By Charles Bankhead, Staff Writer, MedPage Today
Reviewed by Zalman S. Agus, MD; Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania
- Retrospective data from patients with breast, lung, colorectal, genitourinary, or gynecological cancer who had participated in routine screening for depression in cancer clinics revealed a prevalence of major depression ranging from 5-11% in the various cancer groupings.
- The majority of patients were not receiving potentially effective treatment.
The vast majority of clinically depressed cancer patients receive no treatment for the depression, a retrospective study of 21,000 cancer patients showed.
Of 1,538 patients who met diagnostic criteria for clinical depression, 1,130 (73%) did not receive “potentially effective treatment.” Better recognition and management of comorbid depression represents a “pressing need” among cancer patients, Jane Walker, PhD, of the University of Oxford in England, and co-authors reported online in The Lancet Psychiatry.
“Major depression, although ubiquitous among cancer outpatients, is common and therefore merits greater attention,” the authors concluded. “Furthermore, its greater prevalence in patients with some cancer groupings, notably lung cancer, suggests where screening for depression will find the most cases.
“Finally, despite its adverse effects on quality of life and adherence to treatment, depression in patients attending cancer clinics is inadequately managed at present.”
In two additional articles, one in The Lancet and one in The Lancet Oncology, the authors reported findings from two randomized trials that showed improvement in multiple depression-associated outcomes among cancer patients who received multidisciplinary management of depression integrated into their cancer care.
Cancer and Depression
Comorbid depression exacerbates several adverse effects of cancer, including anxiety, pain, fatigue, and functioning. Clinically depressed cancer patients have higher rates of suicidal ideation and poor adherence to cancer treatment, the authors noted in their introduction.
Beginning in 2015 the American College of Surgeons’ Commission on Cancer will require cancer centers in the U.S. to screen patients for psychosocial distress, including depression.
Effective treatment of comorbid depression begins with an appreciation of the magnitude of the problem. Currently available data lack the robustness needed to address basic questions regarding depression in cancer patients, the authors continued. Even the few high-quality studies did not adequately assess the prevalence of depression in cancer patients.
To inform decision-making, Walker and colleagues performed a cross-sectional analysis of clinical data for cancer patients treated at three cancer centers in Scotland. Collectively, the centers have a service area that encompasses 4 million people.
Analysis of records for 26,570 patients identified 21,151 patients who had complete clinical data and had been screened for depression. The screen consisted primarily of a structured interview and two depression-centered surveys: the Hospital Anxiety and Depression Scale and the Structured Clinical Interview for DSM-IV.
The depression screen identified 1,599 patients with diagnoses of major depression. The prevalence of depression was highest among patients with lung cancer (13.1%), gynecologic cancer (10.9%), breast cancer (9.3%), colorectal cancer (7.0%), and genitourinary cancer (5.6%). Depressed patients tended to be older, were more likely to be women, and tended to be more socially isolated and deprived.
The authors found that 1,538 of the 1,599 patients had complete data and formed the basis for the analysis. Overall, 27% of the patients received any type of potentially effective treatment for depression.
“Perhaps our most important finding was that most cancer outpatients with depression were not in receipt of potentially effective treatment for their depression,” the authors concluded. “Although undertreatment of major depression has previously been reported for the general population, and for those who self-reported a diagnosis of cancer when asked in a survey, the undertreatment of patients attending specialist cancer services is especially concerning.”
In two additional publications, the authors presented results from interventions for cancer patients with comorbid depression. The larger of the two studies involved 500 patients with various types of cancer. The second focused on management of depression in patients with poor-prognosis cancers.
In the larger study, patients were randomized to depression care or usual care, in addition to their primary treatment for cancer. The depression care was a multifaceted program directed by cancer nurse specialists and psychiatrists in collaboration with primary care physicians. The program included both medication and behavioral/psychosocial therapy.
The primary outcome was a minimum 50% reduction in depression severity at 24 weeks, as defined by the 20-item Symptom Checklist Depression Scale (SCL-20).
The results showed that 63% of patients in the depression-care arm met response criteria compared with 17% of patients in the usual-care group (OR 8.5, 95% CI 5.5-13.4, P<0.0001), Michael Sharpe, MD, of the University of Oxford, and co-authors reported online in The Lancet.
Additionally, patients randomized to the depression intervention had less depression, anxiety, pain, and fatigue, as well as better functioning, health, quality of life, and perceived quality of depression care at all time points during the 24 weeks (P<0.05).
“This striking effectiveness of depression care for people with cancer is probably attributable to the fact that it was intensive … systematically implemented … and integrated with the patient’s cancer and primary care to promote acceptability and adherence,” Sharpe and co-authors said of the results.
The same group of investigators also examined the effect of an integrated depression intervention in 142 patients with lung cancer. As in the larger trial, patients were randomly assigned to the multidisciplinary intervention or usual care, in addition to cancer treatment. The primary outcome was the change in SCL-20 score (range of 0-4) from baseline until the patient’s end of participation in the trial or a maximum of 32 weeks.
The results showed that the intervention group had a significantly lower SCL-20 score (1.24 versus 1.61, mean difference -0.38, 95% CI minus 0.58-minus 0.18). The standardized mean difference between groups was minus 0.62 (95% CI minus 0.94-minus 0./29).
Self-rated depression improvement, anxiety, quality of life, role function, perceived quality of care, and proportion of patients achieving a 12-week treatment response were significantly better in the intervention group compared with patients randomized to usual care.
“Our results suggest that it is possible to effectively treat major depression in this [poor-prognosis] patient group,” Walker and co-authors concluded in The Lancet Oncology. “Depression care for people with lung cancer was substantially more efficacious than was usual care, even when the primary care physician and patient were informed of the depression diagnosis.”
The intervention also was cost-effective, commented Walter F. Baile, MD, of MD Anderson Cancer Center in Houston. The average cost of £613 amounts to less than $1,000.
“Given the low cost and the very positive therapeutic outcome, insurance companies should pay for this intervention,” Baile, who was not involved in the study, told MedPage Today. “It costs less than $1,000. Can you imagine that? That is pretty remarkable, given that we have all these improvements in quality of life, fatigue, and physical functioning.”
“Depression is real. It is not something that people imagine or something that is here today and gone tomorrow. These are illnesses that will not get better on their own in a substantial number of patients. They are illnesses that increase the burden of cancer on patients.”
A point that the authors did not belabor to a great extent involved outcomes for patients who were randomized to usual care. The patients in the control group did much worse, illustrating the downside of not treating depression in cancer patients, Baile added.
In summarizing the larger trial’s results, Sharpe and co-authors agreed.
“We were surprised by how poor the outcome with usual care was, especially since usual care was enhanced by informing patients, oncologists, and primary care physicians of the patients’ diagnosis of major depression,” they said.
“Other trials have recorded similarly poor outcomes with usual care for patients with major depression comorbid with medical conditions,” Sharpe and colleagues added. “Therefore, the frequent clinical practice of managing depression by merely communicating the diagnosis to the patient’s primary care physician … cannot be relied on to produce good outcomes.”
All three studies were supported by Cancer Research UK and by the Chief Scientist Office of the Scottish Government.
Authors of the three studies disclosed no relevant relationships with industry.