High levels of anxiety and depression have been recorded among newly diagnosed cancer patients awaiting surgery in Sri Lanka.
These findings were made in an original paper on a ‘Brief psychological intervention to reduce psychological distress among pre-operative cancer patients: A randomised, single blind, two arm, parallel group, controlled trial in a selected tertiary care hospital in Sri Lanka’ which was authored by P.S. Alles (attached to the Sri Jayewardenepura University's Medical Sciences Faculty's Psychiatry Department), D. Alagiyawanna (attached to the same Faculty's Community Medicine Department), M. Seneviwickrama (attached to the same University's Centre for Cancer Research), S. Nanayakkara (attached to the Colombo South Teaching Hospital's Sri Jayewardenepura University Psychiatry Unit), M. Kariyawasam (attached to the same Hospital's Sri Jayewardenepura University Surgical Unit) and A. Pathirana (attached to the same Faculty's Surgery Department) and published in the Sri Lanka Journal of Psychiatry's 14th Volume's Second Issue in April of this year.
The diagnosis of cancer is, as mentioned in J.C. Holland's ‘Distress screening and the integration of psychosocial care into routine oncologic (branch of medicine that deals with the study, diagnosis, classification, treatment, and prevention of tumours including cancer) care’ and A. Werner, C. Stenner and J. Schüz's ‘Patient versus clinician symptom reporting: How accurate is the detection of distress in the oncologic after care?’, a traumatic event that can have a significant impact on an individual’s psychological wellbeing. Patients with cancer often suffer from anxiety and depression, with prevalence rates ranging from 40% to 80% (L. Anguiano, D.K. Mayer, M.L. Piven and D. Rosenstein's ‘A literature review of suicide in cancer patients’, M.J. Cordova, M.B. Riba and D. Spiegel's ‘Post-traumatic stress disorder and cancer’, J. Giese-Davis, K. Collie, K.M.S. Rancourt, E. Neri, H.C. Kraemer and D. Spiegel's ‘Decrease in depression symptoms is associated with longer survival in patients with metastatic [a pathogenic agent's spread from an initial or primary site to a different or secondary site within the host's body with the term being typically used to refer to metastasis by a cancerous tumour] breast cancer: A secondary analysis’, R.D. Nipp, A. El-Jawahri, J.N. Fishbein, E.R. Gallagher, J.M. Stagl, E.R. Park, V.A. Jackson, W.F. Pirl, J.A. Greer and J.S. Temel's ‘Factors associated with depression and anxiety symptoms in family caregivers of patients with incurable cancer’, and Y.L. Yang, G.Y. Sui, G.C. Liu, D.S. Huang, S.M. Wang and L. Wang's ‘The effects of psychological interventions on depression and anxiety among Chinese adults with cancer: A meta-analysis of randomised controlled studies’).
Psychological distress has been found to interfere with effective coping, treatment adherence, health-related behaviour, and overall survival. Despite the high prevalence of psychological distress among cancer patients, there is a low concordance between the distress ratings of patients and physicians. As a result, screening for distress is necessary to identify those patients with high distress.
C. Grimmett, N. Heneka and S. Chambers's ‘Psychological interventions prior to cancer surgery: A review of reviews’ points towards the potential of improving both psychological and treatment outcomes via the provision of psychological support early in the cancer pathway. Therefore, routine assessment and the treatment of cancer related distress are recommended by numerous regulatory bodies, including the National Comprehensive Cancer Network and the International Psycho-Oncology Society (per L.E. Carlson, A. Waller and A. Mitchell's ‘Screening for distress and unmet needs in patients with cancer: Review and recommendations’). Most psychological interventions are difficult to be applied in low-resource settings due to the scarcity of trained professionals, the large caseload, and the lack of integrated cancer care. In such circumstances, brief psychological interventions have been proposed as a potential solution. Though the effectiveness of psychological interventions has been studied in different cancer trajectories with promising results (per H. Faller, M. Schuler, M. Richard, U. Heckl, J. Weis and R. Küffner's ‘Effects of psycho-oncologic interventions on emotional distress and the quality of life in adult patients with cancer: Systematic review and meta-analysis’ and A. Pitman, S. Suleman, N. Hyde and A. Hodgkiss's ‘Depression and anxiety in patients with cancer’), evidence on the effectiveness of short term, simple multi modal psychological prehabilitation interventions are scarce (per T. Hanalis-Miller, G. Nudelman, S. Ben-Eliyahu and R. Jacoby's ‘The effect of pre-operative psychological interventions on psychological, physiological, and immunological indices in oncology patients: A scoping review’).
In Sri Lanka, the duration from the cancer diagnosis to surgical intervention takes four to six weeks.
