Palliative and Supportive Care (2016), 14, 42– 51. # Cambridge University Press, 2015 1478-9515/15 doi:10.1017/S1478951515000711
Persistence of psychological distress and correlated factors among patients with head and neck cancer
KANAKO ICHIKURA, M.SC.,1,2 AYA YAMASHITA, PH.D.,1 TARO SUGIMOTO, SEIJI KISHIMOTO, M.D., PH.D.,4,5 AND EISUKE MATSUSHIMA, M.D., PH.D.1
3 M.D.,
1
Section of Liaison Psychiatry and Palliative Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan Research Fellow of the Japanese Society for the Promotion of Science, Tokyo, Japan 3 Department of Otorhinolaryngology, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan 4 Chief of Head and Neck Surgery, Kameda Medical Center, Chiba, Japan 5 Section of Head and Neck Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan 2
(RECEIVED January 28, 2015; ACCEPTED April 15, 2015)
ABSTRACT Objective: Many patients with head and neck cancer (HNC) suffer from psychological distress associated with dysfunction and/or disfigurement. Our aim was to evaluate the ratio of patients with persistence of psychological distress during hospitalization and identify the predictors of persistence or change in psychological distress among HNC patients. Method: We conducted a single-center longitudinal study with self-completed questionnaires. We evaluated psychological distress (the Hospital Anxiety and Depression Scale; HADS) and functional level (the Functional Assessment of Cancer Therapy –Head and Neck Scale; FACT– H&N) among patients during hospitalization at the Medical Hospital of Tokyo Medical and Dental University. Results: Of 160 patients, 117 (73.1%) completed the questionnaire at both admission and discharge. Some 42 (52.5%) patients reported persistent psychological distress. The physical well-being of patients with continued distress was significantly lower than that of other patients (21.7 + 4.7, 19.4 + 6.1, 19.5 + 5.4; p , 0.01), and the emotional well-being of patients with continued distress was significantly lower than that in patients with no distress and reduced distress (22.3 + 3.5, 20.5 + 2.5; p , 0.01). Significant of results: Impaired physical and emotional function appears to be associated with persistent psychological distress among HNC patients. Psychological interventions focused on relaxation, cognition, or behavior may be efficacious in preventing such persistent distress. KEYWORDS: Anxiety, Depression, Psychological distress, Head and neck cancer, Well-being
INTRODUCTION
motherapy, and radiation therapy—have developed at a rapid pace. As a result, the five-year survival rate among patients with HNC has improved moderately (American Society of Clinical Oncology, 2014; Pulte & Brenner, 2010). However, most HNC patients suffer from dysfunction and disfigurement caused by these medical treatments and have difficulty breathing, eating, and communicating (Danker et al., 2010; Semple et al., 2008). The suicide rate among HNC patients is more than four times greater than that of the general population (Zeller, 2006),
Head and neck cancer (HNC) is a collective term describing malignancy located around the oral, larynx, pharynx, and maxillofacial areas. Common treatments for HNC—including surgical operations, cheAddress correspondence and reprint requests to: Kanako Ichikura, Section of Liaison Psychiatry and Palliative Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan. E-mail: [email protected], [email protected]
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Persistence of psychological distress among HNC patients
and 15– 44% of patients experience psychological distress (depression and anxiety) at some point during the course of their illness (Joseph et al., 2013; Neilson et al., 2013). In particular, depression has a highly negative impact on patients’ lives. Depression can lead to lowered quality of life, poor treatment adherence, poor mental adjustment to cancer, high pain sensitivity, severe physical symptoms, long length of hospital stays, and a decreased survival rate (Aarstad et al., 2014; de Leeuw et al., 2000; Haisfield-Wolfe et al., 2012; Johansson et al., 2011; Satin et al., 2009). Therefore, identification and treatment of depression is crucial in HNC patients. Not all HNC patients with depressive symptoms experience depressive disorder. Indeed, one study reported that only 6.5% of HNC patients are diagnosed with major depressive disorder (MDD) (Singer et al., 2008). Although this percentage is higher than that of the general population, this statistic indicates that HNC patients with MDD may comprise an important subgroup of all patients who experience depressive symptoms. Depression is considered to be a continuous phenomenon that ranges from minor mood swings to major depressive disorder in individuals with head and neck cancer (Haisfield-Wolfe et al., 2009), and persistent depressive symptoms may lead to depressive disorders. Therefore, addressing the persistence of psychological distress among HNC patients is critical to preventing MDD. To the best of our knowledge, however, no studies have examined the factors affecting persistence or change in psychological distress in HNC patients. Understanding the different functional problems faced by patients with persistent distress versus those with reduced distress could be useful for improving psychosocial care in the HNC patient population. The primary aim of this study was thus to evaluate the ratio of patients with persistence of psychological distress in HNC patients during a period of hospital treatment, and to identify the correlated factors affecting persistence of psychological distress. Pretreatment distress is a strong risk factor for posttreatment distress among patients who have undergone surgery or radiation therapy (Adachi et al., 2014; Badr et al., 2014). One study suggested that psychological distress resulting from a diagnosis of HNC persisted, on average, for three years (Joseph et al., 2013). Therefore, reducing pretreatment distress may contribute to prevention of persistent distress. Our secondary aim was to examine the effect of pretreatment factors on psychological distress at the time of hospital admission. Our results could help create a care system for HNC patients prior to receiving treatment.
METHODS Study Design and Participants We used a single-center longitudinal design in which patients self-completed questionnaires. From our research database of patients admitted to the Department of Otorhinolaryngology or the Department of Head and Neck Surgery at the Medical Hospital of Tokyo Medical and Dental University (TMDU) between October of 2011 and August of 2013, we selected patients with laryngeal, pharyngeal, oral, maxillary sinus, paranasal sinus, or nasal cavity cancer. The following patients were excluded from the study: those with severe physical or mental problems, those with insufficient literacy skills, and patients older than 90 years of age. Study Procedures We collected continuous data from all patients admitted to the TMDU. At the time of hospital admission, two researchers (IK and YA), who were not engaged in medical treatments, informed the patients about the purpose of our study and gained their consent for participation. All consenting participants were then approached to complete the questionnaires prior to initiating treatment. The researchers assisted those patients who were unable to independently write their answers because of physical problems. Data were collected at the time of hospital admission (time 1) and at hospital discharge (time 2). Ethics All procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all patients in writing. This study assured anonymity and was approved by the ethics committee of the TMDU (1057). Measures Demographic and Clinical Characteristics We collected demographic and clinical information from the patient medical records to identify potential confounders for psychological distress. We included the following data: age, gender, history of alcohol intake, history of smoking, frequency of going out, original cancer, TNM classification, time since diagnosis, whether they were receiving initial treatment or not, treatment type, length of hospital stay, whether they continued therapy after discharge, outcome at the time of hospital discharge, and outcome one year after hospital discharge.
44 Functional Level (Well-Being) We used the Functional Assessment of Cancer Therapy – Head and Neck Scale (FACT– H&N) to measure patient function in terms of predictors of psychological distress (List et al., 1996). The FACT– H&N is a 38-item self-related scale used to measure function and well-being in cancer patients. The scale has five factors: physical well-being (7 items), social/family well-being (7 items), emotional well-being (6 items), functional well-being (7 items), and a head and neck cancer subscale (11 items).
