Journal Article Annotations
2023, 1st Quarter
Annotations by Christian Bjerre Real, MD, MMCI, Deepti Chopra, MBBS, MPH, Daniel McFarland, MD, Marie Tobin, MD, Barbara Lubrano di Ciccone, MD
This was a single canter, cross-sectional study which evaluated the relationship between demoralization and health related quality of life measures in a sample of cancer patients with a life expectancy of 4 months or less. The authors compared demoralization with physical, psychological, and spiritual measures. In a multiple regression analysis, dimensions of disheartenment and sense of failure within the demoralization measure appeared to be significantly associated with health-related quality of life.
Strength and weaknesses:
The study employed well-validated measures of demoralization, depression, quality of life, and spiritual wellbeing. The cross-sectional nature of the study bars our capacity to determine cause-effect relationship between variables, but it certainly adds to the evidence of the relationship between demoralization, physical symptoms, and psychological distress outside the typical DSM-5 framework. Generalizability is limited as this is a single canter study. Moreover, the study does not provide detailed information on the racial or ethnic makeup of the sample, which could limit the ability to identify potential disparities in the findings based on race or ethnicity. The study did not address the potential impact of economic factors (outside employment/unemployment/retirement) on demoralization or quality of life.
Demoralization is a clinically significant measure of distress. Although associated with depression, a significant proportion of individuals with significant demoralization, don’t present with clear symptoms of depression. Pointing out dimensions of “disheartenment” and “sense of failure” as associated with worsened quality of life, can help our attunement to these issues during the clinical interview. Also, deepening our understanding in the association between demoralization and physical symptoms, will lead the C-L psychiatrist to further advocate for symptom control to improve psychological outcomes.
This study looked at 83 cancer patients over the age of 65 who were treated with medical cannabis for cancer-related symptoms (pain, nausea and/or anorexia). The majority of patients had a Karnofsky Performance Scale rating of 70 or greater. Approximately half of patients had documented stage IV disease. Patients preferred to use oil tincture as the route of administration compared to vape and pill, possibly due to the ease of swallowing and avoidance of exacerbating underlying lung disease or cancer. Nearly one-third of patients had prior history of illicit cannabis use, and one-fifth had a prior history of illicit drug use of substances other than cannabis. Pain, nausea, anxiety, and anorexia numerical scores (0-10) were measured by the Edmonton Symptom Assessment System (ESAS) at initial and follow up visits. Although nearly 40% of patients reported a 30% reduction in pain score, and 30% reported a reduction in nausea with 20-30% reporting an improved appetite the results were not statistically significant. Similar results were obtained for anxiety. Nearly one quarter of patients reported a 30% reduction in anxiety scores, though results were not statistically significant.
Strength and weaknesses:
Strengths: The idea that medical cannabis can be helpful in the management of common symptoms found in cancer patients has grown over the recent years. This study is the first known report of the efficacy of medical cannabis on the symptoms of elderly cancer patients. Although there was a lack of statistically significance, the results showed a trend in reduction of pain, nausea, anorexia, insomnia, and anxiety in some patients in addition to improvement in sleep. There are weaknesses to this study: it was a retrospective study conducted at a single-center with a small sample size. Patients being lost to follow up, incomplete ESAS questionnaires, and inconsistent assessments further strain the limited sample size. Of note, the recorded formulations and ratios of medical cannabis were not consistently recorded.
C-L psychiatrists are commonly involved in the care of cancer patients suffering from insomnia, anorexia, and anxiety. Patients and other providers look upon the C-L psychiatrist to provide opinion in the treatment of these symptoms, including potential benefits of cannabis use.
Effective treatment of clinically significant distress in patients with cancer has been shown to improve treatment adherence, course and prognosis. The validated Distress Thermometer (DT) and 34-Item Problem List (PL) are simple self-report instruments to measure distress and the physical, psychological, and spiritual sourcesof that distress. In this exploratory study, the authors measure the sources and severity of distress using the DT and PL in 323 patients within two weeks of being diagnosed with lung cancer. The 153 patients who reported high distress had lower overall survival (25 months) compared to 43 months in the 270 patients with low distress. Patients with problems eating, bathing, and dressing had lower survival. Interestingly, patients who reported the absence of “diarrhea” and “nervousness” had lower survival. These results may be indicative of patients ending active treatment, which can lead to more advanced illness.
Strengths and weaknesses:
The study’s strengths include focusing on one cancer type, measuring distress within two weeks of diagnosis and including patients at all stages of treatment. Weaknesses include the retrospective, chart review design and failure to characterize emotional distress more fully by assessesing for anxiety and depression.
This study highlights the survival implications of distress in the early stages of cancer treatment. Consult-liaison psychiatrists are uniquely placed to identify and encourage the management of patients’ physical problems that were identified in the study to be associated with lower survival.