Clinic-based depression screening in lung cancer patients using the PHQ-2 and PHQ-9 depression questionnaires: a pilot study

Mobile Mindfulness Meditation for Cancer-Related Anxiety and Neuropathy: Protocol for a Randomized Controlled Trial

BACKGROUND

Anxiety- and cancer-related neuropathy are two persistent effects related to treatment for cancer. Mindfulness meditation has been used with substantial impact as a nonpharmacologic intervention to mitigate side and late effects of treatment. Mobile apps are ubiquitous for most of the general population, yet have a particular relevance for cancer survivors, given that physical and geographic limitations can be present.

OBJECTIVE

This study aims to describe an ongoing trial of the Mindfulness Coach mobile app for cancer survivors.

METHODS

In this randomized waitlist controlled trial, cancer survivors experiencing anxiety- or cancer-related neuropathy (200 for neuropathy and 200 for anxiety) and who had finished primary cancer treatment were invited to participate. Data were collected at 3 time points regardless of randomization condition: baseline, 8 weeks, and 16 weeks. Both face-to-face and web-based recruitment strategies were used. The trial was opened for 2 separate primary outcomes (anxiety- or cancer-related neuropathy). The goal was not to compare these groups but to compare treatment and waitlist groups for each condition. In addition to evaluating the impact of mobile mindfulness on reported anxiety- or cancer-related neuropathy, other pain, fatigue, trauma, sleep, and satisfaction with the Mindfulness Coach app will also be assessed.

RESULTS

Outcomes of the study are expected in early 2024.

CONCLUSIONS

Mindfulness meditation has become widely practiced, and the use of mobile technology has become ubiquitous. Finding ways to deliver mindfulness meditation to people who have been treated for cancer allows for the intervention to be accessible to a larger number of survivors. The results of this intervention could have implications for further understanding the impact of mindfulness meditation on 2 persistent side and late effects of treatment of cancer, namely anxiety- and cancer-related neuropathy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03581357; https://ClinicalTrials.gov/study/NCT03581357.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47745.

Association between residential greenspace and mental health among cancer survivors in Shanghai, China

BACKGROUND

Living near and enjoying visually green landscapes is associated with better mental health, but evidence focusing on vulnerable populations (such as cancer survivors) is sparse. The purpose of this study was to explore the association between residential greenspace and anxiety and depressive symptoms among cancer survivors in Shanghai, China.

METHODS

In total, 4195 cancer survivors participated in this study from the 2022 Shanghai Cancer Patient Needs Survey. The estimation of residential greenspaces was based on Normalized Difference Vegetation Index (NDVI) and Enhanced Vegetation Index (EVI). The presence and severity of depressive and anxiety symptoms were assessed by using the Patient Health Questionnaire-2 (PHQ-2) and Generalized Anxiety Disorder-2 (GAD-2). The relation between mental health and green space was assessed using the Generalized Additive Model (GAM) after controlling for relevant individual covariates and contextual characteristics.

RESULTS

The prevalence of anxiety and depression in cancer survivors was 36.2% and 28.3% respectively. After multivariate adjustment, each increase in inter-quartile range (IQR) for NDVI in the 250 m buffer (NDVI-250m) was associated with a decrease in PHQ-2 score (△score (95%CI): 0.018 (-0.034, -0.002)) and GAD-2 score (△score (95%CI): 0.018 (-0.034, -0.002)), respectively. We observed that an increase in IQR for NDVI-250m was associated with a 3.3% (Odds ratio (OR) (95%CI):0.967 (0.943, 0.991)) reduction in anxiety symptoms. More pronounced greenspace-mental health effects were found among young adults (18-65 years) and participants living in suburban areas, compared to young people over 65 and those living in urban areas (P-interaction < 0.05).

CONCLUSIONS

Higher levels of residential green space are associated with lower risk of depression and anxiety disorders. Our findings will fill the gap in the relationship between green space and mental health among cancer survivors in urban China, and provide new evidence for garden afforestation, community planning and policy-making. To better understand this association, more longitudinal studies are necessary to investigate the mechanisms involved.

