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This is a briefing given to the COMPASS group http://www.compasscollaborative.com/ part of the NCRI regarding the latest methods of screening for distress in cancer.
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Alex Mitchell Leicester Royal InfirmaryElena Baker-Glenn University of NottinghamPaul Symonds Leicester Royal InfirmaryChris Coggan Leicester General Hospital
March 2008March 2008
COMPASS – New Developments in Rapid Screening in Cancer
1. What Is the Purpose of Screening?Detection Rates, Unassisted Rates, Mj Mn Subsyndromal disorders
2. Current MethodsWho is looking?; Vs case finding,
3a. Verbal MethodsEvidence?
3b. Distress ThermometerEvidence?
4. Emotion thermometersValidation
5. Future Methods
MethodologyMethodology
Study I: Baker-Glen, Symonds, Granger “ET Validation”(a) n=140 chemotherapy attendees(b) n=70 chemotherapy f/u
Study II: Sampson, Symonds, Granger “ET Extension”(c) n=250 chemotherapy + late
Study III: Lord, Symonds, Granger “Coping”(d) n=250
Study IV: Mitchell, Symonds, Steward “SMI RCT”(e) n=300
1. Purpose of Screening?1. Purpose of Screening?
Depression
13%
20%
48%
30%
38%
?%
Anxiety
Distress
Pooled Analysis of 38 studies
Setting: mostly oncology
Instruments: mixedPoint prevalence n=6414
Rates of Mj Mn SSRates of Mj Mn SS
11.6
8.5
31
51.1
10.3
4.7
37.2
52.2
0
10
20
30
40
50
60
Major Depression Minor Depression Subsyndromal Any Mood Problem
Baseline1 Month
OutcomeOutcome0.27
0.09
0.18
0.18
0.27
Major DepressionMinor DepressionSub-SyndromalRemissionLost
2. Current Detection Methods 2. Current Detection Methods
Unassisted Accuracy?
Screening Habits?
What are the optimal questions?
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
Loss
of
ener
gy
Dim
inis
hed
driv
e
Slee
p di
stur
banc
e
Con
cent
rati
on/i
ndec
isio
n
Dep
ress
ed m
ood
Anx
iety
Dim
inis
hed
conc
entr
atio
n
Inso
mni
a
Dim
inis
hed
inte
rest
/ple
asur
e
Psyc
hic
anxi
ety
Hel
ples
snes
s
Wor
thle
ssne
ss
Hop
eles
snes
s
Som
atic
anx
iety
Tho
ught
s of
dea
th
Ang
er
Exce
ssiv
e gu
ilt
Psyc
hom
otor
cha
nge
Inde
cisi
vene
ss
Dec
reas
ed a
ppet
ite
Psyc
hom
otor
agi
tati
on
Psyc
hom
otor
ret
arda
tion
Dec
reas
ed w
eigh
t
Lack
of
reac
tive
moo
d
Incr
ease
d ap
peti
te
Hyp
erso
mni
a
Incr
ease
d w
eigh
t
All Case ProportionDepressed ProportionNon-Depressed Proportion
Mitchell, Zimmerman et al MIDAS Database. Psychol Med 2007 Submitted
N=1500
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Depressed Mood
Diminished driveDiminished interest/pleasure
Loss of energySleep disturbance
Diminished concentration
Sensitivity
1 - Specificity
3. Rapid Screening 3. Rapid Screening
Test DurationTest Duration
Ultra-short screening tools were defined as those with 1-4 items taking less than 2 minutes to complete.
Short screening tools were defined as those with 5-14 items, taking between 2 and five minutes to complete.
Standard screening tools were defined as those with 15 or more items, taking more than five minutes to complete.
