Andrea Vodermaier

Screening for Emotional Distress in Cancer Patients: A Systematic Review of Assessment Instruments

Screening for emotional distress is becoming increasingly common in cancer care. This systematic review examines the psychometric properties of the existing tools used to screen patients for emotional distress, with the goal of encouraging screening programs to use standardized tools that have strong psychometrics. Systematic searches of MEDLINE and PsycINFO databases for English-language studies in cancer patients were performed using a uniform set of key words (eg, depression, anxiety, screening, validation, and scale), and the retrieved studies were independently evaluated by two reviewers. Evaluation criteria included the number of validation studies, the number of participants, generalizability, reliability, the quality of the criterion measure, sensitivity, and specificity. The literature search yielded 106 validation studies that described a total of 33 screening measures. Many generic and cancer-specific scales satisfied a fairly high threshold of quality in terms of their psychometric properties and generalizability. Among the ultrashort measures (ie, those containing one to four items), the Combined Depression Questions performed best in patients receiving palliative care. Among the short measures (ie, those containing five to 20 items), the Center for Epidemiologic Studies–Depression Scale and the Hospital Anxiety and Depression Scale demonstrated adequate psychometric properties. Among the long measures (ie, those containing 21–50 items), the Beck Depression Inventory and the General Health Questionaire–28 met all evaluation criteria. The PsychoSocial Screen for Cancer, the Questionnaire on Stress in Cancer Patients–Revised, and the Rotterdam Symptom Checklist are long measures that can also be recommended for routine screening. In addition, other measures may be considered for specific indications or disease types. Some measures, particularly newly developed cancer-specific scales, require further validation against structured clinical interviews (the criterion standard for validation measures) before they can be recommended.

Accuracy of the Hospital Anxiety and Depression Scale as a screening tool in cancer patients: a systematic review and meta-analysis

PurposeThe Hospital Anxiety and Depression Scale (HADS) is the most extensively validated scale for screening emotional distress in cancer patients. However, thresholds for clinical decision making vary widely across studies. A meta-analysis was conducted with the aim of identifying optimal, empirically derived cut-offs.MethodsPubMed, Embase, and PsycINFO databases were searched for studies that compared the HADS total and its subscale scores against a semi-structured or structured clinical interview as a reference standard with regard to its screening efficacy for any mental disorders and depressive disorders alone. Separate pooled analyses were conducted for single or two adjacent thresholds. A total of 28 studies (inter-rater agreement, κ = 0.86) were included.ResultsThe best thresholds for screening for mental disorders were 10 or 11 on the HADS total (sensitivity 0.80; specificity 0.74), 5 on the HADS depression subscale (sensitivity 0.84; specificity 0.50), and 7 or 8 on the HADS anxiety subscale (sensitivity 0.73; specificity 0.65). Respective thresholds for depression screening were 15 for the HADS total (sensitivity 0.87; specificity 0.88), 7 for the HADS depression subscale (sensitivity 0.86; specificity 0.81), and 10 or 11 for the HADS anxiety subscale (sensitivity 0.63; specificity 0.83).ConclusionsThe HADS anxiety subscale performed worse than the total and the depression subscales for both indicators. Diagnostic accuracy varied widely by threshold but was consistently superior for depression screening than for screening of any mental disorder.

Disease stage predicts post-diagnosis anxiety and depression only in some types of cancer

Background:We hypothesised that patients with advanced disease or a cancer type that has a poor prognosis may be more likely to report anxiety and depressive symptoms after diagnosis; younger age and female gender may moderate these effects.Methods:Patients (n=3850) were consecutively assessed with PSSCAN, a standardised, validated tool, at two large cancer centres between 2004 and 2009.Results:Female patients reported more anxiety and depressive symptoms (P=0.003 to P<0.001) compared with men and a healthy comparison group. Older age was associated with fewer anxiety (P=0.033 to P<0.001) and fewer depressive symptoms (P<0.001), but this was not true for lung cancer. Presence of metastases was associated with more anxiety symptoms in patients with gastrointestinal (P=0.044; R2Δ=0.001), lung (P=0.011; R2Δ=0.016), and prostate (P=0.032; R2Δ=0.008) cancer, but this was not true for breast cancer. Furthermore, early disease stage was associated with fewer depressive symptoms among older prostate cancer patients (P=0.021; R2Δ=0.008). Men with early lung cancer reported fewer anxiety (P=0.020; R2Δ=0.013) and depressive (P=0.017; R2Δ=0.016) symptoms than men with advanced disease or women.Conclusion:As hypothesised, disease stage was directly associated with emotional distress, except for patients with breast cancer. Furthermore, age and gender moderated some of these effects.

