Caryn Mei Hsien Chan

Effects of depression and anxiety on mortality in a mixed cancer group: a longitudinal approach using standardised diagnostic interviews

Distress and psychiatric morbidity in cancer patients are associated with poorer outcomes including mortality. In this study, we examined the prevalence of psychiatric morbidity and its association with cancer survival over time.

Course and predictors of post‐traumatic stress disorder in a cohort of psychologically distressed patients with cancer: A 4‐year follow‐up study

Scant evidence exists on the long‐term course of cancer‐related post‐traumatic stress disorder (PTSD). This is among the few studies worldwide, and the first in the South‐East Asian region, to prospectively evaluate PTSD in patients with cancer using gold‐standard clinical interviews. The objective of the study was to assess the course and predictors of PTSD in adult patients with cancer in a South‐East Asian population.

Symptom Prevalence and Related Distress in Cancer Patients Undergoing Chemotherapy

BACKGROUND Much has been done to examine the psychological impact of cancer treatment, but it remains unclear to what extent anxiety and depression is related to symptom prevalence. The present study concerned the characteristics and frequency of distress as related to symptom prevalence in cancer patients undergoing chemotherapy in Malaysia. MATERIALS AND METHODS Participants were 303 consecutive adult cancer patients undergoing chemotherapy in an academic medical center. The short form Memorial Symptom Assessment Scale (MSAS-SF), which covers three domains of symptoms (global distress, physical- and psychological symptoms) was used to cross-sectionally measure symptom frequency and associated distress via self-reporting. One-way ANOVA and t-tests were used to test mean differences among MSAS-SF subscale scores. RESULTS Complete data were available for 303 patients. The mean number of symptoms was 14.5. The five most prevalent were fatigue, dry mouth, hair loss, drowsiness and lack of appetite. Overall, symptom burden and frequency were higher than in other published MSAS-SF studies. Higher symptom frequency was also found to be significantly related to greater distress in cancer patients undergoing chemotherapy. CONCLUSIONS Patients undergoing chemotherapy suffer from multiple physical and psychological symptoms. Better symptom control or palliative care is needed. Greater frequency of reported symptoms may also indicate a subconscious bid by patients for care and reassurance - thus tailored intervention to manage distress should be offered.

Reply to Do 1 in 5 cancer patients develop post-traumatic stress disorder?: Correspondence

We recently read a BBC News article in the United Kingdom claiming that “a fifth of cancer patients experience PTSD [post-traumatic stress disorder], a Malaysian study has found.” On reviewing the full study, “Course and Predictors of Post-Traumatic Stress Disorder in a Cohort of Psychologically Distressed Patients With Cancer: A 4-Year Follow-Up Study” by Chan et al, we are concerned about the way in which the results are represented in the study and, subsequently, in the article. The study covered 469 eligible patients who had completed the Hospital and Anxiety Depression Scale at the baseline and at 4 to 6 weeks. For anyone scoring higher than 8 on either the anxiety or depression subscale or higher than 16 overall on this questionnaire, a full Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) was performed by a clinical psychologist. After dropouts, 204 patients were grouped into categories according to the results of the SCID (no PTSD, subsyndromal PTSD, or full PTSD) in addition to 236 patients with nonprobable PTSD who did not undergo the SCID. In the Results section, it states that “at the 6-month follow-up, 27 of 203 patients (13.3%) met the full criteria for PTSD, and another 17 patients (8.4%) had subsyndromal PTSD symptoms. This yielded a 21.7% PTSD incidence when patients with both full and subsyndromal PTSD were aggregated.” However, because there were 439 patients, of whom 236 had nonprobable PTSD, we calculated an incidence of 6.2% for full PTSD (27 of 439 patients) and an incidence of 3.87% for subsyndromal PTSD (17 of 439). The study’s Discussion section states that “approximately 1 in 5 patients (21.7%) with cancer at the 6-month follow-up had PTSD”; this is significantly higher than prevalence estimates. However, we do not believe that this is correct. This 1-in-5 figure was derived only from the patients who had an elevated Hospital and Anxiety Depression Scale score. With the whole population, the value drops to 6.1% (or 10% if subsyndromal PTSD is included). We are concerned that this idea of 1 in 5 patients with cancer having PTSD is misleading and has been published within mainstream media across the world, including BBC News, the Huffington Post, and Times Now, and it has the potential to cause alarm in cancer sufferers and their relatives. We look forward to receiving a response from the authors.

