Relationship between depression and pancreatic cancer in the general population

Upregulation of Lactobacillus spp. in gut microbiota as a novel mechanism for environmental eustress-induced anti-pancreatic cancer effects

Pancreatic ductal adenocarcinoma (PDAC) is a highly lethal malignancy with limited effective treatment options. Emerging evidence links enriched environment (EE)-induced eustress to PDAC inhibition. However, the underlying mechanisms remain unclear. In this study, we explored the role of gut microbiota in PDAC-suppressive effects of EE. We demonstrated that depletion of gut microbiota with antibiotics abolished EE-induced tumor suppression, while fecal microbiota transplantation (FMT) from EE mice significantly inhibited tumor growth in both subcutaneous and orthotopic PDAC models housed in standard environment. 16S rRNA sequencing revealed that EE enhanced gut microbiota diversity and selectively enriched probiotic Lactobacillus, particularly L. reuteri. Treatment with L. reuteri significantly suppressed PDAC tumor growth and increased natural killer (NK) cell infiltration into the tumor microenvironment. Depletion of NK cells alleviated the anti-tumor effects of L. reuteri, underscoring the essential role of NK cell-mediated immunity in anti-tumor response. Clinical analysis of PDAC patients showed that higher fecal Lactobacillus abundance correlated with improved progression-free and overall survival, further supporting the therapeutic potential of L. reuteri in PDAC. Overall, this study identifies gut microbiota as a systemic regulator of PDAC under psychological stress. Supplementation of psychobiotic Lactobacillus may offer a novel therapeutic strategy for PDAC.

Pancreatic cancer and depression

Pancreatic cancer is a highly devastating disease with high mortality rates. Even patients who undergo potential curative surgery have a high risk for recurrence. The incidence of depression and anxiety are higher in patients with cancer than the general population. However, patients with pancreatic cancer are at most of risk of both depression and anxiety and there seems to be a biological link. In some patients, depression seems to be a precursor to pancreatic cancer. In this article we discuss the biological link between depression anxiety and hepatobiliary malignancies and discuss treatment strategies.

Pre-existing psychological disorders, diabetes, and pancreatic cancer: A population-based study of 38,952 Finns

BACKGROUND

It remains unclear how pre-existing depression, anxiety, and diabetes of different durations are associated with the risk of pancreatic cancer, its clinical characteristics, treatment modalities, and subsequent survival.

METHODS

From a register-based random sample of Finns residing in Finland at the end of the period 1987-2007, 6492 patients diagnosed with primary pancreatic cancer in 2000-2014, and 32 460 controls matched for birth cohort and sex, were identified. Pre-existing depression, anxiety, and diabetes were ascertained from the records of prescribed medication purchases. Information on pancreatic cancer outcomes was obtained from the Finnish cancer register. Data were analyzed using logistic and Cox regressions.

RESULTS

The risk of developing pancreatic cancer was found to be associated with long-term anxiety (treatment started 36 + months before the cancer diagnosis) (odds ratio (OR): 1.13, 95% confidence interval (95%CI): 1.04-1.22) and long-term diabetes (OR 1.72, 95%CI 1.55-1.90), as well as with new-onset (treatment started 0-24 months before the cancer diagnosis) depression (OR 1.59, 95%CI 1.34-1.88), anxiety (OR 1.76, 95%CI 1.50-2.07), and diabetes (OR 3.92, 95%CI 3.44-4.48). However, the effects of these new-onset conditions were driven by cases that began treatment within 3 months before the cancer diagnosis (concomitant period). Patients with long-term depression, anxiety and diabetes and those with new-onset anxiety had a higher risk of not receiving standard treatments. Lower survival was found for pancreatic cancer patients with new-onset depression (hazards ratio (HR) 1.38, 95%CI 1.16-1.64). Survival was not associated with pre-existing anxiety or diabetes.

CONCLUSIONS

The associations between pancreatic cancer risk and pre-existing depression and anxiety were mostly driven by concomitant effects. Individuals with diabetes, regardless of duration, should be closely monitored for pancreatic cancer. Pancreatic cancer patients with new-onset depression should be targeted to improve their survival.

Prodromal depression and anxiety are associated with worse treatment compliance and survival among patients with pancreatic cancer

OBJECTIVE

To determine the frequency of depression or anxiety preceding a diagnosis of pancreatic cancer (PC). Further, to examine the association of PC-associated depression or anxiety with treatment compliance and survival.

METHODS

856 patients with PC from a single institution were identified using International Classification of Diseases (ICD) codes. For each case, two non-cancer age- and sex-matched controls were included. Dates of depression or anxiety diagnosis identified using ICD codes were compared to the date of PC diagnosis. The medical record was queried to further explore psychiatric symptoms. Multivariable analyses were performed to examine if prediagnosis depression or anxiety was associated with receipt of treatment or survival.

RESULTS

A greater proportion of patients with PC experienced depression or anxiety in the year preceding diagnosis than the overall frequency in controls (4.6% vs. 2.6%, p = 0.005) based on ICD codes. Patients with PC exhibited signs of prodromal depression or anxiety based on ICD codes, clinical documentation of psychiatric symptoms, or initiation of new psychiatric medications more often than controls (20.7% vs. 6.7%, p < 0.001). Prediagnosis depression or anxiety was associated with a reduced likelihood of receiving chemotherapy (OR = 0.58, p = 0.04). There was an associated decrease in overall survival among patients with metastatic disease who experienced depression or anxiety before PC diagnosis (HR = 1.32, p = 0.04).

CONCLUSIONS

The frequency of depression or anxiety among patients with PC was higher than the general population. Prediagnosis psychiatric symptoms were associated with reduced chemotherapy utilization and worse overall survival. Thus, timely identification and treatment of these symptoms may improve outcomes.

A Community-Based Pancreatic Cancer Screening Study in High-Risk Individuals: Preliminary Efficacy and Safety Results

INTRODUCTION

Pancreatic cancer (PC) screening recommendations have been based on studies performed solely at high-volume academic centers. To make PC screening more widely available, community-based efforts are essential. We implemented a prospective PC screening study in the community of Fairfield County, CT, and report our early safety and efficacy results.