International Perspectives on Genetic Counseling and Testing for Breast Cancer Risk

Familial cancer services have been developed in many countries in response to a rapidly evolving demand for genetic counseling and testing for breast cancer risk. This article presents a synthesis of the literature on international aspects of genetic counseling and testing and discusses similarities and differences in the provision of genetic counseling and testing, taking seven countries with well established familial cancer services as a case study (Australia, Canada, France, Germany, Netherlands, UK and US). Potential international differences are discussed in terms of: provider and patient attitudes to genetic counseling and genetic testing; utilization rates of genetic testing and prophylactic surgery; and the psychological impact of genetic testing for breast cancer risk. The comparative analyses of utilization rates and the psychological impact of testing indicate a wide range of variability in uptake rates and psychological outcomes, most likely reflecting sample variability and methodological differences in measurement. International comparison studies using controlled designs would be required to ascertain whether international differences exist, and to disentangle the differential role of clinical, individual and family context factors, on the one hand, and the cultural and health system-related factors unique to particular countries, on the other.

The Psychosocial Screen for Cancer (PSSCAN): Further validation and normative data

BackgroundWe have previously reported on the development of a cancer-specific screening instrument for anxiety and depression (PSSCAN). No information on cut-off scores or their meaning for diagnosis was available when PSSCAN was first described. Needed were additional analyses to recommend empirically justified cut-off scores as well as data norms for healthy adult samples so as to lend meaning to the recommended cut-off scores.MethodsWe computed sensitivity/specificity indices based on a sample of 101 cancer patients who had provided PSSCAN data on anxiety and depression and who had completed another standardized instrument with strong psychometrics. Next, we compared mean scores for four samples with known differences in health status, a healthy community sample (n = 561), a sample of patients with a representative mix of cancer subtypes (n = 570), a more severely ill sample of in-patients with cancer (n = 78), and a community sample with a chronic illness other than cancer (n = 85).ResultsSensitivity/specificity analyses revealed that an excellent balance of sensitivity/specificity was achievable with 92%/98% respectively for clinical anxiety and 100% and 86% respectively for clinical depression. Newly diagnosed patients with cancer were no more anxious than healthy community controls but showed elevations in depression scores. Both, patients with chronic illness other than cancer and those with longer-standing cancer diagnoses revealed greater levels of distress than newly diagnosed cancer patients or healthy adult controls.ConclusionThese additional data on criterion validity and community versus patient norms for PSSCAN serve to enhance its utility for clinical practice.

Mismatch of desired versus perceived social support and associated levels of anxiety and depression in newly diagnosed cancer patients.

PurposePerceived social support serves as a buffer against stress in cancer patients as well as in the healthy. However, not all individuals low in support necessarily want more support. We, therefore, tested a match–mismatch model (low versus high perceived support relative to low versus high desired support) with regard to its association with emotional distress.MethodsParticipants included two large samples of n = 576 consecutively recruited, newly diagnosed cancer patients and n = 383 healthy controls. The hypothesized interaction effects of perceived and desired support and its impact on anxiety and depressive symptoms were tested via hierarchical linear regression.ResultsPerceived social support and desire for support were orthogonal in cancer patients (r = −0.03, p = 0.56). In accordance with the match–mismatch model, only those cancer patients with a high desire for support but who perceived low support exceeded cut-offs suggestive of anxiety and/or depressive disorder, whereas the other patient groups did not show clinical symptoms. Results for healthy controls were weaker.ConclusionsThe findings support the hypothesized match–mismatch model suggesting that lack of social support is only associated with emotional distress when patients desire more support than they actually perceive as having. Perceived as well as desired social support are, therefore, relevant and non-overlapping constructs to be included in screening tools for emotional distress in order to heighten the utility of screening as a decision aid to guide psycho-oncological follow-up.

On the uniqueness of, and diversity within, cancers: A commentary on Kangas and Gross 2018:

This commentary accompanies publication of Kangas and Gross’ phase model of emotion coping throughout the process of cancer care. While supporting the model, this commentary additionally highlights the already existing knowledge about the critical role of tumor stage, patient age, uncertainty and fear of recurrence, and gender differences. It is briefly described how all of these factors moderate and mediate the emotion coping process.