological therapy in routine cancer care, a qualitative study of oncology health professionals’ attitudes

Background

Web‐based mental health interventions (e‐MhIs) show promise for increasing accessibility and acceptability of therapy for cancer patients.

Aim

This study aimed to elicit health professionals' (HPs) views on optimal models for including e‐MhIs within standard cancer care.

Materials & Method

Cancer HPs who worked in a service where an e‐MhI was available to patients, and multi‐disciplinary HPs interested in supportive care, were invited to participate via email. In semi‐structured phone interviews, participants' views on e‐MhIs were elicited. They were then presented with five model vignettes varying in local and centralised staff input, and asked to indicate their preference and views on each. A thematic analysis was applied to the data.

Results

Twelve nurses, nine psychologists, seven social workers, and three oncologists participated. Four key themes were identified: looking after patients, relationships and multidisciplinary care, trust, and feasibility, all contributing to a meta‐theme of tension. Participants were motivated to ensure optimal patient outcomes and thus needed to trust the intervention content and process. They believed personal relationships increased patient engagement while affording greater work satisfaction for HPs. Most participants preferred a fully integrated model of care involving local HP assessment and design of a tailored therapy incorporating some e‐MhI components where appropriate, but recognised this gold standard was likely not feasible given current resources.

Discussion and Conclusion

Co‐design with local staff of optimal models of care for the content and process of implementing e‐MhIs is required, with due consideration of the patient group, staffing levels, local workflows and HP preferences, to ensure sustainability and optimal patient outcomes.

Clinical Trial Registration

The ADAPT Cluster RCT is registered with the ANZCTR Registration number: ACTRN12617000411347.

Neuropsychiatric Disorders and Frailty in Older Adults over the Spectrum of Cancer: A Narrative Review

BACKGROUND

The interplay between different neuropsychiatric conditions, beyond dementia, in the presence of a diagnosis of cancer in older adults may mediate patients' fitness and cancer-related outcomes. Here, we aimed to investigate the presence of depression, sleep disturbances, anxiety, attitude, motivation, and support in older adults receiving a diagnosis of cancer and the dimension of frailty in order to understand the magnitude of the problem.

METHODS

This review provides an update of the state of the art based on references from searches of PubMed between 2000 and June 2021.

RESULTS

The evidence obtained underscored the tight association between frailty and unfavorable clinical outcomes in older adults with cancer. Given the intrinsic correlation of neuropsychiatric disorders with frailty in the realm of cancer survivorship, the evidence showed they might have a correlation with unfavorable clinical outcomes, late-life geriatric syndromes and higher degree of frailty.

CONCLUSIONS

The identification of common vulnerabilities among neuropsychiatric disorders, frailty, and cancer may hold promise to unmask similar shared pathways, potentially intercepting targeted new interventions over the spectrum of cancer with the delivery of better pathways of care for older adults with cancer.

Diagnostic timelines and self-reported symptoms of patients with lung and gastrointestinal cancers undergoing radiation therapy. Retrospective case control study

BACKGROUND

Previous studies have found that patients with lung cancer report worse patient experience compared to other tumour groups. Reasons that may negatively impact patient experience include delays in diagnosis as well as inadequate symptom management. The purpose of this study was to compare the diagnostic timelines and symptom reports of patients with lung and gastrointestinal (GI) cancers.

METHODS

This study included patients diagnosed with lung or GI cancers who attended a radiation oncology (RO) consultation and/or received radiation treatment between May and August 2019 at the Tom Baker Cancer Centre, Calgary, Alberta, Canada. Data collected included demographics, dates of diagnostic time points, and self-reported symptom scores across 3 time points. A descriptive analysis was completed, and the median number of days between time points was compared between tumour groups.

RESULTS

Patients with lung cancer had longer diagnostic timelines compared to GI patients. The median number of days between the first investigative test and biopsy was 21 days longer for patients with lung cancer (p < 0.05). From RO consultation to the first treatment review appointment, 25% and 4% of lung and GI patients, respectively, reported worsening of symptoms. A greater proportion of lung patients reported worse symptom scores during treatment compared to GI patients. This varied by specific symptom.

CONCLUSIONS

Patients with lung cancer experienced delays in receiving a diagnosis and worse symptom burden during radiation therapy in this study. We identified potential targets to improve patient experience.

Recent trends in the management of depression in persons with cancer

PURPOSE OF REVIEW

Depression is a prevalent comorbidity in cancer that significantly increases the risk for numerous negative health outcomes. This review updates the current evidence base for management of depression in cancer, highlighting new research directions based on the inflammatory hypothesis of depression.

RECENT FINDINGS

Research on pharmacotherapy and psychotherapy for depression in cancer has shown mixed efficacy partly because of methodological issues arising from the phenomenology of depression in cancer. After decades of stagnancy, more recent high-quality clinical trials are beginning to provide an evidence base to guide treatment. Inflammatory cytokine-associated depression is a subtype of depression that may have particular relevance in cancer, opening new avenues to explore therapeutic targets and biobehavioral impacts of interventions, which may improve cancer outcomes.

SUMMARY

The continuum of severity in cancer-related depression is important to consider in management approaches. Choice of treatment should be personalized to the patient and their symptom profile as there is currently insufficient evidence to recommend any particular medication or psychotherapy over another. Psychological interventions should be considered first line for mild-to-moderate depression, and pharmacological treatment added for more severe depression, which can be optimally delivered within a collaborative care model.

VIDEO ABSTRACT

http://links.lww.com/YCO/A62.