METHODS

Eligible individuals were enrolled into an investigator-initiated study and underwent a baseline and 3 annual magnetic resonance imagings/magnetic resonance cholangiopancreatographies (MRIs/MRCPs) with gadolinium, biannual blood donations for biobanking, and assessments for anxiety and depression. All MRIs were presented at a multidisciplinary board to determine whether further investigation was warranted.

RESULTS

Seventy-five individuals have been enrolled and 201 MRIs performed over a 2.6-year average length of follow-up. Abnormal pancreatic findings (predominantly small cysts) were detected in 58.7% of the participants. Among these, 6.7% underwent endoscopic ultrasound, with 1 case complicated by postprocedural pancreatitis. One surgical resection was performed on a 4.7-cm intraductal papillary mucinous neoplasm with a focus on low-grade pancreatic intraepithelial neoplasia. One incidental finding of fibrosing mediastinitis was detected. Anxiety and depression scores decreased over the course of this study from 21.4% to 5.4% and 10.7% to 3.6%, respectively.

DISCUSSION

This preliminary report supports the feasibility of performing MRI/magnetic resonance cholangiopancreatographies-based PC screening as part of a clinical trial in a community setting. A longer follow-up is needed to better assess safety and efficacy. To the best of our knowledge, this is the first report from a community-based PC screening effort ( clinicaltrials.gov ID: NCT03250078).

Emerging Roles of the Nervous System in Gastrointestinal Cancer Development

Simple Summary

Nerve–cancer cross-talk has increasingly become a focus of the oncology field, particularly in gastrointestinal (GI) cancers. The indispensable roles of the nervous system in GI tumorigenesis and malignancy have been dissected by epidemiological, experimental animal and mechanistic data. Herein, we review and integrate recent discoveries linking the nervous system to GI cancer initiation and progression, and focus on the molecular mechanisms by which nerves and neural receptor pathways drive GI malignancy.

Abstract

Our understanding of the fascinating connection between nervous system and gastrointestinal (GI) tumorigenesis has expanded greatly in recent years. Recent studies revealed that neurogenesis plays an active part in GI tumor initiation and progression. Tumor-driven neurogenesis, as well as neurite outgrowth of the pre-existing peripheral nervous system (PNS), may fuel GI tumor progression via facilitating cancer cell proliferation, chemoresistance, invasion and immune escape. Neurotransmitters and neuropeptides drive the activation of various oncogenic pathways downstream of neural receptors within cancer cells, underscoring the importance of neural signaling pathways in GI tumor malignancy. In addition, neural infiltration also plays an integral role in tumor microenvironments, and contributes to an environment in favor of tumor angiogenesis, immune evasion and invasion. Blockade of tumor innervation via denervation or pharmacological agents may serve as a promising therapeutic strategy against GI tumors. In this review, we summarize recent findings linking the nervous system to GI tumor progression, set the spotlight on the molecular mechanisms by which neural signaling fuels cancer aggressiveness, and highlight the importance of targeting neural mechanisms in GI tumor therapy.

Pancreatic Cancer-Associated Depression: A Case Report and Review of the Literature

The prevalence of major depressive disorder (MDD) in pancreatic cancer (PC) has been reported up to 7 times higher than the general population. Despite repeated studies that show worse quality of life, survival outcomes, and treatment compliance in cancer patients with depression, baseline antidepressant use ranges from 15% to 27%. A meta-analysis of 6 prospective trials specific to PC estimates that 43% of patients with PC experience depression after diagnosis. This is especially alarming in patients with PC, who may experience a prodrome of symptoms including depression and loss of drive. In fact, this prodrome of symptoms may very well be due to an overexpression of indoleamine 2,3-dioxgenase, an enzyme in the kynurenine pathway that leads to serotonin depletion and the buildup of cytotoxic metabolites in the brain. In this literature review, we outline all previous studies pertinent to PC and depression, as well as the molecular underpinnings that may contribute to states of depression, and report on previous randomized control trials in cancer populations that investigate the use of antidepressants to treat depressive symptoms and improve quality of life both prophylactically and after the onset of major depressive disorder. In addition, we detail a case report outlining the precipitous decline in health in 1 patient with PC and depression.

Association between chronological depressive changes and physical symptoms in postoperative pancreatic cancer patients

Background

Pancreatic cancer (PC) has poorer prognosis and higher surgical invasiveness than many other cancers, with associated psychiatric symptoms including depression and anxiety. Perioperative depression has not been investigated in PC patients regarding surgical stress and relevant interventions.

Methods

We evaluated chronological depressive changes and subjective physical symptoms in surgically treated PC patients preoperatively and at 3 and 6 months postoperatively.

Enrolled patients undergoing pancreatic tumor surgery completed questionnaires based on the Self-Rating Depression Scale (SDS) and Functional Assessment of Cancer Therapy for Patients with Hepatobiliary Cancer (FACT-Hep) preoperatively, and at 3 and 6 months postoperatively. Responses were analyzed with JMP® Pro using one-way and two-way ANOVA, Spearman’s rank correlation coefficient, and multiple regression analysis.

Results

Malignancy was diagnosed in 73 of 101 patients postoperatively; SDS score was significantly higher in these patients than in those with benign tumors at all timepoints: malignant/benign, 41.8/37.9 preoperatively (p = 0.004); 43.5/37.8 3 months postoperatively (p = 0.006); and 42.9/37.7 6 months postoperatively (p = 0.020). SDS scores were significantly higher in patients < 65 years old with malignancy at 3 months than at 6 months postoperatively (44.6/42.5, p = 0.046) and in patients with malignancy who underwent pancreaticoduodenectomy at 3 months postoperatively than preoperatively (43.4/41.1; p = 0.028). SDS scores moderately correlated with 8 physical symptom-related FACT-Hep items 3 months postoperatively (p < 0.05), showing low-to-moderate correlation with 16 physical symptom-related FACT-Hep items at 6 months postoperatively (p < 0.05). Multiple regression analysis of FACT-Hep symptoms significantly correlated with SDS scores revealed the following significant variables: “lack of energy” (p < 0.000) and “pain” (p = 0.018) preoperatively (R² = 0.43); “able to perform usual activities” (p = 0.031) and “lack of energy” (p < 0.000) at 3 months postoperatively (R² = 0.51); and “stomach swelling or cramps” (p = 0.034) and “bowel control” (p = 0.049) at 6 months postoperatively (R² = 0.52).

