Alex Mitchell www.psycho-oncology.info Department of Cancer & Molecular Medicine, University of Leicester Department of Liaison Psychiatry, Leicester General Hospital University of Sydney POCOG August 2011 University of Sydney POCOG August 2011 The Future of Psycho-oncology: Research & Clinical
This is an invited talk on the "The Future of Psycho-Oncology" given to the POCOG group of the University of Sydney (lead Phyllis Butow) in August 2011.
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Alex Mitchell www.psycho-oncology.info
Department of Cancer & Molecular Medicine, University of LeicesterDepartment of Liaison Psychiatry, Leicester General Hospital
University of Sydney POCOG August 2011University of Sydney POCOG August 2011
The Future of Psycho-oncology:Research & ClinicalThe Future of Psycho-oncology:Research & Clinical
% Receiving Any treatment for Mental Health% Receiving Any treatment for Mental Health
In 196190% of US doctors indicated a preference for not
telling a diagnosis of cancer.
In 197997% indicated a preference for revealing a diagnosis
of cancer.
Novack DH, Plumer R, Smith RL, et al. Changes in physicians’ attitudes toward telling the cancer patient. JAMA 1979; 241: 897–900.
InformationInformation
Psychooncology. 2011 Feb;20(2):213-8. doi: 10.1002/pon.1727. Patient and oncologist estimates of survival in advanced cancer patients. Steven Kao SC, Butow P, Bray V, Clarke SJ, Vardy J.
The oncologists were 32% accurate in predicting survival and overestimated survival 42% of the time
J Clin Oncol. 2011 May 20;29(15):2077-84. Epub 2011 Apr 11. Supporting treatment decision making in advanced cancer: a randomized trial of a decision aid for patients with advanced colorectal cancer considering chemotherapy. Natasha Leighl NB, Shepherd HL, Butow PN
Change 3: Clear Evidence BaseChange 3: Clear Evidence Base
Prevalence of depression
Relative risk of depression
Prevalence of depression in Oncology settings
70 studies involving 10,071 individuals;14 countries.16.3% (95% CI = 13.9% to 19.5%)
Mj 15% Mn 19% Adj 20% Anx 10% Dysthymia 3%
Proportion meta-analysis plot [random effects]
0.0 0.3 0.6 0.9
combined 0.1730 (0.1375, 0.2116)
Colon et al (1991) 0.0100 (0.0003, 0.0545)
Massie and Holland (1987) 0.0147 (0.0063, 0.0287)
Hardman et al (1989) 0.0317 (0.0087, 0.0793)
Derogatis et al (1983) 0.0372 (0.0162, 0.0720)
Lansky et al (1985) 0.0455 (0.0291, 0.0676)
Mehnert et al (2007) 0.0472 (0.0175, 0.1000)
Katz et al (2004) 0.0500 (0.0104, 0.1392)
Singer et al (2008) 0.0519 (0.0300, 0.0830)
Sneeuw et al (1994) 0.0540 (0.0367, 0.0761)
Pasacreta et al (1997) 0.0633 (0.0209, 0.1416)
Lee et al (1992) 0.0660 (0.0356, 0.1102)
Reuter and Hart (2001) 0.0761 (0.0422, 0.1244)
Grassi et al (2009) 0.0826 (0.0385, 0.1510)
Grassi et al (1993) 0.0828 (0.0448, 0.1374)
Walker et al (2007) 0.0831 (0.0568, 0.1165)
Kawase et al (2006) 0.0851 (0.0553, 0.1240)
Coyne et al (2004) 0.0885 (0.0433, 0.1567)
Alexander et al (2010) 0.0900 (0.0542, 0.1385)
Love et al (2002) 0.0957 (0.0650, 0.1346)
Ozalp et al (2008) 0.0971 (0.0576, 0.1510)