Investigating how cancer-related symptoms influence work outcomes among cancer survivors: a systematic review

Purpose

The purpose of this study is to investigate how different cancer-related symptoms influence work outcomes among cancer survivors.

Methods

A literature search was performed in PubMed, EMBASE, CINAHL, PsycINFO, and Scopus to identify studies published between 1st January 1999 and 30th October 2020 that investigated the impact of specific cancer-related symptoms on work outcomes among cancer survivors who have completed primary antineoplastic treatment. Study findings were extracted and grouped by symptoms and work outcomes, allowing comparison of associations between these outcomes.

Results

Seventy-three articles representing 68 studies were eligible for inclusion. From these studies, 27 cancer-related symptoms, 9 work outcomes, and 68 unique associations between specific symptoms and work outcomes were identified. Work status (return to work and employment rates) was most commonly studied, and symptom burden was mainly measured from the patient’s perspective. Higher symptom burden was generally associated with trends of poorer work outcomes. Significant associations were reported in most studies evaluating body image issues and work status, oral dysfunction and work status, fatigue and work ability, and depression and work ability.

Conclusion

Several cancer-related symptoms were consistently associated with inferior work outcomes among cancer survivors. Body image issues and oral dysfunction were shown to be associated with poorer employment rates, while fatigue and depression were linked to lower levels of work performance.

Implications for Cancer Survivors

Failure to return to work and decreased productivity post-cancer treatment can have negative consequences for cancer survivors and society at large. Findings from this review will guide the development of work rehabilitation programs for cancer survivors.

Protocol registration

PROSPERO identifier CRD42020187754

Supplementary Information

The online version contains supplementary material available at 10.1007/s11764-021-01097-5.

Physician-Perceived Predictive Factors for the Effectiveness of Drugs for Treating Cancer Dyspnea: Results of a Nationwide Survey of Japanese Palliative Care Physicians

Background: Dyspnea is a common and distressing symptom in patients with advanced cancer. Opioids, benzodiazepines, and corticosteroids are commonly prescribed pharmacological treatments for cancer dyspnea.

Objective: The objective of this survey was to investigate physician-perceived predictive factors for the effectiveness of opioids, benzodiazepines, and corticosteroids in treating cancer dyspnea.

Design: This study involves a nationwide survey using self-report questionnaires.

Setting/Subjects: Random sampling selected 268 Japanese certified palliative care physicians in Japan.

Measurements: We inquired about the 12 physician-perceived predictive factors for the effectiveness of drugs (opioids, benzodiazepines, and corticosteroids) in treating cancer dyspnea.

Results: The frequently selected physician-perceived predictive factors for the effectiveness of opioids were tachypnea, respiratory effort, opioid naive, Eastern Cooperative Oncology Group Performance Status 0–2, multiple lung tumors, dry cough, pleural effusion, and pleural lesion. Benzodiazepines were predicted to be effective against dyspnea in patients with depression and severe anxiety. Meanwhile, corticosteroids were predicted to be effective against dyspnea in patients with lymphangitis carcinomatosa, superior vena cava syndrome, major airway obstruction, and audible wheezing. Japanese palliative care physicians anticipate that different drug classes will be effective for treating dyspnea in patients with specific factors.

Conclusions: Japanese palliative care physicians expect that different drugs will be effective for dyspnea in patients with specific predictive factors. Future prospective studies are required to assess the effectiveness of each drug class against specific dyspnea.

Use of psychotropic drugs among older patients with bladder cancer in the United States

OBJECTIVE

Older patients diagnosed with cancer are at increased risk of physical and emotional distress; however, prescription utilization patterns largely remain to be elucidated. Our objective was to comprehensively assess prescription patterns and predictors in older patients with bladder cancer.

METHODS

A total of 10,516 older patients diagnosed with clinical stage T1-T4a, N0, M0 bladder urothelial carcinoma from 1 January 2008 to 31 December 2012 from the Surveillance, Epidemiology, and End Results (SEER)-Medicare were analyzed. We used multivariable analysis to determine predictors associated with psychotropic prescription rates (one or more). Medication possession ratio (MPR) was used as an index to measure adherence in intervals of 3 months, 6 months, 1 year, and 2 years. Evaluation of psychotropic prescribing patterns and adherence across different drugs and demographic factors was done.

RESULTS

Of the 10,516 older patients, 5621 (53%) were prescribed psychotropic drugs following cancer diagnosis. Overall, 3972 (38%) patients had previous psychotropic prescriptions prior to cancer diagnosis, and these patients were much more likely to receive a post-cancer diagnosis prescription. Prescription rates for psychotropic medications were higher among patients with higher stage BC (p < 0.001). Gamma aminobutyric acid modulators/stimulators and serotonin reuptake inhibitors/stimulators were the highest prescribed psychotropic drugs in 21% of all patients. Adherence for all drugs was 32% at 3 months and continued to decrease over time.

CONCLUSION

Over half of the patients received psychotropic prescriptions within 2 years of their cancer diagnosis. Given the chronicity of psychiatric disorders with observed significantly low adherence to medications that warrants an emphasis on prolonged patient monitoring and further investigation.

Evaluation of Older Age and Frailty as Factors Associated With Depression and Postoperative Decision Regret in Patients Undergoing Major Head and Neck Surgery

Importance

Clinicians should understand the prevalence of depression and decision regret in patients with head and neck cancer and whether these factors differ with age or frailty.

Objectives

To assess whether age and frailty are associated with preoperative and/or worsening postoperative depression and postoperative decision regret in patients undergoing major head and neck surgery and to identify additional factors associated with depression and decision regret.

