Download Psychosocial distress is prevalent in head and neck cancer patients

The Laryngoscope
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Psychosocial Distress is Prevalent in Head and Neck Cancer Patients
Luke Buchmann, MD; John Conlee, PhD, MSW; Jason Hunt, MD;
Jayant Agarwal, MD; Shelley White, MSW
Objectives/Hypothesis: The purpose of this study is to evaluate the levels of psychological distress in head and neck
cancer patients using a validated screening tool. We aim to characterize distress in this cancer population and understand the
factors driving distress levels.
Study Design: Review of prospectively gathered data.
Methods: A review of prospectively gathered data was undertaken from 89 head and neck cancer patients (HNC) who
completed the Distress Thermometer and Problem List (DT) from the National Comprehensive Cancer Network (NCCN).
Results: Distress levels were high in the overall population. The level of distress was significantly greater in patients
with a self-reported history of depression (P <.001), family concerns (P ¼ .030), emotional concerns (P ¼ .001) and physical
concerns (P ¼ .014).
Conclusions: Psychosocial distress was found to be high in the HNC population. Factors associated with increased
distress level included a self-reported history of depression, family concerns, emotional concerns, and physical concerns.
Key Words: Distress, quality of life, head and neck cancer, depression.
Level of Evidence: 4.
Laryngoscope, 123:1424–1429, 2013
INTRODUCTION
Despite steady improvement in the rates of survival,1 cancer remains one of the most emotionally
distressing conditions in modern medicine.2 Although
distress is prevalent among cancer patients, fewer than
10% are referred for psychosocial intervention.3 The
early detection and treatment of distress has the potential to improve quality of life (QOL) and overall
survival in patients with cancer.3–5 The Distress Management Panel of the National Comprehensive Cancer
Network (NCCN) has established guidelines for the
recognition, monitoring, documentation, and prompt
treatment of distress at all stages of disease.6 These
guidelines suggest that all patients should be screened
for distress during their initial visit and at appropriate
intervals thereafter, particularly during changes in
disease status and treatment. Screening for distress at
the initial visit identifies the most vulnerable patients
From the Division of Otolaryngology Head and Neck Surgery,
Department of Surgery (L.B., J.H.); the Patient and Family Services (J.C.,
S.W.); and the Division of Plastic and Reconstructive Surgery, Department
of Surgery (J.A.), The University of Utah, Huntsman Cancer Institute; and
the Department of Surgery, Division of Otolaryngology Head and Neck
Surgery (L.B.), George E. Wahlen Veterans Administration Medical Center,
Salt Lake City, Utah, U.S.A.
Editor’s Note: This Manuscript was accepted for publication
October 22, 2012.
Presented at the International Society of Psycho-oncology. Quebec,
Canada, May 27–29, 2010.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Luke Buchmann, MD, Division of
Otolaryngology Head and Neck Surgery, Department of Surgery, The
University of Utah, Huntsman Cancer Institute, Salt Lake City, UT
84112. E-mail: [email protected]
DOI: 10.1002/lary.23886
Laryngoscope 123: June 2013
1424
during the first weeks of care.5,7 The NCCN has developed the Distress Thermometer (DT) and Problems List
as a validated screening tool to assess distress in cancer
patients. The DT rates the level of distress from 0 to
10. A cutoff of 4 or greater indicates significant levels
of distress and has been validated against the hospital
anxiety and depression scale (HADS) and Brief Symptom Inventory (BSI-18).8 Mitchell has evaluated short
methods to screen for distress, such as the DT, and
has determined that they are a valid and efficient
method for screening a large population of patients to
identify those who would benefit from more focused
evaluation.9,10
Head and neck cancer (HNC) populations have significant psychosocial issues. In a recent study, 58% of
patients with HNC had mild to severe depression before
the initiation of radiotherapy, and the percentage with
severe depression increased to 67% on the final day of
treatment.11 The consequences of untreated depression
can be severe, affecting QOL, treatment compliance, and
survival.12–14 The incidence of suicide is more than four
times higher among patients with HNC than among the
general population.15 Distress has been studied in other
cancer sites including the lung, breast cancer, and gynecologic cancer populations.16–18 To our knowledge
distress has not been specifically addressed in the HNC
population. Otolaryngologists who care for HNC patients
would benefit from information regarding distress in
their patients to facilitate improvement in comprehensive care of this patient population. The present study
examines the prevalence and characteristics of distress
in HNC patients during initial clinic visits, and evaluates the DT as an effective screening tool in this specific
patient population.
