POCOG - The Future of Psycho-Oncology (Aug 2011)

Alex Mitchell www.psycho-oncology.info

Department of Cancer & Molecular Medicine, University of LeicesterDepartment of Liaison Psychiatry, Leicester General Hospital

University of Sydney POCOG August 2011University of Sydney POCOG August 2011

The Future of Psycho-oncology:Research & ClinicalThe Future of Psycho-oncology:Research & Clinical

% Receiving Any treatment for Mental Health% Receiving Any treatment for Mental Health

7.2

34.6

5.7 6.3 6.4

11.7

19.1

14

8.9

3.9 3.25.7

32.7

5 57.7

11

16.1

6.5 6.2

2.3 1.8

0

5

10

15

20

25

30

35

40Al

l Pat

ient s

Men

t al Il

l Hea

l th

No M

enta

l Ill H

eal th

No c

hro n

ic m

edica

l con

d itio

n1

c hro

nic m

edica

l con

ditio

n2

chro

nic m

edica

l con

ditio

n3

c hro

nic m

edica

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n

18-4

4 ye

ars

45-6

4 y e

ars

65-7

4 y e

ars

75+

Cancer n=4878

No Cancer n=90,737

Hewitt Journal of Clinical Oncology, Vol 20, Issue 23, 2002: 4581-4590

0 10 20 30 40 50 60 70 80

Are you currently seeing a: Pastoral care provider, like a chaplain, priest, or rabbi?

Have you received any treatment for mental stress, worry, or mood changes over the lastmonth

Have you been sent to see another health care provider for treatment for your mental stress,worry, or mood changes?

If taking treatment has anyone from your cancer care team asked you how well the treatmentwas working?

Over the past month, have you talked with your cancer care team about distress?

Have you been given medicines to take for mental stress, worry, or mood changes?

Were you offered a visit with a: Mental health provider, like a therapist, counselor,psychologist or psychiatrist?

Were you given suggestions, other than taking medications, by your cancer care team?

At your last visit, did a member of your cancer care team ask you about mental stress,worry, or mood changes?

Do you feel your cancer care team has provided the education or support you need?

Are you doing anything on your own for your mental stress, worry, or mood changes?

Cella (2008) Suport Care Cancer. 2008 Feb;16(2):151-9. Epub 2007 Jul

What about preventive cancer care?What about preventive cancer care?

Do our vulnerable patients get enhanced access?

Summary meta-analysis plot [random effects]

0.001 0.01 0.1 0.2 0.5 1 2

combined 0.692 (0.624, 0.768)

Ludman et al (2010) 0.490 (0.310, 0.760)

masterton et al (2010) 0.670 (0.420, 1.075)

Werneke et al. (2006) [psychosis] 0.330 (0.180, 0.610)

Werneke et al. (2006) [severe mental illness] 0.400 (0.290, 0.550)

Werneke et al. (2006) [any mental illness] 0.910 (0.800, 1.040)

Stecker et al (2007) 0.867 (0.662, 1.130)

Pirraglia et al (2004) [moderate depression] 1.010 (0.860, 1.180)

Pirraglia et al (2004) [severe depression] 0.840 (0.730, 0.970)

Peytremann- Bridevaux et al (2008) 1.000 (0.800, 1.200)

Patten et al (2009) 0.800 (0.400, 1.600)

Lindamer et al (2003) 0.040 (0.002, 0.250)

Lasser et al (2003) 0.350 (0.240, 0.510)

Iezzoni et al (2001) 0.600 (0.400, 1.100)

Green and Pope (2000) 1.370 (1.040, 1.810)

Druss et al (2008) [specialist] 0.820 (0.690, 0.970)

Druss et al (2008) [primary care] 1.350 (1.160, 1.610)

Druss et al (2008) [depression] 0.820 (0.790, 0.847)

Druss et al (2002) [dual diagnosis] 0.520 (0.340, 0.790)

Druss et al (2002) 0.780 (0.670, 0.910)

Chochinov et al (2009) 0.640 (0.580, 0.710)

Carney & Jones (2006) [medium severity] 0.470 (0.330, 0.670)