Design, Setting, and Participants

This prospective cohort study was conducted at a single institution, with patients aged 50 years or older undergoing major head and neck surgery recruited from December 1, 2011, to April 30, 2014. Statistical analysis was performed from July 1, 2018, to June 30, 2019.

Main Outcomes and Measures

Frailty, functional, and geriatric depression assessments were completed before surgery and 3, 6, and 12 months after surgery. Decision regret assessment was completed 6 months after surgery. The prevalence of depression and decision regret was determined by age group. Change in depression over time was compared between age groups using a linear-effects model. Variables potentially associated with moderate to severe depression and decision regret were analyzed using a logistic regression model.

Results

The study included 274 patients (68 women and 206 men; mean [SD] age, 67.8 [9.5] years). Of these, 105 (38.3%) were 50 to 64 years of age and 169 (61.7%) were 65 years or older. The rate of preoperative moderate to severe depression was 9.6% (21 of 219), with no difference between younger and older adult cohorts. For both age groups, depression scores increased in the postoperative period from baseline to 6 months. At 12 months, there was a difference in depression scores between the younger and older adult cohort (4.8 [4.6] vs 3.1 [3.6]). A higher preoperative Fried Frailty Index score (odds ratio, 2.58 [95% CI, 1.63-4.06]) was associated with preoperative moderate to severe depression. For all patients, the mean Decision Regret Scale score was 18.2 (range, 0-95), and 26.7% of patients (48 of 180) had moderate to severe regret. There was no difference in Decision Regret Scale scores between younger and older patients. Preoperative depression but not frailty is associated with postoperative moderate to severe decision regret (odds ratio, 1.17 [95% CI, 1.06-1.28]).

Conclusions and Relevance

In this cohort study, there was no difference based on age in the prevalence of moderate to severe depression or decision regret. A higher preoperative frailty score was associated with depression but not decision regret. Preoperative depression was the only factor associated with moderate to severe decision regret on multivariate analysis. Understanding the prevalence of and factors associated with moderate to severe depression and decision regret may aid in identifying patients who would benefit from more extensive preoperative counseling and preoperative and postoperative multispecialty assessment and treatment.

Use of Medications for Treating Anxiety or Depression among Testicular Cancer Survivors: A Multi-Institutional Study

BACKGROUND

This study examined sociodemographic factors, cisplatin-related adverse health outcomes (AHO), and cumulative burden of morbidity (CBM_Pt) scores associated with medication use for anxiety and/or depression in testicular cancer survivors (TCS).

METHODS

A total of 1,802 TCS who completed cisplatin-based chemotherapy ≥12 months previously completed questionnaires regarding sociodemographic features and cisplatin-related AHOs [hearing impairment, tinnitus, peripheral sensory neuropathy (PSN), and kidney disease]. A CBM_Pt score encompassed the number and severity of cisplatin-related AHOs. Multivariable logistic regression models assessed the relationship of individual AHOs and CBM_Pt with medication use for anxiety and/or depression.

RESULTS

A total of 151 TCS (8.4%) used medications for anxiety and/or depression. No cisplatin-related AHOs were reported by 511 (28.4%) participants, whereas 622 (34.5%), 334 (18.5%), 287 (15.9%), and 48 (2.7%), respectively, had very low, low, medium, and high CBM_Pt scores. In the multivariable model, higher CBM_Pt scores were significantly associated with medication use for anxiety and/or depression (P < 0.0001). In addition, tinnitus (P = 0.0009), PSN (P = 0.02), and having health insurance (P = 0.05) were significantly associated with greater use of these medications, whereas being employed (P = 0.0005) and vigorous physical activity (P = 0.01) were significantly associated with diminished use.

CONCLUSIONS

TCS with higher CBM_Pt scores had a higher probability of using medications for anxiety and/or depression, and conversely, those who were employed and physically active tended to have reduced use of these medications.

IMPACT

Healthcare providers should encourage TCS to increase physical activity to improve both physical and mental health. Rehabilitation programs should assess work-related skills and provide career development counseling/training.

Prevalence of psychotropic and opioid prescribing among hospice beneficiaries in the United States, 2014-2016

BACKGROUND/OBJECTIVES

Psychotropic and opioid medications are routinely prescribed for symptom management in hospice, but national estimates of prescribing are lacking. Changes in Medicare hospice payment in 2014 provide the first opportunity to examine psychotropic and opioid prescribing among hospice beneficiaries, and the factors associated with use of specific medication classes.

DESIGN

Cross-sectional analysis of a 20% sample of traditional and managed Medicare with Part D enrolled in hospice, 2014-2016.

SETTING

Beneficiaries enrolled in the Medicare hospice benefit.

PARTICIPANTS

Medicare beneficiaries ≥65 newly enrolled in hospice between July 1, 2014 and December 31, 2016 (N = 554,022).

MAIN OUTCOME

Prevalence of psychotropic and opioid medication prescribing by class and factors associated with prescribing.

RESULTS

70.3% of hospice beneficiaries were prescribed a psychotropic and 63.3% were prescribed an opioid. The most common psychotropic classes prescribed were: benzodiazepines (60.6%), antipsychotics (38.3%), antidepressants (18.4%), and antiepileptics (10.2%). Lorazepam (56.4%), morphine (52.8%), and haloperidol (28.6%) were received by the most beneficiaries. Prevalence of any psychotropic and opioid prescription was highest among beneficiaries who were female (76.7%), non-Hispanic white (76.6%), and those with cancer (78.9%). Compared to white beneficiaries, non-Hispanic black beneficiaries were less likely to receive nearly every class of medication, with significantly lower odds of receiving opioids (64.1% vs 57.9%; AOR 0.75, 95% CI 0.72-0.77) and benzodiazepines (61.6% vs 52.2%; AOR 0.66, 95% CI 0.64-0.68). Differences were seen across hospice diagnosis; those with cancer were more likely to receive opioids, benzodiazepines, and antipsychotics but less likely to receive antidepressants and antiepileptics.