Conclusions

PC patients experience persistently high levels of depression preoperatively through 6 months postoperatively, with associated subjective symptoms including pain and gastrointestinal symptoms.

Trial registration

UMIN Clinical Trials Registry 000009592, Registered 20 December 2012.

Pancreatic Cancer and Depression: A Narrative Review

Depression is a common concomitant of pancreatic cancer, and, because it often occurs before the cancer is diagnosed, its occurrence is likely to be intrinsic to the condition rather than a reaction to such a diagnosis. Because pancreatic cancer is associated with a very high mortality, its early detection is a key task. We therefore review relevant literature to determine whether the depression is prototypically distinctive and whether its identification might lead to earlier diagnosis of pancreatic cancer. We report on the epidemiology and prognosis of pancreatic cancer and on the prevalence, description, and possible mechanisms involved for the occurrence of any associated depressive state, before reviewing the comparative utility of depression in relation to other risk factors in aiding diagnosis. Published studies fail to identify any distinct depressive prototypic phenotype to depression associated with pancreatic cancer. Although it is a relatively common concomitant of pancreatic cancer, the utility of depression as a marker of the condition is not suggested from a key study evaluating its contribution in relation to other symptoms and risk factors.

Pilot study of an interdisciplinary supportive care planning intervention in pancreatic cancer

PURPOSE

A diagnosis of pancreatic cancer is often associated with higher symptom burden, lower functional status, and worse quality of life (QOL). To date, few interventions have focused on the unique QOL needs of patients with pancreatic cancer. The purpose of this pilot study is to determine the feasibility of an interdisciplinary supportive care planning intervention in patients with pancreatic cancer during disease-focused treatments.

METHODS

Patients enrolled in this prospective, pre- and post-intervention pilot study received a supportive care intervention that included the following three components: comprehensive QOL assessment, case presentation at interdisciplinary care meetings, and two nurse-administered educational sessions on QOL concerns. Patients completed outcome measures that included the FACT-Hep, FACIT-Sp-12, and self-report of finances and out-of-pocket costs since diagnosis. Measures were completed at baseline prior to receiving the intervention, and follow-up occurred at 1 and 2 months post-intervention.

RESULTS

A total of 10 patients were enrolled during a 4-month period who provided informed consent, received the intervention, and completed the study (58 % accrual). Examination of pre- and post-intervention QOL outcomes revealed changes across the three evaluation time points that were not statistically significant. Patients were highly satisfied with the intervention, with 80 % reporting that the intervention was "excellent." Discussions during the interdisciplinary care meetings and educational sessions were largely focused on physical and psychosocial needs.

CONCLUSIONS

An interdisciplinary supportive care planning intervention was potentially feasible and acceptable for pancreatic cancer patients in an ambulatory care setting.

Mood and anxiety disorders as early manifestations of medical illness: a systematic review

BACKGROUND

Affective disturbances involving alterations of mood, anxiety and irritability may be early symptoms of medical illnesses. The aim of this paper was to provide a systematic review of the literature with qualitative data synthesis.

METHODS

MEDLINE, PsycINFO, EMBASE, Cochrane, and ISI Web of Science were systematically searched from inception to February 2014. Search terms were 'prodrome/early symptom', combined using the Boolean 'AND' operator with 'anxiety/depression/mania/hypomania/irritability/irritable mood/hostility', combined with the Boolean 'AND' operator with 'medical illness/medical disorder'. PRISMA guidelines were followed.

RESULTS

A total of 21 studies met the inclusion criteria and were analyzed. Depression was found to be the most common affective prodrome of medical disorders and was consistently reported in Cushing's syndrome, hypothyroidism, hyperparathyroidism, pancreatic and lung cancer, myocardial infarction, Wilson's disease, and AIDS. Mania, anxiety and irritability were less frequent.

CONCLUSIONS

Physicians may not pursue medical workup of cases that appear to be psychiatric in nature. They should be alerted that disturbances in mood, anxiety and irritability may antedate the appearance of a medical disorder.

Measuring sickness behavior in the context of pancreatic cancer

Sickness behavior has been widely recognized as a symptom cluster that is associated with pro-inflammatory cytokine activation resulting from diverse conditions. The symptoms that comprise sickness behavior overlap substantially with major depressive disorder (MDD), which raises questions about the relationship between these two constructs, both of which occur frequently in patients with cancer. The construct of sickness behavior, while well-established in animal research, has rarely been applied to studies examining cytokines and depression in humans, perhaps because no reliable or validated measure of sickness behavior has been developed. We developed a version of a sickness behavior measure (the Sickness Behavior Inventory or SBI) and conducted a preliminary examination of its scale properties. Specifically, we hypothesized that a measure of sickness behavior would be significantly associated with five biomarkers of immune functioning (serum IL-6, TNF-α, IL-1b, IL-4, IL-10) in a human sample. The sample was comprised of four groups: individuals with pancreatic cancer and MDD (n = 16), individuals with pancreatic cancer and who did not have a diagnosis of MDD (n =2 6), individuals without cancer who had MDD (n = 7), and individuals who did not have cancer or MDD (n = 25). The SBI demonstrated moderate reliability (Cronbach's alpha = .66), and total scores were significantly correlated with IL-6 (rs = .26, p = .03), but not with other markers of immune functioning. Factor analysis supported a 3-factor model of sickness behavior with different associations between the three SBI factors and cytokines. These results highlight the need to further refine symptom measurement to better understand the relationships among immune functioning, cancer, depression, and sickness behavior.