Ichikura et al.
tion factor (VIF) (Katz, 2003). A VIF exceeding 10 is regarded as indicating serious multicollinearity, and values greater than 4.0 may be a cause for concern (Katz, 2003). We conducted all analyses using R version 2.15.1., with the R packages “rpsychi” and “car” (R Development Core Team, 2011). All tables and figures were created using Microsoft Office 2013. RESULTS Participant Characteristics
Psychological Distress (Anxiety and Depression) We evaluated psychological distress using the Hospital Anxiety and Depression Scale (HADS) (Zigmond & Snaith, 1983), which is a 14-item self-related scale used to measure psychological distress. The scale has two factors: anxiety and depression. It is a 4-point Likert-type scale ranging from 0 to 3 (overall score 0 – 42). We used an optimal cutoff point of 10/11 to screen for adjustment or major depressive disorder (Carroll et al., 1993; Kugaya et al., 1998). Statistical Analysis We first examined the frequency of psychological distress (HADS – total 11) at time 1 and time 2 and categorized the participants into four groups based on their status at these timepoints: (1) a no-distress group (without distress to without distress); (2) a reduced-distress group (with distress to without distress); (3) an increased-distress group (without distress to with distress); and (4) a continued-distress group (with distress to with distress). We then summarized the demographic and clinical characteristics of these four groups using standard descriptive statistics. We next used an ANOVA to evaluate the differences between the four groups in terms of functional level (FACT score). We employed logistic regression modeling to examine the association between functional level and psychological distress at time 2. We then calculated the odds ratios (ORs) and 95% confidence intervals (95% CI) after controlling simultaneously for potential confounders. The following variables were considered in the models: age (nominal), frequency of going out (nominal), T classification (continuous), presence of surgery treatment (nominal), and whether the patient was receiving initial treatment or not (nominal). The independent variables included in this model were chosen based on a-priori clinical judgment and the existing literature. We utilized the likelihood ratio test to determine the statistical significance of the interaction terms in the logistic regression models. We assessed multicollinearity using the variance infla-
Of 186 patients with head and neck cancer, data from 167 participants were considered potentially suitable for our study (Figure 1). A total of 7 patients were excluded because they had physical difficulty at the time of hospital admission, leaving 160 participants. Some 43 patients dropped out of the study because they were discharged from the hospital and left without returning their questionnaires, leaving a total of 117 participants for whom we analyzed data. As mentioned above, we created four participant groups: the no-distress group (n ¼ 45), the reduceddistress group (n ¼ 17), the increased-distress group (n ¼ 13), and the continued-distress group (n ¼ 42). These groups were created according to psychological distress scores (HADS –total) at times 1 and 2 (Figure 2). Some 42 (52.5%) participants reported continued psychological distress from the time of hospital admission through to hospital discharge. Participant characteristics are presented in Table 1. Some 65 (55.6%) participants were over 65 years of age, 102 (87.2%) were male, and 85 (72.6%) had a history of smoking. The underlying diseases and received therapeutic treatments during hospitalization are also given in Table 1. The frequency of elderly (65 years old) patients was significantly higher in the increased-distress (n ¼ 12, 92.3%) and continued-distress groups (n ¼ 27, 64.3%). Additionally, the frequency of patients with pharyngeal cancer was significantly higher in the reduced-distress group (n ¼ 11, 64.7%), and the frequency of patients with oral cancer was significantly higher in the continued-distress group (n ¼ 14, 33.3%). Differences in Functional Level Between the Four Groups Table 2 presents the differences in functional level between the four groups for each of the five FACT factors, including the means (M ) and standard deviations (SD). The ANOVA revealed significant differences between the four groups for all five FACT factors. Tukey multiple comparisons indicated that the patient physical well-being scores were
45
Persistence of psychological distress among HNC patients
Fig. 1. Patient recruitment flowchart.
significantly lower in the continued-distress group (14.7 + 5.2) compared with the other groups (21.7 + 4.7, 19.4 + 6.1, 19.5 + 5.4; p , 0.01), and that the emotional well-being scores were significantly lower in patients in the continued-distress group (13.4 + 4.2) compared with the no-distress group and the reduced-distress group (22.3 + 3.5, 20.5 + 2.5; p , 0.01).
(Table 3), with adjusted OR of 0.33 (95% CI ¼ 0.12 – 0.92), 4.18 (95% CI ¼ 1.15 – 15.24), 0.78 (CI95% ¼ 0.67 – 0.90), 0.79 (95% CI ¼ 0.69 – 0.91), and 0.85 (95% CI ¼ 0.76 – 0.94). The likelihood ratio test indicated that none of the interactions between independent variables were significant. We found no evidence for multicollinearity because the VIF for the independent variables in this model was less than 4.0.
Factors Influencing Psychological Distress at the Time of Hospital Admission
DISCUSSION
Table 3 presents the factors influencing psychological distress (HADS – total 11) at time 1, with each OR and 95% CI. A logistic regression analysis revealed that younger age (65 years old), scheduled surgery, and poor physical, emotional, and functional well-being were risk factors for psychological distress at the time of hospital admission
The primary aim of our study was to evaluate the ratio of patients with persistence of psychological distress over a period of hospital treatment in HNC patients. Our data revealed that half of our HNC patients experienced psychological distress and 70% reported continuous symptoms over the entire duration of their hospital stay. Additionally,
Fig. 2. Change in psychological distress from the time of admission until discharge.
46
Table 1. Demographic and clinical characteristics of the study participants (N ¼ 117) All (N ¼ 117) n (%)
No Distress (n ¼ 45) n (%)
Decreased Distress (n ¼ 17) n (%)
Increased Distress (n ¼ 13) n (%)
Continued Distress (n ¼ 42) n (%)
65 (55.6) 52 (44.4)
19 (42.2) 26 (57.8)
7 (41.2) 10 (58.8)
12 (92.3) 1 (7.7)
27 (64.3) 15 (35.7)
102 (87.2) 15 (12.8)
37 (82.2) 8 (17.8)
16 (94.1) 1 (5.9)
12 (92.3) 1 (7.7)
37 (88.1) 5 (11.9)
26 (22.2) 88 (75.2) 3 (2.6)
9 (20.0) 36 (80.0) 0 (0.0)
5 (29.4) 11 (64.7) 1 (5.9)
2 (15.4) 10 (76.9) 1 (7.7)
10 (23.8) 31 (73.8) 1 (2.4)
28 (23.9) 85 (72.6) 4 (3.4)
13 (28.9) 31 (68.9) 1 (2.2)
3 (17.6) 13 (76.5) 1 (5.9)
3 (23.1) 9 (69.2) 1 (7.7)
9 (21.4) 32 (76.2) 1 (2.4)
66 (56.4) 49 (41.9) 2 (1.7)
24 (53.3) 20 (44.4) 1 (2.2)
10 (58.8) 6 (35.3) 1 (5.9)
8 (61.5) 5 (38.5) 0 (0.0)
24 (57.1) 18 (42.9) 0 (0.0)
14 (12.0) 65 (55.6)
4 (8.9) 27 (60.0)
4 (23.5) 11 (64.7)
4 (30.8) 7 (53.8)
2 (4.8) 20 (47.6)
27 (23.1) 11 (9.4)
11 (24.4) 3 (6.7)
1 (5.9) 1 (5.9)
1 (7.7) 1 (7.7)
14 (33.3) 6 (14.3)
18 54 19 19
(15.4) (46.2) (16.2) (16.2)
8 (17.8) 21 (46.7) 8 (17.8) 5 (11.1)
3 (17.6) 9 (52.9) 2 (11.8) 2 (11.8)
1 (7.7) 8 (61.5) 2 (15.4) 2 (15.4)
6 (14.3) 16 (38.1) 7 (16.7) 10 (23.8)
58 15 36 1 1
(49.6) (12.8) (30.8) (0.9) (0.9)
24 (53.3) 3 (6.7) 15 (33.3) 0 (0.0) 0 (0.0)
10 (58.8) 5 (29.4) 1 (5.9) 0 (0.0) 1 (5.9)
7 (53.8) 0 (0.0) 6 (46.2) 0 (0.0) 0 (0.0)
17 (40.5) 7 (16.7) 14 (33.3) 1 (2.4) 0 (0.0)
109 (93.2) 2 (1.7)
42 (93.3) 0 (0.0)
16 (94.1) 1 (5.9)
13 (100.0) 0 (0.0)
38 (90.5) 1 (2.4)
p
Demographic characteristics Age Elderly group (≥65 years) Younger group (,65 years) Gender Male Female Alcohol No Yes Unclear Smoking No Yes Unclear Going out Sometimes Everyday Unclear
0.00
**
0.67 0.79
0.82
0.95
Clinical characteristics 0.03
*
0.89
0.03
*
0.35
Continued
Ichikura et al.