Alles et al.'s study utilised a parallel group, two armed, prospective, randomised, controlled trial design to detect the effect of a brief psychological intervention on psychological distress in pre-operative cancer patients. One arm received routine clinical care while the other arm received a brief psychological intervention. The allocation ratio was one:one and determined using computer generated random numbers. The study included newly diagnosed cancer patients aged 18-65 years awaiting surgical interventions at the Colombo South Teaching Hospital. Patients with a past history of cancer, psychiatric diagnosis, cerebral involvement, severe physical pain or travelling difficulties were excluded. Those who required treatment for anxiety and depression were excluded. Based on the allocation, the patients were directed to receive either intervention or control.
Intervention
This study employed multi modal prehabilitation with a psychological component; a combination of education of their cancer, progressive deep muscle relaxation technique, and problem solving. Two structured intervention sessions took place over a period of three weeks. The first intervention session comprised of a half an hour discussion regarding the concerns of the diagnosis, and validating their anxiety (both done by the Surgical Senior Registrar), followed by deep muscle relaxation training for half an hour, and an hour of problem solving technique (both done by the Consultant Psychiatrist).
Patients were instructed to practise 30 minutes of deep muscle relaxation daily and to maintain a diary. Session one: Face to face session – two hours (i – education on diagnosis and management – Senior Registrar in Surgery – 30 minutes [tailored discussion on diagnosis, treatment, the care team, and the available resources; and ensuring patient understanding and allowing them to express emotions]; ii – relaxation training practice session on managing the stress response – Consultant Psychiatrist – 30 minutes [brief explanation of the stress response and its effects on cancer management; training on the progressive deep muscle relaxation technique and encouraging daily practice with the maintenance of a diary; and the validation of distress and the explanation of coping needs]; and iii – problem solving counselling – Consultant Psychiatrist – one hour [discussing concerns and stressors, identifying, and categorising amenable problems; prioritising problems and solving through a six step procedure; and addressing important but unsolvable problems, such as cancer related distress]).
The second stage of the intervention was a two hour session which included the continuation of answering further queries (by the Surgical Registrar), problem solving counselling and going through the diary after one week from the first intervention. In addition to the intervention, this group received routine preoperative care. Session two: face to face session – two hours (excluding exposure to other stress reduction programmes; clarification of questions on cancer related problems [by the Surgical Registrar] – 30 minutes; continued relaxation training and practice session [by the Consultant Psychiatrist] – 30 minutes; and continued problem solving counselling and addressing negative thoughts related to cancer – one hour).
The control group was given routine advice regarding investigations and routine care. These included a 10-minute discussion about the surgical procedure, the complications, the pros and cons of the surgery and the hospital stay by a multidisciplinary team including a surgeon, medical officers, and a nurse, and pre-operative oncological referral if necessary. In the routine care, patients are referred to a nutritionist, endocrinologist (a medical doctor who specialises in the diagnosis and treatment of problems with the endocrine [a messenger system in an organism comprising feedback loops of hormones that are released by internal glands directly into the circulatory system and that target and regulate distant organs] glands and hormone related diseases and conditions), urologist (a medical doctor specialising in conditions that affect the urinary tract in men, women and children, and diseases that affect the reproductive system), physician, or psychiatrist, depending on the need. Pre-operative investigations were arranged to reduce the hospital stay.
The outcomes were assessed three weeks after the initiation of the intervention since the average waiting time is four to six weeks at the Colombo South Teaching Hospital. The primary outcome was the interviewer administered Hospital Anxiety and Depression Scale (HADS) (A.S. Zigmond and R.P. Snaith's ‘The HADS’) scores. The secondary outcome, the patients’ perceptions of the intervention, was assessed using a four item questionnaire in a five point Likert scale under four domains: patients’ satisfaction on the knowledge and care that they received, the general well-being during the study period, and support by the family. The psychological distress of the participants was assessed at the baseline, and at the end of three weeks from the baseline using the HADS score. In addition, the first assessment included a questionnaire to assess the worries related to their cancer related coping methods. The second assessment included the HADS score, and the patients’ perception of the care given preoperatively in both the groups. In addition, this included the assessment of adherence to the intervention from the intervention group. Participants lost to follow up were contacted via phone to determine the reason for default.
To recruit the calculated sample size, 153 potential participants were screened.
Results
Out of the 88 patients enrolled to this study (46 to the intervention and 42 to the control arm), at the end of the three weeks follow up period, 37 patients were retained in each arm while 14 participants were lost to follow up as nine in the intervention group and five in the control group. The reasons for being lost to follow up included not being contactable, discontinuing the intervention due to severe anxiety and the postponement of the surgery due to Covid-19, and medical complications.