CONCLUSIONS

Psychotropic and opioid medications are frequently prescribed in hospice. Observed variations in prescribing across race and ethnicity may reflect disparities in prescribing as well as patient preferences for care. Further work is important to understand factors driving prescribing given limited studies surrounding medication prescribing in hospice.

Effect of SSRI exposure on the proliferation rate and glucose uptake in breast and ovary cancer cell lines

Breast cancer is the most prevalent malignancy amongst women worldwide while ovarian cancer represents the leading cause of death among gynecological malignancies. Women suffering from these cancers displayed heightened rates of major depressive disorder, and antidepressant treatment with selective serotonin reuptake inhibitors (SSRIs) is frequently recommended. Recently, narrative reviews and meta-analyses showed increased recurrence risks and mortality rates in SSRI-treated women with breast and ovarian cancer. We therefore examined whether three commonly prescribed SSRIs, fluoxetine, sertraline and citalopram, affect proliferation or glucose uptake of human breast and ovarian cancer cell lines characterized by different malignancies and metastatic potential. SSRI treatment or serotonin stimulation with therapeutically relevant concentrations over various time periods revealed no consistent dose- or time-dependent effect on proliferation rates. A marginal, but significant increase in glucose uptake was observed in SK-OV-3 ovarian cancer cells upon fluoxetine or sertraline, but not citalopram treatment. In three breast cancer cell lines and in two additional ovarian cancer cell lines no significant effect of SSRIs on glucose uptake was observed. Our data suggest that the observed increase in recurrence- and mortality rates in SSRI-treated cancer patients is unlikely to be linked to antidepressant therapies.

Depression among older adults with gastrointestinal malignancies

BACKGROUND

Depression among older adults with cancer is under recognized and under treated. This study characterizes the burden of depression in older adults with gastrointestinal (GI) malignancies prior to chemotherapy and its relationship with geriatric assessment (GA) domains, health-related quality of life (HRQOL), and self-reported healthcare utilization.

METHODS

Patients ≥60 years in GI oncology clinics at UAB were asked to complete a GA entitled the Cancer & Aging Resilience Evaluation (CARE). We examined depression using the Patient-Reported Outcomes Measurement Information System (PROMIS®) Depression four-item short form; moderate/severe depression was defined by a t-score ≥ 60. Multivariate analysis was used to examine associations between those with and without moderate/severe depression.

RESULTS

Of 355 included patients, 46 had mild depression (13%) and an additional 46 patients had moderate/severe depression (13%). After adjustment for age, sex, education, cancer type, and cancer stage, those who reported moderate/severe depression had a significantly increased odds of reporting falls (adjusted odds ratio [aOR] 4.01, 95% confidence interval [CI] 1.94-8.26), dependence in IADLs (aOR 7.06,CI 2.91-17.1), dependence in ADLs (aOR 6.23, CI 2.89-13.4), malnutrition (aOR 5.86, CI 2.40-14.3), frailty (aOR 13.7, CI 5.80-32.1), and fatigue (aOR 11.2, CI 3.31-37.6). Moderate/severe depression was also significantly associated with worse physical (aOR 7.58, CI 3.30-17.4) and mental (aOR 26.3, CI 10.1-68.8) HRQOL sub-scores, without significant differences in healthcare utilization.

CONCLUSIONS

More than one out of eight older adults with a GI malignancy reported moderate/severe depression prior to chemotherapy, which was associated with impairments in several GA domains and HRQOL.

Soothing liver-qi stagnation method for cancer-related depression: A protocol for systematic review and meta-analysis

BACKGROUND

Cancer-related depression (CRD) is the most common mood disorder in patients with malignant tumors, negatively influencing the patient's daily life. Traditional Chinese medicine, as an alternative CRD therapy, has shown good treatment performance in recently years. Soothing liver-qi stagnation, as a classic therapy for depression, is based on traditional Chinese medicine theory. However, there is no evidence-based medical confirmation for the soothing liver-qi stagnation method for CRD treatment.

METHODS

We will systematically search relevant articles from their inception to July 1, 2019 in the following electronic databases: the Cochrane Library, PubMed, EMBASE, Chinese National Knowledge Infrastructure Database, Chinese Biomedical Literature Database, Chinese Science and Technique Journals Database, and the Wan-fang Database. The primary outcome is the total scores of the Hamilton rating scale for depression and, the efficacy rate of reducing Hamilton rating scale for depression scores. The secondary outcomes are adverse reactions and quality of life as assessed by standard instruments. Two researchers will independently perform study selection, data extraction, and quality assessment. If there is any disagreement, it will be settled through third-party negotiations. We will assess the risk of bias and data synthesis using Review Manager (the Cochrane Collaboration) software, Version 5.3.0.

RESULTS

This work will evaluate the clinical effectiveness and safety of the soothing liver-qi stagnation method for CRD.

CONCLUSION

This study may provide evidence-based medical corroboration for clinical application of the soothing liver-qi stagnation method for CRD treatment.

PROSPERO REGISTRATION NUMBER

CRD42019145678.