Buchmann et al.: Psychosocial Distress Is Prevalent in Head and Neck Cancer Patients
Fig. 1. Distress Thermometer and Problem List.
MATERIALS AND METHODS
The study has been reviewed and approved by the Institutional Review Board (IRB) of The University of Utah. This
study surveyed the prevalence of distress in newly registered
patients with HNC over a period of 8 consecutive months from
November 1, 2007 through June 30, 2008.
As part of normal clinical practice, all patients completed
the DT during the first clinic visit (Fig. 1). Chart abstraction
was conducted only for those patients who completed the
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questionnaire. A waiver of consent was received from the IRB
to look at the DT and relevant clinical information for research
purposes. Since all new patients completed the DT, there was
little source of selection bias in this cohort. The objective was to
survey newly registered patients during the early evaluation of
their cancer diagnosis and treatment, including treatment of
recurrent disease. All data from each DT was entered into
the database and combined with additional demographic and
clinical information.
Buchmann et al.: Psychosocial Distress Is Prevalent in Head and Neck Cancer Patients
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TABLE I.
Characteristics of Gender and Marital Status and Distress Scores.
Variable
N
%
Distress (6 SD)
Significance
Male
49
55
3.53 (2.87)
NS
Female
Married
40
55
45
62
4.10 (2.33)
3.51 (2.46)
NS
Single
34
38
4.24 (2.89)
Chart Review
Patients who completed the DT were used for chart
abstraction and inclusion in the study. The listing of independent variables was divided into three separate categories:
demographic, psychosocial, and clinical. All demographic and
clinical variables were obtained from the medical record, while
all psychosocial variables were found in the DT. Each medical
record was searched for a history and physical, laboratory
values, and demographics information. Health information not
found for any of the variables, or found outside of the 4-week
window of the new registration date, was listed as missing.
control for such variables in an evaluation of predictors of overall distress.
Regression analyses were conducted using the demographic and clinical variables with significant bivariate
associations and each of the five domains. Specific concerns
listed under each domain were used in the regression model.
Nonsignificant predictors were eliminated from the model, leaving only those variables that account for the largest amount of
variance in reported distress level.
Logistic regression with hierarchical variable entry was
used to evaluate predictors of clinical distress above clinical cutoff scores of 4 or 5. For each cutoff score, two logistic regression
analyses were conducted: one using the five concern domains
and the second using the 20 specific concerns potentially
endorsed by each patient. Both analyses contained the demographic and clinical variables found to have significant bivariate
relationships with clinically significant distress. Odds ratios were
generated for the predictors of clinically significant distress at
both the domain level and the level of individual concerns. Predictors of clinically significant distress were generated for the
entire sample, as well as for each gender-specific sample.
RESULTS
DT Screening Instrument
The Distress Thermometer and problem list was initially
developed to evaluate prostate cancer patients and subsequently validated in broader cancer populations.8,19 The
instrument measures the global level of distress using a visual
analogue scale from 0–10 in the shape of a thermometer, with
the zero point identified as ‘‘No Distress’’ and the 10th point
labeled by ‘‘Extreme Distress.’’ In addition, the problem list
uses self-reported sources of distress and includes Emotional,
Family, Physical, Practical, and Spiritual. These categories are
referred to here as five domains.
Data Analysis
A database was created using SPSS (version 18, IBM,
Armonk, NY) statistical software to accommodate a grand total
of 48 variables, including 6 demographic variables, 26 psychosocial variables, and 16 clinical variables.