Original cancer Laryngeal cancer Pharyngeal cancer (epipharynx, oropharynx, or hypopharynx) Oral cancer (oral or tongue) Other T 1 2 3 4 N 0 1 2 3 4 M 0 1
Initial treatment No (metastatic, recurrent, or remaining cancer) Yes Surgery No Yes Chemotherapy No Yes Radiation therapy No Yes Continued therapy after discharge No Yes Outcome at the time of hospital discharge Improved No change Outcome one year after hospital discharge At follow-up With remaining cancer in active treatment With recurrent or metastatic cancer in active treatment In best supportive care Death Unclear
All (N ¼ 117) n (%)
No Distress (n ¼ 45) n (%)
Decreased Distress (n ¼ 17) n (%)
Increased Distress (n ¼ 13) n (%)
Continued Distress (n ¼ 42) n (%)
69 (59.0)
28 (62.2)
10 (58.8)
6 (46.2)
25 (59.5)
48 (41.0)
17 (37.8)
7 (41.2)
7 (53.8)
17 (40.5)
52 (44.4) 65 (55.6)
20 (44.4) 25 (55.6)
7 (41.2) 10 (58.8)
7 (53.8) 6 (46.2)
18 (42.9) 24 (57.1)
64 (54.7) 53 (45.3)
25 (55.6) 20 (44.4)
9 (52.9) 8 (47.1)
6 (46.2) 7 (53.8)
24 (57.1) 18 (42.9)
100 (85.5) 17 (14.5)
38 (84.4) 7 (15.6)
15 (88.2) 2 (11.8)
11 (84.6) 2 (15.4)
36 (85.7) 6 (14.3)
56 (47.9) 61 (52.1)
23 (51.1) 22 (48.9)
8 (47.1) 9 (52.9)
4 (30.8) 9 (69.2)
21 (50.0) 21 (50.0)
p 0.79
0.92 0.93 0.99 0.63
Persistence of psychological distress among HNC patients
Table 1. Continued
0.45 89 (76.1) 28 (23.9)
37 (82.2) 8 (17.8)
13 (76.5) 4 (23.5)
8 (61.5) 5 (38.5)
31 (73.8) 11 (26.2)
60 (51.3) 9 (7.7)
25 (55.6) 5 (11.1)
6 (35.3) 3 (17.6)
9 (69.2) 0 (0.0)
20 (47.6) 1 (2.4)
38 (32.5)
12 (26.7)
6 (35.3)
3 (23.1)
17 (40.5)
5 (4.3) 3 (2.6) 2 (1.7)
1 (2.2) 1 (2.2) 1 (2.2)
1 (5.9) 0 (0.0) 1 (5.9)
1 (7.7) 0 (0.0) 0 (0.0)
2 (4.8) 2 (4.8) 0 (0.0)
M + SD
M + SD
M + SD
M + SD
M + SD
454.6 + 924.5
388.7 + 711.7
268.0 + 618.0
685.5 + 1270.6
180.4 + 212.4
17.7 + 11.5
16.2 + 8.7
22.1 + 10.6
19.5 + 13.4
17.0 + 13.6
0.40
Time since diagnosis (days)
0.20
Length of hospital stay (days)
M ¼ mean, SD ¼ standard deviation. *p , 0.05,
0.30
**
p , 0.01.
47
48
Ichikura et al.
Table 2. Differences in functional level based on changes in psychological distress following hospitalization
Functional level at time 1 (FACT– physical) (FACT–social) (FACT– emotional)
(FACT– functional) (FACT–H&N)
No Distress (n ¼ 45)
Reduced Distress (n ¼ 17)
Increased Distress (n ¼ 13)
Continued Distress (n ¼ 13)
M + SD
M + SD
M + SD
M + SD
21.7 + 4.7
19.4 + 6.1
19.5 + 5.4
14.7 + 5.2
22.6 + 6.0 22.3 + 3.5
19.1 + 8.3 20.5 + 2.5
20.4 + 7.1 16.3 + 2.5
17.9 + 5.4 13.4 + 4.2
p
0.00 **
No . Continued
0.00 ** 0.00 **
Reduced . Continued Increased . Continued No . Continued No . Continued No . Increased Reduced . Continued Reduced . Increased No . Continued
19.0 + 7.4
14.8 + 6.8
13.7 + 6.8
11.6 + 5.6
0.00 **
22.3 + 6.4
17.2 + 5.7
19.8 + 6.2
15.7 + 5.4
0.00 **
M ¼ mean, SD ¼ standard deviation. *p , 0. 05,
Tukey Multiple Comparisons
Nothing . Reduced Nothing . Continued
**
p , 0.01.
physical and emotional well-being in patients with reduced distress was higher than that in patients with continued distress. Previous studies have suggested that 15 to 30% of HNC patients experience psychological distress at
the time of diagnosis and during pretreatment (Joseph et al., 2013; Neilson et al., 2010). Additionally, pretreatment levels of psychological distress have been found to predict levels of psychological distress during posttreatment and follow-up (Adachi et al.,
Table 3. Logistic regression modeling of factors influencing psychological distress at the time of hospital admission (n ¼ 160) Variable Age Younger Older Going out Sometimes Everyday T [Continuous value] Surgery No Yes Initial treatment Treatment for recurrent or remaining cancer Initial treatment Functional level at time 2 [Continuous value] FACT–physical FACT–social FACT–emotional FACT–functional FACT–H&N
Crude OR (CI95%)
Adjusted OR (CI95%)
1 [Ref]
1 [Ref]
.73 (0.37– 1.42)
.33 (0.12– 0.92)
0.03
1 [Ref] 0.96 (0.49– 1.88)
1 [Ref] 2.21 (0.81– 6.00)
0.12
1.27 (0.89– 1.81)
1.19 (0.62– 2.26)
0.60
1 [Ref] 1.11 (0.56– 2.17)
1 [Ref] 4.18 (1.15– 15.24)
0.03
1 [Ref] 1.01 (0.51– 1.98)
1 [Ref] 0.97 (0.36– 2.63)
0.96
0.75 (0.67– 0.85) 0.93 (0.88– 0.99) 0.77 (0.69– 0.85) 0.83 (0.77– 0.90) 0.89 (0.83– 0.95)
0.78 (0.67– 0.90) 0.95 (0.87– 1.04) 0.79 (0.69– 0.91) 0.85 (0.76– 0.94) 1.06 (0.95– 1.17)
0.00 0.24 0.00 0.00 0.31
OR ¼ odds ratio, CI ¼ confidence interval, [Ref] ¼ reference level. *p , 0.05.