Prodromal depression in pancreatic cancer: Retrospective evaluation on ten patients

Objective:

Since the description by Yaskin in 1931, it has been observed that pancreatic cancer and depression are two clinical entities that share a high affinity. This observation relies on the higher incidence of depressive syndromes associated with pancreatic cancer than in any other type of digestive tumor, and on the possible occurrence of depressive symptoms several months before the diagnosis of cancer. We present here a series of cases whose screening returned positive for depression-related diagnoses in the months prior to revelation of the cancer.

Method:

We employed a structured psychiatric interview based on DSM–IV criteria (SCID–I). The diagnoses considered were major depressive episode, minor depressive episode, and subsyndromal depression. All subjects were free of psychiatric history.

Results:

Some 15 patients were initially included: 10 presented compatible criteria for a past depressive episode, 2 presented a major depressive episode, 4 met the diagnosis of minor depression, and 4 evidenced subsyndromal depression over the one-year period prior to cancer diagnosis.

Significance of results:

This series of cases is consistent with previous work on the subject that suggested an increased vulnerability to depressive events in the premorbid phase of pancreatic cancer. If the possibility of depressive syndromes constituting the early stages of neoplastic disease is a common idea, it is still impossible to determine the natural history of these two disorders and therefore their causal linkage.

Health outcome disparities among subgroups of people with disabilities: a scoping review

BACKGROUND

A growing body of research has found that people with disabilities experience lower health status and an excess burden of disease relative to the general US population. However, the population of people with disabilities is quite diverse. Thus, it is important to understand health differences between subgroups of people with disabilities in order to most effectively target interventions to address disparities. An initial step in this process is reviewing and synthesizing available research addressing these subgroup differences.

OBJECTIVES

To conduct a scoping review of literature to describe recent research activity that has examined health outcome disparities within populations of people with disabilities.

METHODS

We searched for relevant articles in MEDLINE, PsycINFO, and CINAHL databases. Three staff independently reviewed abstracts according to inclusion criteria. Two authors then independently extracted data from each included article.

RESULTS

For many of the health outcomes of interest, there was no published literature in relation to key disparity factors (e.g. race, income) within the population of people with disabilities. The health outcomes most frequently examined were diabetes and heart disease. The most frequently examined disparity factors were the type of disabling condition and gender.

CONCLUSIONS

There are significant gaps in available research. Building a body of research that identifies disparities and potentially vulnerable subgroups may improve understanding of the causes of disparities and contribute to efforts to improve quality of life and health outcomes for individuals with disabilities.

Transcranial direct current stimulation and repetitive transcranial magnetic stimulation in consultation-liaison psychiatry

Patients with clinical diseases often present psychiatric conditions whose pharmacological treatment is hampered due to hazardous interactions with the clinical treatment and/or disease. This is particularly relevant for major depressive disorder, the most common psychiatric disorder in the general hospital. In this context, nonpharmacological interventions could be useful therapies; and, among those, noninvasive brain stimulation (NIBS) might be an interesting option. The main methods of NIBS are repetitive transcranial magnetic stimulation (rTMS), which was recently approved as a nonresearch treatment for some psychiatric conditions, and transcranial direct current stimulation (tDCS), a technique that is currently limited to research scenarios but has shown promising results. Therefore, our aim was to review the main medical conditions associated with high depression rates, the main obstacles for depression treatment, and whether these therapies could be a useful intervention for such conditions. We found that depression is an important and prevalent comorbidity in a variety of diseases such as epilepsy, stroke, Parkinson's disease, myocardial infarction, cancer, and in other conditions such as pregnancy and in patients without enteral access. We found that treatment of depression is often suboptimal within the above contexts and that rTMS and tDCS therapies have been insufficiently appraised. We discuss whether rTMS and tDCS could have a significant impact in treating depression that develops within a clinical context, considering its unique characteristics such as the absence of pharmacological interactions, the use of a nonenteral route, and as an augmentation therapy for antidepressants.

Pancreatic cancer risk after loss of a child: a register-based study in Sweden during 1991-2009

The potential role of psychological stress in pancreatic cancer has rarely been investigated in epidemiologic studies. During 1991-2009, we conducted a nested case-control study based on Swedish national population and health registers to investigate whether severe psychological stress induced by the death of a child was associated with subsequent risk of pancreatic cancer. The study included 16,522 cases and 82,107 controls who were matched to the cases on sex and year of birth. Conditional logistic regression was used to estimate odds ratios and 95% confidence intervals. Overall, loss of a child was associated with an odds ratio of 1.09 for pancreatic cancer (95% confidence interval (CI): 1.02, 1.17). The risk elevation was mainly seen during the first 5 years after the loss (odds ratio (OR) = 1.27, 95% CI: 1.12, 1.45) and for loss of a child due to suicide (OR = 1.23, 95% CI: 1.03, 1.46). The association was statistically significant among women but not among men, and it appeared stronger for early-onset pancreatic cancer. Persons with a history of psychiatric illness had the greatest risk increase after child loss (OR = 1.43, 95% CI: 1.17, 1.76). Although other explanations are possible, our findings provide some evidence that psychological stress may be associated with pancreatic cancer.

The effect of depression on stage at diagnosis, treatment, and survival in pancreatic adenocarcinoma

BACKGROUND

Depression has been associated with delayed presentation, inadequate treatment, and poor survival in patients with cancer.

METHODS

Using Surveillance, Epidemiology and End Results and Medicare linked data (1992-2005), we identified patients with pancreatic adenocarcinoma (N = 23,745). International classification of diseases, 9th edition, clinical modification codes were used to evaluate depression during the 3 to 27 months before the diagnosis of cancer. The effect of depression on receipt of therapy and survival was evaluated in univariate and multivariate models.

