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Influence of Prior Psychiatric Disorders on the Treatment Course of Gynaecological Cancer – A Nationwide Cohort Study
Abstract
Aims:
To examine the influence of pre-existing psychiatric disorder on the choice of treatment in patients with gynaecological cancer.
Materials and methods:
The analyses were based on all patients who underwent surgical treatment for endometrial, ovarian or cervical cancer who were registered in the Danish Gynecological Cancer Database in the years 2007-2014 (3059 patients with ovarian cancer, 5100 patients with endometrial cancer and 1150 with cervical cancer). Logistic regression model and Cox regression model, adjusted for relevant confounders, were used to estimate the effect of pre-existing psychiatric disorder on the course of cancer treatment. Our outcomes were (i) presurgical oncological treatment, (ii) macroradical surgery for patients with ovarian cancer, (iii) radiation/chemotherapy within 30 days and 100 days after surgery and (iv) time from surgery to first oncological treatment.
Results:
In the group of patients with ovarian cancer, more patients with a psychiatric disorder received macroradical surgery versus patients without a psychiatric disorder, corresponding to an adjusted odds ratio of 1.24 (95% confidence interval 0.62-2.41) and the chance for having oncological treatment within 100 days was odds ratio = 1.26 (95% confidence interval 0.77-2.10). As for patients with endometrial cancer, all outcome estimates were close to unity. The adjusted odds ratio for oncological treatment within 30 days after surgery in patients with cervical cancer with a history of psychiatric disorder was 0.20 (95% confidence interval 0.03-1.54).
Conclusions:
We did not find any significant differences in the treatment of ovarian and endometrial cancer in patients with pre-existing psychiatric diagnoses. When it comes to oncological treatment, we suggest that increased attention should be paid to patients with cervical cancer having a pre-existing psychiatric diagnosis.
... Recently, there have been increased efforts to examine the association of pre-existing mental illness and health outcomes. [3][4][5] For example, Iglay et al. noted that among Medicare beneficiaries with breast cancer, women with bipolar disorder, schizophrenia or other psychotic disorders were more likely to present with advanced breast cancer. 3 Women with mental health diagnoses were also less likely to receive treatment consistent with national guidelines. ...
Background
Among patients with pancreatic cancer, the association of pre-existing mental illness with long-term outcomes remains unknown.
Methods
Individuals diagnosed with pancreatic adenocarcinoma were identified in the SEER-Medicare database. Patients were classified as having mental illness if an ICD9/10CM code for anxiety, depression, bipolar disorder, schizophrenia or other psychotic disorder was recorded.
Results
Among the 54,234 Medicare beneficiaries with pancreatic cancer, roughly 1 in 12 (n = 4793, 8.83%) individuals had a diagnosis of a mental illness. The majority (n = 4029, 84.1%) had anxiety or depression, while 16% (n = 764) had bipolar/schizophrenic disorders. On multivariable analysis, among patients with early stage cancer, individuals with pre-existing anxiety/depression and bipolar/schizophrenic disorders had 22% (OR 0.78, 95% CI 0.69–0.86) and 46% (OR 0.54, 95% CI 0.42–0.70) reduced odds, respectively, to undergo cancer-directed surgery. Furthermore, patients with a pre-existing history of bipolar/schizophrenic disorders had a 20% (HR 1.20, 95% CI 1.21–1.40) higher risk of all-cause mortality and 27% (HR 1.27, 95% CI 1.17–1.37) higher risk of pancreatic cancer-specific mortality compared to individuals without a history of mental illness.
Conclusion
One in twelve patients with pancreatic cancer had a pre-existing mental illness. Individuals with mental illness were more likely to have worse overall and cancer-specific long-term outcomes.
Background
People with severe mental illness have significant comorbidities and a reduced life expectancy. This project answered the following question: what evidence is there relating to the organisation, provision and receipt of care for people with severe mental illness who have an additional diagnosis of advanced incurable cancer and/or end-stage lung, heart, renal or liver failure and who are likely to die within the next 12 months?
Objectives
The objectives were to locate, appraise and synthesise relevant research; to locate and synthesise policy, guidance, case reports and other grey and non-research literature; to produce outputs with clear implications for service commissioning, organisation and provision; and to make recommendations for future research.
Review methods
This systematic review and narrative synthesis followed international standards and was informed by an advisory group that included people with experience of mental health and end-of-life services. Database searches were supplemented with searches for grey and non-research literature. Relevance and quality were assessed, and data were extracted prior to narrative synthesis. Confidence in synthesised research findings was assessed using the Grading of Recommendations, Assessment, Development and Evaluation and the Confidence in the Evidence from Reviews of Qualitative Research approaches.
Results
One hundred and four publications were included in two syntheses: 34 research publications, 42 case studies and 28 non-research items. No research was excluded because of poor quality. Research, policy and guidance were synthesised using four themes: structure of the system, professional issues, contexts of care and living with severe mental illness. Case studies were synthesised using five themes: diagnostic delay and overshadowing, decisional capacity and dilemmas, medical futility, individuals and their networks, and care provision.
