Medical Matters: Depressed cancer patients need special treatment

It’s not that many decades ago since cancer was seen as something of a stigma. People either avoided the word completely or used euphemisms such as “the big C”. Thankfully, those days are almost behind us. But stigma attaches itself to other diseases, most notably psychological illness.

Mental health advocate and TD Dan Neville has called for the de-stigmatisation of mental illness, saying “many people are still unnerved by the idea of mental ill health and there has traditionally been a reluctance to discuss mental illness in our society”.

All of which must make it especially difficult for people with both cancer and depression. Distress, the range of unpleasant emotions associated with a cancer experience, is common in patients and their families.

Some manage to include the new reality in their lives; for others, unfortunately, emotional distress goes undetected and may progress to clinical anxiety and depression.

An editorial last year in the journal Cancer World had this to say: "There are a number of factors that contribute to this unsatisfactory situation. Patients are sometimes reluctant to seek help or admit to feeling distressed, because of taboos surrounding mental health disorders. These taboos can also influence clinicians, who may be reluctant to label a patient as having a mental health condition.

“Lack of experience, lack of time, low index of suspicion and failing to inquire about relevant symptoms can all play a role. Lack of specialist support once mental health problems are picked up is also an issue.”

Distress thermometer

The

International Psycho-social Oncology Society

(IPOS) is campaigning to have emotional distress measured as the “sixth vital sign” in cancer patients. Incorporating regular screening for distress into routine cancer care is an important first step, which should be easier now that an easy-to-use self-assessment device, the distress thermometer, is available.

But progress is being made in the area of cancer patients with depression as evidenced by the simultaneous publication of a suite of three papers last month in the Lancet Psychiatry, the Lancet and the Lancet Oncology.

An analysis of data from more than 21,000 patients attending cancer clinics in Scotland, published in the Lancet Psychiatry, found that major depression is substantially more common in cancer patients than in the general population. Major depression was most common in patients with lung cancer (13 per cent) and lowest in those with genitourinary cancer (6 per cent). Unfortunately, almost three-quarters of depressed cancer patients were not receiving treatment.

But good news came in the other two papers which showed that a new integrated treatment programme reduces depression and improves quality of life.

The SMaRT Oncology-2 randomised trial, published in the Lancet, evaluated the effectiveness of a new programme called "Depression Care for People with Cancer" (DCPC). Delivered by a team of specially trained cancer nurses and psychiatrists, DCPC includes both antidepressant and psychological therapy.

Carried out on 500 adults with major depression and a cancer with a good prognosis – where the predicted survival was more than 12 months – the trial compared DCPC with usual care. DCPC was strikingly more effective at reducing depression. At six months, some 62 per cent of the patients who received DCPC responded to treatment compared with only 17 per cent of those who received usual care. The programme also improved anxiety, pain, fatigue, functioning, and overall quality of life.

The third trial showed DCPC was also effective in people with a poor cancer prognosis, albeit to a lesser degree.

Commenting on the results, lead author Prof Michael Sharpe said: "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."

It would be hard to come up with a more resounding recommendation than that.

mhouston@irishtimes.com muirishouston.com