This is an introductory talk from the undergraduate lecturers in yr 5 cancer block, university of Leicester

1. Alex Mitchell
Consultant in Liaison Psychiatry and Hon SnR Lecturer in
Psycho-oncology, University Hospitals Leicester
alex.mitchell@leicspart.nhs.uk
alex.mitchell@leicspart.nhs.uk Undergraduates (Feb11)
Undergraduates (Feb11)

2. Most commonly diagnosed cancers worldwide
Males UK Rank
Females UK Rank
Lung 16 15 (2nd) Breast 23 31 (1st)
Prostate 14 24 (1st) Colorectum 9 12 (2nd)
Colorectum 10 14 (3rd) Cervix 9 2 (11th)
Stomach 10 3 (8th) Lung (3rd)
9 12
Liver 8 1 (15th) Stomach 6 2 (13th)
Oesophagus 5 3 (6th) Uterus 5 5 (4th)
Bladder 4 5 (4th) (19th)
Liver 4 1
NHL 3 4 (5th)
Ovary 4 5 (5th)
Leukaemia 3 3 (10th)
Thyroid 3 1 (18th)
Lip, oral cavity 3 2 (12th)
NHL 3 3 (7th)
All others 23 25
All others 27 27
world (%) uk (%)
world(%) uk(%)

3. 5 Year Survival in US Cancers (2008 American Cancer Society, Atlanta)
100
90
80
1975-1977
70 1984-1986
1996-2004
60 Change
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Annual report to the national of status of cancer 1975 – 2005 J Natl Cancer Inst 2008;100: 1672 – 1694

4. 10.9million incident cases (1mi breast, lung colorectal); 25mi prevalent cases

5. Total prevalence = 13.8raw 000'S in 2010
million
3500 Projected = 18.2million in 2020
3000
2500
2000
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1500
1000
500
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Angela B. Mariotto J Natl Cancer Inst 2011;103:117–128

6. What is the prevalence of depression?
Levine PM, Silberfarb PM, Lipowski ZJ. Mental disorders in cancer
patients. Cancer 1978;42:1385–91.
Dartmouth Medical School and the Norris Cotton Cancer Center, New Hampshire

7. Prevalence of depression in Oncology settings Plumb & Holland (1981)
Proportion meta-analysis plot [random effects]
0.7750 (0.6679, 0.8609)
Levine et al (1978) 0.5600 (0.4572, 0.6592)
Ciaramella and Poli (2001) 0.4900 (0.3886, 0.5920)
Massie et al (1979) 0.4850 (0.4303, 0.5401)
70 studies involving 10,071 individuals;14 countries. Bukberg et al (1984)
Passik et al (2001)
0.4194 (0.2951, 0.5515)
0.4167 (0.2907, 0.5512)
16.3% (95% CI = 13.9% to 19.5%) Baile et al (1992)
Morton et al (1984)
Hall et al (1999)
0.4000 (0.2570, 0.5567)
0.3958 (0.2577, 0.5473)
0.3722 (0.3139, 0.4333)
Burgess et al (2005) 0.3317 (0.2672, 0.4012)
Jenkins et al (1991) 0.3182 (0.1386, 0.5487)
Mj 15% Mn 19% Adj 20% Anx 10% Dysthymia 3%
Green et al (1998) 0.3125 (0.2417, 0.3904)
Kathol et al (1990) 0.2961 (0.2248, 0.3754)
Hosaka and Aoki (1996) 0.2800 (0.1623, 0.4249)
Fallowfield et al (1990) 0.2565 (0.2054, 0.3131)
Golden et al (1991) 0.2308 (0.1353, 0.3519)
Spiegel et al (1984) 0.2292 (0.1495, 0.3261)
Evans et al (1986) 0.2289 (0.1438, 0.3342)
Grandi et al (1987) 0.2222 (0.0641, 0.4764)
Maunsell et al (1992) 0.2146 (0.1605, 0.2772)
Berard et al (1998) 0.2100 (0.1349, 0.3029)
Joffe et al (1986) 0.1905 (0.0545, 0.4191)
Berard et al (1998) 0.1900 (0.1184, 0.2807)
Devlen et al (1987) 0.1889 (0.1141, 0.2851)
Leopold et al (1998) 0.1887 (0.0944, 0.3197)
Akizuki et al (2005) 0.1797 (0.1376, 0.2283)
Razavi et al (1990) 0.1667 (0.1189, 0.2241)
Gandubert et al (2009) 0.1597 (0.1040, 0.2300)
Alexander et al (1993) 0.1333 (0.0594, 0.2459)
Kugaya et al (1998) 0.1328 (0.0793, 0.2041)
Payne et al (1999) 0.1290 (0.0363, 0.2983)
Ibbotson et al (1994) 0.1242 (0.0776, 0.1853)
Prieto et al (2002) 0.1227 (0.0825, 0.1735)
Morasso et al (1996) 0.1121 (0.0593, 0.1877)
Desai et al (1999) [early] 0.1111 (0.0371, 0.2405)
Silberfarb et al (1980) 0.1027 (0.0587, 0.1638)
Costantini et al (1999) 0.0985 (0.0535, 0.1625)
Morasso et al (2001) 0.0985 (0.0535, 0.1625)
Ozalp et al (2008) 0.0971 (0.0576, 0.1510)
Love et al (2002) 0.0957 (0.0650, 0.1346)
Alexander et al (2010) 0.0900 (0.0542, 0.1385)
Coyne et al (2004) 0.0885 (0.0433, 0.1567)
Kawase et al (2006) 0.0851 (0.0553, 0.1240)
Walker et al (2007) 0.0831 (0.0568, 0.1165)
Grassi et al (1993) 0.0828 (0.0448, 0.1374)
Grassi et al (2009) 0.0826 (0.0385, 0.1510)
Reuter and Hart (2001) 0.0761 (0.0422, 0.1244)
Lee et al (1992) 0.0660 (0.0356, 0.1102)
Pasacreta et al (1997) 0.0633 (0.0209, 0.1416)
Sneeuw et al (1994) 0.0540 (0.0367, 0.0761)
Singer et al (2008) 0.0519 (0.0300, 0.0830)
Katz et al (2004) 0.0500 (0.0104, 0.1392)
Mehnert et al (2007) 0.0472 (0.0175, 0.1000)
Lansky et al (1985) 0.0455 (0.0291, 0.0676)
Derogatis et al (1983) 0.0372 (0.0162, 0.0720)
Hardman et al (1989) 0.0317 (0.0087, 0.0793)
Massie and Holland (1987) 0.0147 (0.0063, 0.0287)
Colon et al (1991) 0.0100 (0.0003, 0.0545)
combined 0.1730 (0.1375, 0.2116)
0.0 0.3 0.6 0.9
proportion (95% confidence interval)

