Support Care Cancer (2014) 22:871–879 DOI 10.1007/s00520-013-2042-x
ORIGINAL ARTICLE
Association between supportive care interventions and patient self-reported depression among advanced cancer outpatients Wadih Rhondali & Sriram Yennurajalingam & Jeanette Ferrer & Gary Chisholm & Marilene Filbet & Eduardo Bruera
Received: 15 May 2013 / Accepted: 28 October 2013 / Published online: 16 November 2013 # Springer-Verlag Berlin Heidelberg 2013
Abstract Purpose Advanced cancer patients often experience moderate to severe physical and emotional distress. One of the main components of emotional distress is depression. The objective of this study was to examine the association between supportive care interventions and patient self-reported depression (PSRD) among advanced cancer outpatients. Methods We included consecutive patients seen in the outpatient Supportive Care Center between February 2008 and February 2010 with at least one follow-up visit. We used the Edmonton Symptom Assessment Scale (ESAS) to assess their symptom intensity. Clinical improvement of PSRD was defined as an improvement of at least 30 % between the initial visit and the first follow-up. We used logistic regression models to assess possible predictors of improvement in PSRD. Results We included 444 patients with a median age of 59 years (Q1–Q3; 51–65). The most common type of cancer W. Rhondali : S. Yennurajalingam : E. Bruera (*) Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 1414, Houston, TX 77030, USA e-mail: [email protected] W. Rhondali : M. Filbet Department of Palliative Care, Centre Hospitalier de Lyon-Sud, Hospices Civils de Lyon, 164 chemin du Grand Revoyet, 69495, Pierre Bénite Cedex Lyon, France J. Ferrer Department of Palliative Care, Lyndon Baines Johnson General Hospital, Houston, TX 77026, USA G. Chisholm Department of Biostatistics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 1411, Houston, TX 77030, USA
was gastrointestinal (98, 22 %). Out of the 444 patients, 160 (36 %) reported moderate/severe depression at baseline (ESAS item score≥4/10). Higher baseline depression intensity was significantly associated to anxiety (r =0.568, p = 0.046), total symptom distress score (TSDS; r =0.550, p < 0.001) and personal history of depression (r =0.242, p = 0.001). Of the 160 patients, 90 (56 %) with moderate/severe PSRD at baseline showed a significant improvement at the follow-up visit (p =0.038). Improvement in anxiety, sedation, and feeling of well-being were associated with higher depression improvement (OR 7.93, CI 3.74–16.80 and OR 2.44, CI 1.09–5.46, respectively). Conclusions More than 50 % patients with moderate/severe PSRD significantly improved after one single supportive/ palliative care consultation. Improvements of anxiety and sedation were independently associated with PSRD improvement. Keywords Supportive care . Depression . Symptom management
Introduction Patients with advanced cancer experience severe physical and psychosocial symptoms [1, 2]. Psychosocial distress and especially depression can strongly impair patient quality of life, along with an aggravation of physical symptoms such as pain, fatigue, and loss of appetite [3–5]. Depressive symptoms (asthenia, sleep disturbances, anorexia, etc.) have been reported to significantly affect patient functioning, whether physical, social, or mental and to decrease patient's adherence to medical treatments [6]. Exacerbations of physical symptoms can be observed, such as pain
872
becoming refractory and uncontrollable, or multiplication of somatic complaints [7]. Moreover, recent studies have reported depression as an independent predictive factor in cancerrelated mortality [8–10]. Unmanaged depression is also responsible for substantial economic repercussions (medical and drug over-consumption, longer hospital stays) [11–13]. In advanced cancer, depression frequency has been reported to be around 25 % (95 % CI 17.5–32.4) [14], with variations related to the cancer site and stage, cancer-related symptom intensity, previous psychological factors (personal history of depression, alcoholism), spiritual, social, and financial factors [15–17]. Almost half of these patients did not receive any depression specific management [18], although the benefit of such intervention (combination of supportive psychotherapy, cognitive and behavioral techniques, and pharmacotherapy) has been established [15, 19–25]. One of the main issues resulting in depression under recognition is the lack of systematic screening in daily practice [26] as well as the complexity of symptom distress in advanced cancer patients that are more likely to experience other cancer-related symptoms such as fatigue, anorexia, weight loss, or sleep disturbances [7, 27]. Despite of NCCN and EAPC guidelines to include mood screening in routine care using validated tool (e.g., distress thermometer with a cutoff≥4) [13, 25], the implementation of these recommendations has been low [28, 29]. Palliative care services have been shown to be effective in managing distressing symptoms in advanced cancer patients [30–32]. However, response rates and factors associated with improvement of depression remain unclear. The objective of this retrospective study was to examine the association between supportive care interventions and patient self-reported depression (PSRD) among advanced cancer outpatients.
