Evidence Based Screening for Depression in Cancer
 Evidence Based Screening for Depression in Cancer
 Improving the Accura...
1. Background

  How common is Depression in cancer?


  How common is Distress in cancer?


  Implications for => mortali...
48%


          Distress/Adjustment Disorder
                                 N=10

                                      ...
Implications for Mortality




  Comment: Slide illustrates new 2009
  meta-analysis on mortality vs depression
Introducing the Distress Thermometer
300          Comment: Slide illustrates pooled scores
             on DT from five studies
                               ...
2. Tools and Scales

   What methods are used to detect mood disorders?


   How often do clinicians look for mood complic...
Methods to Evaluate Depression



                        Conventional Scales

                            Short (5-10) Lo...
Methods to Evaluate Depression



                            Conventional Scales

                               Short (5...
Methods to Evaluate Depression



 Unassisted Clinician                       Conventional Scales

Untrained Trained      ...
“Validated” Tools




 Comment: Slide illustrates potential pool
 of validated tools in cancer
Comment: Frequency of cancer specialists
n=226   enquiry about depression/distress from
        Mitchell et al (2008)
Cancer Staff                                                                       Psychiatrists
           Current Method...
Cancer Staff                                           Psychiatrists
              Ideal Method (n=226)

                 ...
3. Cancer Care - Meta-Analysis

   How well do CNS recognize distress?


   How well do CNS recognize depression?


   How...
Local Study: Recognition by CNS in oncology


N=350 nurse specialists’ assessments (2008-2009)

       2/3rd Chemotherapy ...
Detection sensitivity = 50.6%
1.00
                                   Detection specificity = 79.4%
           Post-test P...
90

                                                                                        83.3


80                     ...
Testing Clinicians: A Meta-Analysis
Methods (currently unpublished)

13 studies reported in 8 publications.
  2 anxiety
  ...
Oncologists vs Nurses vs GPs
Who is better?
1.00



           Post-test Probability
                                         GP+
                                    ...
4. Cancer Care – Screening Data

   What resources are available locally re identification


   How much difference does a...
Comment: Slide illustrates actual gain in
meta-analysis of screening
implementation in primary care
Introducing the Emotion Thermometers
1.00


0.90


0.80
                                                                                 Ten
0.70              ...
Vs            DT    DepT
HADS-A




AUC:
DT=0.82
DepT=0.84
AnxT=0.87    AnxT   AngT
AngT=0.685
0
                                       10
                                            20
                               ...
-30
      -20
                 -10
                                      0
                                          10
  ...
Summary & Plans
2006 – Examined screening habits
      - Meta-analysis of DT

2007 - Validated ET
       - Meta-analysis o...
Credits & Acknowledgments

  Elena Baker-Glenn      University of Nottingham
  Paul Symonds           Leicester Royal Infi...
FURTHER READING:

Screening for Depression in Clinical Practice An
   Evidence-Based guide

   ISBN 0195380193
   Paperbac...
Leicester09 - Evidence Based Screening For Depression In Oncology Settings (Nov09)
Leicester09 - Evidence Based Screening For Depression In Oncology Settings (Nov09)
Leicester09 - Evidence Based Screening For Depression In Oncology Settings (Nov09)
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Leicester09 - Evidence Based Screening For Depression In Oncology Settings (Nov09)

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This is a lecture from November 2009 to the cancer profressionals in Leicester. The aim was to introduce plans to roll out a screening programme in radiotherapy.

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Leicester09 - Evidence Based Screening For Depression In Oncology Settings (Nov09)