8. Prevalence of depression in Palliative settings
24 studies involving 4007 individuals
16.9% (95% CI = 13.2% to 20.3%) Proportion meta-analysis plot [random effects]
Lloyd-Williams et al (2007) 0.30 (0.24, 0.36)
14% major 9% minor adj 15% anx 10% Jen et al (2006) 0.27 (0.19, 0.36)
Lloyd-Williams et al (2003) 0.27 (0.17, 0.39)
Payne et al (2007) 0.26 (0.19, 0.33)
Desai et al (1999) [late] 0.25 (0.10, 0.47)
Hopwood et al (1991) 0.25 (0.16, 0.36)
Lloyd-Williams et al (2001) 0.22 (0.14, 0.31)
Minagawa et al (1996) 0.20 (0.11, 0.34)
Meyer et al (2003) 0.20 (0.10, 0.35)
Breitbart et al (2000) 0.18 (0.11, 0.28)
Le Fevre et al (1999) 0.18 (0.10, 0.28)
Chochinov et al (1994) 0.17 (0.11, 0.24)
Kelly et al (2004) 0.14 (0.06, 0.26)
Wilson et al (2007) 0.13 (0.10, 0.17)
Chochinov et al (1997) 0.12 (0.08, 0.18)
Wilson et al (2004) 0.12 (0.05, 0.22)
Love et al (2004) 0.07 (0.04, 0.11)
Kadan-Lottich et al (2005) 0.07 (0.04, 0.11)
Akechi et al (2004) 0.07 (0.04, 0.11)
Maguire et al (1999) 0.05 (0.01, 0.14)
combined 0.17 (0.13, 0.21)
0.0 0.2 0.4 0.6
proportion (95% confidence interval)

9. 3500
Total prevalence Dep = 2 million in 2010
3000
Projected depression = 2.7 million in 2020
2500
Popn Orange Country
2000
raw 000'S
1500 DISTRESS
DEPRESSION
1000
500
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=> Who is helped?

