Anxiety and depression after cancer diagnosis: Prevalence rates
by cancer type, gender, and age Wolfgang Lindena, b, , 1, , Andrea
Vodermaiera, c, , 1, Regina MacKenzieb, Duncan GreigaShow
moredoi:10.1016/j.jad.2012.03.025
AbstractBackgroundReported prevalence of emotional distress in
cancer patients varies widely across studies. The present study
determined prevalence of anxiety and depression (separated for
presence of symptoms versus clinical levels) in a large,
representative sample of cancer patients after
diagnosis.MethodDuring the years 20042009, 10,153 consecutive
patients were routinely screened with the Psychosocial Screen for
Cancer questionnaire at two major cancer centers.ResultsPatients'
mean age was 59years and 45% were men. Across cancer types, 19.0%
of patients showed clinical levels of anxiety and another 22.6% had
subclinical symptoms. Further, 12.9% of patients reported clinical
symptoms of depression and an additional 16.5% described
subclinical symptoms. Analyses by cancer type revealed significant
differences such that patients with lung, gynecological, or
hematological cancer reported the highest levels of distress at the
time point of cancer diagnosis. As expected, women showed higher
rates of anxiety and depression, and for some cancer types the
prevalence was two to three times higher than that seen for men. In
some cancer types emotional distress was inversely related to age.
Patients younger than 50 and women across all cancer types revealed
either subclinical or clinical levels of anxiety in over 50% of
cases.LimitationsFindings describe levels of emotional distress
after diagnosis but cannot inform about trajectories of anxiety and
depression over time.ConclusionGiven that levels of anxiety and
depression varied widely by cancer type, gender, and age, these
results inform which cancer patients are most likely in need of
psychosocial support.Keywords Anxiety; Depression; Cancer
diagnosis; Cancer type; Gender; Age
1. IntroductionEmotional distress in cancer patients
(operationally defined here as anxiety or depression) reduces
patients' quality of life, negatively impacts compliance with
medical treatment (DiMatteo et al., 2000andGreer et al., 2008), and
carries an elevated risk of mortality (Pinquart and Duberstein,
2010andSatin et al., 2009). For this reason, emotional distress is
recognized as the sixth vital sign in cancer care (Bultz and
Carlson, 2005), calling for systematic allocation of supportive
resources. Cost-effective resource allocation, however, requires
precise knowledge of the extent of a problem. Correspondingly,
researchers have reported the prevalence rates of anxiety and
depression in the cancer population but this literature can be
difficult to interpret because:[a]researchers do not always clarify
whether an actual clinical diagnosis has been made or whether
symptoms were present;[b]diagnostic cut-offs are sometimes not
empirically validated and diagnoses are at times based on different
diagnostic systems, with the latter resulting in prevalence
estimates that range from 25% to 38% in the same sample (Kathol et
al., 1990);[c]the quality of measurement tools varies greatly
(Vodermaier et al., 2009); and[d]prevalence rates are often
assessed at varying time points in the trajectory of the disease
although emotional distress is known to change as patients
transition through stages of diagnosis, acute treatment, and
post-treatment (Stommel et al., 2004). Prevalence rates for
distress also depend on whether or not patients have responded
positively to treatment or not (Hopwood et al., 2009andvan't
Spijker et al., 1997).When researchers report on the prevalence of
emotional distress they frequently acknowledge a wide range of
observed prevalence rates. Massie (2004) reported that major
depression in cancer patients ranged from 0 to 38%. Variability in
reported prevalence rates is echoed in a meta-analysis (van't
Spijker et al., 1997) where prevalence rates ranged from 0% to 46%
for depression and 1% to 49% for anxiety. Reporting such wide
ranges is not helpful to administrators who must allocate finite
resources to help alleviate emotional distress in patients. A more
recent meta-analysis restricted to cancer inpatients and
high-quality prevalence estimates based on structured clinical
interviews (as compared to self-report scales or physician
judgment) demonstrated that one third of cancer patients suffer
from some type of mental disorder during active treatment (Singer
et al., 2010).We posit that large-sample studies are more likely to
sample broadly and to reveal replicable findings and as shown in
Table1, a number of large sample studies of distress prevalence
exist (where large is arbitrarily defined as n>1000)
(Brintzenhofe-Szoc et al., 2009, Caminiti et al., 2004, Carlson et
al., 2004, Hinz et al., 2010, Hopwood et al., 2009, Sharpe et al.,
2004andZabora et al., 2001). Together, these studies possess many
strengths, including the noted large samples, no restrictions
regarding cancer types (except for one study), and use of
standardized tools. Noted weaknesses, however, include
non-consecutive recruitment and variable timing of assessment
within the disease and treatment trajectory.Table1. Prevalence
studies of patients with cancer, N>1000.Study and sample
sizeTypes of cancer included[a] Standardized measure?[b] Cut-offs
empirically determined?Differentiation of disorder from presence of
symptomsConsecutive recruitmentAssessment conducted at fixed time
in disease trajectory?
