IPOS07 - Evidence Base For Ultra Screening In Cancer [Sept 2007]

Alex MitchellHon. Senior Lecturer in Psycho-oncology,

Leicester Royal Infirmary

IPOS Symposium (Sept 2007)IPOS Symposium (Sept 2007)[email protected]@leicspart.nhs.uk

1. What Is the Purpose of Screening?

Detection Rates, Unassisted Rates, Who is looking?

2. What Is Ultra-Screening?

Vs case finding

3. Distress Thermometer

Evidence?

4. Implementing ScreeningUltra-screening in secondary care

1. Purpose of Screening?1. Purpose of Screening?

No Distress61%

Pooled Analysis of 38 studies

Setting: mostly oncologyInstruments: mixedPoint prevalence n=6400

Mitchell (2007) JCO

Distress

Distress39%

Anxiety38%

Depression19%

% Receiving Any treatment for Depression% Receiving Any treatment for Depression

10.9 11.3

8.18.8

4.3

5.6

10.9

13.8

6.8

17.9

3.4

5.5

15.4

7.2

0

2

4

6

8

10

12

14

16

18

20

High Inc

omeBelg

ium

France

German

y

Israe

l

Italy

Japa

nNeth

erlan

dsNew

Zeala

nd

Spain USALow

Inco

me

ChinaColom

biaSouth

Afri

caUkra

ine

Wang P et al (2007) Lancet 2007; 370: 841–50

n=84,850 face-to-face interviews

Accuracy 2x2 TableAccuracy 2x2 Table

PrevalenceSpecificitySensitivity

NPVTrue -VeFalse -VeTest -ve

PPVFalse +veTrue +veTest +ve

DepressionABSENT

DepressionPRESENT

Accuracy of GP’s DiagnosesAccuracy of GP’s Diagnoses

27,6406553

667825,1254050GP -ve

501825152503GP +ve

DepressionABSENT

DepressionPRESENT

Sensitivity38%

PPV 49.8%

Specificity90.1%

NPV 86.1%

Prevalence 19%

N=35 studiesn = 100035,000

Mitchell, Vaze, Rao Unpublished data

Unassisted AccuracyUnassisted Accuracy

Non-Depressed

Depressed

# ofIndividuals

TestResultCut-off / clinical decision

False +veFalse -ve

5%

90%

True -ve

38%

True +ve

50%

Optimum

Unassisted

2. Who Is Looking? 2. Who Is Looking?

Do Clinicians Look for Depression?Do Clinicians Look for Depression?

Mitchell, Kaar, Coggan, Herdman (N=226) Psychooncology 2007

1,2 or 3 Simple QQ15%

Clinical Skills Alone73%

ICD10/DSMIV0%

Short QQ3%

Other/Uncertain9% Other/Uncertain

2%

Use a QQ15%

ICD10/DSMIV13%

Clinical Skills Alone55%

1,2 or 3 Simple QQ15%

Cancer Staff Psychiatrists

Mitchell, Kaar, Poster APA 2007Current Method

86.8

55.6 54.4

43.3

36

29.826.2 25.6 25.2 23.8 24

21.4 21.2

13.9 12.89.5

7.2 7 7 5.9 4.8 4.1 2.6 1.8 1.8 1.3 0.9 0.4 0.40

10

20

30

40

50

60

70

80

90

100Sl

eep

distu

rban

ces;

inso

mni

a; e

arly

wake

ning

Loss

of a

ppet

ite; o

vere

ating

; wei

ght c

hang

es

Depr

esse

d m

ood;

hop

eles

snes

s; sa

d; g

loom

y

Apat

hy; l

etha

rgy;

tired

ness

; las

situd

e

Loss

of i

nter

est;

with

draw

al; in

diffe

renc

e; lo

nelin

ess

Loss

of e

nerg

y; lo

ss o

f driv

e; b

urnt

out

Loss

of l

ibido

; los

s of

sex

driv

e; im

pote

nce

Tear

s; we

eping

; cry

ing

Anxio

us; a

gita

ted;

irrit

able

; res

tless

, ten

se; s

tress

ed

Feel

ing

worth

less

; guil

ty; la

ck o

f sel

f este

em

Som

atic;

vege

tativ

e sy

mpt

oms;

mala

ise; m

ultip

le co

nsult

ation

s

Suici

de th

ough

ts; th

ough

t of s

elf in

jury

Loss

of c

once

ntra

tion;

poo

r mem

ory,

poo

r thi

nkin

g

Dim

inish

ed p

erfo

rman

ce; i

nabi

lity to

cop

e

Emot

ional

labil

ity; m

ood

swin

gs

Loss

of a

ffect

; flat

affe

ct; lo

ss o

f em

otio

n

Loss

of e

njoy

men

t or p

leas

ure;

lack

of h

umor

Beha

viour

al p

robl

ems;

agg

ress

ivene

ss; b

ehav

iour

al c

hang

es

Pess

imism

; neg

ative

atti

tude

s, w

orry

ing

Psyc

hom

otor

reta

rdat

ion;

slow

ness

Head

ache

s; d

izzin

ess

Appe

aran

ce; s

peec

h; e

xces

sive

smilin

g; va

guen

ess,

etc.