The overall distress score was evaluated using the mean
6 standard deviation (6SD) level of distress on the 0 to 10 DT
scale. The mean (6SD) number of domains endorsed on the
problem list and the mean (6SD) number of psychosocial concerns endorsed were calculated for the entire patient sample.
Correlations were calculated to evaluate the bivariate relationships between the level of distress and each of the five
domains (Emotional, Family, Physical, Practical, and Spiritual)
and each of the individual concerns listed on the DT. The most
frequently reported concerns were calculated for the entire sample of male and female patients. Separate analyses of male and
female patients were used to find the most frequently reported
concerns in gender-specific samples with HNC.
Clinically significant distress was evaluated by assessing
the rate of patients reporting distress for two different DT cutoff
scores ( 4 or 5). Demographic variables included sex, age,
race, marital status, insurance status, and level of education.
Clinical variables included tumor histology, site of disease,
stage, chemotherapy, radiation therapy, surgery, complete blood
count, tobacco and alcohol use, self-reported psychiatric diagnosis, and use of antidepressive medications. Both demographic
and clinical variables were correlated with the overall level of
distress for the entire sample of patients and for each gender
separately. Variables shown to have significant bivariate associations with distress were used in the regression analysis to
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A total of 89 patients completed the DT with sufficient clinical data to be included in the study. Mean age
6 standard deviation (6SD) for the entire sample was
56.6 (616.1) years. Eighty-seven of the 89 patients were
non-Hispanic white. The mean distress (6SD) for all
patients was 3.8 (62.6). Distress characteristics by sex
and marital status can be found in Table I. Across the
sample, primary tumor sites were localized in discrete
regions of the head and neck (Fig. 2). The prevalence of
distress between groups was not significantly different
(P ¼ .661).
Several psychosocial and clinical variables were
examined across patients. Distress scores did not differ
between groups with new versus recurrent cancer, metastatic versus nonmetastatic cancer, the presence of
co-morbidities, a history of radiotherapy or chemotherapy, and the presence of tobacco or alcohol use. The level
of distress was significantly greater in patients with a
self-reported history of depression (P <.001) and in
patients with a history of antidepressive medication
administration (P <.008).
The rank order of discrete and categorical concerns
demonstrated that emotional factors were foremost in
determining the level of distress. Over half of the
patients identified ‘‘worry’’ as their most prevalent discrete concern, followed by anxiety. Depression and
sadness ranked seventh and eighth out of 20 possible
discrete concerns. Emotional concerns were identified
categorically by nearly three-fourths of the sample, followed by physical concerns, practical concerns, family
concerns, and spiritual concerns.
Spearman’s correlation coefficients were computed
to examine the relationship of overall distress to the
clinical and psychosocial variables being evaluated.
Spearman’s correlation coefficients and the corresponding level of significance for all variables that were
significantly related are shown in Table II. Five of the
six strongest correlations with distress were observed to
be with emotional variables.
Buchmann et al.: Psychosocial Distress Is Prevalent in Head and Neck Cancer Patients
Fig. 2. The prevalence of overall
distress plotted as a function of tumor location. Distress scores were
not significantly different between
patients with different tumor locations in the head and neck. (F ¼
.687, df ¼ 6,82, P ¼ .661). [Color
figure can be viewed in the online
issue, which is available at
wileyonlinelibrary.com.]
Multiple linear regression analysis was conducted
with stepwise variable data entry using all of the variables demonstrating significant bivariate associations at
the .01 level or less. The results indicated that emotional
concerns, self-reporting of depression, and nausea were
independent predictors of the overall level of distress.
These three factors accounted for 46% of the variability
in overall distress.
Discrete DT cutoff scores of 4 or 5 were examined,
each of which establish a threshold for clinically significant distress. Using a cutoff score of 4, 45 patients
(51%) had high levels of distress. With a cutoff score 5, 31 patients (35%) had high levels of distress. Pearson
and Spearman correlation analyses were used to evaluate the correlation of individual psychosocial and clinical
Laryngoscope 123: June 2013
variables to individual distress scores at cutoff levels of
4 or 5.