Zabora et al. (2001)N=4496All[a] Yes, BSI 53[b] Not in cancer
patientsNo, caseness was defined as T-score >62NoNo
Carlson et al. (2004)N=3095All[a] Yes, BSI-18[b] YesNo, caseness
was defined as T-score >62NoNo
Caminiti et al. (2004) N=3293All[a] HADS[b] YesNo, only clinical
caseness reportedNoYes, during chemotherapy
Brintzenhofe-Szoc et al. (2009)N=8265All[a] BSI-53[b] Not in
cancer patientsNoNoNo
Hopwood et al. (2009)N=2208Early stage breast cancer[a] Yes,
HADS[b] YesYesYesYes, in acute care, before radiation
Hinz et al. (2010)N=1529All[a] Yes, HADS[b] YesNo, only caseness
was reportedNoNo
Sharpe et al. (2004)N=5613All[a] Yes, HADS.[b] YesYesYesNo
Linden et al. (this article)N=10,153All[a] Yes, PSSCAN[b]
YesYesYesYes, post-diagnosis but pre-treatment
Table optionsThe present study adds data on subclinical and
clinical symptoms of anxiety and depression in another large sample
and uses a standardized instrument with good psychometric
properties and empirically validated cut-offs. While acknowledging
the substantial overlap of these constructs, we chose not to
aggregate data into a single distress index because anxiety and
depression may have different trajectories from diagnosis to end of
first-line treatment to long-term follow-up (Ando et al., 2009, Den
Oudsten et al., 2010, Kangas et al., 2007andThomas et al., 2011).
Anxiety tends to reflect a reaction to the diagnosis and the
anticipated aversive treatment and is often transient, depression
is more likely to reflect a stable predisposition. Furthermore,
given earlier reports that distress may vary not only by cancer
type but also by age and gender, we explicitly conducted analyses
on these moderator variables as well.2. Methods2.1. ProceduresIn
2004, all British Columbia Cancer Agency centers implemented a
routine screening program for emotional distress. Since then,
patients have routinely completed the Psychosocial Screen for
Cancer (PSSCAN) (Linden et al., 2005andLinden et al., 2009) during
the first visit to a provincial cancer center, prior to beginning
treatment. Patients are free to refuse completion but record checks
during data acquisition revealed that 73% of eligible patients
provided usable data. Unfortunately, the cancer clinics do not
systematically record reasons for non-completion, but clinicians
report that an estimated 1015% of the total patient pool speak
English as a second language and do not complete standardized tests
due to poor comprehension. Other prominent reasons for
non-participation are a high level of medical crisis at arrival in
the cancer clinic and/or lack of lucidity typically due to old age
(Linden et al., 2005).For this study, the psychosocial data
obtained at the two largest centers were merged with electronically
archived medical and demographic data. Given that breast cancer in
men is a very rare disease and difficult to compare with breast
cancer in women, the few men were excluded from analysis.