Methods Participants The Institutional Review Board at The University of Texas MD Anderson Cancer Center approved this study and all patients and caregivers gave written informed consent. We reviewed the electronic medical records of consecutive patients seen in the outpatient Supportive Care Center for an initial consultation between February 18, 2008 and February 18, 2010. Inclusion criteria included a diagnosis of advanced cancer (defined as locally advanced, recurrent, or metastatic disease), and at least one follow-up visit within 30 days of the initial consultation. To be eligible for this study, patients had to have prospectively completed the Edmonton Symptom Assessment Scale (ESAS) questionnaire at the initial and the follow-up clinic visits.
Support Care Cancer (2014) 22:871–879
Supportive care clinic The Supportive Care Center's interdisciplinary team has board-certified palliative care physicians, palliative caretrained registered nurses, pharmacists, nutritionists, chaplains, social worker, psychiatric nurse-counselor, and wound care nurse. The types of clinic visits are new consultations, followup visits, and walk-in visits for symptom management including counseling patients and caregivers with psychosocial distress. The care follows a standardized management plan. All patients are initially assessed by a nurse using the Edmonton Symptom Assessment System (ESAS), Memorial Delirium Assessment Score, and CAGE questionnaire. The findings are discussed with a physician who then conducts an interview with patient and family and a physical examination [33]. Assessments and management of cancer-related symptoms along with counseling, discussions about the goals of care, and assistance with decision making are provided by physician, nurse, social worker, and counselor according to patient's needs. After this initial assessment, patients are given a following date ranging from 1 to 4 weeks from the initial visit according to clinical findings. Patients are given 24 h telephone number that is answered by a specially trained nurse during working hours, Monday to Friday and by a physician on weekend and night. These interventions align with the guidelines established by the National Comprehensive Cancer Network and National Consensus Project [34]. In addition, patients received counseling focusing on the severity of psychosocial distress measured by the ESAS (depression, anxiety, and sensation of well-being). Patients undergo expressive supportive therapy, screening for suicidal ideation or elements of severe depression and if appropriate antidepressants medication is started, screening for the potential of severe psychiatric comorbidities, and if so, they are referred to the psychiatric services. They also received counseling regarding physical activity, exposure to natural light, and they are referred for further counseling as appropriate. Instruments The ESAS measures the response to ten symptoms (pain, fatigue, nausea, depression, anxiety, sedation, Dyspnea, lack of appetite, sleep disturbances, and impaired feeling of wellbeing) in patients with cancer. The ESAS asks patients to rate the intensity of these symptoms over the past 24 h using an 11point numeric rating scale, from 0 (no symptoms) to 10 (worst possible symptoms) [35–37]. This questionnaire has been validated in cancer populations [36, 38, 39]. The ESAS yields a total score and two subscale scores. The TSDS is the sum of the scores for the 10 symptoms for a total score of 0–100 [39].