p
*
*
** ** **
Persistence of psychological distress among HNC patients
49
2014; Joseph et al., 2013). Our results, which are consistent with previous findings, indicate that we should prevent the persistence of psychological distress beginning at initiation of pretreatment and on through to posttreatment. We found physical function to be associated with the persistence of psychological distress in our study population. Indeed, several previous cross-sectional studies have demonstrated a relationship between psychological distress and physical function among patients with HNC (Chiou et al., 2013; Koizumi et al., 2013; Shiraz et al., 2014). We suggest that there are two possible explanations for this relationship. First, psychological distress may occur as a secondary phenomenon in patients with HNC, resulting from the experience of physical disability, especially when swallowing function is affected (Lin et al., 2012). This common reaction can be described as learned helplessness in a psychological setting, which has a negative impact on psychological adjustment among cancer patients (Eskelinen et al., 2014; Pe´rez et al., 2014). Psychosocial approaches that act directly to reduce dysfunction may enhance a patient’s willingness to live, and dysphagia or vocal rehabilitation may have a beneficial effect on diminishing psychological distress (Cousins et al., 2013; Tuomi et al., 2014). Second, pain or fatigue sensitivity may be an intermediate variable in the relationship between psychiatric weakness and psychological distress. HNC patients with poor subjective physical function are more likely to experience psychological distress (Chiou et al., 2013; Koizumi et al., 2013). Accordingly, relaxation therapies have been shown to have a significant impact on psychological adjustment in HNC patients (Allison et al., 2004; Hammerlid et al., 1999). This may be because such therapies work to increase the amount of attention directed toward body sensations other than pain. We also found that emotional function was associated with persistence of psychological distress in our study population. Some previous cross-sectional studies have shown a relationship between psychological distress and emotional function, as well as between psychological distress and physical function (Chiou et al., 2013; Koizumi et al., 2013; Shiraz et al., 2014). Patients with poor emotional function exhibit negative thinking about their disease or about death, and thus often experience persistent psychological distress, even when their physical status improves. In one metaanalysis, psychological interventions, including psychoeducation and supportive psychotherapy, had no effect on individuals with high levels of psychological distress (Semple et al., 2913). Perhaps traditional psychotherapy is not the most efficacious strategy for changing negative thinking about one’s disease or death. Recent studies have suggested a
strong relationship between attention bias and fear of cancer recurrence (Butow et al., 2014; Park et al., 2013). This indicates a potential for developing an alternative psychotherapeutic technique that includes elements of attention training. Our secondary research aim was to examine the effect of pretreatment factors on psychological distress at the time of hospital admission. In accordance with other studies, our results suggest that younger age (less than 65 years old) and scheduled surgery are demographic predictors of psychological distress at the time of hospital admission (Adachi et al., 2014; Duffy et al., 2007; Mochizuki et al., 2009; Rogers et al., 2006). Along with the previous literature, our results provide support for a relationship between physical, emotional, and functional well-being and pretreatment for psychological distress. Specifically, our results mirror those of another study that implicated emotional and functional well-being as a predictor of psychological distress at the time of pretreatment (Koizumi et al., 2013). Therefore, methods for reducing psychological distress in HNC patients should focus on interventions to improve emotional and functional well-being. Patients who have high levels of functional well-being are able to enjoy daily life, including their job, household responsibilities, and leisure time. Therefore, pretreatment interventions that help patients direct their attention toward the activities of daily life (and away from the details of their illness) are likely to be beneficial. Our study has two important limitations associated with systematic error. First, our methods may not have excluded selection bias. Our study participants were selected from only one hospital in Japan, and there were many laryngeal cancer patients in the group. However, we believe the participants in this study to be representative of those currently being treated in Japanese hospitals, so that our results are generalizable. Second, the sample size was insufficient when comparing the four groups using an ANOVA because of a high dropout rate in the follow-up questionnaire. In future research, we may be able to develop strategies to improve the response rate. However, we found no differences between dropout rates for patients with and without psychological distress at admission; therefore, dropout status may have a minimal effect on the background characteristics of the HNC patients in our four groups. As this was an exploratory study with a small sample size, we are planning to conduct a future large-scale observational study to test our hypothesis. CONCLUSION To the best of our knowledge, this is the first study to focus on the persistence of psychological distress
50 among patients with HNC. Our results indicate that persistence of psychological distress is more common among HNC patients during periods of hospitalization and that their distress is affected by physical and emotional function. New therapeutic approaches are necessary to address psychological distress in HNC patients. Such alternative psychological interventions may focus on helping patients to control their physical or emotional attention. This is certainly a topic for future study. ACKNOWLEDGMENTS This study was supported by a grant-in-aid for JSPS Fellows (Social Science: 24-1085) from the Japan Society for the Promotion of Science between April of 2012 and March of 2015. We are grateful to all collaborators for supporting our research program: the participants, the health providers at TMDU hospitals, and laboratory members at the Department of Liaison Psychiatry and Palliative Medicine at TMDU.
CONFLICTS OF INTEREST The authors state that they have no conflicts of interest to declare. REFERENCES Aarstad, H.J., Osthus, A.A., Olofsson, J., et al. (2014). Level of distress predicts subsequent survival in successfully treated head and neck cancer patients: A prospective cohort study. Acta Oto-Laryngologica, 134, 211 –219. Adachi, Y., Kimura, H., Sato, N., et al. (2014). Preoperative level of depression is a predictor of postoperative levels of depression in patients with head and neck cancer. Japanese Journal of Clinical Oncology, 44, 311–317. Allison, P.J., Nicolau, B., Edgar, L., et al. (2004). Teaching head and neck cancer patients coping strategies: results of a feasibility study. Oral Oncology, 40, 538 –544. American Society of Clinical Oncology (2014). Head and neck cancer: Statistics j Cancer.Net. Available from http:// www.cancer.net/cancer-types/head-and-neck-cancer/ statistics. Badr, H., Gupta, V., Sikora, A., et al. (2014). Psychological distress in patients and caregivers over the course of radiotherapy for head and neck Cancer. Oral Oncology, 50, 1005– 1011. Butow, P., Kelly, S., Thewes, B., et al. (2014). Attentional bias and metacognitions in cancer survivors with high fear of cancer recurrence. Psycho-Oncology, 24(4), 416 –423. Carroll, B.T., Kathol, R.G., Noyes, R., et al. (1993). Screening for depression and anxiety in cancer patients using the Hospital Anxiety and Depression Scale. General Hospital Psychiatry, 15, 69– 74. Chiou, W.Y., Lee, M.S., Ho, H.C., et al. (2013). Prognosticators and the relationship of depression and quality of life in head and neck cancer. Indian Journal of Cancer, 50, 14–20. Cousins, N., MacAulay, F., Lang, H., et al. (2013). A systematic review of interventions for eating and drinking
Ichikura et al. problems following treatment for head and neck cancer suggests a need to look beyond swallowing and trismus. Oral Oncology, 49, 387 –400. Danker, H., Wollbru¨ck, D., Singer, S., et al. (2010). Social withdrawal after laryngectomy. European Archives of Oto-Rhino-Laryngology, 267, 593 –600. de Leeuw, J. R., de Graeff, A., Ros, W.J., et al. (2000). Prediction of depressive symptomatology after treatment of head and neck cancer: the influence of pretreatment physical and depressive symptoms, coping, and social support. Head & Neck, 22, 799 –807. Duffy, S.A., Ronis, D.L., Valenstein, M., et al. (2007). Depressive symptoms, smoking, drinking, and quality of life among head and neck cancer patients. Psychosomatics, 48, 142 –148. Eskelinen, M., Korhonen, R., Selander, T., et al. (2014). The Self-Rating Score (SRS) versus the Examiner Rating Score (ERS) in measuring helplessness in healthy individuals and in patients with benign breast disease and breast cancer: A prospective case-control study in Finland. Anticancer Research, 34, 5677–5682. Haisfield-Wolfe, M.E., McGuire, D.B., Soeken, K., et al. (2009). Prevalence and correlates of depression among patients with head and neck cancer: A systematic review of implications for research. Oncology Nursing Forum, 36, E107 –E125. Haisfield-Wolfe, M.E., McGuire, D.B., Soeken, K., et al. (2012). Prevalence and correlates of symptoms and uncertainty in illness among head and neck cancer patients receiving definitive radiation with or without chemotherapy. Supportive Care in Cancer, 20, 1885–1893. Hammerlid, E., Persson, L.O., Sullivan, M., et al. (1999). Quality-of-life effects of psychosocial intervention in patients with head and neck cancer. Otolaryngology– Head and Neck Surgery, 120, 507– 516. Johansson, M., Ryde´n, A. & Finizia, C. (2011). Mental adjustment to cancer and its relation to anxiety, depression, HRQoL and survival in patients with laryngeal cancer: A longitudinal study. BMC Cancer, 11, 283. Joseph, L.A., Routledge, J.A., Burns, M.P., et al. (2013). Value of the Hospital Anxiety and Depression Scale in the follow-up of head and neck cancer patients. The Journal of Laryngology & Otology, 127, 285– 294. Katz, M.H. (2003). Multivariable analysis: A primer for readers of medical research. Annals of Internal Medicine, 138, 644 –650. Koizumi, A., Matsushima, E., Mochizuki, Y., et al. (2013). Changes in the psychological characteristics of oral cancer patients in the perioperative period: A quantitative evaluation. Journal of Medical and Dental Sciences, 60, 41–53. Kugaya, A., Akechi, T., Okuyama, T., et al. (1998). Screening for psychological distress in Japanese cancer patients. Japanese Journal of Clinical Oncology, 28, 333– 338. Lin, B.M., Starmer, H.M. & Gourin, C. G. (2012). The relationship between depressive symptoms, quality of life, and swallowing function in head and neck cancer patients one year after definitive therapy. The Laryngoscope, 122, 1518– 1525. List, M.A., D’Antonio, L.L., Cella, D.F., et al. (1996). The Performance Status Scale for head and neck cancer patients and the Functional Assessment of Cancer Therapy– Head and Neck Scale: A study of utility and validity. Cancer, 77, 2294– 22301.