Operationalizing Depression Screening in Ambulatory Palliative Care: A Quality Improvement Project

BACKGROUND

Depression is common in the palliative care setting and impacts outcomes. Operationalized screening is unusual in palliative care.

LOCAL PROBLEM

Lack of operationalized depression screening at two ambulatory palliative care sites.

METHODS

A fellow-driven quality improvement initiative to implement operationalized depression screening using the patient health questionnaire-2 (PHQ-2). The primary measure was rate of EMR-documented depression screening. Secondary measures were clinician perspectives on the feasibility and acceptability of implementing the PHQ-2.

INTERVENTION

The intervention is a clinic-wide implementation of PHQ-2 screening supported by note templates, brief clinician training, referral resources for clinicians, and opportunities for indirect psychiatric consultation.

RESULTS

Operationalized depression screening rates increased from 2% to 38%. All clinicians felt incorporation of depression screening was useful and feasible.

CONCLUSIONS

Operationalized depression screening is feasible in ambulatory palliative care workflow, though optimization through having screening be completed prior to clinician visit might improve uptake.

Psychological distress prior to surgery is related to symptom burden and health status in lung cancer survivors

PURPOSE

Patients with lung cancer experience a variety of distressing symptoms which could adversely affect quality of life. The aim of this study was to determine whether psychological distress prior to surgery is associated to health status and symptom burden in lung cancer survivors.

METHODS

A longitudinal observational study with 1-year follow-up was carried out. Health status was measured by the WHO Disability Assessment Scale (WHO-DAS 2.0), the Euroqol-5 dimensions (EQ-5D) and the Pittsburgh Sleep Quality Index (PSQI). Symptoms severity included dyspnoea (Multidimensional Profile of Dyspnoea); pain (Brief Pain Inventory); fatigue (Fatigue Severity Scale); and cough (Leicester Cough Questionnaire).

RESULTS

One hundred seventy-four lung cancer patients were included. Patients in the group with psychological distress presented a worse self-perceived health status, functionality and sleep quality. The group with psychological distress also presented higher dyspnoea, fatigue and pain.

CONCLUSION

Patients with psychological distress prior surgery present with a greater symptom burden and a poorer self-perceived health status, lower functionality and sleep quality, than patients without distress 1 year after the lung resection.

Evidence for the 4Ms: Interactions and Outcomes across the Care Continuum

Objectives: An expert panel reviewed and summarized the literature related to the evidence for the 4Ms-what matters, medication, mentation, and mobility-in supporting care for older adults. Methods: In 2017, geriatric experts and health system executives collaborated with the Institute for Healthcare Improvement (IHI) to develop the 4Ms framework. Through a strategic search of the IHI database and recent literature, evidence was compiled in support of the framework's positive clinical outcomes. Results: Asking what matters from the outset of care planning improved both psychological and physiological health statuses. Using screening protocols such as the Beers' criteria inhibited overprescribing. Mentation strategies aided in prevention and treatment. Fall risk and physical function assessment with early goals and safe environments allowed for safe mobility. Discussion: Through a framework that reduces cognitive load of providers and improves the reliability of evidence-based care for older adults, all clinicians and healthcare workers can engage in age-friendly care.

The Impact of a Ketogenic Dietary Intervention on the Quality of Life of Stage II and III Cancer Patients: A Randomized Controlled Trial in the Caribbean

INTRODUCTION

This study sought to determine the impact of a ketogenic dietary intervention on the quality of life of stage II and III cancer patients.

METHODS

A randomized controlled trial was implemented whereby patients in the treatment group followed a modified ketogenic diet (KD) utilizing medium chained triglyceride fats during a four-month period, while the control group followed an institutionalized standard traditional diet. Quality of life and mental health status was assessed using The European Organization for Research and Treatment of Cancer current core questionnaire and The Patient Health Questionnaire. Intervention effects were assessed using repeated measures ANCOVA and multiple linear regression models.