Support Care Cancer (2014) 22:871–879
The physical distress subscore (PHS) was the sum of scores for seven symptoms (pain, nausea, fatigue, sedation, appetite, dyspnea, and sleep), and the psychological distress subscore (PSS) was the sum of scores for three symptoms (depression, anxiety, and feeling of well-being) [40]. The CAGE questionnaire is a four-item validated tool used to screen for a history of alcoholism [41]. A score≥2 is more than 85 % sensitive and 90 % specific for the diagnosis of alcohol abuse and/or dependence [42]. Outcomes measures Demographic information (i.e., age, gender, and ethnicity) and clinical data (i.e., cancer diagnosis, metastatic site) were collected. We reviewed the cancer treatment patient received (chemotherapy, radiation, cancer-related surgery) during the previous month, and we also collected any personal history of depression from patient medical chart. We reviewed the medication regimen (e.g., antidepressants, anxiolytics, neuroleptics, psychostimulants) received by the patient at the initial consult as well as the medication changes or counseling referral after the consult. We also reviewed the electronic medical records to identify if the palliative care team had made the diagnosis of depression. Survival data were collected from the medical chart between the time of the consult and the death of patient. Patients alive at the time of data collection were included in the analysis as censored cases using the date of last consult. We decided to consider the cut off of ≥4 (moderate/severe) because we were interested in the changes in the severity of symptom expression, as recommended for other symptoms [2, 13, 43, 44]. We defined clinical improvement as an improvement of at least 30 % or more (1.2 point or more) on the ESAS between the initial visit and the first follow-up visit, as suggested by others [45–48]. Statistical considerations We report categorical variables with frequencies and percentages and continuous variables by their mean and standard deviation if they were normally distributed. If they were not normally distributed, we report the median and interquartile range (Q1–Q3), and analyzed the data using nonparametric methods. Student's two-tailed t test was used to compare the frequencies of no/mild depression and moderate/severe depression. Assuming alpha=0.05, we calculated that we would have >99 % power to detect a difference of least 30 % on the ESAS scale [36]. Similarly, each individual factor from all of the instruments was tested for any effect on the ESAS score using Student's two-tailed t test. Because there were many comparisons, we corrected the results using Bonferroni methods. Power was estimated
873
to remain >99 % for up to 50 comparisons. Pearson correlation coefficients and associated p values are reported comparing each ESAS item between no/mild and moderate/ severe depression and Spearman correlation coefficients and associated p values are reported comparing for categorical variables between no/mild and moderate/severe depression. The Mann–Whitney U tests and Chi-square tests were performed to determine factors associated with depression, where depression is defined as patients with at least moderate depression (scores≥4; n =160). Estimates of effect size are presented as odds ratios (OR) based on the results of univariate logistic regressions. Stepwise logistic regression was attempted to create a multivariate model for change in ESAS depression item score following palliative care consultation. p Values
ORIGINAL ARTICLE
Association between supportive care interventions and patient self-reported depression among advanced cancer outpatients Wadih Rhondali & Sriram Yennurajalingam & Jeanette Ferrer & Gary Chisholm & Marilene Filbet & Eduardo Bruera
Received: 15 May 2013 / Accepted: 28 October 2013 / Published online: 16 November 2013 # Springer-Verlag Berlin Heidelberg 2013
Abstract Purpose Advanced cancer patients often experience moderate to severe physical and emotional distress. One of the main components of emotional distress is depression. The objective of this study was to examine the association between supportive care interventions and patient self-reported depression (PSRD) among advanced cancer outpatients. Methods We included consecutive patients seen in the outpatient Supportive Care Center between February 2008 and February 2010 with at least one follow-up visit. We used the Edmonton Symptom Assessment Scale (ESAS) to assess their symptom intensity. Clinical improvement of PSRD was defined as an improvement of at least 30 % between the initial visit and the first follow-up. We used logistic regression models to assess possible predictors of improvement in PSRD. Results We included 444 patients with a median age of 59 years (Q1–Q3; 51–65). The most common type of cancer W. Rhondali : S. Yennurajalingam : E. Bruera (*) Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 1414, Houston, TX 77030, USA e-mail: [email protected] W. Rhondali : M. Filbet Department of Palliative Care, Centre Hospitalier de Lyon-Sud, Hospices Civils de Lyon, 164 chemin du Grand Revoyet, 69495, Pierre Bénite Cedex Lyon, France J. Ferrer Department of Palliative Care, Lyndon Baines Johnson General Hospital, Houston, TX 77026, USA G. Chisholm Department of Biostatistics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 1411, Houston, TX 77030, USA