=> Tools table
20 Instruments for Depression20 Instruments for Depression
SDS (20)Personal HQ (16)
GDS (30,15) (5)(4)(2)PHQ9 (9) (2)
DEPS (10)
Zung (20)DADS (7)
CES-D (20) (13)(10) (6)EPDS (10) (8)(6)(5)Distress Therm (1)
BSI (53)MOS-D (8)WHO-5 (5)
BDI (21) (13) (7) (2)MADRAS (10)PHQ2 (2)
HAM-D (21) (7) (6)HADS (7) (1)PHQ1
Long > 10Short > 5 < 11Ultra-short <6
3a. The Verbal Questions3a. The Verbal Questions
1,2 or 3 Simple QQ15%
Clinical Skills Alone73%
ICD10/DSMIV0%
Short QQ3%
Other/Uncertain9% Other/Uncertain
2%
Use a QQ15%
ICD10/DSMIV13%
Clinical Skills Alone55%
1,2 or 3 Simple QQ15%
Cancer Staff Psychiatrists
Mitchell, Kaar, Poster APA 2007Current Method
1,2 or 3 Simple QQ24%
Clinical Skills Alone20%
ICD10/DSMIV24%
Short QQ24%
Long QQ8%
Algorithm26%
Short QQ23%
ICD10/DSMIV0%
Clinical Skills Alone17%
1,2 or 3 Simple QQ34%
Cancer Staff Psychiatrists
Mitchell, Kaar, Poster APA 2007Ideal Method
Effective?
HADS-total score (n=2)
Early stage (n=3)
No diagnostic validity testing (n=39)
Simple Verbal Question Diagnostic Accuracy Studies
(n= 17)
Single depression question (n=9)
DSM Major and minor depression (n=4)
Excluded long, medium, short tests (n= 122)
Non-validated comparison (n= 1)
Insufficient data available(n= 4)
Non-cancer settings(n= 6)
Excluded primary care studies (n= 32)
Non-STARD compliant (n= 2)
Mixed stage (n=3)
Single interest question (n=3)
Two questions (n=5)
Examined Ultra-short tests (n= 98)
Verbal and Non-Verbal Studies (n=59)
Primary data reports (n= 258)
Palliative care (n=11)
Ultra-Short Method
Outcome Measure Setting / Sample
DSM Major Depression (n=11)
ICD10 Depression (n=0)
Non-verbal methods (n= 29)
Submitted BJCa
1.7
2.7
4.7
16.5
13.0
70.2
71.5
66.7
11.5
13.3
15.7
12.5
0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 50.0 55.0 60.0 65.0 70.0 75.0 80.0 85.0 90.0 95.0 100.0
Depression & Interest Q
Interest Question
Depression Question
False Negatives (%)Correctly Diagnosed (%)Correct Reassured (%)False Positives (%)
Depressed Non-Depressed
Depressed
Depressed
Non-Depressed
Non-Depressed
c
Real-World Performance (Prev 18%, TP TN, FP, FN)
3b. The Distress Thermometer3b. The Distress Thermometer
- Please circle the number (0-10) that best describes how much distress you have been experiencing in the past week, including today.
- What phone number would you like us to contact you on if necessary?