RESULTS

The quality of life and mental health of the cancer patients in the treatment group were greatly increased and improved due to the utilization of the diet. Most of the persons in the treatment group attained and maintained ketosis after 2 weeks. Age, gender, and state of the disease seemed to affect the keto-adaptation period in terms of the time taken to keto-adapt.

CONCLUSION

The KD was suitable for stage II and III cancer patients in improving their quality of life, nutritional, functional, and psychosocial statuses.

Symptoms and Needs of Patients with Advanced Lung Cancer: Early Prevalence Assessment

BACKGROUND

Little is known on symptom burden, psychosocial needs, and perception of prognosis in advanced lung cancer patients at the time of diagnosis, although early assessment is strongly recommended within the setting of daily routine care.

METHODS

Twelve study sites cross-sectionally assessed symptoms and psychosocial needs of patients suffering from newly diagnosed incurable lung cancer. Assessment comprised NCCN distress thermometer, FACT-L, SEIQoL-Q, PHQ-4, and shortened and modified SCNS-SF-34 questionnaires. Additional prognostic information from both patients and physicians were collected.

RESULTS

A total of 208 patients were evaluated. Mean age was 63.6 years, 58% were male, 84% suffered from stage IV lung cancer, and 71% had an ECOG performance status of 0-1. Mean distress level was 5.4 (SD 2.5), FACT-L total score was 86 (21.5), and TOI 50.5 (14.9). PHQ-4 was 4.6 (3.3), and shortened and modified SCNS-SF-34 showed 9 (8.7) unmet needs per patient. According to their physicians' perspective, 98.1% of patients were reflecting on and 85.2% were accepting incurability, while 26.5% of patients considered the treatment to be of curative intent.

CONCLUSION

Our findings emphasize substantial domains of symptom burden seen in newly diagnosed, incurable lung cancer patients. Oncologists should be aware of these features and address prognostic issues early in the disease trajectory to facilitate opportunities to improve coping, advance care planning, and appropriate integration of palliative care, thus improving quality of life.

The prevalence and related factors associated with psychosocial distress among 420 hospitalised lung cancer patients in China: A case study

Previous studies have reported high prevalence of psychosocial distress among lung cancer patients in Western countries, but the prevalence of distress in Chinese patients is not established. The study objectives were to report the prevalence of and factors associated with psychosocial distress in a sample of hospitalised patients in China and to implement distress screening in one thoracic specialty department. In this cross-sectional study, adult patients completed a self-reported demographic and clinical questionnaire and the distress thermometer with the problem list. Distress was dichotomised (high vs. low) and compared. Regression analyses were used to determine which variables were associated with psychosocial distress. One hundred eighty-six of 420 patients (38.6%) reported distress ≥4/10. They were unemployed, had New Rural Cooperative Medical System (NRCMS) insurance and Stage IV cancer. NRCMS insurance contributed to the likelihood of high distress and worry. Patients reported significant psychosocial distress during hospitalisation related to practical, emotional and physical problems. In this case study, staff reported they screened consecutive patients but there were no available referrals after discharge. We concluded it may be premature to screen patients for distress prior to instituting resources to establish services. To do otherwise is premature in ensuring patients' relief.

A Patient-Reported Outcome Instrument to Assess Symptom Burden and Predict Survival in Patients with Advanced Cancer: Flipping the Paradigm to Improve Timing of Palliative and End-of-Life Discussions and Reduce Unwanted Health Care Costs

BACKGROUND

Discussions regarding palliative care and end-of-life care issues are frequently delayed past the time of usefulness, resulting in unwanted medical care. We sought to develop a patient-reported outcome (PRO) instrument that allows patients to voice their symptom burdens and facilitate timing of discussions.