Heav

y us

e of

alco

hol, t

obac

co o

r dru

gs

Delu

sions

; hall

ucin

atio

ns; c

onfu

sion

Reac

tion

to p

roba

ble

caus

es o

r life

eve

nts

Fam

ily o

r pas

t hist

ory

of d

epre

ssio

n

Obs

essiv

e id

eatio

n; p

hobia

sLa

ck o

f ins

ight

Perio

d of

life

(men

opau

se)

Krupinski J, Tiller J (2001) The identification and treatment of depressionby general practitioners. Aust N Z J Psychiatry. 35:827– 832.

3. What is Ultra-Screening? 3. What is Ultra-Screening?

Test DurationTest Duration

Ultra-short screening tools were defined as those with 1-4 items taking less than 2 minutes to complete.

Short screening tools were defined as those with 5-14 items, taking between 2 and five minutes to complete.

Standard screening tools were defined as those with 15 or more items, taking more than five minutes to complete.

=> Tools table

20 Instruments for Depression20 Instruments for Depression

SDS (20)EPDS (10)

GDS (30,15)MADRAS (10)

DEPS (10)DADS (7)

Zung (20)DSMIV (9)

CES-D (20,10)PHQ9 (9)Distress Therm (1)

BSI (53)MOS-D (8)WHO-5 (5)

BDI (21,13)BDI (7)PHQ2 (2)

HAM-D (21)HADS (7)PHQ1

Long > 10Short > 5 < 11Ultra-short <6

Razavi D, Delvaux N, Farvacques C and Robaye E (1990) Screening for adjustment disorders and major depressive disorders in cancer in-patients. Br J Psych 156: 79–83

N= 210 cancer in- patients

Cut-off 11

Cut-off 3

Cut-off 21

=> Symptoms

Audience?Audience?

How do we know which are the best symptoms

for detecting depression?

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

Loss

of

ener

gy

Dim

inis

hed

driv

e

Slee

p di

stur

banc

e

Con

cent

rati

on/i

ndec

isio

n

Dep

ress

ed m

ood

Anx

iety

Dim

inis

hed

conc

entr

atio

n

Inso

mni

a

Dim

inis

hed

inte

rest

/ple

asur

e

Psyc

hic

anxi

ety

Hel

ples

snes

s

Wor

thle

ssne

ss

Hop

eles

snes

s

Som

atic

anx

iety

Tho

ught

s of

dea

th

Ang

er

Exce

ssiv

e gu

ilt

Psyc

hom

otor

cha

nge

Inde

cisi

vene

ss

Dec

reas

ed a

ppet

ite

Psyc

hom

otor

agi

tati

on

Psyc

hom

otor

ret

arda

tion

Dec

reas

ed w

eigh

t

Lack

of

reac

tive

moo

d

Incr

ease

d ap

peti

te

Hyp

erso

mni

a

Incr

ease

d w

eigh

t

All Case ProportionDepressed ProportionNon-Depressed Proportion

Mitchell, Zimmerman et al MIDAS Database. Psychol Med 2007 Submitted

N=1500

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Depressed Mood

Diminished driveDiminished interest/pleasure

Loss of energySleep disturbance

Diminished concentration

Sensitivity

1 - Specificity

Mitchell, Zimmerman et al (submitted)Psychol Med

4. The Distress Thermometer4. The Distress Thermometer

Screening Tools- Distress thermometerScreening Tools- Distress thermometer

Developed at the Memorial Sloan-Kettering Cancer Institute from pain VAS

First reported in 1998

Best known example of ultra short screening questionnaire in cancer care

Recommended by the National Comprehensive Cancer Network as a screening measure for distress

- Please circle the number (0-10) that best describes how much distress you have been experiencing in the past week, including today.

- What phone number would you like us to contact you on if necessary?

Please tick WHICH of the following is a cause of distress:

DiarrhoeaAnger

ConstipationWorry

IndigestionSadness

EatingNervousness

Is there anything important you would like to add to the list?__________________________________________________________________________________________

Mouth soresFears

BreathingDepression

Bathing/ DressingEmotional Problems

Getting around

Hot flushesSleepDealing with children

SexualFatigueDealing with partner

Feeling swollenNauseaFamily Problems

Metallic taste in mouthPain

Tingling in hands/ feetPhysical problemsWork/School

Nose dry/ congestedTransport

Skin dry/ itchyLoss of meaning or purpose in lifeMoney

FeversRelating to GodHousing

Changes in UrinationLoss of faithChildcare

Physical Problems contd…Spiritual/ Religious ConcernsPractical Problems

The distress thermometerThe distress thermometer

=> Validity

AudienceAudience

How do we know the “distress” paradigm

is best

See Gil F, Grassi L, Travado L, Tomamichel M, Gonzalez JR. for the SEPOS Group. Use of distress and depression thermometers to measure psychosocial morbidity among southern European cancer patients. Support Care Cancer, 13: 600–606, 2005

Does it WorkAs a rule in & rule out?Does it WorkAs a rule in & rule out?

