Depression affects up to 50% of patients with cancer, and unfortunately many go undiagnosed and suffer in silence. The problem is two-fold: 1) Oncologists often feel too busy or not qualified to be able to diagnose and treat this condition, and 2) The majority of patients do not volunteer their concerns about their psychoemotional distress, either feeling too ashamed to admit that they are not coping well with the emotional and psychological distress of their cancer or believing that their physicians and nurses are not concerned about these issues.
Background:
In some studies, depression has been associated with poorer survival outcomes in those with cancer. In one recently reported study, of 125 women with metastatic breast cancer, the researchers discovered that the women with lower depression scores (least depressed) had a significantly longer survival time compared with the more depressed women (53.6 months versus 25.1 months).
Although depression and cancer progression has yet to be definitively linked, the data is hard to ignore. We know that depression and reduced treatment compliance (i.e. following up on medical appointments, examinations, treatments, etc.) are directly related. Furthermore, we know that depression negatively impacts the body’s immune system and may increase tumor progression through a complex interplay of neurohormonal and inflammatory pathways. (read more here)
Incredibly, simply teaching patients how to cope with the psychoemotional distress of their cancer has been shown to improve cancer-specific survival. In one study of 227 women with breast cancer randomized to either an intervention arm (teaching coping strategies) or control arm, the authors reported a significant reduction in the rates of breast cancer recurrence (45% lower) and death (55% lower) among the women in the intervention arm.
As quoted from a recent Journal of Clinical Oncology article, “Pain and symptom distress, mood disorders, and family caregiver burden are prevalent and carry significant adverse consequences for our patients and their families. Medical care focused on addressing these burdens—pain and other symptoms, mood disorders, and matching care to honestly informed and achievable goals—not only improve quality of life and reduce depression but, as recent studies suggest, may also improve survival. In addition, such interventions pose low or no risk and, compared with other cancer treatments, are low in cost.”
What can be done?
I strongly encourage oncology providers to start assessing for depression in their patients, today. Simple tools have been developed and validated to help in this diagnosis. One of which is the nine-item depression screening tool, PHQ-9 (Patient Health Questionnaire-9), which can be quickly self-administered in the office or at home. It is available here free of charge as a download, and has been translated in many languages. Simply asking our patients “How are you coping?” is a crucial part of our care. I can’t begin to tell you how important simply asking this question has been in so many of my patient interactions. Sadly, I am often the only one who has asked them this question. If you are concerned about how much time this may take out of your tight clinical schedule, trust me I get it but we have to open this door for them. You might be the only one to show them how much you care about their distress, and you absolutely can help them. Your display of empathy and compassion, by inquiring about this common distress starts the dialogue and is the first step to healing.
Involving mental health providers, social workers and nurses in helping our patients cope with their psychoemotional distress is the next step, as treating depression may not be a straightforward intervention. Depending of the severity of the symptoms, there are many therapeutic options available: medications, botanical compounds, exercise, diet modifications, sleep hygiene, talk therapy, support groups, and numerous complementary therapies (i.e. acupuncture, massage, yoga, meditation, reiki, etc.).
Just as much as our conventional oncologic treatments (i.e. chemotherapy, radiation therapy, surgery, etc.) are essential in the management of our patients’ cancer, so is our responsibility to identify and address this common problem.
**As pointed out by one reader of this blog, this also applies to the caregiver. CURE magazine has published a great issue on this topic.**
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