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The Laryngoscope C 2013 The American Laryngological, V Rhinological and Otological Society, Inc. 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 Laryngoscope 123: June 2013 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 1425 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 Laryngoscope 123: June 2013 1426 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 1427 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 Laryngoscope 123: June 2013 1428 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. BIBLIOGRAPHY 1. Jemal A, Siegel R, Ward E, Murray T, Xu J, Thun MJ. Cancer statistics, 2007. CA Cancer J Clin 2007;57:43–66. 2. Holland JC, Weiss TR. History of psycho-oncology. In: Holland JC, ed. Psycho-Oncology. New York, NY: Oxford University Press; 2010:3–12. 3. Holland JC. Preliminary guidelines for the treatment of distress. Oncology 1997;11:109–114. 4. Nezu AM, Nezu CM. Psychological Distress, depression, and anxiety. In: Feuerstein M, ed. Handbook of Cancer Survivorship. New York, NY: Springer; 2007:323–337. 5. Zabora J, BrintzenhofeSzoc K, Jacobsen P, et al. A new psychosocial screening instrument for use with cancer patients. Psychosomatics 2001;42:241–246. 6. Holland JC. NCCN Guidelines Distress Management Version 1.2011. Available at: http://www.nccn.org. 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