10. …but is the prevalence of depression high in long term
survivors? (3+ years)

11. Meta regression using the random effects model on raw porportions
Estimated slope = - 0.02 % per month (p=0.0016). Circles proportional to study size.
0.4
0.3
Proportion
0.2
0.1
0.0
0 20 40 60 80 100
Time (months)

13. 12mo Service Use (NIH, 2002)
40
34.6
35 32.7 Cancer n=4878
No Cancer n=90,737
30
25
19.1
20
% Receiving Any treatment for Mental Health
% Receiving Any treatment for Mental Health
16.1
14
15
11.7 11
8.9
10 7.7
7.2 6.5
5.7 5.7 5 6.3 6.4 6.2
5
5 3.9 3.2
2.3 1.8
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No
Maria Hewitt, Julia H. Rowland Mental Health Service Use Among Adult Cancer Survivors: Analyses of the National Health Interview Survey Journal of Clinical
Oncology, Vol 20, Issue 23 (December), 2002: 4581-4590

14. Two likely reasons…..

15. 94.2%
37.4%
P Wang Harvard
8 yrs N= 9282 NCS‐R
In cancer?=>

18. 100.0
5.9
11.1
14.3
90.0 Comment: Slide illustrates diagnostic 21.4
accuracy according to score on DT 11.8
25.9
80.0 38.7 38.1
43.5 22.2 14.3
46.7
70.0 59.6
21.4
72.4
60.0 Judgement = Non-distressed
33.3 Judgement = Unclear
19.4 19.0 Judgement = Distressed
50.0
26.1
24.4 82.4
40.0
71.4
66.7
30.0
25.0 57.1
41.9 42.9 40.7
20.0 15.8
30.4 28.9
10.0
15.4
11.8
0.0
Zero One Two Three Four Five Six Seven Eight Nine Ten

19. Illness Pathways
Many syndromes are easily overlooked by health professionals leading to unnecessary delays in treatment
Illness Lag Lag Lag Illness
Lag Lag
Begins time time
time time time
Resolves
years months weeks weeks days
Symptoms Help Symptoms Referral Symptoms Treatment
Occur Seeking Recognized Occurs Validated Occurs

20. Illness Pathways – Oncology Studies
Many syndromes are easily overlooked by health professionals leading to unnecessary delays in treatment
Illness Lag Lag Lag Illness
Lag Lag
Begins time time
time time time
Resolves
years months weeks weeks days
Symptoms Help Symptoms Referral Symptoms Treatment
Occur Seeking Recognized Occurs Validated Occurs
Fabida09 – Physical Symptoms & distress
Baker-Glenn08 – Need for help in cancer
Karr07 – Detection by cancer specialists
Mitchell10 – Detection by nurse specialists
Todd10 – RCT of PACT in cancer

21. Cancer in UK
Incident Cancer Cases:
300,000+
Prevalent Cancer Survivors
1-2 million est
Prevalent Cancer Survivors with sig. Burden /yr
1 million
Prevalent Cancer Survivors with sig. Distress
1 million
Prevalent Cancer Survivors with clinical Depression
350,000

22. Depression
Three D’s
Dysfunction
Distress

23. Of the 293 Non-Nil DepT
23%
0.3% DepT
3% 2%
18%
Dysfunction
Distress
28% 26% 22%
Dysfunction Distress
76% 69%

24. 100% 0.02
0.00 0.00 0.00 0.00 0.00
0.03 0.04 0.03
0.01
0.06
0.08
0.09
0.07
0.17
90% 0.20
0.18 0.11
0.19
0.28
0.31
0.18
80%
0.31
0.47
70% 0.20
0.48
0.40
60%
0.50
0.40 0.53
50% 0.45
40% 0.80 0.40
0.69
0.62
30%
0.50
3=Extremely Difficult” 0.43
0.41
20%
2=Very Difficult 0.32
0.33
0.27
0.25
10% 1=Somewhat Difficult 0.20
Unimpaired
0%
Zero One Tw o Three Four Five Six Seven Eight Nine Ten

25. Cancer #s in Leicester
Incident Cancer Cases:
3000
Prevalent Cancer Survivors
12,500 est
Prevalent Cancer Survivors with sign. Burden /yr
6,000
Prevalent Cancer Survivors with sig Depression
2,000

26. Meeting Psychological Needs in Leicester
FTE in Psycho-oncology
?

27. Psycho-oncology in Leicester
FTE in Psycho-oncology
3.0
CNS in UHL
35
UHL Ward Nurses, Chemo Nurses and Rx Radiographers
100
CNS+McMillan+LOROS
70
Oncologists and Haematologists and Palliative Consultants
15