Conclusions
A high degree of confidence applied to 10 of the 52 Grading of Recommendations, Assessment, Development and Evaluation and Confidence in the Evidence from Reviews of Qualitative Research summary statements. Drawing on these statements, policy, services and practice implications are as follows: formal and informal partnership opportunities should be taken across the whole system, and ways need to be found to support people to die where they choose; staff caring for people with severe mental illness at the end of life need education, support and supervision; services for people with severe mental illness at the end of life necessitate a team approach, including advocacy; and the timely provision of palliative care requires proactive physical health care for people with severe mental illness. Research recommendations are as follows: patient- and family-facing studies are needed to establish the factors helping and hindering care in the UK context; and studies are needed that co-produce and evaluate new ways of providing and organising end-of-life care for people with severe mental illness, including people who are structurally disadvantaged.
Limitations
Only English-language items were included, and a meta-analysis could not be performed.
Future work
Future research co-producing and evaluating care in this area is planned.
Study registration
This study is registered as PROSPERO CRD42018108988.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research ; Vol. 10, No. 4. See the NIHR Journals Library website for further project information.
Purpose of review:
The cancer mortality rate in persons with schizophrenia is higher than it is in the general population. The purpose of this review is to determine why, and to identify solutions.
Recent findings:
The recent literature points to three groups of reasons why mortality is high: patient reasons such as nonadherence to treatment, provider reasons such as diagnostic overshadowing, and health system reasons such as a relative lack of collaboration between medicine and psychiatry. Strategies for cancer prevention, early detection, and effective treatment are available but difficult to put into practice because of significant barriers to change, namely poverty, cognitive and volitional deficits, heightened stress, stigma, and side effects of antipsychotic medication. The literature makes recommendations about surmounting these barriers and also offers suggestions with respect to support and palliative care in advanced stages of cancer. Importantly, it offers examples of effective collaboration between mental health and cancer care specialists.
Summary:
The high mortality rate from cancer in the schizophrenia population is a matter of urgent concern. Although reasons are identifiable, solutions remain difficult to implement. As we work toward solutions, quality palliative care at the end of life is required for patients with severe mental illness. VIDEO ABSTRACT:.
Purpose:
This study aimed to compare diagnosis and treatment delays in elderly breast cancer patients with and without pre-existing mental illness.
Methods:
A retrospective cohort study was conducted using the Surveillance, Epidemiology and End Results-Medicare data including 16,636 women 68+ years, who were diagnosed with stage I-IIIa breast cancer in the United States from 2005 to 2007. Mental illness was identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes recorded on inpatient and outpatient claims during the 3 years prior to breast cancer diagnosis. Patients were classified as having no mental illness, anxiety, depression, anxiety and depression, or severe mental illness (bipolar disorder, schizophrenia, and other psychotic disorder). Multivariable binomial regression was used to assess the association between mental illness and delays of ≥60 and ≥90 days after adjustment for confounders.
Results:
Patients with comorbid anxiety and depression had an increased risk for diagnosis delay of ≥90 days from symptom recognition (RR 1.11; 95% CI 1.00, 1.23), and those with severe mental illness had an increased risk for initial treatment delay of ≥60 days from diagnosis (RR 1.36; 95% CI 1.06, 1.74). Patients with any mental illness experienced an increased risk for adjuvant chemotherapy delay of ≥90 days from last operation (RR 1.13; 95% CI 1.01, 1.26) and each category of mental illness, except depression, showed a non-significant trend for this association.
Conclusion:
Breast cancer patients with mental illness should be closely managed by a cross-functional care team, including a psychiatrist, a primary care physician, and an oncologist, to ensure adequate care is received within an appropriate timeframe.
Aim of database
The Danish Gynecological Cancer Database (DGCD) is a nationwide clinical cancer database and its aim is to monitor the treatment quality of Danish gynecological cancer patients, and to generate data for scientific purposes. DGCD also records detailed data on the diagnostic measures for gynecological cancer.
Study population
DGCD was initiated January 1, 2005, and includes all patients treated at Danish hospitals for cancer of the ovaries, peritoneum, fallopian tubes, cervix, vulva, vagina, and uterus, including rare histological types.
Main variables
DGCD data are organized within separate data forms as follows: clinical data, surgery, pathology, pre- and postoperative care, complications, follow-up visits, and final quality check. DGCD is linked with additional data from the Danish “Pathology Registry”, the “National Patient Registry”, and the “Cause of Death Registry” using the unique Danish personal identification number (CPR number).
Descriptive data
Data from DGCD and registers are available online in the Statistical Analysis Software portal. The DGCD forms cover almost all possible clinical variables used to describe gynecological cancer courses. The only limitation is the registration of oncological treatment data, which is incomplete for a large number of patients.
Conclusion
The very complete collection of available data from more registries form one of the unique strengths of DGCD compared to many other clinical databases, and provides unique possibilities for validation and completeness of data. The success of the DGCD is illustrated through annual reports, high coverage, and several peer-reviewed DGCD-based publications.