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Mochizuki, Y., Matsushima, E. & Omura, K. (2009). Perioperative assessment of psychological state and quality of life of head and neck cancer patients undergoing surgery. International Journal of Oral and Maxillofacial Surgery, 38, 151 –159. Neilson, K.A., Pollard, A.C., Boonzaier, A.M., et al. (2010). Psychological distress (depression and anxiety) in people with head and neck cancers. The Medical Journal of Australia, 193, S48–S51. Neilson, K., Pollard, A., Boonzaier, A., et al. (2013). A longitudinal study of distress (depression and anxiety) up to 18 months after radiotherapy for head and neck cancer. Psycho-Oncology, 22, 1843– 1848. Park, C.L., Cho, D., Blank, T.O., et al. (2013). Cognitive and emotional aspects of fear of recurrence: Predictors and relations with adjustment in young to middle-aged cancer survivors. Psycho-Oncology, 22, 1630 –1638. Pe´rez, S., Galdo´n, M.J., Andreu, Y., et al. (2014). Posttraumatic stress symptoms in breast cancer patients: Temporal evolution, predictors, and mediation. Journal of Traumatic Stress, 27, 224 –231. Pulte, D. & Brenner, H. (2010). Changes in survival in head and neck cancers in the late 20th and early 21st century: A period analysis. The Oncologist, 15, 994– 1001. R Development Core Team (2011). R: A language and environment for statistical computing. Vienna: R Foundation for Statistical Computing. Rogers, L.Q., Courneya, K.S., Robbins, K.T., et al. (2006). Physical activity and quality of life in head and neck cancer survivors. Supportive Care in Cancer, 14, 1012–1019.
Satin, J.R., Linden, W. & Phillips, M.J. (2009). Depression as a predictor of disease progression and mortality in cancer patients: A meta-analysis. Cancer, 115, 5349– 5361. Semple, C.J., Dunwoody, L., George Kernohan, W., et al. (2008). Changes and challenges to patients’ lifestyle patterns following treatment for head and neck cancer. Journal of Advanced Nursing, 63, 85– 93. Semple, C., Parahoo, K., Norman, A., et al. (2013). Psychosocial interventions for patients with head and neck cancer. The Cochrane Database of Systematic Reviews, 7. doi:10.1002/14651858.CD009441.pub2 Shiraz, F., Rahtz, E., Bhui, K., et al. (2014). Quality of life, psychological wellbeing and treatment needs of trauma and head and neck cancer patients. The British Journal of Oral & Maxillofacial Surgery, 52, 513 –517. Singer, S., Danker, H., Dietz, A., et al. (2008). Screening for mental disorders in laryngeal cancer patients: A comparison of six methods. Psycho-Oncology, 17, 280– 286. Tuomi, L., Andre´ll, P. & Finizia, C. (2014). Effects of voice rehabilitation after radiation therapy for laryngeal cancer: A randomized controlled study. International Journal of Radiation Oncology, Biology, Physics, 89, 964 –972. Zeller, J.L. (2006). High suicide risk found for patients with head and neck cancer. The Journal of the American Medical Association, 296, 1716–1717. Zigmond, A.S. & Snaith, R.P. (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67, 361 –370.
Persistence of psychological distress and correlated factors among patients with head and neck cancer
KANAKO ICHIKURA, M.SC.,1,2 AYA YAMASHITA, PH.D.,1 TARO SUGIMOTO, SEIJI KISHIMOTO, M.D., PH.D.,4,5 AND EISUKE MATSUSHIMA, M.D., PH.D.1
3 M.D.,
1
Section of Liaison Psychiatry and Palliative Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan Research Fellow of the Japanese Society for the Promotion of Science, Tokyo, Japan 3 Department of Otorhinolaryngology, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan 4 Chief of Head and Neck Surgery, Kameda Medical Center, Chiba, Japan 5 Section of Head and Neck Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan 2
(RECEIVED January 28, 2015; ACCEPTED April 15, 2015)
ABSTRACT Objective: Many patients with head and neck cancer (HNC) suffer from psychological distress associated with dysfunction and/or disfigurement. Our aim was to evaluate the ratio of patients with persistence of psychological distress during hospitalization and identify the predictors of persistence or change in psychological distress among HNC patients. Method: We conducted a single-center longitudinal study with self-completed questionnaires. We evaluated psychological distress (the Hospital Anxiety and Depression Scale; HADS) and functional level (the Functional Assessment of Cancer Therapy –Head and Neck Scale; FACT– H&N) among patients during hospitalization at the Medical Hospital of Tokyo Medical and Dental University. Results: Of 160 patients, 117 (73.1%) completed the questionnaire at both admission and discharge. Some 42 (52.5%) patients reported persistent psychological distress. The physical well-being of patients with continued distress was significantly lower than that of other patients (21.7 + 4.7, 19.4 + 6.1, 19.5 + 5.4; p , 0.01), and the emotional well-being of patients with continued distress was significantly lower than that in patients with no distress and reduced distress (22.3 + 3.5, 20.5 + 2.5; p , 0.01). Significant of results: Impaired physical and emotional function appears to be associated with persistent psychological distress among HNC patients. Psychological interventions focused on relaxation, cognition, or behavior may be efficacious in preventing such persistent distress. KEYWORDS: Anxiety, Depression, Psychological distress, Head and neck cancer, Well-being
INTRODUCTION
motherapy, and radiation therapy—have developed at a rapid pace. As a result, the five-year survival rate among patients with HNC has improved moderately (American Society of Clinical Oncology, 2014; Pulte & Brenner, 2010). However, most HNC patients suffer from dysfunction and disfigurement caused by these medical treatments and have difficulty breathing, eating, and communicating (Danker et al., 2010; Semple et al., 2008). The suicide rate among HNC patients is more than four times greater than that of the general population (Zeller, 2006),
Head and neck cancer (HNC) is a collective term describing malignancy located around the oral, larynx, pharynx, and maxillofacial areas. Common treatments for HNC—including surgical operations, cheAddress correspondence and reprint requests to: Kanako Ichikura, Section of Liaison Psychiatry and Palliative Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan. E-mail: [email protected], [email protected]
42
43
Persistence of psychological distress among HNC patients
and 15– 44% of patients experience psychological distress (depression and anxiety) at some point during the course of their illness (Joseph et al., 2013; Neilson et al., 2013). In particular, depression has a highly negative impact on patients’ lives. Depression can lead to lowered quality of life, poor treatment adherence, poor mental adjustment to cancer, high pain sensitivity, severe physical symptoms, long length of hospital stays, and a decreased survival rate (Aarstad et al., 2014; de Leeuw et al., 2000; Haisfield-Wolfe et al., 2012; Johansson et al., 2011; Satin et al., 2009). Therefore, identification and treatment of depression is crucial in HNC patients. Not all HNC patients with depressive symptoms experience depressive disorder. Indeed, one study reported that only 6.5% of HNC patients are diagnosed with major depressive disorder (MDD) (Singer et al., 2008). Although this percentage is higher than that of the general population, this statistic indicates that HNC patients with MDD may comprise an important subgroup of all patients who experience depressive symptoms. Depression is considered to be a continuous phenomenon that ranges from minor mood swings to major depressive disorder in individuals with head and neck cancer (Haisfield-Wolfe et al., 2009), and persistent depressive symptoms may lead to depressive disorders. Therefore, addressing the persistence of psychological distress among HNC patients is critical to preventing MDD. To the best of our knowledge, however, no studies have examined the factors affecting persistence or change in psychological distress in HNC patients. Understanding the different functional problems faced by patients with persistent distress versus those with reduced distress could be useful for improving psychosocial care in the HNC patient population. The primary aim of this study was thus to evaluate the ratio of patients with persistence of psychological distress in HNC patients during a period of hospital treatment, and to identify the correlated factors affecting persistence of psychological distress. Pretreatment distress is a strong risk factor for posttreatment distress among patients who have undergone surgery or radiation therapy (Adachi et al., 2014; Badr et al., 2014). One study suggested that psychological distress resulting from a diagnosis of HNC persisted, on average, for three years (Joseph et al., 2013). Therefore, reducing pretreatment distress may contribute to prevention of persistent distress. Our secondary aim was to examine the effect of pretreatment factors on psychological distress at the time of hospital admission. Our results could help create a care system for HNC patients prior to receiving treatment.