Similarly, prostate cancer as a tumor type was distinguished from
the large genitourinary category given that it represents a highly
prevalent disease in older men and carries a different prognosis
than other genitourinary cancers. Also, three age groups were
formed: [a] patients below 50 (where cancer is relatively rare),
[b] 50 to 69 (where cancer is on the rise), and [c] >70 (where
cancer is often superimposed on pre-existing health problems). This
study was approved by the Institutional Review Board of the British
Columbia Cancer Agency.2.2. MeasureThe 21-item Psychosocial Screen
for Cancer assesses anxiety and depressive symptoms, perceived
social support, desired social support, and quality of life. The
scale was specifically developed and validated for use with cancer
patients and was designed to serve as a clinical as well as a
research tool. The anxiety and depression subscales were developed
to map onto DSM-IV TR defined disorders, i.e., major depression and
generalized anxiety disorder and these scales were of particular
interest for the present study. Both subscales are comprised of 5
items each. Items are scaled on a 5-point Likert scale (from 1 =
not at all to 5 = very much so), with a potential range of scores
from 5 to 25. An example item of the anxiety subscale is I felt
nervous and shaky inside. And for depression a sample is In the
past year I have had 2weeks or more during which I felt sad, blue
or depressed. These subscales have satisfactory internal
consistency (=.83, for anxiety; =.79 for depression), and are
sensitive to change (testretest reliability over 2months: r=.67 for
anxiety, r=.61 for depression). The anxiety and depression
subscales were highly sensitive and specific when compared to the
Hospital Anxiety and Depression Scale (sensitivity 92% and
specificity 98%, for anxiety; sensitivity 100% and specificity 86%,
for depression; Zigmond and Snaith, 1983). As well, normative data
comparing cancer patients with healthy controls exist (Linden et
al., 2009). Results regarding discriminant validity indicate that
scores of 11 and greater are suggestive of a clinical diagnosis,
and scores greater than 8 but less than 11 indicate the presence of
symptoms for both the anxiety and depression subscales alike.
PSSCAN psychometrics were also judged to meet a satisfactory
standard in a comprehensive comparison of screening tools and
available data indicate that it is suitable as a research tool and
not just a screening tool (Vodermaier et al., 2009).3. Results3.1.
Sample descriptionPatient mean age was 58.9 (14.6) years. 4553
(44.8%) patients were male, and 5600 (55.2%) were female. Absolute
and relative probabilities by cancer types were n=2430 (23.9%)
breast, n=1598 (15.7) prostate, n=1334 (13.1%) gastrointestinal,
n=949 (9.3%) gynecological, n=673 (6.6%) lung, n=550 (5.4%)
neuroendocrine, n=501 (4.9%) skin, n=454 (4.5%) head and neck,
n=302 (3.0%) genitourinary (excluding prostate), n=211 (2.1%) bone,
n=180 (1.8%) hematological, and n=971 (9.6%) other unclassified
primary tumors.3.2. Anxiety mean scoresAs shown in Fig.1, on
average cancer patients experienced anxiety just above the
subclinical threshold (8.1(3.8)). Relative to the total sample,
aggregated across cancer types, patients with gynecological
(d=.29***), hematological (d=.15) and lung cancer (d=.22***)
reported the highest levels of anxiety, whereas patients with skin
(d=.23***) and prostate (d=.43***) cancer were less anxious than
the average cancer patient (Fig.1). These differences were
partially attributable to gender effects (d=.38***), indicating
that female patients with gynecological, hematological, head and
neck, and lung cancers report the highest levels of anxiety
(Fig.3).
Fig.1.Levels of anxiety by cancer type.Figure options
Fig.2.Levels of depression by cancer type.Figure options
Fig.3.Levels of anxiety by cancer type and gender.Figure
optionsThe visual display of age effects in Fig.5 was supplemented
with inferential testing via computation of Pearson-Product moment
correlations given that age is a continuous variable. Overall, age
was not strongly linked to differences in distress levels, never
explaining more than 2.5% of the variance. Nevertheless, younger
patients (below 50) reported higher anxiety than older patients (70
and above). Within tumor groups, visual inspection of graphed data
indicates that middle-aged patients with genitourinary cancers were
most anxious. No age differences for anxiety were evident for lung,
bone, skin and genitourinary cancers. Older age was on average
associated with less anxiety (r=.15).