Three cases are presented that demonstrate the difficulty of assessing medical decision-making capacity in patients with psychiatric illness who are refusing care. Health professionals often assess capacity differently in practice. Provided their patients have some understanding of their illness and have some plans for meeting basic needs, psychiatrists are often inclined to give patients the freedom to refuse care even if they do not exhibit a full understanding of the medical facts of their case and why they are refusing it. Adult medicine physicians, in contrast, are inclined to require patients to state a more complete understanding of the benefits and burdens of evaluation and treatment before allowing them to refuse care when their refusals might result in adverse medical outcomes. The 3 cases exemplify the tension between these approaches and highlight the role of hospital ethics consultation in addressing this conflict.
Purpose:
Although demographic, clinicopathologic, and socioeconomic differences may affect treatment and outcomes of prostate cancer, the effect of mental health disorders remains unclear. We assessed the effect of previously diagnosed depression on outcomes of men with newly diagnosed prostate cancer.
Patients and methods:
We performed a population-based observational cohort study using Surveillance, Epidemiology, and End Results-Medicare linked data of 41,275 men diagnosed with clinically localized prostate cancer from 2004 to 2007. We identified 1,894 men with a depressive disorder in the 2 years before the prostate cancer diagnosis and determined its effect on treatment and survival.
Results:
Men with depressive disorder were older, white or Hispanic, unmarried, resided in nonmetropolitan areas and areas of lower median income, and had more comorbidities (P < .05 for all), but there was no variation in clinicopathologic characteristics. In adjusted analyses, men with depressive disorder were more likely to undergo expectant management for low-, intermediate-, and high-risk disease (P ≤ .05, respectively). Conversely, depressed men were less likely to undergo definitive therapy (surgery or radiation) across all risk strata (P < .01, respectively). Depressed men experienced worse overall mortality across risk strata (low: relative risk [RR], 1.86; 95% CI, 1.48 to 2.33; P < .001; intermediate: RR, 1.25; 95% CI, 1.06 to 1.49; P = .01; high: RR, 1.16; 95% CI, 1.03 to 1.32; P = .02).
Conclusion:
Men with intermediate- or high-risk prostate cancer and a recent diagnosis of depression are less likely to undergo definitive treatment and experience worse overall survival. The effect of depression disorders on prostate cancer treatment and survivorship warrants further study, because both conditions are relatively common in men in the United States.
Danish registers contain information on many important health and social issues. Because all Danish citizens have a unique personal identification number, linkage at the individual level between these nationwide registers and other data sources is possible and feasible. In this paper we briefly introduce selected Danish registers and the data structure and requirements forgetting access to data at Statistics Denmark, which is the main provider of register data. We introduce the Danish Data Archive and briefly present the Act on Processing of Personal Data, which is the legal foundation for analyses of register-based data in Denmark.
The Psychiatric Central Research Register (PCRR) has continued since 1970 with electronic registration of patients treated at psychiatric departments in Denmark.
The register contains dates of onset and end of any treatment; all diagnoses; type of referral; place of treatment; municipality of residence; mode of admission.
Systematic studies validating the clinical diagnoses do not exist. However, several studies have validated specific diagnoses. The nationwide registration of severe mental disorders is almost complete. However, most cases with mild to moderate mental disorders are diagnosed and treated by general practitioners or specialists in psychiatry working in private practice and are thus not registered in the PCRR.
The PCRR is a valuable tool in national health planning and in epidemiological research.
Numerous studies have examined the comorbidity of depression with cancer, and some have indicated that depression may be associated with cancer progression or survival. However, few studies have assessed whether changes in depression symptoms are associated with survival.
In a secondary analysis of a randomized trial of supportive-expressive group therapy, 125 women with metastatic breast cancer (MBC) completed a depression symptom measure (Center for Epidemiologic Studies-Depression Scale [CES-D]) at baseline and were randomly assigned to a treatment group or to a control group that received educational materials. At baseline and three follow-up points, 101 of 125 women completed a depression symptom measure. We used these data in a Cox proportional hazards analysis to examine whether decreasing depression symptoms over the first year of the study (the length of the intervention) would be associated with longer survival.
Median survival time was 53.6 months for women with decreasing CES-D scores over 1 year and 25.1 months for women with increasing CES-D scores. There was a significant effect of change in CES-D over the first year on survival out to 14 years (P = .007) but no significant interaction between treatment condition and CES-D change on survival. Neither demographic nor medical variables explained this association.
Decreasing depression symptoms over the first year were associated with longer subsequent survival for women with MBC in this sample. Further research is necessary to confirm this hypothesis in other samples, and causation cannot be assumed based on this analysis.
Although the effects of cigarette smoking on cancer risk have been well documented, there remain several outstanding issues to be clarified, including the determination of which types of cancer are associated with smoking and estimation of the magnitude of the effect of smoking on different types of cancer. A further issue is whether the effects seen elsewhere can be demonstrated in Canada, where tobacco products differ somewhat from those in other countries.