METHODS Study Design and Participants We used a single-center longitudinal design in which patients self-completed questionnaires. From our research database of patients admitted to the Department of Otorhinolaryngology or the Department of Head and Neck Surgery at the Medical Hospital of Tokyo Medical and Dental University (TMDU) between October of 2011 and August of 2013, we selected patients with laryngeal, pharyngeal, oral, maxillary sinus, paranasal sinus, or nasal cavity cancer. The following patients were excluded from the study: those with severe physical or mental problems, those with insufficient literacy skills, and patients older than 90 years of age. Study Procedures We collected continuous data from all patients admitted to the TMDU. At the time of hospital admission, two researchers (IK and YA), who were not engaged in medical treatments, informed the patients about the purpose of our study and gained their consent for participation. All consenting participants were then approached to complete the questionnaires prior to initiating treatment. The researchers assisted those patients who were unable to independently write their answers because of physical problems. Data were collected at the time of hospital admission (time 1) and at hospital discharge (time 2). Ethics All procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all patients in writing. This study assured anonymity and was approved by the ethics committee of the TMDU (1057). Measures Demographic and Clinical Characteristics We collected demographic and clinical information from the patient medical records to identify potential confounders for psychological distress. We included the following data: age, gender, history of alcohol intake, history of smoking, frequency of going out, original cancer, TNM classification, time since diagnosis, whether they were receiving initial treatment or not, treatment type, length of hospital stay, whether they continued therapy after discharge, outcome at the time of hospital discharge, and outcome one year after hospital discharge.
44 Functional Level (Well-Being) We used the Functional Assessment of Cancer Therapy – Head and Neck Scale (FACT– H&N) to measure patient function in terms of predictors of psychological distress (List et al., 1996). The FACT– H&N is a 38-item self-related scale used to measure function and well-being in cancer patients. The scale has five factors: physical well-being (7 items), social/family well-being (7 items), emotional well-being (6 items), functional well-being (7 items), and a head and neck cancer subscale (11 items).
Ichikura et al.
tion factor (VIF) (Katz, 2003). A VIF exceeding 10 is regarded as indicating serious multicollinearity, and values greater than 4.0 may be a cause for concern (Katz, 2003). We conducted all analyses using R version 2.15.1., with the R packages “rpsychi” and “car” (R Development Core Team, 2011). All tables and figures were created using Microsoft Office 2013. RESULTS Participant Characteristics
Psychological Distress (Anxiety and Depression) We evaluated psychological distress using the Hospital Anxiety and Depression Scale (HADS) (Zigmond & Snaith, 1983), which is a 14-item self-related scale used to measure psychological distress. The scale has two factors: anxiety and depression. It is a 4-point Likert-type scale ranging from 0 to 3 (overall score 0 – 42). We used an optimal cutoff point of 10/11 to screen for adjustment or major depressive disorder (Carroll et al., 1993; Kugaya et al., 1998). Statistical Analysis We first examined the frequency of psychological distress (HADS – total 11) at time 1 and time 2 and categorized the participants into four groups based on their status at these timepoints: (1) a no-distress group (without distress to without distress); (2) a reduced-distress group (with distress to without distress); (3) an increased-distress group (without distress to with distress); and (4) a continued-distress group (with distress to with distress). We then summarized the demographic and clinical characteristics of these four groups using standard descriptive statistics. We next used an ANOVA to evaluate the differences between the four groups in terms of functional level (FACT score). We employed logistic regression modeling to examine the association between functional level and psychological distress at time 2. We then calculated the odds ratios (ORs) and 95% confidence intervals (95% CI) after controlling simultaneously for potential confounders. The following variables were considered in the models: age (nominal), frequency of going out (nominal), T classification (continuous), presence of surgery treatment (nominal), and whether the patient was receiving initial treatment or not (nominal). The independent variables included in this model were chosen based on a-priori clinical judgment and the existing literature. We utilized the likelihood ratio test to determine the statistical significance of the interaction terms in the logistic regression models. We assessed multicollinearity using the variance infla-
Of 186 patients with head and neck cancer, data from 167 participants were considered potentially suitable for our study (Figure 1). A total of 7 patients were excluded because they had physical difficulty at the time of hospital admission, leaving 160 participants. Some 43 patients dropped out of the study because they were discharged from the hospital and left without returning their questionnaires, leaving a total of 117 participants for whom we analyzed data. As mentioned above, we created four participant groups: the no-distress group (n ¼ 45), the reduceddistress group (n ¼ 17), the increased-distress group (n ¼ 13), and the continued-distress group (n ¼ 42). These groups were created according to psychological distress scores (HADS –total) at times 1 and 2 (Figure 2). Some 42 (52.5%) participants reported continued psychological distress from the time of hospital admission through to hospital discharge. Participant characteristics are presented in Table 1. Some 65 (55.6%) participants were over 65 years of age, 102 (87.2%) were male, and 85 (72.6%) had a history of smoking. The underlying diseases and received therapeutic treatments during hospitalization are also given in Table 1. The frequency of elderly (65 years old) patients was significantly higher in the increased-distress (n ¼ 12, 92.3%) and continued-distress groups (n ¼ 27, 64.3%). Additionally, the frequency of patients with pharyngeal cancer was significantly higher in the reduced-distress group (n ¼ 11, 64.7%), and the frequency of patients with oral cancer was significantly higher in the continued-distress group (n ¼ 14, 33.3%). Differences in Functional Level Between the Four Groups Table 2 presents the differences in functional level between the four groups for each of the five FACT factors, including the means (M ) and standard deviations (SD). The ANOVA revealed significant differences between the four groups for all five FACT factors. Tukey multiple comparisons indicated that the patient physical well-being scores were
45
Persistence of psychological distress among HNC patients
Fig. 1. Patient recruitment flowchart.
significantly lower in the continued-distress group (14.7 + 5.2) compared with the other groups (21.7 + 4.7, 19.4 + 6.1, 19.5 + 5.4; p , 0.01), and that the emotional well-being scores were significantly lower in patients in the continued-distress group (13.4 + 4.2) compared with the no-distress group and the reduced-distress group (22.3 + 3.5, 20.5 + 2.5; p , 0.01).
(Table 3), with adjusted OR of 0.33 (95% CI ¼ 0.12 – 0.92), 4.18 (95% CI ¼ 1.15 – 15.24), 0.78 (CI95% ¼ 0.67 – 0.90), 0.79 (95% CI ¼ 0.69 – 0.91), and 0.85 (95% CI ¼ 0.76 – 0.94). The likelihood ratio test indicated that none of the interactions between independent variables were significant. We found no evidence for multicollinearity because the VIF for the independent variables in this model was less than 4.0.
