Several previous studies have shown patients with cancer are more likely to be at increased risk of psychiatric symptoms and disorders, but a new, large study has revealed patients are more specifically at an especially increased risk of several stress-related mental disorders both immediately before and after being diagnosed with cancer. The new paper was published online ahead of print in JAMA Oncology (doi:10.1001/jamaoncol.2016.0483).
"To the best of our knowledge, our study represents the first and largest study to date estimating the burden (and its temporal pattern of) mental disorders potentially related to psychological stress among adult cancer patients during the pre-diagnostic to post-diagnostic periods," the study's lead author Donghao Lu, MD, a PhD candidate in the Department of Medical Epidemiology & Biostatistics at Karolinska Institutet in Stockholm, said in an email.
The researchers cross-referenced data from the 1990 Swedish Population and Housing Census to identify all individuals born and living in Sweden at the time (7,792,012 individuals) with data from the Swedish Cancer Registry, Patient Register, Prescribed Drug Register, Cause of Death Register, and Migration Register. They included 304,118 individuals from the census data who were subsequently diagnosed with a first cancer between 2001 and 2009-and identified if and when those individuals were treated for a mental disorder or were prescribed a psychiatric medication (including antidepressants, anxiolytics, hypnotics, or sedatives). They designated a pre-diagnostic period as the time frame two years prior to the diagnosis of each individual with cancer and the post-diagnostic period as the time period from cancer diagnosis onward.
The researchers then randomly selected 10 individuals from the census data per each patient with cancer who had not been diagnosed with cancer or a mental disorder to serve as a control group (3,041,174 individuals) who matched the year of birth and sex of the patient with cancer.
The data showed the patients with cancer were at a heightened risk of being treated for a stress-related mental disorder-stress reaction/adjustment disorder, depression, anxiety, substance abuse, and somatoform/conversion disorder-from 10 months before cancer diagnosis to the 10 years after being diagnosed with cancer. That risk was highest in the first week following a cancer diagnosis. The data also showed use of any psychiatric medication peaked around three months after cancer diagnosis (18.1% of the patients with cancer versus 11.9 percent of the healthy control group), and decreased slowly thereafter but remained elevated two years after diagnosis (15.4% of the patients with cancer vs. 12.7% of the healthy controls).
Lu elaborated on the implications of those findings for practicing oncology care providers and in terms of rethinking about current guidelines on the role of psychosocial care in cancer care.
1 Other studies have shown cancer patients are at increased risk of psychiatric disorders-what was new about these findings?
"The vast majority of clinical and research efforts have been given to the post-diagnostic period of cancer, focusing on the survivorship, the end-of-life stage, and increasingly also the immediate periods after diagnosis and primary cancer treatment. Whether or not the diagnostic workup leading to a cancer diagnosis increases the risk of mental disorders was however largely unknown.
"We found that among cancer patients, the risks for several common and potentially stress-related mental disorders, including depression, anxiety, substance abuse, somatoform/conversion disorder, and stress reaction/adjustment disorder started to increase from 10 months before cancer diagnosis and peaked during the first week after diagnosis, compared with cancer-free individuals in Sweden.
"We also found that-in addition to depression-anxiety, stress reaction, and adjustment disorders were also common among cancer patients."
2 Psychosocial care and mental health screening are already a part of cancer care (OT 11/25/13 issue) and cancer survivorship care guidelines (OT 5/25/14 issue). What implications do these new findings have on the existing guidelines and how oncologists should use those guidelines in the clinical setting?
"Our findings support the existing guidelines of integrating psychological management into cancer care. And we specifically call for the extended vigilance for multiple mental disorders, instead of focusing on depression or anxiety alone, and we stress the importance of such interventions already [be in place] during the time of cancer diagnostic workup."
3 What did your research reveal about how mental health disorders in patients diagnosed with cancer are different than those diagnosed in others without cancer? And what are the next steps to your research?
"More research is needed to better understand this question. Although our findings highlight the importance of a timely psychological intervention throughout cancer diagnosis, whether or not such intervention should be specifically tailored for cancer patients as compared to individuals without such life-threatening condition remains to be explored.
"We are currently examining in more details the temporal pattern of stress experience as well as its related health outcomes (including mental disorders) within the time period of cancer diagnostic workup and by patient characteristics. We aim to identify specific time windows or high risk groups for potential clinical intervention."