Treating Depression in Cancer Patients

Michael Sharpe, MA, MD

Mary Jane Massie, MD

According to three associated and recently published large randomized studies, while about 75% of cancer patients with major depression do not receive any treatment for their depression, a new system of integrating depression treatment into cancer patient care can transform patient outcomes. In light of this research, we are speaking with Michael Sharpe, MA, MD, professor of psychological medicine at the University of Oxford in the United Kingdom, who is a lead author on all three of the new studies, as well as Mary Jane Massie, MD, a psychiatrist at Memorial Sloan Kettering Cancer Center in New York, who specializes in psychological treatments for those with breast cancer and their families.

 -Interviewed by Anna Azvolinsky 

Cancer Network: Dr. Sharpe, let’s start with you. Can you provide us with the prevalence of depression among patients with different types of cancer and the impetus for these so-called SMaRT Oncology randomized trials that you led, which tested approaches to depression treatment among cancer patients?

Dr. Sharpe: Yes, certainly. Obviously, it’s long been known that people with cancer get depressed. I think there are two important things I should make clear about these studies and why they are a little bit different from a lot of previous studies. The first thing is that we focused on major depression, which is also called clinical depression, and that is really a level and persistence of depression that a psychiatrist would consider to require treatment-this is not lower levels of distress. The second point is that we start with the recognition that cancer is not all one same condition, so when we talk about the overall prevalence of depression in cancer, we don’t give an overall figure, but instead, figures for different types of cancer. We found in our study of 22,000 cancer patients attending specialist cancer clinics in Scotland and the UK that there was a rate of major depression in those patients of about 13%-that was the highest and that was in patients with lung cancer. It went down a little lower in breast cancer and gynecological and colorectal cancer, and was lowest in the genitourinary cancer group, which included a lot of prostate cancer patients, where it was about 6%. These are point prevalences, so all of them are two to three times minimum the general population, but you can see that the rate does vary by different cancer types.

I guess the most important finding in light of our discussion today, is that we also asked those interviewed patients, who were diagnosed with depression, whether they were receiving treatment. And a surprising finding from that was that a full 75% of patients said they were not receiving anything that we considered an adequate psychological or antidepressant drug treatment. We had some inkling that there was an unmet need for depression that was confirmed here and that provided the impetus for our intervention studies.

Cancer Network:Could you summarize the major findings of these studies?

Dr. Sharpe: In this series of three papers, we reported on the prevalence and we reported on two randomized trials. The bigger trial, the 500-patient trial, was done in patients with a variety of cancer types but all of whom had a good prognosis. They were all expected to live for at least a year by their oncologist. They were randomized to receive the usual care for major depression, which would be that they would see their primary care doctor and their oncologist-psychology was available at most of the treatment centers-and we encouraged the patients and clinicians to treat the patients’ depression.

Alternatively, they were randomized to our depression care for people with cancer program, which is a package of interventions. Importantly, it is delivered as part of cancer care, with most of the contact being with a cancer nurse, as well as a psychiatrist and they also relate to the patient’s primary care doctor. And the ingredients that the patients get in there are a lot of education about depression, they have a relationship with a cancer nurse who carries them through the treatment, and they have an option for antidepressants through a psychiatrist who advises their general practitioner, and they also get some basic psychological treatments. They get a very systematic delivery of a package of care, which is part of their cancer treatment-although, the ingredients themselves are all off-the-shelf type of ingredients for depression.

What we found in that trial, was again, quite surprising. In the usual care group, even though we told everyone that the patient was depressed and encouraged the care team to do something about it, only about 17% of patients who had usual care had an improvement in their depression 6 months later. By improvement, I mean a 50% drop in their depression score. Whereas in the group that had the depression care package, more than 60% had an improvement, so that’s a 45% absolute difference between the groups, which is enormous. We also did a smaller trial in lung cancer patients and, in essence, found that the same approach worked in patients with a much poorer prognosis-people expected to live only 6 months, and a number of them died while on the trial. But the same approach also worked in patients with this poor prognosis and that is the subject of the third trial.

Cancer Network:Are these study conclusions enough to help change clinical practice, in your opinion?

Dr. Sharpe: Well, the study on the prevalence of depression, how little treated it is, was done in one healthcare system. I would strongly expect the findings, if done in the United States, would be similar and there is data to suggest that they probably would be, but that would need to be confirmed. With regard to the interventions, I think the SMaRT Oncology 2 trial, the 500-patient effectiveness trial, that was designed as a late phase trial that would inform implementation. I think that the findings of that trial are now implementation-ready. The intervention was not wildly expensive, it cost about $1,000 average per patient. When you consider the overall cost of cancer care, that is not an enormous cost. The use of this in poor-prognosis patients, such as those with lung cancer, that was more of an early phase trial, rather than an efficacy trial, and I think that more work needs to be done before we move into implementation for those patients. But for your average, good-prognosis cancer patient, I think, yes, we now know enough to start implementing this kind of approach now.

Cancer Network: Dr. Massie, what is your perspective on these results? And is treating depression a necessary aspect of cancer patient care?

Dr. Massie: Thank you for inviting me to be with you today. I think we owe Dr. Sharpe and his colleagues a big thank you for doing these excellent studies and making this information available to the oncology community and the medical community. This information of course is picked up by the popular press and certainly enables our patients and their family members to understand the importance of mental health treatment in oncology settings. I think over numerous decades, investigators have attempted to understand the prevalence of psychiatric disorders in cancer patients, and as we researchers and clinicians have been trying to understand more about this, I think times have changed in many cultures, in many countries, making it more acceptable for cancer patients to ask for psychological help. It is more acceptable for oncologic practitioners to form alliances with mental health workers, so they can offer mental health assistance for those who have anxiety disorders or depressive disorders.

Cancer Network:At academic cancer centers, I am sure there is a lot more support for this type of holistic treatment that includes treatment of depression. What can patients do if perhaps that is not available at the center where they are being treated?

Dr. Massie: In the United States, at comprehensive cancer centers, psychiatric or mental health services are a required component of care. But your point is very well taken. Many people, certainly in the United States and other countries, are not treated at academic medical centers. I think that many oncologists very much understand the importance of the treatment of depression in people who have cancer. But they may not so easily find mental health practitioners in their community available to provide evaluation and then treatment services. So, hopefully, as the word gets out about the extraordinary prevalence of depression among individuals with cancer, private practitioners in oncology settings will be able to form linkages with mental health workers, so that all patients with cancer will have access to a good evaluation and appropriate treatment.

Cancer Network:What, in your opinion, is the best way to bring awareness of the need to treat depression in cancer patients?

Dr. Massie: I think that national organizations often have mental health workers on their programs at national meetings. Certainly the service you are providing today for clinicians and researchers is an extremely important part of the process. I think that we see, increasingly, in the lay press in the United States, articles about the emotional toll of cancer and the availability of mental health workers to help treat individuals who are struggling as they go through diagnosis and treatment of cancer. I think that word of mouth certainly gets information out to people, and I think that in a cancer center, in many countries, patients in the waiting room get to hear that we have people who are here to help you-social workers, psychiatrists, psychologists, and other health professionals-who are a part of the team, who understand the rigors of cancer treatment, and who are available to help in an effective way. I think that in the United States we have effective treatments for psychiatric disorders for anxiety and depression. That kind of information is fortunately getting out to patients and their families.

Cancer Network: Thank you so much to both of you for joining us today!

Dr. Sharpe: It’s a pleasure, thank you.

Dr. Massie: Thank you for inviting us.