RESULTS

Of patients with pancreatic cancer in our study, 7.9% had a diagnosis of depression (N = 1,868). Depression was associated with increased age, female sex, white race, single or widowed status, and advanced stage disease (P < .0001). In an adjusted model, patients with locoregional disease and depression had 37% lower odds of undergoing surgical resection (odds ratio, 0.63; 95% confidence interval, 0.52-0.76). In patients with locoregional disease, depression was associated with lower 2-year survival (hazard ratio, 1.20; 95% confidence interval, 1.09-1.32). After adjusting for surgical resection, this association was attenuated (hazard ratio, 1.14; 95% confidence interval, 1.04-1.26). In patients who underwent surgical resection, depression was a significant predictor of survival (hazard ratio, 1.34; 95% confidence interval, 1.04-1.73). Patients with distant disease and depression had 21% lower odds of receiving chemotherapy (odds ratio, 0.79; 95% confidence interval, 0.70-0.90). After adjusting for chemotherapy for distant disease, depression was no longer a significant predictor of survival (hazard ratio, 1.03; 95% confidence interval, 0.97-1.09).

CONCLUSION

The decreased survival associated with depression appears to be mediated by a lower likelihood of appropriate treatment in depressed patients. Accurate recognition and treatment of pancreatic cancer patients with depression may improve treatment rates and survival.

Screening for depression, sleep-related disturbances, and anxiety in patients with adenocarcinoma of the pancreas: a preliminary study

Purpose. Screening for depression, sleep-related disturbances, and anxiety in patients with diagnosed adenocarcinoma of the pancreas. Materials and Methods. Patients were evaluated at initial consultation and subsequent visits at the multidisciplinary pancreatic cancer clinic at our University Cancer Center. Cross-sectional and longitudinal psychosocial distress was assessed utilizing Personal Health Questionnaire 9 (PHQ9) to screen for depression and monitor symptoms, the Penn State Worry Questionnaire (PSWQ) for generalized anxiety, and the University of Michigan Sleep Questionnaire to monitor sleep symptoms. Results. Twenty-two patients diagnosed with pancreatic cancer participated during the 6-month pilot study with longitudinal followup for thirteen patients. In this study, mild-to-moderate depressive symptoms, anxiety, and potential sleep problems were common. The main finding of the study was 23% of the patients who were part of this pilot project screened positive for moderately severe major depressive symptoms, likely anxiety disorder or a potential sleep disorder during the study. One patient screened positive for moderately severe depressive symptoms in longitudinal followup. Conclusions. Depression, anxiety, and sleep problems are evident in patients with pancreatic cancer. Prospective, longitudinal studies, with larger groups of patients, are needed to determine if these comorbid symptoms impact outcome and clinical course.

High level interleukin-6 in the medium of human pancreatic cancer cell culture suppresses production of neurotransmitters by PC12 cell line

It has been suggested that pancreatic cancer is associated with a greater prevalence of depression than many other cancers, but the mechanism accounting for this potential association has not yet been illustrated. In the present study, conditioned media (CM) from three pancreatic cancer cell lines and primary pancreatic cancer cells from two patients were added to culture system of differentiated pheochromocytoma cell line PC12. The release of dopamine (DA) and norepinephrine (NE) by PC12 was significantly inhibited after CM treatment (P < 0.05), similar to what happened after recombinant interleukin 6(IL-6) treatment. Furthermore, pretreatment with anti-IL-6 antibody significantly blocked the inhibitory effects of pancreatic cancer CM on DA and NE production (P < 0.05). We also demonstrated that tyrosine hydroxylase (TH), the rate-limiting enzyme for synthesis of catecholamine, was reduced after exposure to IL-6, which was accompanied by JAK-STAT3 pathway activation. Our results demonstrated that IL-6 in CM from pancreatic cancer down-regulated the production of DA and NE by PC12 cell. The possible underlying mechanisms might be decreasing TH production via activation of JAK-STAT3 signal transduction pathway. The present study might help to better understand the close relationship between pancreatic cancer and depression.

Psychiatric disorders in cancer patients at a university hospital in Japan: descriptive analysis of 765 psychiatric referrals

OBJECTIVE

In cancer patients, adjustment disorders, delirium and depression have been identified as common psychiatric disorders. Although a comparable result was reported in the National Cancer Center in Japan, the nature of patients in that hospital may differ from that in local hospitals. There is a possibility to expand the findings of psycho-oncology by evaluation of the data from a local university hospital and comparison with the National Cancer Center data.

METHODS

We retrospectively reviewed the medical records of cancer patients who were referred to the Department of Psycho-Oncology at Saitama Medical University International Medical Center. We identified their characteristics and psychiatric diagnoses and compared these with the National Cancer Center data.

RESULTS

During the study period, 765 cancer patients were referred. The numbers of inpatients and outpatients were almost the same. The most common psychiatric diagnosis was adjustment disorders (24%), followed by delirium (16%) and then major depressive disorder (12%). The rank of these three was the same as that at the National Cancer Center. Outpatients constituted more than 80% of the patients with major depressive disorder. The proportion of cancer patients with schizophrenia in this study (4.3%) was higher than that in the National Cancer Center (1.6%).

CONCLUSIONS

This study revealed basic information about the consultation data of cancer patients at a local university hospital in Japan. The importance of communication with outpatients was suggested. It seems that cancer treatment for patients with schizophrenia in a local hospital is also important.

Gender Difference in Symptom Presentations Among Patients With Bone Metastases in Gender-Specific and Gender-Neutral Primary Cancers

Background

Studies have assessed gender differences on symptoms commonly experienced by cancer patients at various stages in their disease trajectory using heterogeneous cancer populations with different tumor types. The purpose of our study was to evaluate the effect of gender on symptoms among patients with bone metastases while controlling for gender-specific malignancies.

Methods

A retrospective review of patients receiving palliative radiotherapy for bone metastases was conducted on patients that completed the Brief Pain Inventory (BPI) or Edmonton Symptom Assessment System (ESAS) questionnaires from 1999 - 2004. Baseline and follow-up BPI and ESAS symptom scores were compared between males and females, with and without controlling for gender-specific tumors.