Fig.4.Levels of depression by cancer type and gender.Figure
options
Fig.5.Levels of anxiety by cancer type and age.Figure
options3.3. Prevalence rates of anxietyOn average, 19.0% of
patients showed levels of anxiety in the clinical range, and
another 22.6% reported subclinical symptoms (Fig.1). Female cancer
patients were almost two times more likely than males (24.0% versus
12.9%) to report clinical levels of anxiety (Fig.3). Prevalence
rates of clinical anxiety exceeding 30% were evident for females
with hematological and lung cancers. In terms of age, prevalence
rates varied across cancer types; they were 25.7% for the youngest,
18.9% for the middle, and 11.8% for the oldest age group (Fig.5).
Within tumor groups, younger patients with bone cancer, breast
cancer and prostate cancer were almost three times more likely to
report clinically relevant anxiety than the oldest age group.
Patients with gastrointestinal, hematological and neuroendocrine
cancers were more than two times more likely to report clinical
levels of anxiety than their older counterparts.3.4. Depression
mean scoresAs shown in Fig.2, cancer patients on average
experienced levels of depression below subclinical thresholds.
Patients with lung (d=.21***), hematological (d=.20*) and
gynecological (d=.18***) cancers were the most distressed, whereas
patients with skin (d=.37***) and prostate (d=.18***) cancers were
less depressed than the average cancer patient. Women scored higher
than men (d=.33***; Fig.4). Women with genitourinary,
hematological, and lung cancers reported levels of depression at or
above the subclinical threshold.In terms of age differences across
cancer types, there emerged again a linear but weak relationship
such that younger cancer patients experienced the highest and older
cancer patients the lowest levels of depressive symptoms across all
cancers when aggregated (r=.12), but visual inspection suggested
that patients with genitourinary, gynecological, and hematological
cancer types were the most depressed when they fell into the
middle-aged group (Fig.6). Middle-aged patients with unspecified
primary tumors seemed less depressed than both their older and
younger counterparts.
Fig.6.Levels of depression by cancer type and age.Figure
options3.5. Prevalence rates of depressionOn average, 12.9% of
patients showed levels of depression in the clinical range. Another
16.5% reported subclinical symptoms. Similarly, female cancer
patients were almost two times more likely than males (16.4% versus
8.6%) to report clinical levels of depression. Female patients with
lung cancer demonstrated the highest prevalence rate of depression
with 24.7% being clinically depressed, followed by hematological
(23.2%), and bone cancers (19.4%). Regarding age, younger age was
associated with higher rates of depression but within lung cancer
no age differences emerged. Again, for genitourinary,
gynecological, and hematological cancers an inverse U-shaped
relationship emerged with the middle-aged group being the most
depressed.4. DiscussionThe present study adds a large sample of
patients with all types of cancers to the extant literature on the
prevalence of anxiety and depression but is the first to provide
representative data on anxiety and depressive symptoms for all
cancer types at the same time point in the disease trajectory,
namely after diagnosis but prior to treatment. The sample is larger
than the samples in either one of three earlier meta-analyses
(Mitchell et al., 2011, Singer et al., 2010andvan't Spijker et al.,
1997), or another large systematic review (Ng et al., 2010).
Comparison of observed prevalence rates between the current study
and previous studies calls for cautious interpretation because no
other study using all cancer types had assessed patients at a
standard point in the cancer trajectory. On the other hand, the
prevalence rates reported here do fit well into the range of
prevalence rates reported elsewhere (Brintzenhofe-Szoc et al.,
2009, Caminiti et al., 2004, Carlson et al., 2004, Hinz et al.,
2010, Hopwood et al., 2009, Mitchell et al., 2011, Ng et al.,
2010andZabora et al., 2001) indicating that roughly 19% and 13%
respectively met the threshold for a level of anxiety or depression
within the clinical range.Also of interest is that mean levels of
anxiety and depression were on average not much greater than those
of a healthy population sample (Linden et al., 2009), but that they
varied considerably as a function of cancer type, gender, and age.