Behavioural activation therapy for depression in adults with non-communicable diseases

BACKGROUND

Depression is common in people with non-communicable diseases (NCDs) such as cardiovascular disease, diabetes, cancer, and chronic respiratory conditions. The co-existence of depression and NCDs may affect health behaviours, compliance with treatment, physiological factors, and quality of life. This in turn is associated with worse outcomes for both conditions. Behavioural activation is not currently indicated for the treatment of depression in this population in the UK, but is increasingly being used to treat depression in adults.

OBJECTIVES

To examine the effects of behavioural activation compared with any control group for the treatment of depression in adults with NCDs. To examine the effects of behavioural activation compared with each control group separately (no treatment, waiting list, other psychological therapy, pharmacological treatment, or any other type of treatment as usual) for the treatment of depression in adults with NCDs.

SEARCH METHODS

We searched CCMD-CTR, CENTRAL, Ovid MEDLINE, Embase, four other databases, and two trial registers on 4 October 2019 to identify randomised controlled trials (RCTs) of behavioural activation for depression in participants with NCDs, together with grey literature and reference checking. We applied no restrictions on date, language, or publication status to the searches.

SELECTION CRITERIA

We included RCTs of behavioural activation for the treatment of depression in adults with one of four NCDs: cardiovascular disease, diabetes, cancer, and chronic respiratory conditions. Only participants with a formal diagnosis of both depression and an NCD were eligible. Studies were included if behavioural activation was the main component of the intervention. We included studies with any comparator that was not behavioural activation, and regardless of reported outcomes.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane, including independent screening of titles/abstracts and full-text manuscripts, data extraction, and risk of bias assessments in duplicate. Where necessary, we contacted study authors for more information.

MAIN RESULTS

We included two studies, contributing data from 181 participants to the analyses. Both studies recruited participants from US hospital clinics; one included people who were recovering from a stroke and the other women with breast cancer. For both studies, the intervention consisted of eight weeks of face-to-face behavioural therapy, with one study comparing to poststroke treatment as usual and the other comparing to problem-solving therapy. Both studies were at risk of performance bias and potential conflict of interest arising from author involvement in the development of the intervention. For one study, risks of selection bias and reporting bias were unclear and the study was judged at high risk of attrition bias. Treatment efficacy (remission) was greater for behavioural activation than for comparators in the short term (risk ratio (RR) 1.53, 95% confidence interval (CI) 0.98 to 2.38; low-certainty evidence) and medium term (RR 1.76, 95% CI 1.01 to 3.08; moderate-certainty evidence), but these estimates lacked precision and effects were reduced in the long term (RR 1.42, 95% CI 0.91 to 2.23; moderate-certainty evidence). We found no evidence of a difference in treatment acceptability in the short term (RR 1.81, 95% CI 0.68 to 4.82) and medium term (RR 0.88, 95% CI 0.25 to 3.10) (low-certainty evidence). There was no evidence of a difference in depression symptoms between behavioural activation and comparators (short term: MD -1.15, 95% CI -2.71 to 0.41; low-certainty evidence). One study found no difference for quality of life (short term: MD 0.40, 95% CI -0.16 to 0.96; low-certainty evidence), functioning (short term: MD 2.70, 95% CI -6.99 to 12.39; low-certainty evidence), and anxiety symptoms (short term: MD -1.70, 95% CI -4.50 to 1.10; low-certainty evidence). Neither study reported data on adverse effects.

AUTHORS' CONCLUSIONS

Evidence from this review was not sufficient to draw conclusions on the efficacy and acceptability of behavioural activation for the treatment of depression in adults with NCDs. A future review may wish to include, or focus on, studies of people with subthreshold depression or depression symptoms without a formal diagnosis, as this may inform whether behavioural activation could be used to treat mild or undiagnosed (or both) depressive symptoms in people with NCDs. Evidence from low-resource settings including low- and middle-income countries, for which behavioural activation may offer a feasible alternative to other treatments for depression, would be of interest.

The questionable efficacy of manualized psychological treatments for distressed breast cancer patients: An individual patient data meta-analysis

Previous meta-analyses conclude that psychological treatments are efficacious for emotional distress in breast cancer (BCa). However, the practical relevance of these meta-analyses is questionable; none focused specifically on clinically distressed patients or whether treatment effects were clinically significant. In a two-stage individual patient data (IPD) meta-analysis of 17 randomized controlled trials of manualized psychological treatments in BCa, we evaluated treatment efficacy in distressed BCa patients (n = 1591) using clinical significance and effect size analyses. Outcomes were anxiety, depression, and general distress, evaluated at post-treatment and follow-up. Moderators examined were treatment type, treatment format, therapists' profession, control condition, age, outcome measure, and trial quality. Treated patients were more likely than controls to recover from anxiety and general distress at post-treatment (14-15% more treated patients recovered), but not at mean 8-months follow-up. Overall recovery rates were low: across outcomes, at post-treatment, only 30-32% of treated patients and 15-25% of controls recovered; at follow-up, only 21-30% of treated patients and 18-35% of controls recovered. Small between-group effect sizes in favour of treatment were found across outcomes at post-treatment (g = 0.32-0.34) but not at follow-up. Across the different analysis methods, few moderator effects were found. More efficacious psychological treatments are needed for distressed BCa patients.

