The Most Overlooked Symptom in Cancer Care

Have you ever wondered what symptom is the most hidden among patients with cancer? Is it sexual dysfunction related to treatment, body dysphoria, and heightened feelings of general anxiety? Is it perhaps caregiver burden, as patients struggle to maintain their roles in the family while meeting the sometimes-demanding tasks and schedules associated with cancer treatment and follow-up? Is it early indications of acute confusion, or “chemobrain”? No, it is none of these. The most overlooked symptom in cancer care is depression. Mood disorders are common mental health sequelae of cancer-in fact, the prevalence of mood disorders is two to three times higher among cancer patients than in the general population.[1] Still, depression in patients with cancer is frequently missed by healthcare providers, and there are many reasons for this oversight.

First, depression is an expected corollary of the cancer experience. Hence, the painful nature of depression and its potential impact on daily functioning are accepted as “par for the course.” Second, there are diagnostic quandaries about what constitutes cancer-related depression and what it looks like in the clinical setting. Third, patients may choose not to disclose this symptom. Finally, even when prescribers suspect that their patient may be depressed, they often worry about doing something about it, due to the toxicity associated with antidepressants and their potential negative interactions with other medications. Prescribers also lack the pharmacologic knowledge to optimally manage this mood disorder with medications. Hence, depression remains under-recognized and undertreated.

Mehta and Roth,[2] from Memorial Sloan Kettering Cancer Center's Department of Psychiatry and Behavior, have reinforced the importance of psychosocial distress screening in the oncology setting, to identify patients in need of referral. There are multiple standard evaluation methods for depression in clinical practice, and these include the use of interviews, short questionnaires, and formal assessment instruments. The role of the oncology nurse is to screen for depression, not to diagnose it. We need to respond proactively when patients, through their verbalizations and behavior, portray worrisome indications of depression. Similar to the recognition of actionable elements of physical distress (ie, “His respirations have doubled over the past hour.”; “Her urine is blood-tinged”), psychosocial clues to depression in our patients-through observations, discussions, and clinical red flags-should be shared with the primary oncology provider. For example, you might say, “Mr. Johnson’s wife shared with me today that he’s stopped eating at home, and has no interest in seeing his grandchildren who were always the light of his life”; or “Twice this week when she was having her chemo, Mrs. Davis told me that she doesn’t know if she can take this much longer and that she is useless to her family.”

While nurses and physicians may not feel that they have the expertise to act on their perceptions of psychosocial distress in a patient, there are choices to rectify this situation. They can proactively identify psychological resources to help depressed patients, and take steps to ensure that the appropriate staff members of these organizations have been contracted and are readily available for referral. Oncology professionals also can acquire the expertise needed to treat this symptom of patient distress. Educational offerings can increase healthcare providers’ knowledge about the numerous agents available to treat depression, the drugs that can have negative synergistic interactions with antidepressants, the optimum dosing parameters and expected toxicities of various antidepressant agents, and considerations for stopping antidepressant treatment. This element of practice needs to be elevated to the same level of importance as the attainment of new knowledge about best practices in chemotherapy prescribing and surgery. A holistic orientation to cancer care-in particular, an approach that includes screening and treatment for depression-is a necessity to optimize the quality of life for our patients.

References:

1. Caruso R, Nanni MG, Riba M, et al. Depressive spectrum disorders in cancer: prevalence, risk factors, and screening for depression: a critical review. Acta Oncologica. 2017;56:146-55.
2. Mehta RD, Roth AJ. Psychiatric considerations in the oncology setting. CA Cancer J Clin. 2015;65:299-314.