Spearman correlation coefficients were computed
between distress as a bivariate variable (defined as high
distress when 4 or 5 vs. low distress < 4 or 5) and
each of the clinical and psychosocial variables under
investigation. Spearman’s correlation coefficients and
the corresponding level of significance for all variables
that were related to clinical distress 4 at or above the
.01 level of significance are shown in Table III. Five of
the eight variables showing the strongest association
with distress were observed to be with emotional variables. Spearman’s correlation coefficients and the
corresponding level of significance for all variables that
were related to clinical distress 5 at or above the .01
Buchmann et al.: Psychosocial Distress Is Prevalent in Head and Neck Cancer Patients
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TABLE II.
Significant Spearman’s Correlation Coefficients (q) Between
Level of Overall Distress (Raw Distress Score) and the
Corresponding Variables.
Variable
TABLE IV.
Significant Spearman’s Correlation Coefficients (q) Between
Clinically Significant Distress (Distress Score 4) and
Corresponding Variables.
P
q
Variable
q
p
Emotional Concerns
.538
.001
Emotional concerns
.513
.001
Anxiety
Worry
.485
.422
.001
.001
Anxiety
Physical concerns
.420
.421
.001
.001
Psychiatric diagnosis (H & P)
.416
.001
Worry
.394
.001
Physical concerns
Depression (self-reported DT)
.403
.379
.001
.001
Fatigue
Family concerns
.361
.304
.001
.004
Pain
.294
.005
Psychiatric diagnosis (H & P)
.276
.009
SSRI history
Sleep
.282
.278
.008
.008
Depression (self-reported on DT)
.265
.012
Nausea
.278
.008
Practical concerns
Fatigue
.270
.266
.011
.012
Support
.265
.012
Family concerns
.258
.015
level of significance are shown in Table IV. Five of six
variables showing the strongest relationship with distress were also emotional factors when using a more
rigorous cutoff level for distress.
Predictors of clinically significant distress were
examined using logistic regression with hierarchical
variable data entry. Predictors of clinically significant
distress 4 were having a self-reported history of
depression (odds ratio, 3.99; 95% confidence interval [CI]
1.14–13.93, P ¼ .030), family concerns (odds ratio, 7.20,
95% CI 1.22–42.56, P ¼ .030), emotional concerns (odds
ratio, 13.76, 95% CI 2.53–74.96, P ¼ .001) and physical
concerns (odds ratio, 4.46, 95% CI 1.41–14.07, P ¼ .014).
Predictors of clinically significant distress 5 were
having a self-reported history of depression (odds ratio,
8.25; 95% CI 2.59–26.24, P ¼ .001), having family
concerns (odds ratio, 3.96, 95% CI .969–16.22, P ¼ .055)
and emotional concerns (odds ratio, 15.15, 95% CI 1.76–
130.08, P ¼ .013).
TABLE III.
Significant Spearman’s Correlation Coefficients (q) Between
Clinically Significant Distress (Distress Score 5) and the
Corresponding Variables.
Variable
q
P
Emotional Concerns
.620
.001
Anxiety
.520
.001
Worry
Physical Concerns
.462
.439
.001
.001
Psychiatric Diagnosis (H & P)
.403
.001
Depression (self-reported DT)
Fatigue
.382
.320
.001
.002
SSRI use
.296
.005
Pain
Family Concerns
.295
.277
.005
.009
Sleep
.275
.009
Support
.260
.014
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DISCUSSION
The sensitivity, specificity, and face validity of the
DT and problem list has been empirically determined in
numerous studies comparing the performance of the DT
with accepted psychometric instruments, including the
Public Health Questionnaire 9-item Depression module
(PHQ-9),20 the Hospital Anxiety and Depression Scale
(HADS),8,21,22 the Brief Symptom Inventory-18 (BSI18),5,8 and the Center for Epidemiological StudiesDepression Scale (CES-D).23
Using the DT, we found significant levels of distress
in pre-treatment HNC patients. Depression and anxiety
are both frequent co-morbid psychiatric conditions found
in this cancer population. In a prospective evaluation of
QOL in HNC patients, Hammerlid24 found that pretreatment physical functioning and depression predicted QOL
at 3 years following treatment. The DT is an easy and
validated way to screen a large number of patients for
psychosocial distress who may benefit from more thorough psychosocial evaluation, limiting the resources
needed to address these issues in a busy head and neck
cancer practice.