Radiotherapy side effects: integrating a survivorship clinical lens to better serve patients

The Canadian Cancer Society estimated that 220,400 new cases of cancer would be diagnosed in 2019. Of the affected patients, more than 60% will survive for 5 years or longer after their cancer diagnosis. Furthermore, nearly 40% will receive at least 1 course of radiotherapy (rt). Radiotherapy is used with both curative and palliative intent: to treat early-stage or locally advanced tumours (curative) and for symptom management in advanced disease (palliative). It can be delivered systemically (external-beam rt) or internally (brachytherapy). Although technique improvements have drastically reduced the occurrence of rt-related toxicity, most patients still experience burdensome rt side effects (seffs). Radiotherapy seffs are local or locoregional, and manifest in tissues or organs that were irradiated. Side effects manifesting within weeks after rt completion are termed "early seffs," and those occurring months or years after treatment are termed "late seffs." In addition to radiation oncologists, general practitioners in oncology and primary care providers are involved in survivorship care and management of rt seffs. Here, we present an overview of common seffs and their respective management: anxiety, depression, fatigue, and effects related to the head-and-neck, thoracic, and pelvic treatment sites.

Association between depression and healthcare expenditures among elderly cancer patients

BACKGROUND

Both depression and cancer are economically burdensome. However, how depression affects the healthcare expenditures of elderly cancer patients from payers' and patients' perspectives is largely unknown. This study investigated whether depression resulted in higher healthcare expenditures among these patients from both payers' and patients' perspectives and identified health service use categories associated with increased expenditures.

METHODS

From the Medicare Current Beneficiary Survey (MCBS)-Medicare database, we identified breast, lung and prostate cancer patients aged 65 years and over who were newly diagnosed between 2007 and 2012. Presence of depression was based on self-reports from the surveys. We used generalized linear models (GLM) and two-part models to examine the impact of depression on healthcare expenditures during the first two years of cancer diagnosis controlling for a vast array of covariates. We stratified the analyses of total healthcare expenditures by healthcare services and payers.

RESULTS

Out of the 710 elderly breast, lung and prostate cancer patients in our study cohort, 128 (17.7%) reported depression. Individuals with depression had $11,454 higher total healthcare expenditures, $8213 higher medical provider expenditures and $405 higher other services expenditures compared to their counterparts without depression. Also, they were significantly more likely to have inpatient services. For payers, they incurred $8280 and $1270 higher expenditures from Medicare's and patients' perspectives, respectively.

CONCLUSIONS

Elderly cancer patients with depression have significantly higher healthcare expenditures from both payers' and patients' perspectives and over different expenditure types. More research is needed in depression screening, diagnosis and treatment for this population.

The Relationship between Depressive Symptoms and Demographic-Medical Characteristics among Elder People with Cancer

OBJECTIVE

Cancer is one of the most common life-threatening diseases and a great source of stress in patients. The risk factors of depression differ in elder people compared to other age groups. The present study was designed to determine the relationship between depressive symptoms and demographic-medical characteristics among elder people with cancer.

METHODS

This cross-sectional correlational study recruited 200 elder people with cancer. The eligible patients completed the demographic-medical characteristics questionnaire, the Geriatric Depression Scale, the Abbreviated Mental Test, the Activities of Daily Living Scale, and the Multidimensional Perceived Social Support Scale. The findings were analyzed in SPSS software version 21.0 using the Kruskal-Wallis and Mann-Whitney tests.

RESULTS

A total of 50% of the elder people in this study had mild depression, 18.5% had moderate depression, and 2.5% had severe depression. A significant relationship was observed between depression in the elder people and their marital status (P = 0.025), living arrangement (P = 0.013), and income (P = 0.021). Depression also had a significant relationship with diabetes (P = 0.044) and respiratory diseases (P = 0.040). A significant relationship was also observed between depression and colon cancer (P = 0.007), and the mean depression was lower in the patients with colon cancer compared to those with other cancers. Depression had a significant relationship with complications, including pain (P = 0.001), nausea (P < 0.001), vomiting (P = 0.001), hair loss (P < 0.001), and shortness of breath (P = 0.028).

CONCLUSIONS

Given the high prevalence of depression in this age group, screening and counseling-supportive interventions are recommended for helping prevent depression and come to terms with cancer.

Interventions to prevent suicidal behavior and ideation for patients with cancer: A systematic review

OBJECTIVE

This study aimed to summarize interventions for suicide prevention in patients with cancer and highlight any methodological issues.

METHODS

We searched PubMed, PsycINFO, CINAHL, and the Cochrane database from their inception until July 2018. Additionally, we manually searched the references of included studies and recent systematic reviews of psychotherapy, antidepressants, and collaborative care for cancer patients with depression.

RESULTS

Of the 1365 retrieved articles, 11 randomized controlled trials and 11 intervention studies met the inclusion criteria. These were categorized by type of intervention: psychotherapy, pharmacotherapy, integrated collaborative care, muscle relaxation and therapeutic walking, and cancer treatment. The trials showed little evidence to confirm the effects of suicide prevention strategies. Seven trials were designed to assess the efficacy of interventions treating depression. In all studies, suicidal behavior or ideation was reported as one of the secondary outcomes. Three trials did not report information about suicidal ideation, despite assessing depressive symptoms using scales that contained suicidal ideation items. Most trials demonstrated inadequate study quality.

CONCLUSIONS

Our review summarized interventions for suicide prevention in patients with cancer and revealed methodological issues. The findings highlighted a need to explore new treatment strategies that focus on unique suicide risk factors among patients with cancer.