The mean age of the intervention group was 52.67 years while it was 54.86 years in the control group. In terms of gender, the intervention group had a higher percentage of females (67.39%) compared to the control group (59.52%).
The prevalence of anxiety at the baseline was 90.91% (intervention group 89.13% versus control group 92.86%). For depression, the baseline prevalence was 89.77% (intervention group 86.96% vs. control group 92.86%). The baseline mean HADS score of anxiety in the intervention group was 9.70 compared to 10.81 in the control group. The depression related mean HADS score in the intervention group was 9.67 compared to 10.88 in the control group.
The study evaluated the concerns of patients related to the cancer diagnosis in the intervention and control groups at the baseline (worries about physical disability, hospitalisation, finances, dependents, recurrences, and future treatments). The results showed that the intervention group had lower levels of worry compared to the control group. Specifically, 42.5% of the intervention group and 54.05% of the control group were worried about future treatments, while 40.5% of the intervention group and 43.2% of the control group were concerned about recurrences. The intervention group had lower levels of worry about dependents (53.4% vs. 62.1%). The intervention group had more worries than the control group in finances (59.4% vs. 51.3%), hospitalisation (29.7% vs. 25.5%) and worries about disability (70.3% vs. 66.7%) which ranked the highest among all. However, there were no significant differences in any of these groups.
The group analysis of both the arms revealed a significant reduction in both anxiety and depression. The mean anxiety scores in the intervention group indicated that there is a significant reduction following the brief intervention. The depression related scores of the intervention group followed a similar pattern. The control group showed similar results to that of the intervention group.
However, the magnitude of the reduction (in terms of the prevalence of anxiety and depression) is higher among the intervention group compared to the control group. Furthermore, the reduction in the prevalence of anxiety in the intervention group is 3.7 times higher compared to the reduction in depression.
The post-intervention between group comparison as per the intention to treat analysis showed that anxiety was significantly lower in the intervention group (30.43%) compared to the control group (69.5%). However, the prevalence of depression failed to show a significant reduction following the intervention. The number needed to treat to avert one case of anxiety is three.
In both groups, satisfaction about the knowledge and care that they received from the healthcare providers and the physical wellbeing, and the family support was assessed as secondary outcomes. The comparison between the groups about their satisfaction on the aforementioned four domains showed a higher proportion of satisfied patients in the intervention group. However, only satisfaction on the care received showed a statistically significant association: intervention vs. control 39.13% vs. 26.19% on the knowledge received, 36.96% vs. 14.28% on the care received, 39.13% vs. 28.57% on the physical well-being, and 36.96% vs. 23.81% on family support.
Discussion
This study reported a high prevalence of anxiety (90.91%) and depression (89.77%). The psychological distress was measured one week after breaking the bad news, the time during which the maximum level of anxiety has been reported, per J. Kendall, K. Glaze, S. Oakland, J. Hansen and C. Parry's ‘What do 1,281 distress screeners tell us about cancer patients in a community cancer centre?. Furthermore, this sample consisted only of pre-operative cancer patients. The Covid-19 pandemic that prevailed may also have contributed to the added level of anxiety and depression.
Worries related to physical problems were reported as the major source of distress in cancer patients, followed by emotional problems, according to B. Guan, K. Wang, Y. Shao, X. Cheng, J. Hao, C. Tian, L. Chen, K. Ji and W. Liu's ‘The use of the distress thermometer in advanced cancer in-patients with pain’. Worries related to disability ranked first in both the groups in the instant study. This highlights the importance of addressing patients’ concerns about the physical and functional impact of their cancer diagnosis and treatment. While the intervention showed a significant reduction in anxiety, it did not have a significant effect on depression. S. Williams and J. Dale's ‘The effectiveness of treatment for depression/depressive symptoms in adults with cancer: A systematic review’ noted that interventions for psychological distress among cancer patients have often failed to show an improvement in depression.
Theoretically, the observed improvement in the intervention group might have resulted from the additional time spent with the healthcare providers during the intervention sessions rather than the specific intervention itself. However, regardless of the mechanism, the clinical benefits are important.
In terms of limitations, higher anxiety levels that prevailed due to the Covid-19 pandemic situation could be a limitation. Another limitation would be the non-inclusion of patients diagnosed with oral, haematological (the branch of medicine that is concerned with and specialises in the study of the cause, prognosis, treatment, and prevention of diseases and disorders related to blood and blood related components), and lung cancers.
In conclusion, the study revealed the effectiveness of a brief psychological intervention on reducing their anxiety levels. The study findings highlight the importance of implementing brief interventions to improve the coping skills and mental health of the pre-operative cancer patients to improve their psychological status.