Results

A total of 900 patients completed baseline questionnaires: ESAS (n = 508) or BPI (n = 392). The most common tumor types were lung (26%), breast (25%) and prostate (24%). In all ESAS patients, females had significantly greater severity of tiredness, nausea, depression, anxiety and breathlessness. In the subgroup analysis when gender-specific primary cancers were removed (i.e., breast, prostate and gynecological), no significant differences in ESAS symptoms were found between genders. The BPI functional item of walking ability was significantly worse for females in both the overall and subgroup analyses. Females had worse symptoms at follow-up prior to the removal of gender-specific primaries in both ESAS and BPI.

Conclusions

Gender-specific cancers may significantly bias gender studies of cancer-related symptoms when primary tumor type is not taken into account. Gender differences are best assessed in gender-neutral primaries.

Pancreatic cancer and depression: myth and truth

BACKGROUND

Various studies reported remarkable high incidence rates of depression in cancer patients compared with the general population. Pancreatic cancer is still one of the malignancies with the worst prognosis and therefore it seems quite logical that it is one of the malignancies with the highest incidence rates of major depression.However, what about the scientific background of this relationship? Is depression in patients suffering from pancreatic cancer just due to the confrontation with a life threatening disease and its somatic symptoms or is depression in this particular group of patients a feature of pancreatic cancer per se?

DISCUSSION

Several studies provide evidence of depression to precede the diagnosis of pancreatic cancer and some studies even blame it for its detrimental influence on survival. The immense impact of emotional distress on quality of life of cancer patients enhances the need for its early diagnosis and adequate treatment. Knowledge about underlying pathophysiological mechanisms is required to provide the optimal therapy.

SUMMARY

A review of the literature on this issue should reveal which are the facts and what is myth.

Suicide in patients with pancreatic cancer

BACKGROUND

Depression is highly prevalent in patients with pancreatic cancer and can result in fatal outcomes from suicides. The authors report suicide rates among patients with pancreatic cancer in the United States and identify factors associated with greater suicide rates.

METHODS

The current study reviewed data in the SEER database for patients diagnosed with pancreatic adenocarcinoma from 1995-2005. Logistic regression models were used to perform multivariate modeling for factors associated with suicide, while Kaplan-Meier analysis was used to assess factors affecting survival.

RESULTS

Among 36,221 patients followed for 22,145 person-years, the suicide rate was 135.4 per 100,000 person-years. The corresponding rate in the US population aged 65-74 years was 12.5 per 100,000 person-years, with a Standardized Mortality Ratio (SMR) of 10.8 (95% CI, 9.2-12.7). Greater suicide rates were noted in males (Odds Ratio (OR) 13.5 [95% CI, 3.2-56.9, P < .001]) and, among males, in patients undergoing an operative intervention (OR 2.5 [95% CI, 1.0-6.5, P = .05]). Married men had a lesser risk of committing suicide (OR 0.3 [95% CI, 0.1-0.6, P = .002]). Median survival among patients undergoing operative intervention was 2 months for those who committed suicide compared with 10 months for those who did not commit suicide.

CONCLUSIONS

Male patients with pancreatic adenocarcinoma have a risk of suicide nearly 11 times that of the general population. Patients who undergo an operative intervention are more likely to commit suicide, generally in the early postoperative period.

Mixed anxiety/depression symptoms in a large cancer cohort: prevalence by cancer type

BACKGROUND

Mixed anxiety/depression is associated with poorer psychosocial and treatment outcomes, worse quality of life, pooreradherence to treatment, slower recovery, greater suicide risk, and highercost-utilization.

OBJECTIVE

This study aimed to examine the cancer-specific prevalence of these symptoms.

METHOD

Cross-sectional anxiety and depression symptom data were collected with the Brief Symptom Inventory from adult outpatients presenting to a tertiary cancer center (N=8,265).

RESULTS

Mixed anxiety/depression symptoms were seen in 12.4% of patients; overall depression symptoms in 18.3%, overall anxiety symptoms in 24.0%, pure anxiety symptoms in 11.7%, and pure depression symptoms in 6.0%; 70% had neither. Higher rates of mixed anxiety/depression symptoms were seen with stomach, pancreatic, head and neck, and lung cancers, but lower rates were seen in those with breast cancers. The mixed anxiety/depression phenotype occurs in two-thirds of depressed cancer patients.

DISCUSSION

The fact that 70% of patients did not meet thresholds for depression or anxiety symptoms can be interpreted as a reflection of the resistance to developing a significant level of these symptoms. However, because stomach, pancreatic, head and neck, and lung cancers have higher levels of mixed anxiety/depression symptoms, the question can be raised as to whether these are associated with a more biological type of anxiety/depression (e.g., due to cytokine release) and whether this phenotype should be actively targeted because of its frequent occurrence in these cancers.

Panic as a harbinger of pancreatic cancer

BACKGROUND

Previous literature has discussed the diagnosis of cancer with psychiatric symptoms. There are noted associations made between pancreatic cancer and depression and anxiety symptoms both in literature and textbooks.

METHOD

The authors discuss the case of a patient who presented with anxiety and panic attacks before his diagnosis of pancreatic cancer.

CONCLUSION

There has been a previous association noted between depression and anxiety and pancreatic cancer; however, this work and another report have noted panic episodes preceding diagnosis, as well. These symptoms could prove to be an important marker for early detection.

Effect of antidepressants on body weight, ethology and tumor growth of human pancreatic carcinoma xenografts in nude mice

AIM

To investigate the effects of mirtazapine and fluoxetine, representatives of the noradrenergic and specific serotonergic antidepressant (NaSSA) and selective serotonin reuptake inhibitor (SSRI) antidepressant respectively, on body weight, ingestive behavior, locomotor activity and tumor growth of human pancreatic carcinoma xenografts in nude mice.

METHODS

A subcutaneous xenograft model of human pancreatic cancer cell line SW1990 was established in nude mice. The tumor-bearing mice were randomly divided into mirtazapine group (10 mg/kg per day), fluoxetine group (10 mg/kg per day) and control group (an equivalent normal saline solution) (7 mice in each group). Doses of all drugs were administered orally, once a day for 42 d. Tumor volume and body weight were measured biweekly. Food intake was recorded once a week. Locomotor activity was detected weekly using an open field test (OFT).

