Low-Income Women, Breast and Gynecologic Cancer, and Depression and Anxiety
Low-Income Women, Breast and Gynecologic Cancer, and Depression and Anxiety
Abstract & Commentary
By Robert L. Coleman, MD, Associate Professor, University of Texas; M.D. Anderson Cancer Center, Houston, is Associate Editor for OB/GYN Clinical Alert
Dr. Coleman is on the speaker’s bureau for GlaxoSmithKline, Bristol-Myers Squibb, and Ortho Biotech.
The prevalence of depression among low-income, ethnic minority women with breast or gynecologic cancer is largely unknown, but limited formal screening programs and restricted access to effective therapies would suggest the number to be high. The trial by Ell and colleagues represents a unique insight into the scope of the problem. The principal aims in this report were to quantify the prevalence of depression, to evaluate the receipt of antidepressant medications or counseling services, and to examine the correlates of depression. To do this, they identified 500 women with gynecologic or breast cancer who were currently participating in an ongoing randomized trial of structured case management intervention in order to improve adherence to cancer treatment. From this group, 472 women were receiving cancer care in an urban public medical center and were surveyed for depression, anxiety and pain according to structured questionnaire models. The queries were conducted before and during cancer therapy or during active follow-up.
They found that 24% of this population reported moderate-to-severe levels of a depressive disorder. Depression was more commonly reported in breast cancer patients (30%) than in gynecologic cancer patients (17%). Only 12% of women were receiving medications for depression despite meeting criteria for major depressive disorder (MDD). As anticipated, women receiving medication were less likely to have major depression and pain symptoms. Only 5% reported seeing a counselor or participating in a cancer support group. Surprisingly, neither cancer stage nor treatment status were correlated with depression.
Correlates of MDD were: breast cancer (vs gynecologic cancer), younger age, greater functional impairment, poorer social and family well-being, anxiety, co-morbid arthritis, and fears about treatment side effects. Ell et al concluded that MDD is prevalent among ethnic minority, low-income women with breast or gynecologic cancer. It appears to be correlated with pain, anxiety, and health-related quality of life. Because these women are unlikely to receive depression treatment or supportive counseling, there is a need for routine screening, evaluation, and treatment in this population. (Ell K, et al. Depression, correlates of depression, and receipt of depression care among low-income women with breast or gynecologic cancer. J Clin Oncol.2005;23:3052-3060.)
Commentary
Studies evaluating the effect of cancer, cancer treatment and cancer education on emotional well-being are mounting and bring a consistent message—depression, anxiety, and pain are under-appreciated, under-diagnosed, under-treated and disparately addressed among ethnic minority and impoverished socioeconomic women. Burdensome enough through this oversight, poor access to care even when these maladies are appropriately identified only troubles these women more and represents a daunting challenge for our under-resourced public health system. Nonetheless, the article by Ell et al demonstrates that basic screening is an important first step.
The study is a nested cross-sectional survey of women included in an ongoing randomized trial assessing the impact of structured case management for cancer patients. The intent of this trial is to determine not only the barriers to care but to assess a program to improve adherence to cancer treatment and follow-up. This is an important feature to consider because the results identified in this nested trial represent a point in time of a cohort undergoing care for malignancy—a fluid variable, changing over time. Despite the stasis of the observation, there are several impressive figures identified. First, nearly 1 in 4 of their mostly indigent, minority population met the validated criteria for MDD. While the diagnosis was more commonly identified in breast cancer patients, neither group received adequate therapy for it; and even fewer were in supplementary support groups or counseling. Fully 20% of the women with MDD reported suicide ideation. Other correlates to the diagnosis included younger age, pain, anxiety, and arthritis. Second, barriers to health care were common in depressed women and included many factors which could be positively influenced with directed case management such as understanding treatment recommendations, fears of receiving treatment, inability to get medication, concerns of lost wages, and reminders of appointments. Third, fewer than 1 in 8 women with MDD were receiving active treatment.
Data in this study certainly support Ell et al’s contention that health care practitioners need to investigate ways to improve depression care in these patients. We look forward to the subsequent information obtained from the longitudinal and interventional study Ell et al are currently conducting. As limitations and barriers to care and case management are relieved, better outcomes to cancer therapy and hopefully survival will be realized.
Additional Reading
- Bodurka-Bevers D, et al. Depression, anxiety, and quality of life in patients with epithelial ovarian cancer. Gynecol Oncol. 2000;78 (3 Pt 1):302-308.
- Fowler JM, et al. The gynecologic oncology consult: symptom presentation and concurrent symptoms of depression and anxiety. Obstet Gynecol. 2004;103:1211-1217.
- Golden RN, et al. The detection of depression by patient self-report in women with gynecologic cancer. Int J Psychiatry Med. 1991;21:17-27.
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