Please tick WHICH of the following is a cause of distress:
DiarrhoeaAnger
ConstipationWorry
IndigestionSadness
EatingNervousness
Is there anything important you would like to add to the list?__________________________________________________________________________________________
Mouth soresFears
BreathingDepression
Bathing/ DressingEmotional Problems
Getting around
Hot flushesSleepDealing with children
SexualFatigueDealing with partner
Feeling swollenNauseaFamily Problems
Metallic taste in mouthPain
Tingling in hands/ feetPhysical problemsWork/School
Nose dry/ congestedTransport
Skin dry/ itchyLoss of meaning or purpose in lifeMoney
FeversRelating to GodHousing
Changes in UrinationLoss of faithChildcare
Physical Problems contd…Spiritual/ Religious ConcernsPractical Problems
The distress thermometerThe distress thermometer
=> Validity
Distribution of DT ScoresRansom (2006) PO (n=491)
13.814.7
15.7
13.2
10.4
8.47.7 7.3
3.7 3.3
1.8
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
Score 0 Score 1 Score 2 Score 3 Score 4 Score 5 Score 6 Score 7 Score 8 Score 9 Score 10
Ultra-short Tests & DepressionUltra-short Tests & Depression
36033816787
27952643152Test -ve
18081173635Test +ve
DepressionABSENT
DepressionPRESENT
Sensitivity81%
PPV 32%
Specificity69%
NPV 93%
Prevalence 18%
N=17 studies 3603
Ultra-short Tests & DistressUltra-short Tests & Distress
368222071475
18911514337Test -ve
18316931138Test +ve
DistressABSENT
DistressPRESENT
Sensitivity77%
PPV 65%
Specificity68%
NPV 80%
Prevalence 39%
N=17studies 3682
Ultra-short Tests & AnxietyUltra-short Tests & Anxiety
22151372843
969776193Test -ve
1248596652Test +ve
AnxietyABSENT
AnxietyPRESENT
Sensitivity77%
PPV 55%
Specificity56%
NPV 80%
Prevalence 38%
N= 4 studies 2215
Study I: Baker-Glenn et alStudy I: Baker-Glenn et al
Head-to-head comparison of
HADSPHQ2 (Q1, Q2, Q1 or Q2)PHQ9DT
(3v4)
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
1 - Specificity
Sens
itivi
tyPHQ2 Two QQ
PHQ2 Interest
PHQ9
PHQ2 Depression
HADS-D DT (4v5)
DT (3v4)
HADS-T
4. New Methods for 20084. New Methods for 2008
See Gil F, Grassi L, Travado L, Tomamichel M, Gonzalez JR. for the SEPOS Group. Use of distress and depression thermometers to measure psychosocial morbidity among southern European cancer patients. Support Care Cancer, 13: 600–606, 2005
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
DistressThermometer
AnxietyThermometer
DepressionThermometer
AngerThermometer
TenNineEightSevenSixFiveFourThreeTwoOneZero
ET vs DT?ET vs DT?
Of 130 patients with predominantly early cancer, 37% scored above the cut-off recommended by the NCCN on the DT vs 69% on the ET
Of 63% DT low scorers 51% recorded emotional difficulties on the new Emotion Thermometers (ET) tool
Out of those with any emotional complication, 93.3% would be recognised using the AnxT alone, compared with 54.4% who would be recognised using the DT alone.
HADS-A Score & DT Score
y = 0.9117x + 3.9311R2 = 0.4098
0
5
10
15
20
0 1 2 3 4 5 6 7 8 9 10
HADS-A Score & AnxT Score
y = 1.014x + 2.3207R2 = 0.5702
0
5
10
15
20
0 1 2 3 4 5 6 7 8 9 10
HADS-D Score & DT Score
y = 0.4334x + 3.3146R2 = 0.11870
5
10
15
20
0 1 2 3 4 5 6 7 8 9 10
HADS-D Score & DeptT Score
y = 0.8165x + 2.7614R2 = 0.3048
0
5
10
15
20
0 1 2 3 4 5 6 7 8 9 10
DT DepTVsHADS-A
AnxT AngT
AUC:DT=0.82DepT=0.84AnxT=0.87AngT=0.685
DT DepTVsHADS-D
AnxT AngT
AUC:DT=0.67DepT=0.75AnxT=0.62AngT=0.69
DepT & Major DepressionDepT & Major Depression
21719324
20218814Test -ve
15510Test +ve
DepressionABSENT
DepressionPRESENT
Sensitivity42%
PPV 67%
Specificity97%
NPV 93%
Prevalence 11%
DT 28%
DT79%
DT67%
DT 95%
DT
15%
DT(38%)
AngT(26%)
DepT(30%)
AnxT(65%)
8%
2%
4%
0%
10%
0%
0%
0%
2%
21%
1%
2%
5. Where Next? 5. Where Next?
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