Carney & Jones (2006) [high severity] 0.560 (0.260, 1.210)

Carney & Jones (2006) [low severity] 0.590 (0.450, 0.780)

Carney & Jones (2006) [high severity] 0.340 (0.280, 0.420)

Carney & Jones (2006) [medium severity] 0.630 (0.570, 0.690)

Carney & Jones (2006) [low severity] 0.930 (0.890, 0.970)

Carney & Jones (2006) [severe mental illness] 0.380 (0.330, 0.430)

Carney & Jones (2006) [mild mental illness] 0.980 (0.950, 1.010)

Carney & Jones (2006) [mod mental illness] 0.620 (0.590, 0.660)

odds ratio (95% confidence interval)

Mammography & MI

OR 0.69 (95% CI = 0.62 to 0.77)P < 0.0001N=29

What is Changing?What is Changing?

Demographics

Clinician Expectations

Patient Involvement

Lower EmphasisLower Emphasis

Depression (MDD, DSMIV)

Psychiatrist Judgement vs patient opinion

Ineffective interventions

Communication over Trust (diagnosis alone)

Palliative differences without evidence

Increased EmphasisIncreased Emphasis

Early intervention & prevention

Screening Implementation > Validity

Distress (esp longitudinal)

Outreach and primary care

PROMs

Peer support and SMI models of care

For the FutureFor the Future

Anxiety disorders, Anger, Irritability, Adjustment

Unpopular depressions (MnDD, ADD, Dysthymia)

Function and QoL will be re-invented

Psychosocial input into Rehabilitation approaches

Acceptable Screening with intervention (RCTs)

Symptom Research (back to basics)

Psycho-oncology is Growing!Psycho-oncology is Growing!

2010 1990

Depression 143 12

Distress 121 14

Screening 1700 481

Communication 148 38

Change 1: Epidemiology of CancerChange 1: Epidemiology of Cancer

Survival

Prevalence

0

10

20

30

40

50

60

70

80

90

100

Melanom

aBrea

st (fe

male)

Urinary

bladde

r

Prostat

e

Colon

All site

s

Rectum

Non-H

odgkin

lymph

oma

Ovary

Leuk

emiaLu

ng and

bron

chus

Pancre

as

1975-19771984-19861996-2004Change

5 Year Survival in US Cancers (2008 American Cancer Society, Atlanta)

Annual report to the national of status of cancer 1975 – 2005 J Natl Cancer Inst 2008;100: 1672 – 1694

10.9million incident cases (1mi breast, lung colorectal); 25mi prevalent cases

Australian Bureau of Statistics

Change 2: Clinician BehaviourChange 2: Clinician Behaviour

Information

Assisted decision making

In 196190% of US doctors indicated a preference for not

telling a diagnosis of cancer.

In 197997% indicated a preference for revealing a diagnosis

of cancer.

Novack DH, Plumer R, Smith RL, et al. Changes in physicians’ attitudes toward telling the cancer patient. JAMA 1979; 241: 897–900.

InformationInformation

Psychooncology. 2011 Feb;20(2):213-8. doi: 10.1002/pon.1727. Patient and oncologist estimates of survival in advanced cancer patients. Steven Kao SC, Butow P, Bray V, Clarke SJ, Vardy J.

The oncologists were 32% accurate in predicting survival and overestimated survival 42% of the time

J Clin Oncol. 2011 May 20;29(15):2077-84. Epub 2011 Apr 11. Supporting treatment decision making in advanced cancer: a randomized trial of a decision aid for patients with advanced colorectal cancer considering chemotherapy. Natasha Leighl NB, Shepherd HL, Butow PN

Change 3: Clear Evidence BaseChange 3: Clear Evidence Base

Prevalence of depression

Relative risk of depression

Prevalence of depression in Oncology settings

70 studies involving 10,071 individuals;14 countries.16.3% (95% CI = 13.9% to 19.5%)

Mj 15% Mn 19% Adj 20% Anx 10% Dysthymia 3%

Proportion meta-analysis plot [random effects]

0.0 0.3 0.6 0.9

combined 0.1730 (0.1375, 0.2116)

