Journal Article Annotations
2021, 1st Quarter
Annotations by Carlos Fernandez-Robles
March, 2021
The finding:
This study found several differences when comparing suicide among cancer and non-cancer patients. Cancer cases were older than their non-cancer counterparts, particularly in the 10-44 and 45-64 year groups. Cancer cases had a higher proportion of males, except for the 10-44 year group. Cancer patients were less likely to be employed or to live alone. Interestingly, cancer cases were also less likely to have a psychiatric diagnosis and other medical comorbidities. Finally, patients with cancer were more likely to employ a violent/highly lethal method and to have communicated suicidal intent.
Strength and weaknesses:
This study uses 15 years of high quality and extensive volume data to build a sample of 14,446 suicide cases. It examines established risk factors for suicide and provides interesting information about how these impact suicide risk differently for patients with cancer. Moreover, it compares cancer and non-cancer cases and stratifies cancer cases by age, showing additional and important differences with these comparisons. This study’s main limitation is that data collection relies on clinical and family reports increasing the risk for analysing incomplete or erroneous information. Additionally, little information is included regarding cancer site, stage, and treatment history that could have enriched the results. Finally, a word of caution to the reader: to include all results, the authors present them in a structure that, if not read attentively, can appear contradictory and result in confusion.
Relevance:
Patients with cancer are at an increased risk for suicide. This work brings to light differences in risk factors among patients with cancer who committed suicide than risk factors for the general population. C-L psychiatrists must be aware of these differences when assessing a cancer patient, so appropriate measures to prevent and support patients at risk are implemented earlier. For instance, while living alone is an associated risk factor for suicide, in cancer, it is not; hence, having a support structure does not convey a layer of protection. Conversely, while a psychiatric diagnosis is vital when assessing risk in the general population, the lack of one does not lower the risk among cancer populations.
Type of study:
The finding:
A relation between Patient Rated Outcomes (PRO) and survival exists across many cancer populations, including common malignancies such as lung cancer up to rarer conditions such as myelodysplastic disorders. PROs can provide independent prognostic information for patients at all disease stages. EORTC QLQ-C30’s physical functioning scale is the most frequent independent prognostic factor in multivariable analyses. This meta-analysis estimated a 12% increase in the risk of death for every 10- point decrease on the patient-reported physical functioning scale (range 0-100).
Strength and weaknesses:
This study’s strength emerges from the inclusion of 138 studies, which in turn include 158,127 patients covering a broad range of malignancies. One-third of included studies were randomized, controlled trials. This design allowed them to extend the findings’ external validity and strengthen their estimation of the magnitude of its prognostic value for overall survival. The paper’s limitation resides in its focus only on survival rates and not other outcomes such as clinical response or progression-free survival.
Relevance:
PROs have been part of oncology care and clinical research for a long time. This study highlights the prognostic value of self-reported health status data. The prognostic value of self-reported health status—particularly physical functioning—appears superior to that of information typically captured with traditional clinical exams. These findings make a strong case for methodical PRO collection and use of the data into routine Oncology and C-L psychiatry practices.
Type of study:
The finding:
The authors found that a single question tool to screen for delirium (SQiD) had favourable psychometric properties when compared to the Confusion Assessment Method (CAM) and gold standard psychiatric interview. Specifically, the negative predictive value (74%) was comparable to the CAM (72%) when compared to clinical interview; and it had better sensitivity (44%) than the CAM (28%). The specificity of the SQiD was 87%.
Strength and weaknesses:
The main strength of the study is that it adopted a real-world approach and circumvented training bias by not training staff specifically on the use of the SQiD. The weaknesses are numerous: Only 73 participants received the CAM, SQiD, and clinical interview, which was smaller than their intended sample size. The time between SQiD, CAM, and clinical interview was longer than anticipated, which may have implications for the comparability of the psychometric properties, given that delirium fluctuates throughout the day.
Relevance:
Delirium detection remains a concern in the cancer setting and carries serious consequences if not detected early. Many delirium screening tools exist, and the CAM is perhaps the most widely known among these. In practice, the CAM may not be as sensitive at detecting delirium as initially thought. Many such tools require education of staff, which does not always happen in real-world scenarios. Cognitive testing is also a feature of many delirium screening tools, which can be challenging for a number of reasons including language or communication barriers with the patient. The SQiD’s formats obviates many of these issues, and its high negative-predictive value makes it a good screening tool. It would be even better if its sensitivity were higher. Clinicians may wish to incorporate this single-item question into their conversations with staff and caregivers, and those who test positive may warrant further assessment for delirium.
Type of study:
This is a cross sectional observational study.
Annotation (unstructured)
Several large nationwide cohort studies have suggested a potential anti-tumor role of SSRIs in a number of different cancers. Previous studies have reported on the mTOR-inhibiting effects of fluoxetine and sertraline in gastric, melanoma, and non-small cell lung cancers. This preclinical study further elucidated the role of SSRI (sertraline and fluoxetine) in blocking the mTOR pathway and suppressing tumor growth in hepatocellular carcinoma cells in vitro as well as in mice. As C-L psychiatrists weigh the risks and benefits of SSRIs in the treatment of depression or anxiety in patients with cancer, these preclinical studies may be worth considering. At the very least, they provide a basis for further exploration in human studies.
Type of study:
Randomized controlled trial