Psychological Distress in Patients with Cancer Warrants Attention

Phoebe Starr

December 2017, Vol 7, No 12 - Supportive Care

San Diego, CA—The National Comprehensive Cancer Network (NCCN) estimates that at least 33% of patients with cancer have significant psychological distress, and many patients have some levels of distress. High levels of distress are associated with negative outcomes from cancer treatment. The psychological well-­being of patients with cancer has been less well-studied than the effects of treatments, but recently, more attention is focused on the “whole patient.”

Two studies presented at the 2017 American Society for Radiation Oncology annual meeting focus on this subject. One study showed that significant levels of distress are associated with more missed medical appointments and more hospital admissions than lower levels of distress. A second study showed that 75% of patients with cancer who were diagnosed with depression had not been previously diagnosed with depression, suggesting that better mental health screening is needed for patients with cancer.

Distress Levels

The first study included 54 patients who received external beam radiation with curative intent for 1 year, from 2015 to 2016. The average patient age was 59 years, and 58% of patients were males. The investigators used the NCCN Distress Thermometer to assess patients’ levels of distress. This brief instrument is similar to the visual analog pain scales ranging from 0 = no pain, to 10 = extreme pain, but measures distress levels. Overall, 15% of patients reported severe distress levels (scores, 7-10), 29% reported moderate distress levels (scores, 4-6), 29% reported low distress levels (scores, 1-3), and 25% reported no distress.

Patients with higher distress levels were more likely to miss appointments for radiation therapy than patients with lower distress levels: 57% of patients with severe distress scores missed at least 1 appointment compared with 18% of those with lower distress levels (P <.01).

Hospital admission during treatment was also more common in patients with higher distress levels than in patients with lower distress levels. Of the patients with higher distress levels, 50% were admitted to the hospital compared with 11% for those with lower distress levels (P <.01).

“Our study demonstrates an association between distress and radiotherapy-specific outcomes, adding to the growing body of evidence emphasizing a need for an interdisciplinary approach to cancer care,” said lead investigator Justin Anderson, a medical student at Virginia Commonwealth University School of Medicine, Richmond.

Looking at the contribution of demographic and disease factors associated with distress, cancer stage was the only factor positively associated with distress. Each increase in cancer stage was associated with an average increase of 0.8 points on the distress score (P <.05).

“These findings underscore the importance of devising treatment plans that address mental well-being and are unique to each patient’s individual needs. For example, if a patient is experiencing severe distress—and is therefore at higher risk of missing appointments or being admitted to the hospital—we can offer transportation or housing support,” said Mr Anderson.

Undiagnosed Depression

Depression is 2 to 3 times more common in patients with cancer than in the general population, yet it often goes undiagnosed. A study at an urban cancer center showed that 3 of 4 patients with cancer diagnosed with depression had not been previously diagnosed as depressed.

The study included 400 patients with cancer who received treatment at the University Hospital Cancer Center in Newark, NJ, between 2013 and 2016. Of these, 40% of patients were diagnosed with depression, which is nearly twice as high as estimates of depression among patients with cancer from the National Cancer Institute (ie, 15%-25%). Among patients who were diagnosed with depression, 75% were diagnosed for the first time.

Depression was more likely to occur among female than male patients (47% vs 32%, respectively; P = .007) and in patients with disability who were unable to work versus those who were able to work (48% vs 33%, respectively; P = .005). The rate of depression did not differ according to racial or ethnic group.

Even among patients who were not previously diagnosed with depression, female sex and the inability to work were associated with depression (43% of females vs 29% of males; P = .02; 43% of patients unable to work vs 31% of patients able to work; P = .03).

“Our findings point to a clear need for action, including depression screening during initial and continuing patient visits, initiation of mental health treatments for identified patients, and increased collaboration with mental health providers in cancer treatment centers,” said lead investigator Jason D. Domogauer, MD/PhD candidate, Department of Radiology, Rutgers University New Jersey Medical School, Newark. “These findings are particularly important for urban centers and females, and those who are disabled due to cancer,” he said.