A case-control study was undertaken in Montreal to investigate the associations between a large number of environmental and occupational exposures on the one hand, and several types of cancer on the other. Between 1979 and 1985, interviews were carried out with incident male cases of 21 types of cancer, including 15 anatomical sites and six histological subtypes. The interview was designed to obtain detailed information on smoking histories, job histories, and other potential confounders. Altogether, 3730 cancer patients and 533 population controls were interviewed. For each type of cancer analysed, two control groups were used: population controls and cancer controls (selected from among other cancer patients). The purpose of the present analysis is to estimate the relative risk of each of 21 types of cancer in relation to smoking and to estimate the percentage of cancer cases attributable to cigarette smoking.
Separate analyses conducted with the two control groups produced similar results. Of the many sites of cancer examined, the following were not associated with cigarette smoking: colon, rectum, liver, prostate, kidney and skin (melanoma). Within the lymphoreticular system, there was no excess risk of Hodgkin's lymphoma, although the results for non-Hodgkin's lymphoma were weakly suggestive of an association with smoking. The following sites were clearly associated with smoking: lung (odds ratio [OR] = 12.1), bladder (OR = 2.4), oesophagus (OR = 2.4), stomach (OR = 1.7), and pancreas (OR = 1.6). Population attributable risk percentages due to smoking were 90% for lung, 53% for bladder, 54% for oesophagus, 35% for stomach, and 33% for pancreas.
Of the 21 types of cancer examined, the following were associated with smoking among men in Montreal: lung (including all major histological subtypes), bladder (and its main histological subtypes), oesophagus, stomach and pancreas. Smoking likely accounts for a large proportion of cancers occurring at these sites.
To assess the hazards associated with long term use of tobacco.
Prospective study of mortality in relation to smoking habits assessed in 1951 and again from time to time thereafter, with causes sought of deaths over 40 years (to 1991). Continuation of a study that was last reported after 20 years' follow up (1951-71).
34,439 British male doctors who replied to a postal questionnaire in 1951, of whom 10,000 had died during the first 20 years and another 10,000 have died during the second 20 years.
Excess mortality associated with smoking was about twice as extreme during the second half of the study as it had been during the first half. The death rate ratios during 1971-91 (comparing continuing cigarette smokers with life-long non-smokers) were approximately threefold at ages 45-64 and twofold at ages 65-84. The excess mortality was chiefly from diseases that can be caused by smoking. Positive associations with smoking were confirmed for death from cancers of the mouth, oesophagus, pharynx, larynx, lung, pancreas, and bladder; from chronic obstructive pulmonary disease and other respiratory diseases; from vascular diseases; from peptic ulcer; and (perhaps because of confounding by personality and alcohol use) from cirrhosis, suicide, and poisoning. A negative association was confirmed with death from Parkinson's disease. Those who stopped smoking before middle age subsequently avoided almost all of the excess risk that they would otherwise have suffered, but even those who stopped smoking in middle age were subsequently at substantially less risk than those who continued to smoke.
Results from the first 20 years of this study, and of other studies at that time, substantially underestimated the hazards of long term use of tobacco. It now seems that about half of all regular cigarette smokers will eventually be killed by their habit.
Studies of selected groups of persons with mental illness, such as those who are institutionalized or seen in mental health clinics, have reported rates of smoking to be higher than in persons without mental illness. However, recent population-based, nationally representative data are lacking.
To assess rates of smoking and tobacco cessation in adults, with and without mental illness.
Analysis of data on 4411 respondents aged 15 to 54 years from the National Comorbidity Survey, a nationally representative multistage probability survey conducted from 1991 to 1992.
Rates of smoking and tobacco cessation according to the number and type of psychiatric diagnoses, assessed by a modified version of the Composite International Diagnostic Interview.
Current smoking rates for respondents with no mental illness, lifetime mental illness, and past-month mental illness were 22.5%, 34.8%, and 41.0%, respectively. Lifetime smoking rates were 39.1%, 55.3%, and 59.0%, respectively (P<.001 for all comparisons). Smokers with any history of mental illness had a self-reported quit rate of 37.1% (P =.04), and smokers with past-month mental illness had a self-reported quit rate of 30. 5% (P<.001) compared with smokers without mental illness (42.5%). Odds ratios for current and lifetime smoking in respondents with mental illness in the past month vs respondents without mental illness, adjusted for age, sex, and region of the country, were 2.7 (95% confidence interval [CI], 2.3-3.1) and 2.7 (95% CI, 2.4-3.2), respectively. Persons with a mental disorder in the past month consumed approximately 44.3% of cigarettes smoked by this nationally representative sample.
Persons with mental illness are about twice as likely to smoke as other persons but have substantial quit rates. JAMA. 2000;284:2606-2610.
The evidence for an association between depression and mortality among community-dwelling elderly persons remains inconclusive, although it is well established for younger individuals. Extant studies suggest that this association weakens when adjusted for potential confounding factors, especially functional impairment. A cohort of elderly subjects followed for 3 years was analyzed to determine the association of depression and 3-year mortality, controlling for the major known risk factors for mortality in the elderly population.
