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NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
NCRI - Latest Evidence For Screening In Cancer (March08)
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NCRI - Latest Evidence For Screening In Cancer (March08)

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This is a briefing given to the COMPASS group http://www.compasscollaborative.com/ part of the NCRI regarding the latest methods of screening for distress in cancer.

This is a briefing given to the COMPASS group http://www.compasscollaborative.com/ part of the NCRI regarding the latest methods of screening for distress in cancer.

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  • 1. COMPASS – New Developments in Rapid Screening in Cancer Alex Mitchell Leicester Royal Infirmary Elena Baker-Glenn University of Nottingham Paul Symonds Leicester Royal Infirmary Chris Coggan Leicester General Hospital March 2008 March 2008
  • 2. 1. What Is the Purpose of Screening? Detection Rates, Unassisted Rates, Mj Mn Subsyndromal disorders 2. Current Methods Who is looking?; Vs case finding, 3a. Verbal Methods Evidence? 3b. Distress Thermometer Evidence? 4. Emotion thermometers Validation 5. Future Methods
  • 3. Methodology Study I: Baker-Glen, Symonds, Granger “ET Validation” (a) n=140 chemotherapy attendees (b) n=70 chemotherapy f/u Study II: Sampson, Symonds, Granger “ET Extension” (c) n=250 chemotherapy + late Study III: Lord, Symonds, Granger “Coping” (d) n=250 Study IV: Mitchell, Symonds, Steward “SMI RCT” (e) n=300
  • 4. 1. Purpose of Screening?
  • 5. 30% Distress 48% 20% 38% 13% ?% Pooled Analysis of 38 studies Setting: mostly Anxiety Depression oncology Instruments: mixed Point prevalence n=6414
  • 6. Rates of Mj Mn SS 60 52.2 51.1 Baseline 50 1 Month 40 37.2 31 30 20 11.6 10.3 10 8.5 4.7 0 Major Depression Minor Depression Subsyndrom al Any Mood Problem
  • 7. Outcome 0.27 0.27 Major Depression Minor Depression Sub-Syndromal Remission Lost 0.09 0.18 0.18
  • 8. 2. Current Detection Methods Unassisted Accuracy? Screening Habits? What are the optimal questions?
  • 9. 0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00 Loss of energy Diminished drive Sleep disturbance Concentration/indecision Depressed mood Anxiety Diminished concentration Insomnia Diminished interest/pleasure Psychic anxiety Helplessness Worthlessness Hopelessness Somatic anxiety Thoughts of death Anger Excessive guilt Psychomotor change Indecisiveness Decreased appetite Psychomotor agitation Psychomotor retardation Decreased weight Lack of reactive mood Increased appetite All Case Proportion Hypersomnia Depressed Proportion N=1500 Non-Depressed Proportion Increased weight Mitchell, Zimmerman et al MIDAS Database. Psychol Med 2007 Submitted
  • 10. 1 Depressed Mood S Diminished interest/pleasure e Diminished drive 0.9 n s Loss of energy 0.8 i Sleep disturbance t Diminished concentration i 0.7 v i t 0.6 y 0.5 0.4 0.3 0.2 0.1 1 - Specificity 0 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
  • 11. 3. Rapid Screening
  • 12. Test Duration Ultra-short screening tools were defined as those with 1-4 items taking less than 2 minutes to complete. Short screening tools were defined as those with 5-14 items, taking between 2 and five minutes to complete. Standard screening tools were defined as those with 15 or more items, taking more than five minutes to complete. => Tools table
  • 13. 20 Instruments for Depression Ultra-short <6 Short > 5 < 11 Long > 10 PHQ1 HADS (7) (1) HAM-D (21) (7) (6) PHQ2 (2) MADRAS (10) BDI (21) (13) (7) (2) WHO-5 (5) MOS-D (8) BSI (53) Distress Therm (1) EPDS (10) (8)(6)(5) CES-D (20) (13)(10) (6) DADS (7) Zung (20) PHQ9 (9) (2) GDS (30,15) (5)(4)(2) Personal HQ (16) SDS (20) DEPS (10)
  • 14. 3a. The Verbal Questions
  • 15. Cancer Staff Psychiatrists 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% Current Method Mitchell, Kaar, Poster APA 2007
  • 16. Cancer Staff Psychiatrists 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% Ideal Method Mitchell, Kaar, Poster APA 2007
  • 17. Primary data reports Submitted BJCa (n= 258) Excluded long, medium, short tests (n= 122) Excluded primary care Examined Ultra-short tests studies (n= 32) (n= 98) No diagnostic validity testing (n=39) Verbal and Non-Verbal Non-validated comparison Studies (n=59) (n= 1) Insufficient data available (n= 4) Non-verbal methods (n= 29) Non-cancer settings (n= 6) Simple Verbal Question Non-STARD compliant Diagnostic Accuracy Studies (n= 2) (n= 17) Ultra-Short Outcome Measure Setting / Sample Method Single depression HADS-total score (n=2) Palliative care (n=11) question (n=9) Single interest question DSM Major and minor (n=3) depression (n=4) Mixed stage (n=3) Two questions (n=5) DSM Major Depression (n=11) Early stage (n=3) ICD10 Depression (n=0)