Colon et al (1991) 0.0100 (0.0003, 0.0545)

Massie and Holland (1987) 0.0147 (0.0063, 0.0287)

Hardman et al (1989) 0.0317 (0.0087, 0.0793)

Derogatis et al (1983) 0.0372 (0.0162, 0.0720)

Lansky et al (1985) 0.0455 (0.0291, 0.0676)

Mehnert et al (2007) 0.0472 (0.0175, 0.1000)

Katz et al (2004) 0.0500 (0.0104, 0.1392)

Singer et al (2008) 0.0519 (0.0300, 0.0830)

Sneeuw et al (1994) 0.0540 (0.0367, 0.0761)

Pasacreta et al (1997) 0.0633 (0.0209, 0.1416)

Lee et al (1992) 0.0660 (0.0356, 0.1102)

Reuter and Hart (2001) 0.0761 (0.0422, 0.1244)

Grassi et al (2009) 0.0826 (0.0385, 0.1510)

Grassi et al (1993) 0.0828 (0.0448, 0.1374)

Walker et al (2007) 0.0831 (0.0568, 0.1165)

Kawase et al (2006) 0.0851 (0.0553, 0.1240)

Coyne et al (2004) 0.0885 (0.0433, 0.1567)

Alexander et al (2010) 0.0900 (0.0542, 0.1385)

Love et al (2002) 0.0957 (0.0650, 0.1346)

Ozalp et al (2008) 0.0971 (0.0576, 0.1510)

Morasso et al (2001) 0.0985 (0.0535, 0.1625)

Costantini et al (1999) 0.0985 (0.0535, 0.1625)

Silberfarb et al (1980) 0.1027 (0.0587, 0.1638)

Desai et al (1999) [early] 0.1111 (0.0371, 0.2405)

Morasso et al (1996) 0.1121 (0.0593, 0.1877)

Prieto et al (2002) 0.1227 (0.0825, 0.1735)

Ibbotson et al (1994) 0.1242 (0.0776, 0.1853)

Payne et al (1999) 0.1290 (0.0363, 0.2983)

Kugaya et al (1998) 0.1328 (0.0793, 0.2041)

Alexander et al (1993) 0.1333 (0.0594, 0.2459)

Gandubert et al (2009) 0.1597 (0.1040, 0.2300)

Razavi et al (1990) 0.1667 (0.1189, 0.2241)

Akizuki et al (2005) 0.1797 (0.1376, 0.2283)

Leopold et al (1998) 0.1887 (0.0944, 0.3197)

Devlen et al (1987) 0.1889 (0.1141, 0.2851)

Berard et al (1998) 0.1900 (0.1184, 0.2807)

Joffe et al (1986) 0.1905 (0.0545, 0.4191)

Berard et al (1998) 0.2100 (0.1349, 0.3029)

Maunsell et al (1992) 0.2146 (0.1605, 0.2772)

Grandi et al (1987) 0.2222 (0.0641, 0.4764)

Evans et al (1986) 0.2289 (0.1438, 0.3342)

Spiegel et al (1984) 0.2292 (0.1495, 0.3261)

Golden et al (1991) 0.2308 (0.1353, 0.3519)

Fallowfield et al (1990) 0.2565 (0.2054, 0.3131)

Hosaka and Aoki (1996) 0.2800 (0.1623, 0.4249)

Kathol et al (1990) 0.2961 (0.2248, 0.3754)

Green et al (1998) 0.3125 (0.2417, 0.3904)

Jenkins et al (1991) 0.3182 (0.1386, 0.5487)

Burgess et al (2005) 0.3317 (0.2672, 0.4012)

Hall et al (1999) 0.3722 (0.3139, 0.4333)

Morton et al (1984) 0.3958 (0.2577, 0.5473)

Baile et al (1992) 0.4000 (0.2570, 0.5567)

Passik et al (2001) 0.4167 (0.2907, 0.5512)

Bukberg et al (1984) 0.4194 (0.2951, 0.5515)

Massie et al (1979) 0.4850 (0.4303, 0.5401)

Ciaramella and Poli (2001) 0.4900 (0.3886, 0.5920)