Information on depression (CES-D scores), mortality, demographics, body mass index, chronic disease, smoking history, cognitive impairment, functional impairment, self-rated health, and social support was obtained from a stratified probability-based sample of community-dwelling elderly persons, with equal distribution between African Americans and whites in the Piedmont of North Carolina. Descriptive statistics were calculated, and logistic regression was used for a series of models with progressively more control variables.
The unadjusted relative odds of mortality among depressed subjects at baseline was 1.98 over 3 years of follow-up. Inclusion of age, gender, and race into the model did not reduce the relative odds. When chronic disease and health habits, cognitive impairment, functional impairment, and social support were added to the model, the odds ratios for mortality with depression were 1.74, 1.69, 1.29, and 1.21, respectively. This decrease in odds ratios was not observed for other variables in the model when additional variables were added.
The estimated odds of dying if depressed moved toward unity as other risk factors for mortality were controlled. Unlike other known risk factors for mortality in the elderly population, depression appears to be associated with mortality through a number of independent mechanisms, perhaps through complex feedback loops.
Drugs can cause a variety of blood dyscrasias, e. g., by interfering with hematopoiesis in the bone marrow or damaging mature blood cells by antibodies. Although numerous reports on the risks of adverse hematological effects associated with psychotropic drugs have led to stringent monitoring requirements for some compounds, particularly neuroleptics, it is still difficult to estimate the true prevalence of such risks. Sixteen episodes of thrombocytopenia, 63 of neutropenia, 22 of agranulocytosis, 4 episodes of severe neutro- and thrombocytopenia, and 2 of pancytopenia were documented by the drug safety program in psychiatry AMSP (Arzneimittelsicherheit in der Psychiatrie) in a population of 122,562 patients between 1993 and 2000. All cases were related to the epidemiological data provided for this population and systematically analyzed as regards history of medication, co-medication, and the clinical course. Putative risk rates for the main groups of medications and a number of drugs could be estimated with this database. Most changes in the white blood cell counts, which were rated as probably or definitely drug-induced, were attributed to clozapine (0.18 % of patients exposed), carbamazepine (0.14 %) and perazine (0.09 %). In patients on newer atypical neuroleptics, we documented neutropenia assumed to be probably or definitely drug-related in five patients during treatment with olanzapine and in one case with risperidone. In all five olanzapine-related cases, the drugs were the sole cause of the adverse drug reactions. All surveyed patients who received clozapine showed no difference in age and gender distribution from those who developed hematological changes. Incidences of hematological changes for antidepressants were much lower (about 0.01 %). Although the methodological accuracy of these findings has to be critically discussed these data could be of considerable clinical relevance and should be helpful in making clinical treatment decisions.
The aims of the present study were to assess the prevalence of depressive symptoms at diagnosis, test the association between depressive symptoms and survival, and preliminarily test a mediational model of depression, immunity, and survival in patients with hepatobiliary carcinoma (HBC).
One hundred one patients diagnosed with HBC were prospectively studied. Depressive symptoms were measured at diagnosis using the Center for Epidemiological Studies Depression Scale (CES-D). Sociodemographic and disease-specific data were gathered from the patients' charts. In a subsample of patients, stress; alcohol, tobacco, and drug use; sleep quality; physical activity; social support; natural killer (NK) cell number and cytotoxicity; and plasma levels of interleukin (IL) -4, IL-5, tumor necrosis factor alpha, and interferon gamma were measured. Survival was measured from date of diagnosis to death.
At diagnosis, 37% of patients reported a CES-D score of > or = 16 (clinical range). Using Cox regression analysis, sociodemographic and disease-specific variables and CES-D score significantly predicted survival (Breslow chi2 = 32.4, P = .006). Only vascular invasion (P = .001) and CES-D score > or = 16 (P = .03) were significant predictors. In a subsample of 23 patients, patients who reported a CES-D score of > or = 16 were found to have significantly lower NK cell numbers than patients who reported a CES-D score of less than 16 (F1,21 = 9.39, P = .003). A robust trend was found in which NK cell number was associated with survival. A mediational model linking depressive symptoms and survival, with NK cell number as a mediator, was preliminarily supported.
Secondary to the high prevalence of depressive symptoms and impact on survival, psychological and pharmacologic interventions should be designed and implemented in patients diagnosed with HBC.
Background
Earlier research suggests poorer outcome of cancer care among people with severe mental illness (SMI).AimsTo assess the effect of stage at presentation, comorbidities and treatment on differences in survival among cancer patients with and without a history of SMI in Finland.Method
The total population with a first cancer diagnosis in 1990-2013 was drawn from the Finnish Cancer Registry. Hospital admissions because of SMI and deaths were obtained from administrative registers. We calculated Kaplan-Meier estimates and Cox regression models to examine survival differences.ResultsWe found excess mortality in people with a history of psychotic and substance use disorders. Cancer stage and comorbidity did not explain mortality differences. Controlling for cancer treatment decreased the differences. The mortality gap between patients with psychosis and cancer patients without SMI increased over time.Conclusions
Integrated medical and psychiatric care is needed to improve outcomes of cancer care among patients with SMI.