RESULTS

Compared to the fluoxetine, mirtazapine significantly increased food intake from d 14 to 42 and attenuated the rate of weight loss from d 28 to 42 (t = 4.38, P < 0.05). Compared to the control group, food intake was significantly suppressed from d 21 to 42 and weight loss was promoted from d 35 to 42 in the fluoxetine group (t = 2.52, P < 0.05). There was a significant difference in body weight of the mice after removal of tumors among the three groups. The body weight of mice was the heaviest (13.66 +/- 1.55 g) in the mirtazapine group and the lightest (11.39 +/- 1.45 g) in the fluoxetine group (F( (2,12) ) = 11.43, P < 0.01). The behavioral test on d 7 showed that the horizontal and vertical activities were significantly increased in the mirtazapine group compared with the fluoxetine and control groups (F( (2,18) ) = 10.89, P < 0.01). These effects disappeared in the mirtazapine and fluoxetine groups during 2-6 wk. The grooming activity was higher in the mirtazapine group than in the fluoxetine group (10.1 +/- 2.1 vs 7.1 +/- 1.9 ) (t = 2.40, P < 0.05) in the second week. There was no significant difference in tumor volume and tumor weight of the three groups.

CONCLUSION

Mirtazapine and fluoxetine have no effect on the growth of pancreatic tumor. However, mirtazapine can significantly increase food intake and improve nutrition compared with fluoxetine in a pancreatic cancer mouse model.

Association of preoperative depression and survival after resection of malignant brain astrocytoma

BACKGROUND

Clinical depression has been shown to negatively influence the morbidity and mortality of multiple disease states. It remains unclear if clinical depression affects survival after surgical management of malignant brain astrocytoma. We set out to determine whether patients with a diagnosis of clinical depression before surgery experienced decreased survival independent of treatment modality or degree of disability.

METHODS

One thousand fifty-two patients undergoing surgical management for malignant brain astrocytoma (WHO grade 3 or 4) performed at a single institution from 1995 to 2006 were retrospectively reviewed. The independent association of depression prior to surgery and subsequent survival was assessed via multivariate proportional hazards regression analysis.

RESULTS

Surgical management consisted of primary resection in 605 (58%) patients, secondary resection in 410 (39%), and biopsy in 37 patients (3.5%). Pathology was WHO grade IV in 829 (79%) and grade III in 223 (21%). Forty-nine patients (5%) carried the diagnosis of depression at the time of surgery. Mean age and KPS on admission was 51 +/- 16 and 80 +/- 10 years, respectively. Two hundred ninety patients (28%) received Gliadel (BCNU MGI Pharma, Inc., Bloomington, MN, USA) wafer implantation and 274 (26%) received postoperative temozolomide (concomitant in 102, delayed adjuvant in 172 patients). Subsequent resection was performed at the time of recurrence in 135 (13%) patients a mean of 10 +/- 6 months after surgery. Adjusting for all variables associated with survival in this model, age (P < .001), KPS (P < .001), WHO grade III vs IV (P < .001), primary versus secondary resection (P < .001), gross-total resection (P < .001), Gliadel wafer implantation (P = .048), postoperative temozolomide therapy (P < .001), and subsequent resection at time of recurrence (P < .001); preoperative depression was independently associated with decreased survival (relative risk [95% CI]: 1.41 [1.1-1.96], P < .05). The difference in percent survival between the depression and nondepression cohorts was most notable at 12 months (15% vs 41%) and 20 months (0% vs 21%) after surgery.

CONCLUSION

In our experience, patients who are actively depressed at the time of surgery were associated with decreased survival after surgical management of malignant astrocytoma, independent of degree of disability, tumor grade, or subsequent treatment modalities. In our opinion, the presence of an association between preoperative depression and survival warrants further investigation.

Effect of antidepressants on body weight, ethology and tumor growth of human pancreatic carcinoma xenografts in nude mice

AIM: To investigate the effects of mirtazapine and fluoxetine, representatives of the noradrenergic and specific serotonergic antidepressant (NaSSA) and selective serotonin reuptake inhibitor (SSRI) antidepressant respectively, on body weight, ingestive behavior, locomotor activity and tumor growth of human pancreatic carcinoma xenografts in nude mice.

METHODS: A subcutaneous xenograft model of human pancreatic cancer cell line SW1990 was established in nude mice. The tumor-bearing mice were randomly divided into mirtazapine group [10 mg/(kg·d)], fluoxetine group [10 mg/(kg·d)] and control group (an equivalent normal saline solution) (7 mice in each group). Doses of all drugs were administered orally, once a day for 42 d. Tumor volume and body weight were measured biweekly. Food intake was recorded once a week. Locomotor activity was detected weekly using an open field test (OFT).

RESULTS: Compared to the fluoxetine, mirtazapine significantly increased food intake from d 14 to 42 and attenuated the rate of weight loss from d 28 to 42 (t = 4.38, P < 0.05). Compared to the control group, food intake was significantly suppressed from d 21 to 42 and weight loss was promoted from d 35 to 42 in the fluoxetine group (t = 2.52, P < 0.05). There was a significant difference in body weight of the mice after removal of tumors among the three groups. The body weight of mice was the heaviest (13.66 ± 1.55 g) in the mirtazapine group and the lightest (11.39 ± 1.45 g) in the fluoxetine group (F_(2,12) = 11.43, P < 0.01). The behavioral test on d 7 showed that the horizontal and vertical activities were significantly increased in the mirtazapine group compared with the fluoxetine and control groups (F_(2,18) = 10.89, P < 0.01). These effects disappeared in the mirtazapine and fluoxetine groups during 2-6 wk. The grooming activity was higher in the mirtazapine group than in the fluoxetine group (10.1 ± 2.1 vs 7.1 ± 1.9 ) (t = 2.40, P < 0.05) in the second week. There was no significant difference in tumor volume and tumor weight of the three groups.