Levine et al (1978) 0.5600 (0.4572, 0.6592)

Plumb & Holland (1981) 0.7750 (0.6679, 0.8609)

proportion (95% confidence interval)

Prevalence of depression in Palliative settings

24 studies involving 4007 individuals 16.9% (95% CI = 13.2% to 20.3%)

14% major 9% minor adj 15% anx 10%

Proportion meta-analysis plot [random effects]

0.0 0.2 0.4 0.6

combined 0.17 (0.13, 0.21)

Maguire et al (1999) 0.05 (0.01, 0.14)

Akechi et al (2004) 0.07 (0.04, 0.11)

Kadan-Lottich et al (2005) 0.07 (0.04, 0.11)

Love et al (2004) 0.07 (0.04, 0.11)

Wilson et al (2004) 0.12 (0.05, 0.22)

Chochinov et al (1997) 0.12 (0.08, 0.18)

Wilson et al (2007) 0.13 (0.10, 0.17)

Kelly et al (2004) 0.14 (0.06, 0.26)

Chochinov et al (1994) 0.17 (0.11, 0.24)

Le Fevre et al (1999) 0.18 (0.10, 0.28)

Breitbart et al (2000) 0.18 (0.11, 0.28)

Meyer et al (2003) 0.20 (0.10, 0.35)

Minagawa et al (1996) 0.20 (0.11, 0.34)

Lloyd-Williams et al (2001) 0.22 (0.14, 0.31)

Hopwood et al (1991) 0.25 (0.16, 0.36)

Desai et al (1999) [late] 0.25 (0.10, 0.47)

Payne et al (2007) 0.26 (0.19, 0.33)

Lloyd-Williams et al (2003) 0.27 (0.17, 0.39)

Jen et al (2006) 0.27 (0.19, 0.36)

Lloyd-Williams et al (2007) 0.30 (0.24, 0.36)

proportion (95% confidence interval)

0 20 40 60 80 100

0.0

0.1

0.2

0.3

0.4

Time (months)

Pro

porti

on

Meta regression using the random effects model on raw porportions Estimated slope = - 0.02 % per month (p=0.0016). Circles proportional to study size.

Depression in LTCS vs healthy controls

Relative risk meta-analysis plot (random effects)

0.2 0.5 1 2 5

Ellman et al (1995) 0.58 (0.34, 0.98)

Kim et al (2010) 0.72 (0.63, 0.82)

Vistad et al (2007) 1.94 (0.95, 3.87)

Thorsen et al (2005) 1.06 (0.89, 1.26)

Khan et al (2010) 1.08 (1.04, 1.13)

Keating et al (2005) 1.00 (0.86, 1.16)

Ramsey et al (2002) 1.42 (0.99, 2.03)

Dahl et al (2005) 0.96 (0.82, 1.13)

Pirl et al (2009) 0.79 (0.52, 1.17)

Rasic et al (2008) 0.99 (0.74, 1.32)

Tsai et al (2005) 0.85 (0.35, 1.73)

Tsai et al (2007) 1.48 (0.74, 2.03)

Stek et al (2004) 0.88 (0.50, 1.49)

Bruce et al (2002) 0.77 (0.47, 1.24)

Bergdahl et al (2005) 0.76 (0.33, 1.53)

combined [random] 0.97 (0.86, 1.09)

relative risk (95% confidence interval)

Change 4: DistressChange 4: Distress

6th Vital sign

Patient Opinion

- Please circle the number (0-10) that best describes how much distress you have been experiencing in the past week, including today.

- What phone number would you like us to contact you on if necessary?