SUBJECTS, MATERIALS, AND METHODS

A seven-item PRO instrument (Cota Patient Assessed Symptom Score-7 item [CPASS-7]) covering physical performance status, pain, burden, and depression was administered (September 2015 through October 2016) with correlation to overall survival, correcting for time to complete survey since diagnosis.

RESULTS

A total of 1,191 patients completed CPASS-7 at a median of 560 days following the diagnosis of advanced cancer. Of these patients, 49% were concerned that they could not do the things they wanted; 35% reported decreased performance status. Financial toxicity was reported by 39% of patients, with family burdens noted in 25%. Although depression was reported by 15%, 43% reported lack of pleasure. Pain was reported by 33%. The median CPASS-7 total symptom burden score was 16 (possible 0-112). With a median follow-up of 15 months from initial survey, 46% had died. Patients with symptom burden scores <29 and ≥29 had a 6-month overall survival rate of 87% and 67%, respectively, and 12-month survival rates of 72% and 50%. A one-point score increase resulted in a 1.8% increase in expected hazard.

CONCLUSION

Patients with advanced cancer with higher levels of symptom burden, as self-reported on the CPASS-7, had inferior survival. The PRO facilitates identification of patients appropriate for reassessment of treatment goals and potentially palliative and end-of-life care in response to symptom burden concerns.

IMPLICATIONS FOR PRACTICE

A seven-item patient-reported outcome (PRO) instrument was administered to 1,191 patients with advanced cancers. Patients self-reporting higher levels of physical and psychological symptom burden had inferior overall survival rates. High individual item symptom PRO responses should serve as a useful trigger to initiate supportive interventions, but when scores indicate global problems, discussions regarding end-of-life care might be appropriate.

Patient navigation for lung cancer screening in an urban safety-net system: Protocol for a pragmatic randomized clinical trial

The National Lung Screening Trial demonstrated improved lung cancer mortality with annual low-dose computed tomography (CT) screening, leading to lung cancer screening endorsement by the United States Preventive Services Task Force and coverage by the Centers for Medicare and Medicaid. Adherence to annual CT screens in that trial was 95%, which may not be representative of real-world, particularly medically underserved populations. This pragmatic trial will determine the effect of patient-focused, telephone-based patient navigation on adherence to CT-based lung cancer screening in an urban safety-net population. 340 adults who meet standard eligibility for lung cancer screening (age 55-77years, smoking history≥30 pack-years, quit within 15years if former smoker) are referred through an electronic medical record-based order by physicians in community- and hospital-based primary care settings within the Parkland Health and Hospital System in Dallas County, Texas. Eligible patients are randomized to usual care or patient navigation, which addresses adherence, patient-reported barriers, smoking cessation, and psycho-social concerns related to screening completion. Patients complete surveys and semi-structured interviews at baseline, 6-month, and 18-month follow-ups to assess attitudes toward screening. The primary endpoint of this pragmatic trial is adherence to three sequential, prospectively defined steps in the screening protocol. Secondary endpoints include self-reported tobacco use and other patient-reported outcomes. Results will provide real-world insight into the impact of patient navigation on adherence to CT-based lung cancer screening in a medically underserved population. This study was registered with the NIH ClinicalTrials.gov database (NCT02758054) on April 26, 2016.

Quality of Life following Stereotactic Radiosurgery for Single and Multiple Brain Metastases

BACKGROUND: Given the neurological morbidity and poor prognosis associated with brain metastases, it is critical to deliver appropriate therapy while remaining mindful of patient quality of life (QOL). For many patients, stereotactic radiosurgery (SRS) effectively controls intracranial disease, but QOL outcomes have not been characterized.

OBJECTIVE: To determine the effect of number of brain metastases upon QOL preservation following SRS.

METHODS: The EuroQol 5 Dimensions questionnaire (EQ-5D) and Patient Health Questionnaire 9 instruments were prospectively collected from a cohort of patients undergoing SRS for brain metastasis between 2008 and 2015. These instruments served as measures of overall QOL and depression. QOL deterioration exceeding the minimum clinically important difference was considered failure. Freedom from 12-month EQ-5D index failure was the primary outcome.

