Development of computer adaptive testing for measuring depression in patients with cancer.

The usefulness of depression scales for patients with cancer based on item response theory (IRT) and computer adaptive testing (CAT) has not yet been fully explored. This study thus aimed to develop an IRT-based tool for measuring depression in patients with cancer. We analyzed data from 393 patients with cancer from four tertiary centers in Japan who had not received psychiatric treatment. They answered 62 questions across five categories regarding their psychiatric status over the previous week. We selected 28 items that satisfied the assumptions of IRT, fitted a graded response model to these items, and performed CAT simulations. The CAT simulation used an average of 6.96 items and showed a Pearson's correlation coefficient of 0.916 (95% confidence interval, 0.899-0.931) between the degree of depression estimated by simulation and that estimated using all 28 items. The measurement precision of CAT with only four items was superior to that of the estimation using the calibrated Patient Health Questionnaire-9. These results imply that this scale is useful and accurate for measuring depression in patients with cancer.

Stress and coping strategies among allogeneic haematopoietic stem cell transplantation survivors: A qualitative study.

OBJECTIVE: The aim of this qualitative study was to explore allogeneic haematopoietic stem cell transplantation (allo-HSCT) survivors' perspectives of stresses and their coping strategies, in order to attain a deeper understanding of their experience. METHODS: We conducted semi-structured interviews with 20 Japanese allo-HSCT survivors about the stresses they experienced and how they coped. We then conducted a content-driven thematic analysis of the interview results. The interview questions probed stresses and coping strategies related to allo-HSCT. RESULTS: We identified 74 stresses across 7 domains: symptoms after transplantation, limitations in daily life, appearance changes, relationship anxieties, work impairment and financial issues, uncertainty and disappointed expectations. In addition, 21 coping strategies were identified across 3 domains: direct efforts to manage problems, adaptive attitude, and seeking and using social support. CONCLUSION: By identifying a broad range of stressors associated with allo-HSCT, insight was gained as to the impact of allo-HSCT on survivors' lives. These results provide a foundation for the future development of resources for survivors, their significant others and clinicians. Stressors and coping strategies among allo-HSCT survivors were comprehensively characterised, which will provide useful information for patients and enable healthcare practitioners to provide better care.

Explicit prognostic disclosure to Asian women with breast cancer: A randomized, scripted video-vignette study (J-SUPPORT1601).

BACKGROUND: Nondisclosure of a poor prognosis to patients with advanced cancer remains a typical practice in Asia. Although the importance of prognostic communication has increasingly been recognized worldwide, little is known about whether explicit prognostic disclosure positively affects Asian patients with advanced cancer. The objective of this study was to examine the effects of explicit prognostic communication on patients with cancer recurrence. METHODS: In this randomized, video-vignette study, Japanese women with breast cancer who had undergone curative surgery viewed videos of prognostic communication between a patient with recurrent, incurable breast cancer and her oncologist. The videos differed only in the presence or absence of explicit prognostic disclosure. The primary outcome was participants' uncertainty (rated from 0 to 10), and the secondary outcomes included anxiety (measured on the State-Trait Anxiety Inventory-State: range, 20-80), satisfaction (Patient Satisfaction Questionnaire; range 0-10), self-efficacy (range, 0-10), and willingness to discuss advance care planning (range, 1-4). RESULTS: In total, 105 women participated (mean ± SD age, 53.8 ± 8.2 years). After viewing the video with more versus less explicit disclosure, participants showed significantly lower uncertainty (mean ± SE scores, 5.3 ±0.2 vs 5.7 ± 0.2, respectively; P = .032) and higher satisfaction (5.6 ± 0.2 vs 5.2 ± 0.2, respectively; P = .010) without increasing anxiety (changes in scores on the State-Trait Anxiety Inventory-State: 0.06 ± 0.5 vs 0.6 ± 0.5, respectively; P = .198). No significant differences were observed in self-efficacy (5.2 ± 0.2 vs 5.0 ± 0.2, respectively; P = .277) or willingness to discuss advance care planning (2.7 ± 0.1 vs 2.7 ± 0.1, respectively; P = .240). CONCLUSIONS: Explicit prognostic disclosure prompted better outcomes than nondisclosure in Japanese women with breast cancer. When asked about the prognosis by Asian patients with cancer, clinicians may be encouraged to respect their wishes and explicitly discuss the prognosis if deemed appropriate.

