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Michigan Oncology Journal Summer 2000

Screening and Treating Distress in Cancer Patients: Integration of Research and Clinical Practice

Peter C. Trask, Ph.D.,
Research Investigator and Coordinator of Clinic Research
Behavioral Medicine Program, Department of Psychiatry

Amber G. Paterson, Ph.D.,
Research Fellow, Department of Psychiatry

Michelle Riba, M.D.,
Clinical Assistant Professor
Department of Psychiatry,Director of Psycho-Oncology Program
Treating distress is one of the ways those affiliated with the Psycho-Oncology Program, a cooperative venture between the University of Michigan Comprehensive Cancer Center (UMCCC) and the Department of Psychiatry, are trying to help patients deal with cancer. Distress is a problem that impacts individuals with cancer and those around them. For example, distress in medical patients has been associated with delays in immune response, healing and recovery times, reduced survival times, and increased utilization of medical and social services, in addition to impairments in personal, social, and occupational functioning (1, 2, 3, 4). Unfortunately, although these facts are generally known, incorporating this information appropriately into clinical practice can be difficult and has led to several questions including: How does one identify and treat a distressed patient most effectively? How and when is distress best measured? Which interventions yield the best results? In an attempt to answer these questions and improve the quality of care provided to distressed cancer patients, Peter Trask, Ph.D., and Amber Paterson, M.S., in collaboration with Michelle Riba, M.D., and Tim Johnson, M.D., Director of the Multidisciplinary Melanoma Clinic, as well as faculty and staff in the Melanoma Clinic and the Bone Marrow Transplant Program, are conducting studies focused on screening, evaluating and treating distress in these patients.

Melanoma accounts for only 5% of skin cancer cases, but over 75% of skin cancer-related deaths (5), and continues to increase in men and women faster than any other solid tumor. Early treatment is especially important given that survival rate and treatments depend on depth of tumor and spread of disease (6, 7). This population is susceptible to demonstrating a wide range of emotional distress in response to both the primary and adjuvant therapies, as well as potential or perceived changes to quality of life, and may respond to interventions aimed at reducing distress. Given that several studies have reported that baseline levels of emotional distress and coping are significant predictors of recurrence of disease and survival (8, 9), longitudinal studies of distress that include a pre-treatment baseline assessment appear to be important.

Bone marrow transplantation (BMT) is used to treat a variety of cancers (e.g., Hodgkin's disease, leukemia, breast cancer, multiple myeloma). Recipients of bone marrow transplantation undergo an intensive procedure requiring isolation and a lengthy convalescent period (6 weeks in hospital) that often results in significant physical and psychosocial morbidity (10, 11), including reports of suicide attempts (12), and the development of Post-Traumatic Stress Disorder symptomatology (13). Recent research has found clinically significant scores on measures of anxiety and depression in 30 to 50% of patients in the months and years following transplant (14, 15, 16), including persistence of symptoms for up to 6 years (15). Global ratings of distress have been found to be elevated in as many as 93% of patients over an average of 3 years post-transplant. Such dysfunction has been found to be significantly higher than similar ratings by both healthy controls and other cancer patients (17, 18) and has been associated with longer hospital stays, poorer treatment outcomes and lower survival rates (19, 20). Additional areas of specific concern associated with impairment and distress include pain, fatigue and sexual functioning (21).

Melanoma and BMT are two areas where patients may experience a significant amount of distress and may benefit from psychological intervention. In particular, the potentially rigorous and comprehensive treatments undertaken by these patients puts them at greater risk for experiencing significant distress. Normally, distressed oncology patients are referred to members of the psycho-oncology program only when problems are noted by someone on the consulting/ treatment team. One exception to this is a pre-BMT psychological evaluation, in which Brook Brines, Ph.D., routinely completes a psychiatric history and assesses prospective recipients' levels of distress at the time of admission. She suggested that an "early red flag" would often be helpful in minimizing the impact of patients' distress and ensuring as smooth a process as possible for all involved. Given this, as part of two studies being conducted with the help of an award from the Faculty Group Practice, distress is being assessed at the time of initial consultation in both the Melanoma and BMT programs to determine if earlier identification of patient distress is possible and/or useful.

The basic design of the melanoma and BMT studies is essentially identical. Upon arrival to the clinic and prior to any intervention, patients complete a series of questionnaires on emotional distress, quality of life, coping strategies and anxiety designed to provide baseline levels of distress at initial contact with the UMCCC. Those who go on to receive treatment at the University of Michigan are asked to participate in a second phase, in which distress is again evaluated following the medical intervention and participants are divided by distress level into low, medium and high distress groups. Within each group, individuals are randomly assigned to either standard medical care or standard medical care plus a psychological intervention. Following the intervention, individuals are again assessed and receive subsequent assessment at 6- and 12-month follow-up appointments to determine if distress has returned. In this way, it is hoped that early predictors of distress and efficacious methods for its reduction may be identified so that they may be easily incorporated into clinical practice.

Currently, the studies are in two separate phases. Although the BMT study is still in the design phase, the melanoma study has been running for the past month. During that time, 50 patients have agreed to participate in the first part of the study, that which assesses distress at the time of consultation. Of the 50 individuals, complete data has been obtained on 27 of them, with the majority of the remainder not having had the opportunity to return the questionnaire package. Of these 27 individuals, 43% are male and 57% are female. The majority of participants are either currently working or are retired and the overwhelming majority are Caucasian. Eighty-five percent of the participants are married, with 7.4% being divorced, and 3.7% being either never married or widowed. In terms of education, 42.3% have completed at least high school and 34.6% have completed college. The majority of participants reported minimal use of alcohol, marijuana or other substances, and 53.8% reported never having smoked.