RESULTS: One hundred and twenty-two SRS treatments (67 patients, 421 lesions) were eligible for inclusion. Intracranial failure (local or distant) occurred following 61% of treatments. Among 421 lesions, 8% progressed locally. Median follow-up was 12 months.

All subscores of the EQ-5D instrument expectantly worsened at last follow-up; however, the magnitude of this difference (0.079) did not exceed the EQ-5D index minimum clinically important difference (mean 0.752 vs 0.673, P &lt; .01). Twelve-month EQ-5D index QOL preservation was 79%. Patients with more than 3 brain metastases had a greater rate of EQ-5D index deterioration (hazard ratio 4.14, P &lt; .01) than those with a single metastasis.

CONCLUSIONS: Among patients with brain metastasis, QOL preservation must remain paramount as multimodality therapy continues to improve. In the present investigation, 12-month QOL preservation was 79%. However, patients with more than 3 brain metastases were at significantly greater risk for QOL decline.

A Patient-Reported Outcome Instrument to Facilitate Timing of End-of-Life Discussions among Patients with Advanced Cancers

BACKGROUND

Honoring the wishes of cancer patients is a responsibility of oncologists; however, end-of-life care (EOLC) discussions are frequently delayed past the point of usefulness.

OBJECTIVE

To develop a patient-reported outcome (PRO) screening tool that facilitates timing of EOLC discussions.

DESIGN

A seven-item PRO instrument covering four clinical and personhood domains [performance status, pain, burden (financial and family), and depression] was administered to patients with advanced malignancies undergoing noncurative therapy. The PRO instrument included the patient's assessment of the importance of each domain. Results were correlated with the oncologist's assessment of appropriateness of continuing aggressive therapy.

SETTING/SUBJECTS

Four hundred thirty-three patients fully completed the PRO instrument between February and March 2015 at a single outpatient cancer center.

RESULTS

There was a difference (p < 0.0001) in median scores among cohorts deemed by their oncologists appropriate to continue noncurative treatments versus patients whose physicians were contemplating or actively engaged in EOLC discussions. The scores for the four individual domains also differed among cohorts. An upper threshold score comprising 46% of patients deemed appropriate to curtail treatment (but inclusive of only 26% of patients deemed appropriate to continue) was determined, facilitating identification of patients for EOLC discussions.

CONCLUSIONS

A seven-item patient-centric PRO instrument was able to separate advanced malignancy patients into cohorts who their physicians deemed were at differing stages in their cancer journey with increasing needs for advance care planning. A study to determine if the threshold scores identified in this pilot correlate with palliative/EOL consultation frequency and patient survival is underway.

Symptom burden in lung cancer: management updates

Lung cancer is recognized to carry a high symptom burden with associated lowered quality of life as compared with other cancers. Research has shown that symptom severity can be a prognostic indicator of poorer clinical outcomes and survival post treatment. The purpose of this paper is to review current literature relative to symptom burden associated with diagnosis, medical and/or surgical intervention, assessment and management updates, and emerging initiatives that promote positive outcomes based on updated evidence. Discussion relative to interdisciplinary coordination of supportive services and palliative care initiation is provided.

Diagnostic accuracy of the Patient Health Questionnaire-9 for assessment of depression in type II diabetes mellitus and/or coronary heart disease in primary care

BACKGROUND

Depression is common among type 2 diabetes mellitus (DM2)/coronary heart disease (CHD) patients and is associated with adverse health effects. A promising strategy to reduce burden of disease is to identify patients at risk for depression in order to offer indicated prevention. This study aims to assess the diagnostic accuracy of the Patient Health Questionnaire-9 (PHQ-9) to be used as a tool to identify high risk patients.

