Dr Jeremy Couper1
Ms Annabel Pollard1
A/Professor June Corry1
Dr Ann Boonzaier1
Associate Professor David Smith2
Professor Dr David Castle3
Dr Kate Neilson1
Karen Mead 2
Professor Tom Trauer3
1Peter MacCallum Cancer Centre
3St Vincent’s Hospital
beyondblue Victorian Centre of Excellence
Project completion year
Head and neck cancer (HNC) patients undergo some of the most debilitating and disfiguring treatments among all cancer patients, but limited research has been undertaken to assess the rates of psychological distress and unmet psychosocial needs amongst this group.
The project aimed to:
- assess the prevalence of depression and anxiety in an Australian HNC population
- follow the psychological trajectory of this group by obtaining data at three time points to identify the changing needs of people with HNC over time
- validate the DASS21 questionnaire in this population
- identify opportunities for early clinical interventions.
This was a longitudinal study of HNC outpatients attending for radiotherapy planning. Eligibility criteria were a diagnosis for the first time of HNC, age >17 years, where the patient agreed to undertake cancer treatment involving radiotherapy with curative intent.
Participant data was collected at three time points: at pre-treatment (before radiotherapy), three weeks and 18 months post-treatment. Measures included a demographic questionnaire, the Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith 1983), the Functional Assessment of Chronic Illness Therapy – Head and Neck Version (FACT-H&N; List, et al. 1996), the Depression, Anxiety and Stress Scale (DASS21; Lovibond & Lovibond, 1995), and the Structured Clinical Interview (SCID-I, non-patient edition; First, et al., 2002). A semi-structured interview was conducted at three weeks and then 18 months post-treatment for a subset of participants.
1. The prevalence of depression and anxiety symptoms in an Australian HNC population
Symptoms of depression and anxiety
- The percentage of participants classified above the cut off for symptoms of depression on the HADS was 17 per cent pre-treatment, 30 per cent three weeks post-treatment and 8 per cent 18 months post-treatment. On the anxiety subscale, 22 per cent pre-treatment, 18 per cent three weeks post-treatment, and 22 per cent 18 months post treatment scored above the cut off.
- When compared to past research (Crawford et al., 2001), results indicate that more HNC patients experience symptoms of depression pre-treatment and three weeks post-radiotherapy treatment than other people in the general population.
- A total of 29 per cent of participants assessed with the SCID-I met the criteria for a psychiatric diagnosis three weeks post-radiotherapy. More specifically, 11.8 per cent of participants interviewed met the criteria for an anxiety disorder, and 23.5 per cent for a mood disorder.
2. Changes in depression/anxiety symptoms and quality of life: comparison of pre- and post-treatment results
- Participants reported significantly more symptoms of depression three weeks post-treatment and significantly fewer symptoms of anxiety three weeks post-treatment when compared to pre-treatment and 18 month post-treatment scores. This indicates that symptoms of depression are a difficulty for HNC patients in the immediate period following radiotherapy.
3. Opportunities for early intervention to support HNC patients
Risk factors for three week post-treatment depression and anxiety symptoms
Results indicate a number of risk factors for depression and anxiety three weeks post-treatment, such as:
- patients were likely to report more symptoms of depression post-treatment if their cancer treatment program included chemotherapy
- men were more likely than women to report more symptoms of anxiety post-treatment
- patients with more depression/anxiety symptoms pre-treatment continued to report more symptoms of depression and anxiety post-treatment.
Results also demonstrate that participants with more HNC-related symptoms (cancer symptoms and treatment side effects) also reported more symptoms of depression and anxiety. This may indicate that more severe physical symptoms experienced post-treatment by HNC patients lead to symptoms of depression.
Participant reports of their experiences during treatment for cancer and unmet needs
- Qualitative data from three-week post-treatment interviews corroborates the relationship between treatment side-effects and changes in mood. Results suggest that many HNC patients described ‘feeling OK’ until the end of treatment. After this time many experienced negative mood changes which they attributed to the side effects of the treatment as well as the treatment process.
- Examination of 18-month post-treatment interviews content reveals participants described some improvement in their mood and treatment side-effects, although many continued to experience significant side-effects (particularly difficulty eating). Some participants described other difficulties, including regret and persistent feelings of depression and anxiety.
- Many participants interviewed at three weeks and at 18 months post-treatment identified a need for more information about treatment side-effects as well as a need for ongoing support services in the post-treatment period to assist with managing ongoing side-effects and to provide psychosocial support.
Implications for policy and practice
This study was primarily observational in nature and aimed to develop an understanding and recommendations to improve care for HNC patients. Study participants were screened for depression and anxiety and those reporting clinical significant outcomes of depression and/or anxiety were offered access to clinical services.
The results of this study demonstrate the need for resources to support the long-term needs of patients with HNC, including:
- the development of services to prevent depression and better manage side-effects to assist this patient group as they proceed through their medical treatment for cancer. Non-medical support, such as that provided by nursing and allied health professionals, is a vital component of cancer care and cancer rehabilitation.
- more practical information and support, particularly around managing treatment side-effects and how to access services post-treatment.
Kate Neilson, Annabel Pollard, Ann Boonzaier, June Corry, David Castle, Marcelle Gray, Karen Mead, David Smith, Tom Trauer, and Jeremy Couper. (2010). An Investigation of Psychological Distress (Depression and Anxiety) in People with Head and Neck Cancer. Medical Journal of Australia., 193 (5), s48-s51.
A Qualitative Study of Head and Neck Patient Experiences Following Radiotherapy. K Neilson, A Boonzaier, A Pollard, June Corry, David Castle, David Smith, Jeremy Couper. European Journal of Cancer Care.
Screening for Anxiety and Depression in Australian Head and Neck Cancer Patients: Comparison of the HADS and DASS21. Marcelle Gray, Kate Neilson, Annabel Pollard, Ann Boonzaier, June Corry, David Castle, Karen Mead, David Smith, John Reece, and Jeremy Couper.
Quality of Life (depression and anxiety) 18 months after treatment for Head and Neck Cancer. Kate Neilson, Annabel Pollard, Ann Boonzaier, June Corry, David Castle, Marcelle Gray, Karen Mead, David Smith, Tom Trauer, and Jeremy Couper.