This implies that there are distinct risk groups covering a full
range of prevalence rates from essentially population norm for
prostate and skin cancer to majority depressed or anxious for lung
and hematological cancer. In contrast to van't Spijker et al.'s
meta-analytic findings (1997), where women had lower rates of
emotional distress, our results showed that across all cancer types
female cancer patients showed higher prevalence rates of anxiety
and depression than men. This finding is consistent with higher
rates of anxiety and depression in the general healthy female
population as compared to men (Piccinelli and Wilkinson, 2000).
This gender difference may reflect a gender difference in
willingness to report distress but could also arise because women
tend to use emotional approach coping (Goldzweig et al., 2009,
Jacobs-Lawson et al., 2010andStanton et al., 2000). Our data
suggest that men initially experience cancer as less threatening
and this may arise in part from the high prevalence of prostate
cancer which indeed has a good overall prognosis. Given the timing
of our participant recruitment, we do not, however, know how men
respond when cancer progresses and a prognosis may
worsen.Interestingly, a clear inverse relationship between
emotional distress and age was seen. Prevalence rates of anxiety
and depression were higher in the youngest age group and lowest in
older adults, likely due to more disruption of everyday living in
younger cancer patients, whereas older patients may already have
impairments in physical function and are cognitively and
emotionally better prepared to accept illness. However, for a
number of cancer types no age effect emerged suggesting that
cancers with unfavorable prognosis (i.e., gynecological,
hematological, lung) affect all age groups equally. This, in turn,
may reflect a ceiling effect.Which factors account for divergent
levels of emotional distress between cancer groups? The highest
levels of emotional distress were reported from women patients with
lung and hematological cancer and this confirms results of smaller
studies (Castelli et al., 2009andNron et al., 2007), which showed
very high prevalence rates of depression. Advanced stage, poor
prognosis, and invasive treatment, therefore, are plausible sources
for elevated levels of emotional distress (Vodermaier et al.,
2011). To illustrate the range of varying prognoses, 5-year
survival rates are 25% for lung cancer and 57% for leukemia in
British Columbia (www.bccancer.bc.ca).What do psychological
symptoms at the time point of cancer diagnosis represent? For most
patients they are a natural reaction to what the patient perceives
to be great uncertainty and thus a severe stressor. In others, the
larger emotional reaction may be superimposed upon a latent
vulnerability, e.g., preexisting mental disorders. Also, anxiety
may be more of a reaction to acute events and is likely to decrease
after completion of primary treatment (Thomas et al., 2011) once
patients have become familiar with the side effects of treatment
and also may have received positive prognostic information.
