Friday, 29 August 2014

Depression therapy aids other cancer symptoms

Depression therapy aids other cancer symptoms

"Depression therapy could help cancer patients fight illness," reports The Daily Telegraph.

The headline follows a study of intensive treatment of clinical depression given to people who had both depression and cancer – delivered as part of their cancer care. It found that not only did people’s mood improve, but cancer-related symptoms such as pain and fatigue were also reduced compared to that seen with the usual care given.

The treatment programme, called Depression Care for People with Cancer (DCPC), involves a team of specially trained cancer nurses and psychiatrists who work closely with the patient’s cancer doctors and GP.

A related study, also published today, found that clinical depression is a common problem for people living with cancer. For example, it found that around one in eight people with lung cancer also had clinical depression.

It should be noted that the trial involved patients with a good outlook for their cancer, which may have been a factor in their response to treatment for depression.

However, a second trial of the depression treatment programme, this time involving lung cancer patients, also published today but not analysed here, showed a similar benefit, despite their poorer cancer prognosis.

This was a randomised controlled trial, which is the best type of study to examine the effectiveness of healthcare treatments, so the results are likely to be reliable. It is hoped that the positive results will be replicated in larger populations.

Where did the story come from?

The study was carried out by researchers from the Universities of Oxford and Edinburgh, and was funded by Cancer Research UK and the Scottish government.

The study was published in the peer-reviewed medical journal The Lancet.

The study is one of three depression-related cancer studies published by The Lancet.

The first looks at how common clinical depression is in cancer patients.

The third study assesses how effective the DCPC programme is in patients with cases of lung cancer that have a poor prognosis.

The study was covered fairly by the UK media.

What kind of research was this?

This was a randomised controlled trial of an integrated treatment programme for clinical depression in patients with cancer, compared to the results seen with usual care.

The authors point out that clinical depression affects about 10% of people with cancer and is associated with: worse anxiety, pain, fatigue and functioning; suicidal thoughts; and poor adherence to anticancer treatments.

However, at present, there is no good evidence for how best to treat depression in cancer patients and how to integrate treatment into their cancer care.

Their integrated treatment programme involves a psychiatrist and the care manager working with the patient’s specialist doctor, GP and cancer nurses to provide an intensive systematic treatment for depression, including both drugs and psychological treatment.

It’s worth pointing out that what is new here is not the actual treatments for depression – rather the way they are delivered, as an integrated part of the patient’s cancer care.

What did the research involve?

Between 2008 and 2011, researchers enrolled 500 participants attending three cancer centres in Scotland. Participants were aged 18 or over, with a good cancer prognosis – with a predicted survival of at least a year. They had all been diagnosed with clinical depression of at least four weeks' duration.

253 participants were randomly assigned to the new DCPC programme, with 247 assigned to usual care.

In the DCPC group, depression care was delivered by specially trained cancer nurses, under the supervision of a psychiatrist. The programme was designed to be integrated with the patient’s cancer care, with psychiatrists working in collaboration with the patient’s oncology team and their GP.

The nurses established a therapeutic relationship with the patient, provided information about depression and its treatment, delivered psychological interventions and monitored progress, using a validated depression questionnaire. The psychiatrists supervised treatment, advised GPs about prescribing antidepressants and provided direct consultations with patients who were not improving.

The initial treatment phase comprised a maximum of 10 sessions with the nurse (at the clinic or, if necessary, by telephone) over a four-month period. After this, the patient’s progress was monitored monthly by telephone for a further eight months, and additional sessions with the nurse were provided for patients not meeting treatment targets. All cases were reviewed on a weekly basis, in supervision meetings attended by nurses and a psychiatrist.

In the usual care group, the patient's GP and cancer doctors were informed about the clinical depression diagnosis and asked to treat their patients as they normally would. This might involve the GP prescribing antidepressants, or a referral of the patient to mental health services for assessment or psychological treatment.

At 24 weeks, researchers looked at the patient's primary response to their treatment, defined as at least a 50% reduction in depression severity and measured using a self-rated symptom checklist. A 50% reduction in score has been shown to be comparable to no longer meeting diagnostic criteria for major depression.

Researchers also looked at each patient’s levels of anxiety, pain, fatigue, physical and social functioning, as well as their overall health and quality of life, using validated questionnaires, and the patient’s opinion of the quality of depression care.

They analysed the results using standard statistical methods.

What were the basic results?

Researchers found that in 62% of participants in the DCPC group, the severity of depression decreased by 50% or more, compared with a 17% decrease in the usual care group (absolute difference 45%, 95% confidence interval (CI) 37 to 53; adjusted odds ratio (OR) 8.5, 95% CI 5.5 to 13.4).

Compared with patients in the usual care group, participants in the DCPC group also had less anxiety, pain and fatigue, as well as better functioning, health and quality of life. They also rated their depression care as being better.

During the study, 34 cancer-related deaths occurred (19 in the DCPC group, 15 in the usual care group); one patient in the DCPC group was admitted to a psychiatric ward and one patient in this group attempted suicide. None of these events were judged to be related to the trial's treatments or procedures.

How did the researchers interpret the results?

The researchers say their findings suggest that DCPC is an effective treatment for clinical depression in patients with cancer, and also offers a model for the treatment of depression occurring with other chronic medical conditions.

According to lead author Professor Michael Sharpe, from the University of Oxford in the UK: “The huge benefit that DCPC delivers for patients with cancer and depression shows what we can achieve for patients if we take as much care with the treatment of their depression as we do with the treatment of their cancer.”


Not surprisingly, this well-conducted study suggests that offering cancer patients with clinical depression an intensive, systematic treatment for depression involving all the people involved in their care, works better than the current approach.

As the authors point out, the trial had some limitations. The sample was mainly women receiving follow-up or adjuvant treatment for breast and gynaecological cancers, so it is unclear whether the findings are generalisable to other cancer patients.

Also, patients and their GPs could not be “masked” as to whether they were in the DCPC group or the group receiving usual care, which might have influenced the findings.

The striking results for patients in the DCPC group is probably attributable to treatment for depression being intensive, systematically implemented and integrated with the patient’s cancer care.

It is noteworthy that in the group receiving usual care, prescribing antidepressants was not actively managed – by, for example, changing the drug or adjusting the dose, according to the patient’s response. Few patients in this group received psychological treatment, despite the option being available.

Due to the very positive results achieved using the DCPC approach, the programme is likely to be assessed using other groups of people with cancer. If it continues to prove successful, it may become part of standard cancer treatment protocols.

If you are concerned that you have mental health problems that are being left untreated, talk to your cancer nurse or GP. They should be able to provide extra support and treatment as required.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join theHealthy Evidence forum.

Links To The Headlines

Cancer patients with depression 'are being overlooked'. BBC News, August 28 2014

Do more for depressed cancer patients – study. The Guardian, August 28 2014

Depression therapy could help cancer patient fight illness. The Daily Telegraph, August 28 2014

Study: Depression among cancer patients 'overlooked'. ITV News, August 28 2014

Links To Science

Sharpe M, Walker J, Hansen CH, et al. Integrated collaborative care for comorbid major depression in patients with cancer (SMaRT Oncology-2): a multicentre randomised controlled effectiveness trial. The Lancet. Published online August 28 2014

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