憂鬱並不是癌症一定會出現的併發症

注意情緒上的異常

  【24drs.com】January 21, 2011 — 一篇新的後設分析結果指出,與癌症有關的情緒併發症中,最被廣泛研究的憂鬱症,並不是像一般所認知的那麼常見。
  
  來自英國李斯特城皇家醫院和萊斯特郡信託夥伴的癌症研究暨分子醫學系的Alex Mitchell教授寫道,不論是腫瘤、血液腫瘤或是緩和醫療病患,實際上並不確定癌症病患的情緒異常盛行率。
  
  舉例來說,回顧緩和照護之癌症病患的憂鬱顯示,盛行率介於1%和69%。
  
  不過,這篇後設分析發現,憂鬱僅影響了大約16%的腫瘤、血液腫瘤或緩和醫療病患。
  
  作者們寫道,這個比率是「適中的」,因而認為「憂鬱並非癌症無可避免的併發症」;這篇分析線上登載於1月19日的Lancet Oncology期刊。
  
  但是,憂鬱只是問題之一。Mitchell教授等人認為,在這三類住院病患中,約有30%-40%的癌症病患合併有某種情緒異常;該研究呼籲,醫師仍應留意情緒併發症,而不只有憂鬱症。
  
  他們也建議醫師使用簡便的篩檢工具,分析病患的壓力、日常活動、生活品質、未被滿足的需求,以及求助的慾望。
  
  一名未參與該後設分析的專家認為,此處所提的觀念是一個極大的挑戰,換句話說,對於有憂鬱和/或其他情緒異常的癌症病患該如何處置。
  
  德州大學安德森癌症中心緩和照護與復健醫學系主任Eduardo Bruera醫師表示,使用簡單的工具進行例行性篩檢是很有用的,不過,這只適用於有讓病患轉診進行後續評估與處置的制度下;在忙碌的腫瘤科不太容易提供情緒方面的跨科照護給這些病患。
  
  Bruera醫師解釋,癌症中心除外,在安德森癌症中心,多數病患接受了某種篩檢,所有轉診到支持/緩和照護的病患接受Edmonton症狀評估量表(Edmonton Symptom Assessment Scale)進行焦慮與憂鬱評估。這是一個很簡單的病患評量工具,可以在一、兩分鐘內獲得一個顯示多種生理和情緒症狀的圖表。
  
  因此,在許多癌症中心,癌症病患可以在裡面治療憂鬱和其他情緒異常。
  
  Bruera醫師指出,在多數癌症中心內,支持與緩和照護團隊可以和腫瘤科合作,以幫助病患在癌症治療期間及治療後表達出他們最大的生理和情緒功能。
  
  【研究發現】
  作者們寫道,在癌症病患中,憂鬱有嚴重的後遺症,研究指出,它會減少醫療照護的參與度、延長住院天數、顯著影響生活品質和存活。
  
  此外,根據Mitchell教授等人表示,雖然有多年研究,但癌症病患的憂鬱盛行率仍然有諸多爭議。
  
  因此,研究人員希望進行一個高品質的文獻回顧,納入住院成年癌症病患的憂鬱盛行率和相關情緒異常等資料。
  
  作者們表示,這篇回顧包括了超過14,000名病患,是迄今最佳的研究。他們宣稱,雖然已經有許多資料豐富的系統性回顧發表,但是還沒有研究有這麼充足的癌症病患情緒異常資料庫進行量化分析。
  
  藉由精神疾病診斷與統計手冊(Diagnostic and Statistical Manual of Mental Disorders,DSM)或國際疾病分類(International Classification of Diseases,ICD)的定義,他們搜尋了:由正式訪談定義的有症狀的(臨床)憂鬱症;重度與輕度憂鬱症,這是針對DSM研究規範訪談(DSM-IV所列的輕度憂鬱是沒有其他特定原因的憂鬱異常);心情惡劣;適應障礙(不論有無合併憂鬱症);焦慮異常;合併情緒異常等相關文獻。
  
  他們檢視了433篇相關文獻,最後有其中94篇適合回顧(24篇屬於緩和照護、70篇為非緩和照護),且包括了癌症診斷後5年內的病患資料。
  
  在緩和照護對象中,後設分析彙整的憂鬱盛行率為16.5%;重度憂鬱症是14.3%;輕度憂鬱症是9.6%。適應障礙的盛行率是15.4%,焦慮異常是9.8%,所有情緒異常的盛行率是 29.0%。
  
  在腫瘤與血液腫瘤病患中,憂鬱盛行率是16.3%;重度憂鬱症是14.9%;輕度憂鬱症是19.2%。適應障礙的盛行率是19.4%,焦慮異常是10.3%,心情惡劣是2.7%。合併診斷相當常見,所有情緒異常的盛行率是38.2%。
  
  綜觀所有研究,他們指出,癌症病患中,有症狀的憂鬱症比率適中,只有合併所有類型與相關情緒異常時,憂鬱症才算常見。
  
  研究人員指出,在緩和與非緩和對象中,憂鬱和焦慮的比率並無顯著差異,有關癌症憂鬱和癌症分期的影響可能是被過度強調了。
  
  不過,有憂鬱症的癌症病患仍不在少數,研究人員估計,不論何時,英國約有34萬人,美國約有200萬人有重度憂鬱和癌症。
  
  作者們皆宣告沒有相關資金上的往來。
  
  Lancet Oncol. 線上登載於2011年1月19日。

Depression Not an "Invariable Complication" of Cancer

By Nick Mulcahy
Medscape Medical News

January 21, 2011 — Depression — the most extensively studied mood complication associated with cancer — is "less common in patients with cancer than previously thought," according to the authors of a new meta-analysis.