Reply to Course and predictors of posttraumatic stress disorder in a cohort of psychologically distressed patients with cancer: A 4-year follow-up study-methodological and statistical issues: Correspondence

I read the article by Chan et al that was published in January 2018 with great interest. The study was conducted to examine the course and predictors of posttraumatic stress disorder (PTSD) in adult patients with cancer in a SouthEast Asian population. Although the valuable longitudinal study has been conducted by the authors, some important statistical issues need to be noted. The authors applied repeated-measures analysis of variance as a classic statistical test to assess the effect of psychological distress (measured at baseline and at 4-6 weeks, 1 year, and 4 years) on PTSD (measured at the 6month and 4-year follow-ups). They then applied 2 binary logistic regression models to their study’s data to determine the predictors of PTSD, which is problematic and does not consider the correlated structure of the exposure and outcome variables and may lead to biased results. To address the aforementioned limitation, parametric Gformula and G-estimation were suggested by Mansournia et al in 2017 to address the correlated structure of outcome and exposure variables simultaneously. In addition, the authors used only a crude logistic regression model to determine the predictors of PTSD in their study, but I wonder why the multivariable model was not constructed and no confounder was controlled. The parametric G-formula and G-estimation not only address the correlated structure of the exposure and outcome variables, but also can adjust the resulting effect size estimates for fixed or time-varying confounders. I believe the take-home message from the study by Chan et al is that the longitudinal data need to be analyzed through advanced statistical methods to address the correlated structure of the outcome and exposure variables, adjusting for fixed or time-varying confounding variables.

Rationalizations and identity conflict following smoking relapse: a thematic analysis

Abstract Introduction: Little is known about how smokers respond cognitively and emotionally to the experience of “late” relapse after the acute withdrawal phase. This study assessed the kinds of thoughts and feelings that emerge in order to provide a basis for quantitative research assessing prevalence of different types of response and implications for future quit attempts. Methods: Face-to-face in-depth interviews were conducted among 14 people attending a quit smoking clinic in Malaysia who had relapsed after at least 6 weeks of abstinence. Transcripts were analyzed using thematic analysis to enable emergence of important aspects of the experience. Results: Following relapse, smokers often engaged in rationalizations and activities to minimize worry about the harmful effects of smoking by switching to a lower-tar cigarette, reducing the number of cigarette smoked, attempting to reduce cigarette smoke inhalation, comparing themselves with other smokers, and minimizing the health risks associated with smoking. In some cases, smokers retained a “non-smoker” identity despite having relapsed. Conclusion: Smoking relapsers rationalize their failure to quit and minimize their health risk in order to protect their image as non-smokers while it remains a source of identity conflict.

Patient-Centredness, Job Satisfaction and Psychological Distress: a Brief Survey Comparing Oncology Nurses and Doctors.

BACKGROUND We aimed to explore whether levels of patient-centredness, job satisfaction and psychological distress varied between oncology nurses and doctors. MATERIALS AND METHODS In a cross-sectional study using self-administered questionnaires, a total of 24 nurses and 43 doctors were assessed for patient-centredness, psychological distress, and job satisfaction using the Patient-Practitioner Orientation Scale, Hospital Anxiety and Depression Scale, and Job Satisfaction Scale. Data were analysed using descriptive statistics, independent samples t-test and MANCOVA, with p<0.05 considered significant. RESULTS Overall response rate was 95.6% (43/45) for physicians and 85.7% (24/28) for nurses. Even after adjusting for known covariates, our principal finding was that doctors reported greater psychological distress compared to nurses (p=0.009). Doctors also reported lower job satisfaction compared to nurses (p = 0.017), despite higher levels of patient-centredness found in nurses (p=0.001). Findings may be explained in part by differences in job characteristics and demands. CONCLUSIONS Mental health is an important concern not just in cancer patients but among healthcare professionals in oncology.