Long-term survivors of head and neck cancer who have undergone radiation treatment report episodes of depression at almost twice the rate found in the general population during the first year, but many do not seek treatment. That is the conclusion of a new analysis, published online ahead of print in the Journal of the American Medical Association: Otolaryngology, Head, and Neck Surgery (doi:10.1001/jamaoto.2013.4072) by researchers at the University of California, Davis.
“Despite a relatively high rate of depression among patients in the post-radiation therapy setting, mental health services are severely underutilized,” said lead author Allen M. Chen, MD, now Associate Professor and Vice-Chair in the Department of Radiation Oncology at the David Geffen School of Medicine of UCLA.
He and his colleagues asked some 200 disease-free patients who had undergone radiation treatment for squamous cell carcinoma of the head and neck to rate their mood at one, three, and five years later. Those who responded that they were “somewhat depressed” or “extremely depressed” were also asked if they were undergoing counseling or treatment for depression or had done so since treatment.
The prevalence of depression was 17 percent during the first year, 15 percent in the second year, and 13 percent the following year. By comparison, about 6.7 percent of U.S. adults suffer from major depression in any given year, according to the National Institute of Mental Health.
Only six percent of the surveyed patients reported using antidepressants in the first year and 11 percent during the second year, but at three years none of them were using medication. The rates of patients undergoing or actively seeking psychotherapy or counseling were three, six, and zero percent over the three-year period, respectively.
The study excluded patients with a history of mood disorder, use of mental health services in the past, or who had previous or current use of antidepressants.
Variables that were found to be significantly associated with depression included use of a tracheostomy tube or the presence of laryngeal stoma, gastrostomy tube dependence, and continuing to smoke at follow-up.
“The fact that none of these patients had a pre-existing diagnosis of mental health problems suggests that the diagnosis of cancer and/or sequelae of treatment were likely the primary causes for their psychosocial symptoms,” Chen said in an interview.
Other studies have reported levels of depression among head and neck cancer patients ranging from eight to 44 percent at various time points during treatment, with the wide range likely due to the variability in screening instruments and patient characteristics across studies, he explained.
Why do so few such survivors seek help for depressive symptoms? Several factors might be involved, Chen said: “These were patients I personally cared for and I generally referred them to mental health or psychosocial counseling, but it was increasingly obvious that compliance was poor. I believe insurance issues or a lack of resources to pay for evaluation and/or treatment was a major issue.
“Head and neck cancer patients tend to be lower on the socioeconomic scale, and mental health services are typically not free. There is also a persistent social stigma attached to depression, which can make follow-through difficult. But this is just speculation.”
It is also unclear why such patients might be more prone than the general public toward depression, especially after surviving cancer, he said, but increased social isolation due to the physical aftereffects of treatment is a possible factor.
“Head and neck cancer often results in a lot of functional deficits and disfigurement that can interfere with social behaviors, such as difficulty swallowing, chronic dry mouth, and problems with breathing and speaking,” he explained. “Physicians need to be more aware of how psychosocial distress affects long-term quality of life in these patients, and I believe oncologists should take the lead in this.
“It is important that treatment centers have a team of dedicated, site-specific nurses and social workers who can work with insurance companies to get coverage for mental health issues and encourage patients to seek counseling and join support groups whenever possible.”
The Anxiety Curve
Although depressive symptoms may begin to ease with the passage of several years, many cancer survivors later develop clinical anxiety, according to another new study (Lancet Oncol 2013;14:721–732).
“Depression is an important problem after cancer, but it tends to improve within two years of a diagnosis unless there is a further complication,” said lead author Alex Mitchell, MRCPsych, an honorary senior lecturer based at Leicester General Hospital. “Anxiety is less predictable and is a cause for concern, even 10 years after a diagnosis, but screening for anxiety has been largely overlooked in these patients.”
In that study, he and his colleagues conducted a systematic review and meta-analysis of studies on depression and anxiety involving about half a million cancer patients at least two years after diagnosis. While the levels of depression were roughly equal to the rates for adults without a history of cancer after two years (11.6% vs. 10.2%), survivors were 27 percent more likely to experience anxiety at two years, and the rate increased to 50 percent after 10 years.
“I feel that a major limitation in the study by Dr. Chen and his colleagues is that they did not ask patients about anxiety, which we and others have found to be a significant mental health issue long after cancer has been treated,” Mitchell said. “The strength of the study is not in its assessment of depression, but in its clarification of the gap in mental health treatment for cancer survivors.”
‘Worrisome Psychosocial Care Gap’
There is a great deal of evidence that psychosocial needs are the predominant oversight in cancer patients, he noted, pointing to, for example, a 2012 study of 3,000 cancer patients 14 months after diagnosis, which found that 30.6 percent had unmet psychosocial needs, as well as previous research suggesting that in any given year only 20 and 40 percent of patients receive any psychosocial help.
In addition, a 2010 study of breast cancer patients treated at 101 hospitals in Germany found that only one-third received care from a psycho-oncology service. That rate was similar to a 2005 study of U.S. patients receiving psychosocial care in primary health settings.
“In other words, receiving mainstream medical care in a comprehensive or specialist cancer center is no guarantee that all patients will receive good-quality psychosocial care,” Mitchell said.
Another example was an audit of 1,660 medical records across Florida cancer centers, published in 2010, which found that only 52 percent of records included evidence of an assessment of psychosocial well-being (Paul Jacobsen et al: Psychooncology 2011;20:1221–1227).
“While the study by Dr. Chen and his colleagues shows that head and neck cancer patients appear to be especially vulnerable to untreated depression, mental health problems and a lack of treatment are common across all types of cancer,” Mitchell said. “It is up to cancer professionals and mental health specialists to decide how best to address this worrying psychosocial care gap.”