Please tick WHICH of the following is a cause of distress: Practical Problems Spiritual/ Religious Concerns Physical Problems contd…

Childcare Loss of faith Changes in Urination

Housing Relating to God Fevers

Money Loss of meaning or purpose in life

Skin dry/ itchy

Transport Nose dry/ congested

Work/School Physical problems Tingling in hands/ feet

Pain Metallic taste in mouth

Family Problems Nausea Feeling swollen

Dealing with partner Fatigue Sexual

Dealing with children Sleep Hot flushes

Getting around

Emotional Problems Bathing/ Dressing

Depression Breathing

Fears Mouth sores Is there anything important you would like to add to the list?__________________________________________________________________________________________

Nervousness Eating

Sadness Indigestion

Worry Constipation

Anger Diarrhoea

Distress thermometer

ScoreRansom 2006

Tuinman2008

Mitchell 2009

Lord 2010

Hoffman 2004

Gessler2009

Clover 2009

Jacobsen 2005 Sum

Proportion

Zero 68 38 61 123 14 27 65 71 467 18.4%

One 72 31 42 68 5 26 39 46 329 12.9%

Two 77 22 35 44 5 18 30 54 285 11.2%

Three 65 37 42 46 8 23 45 46 312 12.3%

Four 51 29 29 30 8 7 21 31 206 8.1%

Five 41 46 62 40 11 13 41 48 302 11.9%

Six 38 32 23 28 2 16 26 31 196 7.7%

Seven 36 21 23 38 2 15 32 16 183 7.2%

Eight 18 12 18 29 6 9 19 15 126 5.0%

Nine 16 5 8 14 3 3 13 9 71 2.8%

Ten 9 4 7 20 4 0 9 13 66 2.6%

Sum 491 277 350 480 68 157 340 380 2543

Proportion 19.3% 10.9% 13.8% 18.9% 2.7% 6.2% 13.4% 14.9%

Proportion

18 .4 %

12 .9 %

11.2 %12 .3 %

8 .1%

11.9 %

5.0 %

2 .8 % 2 .6 %

7.7% 7.2 %

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%

Zero One Two Three Four Five Six Seven Eight Nine Ten

Insignificant SevereModerateMildMinimal

p124

50%

0.80

0.69

0.62

0.50

0.410.43

0.32

0.25

0.33

0.27

0.20

0.18

0.31

0.31

0.47

0.48

0.40

0.40 0.53

0.50

0.45

0.40

0.01

0.00

0.08

0.03

0.07

0.11

0.280.19

0.17

0.18

0.20

0.020.00 0.00 0.00

0.040.06

0.000.03

0.00

0.09

0.20

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Zero One Tw o Three Four Five Six Seven Eight Nine Ten

3=Extremely Difficult”

2=Very Difficult

1=Somewhat Difficult

Unimpaired

Change 5: Know Clinicians LimitationsChange 5: Know Clinicians Limitations

How Often

What method?

n=226Comment: Frequency of cancer specialists enquiry about depression/distress from Mitchell et al (2008)

1,2 or 3 Simple QQ15%

Clinical Skills Alone73%

ICD10/DSMIV0%

Short QQ3%

Other/Uncertain9% Other/Uncertain

2%

Use a QQ15%

ICD10/DSMIV13%

Clinical Skills Alone55%

1,2 or 3 Simple QQ15%

Cancer StaffCurrent Method (n=226)

Psychiatrists

Comment: Current preferred method of eliciting symptoms of distress/depression

1,2 or 3 Simple QQ24%

Clinical Skills Alone20%

ICD10/DSMIV24%

Short QQ24%

Long QQ8%

Algorithm26%

Short QQ23%

ICD10/DSMIV0%

Clinical Skills Alone17%

1,2 or 3 Simple QQ34%

Cancer StaffIdeal Method (n=226)

Psychiatrists

Effective?

Comment: “Ideal” method of eliciting symptoms of distress/depression according to clinician

Comment: Slide illustrates diagnostic accuracy according to score on DT

11.815.4

30.4 28.9

41.9 42.9 40.7

57.1

82.4

66.771.4

15.8

25.0

26.124.4

19.4 19.0

33.3

21.4

11.8

22.2 14.3

72.4

59.6

43.546.7

38.7 38.1

25.921.4

5.911.1

14.3

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Zero One Two Three Four Five Six Seven Eight Nine Ten

Judgement = Non-distressedJudgement = UnclearJudgement = Distressed

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Pre-test Probability

Post

-test

Pro

babi

lity

Ave Confidence+

Ave Confidence-

Baseline Probability

Above Ave Confidence+

Above Ave Confidence-

High Confidence+

High Confidence-

Low confidence = more cautious, fewer false positives, more false negatives

High confidence = less cautious, more false positives, low false negatives

p180

Change 6: Screening EvolvesChange 6: Screening Evolves

Ultra-short

Brief

Lengthy (conventional)

Comment: This is a reminder of the structure of the HADS scale, this version adapter for cancer.

