This is a lecture from November 2009 to the cancer profressionals in Leicester. The aim was to introduce plans to roll out a screening programme in radiotherapy.
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Leicester09 - Evidence Based Screening For Depression In Oncology Settings (Nov09)
1. Evidence Based Screening for Depression in Cancer
Evidence Based Screening for Depression in Cancer
Improving the Accuracy of Health Professionals In Oncology
Improving the Accuracy of Health Professionals In Oncology
Alex Mitchell www.psycho-oncology.info
Department of Cancer & Molecular Medicine, Leicester Royal Infirmary
Department of Liaison Psychiatry, Leicester General Hospital
Oncology Seminar Series Nov 2009
Oncology Seminar Series Nov 2009
2. 1. Background
How common is Depression in cancer?
How common is Distress in cancer?
Implications for => mortality
12. Comment: Frequency of cancer specialists
n=226 enquiry about depression/distress from
Mitchell et al (2008)
13. Cancer Staff Psychiatrists
Current Method (n=226)
Other/Uncertain
9% Other/Uncertain
ICD10/DSMIV 2%
0% ICD10/DSMIV
13%
Short QQ
3%
1,2 or 3 Sim ple
QQ
15%
Clinical Skills
Use a QQ Alone
15% 55%
Clinical Skills
Alone
73% 1,2 or 3 Sim ple
QQ
15%
Comment: Current preferred method of eliciting
symptoms of distress/depression
14. Cancer Staff Psychiatrists
Ideal Method (n=226)
Effective?
Long QQ
8%
Clinical Skills Clinical Skills
Alone Alone
Algorithm 20%
17%
26%
ICD10/DSMIV
24%
ICD10/DSMIV 1,2 or 3 Sim ple
0% 1,2 or 3 Sim ple QQ
QQ 24%
Short QQ 34%
23%
Short QQ
24%
Comment: “Ideal” method of eliciting
symptoms of distress/depression according
to clinician
15. 3. Cancer Care - Meta-Analysis
How well do CNS recognize distress?
How well do CNS recognize depression?
How well do oncologist do?
CNS = Clinical Nurse Specialists
16. Local Study: Recognition by CNS in oncology
N=350 nurse specialists’ assessments (2008-2009)
2/3rd Chemotherapy suite LRI
1/3rd Community
Northampton, Kettering, Breast Ca GGH
Mostly early or mixed cancer (1/3 late)
“Is you patient suffering significant distress, depression, anxiety,
anger or are they well or are you unsure?”
17. Detection sensitivity = 50.6%
1.00
Detection specificity = 79.4%
Post-test Probability
Overall accuracy = 65.4%.
0.90
0.80
0.70
0.60
CHEMO+
0.50
CHEMO-
0.40
Baseline Probability
0.30 COMMU+
COMMU-
0.20
0.10
Pre-test Probability
0.00
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Comment: Slide illustrates performance of chemotherapy vs community nurses in oncology
18. 90
83.3
80 Series1
Comment: Slide illustrates diagnostic
Series2
accuracy according to score on DT
71.4
70
62.5
60
56.5
50
43.5 43.5
41.4
40
30 28.6 28.6
20
16.7
13.1
10
0
Zero One Two Three Four Five Six Seven Eight Nine Ten
19. Testing Clinicians: A Meta-Analysis
Methods (currently unpublished)
13 studies reported in 8 publications.
2 anxiety
4 depression
7 broadly defined distress.
9 studies involved medical staff / 4 studies nursing staff.
Gold standard tools including GHQ60, GHQ12 HADS-T, HADS-D,
Zung and SCID.
The total sample size was 4786 (median 171)
Oncologists
SE =38.1% and SP = 78.6%; a fraction correct of 65.4%.
21. 1.00
Post-test Probability
GP+
GP-
0.90 Baseline Probability
Nurse+
Nurse-
0.80 Oncologist+
Oncologists-
0.70
0.60
0.50
0.40
0.30 Comment: Doctors appear to be more
successful at ruling-in or giving a
diagnosis, nurses more successful at
0.20 ruling out
0.10
Pre-test Probability
0.00
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
22. 4. Cancer Care – Screening Data
What resources are available locally re identification
How much difference does a screening tool make?
26. 1.00
0.90
0.80
Ten
0.70 Nine
Eight
0.60 Seven
Six
0.50
Five
Four
0.40
Three
Two
0.30
One
0.20
Zero
Comment: Slide illustrates scores on ET
0.10 tool
0.00
Distress Anxiety Depression Anger
Thermometer Thermometer Thermometer Thermometer
29. 0
10
20
30
40
50
60
70
80
Fa
tig
ue
La Pa
ck in
of
en
er
We gy
ak
Ap ne
pe ss
tite
Ne l os
rv o s
us
ne
We ss
ig h
t lo
Dr ss
De ym
p re ou
ss th
ed
mo
Co od
ns
tip
ati
on
Wo
rry
ing
In s
om
n ia
Dy
sp
ne
a
Na
us
ea
An
xie
Irr ty
ita
bil
ity
Blo
ati
Co ng
gn Co
itiv ug
es h
ym
pto
Ea ms
rl y
Ta sa
s te tie
ty
ch
an
ge
So
re s
mo
Dr uth
ow /
sin
es
Ur s
i na Ed
ry em
sy a
mp
tom
Diz s
zin
es
Dy s
sp
ha
g ia
Co
nfu
si o
Bl n
ee
Ne d in
ur g
o lo
Ho g ic
ars al
en
Self-Reported Symptoms in Cancer by Frq
es
Dy s
Sk sp
in ep
sy sia
mp
tom
Di s
arr
he
a
Pr
ur
itu
s
Hic
cu
p
30. -30
-20
-10
0
10
20
30
40
50
Weight loss
Drowsiness
Neurological symptoms
Fatigue
Weakness
Confusion
Skin symptoms
Dyspnea
Appetite loss
Anxiety
Dysphagia
More common in Late stages
Bleeding
Diarrhea
Dry mouth
Constipation
Dizziness
Dyspepsia
Edema
Urinary symptoms
Cough
Nausea
Self-Reported Symptoms in Cancer by Frq
Depressed mood
Insomnia
More common in early stages
Irritability
Pain
31.
32. Summary & Plans
2006 – Examined screening habits
- Meta-analysis of DT
2007 - Validated ET
- Meta-analysis of verbal methods
2008 – Pilot (community) screening data, viability
- Network –wide training L2
2009 – Nursing Recognition
- Chemotherapy screen implementation
- Meta-analysis of all tools
2010 – Radiotherapy screen implementation
– RCT of screen + intervention
33. Credits & Acknowledgments
Elena Baker-Glenn University of Nottingham
Paul Symonds Leicester Royal Infirmary
Chris Coggan Leicester General Hospital
Burt Park University of Nottingham
Lorraine Granger Leicester Royal Infirmary
Mark Zimmerman Brown University, Rhode Island
Brett Thombs McGill University Canada
James Coyne University of Pennsylvania
Nadia Husain Leicester General Hospital
Joanne Herdman Leicester General Hospital
Jo Kavanagh Leicester Royal Infirmary
For more information www.psycho-oncology.info
34. FURTHER READING:
Screening for Depression in Clinical Practice An
Evidence-Based guide
ISBN 0195380193
Paperback, 416 pages
Nov 2009
Price: £39.99