Psychological Distress in Patients with Cancer Warrants Attention

San Diego, CA—The National Comprehensive Cancer Network 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 studied less frequently than the effects of treatments, but, recently, more attention has been focused on the whole patient.

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

Distress Levels

The first study, conducted by Justin Anderson, a medical student, Virginia Commonwealth University School of Medicine, Richmond, and colleagues, included 54 patients treated with external beam radiation with curative intent over a 1-year period from 2015 to 2016. The average age of the patients was 59 years, and 58% were men. Mr Anderson and colleagues used the National Comprehensive Cancer Network Distress Thermometer to assess patients’ levels of distress. This brief instrument is similar to visual analog pain scales ranging from 0 (no pain) to 10 (extreme pain), but measures distress levels instead of pain.

Fifteen percent of patients reported severe distress levels (scores of 7-10), 29% reported moderate distress levels (scores of 4-6), 29% reported low distress levels (scores of 1-3), and 25% reported no distress (scores of 0).

Patients with higher distress levels were more likely to miss appointments during the course of radiation therapy; 57% of patients with severe distress scores missed ≥1 appointments compared with 18% of patients with moderate, low, or no distress (P <.01).

Hospital admissions during treatment were also more frequent in patients with higher distress levels; 50% of patients with severe distress scores were admitted to the hospital compared with 11% of patients with moderate, low, or no distress (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,” Mr Anderson told attendees.

Looking at the contribution of demographic and disease factors, Mr Anderson and colleagues noted that 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 in the patient’s 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 therefore is at higher risk of missing appointments or being admitted to the hospital—we can offer transportation or housing support,” Mr Anderson stated.

Undiagnosed Depression

Depression is 2 to 3 times more common in patients with cancer than among the general population, yet the disorder often goes undiagnosed. The second study, which took place at an urban cancer center, found that 75% of patients with cancer diagnosed with depression had not been previously identified or diagnosed as having the disorder.

The study included 400 patients with cancer treated at the University Hospital Cancer Center, Newark, NJ, between 2013 and 2016, and was conducted by Jason Domogauer, MD/PhD candidate, Rutgers New Jersey Medical School, Newark. Of these 400 patients, 40% were diagnosed with depression for the first time at the cancer center. This percentage is approximately twice as high as the National Cancer Institute’s estimates of depression among patients with cancer—15% to 25%.

Depression was more common among women than men (47% vs 32%, respectively; P = .007), and more common among patients who were unable to work because of disabilities (48%) than in those able to work (33%; P = .005). The rate of depression did not differ by racial or ethnic group.

Even among patients not previously diagnosed with depression, the disorder was more common among women (43% vs 29% of men; P = .02) and those unable to work because of disability (43% 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. These efforts are particularly important for patients in urban centers, those who are female, and those who are unable to work because of their disease,” said Mr Domogauer.