Aims:
To examine the influence of a history of depression in the process of diagnostic evaluation and the choice of treatment in lung cancer.
Materials and methods:
The analysis was based on all patients with non-small cell lung cancer who were registered in 2008-2014; in total, 27 234 patients. To estimate the effect of depression on the diagnostic process and the choice of treatment in lung cancer we fitted a logistic regression model and a Cox regression model adjusting for age, gender, resection and stage.
Results:
Depression in a patient's anamnesis had no significant effect on the delay in diagnostic evaluation (hazard ratio = 0.99 with 95% confidence interval 0.90; 1.09). Patients with a history of periodic depression had a 33% lower treatment rate (odds ratio = 0.66 with 95% confidence interval 0.51; 0.85) than patients without a history of depression.
Conclusions:
Our study shows that patients with a history of periodic depression need special attention when diagnosed with lung cancer.
Gynaecological cancers accounted for 16.3% of all cancers and for 13.9% of all cancer deaths in women globally in 2012. Cancer of the cervix is the most common gynaecological cancer, followed by cancers of the uterus and the ovary. While cervical cancer is almost exclusively triggered by human papilloma virus infection, approximately 5% of all uterine cancers and 20% of all ovarian cancers are caused by germline mutations in cancer predisposition genes. A number of genetic syndromes are associated with rarer gynaecological tumours. This review focuses on the epidemiology and pathology of inherited gynaecological cancer predisposition syndromes arising due to germline mutations.
To investigate the actual time from primary surgery for epithelial ovarian cancer (OC) to initiation of chemotherapy (TI) amongst Danish women in 2005-2006, and to compare the survival for groups with early initiation (≤median TI) and late initiation of adjuvant chemotherapy (>median TI).
All Danish women who underwent surgery for OC in the period 1 January 2005 to 31 December 2006 recorded in the Danish Gynaecological Cancer Database (DGCD) were included. The five-year survival was estimated overall and by TI exposure. The Cox proportional hazard regression analysis was used to compute the adjusted hazard ratio (HR).
The median TI was 32days (25-75% quartile: 24days; 41days). The strongest prognostic factors for death were residual tumour and the International Federation of Obstetrics and Gynecology (FIGO) stage. The unadjusted HR for death in patients with TI>32days compared with TI≤32days was 0.85 (95% CI: 0.70; 1.04), p-value 0.12. When adjusted for residual tumour and FIGO-stage the HR was 1.13 (95% CI: 0.92; 1.39), p-value 0.26. The overall five-year survival was 42.8%, (95% CI: 38.9%; 46.5%).
This nationwide population-based cohort study revealed a non-significant increased risk of death for patients with TI>32days compared with the reference TI≤32days. The strongest prognostic factors were residual tumour after surgery and FIGO-stage. The overall five-year survival was 42.8% (95% CI: 38.9%; 46.5%).
Individuals with schizophrenia are a vulnerable population that has been relatively neglected in health disparities research. Despite having an equivalent risk of developing most cancers, patients with schizophrenia are more likely to die of cancer than the general population. Cancer care disparities are likely the result of patient-, provider-, and systems-level factors and influenced by the pervasive stigma of mental illness. Individuals with schizophrenia have higher rates of health behaviors linked with cancer mortality including cigarette smoking. They also have significant medical comorbidity, are less likely to have up-to-date cancer screening, and may present at more advanced stages of illness. Patients with schizophrenia may be less likely to receive chemotherapy or radiotherapy, have more postoperative complications, and have less access to palliative care. However, opportunities exist for the interdisciplinary team, including medical, surgical, and radiation oncologists; psychiatrists; and primary care physicians, to intervene throughout the continuum of cancer care to promote survival and quality of life. This review summarizes data on overall and cancer-specific mortality for individuals with schizophrenia and reviews specific disparities across the cancer care continuum of screening, diagnosis, treatment, and end-of-life care. Using a case, the authors illustrate clinical challenges for this population including communication, informed consent, and risk of suicide, and provide suggestions for care. Finally, recommendations for research to address the disparities in cancer care for individuals with schizophrenia are discussed. Despite significant challenges, with collaboration between oncology and mental health teams, individuals with schizophrenia can receive high-quality cancer care. Cancer 2013;. © 2013 American Cancer Society.
Schizophrenia has a powerful impact on the outcomes of treatment for physical disorders. This study sought to estimate how the presence of schizophrenia disrupts the course of diagnosis and initial treatment of breast cancer.
We searched the Patient Treatment File, a comprehensive computer-based system for inpatient data in the Department of Veterans Affairs (DVA) medical system, to identify patients with codes for schizophrenia or schizoaffective disorder who later developed breast cancer. These data were augmented with chart-based clinical data.
There were 56 evaluable patients from 34 DVA facilities; 37 (66%) were female. Delay in diagnosis was common. The mean size of the primary tumor was 4 cm in those for whom these data were recorded. Delay in diagnosis was common and many never received the indicated surgery. Distant metastases were present on diagnosis in 12 (21%) and developed after diagnosis in 14 (25%) others, including 7 who inappropriately delayed or refused indicated surgery and 4 who inappropriately delayed or refused indicated neoadjuvant chemotherapy. Twelve verbally abused or physically attacked caregivers.