Morasso et al (2001) 0.0985 (0.0535, 0.1625)
Costantini et al (1999) 0.0985 (0.0535, 0.1625)
Silberfarb et al (1980) 0.1027 (0.0587, 0.1638)
Desai et al (1999) [early] 0.1111 (0.0371, 0.2405)
Morasso et al (1996) 0.1121 (0.0593, 0.1877)
Prieto et al (2002) 0.1227 (0.0825, 0.1735)
Ibbotson et al (1994) 0.1242 (0.0776, 0.1853)
Payne et al (1999) 0.1290 (0.0363, 0.2983)
Kugaya et al (1998) 0.1328 (0.0793, 0.2041)
Alexander et al (1993) 0.1333 (0.0594, 0.2459)
Gandubert et al (2009) 0.1597 (0.1040, 0.2300)
Razavi et al (1990) 0.1667 (0.1189, 0.2241)
Akizuki et al (2005) 0.1797 (0.1376, 0.2283)
Leopold et al (1998) 0.1887 (0.0944, 0.3197)
Devlen et al (1987) 0.1889 (0.1141, 0.2851)
Berard et al (1998) 0.1900 (0.1184, 0.2807)
Joffe et al (1986) 0.1905 (0.0545, 0.4191)
Berard et al (1998) 0.2100 (0.1349, 0.3029)
Maunsell et al (1992) 0.2146 (0.1605, 0.2772)
Grandi et al (1987) 0.2222 (0.0641, 0.4764)
Evans et al (1986) 0.2289 (0.1438, 0.3342)
Spiegel et al (1984) 0.2292 (0.1495, 0.3261)
Golden et al (1991) 0.2308 (0.1353, 0.3519)
Fallowfield et al (1990) 0.2565 (0.2054, 0.3131)
Hosaka and Aoki (1996) 0.2800 (0.1623, 0.4249)
Kathol et al (1990) 0.2961 (0.2248, 0.3754)
Green et al (1998) 0.3125 (0.2417, 0.3904)
Jenkins et al (1991) 0.3182 (0.1386, 0.5487)
Burgess et al (2005) 0.3317 (0.2672, 0.4012)
Hall et al (1999) 0.3722 (0.3139, 0.4333)
Morton et al (1984) 0.3958 (0.2577, 0.5473)
Baile et al (1992) 0.4000 (0.2570, 0.5567)
Passik et al (2001) 0.4167 (0.2907, 0.5512)
Bukberg et al (1984) 0.4194 (0.2951, 0.5515)
Massie et al (1979) 0.4850 (0.4303, 0.5401)
Ciaramella and Poli (2001) 0.4900 (0.3886, 0.5920)
Levine et al (1978) 0.5600 (0.4572, 0.6592)
Plumb & Holland (1981) 0.7750 (0.6679, 0.8609)
proportion (95% confidence interval)
Prevalence of depression in Palliative settings
24 studies involving 4007 individuals 16.9% (95% CI = 13.2% to 20.3%)
14% major 9% minor adj 15% anx 10%
Proportion meta-analysis plot [random effects]
0.0 0.2 0.4 0.6
combined 0.17 (0.13, 0.21)
Maguire et al (1999) 0.05 (0.01, 0.14)
Akechi et al (2004) 0.07 (0.04, 0.11)
Kadan-Lottich et al (2005) 0.07 (0.04, 0.11)
Love et al (2004) 0.07 (0.04, 0.11)
Wilson et al (2004) 0.12 (0.05, 0.22)
Chochinov et al (1997) 0.12 (0.08, 0.18)
Wilson et al (2007) 0.13 (0.10, 0.17)
Kelly et al (2004) 0.14 (0.06, 0.26)
Chochinov et al (1994) 0.17 (0.11, 0.24)
Le Fevre et al (1999) 0.18 (0.10, 0.28)
Breitbart et al (2000) 0.18 (0.11, 0.28)
Meyer et al (2003) 0.20 (0.10, 0.35)
Minagawa et al (1996) 0.20 (0.11, 0.34)
Lloyd-Williams et al (2001) 0.22 (0.14, 0.31)
Hopwood et al (1991) 0.25 (0.16, 0.36)
Desai et al (1999) [late] 0.25 (0.10, 0.47)
Payne et al (2007) 0.26 (0.19, 0.33)
Lloyd-Williams et al (2003) 0.27 (0.17, 0.39)
Jen et al (2006) 0.27 (0.19, 0.36)
Lloyd-Williams et al (2007) 0.30 (0.24, 0.36)
proportion (95% confidence interval)
0 20 40 60 80 100
0.0
0.1
0.2
0.3
0.4
Time (months)
Pro
porti
on
Meta regression using the random effects model on raw porportions Estimated slope = - 0.02 % per month (p=0.0016). Circles proportional to study size.