Of greater interest is the amount of distress individuals are reporting at the time of presentation to the Melanoma Clinic. Figure 1 presents the mean and range of scores on the Brief Symptom Inventory, which is being used to determine the amount of distress. The measure is scored with a mean of 50 and a standard deviation of 10, such that scores above 60 are indicative of moderate distress and scores above 70 representative of severe distress. Looking at the BSI as a measure of overall distress, it appears that individuals are presenting to the Melanoma Clinic on average without a clinically significant level of distress. Of greater importance is the wide range of distress in individuals at this time point. Although the group, on average, does not exhibit a significant level of distress, there are several individuals who are exhibiting significant emotional difficulties. Given that this is their first exposure to the clinic, the current study is especially interested in determining whether this level of distress remits following psychological intervention.

Individuals reported using a variety of coping strategies to deal with their illness, with "seeking social support" and "use of problem-solving coping" being the two most frequently used. Figure 2 presents the average scores on the various coping scales. In terms of health functioning, the majority of individuals reported having excellent or very good health in areas such as physical functioning and mental health. Finally, initial correlations between the variables revealed that higher levels of distress were associated with more acceptance coping, more trait anxiety, and lower levels of social functioning, vitality and mental health.

What these preliminary data indicate is that while patients are reporting average levels of distress at presentation to the clinic, there is a wide variability, with some individuals being significantly distressed. Those individuals who are generally reporting healthy strategies of coping with the stress of a possible diagnosis of melanoma are functioning well. However, the data also suggest that individuals experiencing higher levels of distress tend to utilize less adaptive coping strategies, such as being confrontational or simply accepting events. These individuals with increased distress and less adaptive coping styles also report more difficulties in social functioning at the time of their initial consultation to the Melanoma clinic.

At this time we have not started the second part of the study, the intervention. It will be interesting to determine whether individuals distressed at consultation remain distressed, and whether provision of a psychological intervention serves to reduce that distress. Given the initial success of the melanoma study, we are looking forward to implementing it with the bone marrow transplant population.

References

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4. Linn, MW, Linn, BS, & Jensen, J. Stressful events, dysphoric mood, and immune responsiveness. Psychological Reports 1984;54:219-222.

5. Fawzy, FI, & Fawzy, NW. Skin neoplasms and malignant melanoma. In JC Holland (Ed.), Psycho-oncology, (pp. 371-379). 1998; New York: Oxford University Press.

6. Johnson, TM, Smith, JW, Nelson, BR, & Chang, AC. Current therapy for cutaneous melanoma. J Am Acad Dermatol. 1995;32:689-707.

7. Jakowitz, JG, & Meyskens, Fl, Jr. Evaluation and treatment of the patient with early melanoma. Compr Ther 1995;21:46-50.

8. Fawzy, FI, Fawzy, NW, Hyun CS et al. Malignant melanoma: Effects of an early structured intervention, coping, and affective state on recurrence and survival 6 years later. Arch Gen Psychiatry 1993;50:681-689.

9. Andrykowski MA, & McQuellon, RP. Bone marrow transplantation. In JC Holland (Ed.), Psycho-oncology, (pp. 289-299). 1998; New York: Oxford University Press.

10. Gale, RP. Progress in bone marrow transplantation in man. Survey of Immunological Research 1982;1:40-66.

11. Colon, EA, Callies, AL, Popkin, MK, & McGlave PB. Depressed mood and other variables related to bone marrow transplantation survival in acute leukemia. Psychosomatics 1991;32:420-425.

12. Molassiotis, A, & Morris, PJ. Suicide and suicidal ideation after marrow transplantation. Bone Marrow Transplant 1997; 19:87-90.

13. Jacobsen, PB, Widows, MR, Hann, DM, Andrykowski, MA, Kronish, LE, & Fields, KK. Posttraumatic stress disorder symptoms after bone marrow transplantation for breast cancer. Psychosomatic Medicine 1998;60:366-371.

14. McQuellon, RP, Craven, B, Russell, GB, et al. Quality of life in breast cancer patients before and after autologous bone marrow transplantation. Bone Marrow Transplant 1996; 18: 579-584.

15. Syrjala KL, Chapko MK, Vitaliano PP, et al. Recovery after allogeneic marrow transplantation: Prospective study of predictors of long-term physical and psycho-social functioning. Bone Marrow Transplantation 1993; 11:319-327.

16. Leigh S, Wilson KCM, Burns R, & Clark RE. Psychosocial morbidity in bone marrow transplant recipients: A prospective study. Bone Marrow Transplantation 1995; 16:635-640.

17. Winningham, ML, Nail, LM, Burke, MB, et al. Fatigue and the cancer experience: The state of the knowledge. Oncology Nursing Forum 1994; 21:23-36.

18. Molassiotis, A, ven den Akker, OBA, Milligan, DW, et al. Quality of life in long-term survivors of marrow transplantation: Comparison with a matched group receiving maintenance chemotherapy. Bone Marrow Transplant 1996; 17: 249-258.

19. Andrykowski, MA, Brady, MJ, & Henslee-Downey, PJ. Psychosocial factors predictive of survival after allogeneic bone marrow transplantation for leukemia. Psychosomatic Medicine 1994; 56:432-439.

20. Futterman, AD, Wellisch, DK, Bond, G, & Carr, CR The psychosocial levels system: A new rating scale to identify and assess emotional difficulties during bone marrow transplantation. Psychosomatics 1991;32:177-186.

21. Winer, EP, Lindley, C, Hardee, M, et al., Quality of life in patients surviving at least 12 months following high dose chemotherapy with autologous bone marrow support. Psycho-oncology 1999; 8: 167-176.

Figure 2 Average Scores on Scales on the Ways of Coping Questionnaire

 

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