Cost-Related Medication Nonadherence and Cost-Reduction Strategies Among Elderly Cancer Survivors with Self-Reported Symptoms of Depression

How depression affects the medication cost burden for elderly cancer survivors has not been well studied. This study aims to investigate whether depression is associated with higher rates of cost-related medication nonadherence, and cost-reduction strategies among the elderly cancer survivors. Self-reports from survey files of the 2015 Medicare Current Beneficiary Survey-Medicare database were used to identify elderly cancer patients aged 65 years and older with and without depression. The 2 outcomes were cost-related nonadherence (CRN) and adoption of cost-reduction strategies. Bivariate analysis was used to describe the sample. Multivariable logistic regression was performed to examine the impact of depression on CRN and the use of cost-reduction strategies, after controlling for all other covariates. Among the 3765 elderly cancer survivors identified, 523 (14%) reported depression. In the group with depression, 26% reported CRN compared with 12% of the group without depression; 71% of individuals with depression reported having cost-reduction strategies while 65% of individuals with no depression reported such activity. In adjusted analyses, individuals with depression were significantly more likely to report CRN (adjusted odds ratio, 1.84; 95% confidence interval 1.33-2.54) and cost-reduction strategies (adjusted odds ratio, 1.37; 95% confidence interval, 1.07-1.76). Depression was associated with higher probabilities of both CRN and the adoption of cost-reduction strategies, indicating that depression can exacerbate the medication cost burden for elderly cancer survivors. It is important to detect and manage depression in elderly cancer survivors to reduce CRN and cost-reduction strategies.

SMART: Study protocol for a sequential multiple assignment randomized controlled trial to optimize weight loss management

BACKGROUND

Stepped care is a rational resource allocation approach to reduce population obesity. Evidence is lacking to guide decisions on use of low cost treatment components such as mobile health (mHealth) tools without compromising weight loss of those needing more expensive traditional treatment components (e.g., coaching, meal replacement). A sequential multiple assignment randomization trial (SMART) will be conducted to inform the development of an empirically based stepped care intervention that incorporates mHealth and traditional treatment components.

OBJECTIVE

The primary aim tests the non-inferiority of app alone, compared to app plus coaching, as first line obesity treatment, measured by weight change from baseline to 6 months. Secondary aims are to identify the best tactic to address early treatment non-response and the optimal treatment sequence for resource efficient weight loss.

STUDY DESIGN

Four hundred participants, 18-60 years old with Body Mass Index between 27 and 45 kg/m2 will be randomized to receive a weight loss smartphone app (APP) or the app plus weekly coaching (APP + C) for a 12 week period. Those achieving <0.5 lb. weight loss on average per week, assessed by wireless scale at 2, 4, and 8 weeks, will be classified as non-responders and re-randomized once to step-up modestly (adding another mHealth component) or vigorously (adding mHealth and traditional treatment components) for the remaining treatment period. Weight will be assessed in person at baseline, 3, 6, and 12 months.

SIGNIFICANCE

Results will inform construction of an obesity treatment algorithm that balances weight loss outcomes with resource consumption.

The use of antidepressants in oncology: a review and practical tips for oncologists

Background

The use of psychotropic drugs, namely those with an antidepressant profile (ADs), is a mandatory part of an integrated treatment of psychiatric disorders among cancer patients. We aimed to synthetize the most relevant data emerging from published studies to provide tips about the use of ADs in oncology.

Design

A search was made of the major databases over the last 30 years (Embase/Medline, PsycLIT, PsycINFO, the Cochrane Library), including narrative reviews, systematic reviews and meta-analyses summarizing the results from observational studies and randomized clinical trials assessing effectiveness, safety profile, interactions, contraindications and use of ADs in oncology with regard to both psychiatric (depressive spectrum, stress-related, anxiety disorders) and cancer-related symptoms (e.g. pain, hot flashes and fatigue).

Results

The weight of evidence supports the efficacy of ADs for more severe major depression in individuals with cancer and as an adjuvant treatment in cancer-related symptoms, although the methodological limitations of reported randomized controlled trials do not permit definite conclusions. Data also indicate that there should be caution in the use of ADs in cancer patients in terms of their safety profile and potential clinically significant interactions with other prescribed medications. Practical recommendations that have been made for the use of ADs in cancer patients, in the context of a multimodal approach to depression treatment, have been summarized here.

Conclusions

ADs are a relatively safe and effective treatment for more severe major depression in cancer patients. However, more research is urgently needed regarding the efficacy of ADs in different cancer types and cancer settings, their interactions with anticancer agents and their additive benefit when integrated with psychosocial interventions.

Identification and treatment of depressive disorders in older adults with cancer

The increasing number of older adults living with cancer will inevitably include vulnerable subgroups who experience a range of depressive symptoms throughout the care continuum. It is well established that depression can lead to decreased quality of life, poor treatment adherence, increased length of hospital stay and health service utilization, and in severe cases, suicide. Thus, clinicians working in oncology must be able to identify, conceptualize, and treat (or connect to services) the mental health concerns of their older patients. This brief review describes the unique etiologies, features, and treatments for depressive syndromes among older adults in the oncology setting, drawing on the literature and prevailing depression management guidelines from both psycho-oncology and geriatric depression research.

Is care really shared? A systematic review of collaborative care (shared care) interventions for adult cancer patients with depression

Background

Collaborative care involves active engagement of primary care and hospital physicians in shared care of patients beyond usual discharge summaries. This enhances community-based care and reduces dependence on specialists and hospitals. The model, successfully implemented in chronic care management, may have utility for treatment of depression in cancer. The aim of this systematic review was to identify components, delivery and roles and responsibilities within collaborative interventions for depression in the context of cancer.

Methods

Medline, PsycINFO, CINAHL, Embase, Cochrane Library and Central Register for Controlled Trials databases were searched to identify studies of randomised controlled trials comparing a treatment intervention that met the definition of collaborative model of depression care with usual care or other control condition. Studies of adult cancer patients with major depression or a non-bipolar depressive disorder published in English between 2005 and January 2018 were included. Cochrane checklist for risk of bias was completed (Study Prospero registration: CRD42018086515).