Validity of HADS vs depression (DSMIV)Validity of HADS vs depression (DSMIV)

SE 71.6% (68.3)

SP 82.6% (85.7)

Prev 13%

PPV 38%

NPV 95%

Somatic Bias in Mood Scales

Observation

Interview

Visual

Self-Report

DepressionScreeningmethods

DISCS

VA-SES

ET/DT

HAMD-D17

PhysicalGeneral

Signs ofDS

6

Stroke AphasicDepression

Scale21/10

MADRAS10

Trained

ConfidentSkilledClinician

Alone

YALE

SMILEY

Validity of Methods to Evaluate Depression

Unassisted Clinician Conventional Scales

Ultra-Short (<5) Short (5-10) Long (10+)Untrained Trained

British Journal of Cancer (2007) 96, 868 – 874

Validity of DT vs depression (DSMIV)Validity of DT vs depression (DSMIV)

SE 80%

SP 60%

PPV 32%

NPV 93%

Tools Compared_Palliative and Non-Palliative

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Pre-test Probability

Post

-test

Pro

babi

lity

1Q+1Q-Baseline ProbabilityHADS-D+HADS-D-HADS-T+HADS-T-BDI+BDI-HADS-A+HASD-A-DT+DT-

Tools Compared in Palliative Alone

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Pre-test Probability

Pos

t-tes

t Pro

babi

lity

HADS-D+

HADS-D-

Baseline Probability

2Q+

2Q-

EPDS+

EPDS-

1Q+

1Q-

Change 7: Underserved needsChange 7: Underserved needs

Underserved populationsUnderserved populations

More preferred to receive sensitive information from their general practitioner (BSA 62.5% versus 33%

DT vs DSMIV DepressionDT vs DSMIV Depression

SE SP PPV NPV

DTma 80.9% 60.2% 32.8% 92.9%

DTLeicesterBW 82.4% 68.6% 28.0% 98.3%

DTLeicesterBSA 100% 59.6% 26.8% 100%

BSA = British South Asian BW= British White

Change 8: Help Appears!Change 8: Help Appears!

DT DepTVsHADS-A

AnxT AngT

AUC:DT=0.82DepT=0.84AnxT=0.87AngT=0.685

8%

DT37%

DepT23%

AngT18%

AnxT47%

4%

7%

1%

1%

9%

3%

0%

2%

4%

15%

3%

2%

Nil41%

Non-Nil59%

DT

AnxT AngT

DepT

Change 9: Implementation RCTsChange 9: Implementation RCTs

What can enhance detection?

Comment: Slide illustrates actual gain in meta-analysis of screening implementation in primary care

Pre-Post Screen - DistressPre-Post Screen - Distress

Before After

Sensitivity of 49.7% 55.8% =>+5%

Specificity of 79.3% 79.8% =>+1%

PPV was 67.3% 70.9% =>+4%

NPV was 64.1% 67.2% =>+3%

There was a non-significant trend for improve detection sensitivity (Chi² = 1.12 P = 0.29).

Qualitative AspectsQualitative Aspects

DISTRESS

43% of CNS reported the tool helped them talk with the patient about psychosocial issues esp in those with distress

28% said it helped inform their clinical judgement

DEPRESSION

38% of occasions reported useful in improving communication.