  1. 1. Evidence Based Screening for Depression in Cancer Evidence Based Screening for Depression in Cancer Improving the Accuracy of Health Professionals In Oncology Improving the Accuracy of Health Professionals In Oncology Alex Mitchell www.psycho-oncology.info Department of Cancer & Molecular Medicine, Leicester Royal Infirmary Department of Liaison Psychiatry, Leicester General Hospital Oncology Seminar Series Nov 2009 Oncology Seminar Series Nov 2009
  2. 2. 1. Background How common is Depression in cancer? How common is Distress in cancer? Implications for => mortality
  3. 3. 48% Distress/Adjustment Disorder N=10 57% 38% 20% 18% 13% Anxiety N=4 Depression N=11 Comment: Slide illustrates meta-analytic rates of mood disorder
  4. 4. Implications for Mortality Comment: Slide illustrates new 2009 meta-analysis on mortality vs depression
  5. 5. Introducing the Distress Thermometer
  6. 6. 300 Comment: Slide illustrates pooled scores on DT from five studies Jacobsen 2005 Hoffman 2004 250 Mitchell 2009 Tuinman 2008 Ransom 2006 71 200 48 14 46 46 54 11 150 5 8 61 5 31 42 42 35 62 8 31 100 29 2 31 22 16 38 37 23 2 23 29 46 15 32 50 6 21 72 77 18 9 68 65 3 13 51 12 8 41 4 38 36 5 7 18 4 16 9 0 Zero One Two Three Four Five Six Seven Eight Nine Ten Distress = 50%
  7. 7. 2. Tools and Scales What methods are used to detect mood disorders? How often do clinicians look for mood complications?
  8. 8. Methods to Evaluate Depression Conventional Scales Short (5-10) Long (10+)
  9. 9. Methods to Evaluate Depression Conventional Scales Short (5-10) Long (10+) Ultra-Short (<5)
  10. 10. Methods to Evaluate Depression Unassisted Clinician Conventional Scales Untrained Trained Ultra-Short (<5) Short (5-10) Long (10+) Acceptability ? Accuracy? Accuracy? Routine Implementation vs Comment: schematic overview of methods to evaluate depression
  11. 11. “Validated” Tools Comment: Slide illustrates potential pool of validated tools in cancer
  12. 12. Comment: Frequency of cancer specialists n=226 enquiry about depression/distress from Mitchell et al (2008)
  13. 13. Cancer Staff Psychiatrists Current Method (n=226) Other/Uncertain 9% Other/Uncertain ICD10/DSMIV 2% 0% ICD10/DSMIV 13% Short QQ 3% 1,2 or 3 Sim ple QQ 15% Clinical Skills Use a QQ Alone 15% 55% Clinical Skills Alone 73% 1,2 or 3 Sim ple QQ 15% Comment: Current preferred method of eliciting symptoms of distress/depression
  14. 14. Cancer Staff Psychiatrists Ideal Method (n=226) Effective? Long QQ 8% Clinical Skills Clinical Skills Alone Alone Algorithm 20% 17% 26% ICD10/DSMIV 24% ICD10/DSMIV 1,2 or 3 Sim ple 0% 1,2 or 3 Sim ple QQ QQ 24% Short QQ 34% 23% Short QQ 24% Comment: “Ideal” method of eliciting symptoms of distress/depression according to clinician
  15. 15. 3. Cancer Care - Meta-Analysis How well do CNS recognize distress? How well do CNS recognize depression? How well do oncologist do? CNS = Clinical Nurse Specialists
  16. 16. Local Study: Recognition by CNS in oncology N=350 nurse specialists’ assessments (2008-2009) 2/3rd Chemotherapy suite LRI 1/3rd Community Northampton, Kettering, Breast Ca GGH Mostly early or mixed cancer (1/3 late) “Is you patient suffering significant distress, depression, anxiety, anger or are they well or are you unsure?”
  17. 17. Detection sensitivity = 50.6% 1.00 Detection specificity = 79.4% Post-test Probability Overall accuracy = 65.4%. 0.90 0.80 0.70 0.60 CHEMO+ 0.50 CHEMO- 0.40 Baseline Probability 0.30 COMMU+ COMMU- 0.20 0.10 Pre-test Probability 0.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 Comment: Slide illustrates performance of chemotherapy vs community nurses in oncology