Results

Of 8 studies identified, none adhered to the definition of ‘collaborative care’. Interventions delivered were multi-disciplinary, with care co-ordinated by nurses (n = 5) or social workers (n = 2) under the direction of psychiatrists (n = 7). Care was primarily delivered in cancer centres (n = 5). Care co-ordinators advised primary care physicians (GPs) of medication changes (n = 3) but few studies (n = 2) actively involved GPs in medication prescribing and management.

Conclusions

This review highlighted joint participation of GPs and specialist care physicians in collaborative care depression management is promoted but not achieved in cancer care. Current models reflect hospital-based multi-disciplinary models of care.

Protocol registration

The protocol for this systematic review has been registered with PROSPERO. The registration number is CRD42018086515.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3946-z) contains supplementary material, which is available to authorized users.

Spirit-Quieting Traditional Chinese Medicine may Improve Survival in Prostate Cancer Patients with Depression

Depression is associated with higher mortality in prostate cancer. However, whether traditional Chinese medicine (TCM) for depression improves outcomes in patients with prostate cancer is unclear. This retrospective cohort study evaluated the association between TCM for depression and mortality in patients with prostate cancer. During the period 1998⁻2012, a total of 248 prostate cancer patients in Taiwan with depression were enrolled and divided into three groups: TCM for depression (n = 81, 32.7%), TCM for other purposes (n = 53, 21.3%), and no TCM (n = 114, 46.0%). During a median follow-up of 6.2 years, 12 (14.8%), 13 (24.5%), and 36 (31.6%) deaths occurred in the TCM for depression, TCM for other purposes, and no TCM groups, respectively. After adjusting age at diagnosis, urbanization, insured amount, comorbidity disease, and prostate cancer type, TCM for depression was associated with a significantly lower risk of overall mortality based on a multivariate-adjusted Cox proportional-hazards model (hazard ratio 0.42, 95% confidence interval: 0.21⁻0.85, p = 0.02) and Kaplan⁻Meier survival curve (log-rank test, p = 0.0055) compared to no TCM. In conclusion, TCM for depression may have a positive association with the survival of prostate cancer patients with depression.

Twelve Chinese herbal preparations for the treatment of depression or depressive symptoms in cancer patients: a systematic review and meta-analysis of randomized controlled trials

Background

Patients with cancer are vulnerable to depression or other depressive conditions. The aim of this paper was to evaluate the efficacy and safety of Chinese herbal medicine (CHM) for the treatment of depression or depressive symptoms in cancer patients.

Methods

CENTRAL, MEDLINE, EMBASE, PsycINFO, CNKI, VIP, SinoMed, and online clinical trial registry websites were searched for relevant RCTs until May 2017. The methodological quality of each included study was assessed with the “risk of bias” tool. Review Manager 5.3.5 was used to analyze the data.

Results

We identified 18 RCTs that included data from 1441 participants. Twelve different types of Chinese herbal preparations were investigated by these studies, and they showed a better therapeutic effect in most comparisons when measured in terms of depression rating scale scores, with SMDs (95% CI) of − 2.30 (− 3.54, − 1.05) (CHM versus no treatment), − 0.61 (− 1.03, − 0.18) (CHM versus antidepressants), and − 0.55 (− 1.07, − 0.02) (CHM plus psychological treatments versus psychological treatments), or when measured in terms of treatment response rate, with RRs (95% CI) of 1.65 (1.19, 2.29) (CHM versus no treatment), 1.15 (1.03, 1.28) (CHM versus psychological treatments), 1.32 (1.07, 1.63) (CHM plus antidepressants versus antidepressants), and 1.70 (1.02, 2.85) (CHM plus psychological treatments versus psychological treatments). Compared with antidepressants, these CHMs showed borderline superiority for improving the response rate, with an RR (95% CI) of 1.08 (0.93, 1.26). Subgroup analysis based on psychiatric diagnosis (depression versus depressive symptoms) did not modify the direction of these estimates and neither could it explain the high level of heterogeneity. Patients in the CHM group experienced fewer adverse events of cardiac toxicity (P = 0.02), functional gastrointestinal disorders (P = 0.008), sleep disturbances (P = 0.02), blurred vision (P = 0.02) and fatigue (P = 0.03) than the patients in the no treatment group or the antidepressants group.

Conclusions

According to the investigation of the twelve herbal preparations, the CHM intervention appears to alleviate depressive symptoms in cancer patients, either alone or combined with antidepressants or psychological treatments. However, a high risk of bias and high heterogeneity made the mean estimates uncertain. Well-designed trials with comprehensive and transparent reporting are warranted in the future.

Electronic supplementary material

The online version of this article (10.1186/s12906-019-2441-8) contains supplementary material, which is available to authorized users.

Psycho-oncology

Medical progress, the improvement of general living conditions, and an increase in life expectancy have led to an increase in the general prevalence of oncologic disease. More importantly, more and more patients survive cancer or live with the disease for long periods of time. While the battle for survivorship is continuously being fought, improving patients' quality of life has come to the fore. Psychosocial issues may modulate the course of the disease, but mainly have a deep impact on patients' physical and mental wellbeing. Psycho-oncology has risen as a relatively new interdisciplinary field with the aim of addressing these issues and providing support for patients confronting numerous challenges throughout the different stages of the disease. In this article, we provide an overview of the current knowledge of body-mind interactions in cancer and an outline of the broad spectrum of psycho-oncologic care, with a special focus on the treatment of pain, fatigue, sexual issues, and fear of progression.