The management of comorbid depression may not extend survival in patients with cancer, but the resultant quality-of-life improvements are an important part of cancer care, say researchers.
The new findings come from a secondary analysis of all-cause mortality data in a total of 642 patients from the randomized SMaRT Oncology-2 and SMaRT Oncology-3 trials.
Previously, findings from both trials demonstrated that even in patients with a poor prognosis, the comprehensive Depression Care for People with Cancer (DCPC) program significantly reduced comorbid major depression and improved quality of life compared with usual care.
However, the new analysis shows that the effective treatment of comorbid depression had no significant effect on survival (pooled hazard ratio [HR], 0.92; P = .51).
Survival was marginally better after depression care in SMaRT Oncology-3 patients with lung cancer who had an estimated survival of 3 months or longer (HR, 0.82; P = .28) compared with SMaRT Oncology-2 patients expected to live for 12 months or longer (HR, 1.02; P = .93).
A total of 135 (27%) of 500 SMaRT Oncology-2 participants died after a median follow-up of 5 years, and 114 (80%) of 142 SMaRT Oncology-3 participants died after a median follow-up of 1 year. Most of the deaths were cancer related.
The new survival analysis, led by Michael Sharpe, MD, from the University of Oxford Department of Psychiatry, Warneford Hospital, United Kingdom, was published online March 12 in Lancet Psychiatry.
“Although the treatment programme was highly effective in improving depression, we did not find significant evidence that it also improved survival…. Nonetheless, the evidence for a beneficial effect on quality of life already indicates the treatment of depression in people with cancer,” the study authors emphasize.
Mental health and cancer are closely linked, they point out. Patients with depression have a higher incidence of specific cancers, and in observational studies, they have a worse prognosis than peers who are not depressed.
“What is not clear is whether this association can be positively influenced, either by the effective treatment of depression or by addressing the causative factors,” writes Alex J Mitchell, MD, from the University Hospitals of Leicester, University of Leicester, United Kingdom, in an accompanying commentary.
When asked to comment, Kelly Trevino, PhD, a clinical psychologist at New York-Presbyterian and Weill Cornell Medicine in New York City, noted that prolonged survival isn’t always the most important outcome for patients with cancer.
“If we are able to improve length of life only for patients to have poor quality of life, we have really done a disservice to our patients,” she told Medscape Medical News.
“As cancer treatments have improved, length of life has increased,” Trevino commented. “We must have empirically based strategies for improving quality of life as our colleagues in cancer treatments improve length of life.”
Study Details
The SMaRT Oncology-2 and SMaRT Oncology-3 trials were conducted between 2008 and 2011 at three cancer centers in Scotland. In both trials, clinic outpatients were randomly assigned 1:1 to usual care or to the DCPC program. The latter consisted of pharmacologic and psychological treatment delivered by a team of cancer nurses and psychiatrists in collaboration with oncologists and primary care physicians.
An earlier literature search of randomized trials from January 1, 1900, to January 1, 2018, failed to produce any reports on survival associated with interventions for comorbid major depression in patients with cancer. The researchers then looked at long-term mortality data for SMaRT Oncology-2 and SMaRT Oncology-3 participants. Deaths from all causes up to July 31, 2015, were accessed from the National Records of Scotland database.
In SMaRT Oncology-2 participants, 69% of the usual care group and 72% of the DCPC group survived to 6 years. Similarly, in the SMaRT Oncology-3 participants, 15% receiving usual care and 23% receiving DCPC care survived over the total follow-up period. There were no significant survival differences between usual care and DCPC care in either group in both trials.
What’s needed now are larger trials with longer follow-up, Sharpe and colleagues say.
In his commentary, however, Mitchell says that randomized trials in patients with cancer and depression are unlikely to correct historic inequities in the quality of cancer care. Evidence that the quality of medical care affects the survival effects of depression “has been a consistent theme over the past 10 years,” he points out. Previous studies show that patients being treated for depression or other mental illness receive less population-based preventive screening for cancer. They also tend to be diagnosed when disease is more advanced and to receive lower-quality cancer care than patients without mental health conditions.
“These factors alone could account for most of the survival disadvantage in patients with mental ill health,” Mitchell says.
Despite this, he emphasizes, “depression remains a key target for prompt recognition and appropriate treatment, including the urgent necessity to reduce any inequalities in cancer care related to patients’ pre-existing or current mental ill health.”
This study was funded by the National Institute for Health Research, the Oxford NHS Foundation Trust, and the Scottish Department of Health. The SMaRT Oncology-2 and –3 trials were funded by Cancer Research UK. Sharpe and the study coauthors, as well as Mitchell and Trevino, have disclosed no relevant financial relationships.
Lancet Psychiatry. Published online March 12, 2018. Abstract, Commentary
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