Preoperative Anxiety as a Predictor of Delirium in Cancer Patients: A Prospective Observational Cohort Study.

BACKGROUND: Postoperative delirium is a common and important complication in cancer patients. We need to identify patients at high risk of postoperative delirium such that it can be prevented preoperatively or in early postoperative phase. The aim of this study was to investigate whether preoperative anxiety predicted onset of postoperative delirium in cancer patients, not only in order to identify high-risk groups but also to help develop new preventive approaches. METHODS: This was a prospective observational cohort study of cancer patients undergoing tumor resections. Postoperative delirium was assessed using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Preoperative anxiety was evaluated with the Hospital Anxiety and Depression Scale-Anxiety (HADS-A), and we defined HADS-A > 7 as clinical anxiety. We conducted multivariate logistic regression to determine which factors were predictors of delirium. RESULTS: The final analysis included 91 patients, 29 of whom met the criteria for postoperative delirium. In multivariable logistic regression, age (5-year increments; odds ratio (OR) = 1.565, 95% confidence interval (CI) = 1.057-2.317, p = 0.025) and HADS-A > 7 (OR = 4.370, 95% CI = 1.051-18.178, p = 0.043) predicted delirium onset. These variables explained 74.2% of the variance. CONCLUSIONS: Preoperative anxiety strongly predicted postoperative delirium in cancer patients. Our findings suggest that preoperative anxiety may be a new target for prevention of postoperative delirium. Trial registration number This study was registered at UMIN000018980.

Fan Therapy Is Effective in Relieving Dyspnea in Patients With Terminally Ill Cancer: A Parallel-Arm, Randomized Controlled Trial.

CONTEXT: Dyspnea is a common distressing symptom among patients with advanced cancer. OBJECTIVE: The objective of this study was to determine the effect of fan therapy on dyspnea in patients with terminally ill cancer. METHODS: This parallel-arm, randomized controlled trial included 40 patients with advanced cancer from a palliative care unit at the National Cancer Center Hospital in Japan. All patients experienced dyspnea at rest with a score of at least three points on a subjective 0- to 10-point Numerical Rating Scale (NRS), showed peripheral oxygen saturation levels of ≥90%, had an Eastern Cooperative Oncology Group grade of 3 or 4, and were aged 20 years or more. In one group, a fan was directed to blow air on the patient's face for five minutes. This group was compared to a control group wherein air was blown to the patient's legs. Patients were randomly assigned to each group. The main outcome measure was the difference in dyspnea NRS scores between fan-to-face and fan-to-legs groups. RESULTS: No significant differences were seen in baseline dyspnea NRS between groups (mean score, 5.3 vs. 5.1, P = 0.665). Mean dyspnea changed by -1.35 points (95% CI, -1.86 to -0.84) in patients assigned to receive fan-to-face and by -0.1 points (-0.53 to 0.33) in patients assigned to receive fan-to-legs (P < 0.001). The proportion of patients with a one-point reduction in dyspnea NRS was significantly higher in the fan-to-face arm than in the fan-to-legs arm (80% [n = 16] vs. 25% [n = 5], P = 0.001). CONCLUSION: Fan-to-face is effective in alleviating dyspnea in patients with terminally ill cancer.

Japanese physicians' attitudes toward end-of-life discussion with pediatric patients with cancer.