Factors Influencing Psychological Distress at the Time of Hospital Admission
DISCUSSION
Table 3 presents the factors influencing psychological distress (HADS – total 11) at time 1, with each OR and 95% CI. A logistic regression analysis revealed that younger age (65 years old), scheduled surgery, and poor physical, emotional, and functional well-being were risk factors for psychological distress at the time of hospital admission
The primary aim of our study was to evaluate the ratio of patients with persistence of psychological distress over a period of hospital treatment in HNC patients. Our data revealed that half of our HNC patients experienced psychological distress and 70% reported continuous symptoms over the entire duration of their hospital stay. Additionally,
Fig. 2. Change in psychological distress from the time of admission until discharge.
46
Table 1. Demographic and clinical characteristics of the study participants (N ¼ 117) All (N ¼ 117) n (%)
No Distress (n ¼ 45) n (%)
Decreased Distress (n ¼ 17) n (%)
Increased Distress (n ¼ 13) n (%)
Continued Distress (n ¼ 42) n (%)
65 (55.6) 52 (44.4)
19 (42.2) 26 (57.8)
7 (41.2) 10 (58.8)
12 (92.3) 1 (7.7)
27 (64.3) 15 (35.7)
102 (87.2) 15 (12.8)
37 (82.2) 8 (17.8)
16 (94.1) 1 (5.9)
12 (92.3) 1 (7.7)
37 (88.1) 5 (11.9)
26 (22.2) 88 (75.2) 3 (2.6)
9 (20.0) 36 (80.0) 0 (0.0)
5 (29.4) 11 (64.7) 1 (5.9)
2 (15.4) 10 (76.9) 1 (7.7)
10 (23.8) 31 (73.8) 1 (2.4)
28 (23.9) 85 (72.6) 4 (3.4)
13 (28.9) 31 (68.9) 1 (2.2)
3 (17.6) 13 (76.5) 1 (5.9)
3 (23.1) 9 (69.2) 1 (7.7)
9 (21.4) 32 (76.2) 1 (2.4)
66 (56.4) 49 (41.9) 2 (1.7)
24 (53.3) 20 (44.4) 1 (2.2)
10 (58.8) 6 (35.3) 1 (5.9)
8 (61.5) 5 (38.5) 0 (0.0)
24 (57.1) 18 (42.9) 0 (0.0)
14 (12.0) 65 (55.6)
4 (8.9) 27 (60.0)
4 (23.5) 11 (64.7)
4 (30.8) 7 (53.8)
2 (4.8) 20 (47.6)
27 (23.1) 11 (9.4)
11 (24.4) 3 (6.7)
1 (5.9) 1 (5.9)
1 (7.7) 1 (7.7)
14 (33.3) 6 (14.3)
18 54 19 19
(15.4) (46.2) (16.2) (16.2)
8 (17.8) 21 (46.7) 8 (17.8) 5 (11.1)
3 (17.6) 9 (52.9) 2 (11.8) 2 (11.8)
1 (7.7) 8 (61.5) 2 (15.4) 2 (15.4)
6 (14.3) 16 (38.1) 7 (16.7) 10 (23.8)
58 15 36 1 1
(49.6) (12.8) (30.8) (0.9) (0.9)
24 (53.3) 3 (6.7) 15 (33.3) 0 (0.0) 0 (0.0)
10 (58.8) 5 (29.4) 1 (5.9) 0 (0.0) 1 (5.9)
7 (53.8) 0 (0.0) 6 (46.2) 0 (0.0) 0 (0.0)
17 (40.5) 7 (16.7) 14 (33.3) 1 (2.4) 0 (0.0)
109 (93.2) 2 (1.7)
42 (93.3) 0 (0.0)
16 (94.1) 1 (5.9)
13 (100.0) 0 (0.0)
38 (90.5) 1 (2.4)
p
Demographic characteristics Age Elderly group (≥65 years) Younger group (,65 years) Gender Male Female Alcohol No Yes Unclear Smoking No Yes Unclear Going out Sometimes Everyday Unclear
0.00
**
0.67 0.79
0.82
0.95
Clinical characteristics 0.03
*
0.89
0.03
*
0.35
Continued
Ichikura et al.
Original cancer Laryngeal cancer Pharyngeal cancer (epipharynx, oropharynx, or hypopharynx) Oral cancer (oral or tongue) Other T 1 2 3 4 N 0 1 2 3 4 M 0 1
Initial treatment No (metastatic, recurrent, or remaining cancer) Yes Surgery No Yes Chemotherapy No Yes Radiation therapy No Yes Continued therapy after discharge No Yes Outcome at the time of hospital discharge Improved No change Outcome one year after hospital discharge At follow-up With remaining cancer in active treatment With recurrent or metastatic cancer in active treatment In best supportive care Death Unclear
All (N ¼ 117) n (%)
No Distress (n ¼ 45) n (%)
Decreased Distress (n ¼ 17) n (%)
Increased Distress (n ¼ 13) n (%)
Continued Distress (n ¼ 42) n (%)
69 (59.0)
28 (62.2)
10 (58.8)
6 (46.2)
25 (59.5)
48 (41.0)
17 (37.8)
7 (41.2)
7 (53.8)
17 (40.5)
52 (44.4) 65 (55.6)
20 (44.4) 25 (55.6)
7 (41.2) 10 (58.8)
7 (53.8) 6 (46.2)
18 (42.9) 24 (57.1)
64 (54.7) 53 (45.3)
25 (55.6) 20 (44.4)
9 (52.9) 8 (47.1)
6 (46.2) 7 (53.8)
24 (57.1) 18 (42.9)
100 (85.5) 17 (14.5)
38 (84.4) 7 (15.6)
15 (88.2) 2 (11.8)
11 (84.6) 2 (15.4)
36 (85.7) 6 (14.3)
56 (47.9) 61 (52.1)
23 (51.1) 22 (48.9)
8 (47.1) 9 (52.9)
4 (30.8) 9 (69.2)
21 (50.0) 21 (50.0)
p 0.79
0.92 0.93 0.99 0.63
Persistence of psychological distress among HNC patients
Table 1. Continued
0.45 89 (76.1) 28 (23.9)
37 (82.2) 8 (17.8)
13 (76.5) 4 (23.5)
8 (61.5) 5 (38.5)
31 (73.8) 11 (26.2)
60 (51.3) 9 (7.7)
25 (55.6) 5 (11.1)
6 (35.3) 3 (17.6)
9 (69.2) 0 (0.0)
20 (47.6) 1 (2.4)
38 (32.5)
12 (26.7)
6 (35.3)
3 (23.1)
17 (40.5)
5 (4.3) 3 (2.6) 2 (1.7)
1 (2.2) 1 (2.2) 1 (2.2)
1 (5.9) 0 (0.0) 1 (5.9)
1 (7.7) 0 (0.0) 0 (0.0)
2 (4.8) 2 (4.8) 0 (0.0)
M + SD
M + SD
M + SD
M + SD
M + SD
454.6 + 924.5
388.7 + 711.7
268.0 + 618.0
685.5 + 1270.6
180.4 + 212.4
17.7 + 11.5
16.2 + 8.7
22.1 + 10.6
19.5 + 13.4
17.0 + 13.6
0.40
Time since diagnosis (days)
0.20
Length of hospital stay (days)
M ¼ mean, SD ¼ standard deviation. *p , 0.05,
0.30
**
p , 0.01.
47
48
Ichikura et al.