28.6% useful for informing clinical judgement

ScreenRoutine vs At-Risk vs Identified

Low High

Follow-up Care

?? Desire for Help

Meetable Unmet Needs

Next StepNext Step 269 Nurse-patientinteractions

Helped 65 (24%) Not Helped 204 (76%)

Unmet Needs 150 (55.8%)

Referred 23 (8.6%) Declined Helped 20 (7.4%)

No Unmet Needs 34 (12.6%)

p179

What is QUICATOUCH?Quick, Individually Customised Assessment using TOUCHscreens

Prevalence over time

0

5

10

15

20

25

30

35

1 2 3 4 5 6 7 8Quarter of screening

% p

atie

nts

over

thre

shol

d Distress

Pain

First occasion of screening (n=4543)

Change 10: Symptom Research Back to BasicsChange 10: Symptom Research Back to Basics

Test Sensitivity Specificity PPV NPV

Clinical

Utility (+)

Clinical

Utility (‐)

Overall

Correct

little interest or pleasure in doing

things

73.5% 69.9% 50.8% 86.2% Poor

(0.374)

Average

(0.602)

70.97

Feeling down, depressed or

hopeless

83.7% 61.7% 48.1% 90.0% Poor

(0.403)

Average

(0.555

68.28

Trouble falling or staying asleep or

sleeping too much

86.7% 92.6% 83.2% 94.3% Good

(0.722

Excellent

(0.873

90.86

Feeling tired or having little energy

81.9% 83.7% 68.0% 91.6% Average

(0.557)

Good

(0.767)

83.15

Poor appetite or overeating

59.6% 89.3% 70.2% 83.9% Poor

(0.419)

Good

(0.749)

80.47

Feeling bad about yourself or that

you are a failure

54.2% 85.5% 61.2% 81.5% Poor

(0.332)

Good

(0.697)

76.16

Trouble concentrating on things

such as reading

69.3% 76.5% 55.6% 85.5% Poor

(0.385)

Good

(0.65)4

74.37

Thoughts that would be better off

dead

19.3% 96.9% 72.7% 73.9% Poor

(0.140)

Good

(0.717)

73.84

Optimal two‐stage combination of

items

100% 91.6% 83.4% 100% Excellent

(0.834)

Excellent

(0.916)

94.09

Whole Sample Palliative Patients Non-Palliative Patients

Symptom MDD No MDD MDD No MDD MDD No MDDlittle interest or pleasure in

doing things69.0% 7.80% 88.0% 9.93% 58.7%** 6.8%

Feeling down, depressed or

hopeless73.2% 6.60% 80.0% 7.95% 69.6% 6.0%

Trouble falling or staying

asleep or sleeping too much85.9% 23.00% 88.0% 23.18% 84.8% 22.9%

Feeling tired or having little

energy94.4% 27.30% 92.0% 24.50% 95.7% 28.6%

Poor appetite or overeating 81.7% 17.00% 88.0% 18.54% 78.3% 16.4%Feeling bad about yourself

or that you are a failure 88.7% 17.20% 80.0% 19.21% 93.5%* 16.4%

Trouble concentrating on

things such as reading 77.5% 6.40% 84.0% 8.61% 73.9% 5.4%

Moving or speaking so

slowly 84.5% 19.50% 88.0% 23.84% 82.6% 17.6%

Thoughts that would be

better off dead 35.2% 3.90% 24.0% 3.31% 41.3% 4.2%

Most Useful Diagnostic Symptoms for Depression in..Most Useful Diagnostic Symptoms for Depression in..

ONCOLOGY SETTINGS

1 Trouble concentrating2 Feeling down depressed or hopeless3 Feeling bad about yourself or that you are a failure 4 little interest or pleasure in doing things5 Moving or speaking so slowly that other people could have noticed

Thoughts that would be better off dead or of Poor appetite or overeatingTrouble falling or staying asleep or sleeping too muchFeeling tired or having little energy

PALLIATIVE SETTINGS

1. little interest or pleasure in doing things2. Trouble concentrating on things such as reading the 3. Feeling down depressed or hopeless4. Poor appetite or overeating

5. Feeling tired or having little energy

Trouble falling or staying asleep or sleeping too muchFeeling bad about yourself or that you are a failure Moving or speaking so slowly that other people could have noticedThoughts that would be better off dead or of

Change 11: Intervention ResearchChange 11: Intervention Research

Future of Psycho-oncology 2011Future of Psycho-oncology 2011

We have to address to basics first

We have to work collaboratively clinicians & researchers

We have to put the patient at the centre