PURPOSE: We explored pediatricians' practices and attitudes concerning end-of-life discussions (EOLds) with pediatric patients with cancer, and identified the determinants of pediatricians' positive attitude toward having EOLds with pediatric patients. METHODS: A multicenter questionnaire survey was conducted with 127 pediatricians specializing in the treatment of pediatric cancer. RESULTS: Forty-two percent of participants reported that EOLds should be held with the young group of children (6-9 years old), 68% with the middle group (10-15 years old), and 93% with the old group (16-18 years old). Meanwhile, 6, 20, and 35% of participants answered that they "always" or "usually" discussed the incurability of the disease with the young, middle, and old groups, respectively; for the patient's imminent death, the rates were 2, 11, and 24%. Pediatricians' attitude that they "should have" EOLds with the young group was predicted by more clinical experience (odds ratio [OR] 1.077; p = 0.007), more confidence in addressing children's anxiety after EOLd (OR 1.756; p = 0.050), weaker belief in the demand for EOLd (OR 0.456; p = 0.015), weaker belief in the necessity of the EOLd for children to enjoy their time until death (OR, 0.506; p = 0.021), and weaker belief in the importance of maintaining a good relationship with the parents (OR 0.381; p = 0.025). CONCLUSIONS: While pediatricians nearly reached consensus on EOLds for the old group, EOLds with the young group remain a controversial subject. While pediatricians who supported EOLds believed in their effectiveness or necessity, those who were against EOLds tended to consider the benefits of not engaging in them.

Evaluation of the Appropriate Washout Period Following Fan Therapy for Dyspnea in Patients With Advanced Cancer: A Pilot Study.

OBJECTIVES: To clarify the duration required for dyspnea to return to baseline severity after fan therapy, to evaluate whether fan-to-legs therapy or no fan therapy would be a suitable control therapy, and to investigate changes in patients' face surface temperature after fan therapy. METHODS: In this pilot study, all participants received 3 interventions in the following order: no fan, fan to legs, and fan to face. Participants used a fan for 5 minutes, and they scored their dyspnea at 10-minute intervals for 60 minutes or until the score had returned to its baseline value, whichever occurred first. Nine patients with advanced cancer admitted to a palliative care unit were included; they had dyspnea at rest and rated its severity as at least 3 points on a 0- to 10-point numerical rating scale. Descriptive statistics and the Wilcoxon signed rank test were used to analyze the data. RESULTS: All patients completed the study. Of the 9 participants, 6 experienced a clinical benefit from using a fan to their faces. Of these patients, only 2 participants' (2 of 6) dyspnea scores returned to baseline by the end of the 60-minute assessment period after exposure to fan-to-face therapy. In fan-to-legs and no fan settings, there was no change in the dyspnea scores. There were significant differences between the baseline face surface temperature and that after fan-to-face and fan-to-legs settings. CONCLUSION: When using a crossover design to investigate the effect of fan therapy on dyspnea, 1 hour is an insufficient washout period.

Yokukansan for the treatment of preoperative anxiety and postoperative delirium in colorectal cancer patients: a retrospective study.

BACKGROUND: Yokukansan (YKS), a Japanese traditional herbal medicine for neurosis and insomnia, is speculated to be useful for perioperative psychiatric symptoms in cancer patients, but there exists little empirical evidence. This study provides preliminary data about the efficacy, feasibility, and side effects of YKS for the treatment of preoperative anxiety and postoperative delirium in cancer patients. METHODS: We retrospectively reviewed the medical records of colorectal cancer patients who took YKS for preoperative anxiety, evaluating the following: (1) patient characteristics, (2) feasibility of taking YKS, (3) changes in preoperative anxiety based on the Clinical Global Impression (CGI) scale and Edmonton Symptom Assessment System-revised (ESAS-r-anxiety), (4) incidence of postoperative delirium and (5) YKS-related side effects. RESULTS: We reviewed 19 medical records. There was a significant difference between ESAS-r-anxiety scores (P = 0.028) before and after taking YKS, but no difference between CGI scores (P = 0.056). The incidence of postoperative delirium was 5.2% (95% CI = 0.0-14.5). One patient could not complete the course of YKS during the perioperative administration period, but there were no side effects of Grade 2 or worse according to the Common Terminology Criteria for Adverse Events v4. CONCLUSIONS: Cancer patients could safely take YKS before surgery. There was a significant improvement in preoperative anxiety after taking YKS, and the incident rate of postoperative delirium was lower than in previous studies. These results suggest that YKS may be useful for perioperative psychiatric symptoms in cancer patients. Further well-designed studies are needed to substantiate our results.