  • 18. Real-World Performance (Prev 18%, TP TN, FP, FN) Depression Question 4.7 13.0 66.7 15.7 Depressed Non-Depressed Interest Question 2.7 12.5 71.5 13.3 c Depressed Non-Depressed False Negatives (%) Correctly Diagnosed (%) Correct Reassured (%) Depression & Interest Q 1.7 16.5 70.2 False Positives (%) 11.5 Depressed Non-Depressed 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 50.0 55.0 60.0 65.0 70.0 75.0 80.0 85.0 90.0 95.0 100. 0
  • 19. 3b. The Distress Thermometer
  • 20. The distress thermometer - Please circle the number (0-10) that best describes how much distress you have been experiencing in the past week, including today. - What phone number would you like us to contact you on if necessary? Please tick WHICH of the following is a cause of distress: Practical Problems Spiritual/ Religious Concerns Physical Problems contd… Childcare Loss of faith Changes in Urination Housing Relating to God Fevers Money Loss of meaning or purpose in life Skin dry/ itchy Transport Nose dry/ congested Work/School Physical problems Tingling in hands/ feet Pain Metallic taste in mouth Family Problems Nausea Feeling swollen Dealing with partner Fatigue Sexual Dealing with children Sleep Hot flushes Getting around Emotional Problems Bathing/ Dressing Depression Breathing Fears Mouth sores Is there anything important you would like to add to the list? Nervousness Eating ______________________________ ______________________________ Sadness Indigestion ______________________________ Worry Constipation Anger Diarrhoea => Validity
  • 21. Distribution of DT Scores Ransom (2006) PO (n=491) 18.0 15.7 16.0 14.7 13.8 14.0 13.2 12.0 10.4 10.0 8.4 7.7 8.0 7.3 6.0 3.7 4.0 3.3 1.8 2.0 0.0 Score 0 Score 1 Score 2 Score 3 Score 4 Score 5 Score 6 Score 7 Score 8 Score 9 Score 10
  • 22. N=17 studies Ultra-short Tests & Depression 3603 Depression Depression PRESENT ABSENT Test +ve 635 1173 1808 PPV 32% Test -ve 152 2643 2795 NPV 93% 787 3816 3603 Sensitivity Specificity Prevalence 18% 81% 69%
  • 23. N=17studies Ultra-short Tests & Distress 3682 Distress Distress PRESENT ABSENT Test +ve 1138 693 1831 PPV 65% Test -ve 337 1514 1891 NPV 80% 1475 2207 3682 Sensitivity Specificity Prevalence 39% 77% 68%
  • 24. N= 4 studies Ultra-short Tests & Anxiety 2215 Anxiety Anxiety PRESENT ABSENT Test +ve 652 596 1248 PPV 55% Test -ve 193 776 969 NPV 80% 843 1372 2215 Sensitivity Specificity Prevalence 38% 77% 56%
  • 25. Study I: Baker-Glenn et al Head-to-head comparison of HADS PHQ2 (Q1, Q2, Q1 or Q2) PHQ9 DT
  • 26. (3v4 )
  • 27. 1 0.9 PHQ2 Two QQ Sensitivity 0.8 PHQ9 0.7 HADS-T DT (3v4) 0.6 PHQ2 Interest 0.5 HADS-D DT (4v5) 0.4 PHQ2 Depression 0.3 0.2 0.1 0 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 1 - Specificity
  • 28. 4. New Methods for 2008
  • 29. See Gil F, Grassi L, Travado L, Tomamichel M, Gonzalez JR. for the SEPOS Group. Use of distress and depression thermometers to measure psychosocial morbidity among southern European cancer patients. Support Care Cancer, 13: 600–606, 2005
  • 30. 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 0.10 0.00 Distress Anxiety Depression Anger Thermometer Thermometer Thermometer Thermometer
  • 31. ET vs DT? Of 130 patients with predominantly early cancer, 37% scored above the cut-off recommended by the NCCN on the DT vs 69% on the ET Of 63% DT low scorers 51% recorded emotional difficulties on the new Emotion Thermometers (ET) tool Out of those with any emotional complication, 93.3% would be recognised using the AnxT alone, compared with 54.4% who would be recognised using the DT alone.
  • 32. HADS-A Score & DT Score 20 15 10 5 y = 0.9117x + 3.9311 R2 = 0.4098 0 0 1 2 3 4 5 6 7 8 9 10
  • 33. HADS-A Score & AnxT Score 20 15 10 5 y = 1.014x + 2.3207 R2 = 0.5702 0 0 1 2 3 4 5 6 7 8 9 10
  • 34. HADS-D Score & DT Score 20 15 10 5 y = 0.4334x + 3.3146 R2 = 0.1187 0 0 1 2 3 4 5 6 7 8 9 10
  • 35. HADS-D Score & DeptT Score 20 15 10 5 y = 0.8165x + 2.7614 R2 = 0.3048 0 0 1 2 3 4 5 6 7 8 9 10
  • 36. Vs DT DepT HADS-A AUC: DT=0.82 DepT=0.84 AnxT=0.87 AnxT AngT AngT=0.685
  • 37. Vs DT DepT HADS-D AUC: DT=0.67 DepT=0.75 AnxT=0.62 AnxT AngT AngT=0.69
  • 38. DepT & Major Depression Depression Depression PRESENT ABSENT Test +ve 10 5 15 PPV 67% DT 28% Test -ve 14 188 202 NPV 93% DT 95% 24 193 217 Sensitivity Specificity Prevalence 11% 42% 97% DT DT 67% 79%
  • 39. DT AngT (38%) (26%) 2% 1% 0% DT 2% 0% 10% 15% 0% 8% 4% 0% 21% 2% AnxT DepT (65%) (30%)
  • 40. 5. Where Next? Help Algorithms

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