CONCLUSION: Mirtazapine and fluoxetine have no effect on the growth of pancreatic tumor. However, mirtazapine can significantly increase food intake and improve nutrition compared with fluoxetine in a pancreatic cancer mouse model.

Incidence and mortality of pancreatic cancer in the Nordic countries 1971-2000

Pancreatic cancer (PC) is the sixth most frequent cause of death from cancer in Europe in men as well as women. Apart from smoking, little is known about the aetiology of PC. This study examines trends in incidence and mortality of PC in Denmark, Finland, Iceland, Norway, and Sweden from 1971 to 2000, using the database NORDCAN, with data on incident cases of PC derived from the national cancer registries and data on deaths from PC from the national registries on causes of death. The analysis included 91 842 incident cases and 96 430 deaths from PC in a total population of about 23 million. The mean age at diagnosis was 69 years for males in the Nordic countries for the period 1996-2000 and 72 years for females. Using the age-specific rates from year 2000 to calculate the cumulative risk, 8.4 of 1 000 Nordic men and 6.7 of 1 000 Nordic women will develop PC before the age of 75 years. Over the past 30 years incidence and mortality rates have been decreasing in males and remained stable without any particular trend in females whether examined by calendar time or birth cohort. However, there are considerable difficulties in obtaining true estimates of the incidence and mortality from PC, since less than 60% of incident cases are verified histologically and autopsy rates have decreased over time.

Effect of BxPC-3-conditioned medium on the metabolism of DA and NE in PC12 cell line and its mechanism of action

AIM: To study the effect of BxPC-3-conditioned medium on the metabolism of DA and NE in PC12 cells and its mechanism of action.

METHODS: PC12 cells were treated with BxPC-3-conditioned medium without IL-6. The rate of apoptosis of PC12 cells was detected by flow cytometry. DA, 5-HT and NE in the medium were measured by HPLC. IL-6 (0.01 mg/L, 0.1 mg/L, 0.25 mg/L, 0.5 mg/L, 1 mg/L, 1.5 mg/L, 2 mg/L) was added into the medium deprived of serum, then the DA, 5-HT and NE in the medium were measured.

RESULTS: There was no significant difference in the rate of apoptosis of PC12 cells in each group. After anti-IL-6 was added into the conditioned medium, the quantity of DA and NE in the medium was increased. The concentration of IL-6 was increased. DA and NE were metabolized in a dose-dependent manner. Addition of 1mg/L IL-6 significantly decreased DA and NE.

CONCLUSION: BxPC-3-conditioned medium has certain effects on the metabolism of DA and NE of PC12 cells by adding IL-6.

Survival in pancreatic carcinoma based on tumor size

OBJECTIVES

The size of pancreatic tumors that can be diagnosed by preoperative imaging continues to decrease because advances in diagnostic imaging. Several surgical series have suggested that survival is better in tumors 20 mm or smaller (vs tumors >20 mm), but the incremental benefit of diagnosing progressively smaller tumors from 30 mm (currently, the average size of pancreatic tumor at diagnosis) to 20 mm or smaller is not known. We investigated survival and resectability as tumor size increased from 20 mm or smaller to 30 mm or larger.

METHODS

This is a retrospective analysis of consecutive patients with pancreatic cancer, who underwent endoscopic ultrasound-guided fine-needle aspiration at MD Anderson Cancer Center between December 2000 and December 2001. Tumor size was based on the combination of endoscopic ultrasound and computed tomography imaging.

RESULTS

The median (+/-SE) for tumors 20 mm or smaller, 21 to 25 mm, 26 to 30 mm and larger than 30 mm was 17.2 +/- 8.2, 12.3 +/- 4.9, 8.5 +/- 3.6, and 7.6 +/- 1.2 months (P = 0.021), respectively. Tumors were resectable in 10 (83%) of 12 tumors 20 mm or smaller, 8 (67%) of 12 tumors 21 to 25 mm, 5 (36%) of 14 of tumors 26 to 30 mm, and 2 (7%) of 27 tumors larger than 30 mm (P < 0.001).

CONCLUSIONS

A dramatic change in survival occurs as the size of pancreatic tumor increases from 20 mm or smaller to 30 mm or larger. To be effective, future strategies for early diagnosis of pancreatic cancer should aim at diagnosing most pancreatic cancers before they are 20 mm in size.

Effects of depression on the survival of pancreatic adenocarcinoma

OBJECTIVES

Depression frequently predates the diagnosis of pancreatic adenocarcinoma. In other malignancies, depression has been shown to adversely affect survival. The purpose of this study was to assess whether survival after resection for pancreatic cancer is shortened by the pretreatment presence of depression.

METHODS

A database of all patients diagnosed with pancreatic cancer was retrospectively reviewed for depression, resection, and chemotherapy and/or radiation therapy. A total of 258 patients were studied; 21% had depression, 19% had surgical resection of the tumor, and 42% were treated with chemotherapy and/or radiation therapy. Survival data was analyzed using Cox proportional hazard regression and life table analysis.

RESULTS

The median survival time for all depressed patients with pancreatic cancer was 5 months compared with 4 months for all nondepressed patients with pancreatic cancer (P < 0.9). There was no difference in stage, rate of surgical resection, rate of chemotherapy administration, or rate of radiation therapy use between depressed and nondepressed patients.

CONCLUSION

Patients who had undergone surgical resection or chemotherapy and/or radiation therapy had longer survival times than those who did not. Depression, although common among patients with pancreatic cancer, does not affect survival.

Hypericum perforatum methanolic extract inhibits growth of human prostatic carcinoma cell line orthotopically implanted in nude mice

The antiproliferative effect of serotonin-reuptake inhibitors (SSRI) and serotonin antagonists has been demonstrated in prostate tumors. Since Hypericum perforatum components act as serotonin-reuptake inhibitors and exert cytotoxic effects on several human cancer cell lines, in this work we analyzed the effect of a treatment with Hypericum perforatum extract (HPE) on the growth of human prostate cancer cells in vitro and in vivo. This study highlighted a significant reduction of tumor growth and number of metastasis suggesting that this natural compound may be useful in the treatment of prostate cancer.