"Substantial uncertainty exists about prevalence of mood disorders in patients with cancer, including those in oncological, hematological, and palliative-care settings," write the authors, led by Alex Mitchell, MRCPsych, from the Department of Cancer Studies and Molecular Medicine at the Leicester Royal Infirmary and Leicestershire Partnership Trust, in the United Kingdom.

For instance, reviews of depression in palliative-care cancer settings have shown prevalences between 1% and 69%, say the authors.

However, the meta-analysis found that depression affects only about 16% of patients in oncological, hematological, and palliative-care settings.

This rate is "modest," and suggests that "depression is not an invariable complication of cancer," write the authors. The analysis was published online January 19 in the Lancet Oncology.

But depression is only one problem. "Some combination of mood disorders" occurs in 30% to 40% of cancer patients in these 3 hospital settings, the authors report. The study's take-away message is that clinicians should remain "vigilant for mood complications, not just depression," suggest Dr. Mitchell and colleagues.

They also recommend that clinicians use simplified screening tools to look out for "distress, activities of daily living, quality of life, unmet needs, and desire for help."

Herein lies the great challenge, suggested an expert not involved with the meta-analysis — namely, how to proceed in the cancer clinic with patients who are depressed and/or have mood disorders.

"Regular screening using a simple tool is very useful. However, this is only true when there is a system in place for referral of patients for further assessment and management," said Eduardo Bruera, MD, chair of the Department of Palliative Care and Rehabilitation Medicine at the University of Texas M.D. Anderson Cancer Center in Houston.

"The busy oncology setting cannot easily provide emotional interdisciplinary care for these patients," Dr. Bruera told Medscape Medical News.

Cancer centers are generally exceptions to this limitation, Dr. Bruera explained. "At M.D. Anderson, most patients undergo some form of screening. All patients referred to supportive/palliative care undergo assessment of anxiety and depression using the [Edmonton Symptom Assessment Scale]. This is a very simple patient-completed tool capable of providing a graphic display of multiple physical and emotional symptoms in a minute or 2," he said.

Thus, at many cancer centers, cancer patients can potentially be treated for depression and other mood disorders in the context of their cancer care, said Dr. Bruera.

"Supportive and palliative-care teams are able to work alongside medical oncologists in most cancer centers to help patients express their maximum physical and emotional function during and after the completion of cancer treatment," he said.

Study Findings

In cancer settings, depression has serious consequences, write the authors. Studies indicate that it reduces participation in medical care, prolongs hospital stays, and significantly affects quality of life and survival, they point out.

Still, "despite many years of research, prevalence of depression in patients with cancer is still subject to much debate," according to Dr. Mitchell and colleagues.

So the investigators set out to do a high-quality review of the literature and included studies with data for the prevalence of depression and related mood disorder in adults with cancer in hospital settings.

The review, which involved more than 14,000 patients, is the best to date, say the authors. "Although several informative systematic reviews have been published, no previous studies have quantitatively analyzed such a robust dataset of mood disorders in cancer settings," they claim.

Using definitions supplied by either the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases (ICD), they sought out studies on syndromal (clinical) depression, defined by formal interview; major and minor depressions, defined by interview against DSM research criteria (minor depression is listed in the DSM-IV text revision under depressive disorder not otherwise specified); dysthymia; adjustment disorder (either alone or in combination with depression); anxiety disorders; and combined mood disorders.

They identified 433 relevant articles, of which 94 were ultimately eligible for review (24 in palliative-care and 70 in nonpalliative-care settings) and involved patient data from the first 5 years after cancer diagnosis.

In palliative-care settings, the meta-analytical pooled prevalence of depression was 16.5%; of major depression was 14.3%; and of minor depression was 9.6%. The prevalence of adjustment disorder alone was 15.4% and of anxiety disorders was 9.8%. The prevalence of all types of mood disorder was 29.0%.

In oncological and hematological settings, the prevalence of depression was 16.3%; of major depression was 14.9%; and of minor depression was 19.2%. The prevalence of adjustment disorder was 19.4%, of anxiety was 10.3%, and of dysthymia was 2.7%. Combination diagnoses were common, including a prevalence of all types of mood disorder of 38.2%.

Across all studies, there were "modest rates of syndromal depression" in patients with cancer, say the authors. Depression is only common when all subtypes and related mood disorders are combined, they add.

The investigators, noting that there was no significant difference in rates of depression and anxiety between palliative and nonpalliative settings, also say that the effect on depression of the cancer setting and the stage of cancer might be overemphasized.

Despite their findings, the authors note that cancer patients with depression still amount to a large group of individuals. They estimate that 340,000 people in the United Kingdom and 2 million in the United States have "major depression and cancer at any time."

The authors have disclosed no relevant financial relationships.

Lancet Oncol. Published online January 19, 2011.

    
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