was gastrointestinal (98, 22 %). Out of the 444 patients, 160 (36 %) reported moderate/severe depression at baseline (ESAS item score≥4/10). Higher baseline depression intensity was significantly associated to anxiety (r =0.568, p = 0.046), total symptom distress score (TSDS; r =0.550, p < 0.001) and personal history of depression (r =0.242, p = 0.001). Of the 160 patients, 90 (56 %) with moderate/severe PSRD at baseline showed a significant improvement at the follow-up visit (p =0.038). Improvement in anxiety, sedation, and feeling of well-being were associated with higher depression improvement (OR 7.93, CI 3.74–16.80 and OR 2.44, CI 1.09–5.46, respectively). Conclusions More than 50 % patients with moderate/severe PSRD significantly improved after one single supportive/ palliative care consultation. Improvements of anxiety and sedation were independently associated with PSRD improvement. Keywords Supportive care . Depression . Symptom management
Introduction Patients with advanced cancer experience severe physical and psychosocial symptoms [1, 2]. Psychosocial distress and especially depression can strongly impair patient quality of life, along with an aggravation of physical symptoms such as pain, fatigue, and loss of appetite [3–5]. Depressive symptoms (asthenia, sleep disturbances, anorexia, etc.) have been reported to significantly affect patient functioning, whether physical, social, or mental and to decrease patient's adherence to medical treatments [6]. Exacerbations of physical symptoms can be observed, such as pain
872
becoming refractory and uncontrollable, or multiplication of somatic complaints [7]. Moreover, recent studies have reported depression as an independent predictive factor in cancerrelated mortality [8–10]. Unmanaged depression is also responsible for substantial economic repercussions (medical and drug over-consumption, longer hospital stays) [11–13]. In advanced cancer, depression frequency has been reported to be around 25 % (95 % CI 17.5–32.4) [14], with variations related to the cancer site and stage, cancer-related symptom intensity, previous psychological factors (personal history of depression, alcoholism), spiritual, social, and financial factors [15–17]. Almost half of these patients did not receive any depression specific management [18], although the benefit of such intervention (combination of supportive psychotherapy, cognitive and behavioral techniques, and pharmacotherapy) has been established [15, 19–25]. One of the main issues resulting in depression under recognition is the lack of systematic screening in daily practice [26] as well as the complexity of symptom distress in advanced cancer patients that are more likely to experience other cancer-related symptoms such as fatigue, anorexia, weight loss, or sleep disturbances [7, 27]. Despite of NCCN and EAPC guidelines to include mood screening in routine care using validated tool (e.g., distress thermometer with a cutoff≥4) [13, 25], the implementation of these recommendations has been low [28, 29]. Palliative care services have been shown to be effective in managing distressing symptoms in advanced cancer patients [30–32]. However, response rates and factors associated with improvement of depression remain unclear. The objective of this retrospective study was to examine the association between supportive care interventions and patient self-reported depression (PSRD) among advanced cancer outpatients.
Methods Participants The Institutional Review Board at The University of Texas MD Anderson Cancer Center approved this study and all patients and caregivers gave written informed consent. We reviewed the electronic medical records of consecutive patients seen in the outpatient Supportive Care Center for an initial consultation between February 18, 2008 and February 18, 2010. Inclusion criteria included a diagnosis of advanced cancer (defined as locally advanced, recurrent, or metastatic disease), and at least one follow-up visit within 30 days of the initial consultation. To be eligible for this study, patients had to have prospectively completed the Edmonton Symptom Assessment Scale (ESAS) questionnaire at the initial and the follow-up clinic visits.