Screening for untreated depression in cancer patients: a Japanese experience.

OBJECTIVE: Guidelines for supportive care in cancer patients have recommended routine psychological screening in clinical practice, and a Japanese national project has recommended screening for depression using the Distress and Impact Thermometer. However, a previous study advocating the validity of the Distress and Impact Thermometer may have overestimated its effectiveness, as the study included already-treated patients who were not screening targets. This study re-evaluated the performance and usefulness of the Distress and Impact Thermometer using an adequate sample size and appropriate study design. METHODS: Patients were consecutively recruited at two highly specialized hospitals and three university hospitals in Japan. Inclusion criteria were (i) undergoing aggressive anti-cancer treatment, (ii) the Eastern Cooperative Oncology Group performance status score <3 and (iii) age >20 years. Patients who were receiving psychiatric treatment were excluded from the study. After completing the Distress and Impact Thermometer, patients were evaluated with the gold-standard Composite International Diagnostic Interview by researchers who were blinded to the patients' Distress and Impact Thermometer scores. RESULTS: Forty-four patients (9%) who were receiving psychiatric treatment were excluded. Of 468 subjects included in the final analysis, only 3 had current depression (0.6%). Using cutoff points recommended by the previous study, the positive and negative predictive values were 0.02 and 0.99, respectively. CONCLUSIONS: Our data indicated that screening for untreated depression in cancer patients was not useful in the specific clinical settings that were studied, and such screening should be implemented in appropriate contexts. Since there are no evidence-based recommendations regarding contexts in which psychological screening is essential, further research is needed.

Prevalence and predictive factors of depression and anxiety in patients with pancreatic cancer: a longitudinal study.

OBJECTIVE: It is known that depression and anxiety occur more frequently in pancreatic cancer patients than in those with other malignancies. However, few studies have assessed depression and anxiety using reliable psychiatric diagnostic tools. The purpose of this study was to determine the prevalence of depression and anxiety among pancreatic cancer patients before and 1 month after the start of anticancer treatment using reliable psychiatric diagnostic tools, and to identify factors that predict their occurrence. METHODS: Pancreatic cancer patients were consecutively recruited. Structured clinical interviews were used to determine the presence of affective disorders, anxiety disorders and adjustment disorders. Baseline interviews were performed prior to initiation of anticancer treatment, while follow-up interviews were performed 1 month after treatment was started. Medical, demographic and psychosocial backgrounds were also assessed as predictive factors. RESULTS: One hundred and ten patients participated in the baseline interview and 91 in the follow-up interview. Depression and anxiety were observed in 15 patients (13.6%) at the baseline, and 15 patients (16.5%) at the follow-up. Lack of confidants was associated with depression and anxiety at the baseline. At the baseline, sadness, lower Karnofsky Performance Status and prior experience with the death of a family member due to cancer predicted newly diagnosed depression and anxiety at the follow-up. CONCLUSION: A considerable percentage of pancreatic cancer patients experienced depression and anxiety. Multidimensional psychosocial predictive factors were found and optimal psychological care should incorporate early detection of sadness.

Impact of depression on health utility value in cancer patients.

