Depression and Cancer 101: Depression May Shorten Survival After a Cancer Diagnosis

Depression affects up to 50% of patients with cancer…and unfortunately many go undiagnosed and suffer in silence.

The problem is two-fold:

1. Oncologists often feel too busy or not qualified to be able to diagnose and treat this condition, and
2. The majority of patients do not volunteer their concerns about their psychoemotional distress, either feeling too ashamed to admit that they are not coping well with the emotional and psychological distress of their cancer or believing that their physicians and nurses are not concerned about these issues.

**Also be sure to read our more recent post on this topic: “Can Coping with Anxiety, Depression and Stress Increase Remission and Survival Time in Cancer Patients? What Every Cancer Patient Needs to Know“**

Studies Associating Depression and Cancer Mortality

Study #1:

Study Design:

• Researchers from the MD Anderson Cancer Centers enrolled 217 patients with newly diagnosed kidney cancer to explore this potential association.
• Whole-genome (DNA) profiles were compared between the patients with the most significant symptoms of depression and the patients with the mildest forms of depression.

 This is What They Found:

• Approximately 25% of all patients in this study were diagnosed with depression.
• Even after taking other disease-related risk factors into account, the diagnosis of depression was associated with shorter survival time.
• Patients with elevated daytime cortisol (a important stress-related hormone) levels were found to have a shorter survival time.
• Specific genes that play a key role in regulating inflammation, were expressed at increased levels in patients with depression.

 Study Bottomline:

• The study authors concluded the link between patients’ mental health and survival time is associated with inflammatory gene regulation.

Study #2:

Study design:

• In an analysis of a randomized trial of supportive-expressive group therapy, 125 women with metastatic breast cancer completed a depression symptom measure (Center for Epidemiologic Studies–Depression Scale [CES-D]) at baseline and were randomly assigned to a treatment group or to a control group that received educational materials.
• At baseline and three follow-up points, 101 of 125 women completed a depression symptom measure.
• The researchers analyzed whether decreasing depression symptoms over the first year of the study (the length of the intervention) would be associated with longer survival.

This is What They Found:

• The women with the lowest depression scores (least depressed) had a significantly longer survival time (median survival time: 53.6 months) compared with the more depressed women (median survival time: 25.1 months).
• Neither demographic nor medical variables explained this association.

Study Bottomline:

Study #3:

Study Design:

• 151 patients with newly diagnosed metastatic lung cancer participated in a randomized trial of early palliative care (EPC) integrated with standard oncology care versus standard oncology care alone (control group.)
• Depression was assessed at baseline and at 12 weeks with the Patient Health Questionnaire-9 (PHQ-9).
• Depression response was considered ≥ 50% reduction in PHQ-9 scores at 12 weeks.
• Survival differences were assessed between the EPC and control groups.

This is What They Found: 

• At baseline, 14% of the patients were diagnosed with major depression.
• A diagnosis of major depression was associated with a reduction in survival time by 18% compared with those patients who did not have major depression.
• Patients (including those with major depression) assigned to EPC had greater improvements in PHQ-9 scores at 12 weeks.
• The patients who received EPC and reported improvements in their depression scores survived longer than those who did not receive EPC.

Study Bottomline:

• Depression predicted worse survival in patients with metastatic lung cancer.
• EPC was associated with greater improvement in depression, which may lead to improved survival times.

Why Might Depression Shorten Survival?

Although depression and cancer progression has yet to be definitively linked, the data is hard to ignore. We know that depression and reduced treatment compliance (i.e. following up on medical appointments, examinations, treatments, etc.) are directly related.

Furthermore, we know that depression negatively impacts the body’s immune system and may increase tumor progression through a complex interplay of neurohormonal and inflammatory pathways, following many of the same physiologic mechanisms that explain how chronic stress feeds cancer (cancer development, progression and recurrence.)

