Annotated Abstracts of Journal Articles
2014, 1st Quarter
Annotations by Jane Walker, MBChB
ANNOTATION (Jane Walker)
The Findings: At 3 months there were no significant differences between the trial arms on the FACIT-Sp quality of life score (primary outcome), symptom distress, or problems with clinical interactions; but patients who received early palliative care did report greater satisfaction with care and better quality of life on the QUAL-E. At 4 months there were greater differences between the groups and these favoured the early palliative care arm.
Strengths and Weaknesses: The trial had a reasonable sample size and used a cluster design to encourage recruitment. However, the early palliative care intervention is not well defined and the differential losses due to deaths and withdrawals limit the interpretation of the 4 month outcomes.
Relevance: This trial was given a headline spot in the Lancet and the findings described as “promising.” A more cautious interpretation is required given the non-significant primary outcome. Trials of more specific interventions will be important, including those that focus on psychological aspects of care.
Background: Patients with advanced cancer have reduced quality of life, which tends to worsen towards the end of life. We assessed the effect of early palliative care in patients with advanced cancer on several aspects of quality of life.
Methods: The study took place at the Princess Margaret Cancer Centre (Toronto, ON, Canada), between Dec 1, 2006, and Feb 28, 2011. 24 medical oncology clinics were cluster randomised (in a 1:1 ratio, using a computer-generated sequence, stratified by clinic size and tumour site [four lung, eight gastrointestinal, four genitourinary, six breast, two gynaecological]), to consultation and follow-up (at least monthly) by a palliative care team or to standard cancer care. Complete masking of interventions was not possible; however, patients provided written informed consent to participate in their own study group, without being informed of the existence of another group. Eligible patients had advanced cancer, European Cooperative Oncology Group performance status of 0-2, and a clinical prognosis of 6-24 months. Quality of life (Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being [FACIT-Sp] scale and Quality of Life at the End of Life [QUAL-E] scale), symptom severity (Edmonton Symptom Assessment System [ESAS]), satisfaction with care (FAMCARE-P16), and problems with medical interactions (Cancer Rehabilitation Evaluation System Medical Interaction Subscale [CARES-MIS]) were measured at baseline and monthly for 4 months. The primary outcome was change score for FACIT-Sp at 3 months. Secondary endpoints included change score for FACIT-Sp at 4 months and change scores for other scales at 3 and 4 months. This trial is registered with ClinicalTrials.gov, number NCT01248624.
Findings: 461 patients completed baseline measures (228 intervention, 233 control); 393 completed at least one follow-up assessment. At 3-months, there was a non-significant difference in change score for FACIT-Sp between intervention and control groups (3·56 points [95% CI -0·27 to 7·40], p=0·07), a significant difference in QUAL-E (2·25 [0·01 to 4·49], p=0·05) and FAMCARE-P16 (3·79 [1·74 to 5·85], p=0·0003), and no difference in ESAS (-1·70 [-5·26 to 1·87], p=0·33) or CARES-MIS (-0·66 [-2·25 to 0·94], p=0·40). At 4 months, there were significant differences in change scores for all outcomes except CARES-MIS. All differences favoured the intervention group.
Interpretation: Although the difference in quality of life was non-significant at the primary endpoint, this trial shows promising findings that support early palliative care for patients with advanced cancer.
Funding: Canadian Cancer Society, Ontario Ministry of Health and Long Term Care
ANNOTATION (Jane Walker)
The Finding: The authors found an association between number of self-reported mental disorders and subsequent cancer diagnosis. Panic, specific phobia and alcohol abuse were associated with subsequent cancer after adjusting for psychiatric comorbidity.
Strengths and Weaknesses: The study is large and drawn from the general population. However the data on mental disorders, cancer diagnosis and the timing of these are all based on self-report.
Relevance: This study reminds us that mental disorders are common in people with cancer and may pre-date the cancer diagnosis. However, the reliance on patient-reported cancer diagnoses and recall of symptoms substantially limits the interpretability of the findings.
Objective: The associations between mental disorders and cancer remain unclear. It is also unknown whether any associations vary according to life stage or gender. This paper examines these research questions using data from the World Mental Health Survey Initiative.
Methods: The World Health Organization Composite International Diagnostic Interview retrospectively assessed the lifetime prevalence of 16 DSM-IV mental disorders in face-to-face household population surveys in nineteen countries (n=52,095). Cancer was indicated by self-report of diagnosis. Smoking was assessed in questions about current and past tobacco use. Survival analyses estimated associations between first onset of mental disorders and subsequently reported cancer.
Results: After adjustment for comorbidity, panic disorder, specific phobia and alcohol abuse were associated with a subsequently self-reported diagnosis of cancer. There was an association between number of mental disorders and the likelihood of reporting a cancer diagnosis following the onset of the mental disorder. This suggests that the associations between mental disorders and cancer risk may be generalised, rather than specific to a particular disorder. Depression is more strongly associated with self-reported cancers diagnosed early in life and in women. PTSD is also associated with cancers diagnosed early in life.
Conclusion: This study reports the magnitude of the associations between mental disorders and a self-reported diagnosis of cancer and provides information about the relevance of comorbidity, gender and the impact at different stages of life. The findings point to a link between the two conditions and lend support to arguments for early identification and treatment of mental disorders.
Chang CK, Hayes RD, Broadbent MT, Hotopf M, Davies E, Møller H, Stewart R
ANNOTATION (Jane Walker)
There were no associations between stage at cancer diagnosis and any of the psychiatric diagnoses studied (schizophrenia, bipolar disorder, schizoaffective disorder, depression, dementia, substance use disorders, anxiety disorders, personality disorders). Schizophrenia, schizoaffective disorder, depression, dementia and substance use disorders were associated with worse survival after cancer diagnosis.
Strengths and Weaknesses: The study is large but suffers from substantial missing data (35% of cancer cases did not have information on stage at diagnosis and could not be included) and psychiatric diagnoses based on secondary mental healthcare data; patients who did not access these services were assumed not to have a mental disorder.
Relevance: This study suggests that patients with mental disorders who access psychiatric services have worse survival after a cancer diagnosis.
Objectives: To assess the stage at cancer diagnosis and survival after cancer diagnosis among people served by secondary mental health services, compared with other local people.
Setting: Using the anonymised linkage between a regional monopoly secondary mental health service provider in southeast London of four London boroughs, Croydon, Lambeth, Lewisham and Southwark, and a population-based cancer register, a historical cohort study was constructed.
Participants: A total of 28 477 cancer cases aged 15+ years with stage of cancer recorded at diagnosis were identified. Among these, 2206 participants had been previously assessed or treated in secondary mental healthcare before their cancer diagnosis and 125 for severe mental illness (schizophrenia, schizoaffective or bipolar disorders).
Primary and secondary outcome measures: Stage when cancer was diagnosed and all-cause mortality after cancer diagnosis among cancer cases registered in the geographical area of southeast London.
Results: Comparisons between people with and without specific psychiatric diagnosis in the same residence area for risks of advanced stage of cancer at diagnosis and general survival after cancer diagnosed were analysed using logistic and Cox models. No associations were found between specific mental disorder diagnoses and beyond local spread of cancer at presentation. However, people with severe mental disorders, depression, dementia and substance use disorders had significantly worse survival after cancer diagnosis, independent of cancer stage at diagnosis and other potential confounders.
Conclusions: Previous findings of associations between mental disorders and cancer mortality are more likely to be accounted for by differences in survival after cancer diagnosis rather than by delayed diagnosis.