Depressive symptoms on the other hand appear to be more stable and
indicative of a trait-type disposition (Ando et al., 2009, Den
Oudsten et al., 2010andKangas et al., 2007).Study strengths are
very large sample, and separately reported prevalence rates of
reporting of symptoms versus more severe range. The sample is
representative of a multi-ethnic, urban population served by a
publicly funded, equal-access health care system. Finally, the data
represent consecutive recruitment of patients conducted at the same
time point in the disease trajectory whereas other large-scale
studies that include different cancer types only report on
convenience samples measured at varying points in the course of
cancer. Furthermore, this dataset has also allowed us to study the
effect of disease stage on distress levels, and these data are
already published elsewhere (Vodermaier et al., 2011).One of the
study's strengths is at the same time also a limitation. The
current data describe levels of emotional distress at the time of
diagnosis and cannot speak to changes in emotional distress over
the disease trajectory. Therefore, findings do not reflect
treatment-induced emotional disturbance or emotional adjustment
during survivorship or palliation. Lastly, the findings need to be
seen in light of their representativeness for the entire cancer
population.It is a strength that recruiting was based on routinely
collected clinical data and consecutive recruiting and as such has
no known major selection bias (except English language
proficiency). Nevertheless, it is worth comparing this sample to
its underlying population, and for this effort we were able to draw
on recent data for British Columbia (www.bccancer.bc.ca) and for
all of Canada (www.cancer.ca/Canada-wide/Cancer research/Cancer
statistics.aspx?sc_lang=en). The rank ordering of most to least
prevalent cancer types for our sample reflects those for the
province and the whole country, however, our data set has a notably
lower prevalence of lung cancer cases than does the province and
the country (6% versus 13% and 14%, respectively) and also has a
somewhat higher prevalence of prostate cancer cases (36% versus 25%
and 27%). We attribute these deviations to regional differences in
how care is provided and where records are kept. For a number of
years now, the charts of deceased patients are moved to a warehouse
and are kept by a private company contracted by the regional health
authority. These charts are not directly accessible to researchers
and, given the high mortality associated with lung cancer, our data
likely under-represent lung cancer patients because the charts of
those who have died were likely removed from the hospital-based
archives. Hence, the prevalence rates in our sample differ for a
few cancer types from provincial data, and this also accounts for
the fact that our sample has slightly more women than men (55%
versus 45%) whereas the entire population of cancer patients has a
48% to 52% ratio for women/men.Although PSSCAN has satisfactory
psychometrics, its anxiety and depression subscales are each only 5
items long and the tool has not been validated using gold standard
structured interviews. We cannot rule out potential confounding of
anxiety or depression with medical problems and/or pharmacological
treatment side effects (Holland and Alici, 2010). Similarly,
patient anxiety and depression need to be understood in the context
of the patient's knowledge about the disease, treatment, and
probable outcomes as well as the quality of the patients' social
network. We also need to sensitize readers to the fact that the
data reflect the population of one limited geographical area in
which all patients receive a similar quality of universal,
third-party paid health care. Cancer may be perceived as an even
greater threat when patients worry about medical bills that may
exceed their resources, or have reason to fear loss of a job if
their country of residence does not provide illness leaves and
disability pensions.The present study offers a clear picture of
absolute prevalence rates of emotional distress and it identifies
distinct at-risk groups. Armed with these data, policy-makers can
now use a data-driven approach to allocate staffing resources to
psychosocial care. Fortunately, many cancer clinics already offer
psycho-oncological services to which vulnerable patients can be
referred, but just because a referral was made does not mean that
all patients will accept this service offer. Also, patients who are
not considered emotionally distressed as defined by cutoffs on the
PSSCAN (or any other sensitive screening tool) may still ask for
psychosocial support and this raises the thorny ethical question of
whether or not, given generally scarce resources, these lower-risk
groups should be offered professional help on demand.For
cost-effective implementation of screening and treatment, some
questions remain unresolved. What kind and how much treatment do
subclinical levels of anxiety and depression require compared to
clinical anxiety and depressive disorder? Do we need repeated
screenings to assure that persistent anxiety and depression
problems are treated? Should anxiety treatments differ as a
function of what patients are specifically afraid of? They may
have, for example, a longstanding, generalized anxiety disorder, or
classically conditioned phobic anxiety responses to aversive cancer
treatment, or may have high levels of fear of recurrence.Role of
funding sourceSupported by CIHR Team for Supportive Cancer Care
(#AQC83559).Conflict of interestThere are no conflicts of interest
or financial interests associated with this work.AcknowledgmentsWe
greatly appreciate the technical assistance of Colleen Wong, Leanne
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361370 [SD-008]Previous presentations: presented in part at the
World Congress for Psycho-Oncology, Quebec City, Canada, May 2629,
2010.Corresponding authors: University of British Columbia,
Department of Psychology, 2136 West Mall, Vancouver BC, Canada, V6T
1Z4. Tel.: +1 604 822 4156; fax: +1 604 822 6923.1Both Dr. Linden
and Dr. Vodermaier share first authorship.