Patients with schizophrenia who later develop breast cancer often deny they have cancer. They often have high-stage disease at diagnosis and often delay or refuse therapy. Breast-conserving multimodality therapy is often not feasible.
The Danish Civil Registration System (CRS) was established in 1968, and all persons alive and living in Denmark were registered for administrative use.
CRS includes individual information on the unique personal identification number, name, gender, date of birth, place of birth, citizenship, identity of parents and continuously updated information on vital status, place of residence and spouses.
Since 1968, CRS has recorded current and historical information on all persons living in Denmark. Among persons born in Denmark in 1960 or later it contains complete information on maternal identity. For women born in Denmark in April 1935 or later it contains complete information on all their children. CRS contains complete information on immigrations and emigrations from 1969 onwards, permanent residence in a Danish municipality from 1971 onwards, and full address in Denmark from 1977 onwards.
CRS in connection with other registers and biobanks will continue to provide the basis for significant knowledge relevant to the aetiological understanding and possible prevention of human diseases.
Drug interactions are commonly seen in the treatment of cancer patients. Psychotropics are often indicated for these patients since they may also suffer from pre-existing psychological disorders or experience insomnia and anxiety associated with cancer therapy. Thus, the risk of anticancer drug (ACD)-psychotropic drug-drug interactions (DDIs) is high. Drug interactions were compiled from the British National Formulary (53rd edn), Lexi-Comp's Drug Information Handbook (15th edn), Micromedex (v5.1), Hansten & Horn's Drug Interactions (2000) and Drug Interaction Facts (2008 edn). Product information of the individual drugs, as well as documented literature on ACD-psychotropic interactions from PubMed and other databases was also incorporated. This paper identifies clinically important ACD-psychotropic DDIs that are frequently observed. Pharmacokinetic DDIs were observed for tyrosine kinase inhibitors, corticosteroids and antimicrotubule agents due to their inhibitory or inductive effects on cytochrome P450 isoenzymes. Pharmacodynamic DDIs were identified for thalidomide with central nervous system depressants, procarbazine with antidepressants, myelosuppressive ACDs with clozapine and anthracyclines with QT-prolonging psychotropics. Clinicians should be vigilant when psychotropics are prescribed concurrently with ACDs. Close monitoring of plasma drug levels should be carried out to avoid toxicity in the patient, as well as to ensure adequate chemotherapeutic and psychotropic coverage.
Cancer of the endometrium is the most common and curable gynecologic malignancy. It has a most easily recognizable symptom in its usual presentation as postmenopausal bleeding. Treatment may vary considerably based on prognostic factors and may include surgery, radiotherapy, hormonal manipulation, or cytotoxic chemotherapy. Rehabilitation is the focus of nursing intervention and is initiated at the time of the cancer diagnosis. The continued effort by investigators to define intermediate and high-risk populations and, thus, appropriate adjuvant treatment will continue to reduce mortality from endometrial carcinoma.
Sixty percent of all cancer occurs in persons aged > or =65 years. This article provides an overview of aspects of the burden of cancer in the elderly, highlighting certain demographic and epidemiologic data. It served as a frame of reference for participants in the Oncology Geriatric Education Retreat, San Juan, Puerto Rico, February 21-26, 1997. Information comes from several major sources: U. S. Bureau of the Census; National Cancer Institute (NCI) Surveillance, Epidemiology, and End Results (SEER) Program; National Center for Health Statistics; National Institute on Aging (NIA)/NCI SEER Study on Comorbidity and Cancer in the Elderly; and NCI cancer prevalence estimates. Data on the aging population demonstrate an unprecedented expansion of the segment of the population aged > or =65 years. By 2030, 1 in 5 Americans will be aged > or =65 years. Because cancer incidence and mortality rates are highest in persons aged > or =65 years, expansion of this age group takes on great importance for medical professionals who provide treatment to older aged cancer patients. In addition, older aged cancer patients are likely to have preexisting conditions at diagnosis, creating a special clinical challenge. There is an urgent need to better understand the influence of aging on the early detection, diagnosis, and treatment of cancer. Clinicians who treat older persons (geriatricians, oncologists, and other health professionals) can benefit from the integration of the knowledge and approaches of each others' fields. The foundation for this multidisciplinary effort is linked with the education and training of future clinicians.
It is likely that patients with gynecological cancers are at risk for psychiatric disorders such as major depression and anxiety disorders. However, relatively little attention has been focused on studying these women. We review here papers that report rates and treatment of psychiatric illness in women with gynecological cancer. This small literature suggests that depression, anxiety, and adjustment disorders do occur with heightened frequency, and appear to worsen over the course of treatment persisting well after the initial diagnosis and therapy. Antidepressants are reported to be effective but compliance is often a problem. Limitations in this literature include a paucity of research specific to gynecological cancers, small sample sizes in reports that do exist, and minimal differentiation between the specific cancers and their rates of depression and anxiety. There is a clear need for more clinical and research attention to this at-risk population.