Support Care Cancer (2014) 22:871–879
Supportive care clinic The Supportive Care Center's interdisciplinary team has board-certified palliative care physicians, palliative caretrained registered nurses, pharmacists, nutritionists, chaplains, social worker, psychiatric nurse-counselor, and wound care nurse. The types of clinic visits are new consultations, followup visits, and walk-in visits for symptom management including counseling patients and caregivers with psychosocial distress. The care follows a standardized management plan. All patients are initially assessed by a nurse using the Edmonton Symptom Assessment System (ESAS), Memorial Delirium Assessment Score, and CAGE questionnaire. The findings are discussed with a physician who then conducts an interview with patient and family and a physical examination [33]. Assessments and management of cancer-related symptoms along with counseling, discussions about the goals of care, and assistance with decision making are provided by physician, nurse, social worker, and counselor according to patient's needs. After this initial assessment, patients are given a following date ranging from 1 to 4 weeks from the initial visit according to clinical findings. Patients are given 24 h telephone number that is answered by a specially trained nurse during working hours, Monday to Friday and by a physician on weekend and night. These interventions align with the guidelines established by the National Comprehensive Cancer Network and National Consensus Project [34]. In addition, patients received counseling focusing on the severity of psychosocial distress measured by the ESAS (depression, anxiety, and sensation of well-being). Patients undergo expressive supportive therapy, screening for suicidal ideation or elements of severe depression and if appropriate antidepressants medication is started, screening for the potential of severe psychiatric comorbidities, and if so, they are referred to the psychiatric services. They also received counseling regarding physical activity, exposure to natural light, and they are referred for further counseling as appropriate. Instruments The ESAS measures the response to ten symptoms (pain, fatigue, nausea, depression, anxiety, sedation, Dyspnea, lack of appetite, sleep disturbances, and impaired feeling of wellbeing) in patients with cancer. The ESAS asks patients to rate the intensity of these symptoms over the past 24 h using an 11point numeric rating scale, from 0 (no symptoms) to 10 (worst possible symptoms) [35–37]. This questionnaire has been validated in cancer populations [36, 38, 39]. The ESAS yields a total score and two subscale scores. The TSDS is the sum of the scores for the 10 symptoms for a total score of 0–100 [39].
Support Care Cancer (2014) 22:871–879
The physical distress subscore (PHS) was the sum of scores for seven symptoms (pain, nausea, fatigue, sedation, appetite, dyspnea, and sleep), and the psychological distress subscore (PSS) was the sum of scores for three symptoms (depression, anxiety, and feeling of well-being) [40]. The CAGE questionnaire is a four-item validated tool used to screen for a history of alcoholism [41]. A score≥2 is more than 85 % sensitive and 90 % specific for the diagnosis of alcohol abuse and/or dependence [42]. Outcomes measures Demographic information (i.e., age, gender, and ethnicity) and clinical data (i.e., cancer diagnosis, metastatic site) were collected. We reviewed the cancer treatment patient received (chemotherapy, radiation, cancer-related surgery) during the previous month, and we also collected any personal history of depression from patient medical chart. We reviewed the medication regimen (e.g., antidepressants, anxiolytics, neuroleptics, psychostimulants) received by the patient at the initial consult as well as the medication changes or counseling referral after the consult. We also reviewed the electronic medical records to identify if the palliative care team had made the diagnosis of depression. Survival data were collected from the medical chart between the time of the consult and the death of patient. Patients alive at the time of data collection were included in the analysis as censored cases using the date of last consult. We decided to consider the cut off of ≥4 (moderate/severe) because we were interested in the changes in the severity of symptom expression, as recommended for other symptoms [2, 13, 43, 44]. We defined clinical improvement as an improvement of at least 30 % or more (1.2 point or more) on the ESAS between the initial visit and the first follow-up visit, as suggested by others [45–48]. Statistical considerations We report categorical variables with frequencies and percentages and continuous variables by their mean and standard deviation if they were normally distributed. If they were not normally distributed, we report the median and interquartile range (Q1–Q3), and analyzed the data using nonparametric methods. Student's two-tailed t test was used to compare the frequencies of no/mild depression and moderate/severe depression. Assuming alpha=0.05, we calculated that we would have >99 % power to detect a difference of least 30 % on the ESAS scale [36]. Similarly, each individual factor from all of the instruments was tested for any effect on the ESAS score using Student's two-tailed t test. Because there were many comparisons, we corrected the results using Bonferroni methods. Power was estimated
873
to remain >99 % for up to 50 comparisons. Pearson correlation coefficients and associated p values are reported comparing each ESAS item between no/mild and moderate/ severe depression and Spearman correlation coefficients and associated p values are reported comparing for categorical variables between no/mild and moderate/severe depression. The Mann–Whitney U tests and Chi-square tests were performed to determine factors associated with depression, where depression is defined as patients with at least moderate depression (scores≥4; n =160). Estimates of effect size are presented as odds ratios (OR) based on the results of univariate logistic regressions. Stepwise logistic regression was attempted to create a multivariate model for change in ESAS depression item score following palliative care consultation. p Values