Depression in LTCS vs healthy controls
Relative risk meta-analysis plot (random effects)
0.2 0.5 1 2 5
Ellman et al (1995) 0.58 (0.34, 0.98)
Kim et al (2010) 0.72 (0.63, 0.82)
Vistad et al (2007) 1.94 (0.95, 3.87)
Thorsen et al (2005) 1.06 (0.89, 1.26)
Khan et al (2010) 1.08 (1.04, 1.13)
Keating et al (2005) 1.00 (0.86, 1.16)
Ramsey et al (2002) 1.42 (0.99, 2.03)
Dahl et al (2005) 0.96 (0.82, 1.13)
Pirl et al (2009) 0.79 (0.52, 1.17)
Rasic et al (2008) 0.99 (0.74, 1.32)
Tsai et al (2005) 0.85 (0.35, 1.73)
Tsai et al (2007) 1.48 (0.74, 2.03)
Stek et al (2004) 0.88 (0.50, 1.49)
Bruce et al (2002) 0.77 (0.47, 1.24)
Bergdahl et al (2005) 0.76 (0.33, 1.53)
combined [random] 0.97 (0.86, 1.09)
relative risk (95% confidence interval)
Change 4: DistressChange 4: Distress
6th Vital sign
Patient Opinion
- 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: Practical Problems Spiritual/ Religious Concerns Physical Problems contd…
Childcare Loss of faith Changes in Urination
Housing Relating to God Fevers
Money Loss of meaning or purpose in life
Skin dry/ itchy
Transport Nose dry/ congested
Work/School Physical problems Tingling in hands/ feet
Pain Metallic taste in mouth
Family Problems Nausea Feeling swollen
Dealing with partner Fatigue Sexual
Dealing with children Sleep Hot flushes
Getting around
Emotional Problems Bathing/ Dressing
Depression Breathing
Fears Mouth sores Is there anything important you would like to add to the list?__________________________________________________________________________________________
Symptom MDD No MDD MDD No MDD MDD No MDDlittle interest or pleasure in
doing things69.0% 7.80% 88.0% 9.93% 58.7%** 6.8%
Feeling down, depressed or
hopeless73.2% 6.60% 80.0% 7.95% 69.6% 6.0%
Trouble falling or staying
asleep or sleeping too much85.9% 23.00% 88.0% 23.18% 84.8% 22.9%
Feeling tired or having little
energy94.4% 27.30% 92.0% 24.50% 95.7% 28.6%
Poor appetite or overeating 81.7% 17.00% 88.0% 18.54% 78.3% 16.4%Feeling bad about yourself
or that you are a failure 88.7% 17.20% 80.0% 19.21% 93.5%* 16.4%
Trouble concentrating on
things such as reading 77.5% 6.40% 84.0% 8.61% 73.9% 5.4%
Moving or speaking so
slowly 84.5% 19.50% 88.0% 23.84% 82.6% 17.6%
Thoughts that would be
better off dead 35.2% 3.90% 24.0% 3.31% 41.3% 4.2%
Most Useful Diagnostic Symptoms for Depression in..Most Useful Diagnostic Symptoms for Depression in..
ONCOLOGY SETTINGS
1 Trouble concentrating2 Feeling down depressed or hopeless3 Feeling bad about yourself or that you are a failure 4 little interest or pleasure in doing things5 Moving or speaking so slowly that other people could have noticed
Thoughts that would be better off dead or of Poor appetite or overeatingTrouble falling or staying asleep or sleeping too muchFeeling tired or having little energy
PALLIATIVE SETTINGS
1. little interest or pleasure in doing things2. Trouble concentrating on things such as reading the 3. Feeling down depressed or hopeless4. Poor appetite or overeating
5. Feeling tired or having little energy
Trouble falling or staying asleep or sleeping too muchFeeling bad about yourself or that you are a failure Moving or speaking so slowly that other people could have noticedThoughts that would be better off dead or of
Change 11: Intervention ResearchChange 11: Intervention Research
Future of Psycho-oncology 2011Future of Psycho-oncology 2011
We have to address to basics first
We have to work collaboratively clinicians & researchers