Gynecological cancers, which account for a substantial proportion of cancer cases in women, can precipitate a wide range of psychological difficulties including affective disturbances, sexual problems, certain somatic symptoms, and family issues. The clinical psychologist has a unique contribution to make in the assessment and treatment of the psychological needs of gynecological cancer patients, while also conducting research and providing training for health professionals regarding the psychological issues associated with gynecological cancer. Although the gynecological cancer setting affords the clinical psychologist multiple personal benefits, strategies must usually be implemented to minimize any negative impact arising from working in an area of considerable psychological stress.
Depression and anxiety are common in medical patients and are associated with diminished health status and increased health care utilization. This article presents a quantitative review and synthesis of studies correlating medical patients' treatment noncompliance with their anxiety and depression.
Research on patient adherence catalogued on MEDLINE and PsychLit from January 1, 1968, through March 31, 1998, was examined, and studies were included in this review if they measured patient compliance and depression or anxiety (with n>10); involved a medical regimen recommended by a nonpsychiatrist physician to a patient not being treated for anxiety, depression, or a psychiatric illness; and measured the relationship between patient compliance and patient anxiety and/or depression (or provided data to calculate it).
Twelve articles about depression and 13 about anxiety met the inclusion criteria. The associations between anxiety and noncompliance were variable, and their averages were small and nonsignificant. The relationship between depression and noncompliance, however, was substantial and significant, with an odds ratio of 3.03 (95% confidence interval, 1.96-4.89).
Compared with nondepressed patients, the odds are 3 times greater that depressed patients will be noncompliant with medical treatment recommendations. Recommendations for future research include attention to causal inferences and exploration of mechanisms to explain the effects. Evidence of strong covariation of depression and medical noncompliance suggests the importance of recognizing depression as a risk factor for poor outcomes among patients who might not be adhering to medical advice.
Depression and cancer commonly co-occur. The prevalence of depression among cancer patients increases with disease severity and symptoms such as pain and fatigue. The literature on depression as a predictor of cancer incidence is mixed, although chronic and severe depression may be associated with elevated cancer risk. There is divided but stronger evidence that depression predicts cancer progression and mortality, although disentangling the deleterious effects of disease progression on mood complicates this research, as does the fact that some symptoms of cancer and its treatment mimic depression. There is evidence that providing psychosocial support reduces depression, anxiety, and pain, and may increase survival time with cancer, although studies in this latter area are also divided. Psychophysiological mechanisms linking depression and cancer progression include dysregulation of the hypothalamic-pituitary-adrenal axis, especially diurnal variation in cortisol and melatonin. Depression also affects components of immune function that may affect cancer surveillance. Thus, there is evidence of a bidirectional relationship between cancer and depression, offering new opportunities for therapeutic intervention.
To assess the effect of a prior diagnosis of depression on the diagnosis, treatment, and survival of older women with breast cancer.
Retrospective analysis of records from Surveillance, Epidemiology and End Results (SEER) and Medicare claims.
Registries from seven major cities and five states.
A total of 24,696 women aged 67 to 90 diagnosed with breast cancer between 1993 and 1996 and included in the SEER Medicare linked database were studied.
Information on patient demographics, tumor characteristics, treatment received, and survival were obtained from SEER, and the Medicare inpatient and professional charges for the 2 years before diagnosis were searched for a diagnosis of depression.
A total of 1,841 of the 24,696 women (7.5%) had been given a diagnosis of depression sometime in the 2 years before the diagnosis of breast cancer. There was no difference in tumor size or stage at diagnosis between depressed and nondepressed women. Women diagnosed with depression were less likely to receive treatment generally considered definitive (59.7% vs 66.2%, P<.0001), and this difference remained after controlling for age, ethnicity, comorbidity, and SEER site. Also, women with a prior diagnosis of depression had a higher risk of death (hazard ratio=1.42; 95% confidence interval= 1.13-1.79) after controlling for other factors that might affect survival. The higher risk of death associated with a prior diagnosis of depression was also seen in analyses restricted to women who received definitive treatment.
Women with a recent diagnosis of depression are at greater risk for receiving nondefinitive treatment and experience worse survival after a diagnosis of breast cancer, but differences in treatment do not explain the worse survival.
The media seem to announce a new scientific discovery related to cancer daily. Oncology nurses are challenged to keep up with the explosion of new knowledge and to understand how it ultimately relates to the care of patients with cancer. A framework for classifying new knowledge can be useful as nurses seek to understand the biology of cancer and its related implications for practice. To understand the molecular roots of cancer, healthcare practitioners specializing in cancer care require insight into genes, their messages, and the proteins produced from those messages, as well as the new tools of molecular biology.
The Danish National Patient Register.
- Lynge E.
- Sandegaard J.L.
- Rebolj M.
Staging in cervical cancer continuously based on a clinical examination.
- Fuglsang K.
- Petersen L.
- Blaakær J.