METHODS

In this cross-sectional study, 586 consecutive DM2/CHD patients aged >18 were recruited through 23 general practices. PHQ-9 outcomes were compared to the Mini International Neuropsychiatric Interview (MINI), which was considered the reference standard. Diagnostic accuracy was evaluated for minor and major depression, comparing both sum- and algorithm based PHQ-9 scores.

RESULTS

For minor depression, the optimal cut-off score was 8 (sensitivity 71%, specificity 71% and an AUC of 0.74). For major depression, the optimal cut-off score was 10 resulting in a sensitivity of 84%, a specificity of 82%, and an AUC of 0.88. The positive predictive value of the PHQ-9 algorithm for diagnosing minor and major depression was 25% and 33%, respectively.

LIMITATIONS

Two main limitations apply. MINI Interviewers were not blinded for PHQ-9 scores and less than 10% of all invited patients could be included in the analyses. This could have resulted in biased outcomes.

CONCLUSIONS

The PHQ-9 sum score performs well in identifying patients at high risk of minor and major depression. However, the PHQ-9 showed suboptimal results for diagnostic purposes. Therefore, it is recommended to combine the use of the PHQ-9 with further diagnostics to identify depression.

Depression screening among older adults attending low-vision rehabilitation and eye-care services: Characteristics of those who screen positive and client acceptability of screening

AIM

To investigate characteristics associated with screening positive for depressive symptoms among older adults accessing low-vision rehabilitation and eye-care services and to determine client acceptability of depression screening using the Patient Health Questionnaire-2 (PHQ-2) in these settings.

METHODS

One-hundred and twenty-four older adults (mean = 77.02 years, SD = 9.12) attending low-vision rehabilitation and eye-care services across Australia were screened for depression and invited to complete a telephone-administered questionnaire to determine characteristics associated with depressive symptoms and client acceptability of screening in these settings.

RESULTS

Thirty-seven per cent (n = 46/124) of participants screened positive for depressive symptoms, and the majority considered the new depression screening method to be a 'good idea' in vision services (85%). Severe vision loss (<6/60 in the better eye) was associated with an increased odds of screening positive for depressive symptoms (odds ratio 2.37; 95% confidence interval 1.08-6.70) even after adjusting for potential confounders. Participants who screened positive had a preference for 'talking' therapy or a combination of medication and 'talking therapy' delivered within their own home (73%) or via telephone (67%).

CONCLUSION

The PHQ-2 appears to be an acceptable method for depression screening in eye-care settings among older adults. Targeted interventions that incorporate home-based or telephone delivered therapy sessions may improve outcomes for depression in this group.

The relationship between positive or negative phrasing and patients' coping with lateral epicondylitis

BACKGROUND

Research suggests that phrases with negative content can affect patients' response to medical procedures and how they cope with medical illnesses. We hypothesized that patients with lateral epicondylitis who describe their condition in positive phrases cope better than those who do not.

METHODS

We prospectively followed up 91 patients with lateral epicondylitis for 12 months. The patients indicated their baseline coping status based on the Pain Catastrophizing Scale (PCS) and were discharged with a wait-and-see policy. During follow-up interviews, the patients described the nature of their condition in their own words and were then categorized into either positive or negative phrasing groups. We compared these two groups regarding current coping status and whether they had sought additional treatment. We also analyzed for the factors associated with these outcomes.

RESULTS

There were no significant differences in baseline PCS scores between the two groups. At follow-up, patients in the positive phrasing group (n = 62) had significantly lower PCS scores and were less likely to seek additional treatment than those in the negative phrasing group (n = 29). Multivariable analyses showed that positive phrasing and low pain levels were independently associated with improvement in PCS scores and that negative phrasing and depression were independently associated with patients' seeking additional treatment.

CONCLUSION

Patients' positive phrasing about their condition are associated with improvement in their coping status and with less use of medical resources in the case of lateral epicondylitis. This study suggests that patients with more positive attitudes toward their illness cope and comply better when a wait-and-see treatment is recommended by their physicians.