OBJECTIVE: The quality-adjusted life year, which is usually calculated from the health utility value, is now a standard measurement used in political decision-making in health. Although depression is the leading cause of decrement in health utility in general population, impact of comorbid depression among cancer patients has not been studied sufficiently. Therefore, this study aimed to measure the impact of depression on cancer patients' health utility score, according to the severity of depression. METHODS: Impact of depression severity (measured by the Patient Health Questionnaire) on health utility score (measured by the EuroQoL-5 scale) was evaluated in a sample of 328 Japanese cancer patients, controlling for performance status, symptom burden, and demographic variables. RESULTS: The patients with depression had significantly lower health utility value than those without depression (mean decrement = 0.14). Decrements in health utility of 0.13, 0.18, and 0.19 were observed for mild, moderate, and moderately severe to severe level of depression, respectively. The difference was significant between groups. Depression severity was a significant predictor for health utility (standardized coefficient beta = -0.25), which was comparable with physical symptom burden and performance status. Participants' age, gender, cancer stage, and comorbid illness were not significant. The model explained 37.9% of the variance. CONCLUSIONS: Even mild level of depression caused clinically meaningful decrement in health utility value in cancer patients, which was comparable with decrements due to major physical complications of cancer. Influence of depression should be carefully investigated when interpreting the quality-adjusted life year among cancer patients. Copyright © 2015 John Wiley & Sons, Ltd.

The Association Between Depressive Symptoms and Age in Cancer Patients: A Multicenter Cross-Sectional Study.

CONTEXT: There is controversy around the association between depressive symptoms and age in adult cancer patients. OBJECTIVES: The aim of this study was to evaluate the following hypotheses: 1) cancer patients' depressive symptoms decrease with age, and 2) in individuals aged 65 years or older, depressive symptoms increase because of the effect of somatic symptoms. METHODS: We retrospectively analyzed a database of 356 cancer patients who were consecutively recruited in a previous multicenter cross-sectional study. Depressive symptoms were assessed by the Patient Health Questionnaire-9 (PHQ-9), and correlations with age and other factors were assessed by hierarchical multivariate regression analysis. Age was entered as the dependent variable in the first step, patient characteristics and cancer-related variables were entered in the second step, and somatic symptoms were entered in the last step. We analyzed this model for both the total sample and the subpopulation aged 65 years or older. RESULTS: In the total sample, the PHQ-9 score was significantly associated with lower age, fatigue, and shortness of breath (adjusted R(2) 14.2%). In the subpopulation aged 65 years or older, no factor was associated with the PHQ-9 score (adjusted R(2) 7.3%). CONCLUSION: The finding that depressive symptoms in cancer patients decreased with age was concordant with our first hypothesis, but the second hypothesis was not supported. Younger cancer patients were vulnerable to depressive symptoms and should be monitored carefully. Further studies using more representative samples are needed to examine in detail the association between depressive symptoms and age in older cancer patients.

Barriers of healthcare providers against end-of-life discussions with pediatric cancer patients.

OBJECTIVE: End-of-life discussions with patients can be one of the most difficult and stressful tasks for the oncologist. However, little is known about the discussions that healthcare providers have with patients in such situations and the difficulties they face. The primary end points of this study were to describe the contents of end-of-life discussion in the pediatric setting and the barriers to end-of-life discussion for pediatric patients, as perceived by pediatric healthcare providers. METHODS: Participants were 10 healthcare providers. Semi-structured interviews were conducted, and the KJ method was performed to analyze the data. RESULTS: We found 23 barriers against end-of-life discussion with pediatric cancer patients. These barriers were classified as follows: healthcare provider factors, patient factors, parent factors and institutional or cultural factors. In addition to barriers found in previous studies, some unique barriers were uncovered such as, 'Lack of confidence to face the patient after the discussion', 'Uncertain responsibility for treatment decision-making' and 'No compelling reason to discuss'. Healthcare providers actively discussed the purpose of treatment and the patients' wishes and concerns; however, they were reluctant to deal with the patients' own impending death and their estimated prognosis. CONCLUSIONS: End-of-life discussion with pediatric patients differs from that with adult patients. Further studies are required to analyze pediatric cases associated with end-of-life discussion and carefully discuss its adequacy, pros and cons.