  18. 18. 90 83.3 80 Series1 Comment: Slide illustrates diagnostic Series2 accuracy according to score on DT 71.4 70 62.5 60 56.5 50 43.5 43.5 41.4 40 30 28.6 28.6 20 16.7 13.1 10 0 Zero One Two Three Four Five Six Seven Eight Nine Ten
  19. 19. Testing Clinicians: A Meta-Analysis Methods (currently unpublished) 13 studies reported in 8 publications. 2 anxiety 4 depression 7 broadly defined distress. 9 studies involved medical staff / 4 studies nursing staff. Gold standard tools including GHQ60, GHQ12 HADS-T, HADS-D, Zung and SCID. The total sample size was 4786 (median 171) Oncologists SE =38.1% and SP = 78.6%; a fraction correct of 65.4%.
  20. 20. Oncologists vs Nurses vs GPs Who is better?
  21. 21. 1.00 Post-test Probability GP+ GP- 0.90 Baseline Probability Nurse+ Nurse- 0.80 Oncologist+ Oncologists- 0.70 0.60 0.50 0.40 0.30 Comment: Doctors appear to be more successful at ruling-in or giving a diagnosis, nurses more successful at 0.20 ruling out 0.10 Pre-test Probability 0.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
  22. 22. 4. Cancer Care – Screening Data What resources are available locally re identification How much difference does a screening tool make?
  23. 23. Comment: Slide illustrates actual gain in meta-analysis of screening implementation in primary care
  24. 24. Introducing the Emotion Thermometers
  25. 25. 1.00 0.90 0.80 Ten 0.70 Nine Eight 0.60 Seven Six 0.50 Five Four 0.40 Three Two 0.30 One 0.20 Zero Comment: Slide illustrates scores on ET 0.10 tool 0.00 Distress Anxiety Depression Anger Thermometer Thermometer Thermometer Thermometer
  26. 26. Vs DT DepT HADS-A AUC: DT=0.82 DepT=0.84 AnxT=0.87 AnxT AngT AngT=0.685
  27. 27. 0 10 20 30 40 50 60 70 80 Fa tig ue La Pa ck in of en er We gy ak Ap ne pe ss tite Ne l os rv o s us ne We ss ig h t lo Dr ss De ym p re ou ss th ed mo Co od ns tip ati on Wo rry ing In s om n ia Dy sp ne a Na us ea An xie Irr ty ita bil ity Blo ati Co ng gn Co itiv ug es h ym pto Ea ms rl y Ta sa s te tie ty ch an ge So re s mo Dr uth ow / sin es Ur s i na Ed ry em sy a mp tom Diz s zin es Dy s sp ha g ia Co nfu si o Bl n ee Ne d in ur g o lo Ho g ic ars al en Self-Reported Symptoms in Cancer by Frq es Dy s Sk sp in ep sy sia mp tom Di s arr he a Pr ur itu s Hic cu p
  28. 28. -30 -20 -10 0 10 20 30 40 50 Weight loss Drowsiness Neurological symptoms Fatigue Weakness Confusion Skin symptoms Dyspnea Appetite loss Anxiety Dysphagia More common in Late stages Bleeding Diarrhea Dry mouth Constipation Dizziness Dyspepsia Edema Urinary symptoms Cough Nausea Self-Reported Symptoms in Cancer by Frq Depressed mood Insomnia More common in early stages Irritability Pain
  29. 29. Summary & Plans 2006 – Examined screening habits - Meta-analysis of DT 2007 - Validated ET - Meta-analysis of verbal methods 2008 – Pilot (community) screening data, viability - Network –wide training L2 2009 – Nursing Recognition - Chemotherapy screen implementation - Meta-analysis of all tools 2010 – Radiotherapy screen implementation – RCT of screen + intervention
  30. 30. Credits & Acknowledgments Elena Baker-Glenn University of Nottingham Paul Symonds Leicester Royal Infirmary Chris Coggan Leicester General Hospital Burt Park University of Nottingham Lorraine Granger Leicester Royal Infirmary Mark Zimmerman Brown University, Rhode Island Brett Thombs McGill University Canada James Coyne University of Pennsylvania Nadia Husain Leicester General Hospital Joanne Herdman Leicester General Hospital Jo Kavanagh Leicester Royal Infirmary For more information www.psycho-oncology.info
  31. 31. FURTHER READING: Screening for Depression in Clinical Practice An Evidence-Based guide ISBN 0195380193 Paperback, 416 pages Nov 2009 Price: £39.99

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