Distribution of DT ScoresRansom (2006) PO (n=491)

13.814.7

15.7

13.2

10.4

8.47.7 7.3

3.7 3.3

1.8

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

Score 0 Score 1 Score 2 Score 3 Score 4 Score 5 Score 6 Score 7 Score 8 Score 9 Score 10

Publications evaluating1item VAS against a diagnostic standard

Studies Excluded

Chochinov HM et al (1997) Am J Psychiatry 154:674–676

Akizuki N et al Psycho-Oncology 13: S1–S233 (2004)*

Akizuki N et al Cancer 2003;97:2605–13. *

Grassi L et al (2006) Psycho-Oncology s162 *

Hoffman et al (2004) Psychooncology.13:792–799 *

Ransom et al (2006) Psychoonc 15(7):604-12 *

Ultra-short tests mentioned in title or abstract

Primary Data Studies

90 5139

No Relevant Data Presented Ultra-short tests accuracy analysed in text

33

Jacobsen et al (2005) Cancer 103:1494–502. *

Williams et al (2005) Stroke. 2005; in press

Bula et al (2003)Age Aging Mar;32(2):231-3.

Patrick-Miller et al (2005) JCO 14S 2004: 6024 *

Studies Excluded Due toSTARD NON-Compliant

Haggman (2004) Phys Ther84:1157-1166.

Publications reporting2 or more combination

Chochinov HM et al (1997) Am J Psychiatry 154:674–676

Publications reporting1 verbal item

Gil et al (2005) Support Care Cancer (2005) 13: 600–606*

Lloyd-Williams et al (2003) (2003) - BMJ 2003;327:372–3

Chochinov HM et al (1997) Am J Psychiatry 154:674–676

Akizuki N et al (2004) Psycho-Oncology 13: S1–S233

Ozalp et al (2006) Psycho-Oncology (in press) *

* Study using the distress thermometer

Talelli et al (2004) J Neurol 251: 191 Suppl. 3

Avasarala et al (2003) Multiple Sclerosis 9 (3): 307-310.

Gori et al (1998) Arch GerontGeria 235-240 Suppl. 6

Akizuki N et al Cancer 2003;97:2605–13.

Akizuki N et al (2006) J Pain Symptom Manage 29:91–99

VAS – Visual analogue scale

Mehnert et al (2006) Zeitschrift Fur Psychiatrie Psychologie Und Psychotherapie 54 (3): 213-223 *

Jefford et al (2004) Br J Ca 91(5):900-906

Akechi T et al (2006) J Pain Symptom Manag 31: 5-12

Akechi T et al (2006) J Pain Symptom Manag 31: 5-12

Trask PC, et al Bone Marrow Transplant (2002) 29, 917–925.

Thorvalsdottir et al (2006)

Psycho-oncology 15(2) s430 *

Carter et al (2006) Psycho-

oncology 15(2) s105 *Studies Excluded due to a

Unavailable data

Kumar et al (2006) Psycho-oncology 15(2) s692 *

Andritsch et al (2006) Psycho-

oncology 15(2) s158 *

Publications evaluating1item VAS against a

severity scale

Gessler et al (2006) UK Psycho-

Oncology, 15: s107 *

4 5 5 910

Studies Excluded due toNon-cancer setting

Muszbek et al. Psycho-Oncology

2004; 13 s63 *

PrevalenceSpecificitySensitivity

NPVTrue -VeFalse -VeTest -ve

PPVFalse +veTrue +veTest +ve

DepressionABSENT

DepressionPRESENT

Ultra-short Tests & DepressionUltra-short Tests & Depression

36033816787

27952643152Test -ve

18081173635Test +ve

DepressionABSENT

DepressionPRESENT

Sensitivity81%

PPV 32%

Specificity69%

NPV 93%

Prevalence 18%

N=17 studies 3603

Ultra-short Tests & DistressUltra-short Tests & Distress

368222071475

18911514337Test -ve

18316931138Test +ve

DistressABSENT

DistressPRESENT

Sensitivity77%

PPV 65%

Specificity68%

NPV 80%

Prevalence 39%

N=17studies 3682

Ultra-short Tests & AnxietyUltra-short Tests & Anxiety

22151372843

969776193Test -ve

1248596652Test +ve

AnxietyABSENT

AnxietyPRESENT

Sensitivity77%

PPV 55%

Specificity56%

NPV 80%

Prevalence 38%

N= 4 studies 2215

PPV DT Distress = 55%; PPV Other Methods 65%

SCAN, SCID, PSE

BDI, MADRAS, Hamilton

HADS, EPDS, PHQ, CES-D

LONG

WHO5, PHQ2, NICE

SHORT

High NPVLow PPV

High NPVMed PPV

High NPVHigh PPV

MEDIUM

5. Implementation5. Implementation