Overall, the HNC patients in this study had a high
level of distress. The percentage of patients with DT levels exceeding the definition of clinically significant
distress based on NCCN guidelines (DT 4) was 51%.
This is similar to lung cancer populations (61%)17 and
gynecologic cancer populations (57%).18 Examination of
the data by logistic regression analysis using a cutoff of
4, demonstrated that patients with a self-reported
history of depression and emotional concerns predicted a
higher distress score. The association of overall distress
levels to a self-reported history of depression and the
use of antidepressive medications should not be dismissed. While the DT is not meant to be a diagnostic
tool, it is interesting that there is an association between
those with a self-reported history of depression and antidepressive medications and the overall DT score. Taking
into consideration the results of the logistic regression
analysis and the presence of emotional issues being predictive of an overall increased distress score, it seems
apparent that this population of patients requires additional evaluation.
From a programmatic perspective, these levels of
distress raise concern about providing effective
Buchmann et al.: Psychosocial Distress Is Prevalent in Head and Neck Cancer Patients
intervention in the form of psychological evaluation and
management. One of the conclusions of this study is that
using an absolute cutoff value of 5 on the DT may
decrease the number of patients considered for psychosocial intervention, for example, in our study 51% of
patients with a DT score of 4 or greater versus 35% of
patients with a DT score of 5 or greater. This would help
address the perceived lack of available time, energy, and
resources needed to address patient needs.25 However,
further studies are needed to critically evaluate whether
a cutoff score of 4 or 5 in the distress screening model
would provide the best patient outcomes.
Compared to the head and neck squamous-cell carcinoma patients, one would suspect that the thyroid
patients would have a lower level of distress due to a
better clinical prognosis. We found that patients with
thyroid cancer had as high a level of distress as the
squamous cell population. This underscores the need to
objectively screen all HNC patients. One cannot predict
the level of distress in a population of patients based on
diagnosis or provider perception of severity of illness.
Additionally, it may be that different psychosocial interventions will be relevant to different needs in cancer
populations. Future studies are needed to identify reasons for these differences in distress across cancer
populations, and identify whether comprehensive HNC
teams will need to develop and employ specific psychosocial interventions for different cancer populations.
All patients who present to the head and neck surgical oncology clinic at the Huntsman Cancer Institute
are given the DT and problem list to complete while
waiting to be seen. A licensed clinical social worker with
a mental health background screens the results, sees all
patients who score a 4 or greater to evaluate the nature
of their distress, and intervenes where necessary in the
form of psychosocial support. The timing of this interaction is variable and can occur before or after the patient
meets with the treating head and neck cancer surgical
oncologist. There is no formal additional evaluation to
determine whether a psychiatric diagnosis is playing a
role and referral to a psychiatrist is made on an individual bases. Determining whether additional evaluation is
necessary based on the distress score is an area of
ongoing investigation in our practice.
CONCLUSION
Head and neck cancer patients experience a high
level of baseline distress, as observed in the current
study. Patients with a self-reported history of depression,
emotional concerns, family concerns, and physical concerns are at the highest risk of distress and require
special attention regarding emotional support and psychosocial intervention. In accordance with NCCN
Distress Management Guidelines, routine screening is
an important aspect of multidisciplinary cancer care.
Laryngoscope 123: June 2013
This study demonstrates that incorporating this screening tool into a head and neck surgical oncology practice
is feasible and has the potential to improve patient care.
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