28. Psychological Distress
Pool x Prev
10,000 x 50% => 5000 (distress/anxiety)
10,000 x 20% => 2000 (depression)
Depression / Staff
2000 / 200 => 10 cases per staff member

29. DepT
DT
23%
37%
4% 3%
3%
DT DepT
7% 1%
Non-Nil 8% 0% Nil
9%
59% 41%
4% 1%
AnxT 2% AngT
15% 2%
AnxT AngT
47% 18%

30. What is the Aim of Psycho-Oncology?
1. Reduce distress & emotional disorders
=>Desensitization by direct intervention
2. Promote detection & treatment by cancer staff
=>Screening
3. Treat less common psychiatric disorders
=> delirium, dementia, psychosis, mania
4. Promote Quality of life
⇒ Regardless of stage, age, cancer type of prognosis
5. Do we influence survival?
=> Observations vs interventional studies

31. 0
10
20
30
40
50
60
70
80
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Self-Reported Symptoms in Cancer by Frq
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Very Common
Hic
Uncommon
Quite Common
cu
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32. Top 10 patient concerns
1 Anxiety 312
2 Family concerns 157
3 Independence/Role 122
4 Appearance 111
5 Pain 86
6 Sleep 76
7 Fatigue/Energy 71
8 Finances 63
9 Weight 52
10 Breathing 49

33. Help Seeking
Do patients always ask for help when needed?

34. % Receiving Any treatment for Depression
20
17.9
18 n=84,850 face-to-face interviews
16 15.4
13.8
14
12 11.3
10.9 10.9
10
8.8
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6.8
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Wang P et al (2007) Lancet 2007; 370: 841–50

35. % Receiving Any treatment for Mental Health
Maria Hewitt, Julia H. Rowland Mental Health Service Use Among Adult Cancer Survivors: Analyses of the National Health Interview Survey Journal of Clinical
Oncology, Vol 20, Issue 23 (December), 2002: 4581-4590
40
34.6
35 32.7 Cancer n=4878
No Cancer n=90,737
30
25
19.1
20
16.1
14
15
11.7 11
8.9
10 7.7
7.2 6.5
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5
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36. 1093 (100%)
Population
462 needs
462 (42%) 322 DSMIV
Meetable Needs
17.3%
25%
388 (84%)
Aware of Need
172 (44%)
Requested Help
80 (47%)
Needs Met

37. Illness Information
Are we providing necessary information promptly and appropriately?

38. Information Delivery
In 1961
90% of US doctors indicated a preference for not
telling a diagnosis of cancer.
In 1979
97% indicated a preference for revealing a diagnosis
of cancer.
Novack DH, Plumer R, Smith RL, et al. Changes in physicians’ attitudes toward
telling the cancer patient. JAMA 1979; 241: 897–900.

39. Trusted Sources of Information

40. Women’s Information Preferences
Check with me that I understand what he/she is saying 99 1
Give me an opportunity to ask questions 99 1
Explain any medical terms 98 2
Listen to my fears and concerns 97 3
Summarize what he/she has told me 94 6
Emphasize the good aspects of my prognosis 90 10
Give me published information on my situation 88 12
Tell me where I can go for additional emotional help 80 20
Write down what he/she has told me 79 21
Give me emotional support 79 21
Talk to me about complementary therapies, 75 25
Give me an audio tape of the discussion 28 72
Check with me that I want to know my prognosis 63 37
N=100 Early breast cancer Lobb et al (2000) Health Expectations, 4, pp.48±57

41. Disclosure of Diagnosis
Family wishes
Palliative vs curative treatment
Overall prognosis
Need for compliance
Patient “emotionally strong”
Patient wishes to know
Patient is religious
Patient in younger
Diagnosis certain

42. Psychiatric Disorders
What are the common psychiatric complications of cancer?

43. Brief Reactive Psychosis
Psychosis Schizophrenia
Mood Persistent Delusional Disorder
Unipolar Depression
Bipolar Affective Disorder Organic Psychosis
Adjustment Disorder
Anxiety Disorders
Post-Partum Affective Disorders
Organic Affective Disorders
Cognition
Delirium
Dementia
Organic Amnesic Syndrome

44. Depression
Can we better understand depression in the context of cancer?

45. Two+ Key symptoms:
• persistent sadness or low mood; and/or
• loss of interests or pleasure
• fatigue or low energy.
Two+ associated symptoms:
• disturbed sleep
• poor concentration or indecisiveness
• low self-confidence
• poor or increased appetite
• suicidal thoughts or acts
• agitation or slowing of movements
• guilt or self-blame.
=> Mild 4/10 Moderate 6/10 Severe 8/10

