pocog - the future of psycho-oncology (aug 2011)
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DESCRIPTION
This is an invited talk on the "The Future of Psycho-Oncology" given to the POCOG group of the University of Sydney (lead Phyllis Butow) in August 2011.TRANSCRIPT
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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
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% 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
l con
ditio
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
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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
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What about preventive cancer care?What about preventive cancer care?
Do our vulnerable patients get enhanced access?
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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
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What is Changing?What is Changing?
Demographics
Clinician Expectations
Patient Involvement
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Lower EmphasisLower Emphasis
Depression (MDD, DSMIV)
Psychiatrist Judgement vs patient opinion
Ineffective interventions
Communication over Trust (diagnosis alone)
Palliative differences without evidence
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Increased EmphasisIncreased Emphasis
Early intervention & prevention
Screening Implementation > Validity
Distress (esp longitudinal)
Outreach and primary care
PROMs
Peer support and SMI models of care
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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)
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Psycho-oncology is Growing!Psycho-oncology is Growing!
2010 1990
Depression 143 12
Distress 121 14
Screening 1700 481
Communication 148 38
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Change 1: Epidemiology of CancerChange 1: Epidemiology of Cancer
Survival
Prevalence
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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
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10.9million incident cases (1mi breast, lung colorectal); 25mi prevalent cases
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Australian Bureau of Statistics
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Change 2: Clinician BehaviourChange 2: Clinician Behaviour
Information
Assisted decision making
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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
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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
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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
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Change 3: Clear Evidence BaseChange 3: Clear Evidence Base
Prevalence of depression
Relative risk of depression
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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)
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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)
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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.
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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)
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Change 4: DistressChange 4: Distress
6th Vital sign
Patient Opinion
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- 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
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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%
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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%
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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
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Change 5: Know Clinicians LimitationsChange 5: Know Clinicians Limitations
How Often
What method?
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n=226Comment: Frequency of cancer specialists enquiry about depression/distress from Mitchell et al (2008)
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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
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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
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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
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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
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Change 6: Screening EvolvesChange 6: Screening Evolves
Ultra-short
Brief
Lengthy (conventional)
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Comment: This is a reminder of the structure of the HADS scale, this version adapter for cancer.
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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%
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Somatic Bias in Mood Scales
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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
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Validity of Methods to Evaluate Depression
Unassisted Clinician Conventional Scales
Ultra-Short (<5) Short (5-10) Long (10+)Untrained Trained
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British Journal of Cancer (2007) 96, 868 – 874
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Validity of DT vs depression (DSMIV)Validity of DT vs depression (DSMIV)
SE 80%
SP 60%
PPV 32%
NPV 93%
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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-
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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-
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Change 7: Underserved needsChange 7: Underserved needs
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Underserved populationsUnderserved populations
More preferred to receive sensitive information from their general practitioner (BSA 62.5% versus 33%
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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
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Change 8: Help Appears!Change 8: Help Appears!
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DT DepTVsHADS-A
AnxT AngT
AUC:DT=0.82DepT=0.84AnxT=0.87AngT=0.685
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8%
DT37%
DepT23%
AngT18%
AnxT47%
4%
7%
1%
1%
9%
3%
0%
2%
4%
15%
3%
2%
Nil41%
Non-Nil59%
DT
AnxT AngT
DepT
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Change 9: Implementation RCTsChange 9: Implementation RCTs
What can enhance detection?
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Comment: Slide illustrates actual gain in meta-analysis of screening implementation in primary care
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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).
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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
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ScreenRoutine vs At-Risk vs Identified
Low High
Follow-up Care
?? Desire for Help
Meetable Unmet Needs
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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
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What is QUICATOUCH?Quick, Individually Customised Assessment using TOUCHscreens
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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)
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Change 10: Symptom Research Back to BasicsChange 10: Symptom Research Back to Basics
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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
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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%
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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
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Change 11: Intervention ResearchChange 11: Intervention Research
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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