Table 2. Differences in functional level based on changes in psychological distress following hospitalization
Functional level at time 1 (FACT– physical) (FACT–social) (FACT– emotional)
(FACT– functional) (FACT–H&N)
No Distress (n ¼ 45)
Reduced Distress (n ¼ 17)
Increased Distress (n ¼ 13)
Continued Distress (n ¼ 13)
M + SD
M + SD
M + SD
M + SD
21.7 + 4.7
19.4 + 6.1
19.5 + 5.4
14.7 + 5.2
22.6 + 6.0 22.3 + 3.5
19.1 + 8.3 20.5 + 2.5
20.4 + 7.1 16.3 + 2.5
17.9 + 5.4 13.4 + 4.2
p
0.00 **
No . Continued
0.00 ** 0.00 **
Reduced . Continued Increased . Continued No . Continued No . Continued No . Increased Reduced . Continued Reduced . Increased No . Continued
19.0 + 7.4
14.8 + 6.8
13.7 + 6.8
11.6 + 5.6
0.00 **
22.3 + 6.4
17.2 + 5.7
19.8 + 6.2
15.7 + 5.4
0.00 **
M ¼ mean, SD ¼ standard deviation. *p , 0. 05,
Tukey Multiple Comparisons
Nothing . Reduced Nothing . Continued
**
p , 0.01.
physical and emotional well-being in patients with reduced distress was higher than that in patients with continued distress. Previous studies have suggested that 15 to 30% of HNC patients experience psychological distress at
the time of diagnosis and during pretreatment (Joseph et al., 2013; Neilson et al., 2010). Additionally, pretreatment levels of psychological distress have been found to predict levels of psychological distress during posttreatment and follow-up (Adachi et al.,
Table 3. Logistic regression modeling of factors influencing psychological distress at the time of hospital admission (n ¼ 160) Variable Age Younger Older Going out Sometimes Everyday T [Continuous value] Surgery No Yes Initial treatment Treatment for recurrent or remaining cancer Initial treatment Functional level at time 2 [Continuous value] FACT–physical FACT–social FACT–emotional FACT–functional FACT–H&N
Crude OR (CI95%)
Adjusted OR (CI95%)
1 [Ref]
1 [Ref]
.73 (0.37– 1.42)
.33 (0.12– 0.92)
0.03
1 [Ref] 0.96 (0.49– 1.88)
1 [Ref] 2.21 (0.81– 6.00)
0.12
1.27 (0.89– 1.81)
1.19 (0.62– 2.26)
0.60
1 [Ref] 1.11 (0.56– 2.17)
1 [Ref] 4.18 (1.15– 15.24)
0.03
1 [Ref] 1.01 (0.51– 1.98)
1 [Ref] 0.97 (0.36– 2.63)
0.96
0.75 (0.67– 0.85) 0.93 (0.88– 0.99) 0.77 (0.69– 0.85) 0.83 (0.77– 0.90) 0.89 (0.83– 0.95)
0.78 (0.67– 0.90) 0.95 (0.87– 1.04) 0.79 (0.69– 0.91) 0.85 (0.76– 0.94) 1.06 (0.95– 1.17)
0.00 0.24 0.00 0.00 0.31
OR ¼ odds ratio, CI ¼ confidence interval, [Ref] ¼ reference level. *p , 0.05.
p
*
*
** ** **
Persistence of psychological distress among HNC patients
49
2014; Joseph et al., 2013). Our results, which are consistent with previous findings, indicate that we should prevent the persistence of psychological distress beginning at initiation of pretreatment and on through to posttreatment. We found physical function to be associated with the persistence of psychological distress in our study population. Indeed, several previous cross-sectional studies have demonstrated a relationship between psychological distress and physical function among patients with HNC (Chiou et al., 2013; Koizumi et al., 2013; Shiraz et al., 2014). We suggest that there are two possible explanations for this relationship. First, psychological distress may occur as a secondary phenomenon in patients with HNC, resulting from the experience of physical disability, especially when swallowing function is affected (Lin et al., 2012). This common reaction can be described as learned helplessness in a psychological setting, which has a negative impact on psychological adjustment among cancer patients (Eskelinen et al., 2014; Pe´rez et al., 2014). Psychosocial approaches that act directly to reduce dysfunction may enhance a patient’s willingness to live, and dysphagia or vocal rehabilitation may have a beneficial effect on diminishing psychological distress (Cousins et al., 2013; Tuomi et al., 2014). Second, pain or fatigue sensitivity may be an intermediate variable in the relationship between psychiatric weakness and psychological distress. HNC patients with poor subjective physical function are more likely to experience psychological distress (Chiou et al., 2013; Koizumi et al., 2013). Accordingly, relaxation therapies have been shown to have a significant impact on psychological adjustment in HNC patients (Allison et al., 2004; Hammerlid et al., 1999). This may be because such therapies work to increase the amount of attention directed toward body sensations other than pain. We also found that emotional function was associated with persistence of psychological distress in our study population. Some previous cross-sectional studies have shown a relationship between psychological distress and emotional function, as well as between psychological distress and physical function (Chiou et al., 2013; Koizumi et al., 2013; Shiraz et al., 2014). Patients with poor emotional function exhibit negative thinking about their disease or about death, and thus often experience persistent psychological distress, even when their physical status improves. In one metaanalysis, psychological interventions, including psychoeducation and supportive psychotherapy, had no effect on individuals with high levels of psychological distress (Semple et al., 2913). Perhaps traditional psychotherapy is not the most efficacious strategy for changing negative thinking about one’s disease or death. Recent studies have suggested a
strong relationship between attention bias and fear of cancer recurrence (Butow et al., 2014; Park et al., 2013). This indicates a potential for developing an alternative psychotherapeutic technique that includes elements of attention training. Our secondary research aim was to examine the effect of pretreatment factors on psychological distress at the time of hospital admission. In accordance with other studies, our results suggest that younger age (less than 65 years old) and scheduled surgery are demographic predictors of psychological distress at the time of hospital admission (Adachi et al., 2014; Duffy et al., 2007; Mochizuki et al., 2009; Rogers et al., 2006). Along with the previous literature, our results provide support for a relationship between physical, emotional, and functional well-being and pretreatment for psychological distress. Specifically, our results mirror those of another study that implicated emotional and functional well-being as a predictor of psychological distress at the time of pretreatment (Koizumi et al., 2013). Therefore, methods for reducing psychological distress in HNC patients should focus on interventions to improve emotional and functional well-being. Patients who have high levels of functional well-being are able to enjoy daily life, including their job, household responsibilities, and leisure time. Therefore, pretreatment interventions that help patients direct their attention toward the activities of daily life (and away from the details of their illness) are likely to be beneficial. Our study has two important limitations associated with systematic error. First, our methods may not have excluded selection bias. Our study participants were selected from only one hospital in Japan, and there were many laryngeal cancer patients in the group. However, we believe the participants in this study to be representative of those currently being treated in Japanese hospitals, so that our results are generalizable. Second, the sample size was insufficient when comparing the four groups using an ANOVA because of a high dropout rate in the follow-up questionnaire. In future research, we may be able to develop strategies to improve the response rate. However, we found no differences between dropout rates for patients with and without psychological distress at admission; therefore, dropout status may have a minimal effect on the background characteristics of the HNC patients in our four groups. As this was an exploratory study with a small sample size, we are planning to conduct a future large-scale observational study to test our hypothesis. CONCLUSION To the best of our knowledge, this is the first study to focus on the persistence of psychological distress
50 among patients with HNC. Our results indicate that persistence of psychological distress is more common among HNC patients during periods of hospitalization and that their distress is affected by physical and emotional function. New therapeutic approaches are necessary to address psychological distress in HNC patients. Such alternative psychological interventions may focus on helping patients to control their physical or emotional attention. This is certainly a topic for future study. ACKNOWLEDGMENTS This study was supported by a grant-in-aid for JSPS Fellows (Social Science: 24-1085) from the Japan Society for the Promotion of Science between April of 2012 and March of 2015. We are grateful to all collaborators for supporting our research program: the participants, the health providers at TMDU hospitals, and laboratory members at the Department of Liaison Psychiatry and Palliative Medicine at TMDU.
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