46. Core Symptoms ICD10 DSMIV
Persistent sadness or low mood Yes (core) Yes (core)
Loss of interests or pleasure Yes (core) Yes (core)
Fatigue or low energy Yes (core) Yes
Disturbed sleep Yes Yes
Poor concentration or Yes Yes
indecisiveness
Low self-confidence Yes No
Poor or increased appetite Yes No
Suicidal thoughts or acts Yes Yes
Agitation or slowing of Yes Yes
movements
Guilt or self-blame Yes Yes
Significant change in weight No Yes

48. Lung (43%)
Brain
Hodgkin’s disease
pancreas
lymphoma
liver
head and neck
Breast (35%)
leukaemia
melanoma
colon
prostate
gynaecological (29.6%)
Zabora J, et al The prevalence of psychological distress by cancer site.
Psycho-Oncology 2001;10(1):19 –28. n=4496,

49. Cancer Related
Poor Quality of Life = Strong
Pain = Moderate - Strong
Later stage disease / poorer prognosis = moderate
Greater uncertainty about the future = moderate
greater disease burden / complications = weak
Non-Cancer Related
younger age = weak
Lack social support = moderate
Previous depression = moderate
Additional difficulties = strong

51. Help!

52. 2x2 Help Table
Clinician thinks: Clinician thinks:
Help Needed Help Not Needed
Patient Says: => Intervention => Refuse?
Help Wanted
Patient Says: => Delay =>Agree discharge
Help Not Wanted

53. 2x2 Clinician Help Table : ACTUAL HELP
Clinician thinks: Clinician thinks no
Unmet Needs Unmet Needs
Patient Says: => Intervention => Low grade
Help Wanted
Patient Distressed => Intervention =>??
Patient Not => Monitor? => discharge?
distressed or
Help Not Wanted

54. 2x2 Clinician Help Table : ACTUAL HELP
Clinician thinks: Clinician thinks
Unmet Needs no Unmet Needs
Patient Says: Helped 1/3 Helped 1/2
Help Wanted
Patient Helped 2/3 Helped 1/2
Distressed
Patient Not Helped 1/4 Helped 1/6
distressed or
Help Not Wanted

55. Help – Who Wants Help?
20% said they wanted professional help for
psychosocial issues.
Only 36% of those distressed on the DT wanted help.

56. What Kind of Help is Wanted?
19% wanted medication (eg antidepressants)
31% want self help guidelines
31% wanted group therapy
56% wanted illness information.
58% complementary therapies
62% face-to-face psychological support

57. Help – Who From?
Nurse specialists (54%)
Family and friends (21%)
Spiritual advisor (8%)
Psychiatrist (4%).

58. Why Not Needed?
“getting help elsewhere” (57%)
“feel well” (41%)
“coping on my own” (31%)
“fear of stigma”, “fear of side effects”, “not likely to be
effective for me”, and “don’t like to talk about
problems” (all less than 10%)

59. Promoting recognition & treatment

60. Do Clinicians Look for Depression/Distress?
Mitchell, Kaar, Coggan, Herdman (N=226)

61. A
Form al QQ
Mitchell, Kaar, Coggan, Herdman 6%
N=226
Ultra-Short QQ
30%
Refer to Specialist
1%
Clinical Skills Alone
63%

62. Distress Thermometer – Pooled
Proportion
20.0%
Insignificant Minim al Mild Moderate Severe
18.0%
16.0%
14.0%
12.0%
10.0%
18 . 4 %
8.0%
12 . 9 %
6.0% 12 .3 % 11.9 %
p124
11. 2 %
4.0% 8 . 1%
7.7%
7.2 %
5.0 %
2.0%
2 .8 % 2 .6 %
0.0%
Zero One Tw o Three Four Five Six Seven Eight Nine Ten
50%

63. 100.0
5.9
11.1
14.3
90.0 Comment: Slide illustrates diagnostic 21.4
accuracy according to score on DT 11.8
25.9
80.0 38.7 38.1
43.5 22.2 14.3
46.7
70.0 59.6
21.4
72.4
60.0 Judgement = Non-distressed
33.3 Judgement = Unclear
19.4 19.0 Judgement = Distressed
50.0
26.1
24.4 82.4
40.0
71.4
66.7
30.0
25.0 57.1
41.9 42.9 40.7
20.0 15.8
30.4 28.9
10.0
15.4
11.8
0.0
Zero One Two Three Four Five Six Seven Eight Nine Ten

65. Phase II