Chronic exposure to stress hormones (i.e. cortisol) is associated with the following cancer-promoting effects:

• Increasing free radical formation
• Increasing inflammation
• Decreasing the immune response
• Decreasing tumor cell death
• Decreasing the activity of DNA repair
• Increasing production of IGF-1 and other cancerous growth factors
• Increasing the production of tumor blood vessel growth factors (VEGF)

**Learn more about stress and cancer in our Stress 101 article**

It’s Important to Identify Depression:

What is depression? (from the Center for Epidemiologic Studies, National Institute of Mental Health )

• Everyone occasionally feels blue or sad, but these feelings are usually fleeting and pass within a few hours or a couple of days.
• When people have a depressive disorder, they feel really sad for a long time and cannot shake this feeling. They also often have problems with sleeping, trouble with appetite, feel tired a lot of the time, and have problems concentrating. Depressive disorder interferes with their ability to do things in their lives that they normally can do well; and it causes pain for both the people with the disorder and those who care about them.
• Depressive disorder is a common but serious illness. Many people never seek treatment for their depression, but most people who experience depression feel better if they get treatment.

A Self-Administered Screening Test for Depression (“CES-D”):

One of the most common screening tests for helping an individual to determine his or her depression score, the Center for Epidemiologic Studies Depression Scale (CES-D). The quick, 20-question self-test measures depressive feelings and behaviors during the past week. There are three scoring ranges:

• Less than 15 (No Depression)
• 15-21 (Mild to Moderate Depression)
• Over 21 (Possibility of Major Depression)

**You can take the test online here**

Where Do I Go For Help?

1) Ask your health care team for a referral to a mental health professional.

2) There are many useful online resources, including:

• The Mental Health Services Locator (supported by the Substance Abuse and Mental Health Services Administration): http://store.samhsa.gov/mhlocator
• The American Psychological Association: http://www.apa.org/
• The American Psychiatric Association: http://www.psych.org/
• The National Alliance on Mental Illness: http://www.nami.org/
• The National Suicide Prevention Lifeline:http://www.suicidepreventionlifeline.org/ and toll-free 1-800-273-8255
• Livestrong Cancer Navigation Services: http://www.livestrong.org/Get-Help/Get-One-On-One-Support
• CancerCare Counseling Services: http://www.cancercare.org/counseling
• American Cancer Society: http://www.cancer.org/Treatment/SupportProgramsServices/index

3) An emergency room doctor also can provide temporary help and can tell you where and how to get further help.

4) Live online counseling with mental health professions is becoming increasingly popular. Most sites require a payment upfront for counseling services. All of the mental health professionals have online ratings and testimonials that you can read before you pick your counselor. Here are the most popular sites:

• JustAnswer (In my opinion, this is the best one to date.)
• TherapyHub
• LivePerson

What is Our Responsibility as a Member of the Cancer Care Team?

I strongly encourage oncology providers to start assessing for depression in their patients, today.

Simple tools, such as the above mentioned CES-D, have been developed and validated to help in this diagnosis. Another validated questionnaire that is commonly used is the nine-item depression screening tool, PHQ-9 (Patient Health Questionnaire-9), which can be quickly self-administered in the office or at home.

Simply asking our patients “How are you coping?” is a crucial part of our care. I can’t begin to tell you how important simply asking this question has been in so many of my patient interactions. Sadly, I am often the only one who has asked them this question. If you are concerned about how much time this may take out of your tight clinical schedule, trust me I get it but we have to open this door for them. You might be the only one to show them how much you care about their distress, and you absolutely can help them. Your display of empathy and compassion, by inquiring about this common distress starts the dialogue and is the first step to healing.

Involving mental health providers, social workers and nurses in helping our patients cope with their psychoemotional distress is the next step, as treating depression may not be a straightforward intervention. Depending of the severity of the symptoms, there are many therapeutic options available: medications, botanical compounds, exercise, diet modifications, sleep hygiene, talk therapy, support groups, and numerous complementary therapies (i.e. acupuncture, massage, yoga, meditation, reiki, etc.).

Just as much as our conventional oncologic treatments (i.e. chemotherapy, radiation therapy, surgery, etc.) are essential in the management of our patients’ cancer, so is our responsibility to identify and address this common problem.

As quoted from a recent Journal of Clinical Oncology article, “Pain and symptom distress, mood disorders, and family caregiver burden are prevalent and carry significant adverse consequences for our patients and their families. Medical care focused on addressing these burdens—pain and other symptoms, mood disorders, and matching care to honestly informed and achievable goals—not only improve quality of life and reduce depression but, as recent studies suggest, may also improve survival. In addition, such interventions pose low or no risk and, compared with other cancer treatments, are low in cost.”