In this lecture, we will be talking about depression and anxiety, and lung and esophageal cancers. Depression and anxiety disorders are generally under diagnosed and under treated. Why is that so? Well, there's still stigma. And it's not right, but there's stigma about having a psychiatric condition. And for some patients, the double whammy of having cancer and a psychiatric condition may be really too much. And they worry about telling their oncologists, radiation oncologists, or surgeon about their history of a psychiatric condition of having suicidal thoughts, of being depressed, of having substance abuse. It's important to ask about psychiatric conditions. So that it would help free the patient up to tell us about these conditions. So that we can begin an open, honest, and trusting dialogue with our patients, and to improve communication. Patients are also worried and fearful about talking about their depression and anxiety. They worry about if they tell their clinician. Perhaps they won't get treated appropriately, or they won't be eligible for a clinical trial, or won't be eligible for certain kinds of medications. Since some medications may in fact for the cancer, impact on depression and anxiety. Patients may not know that they're depressed, or anxious. Because there are sometimes overlapping symptoms between the cancer itself and depression and anxiety. So it's often very difficult and complicated for patients, their families. And even we as clinicians, to determine if this is depression and anxiety, or the underlying cancer. And depression is often masked by anxiety symptoms or medical issues. So the medication itself that the patient takes may actually look in a specific patient like the patient's depressed or anxious. So, steroids might be a good example. High dose steroids can make a patient look anxious or not sleeping or restless or agitated. So in a very busy oncology office where doctors are very busy and patients feel stigmatized or fearful. Sometimes we don't ask and patients don't tell. And that's why it's very important for us to have guidelines. Forcing us, encouraging us to ask of that distress if the patient's to feel that this is a normal part of their exam. And to tell us about their distress and why they might be distressed. Again, not all distress is psychiatric. But some of it might be. About 13% of cancer patients develop a major depressive disorder within two years of diagnosis. So this is very important and it tells us that just because somebody has diagnosed with cancer. And at the very beginning of the care, patients are still at risk for having depression even two years out. And in fact, depression is very prevalent in oropharyngeal cancer, head-neck cancers. And it's a wide range depending on the kind of follow up and the type of patient and the stage, and the age of the patient. But it can be from 22-57% of all head-neck cancer patients will have depression. Pancreatic cancer have a very high rate of depression. Breast, and it goes from 1-46% again, the large range has to do with the type of patient who is being surveyed. How long the patient is being evaluated for. What kind of screening is being used in the study. And then lung cancer, you can see 11 to 44%. Again, very high numbers for the prevalence of depression. These types of cancers. And then for other cancers such as colon, gynecological cancers, and lymphomas just as examples. And you can get further information about this if you go to the National Cancer Institute, monographs are on their web pages. So what do we mean when we say depression? Well, now we have the DSM. The Diagnostic and Statistical Manual version 5, DSM5. And you can look up further symptoms about depression, but these are the main ones. Sad mood, hopelessness or helplessness, loss of interest or pleasure, worthlessness, guilt, self-reproach, decreased ability to concentrate, suicidal ideation and changes in appetite, sleep, energy problems. And patients could be eating more or eating less, sleeping more or less and have low or high energy. What we think about is about two weeks of these sort of symptoms. Generally prevalent for each day, and impacting on the patient's functionality. And when patients have these symptoms for about two weeks, every day, and it's impacting. Then it's important for the patient to get care and to see a professional. The risk factors for depression for lung or esophageal cancer patients are a history of depression or anxiety before the cancer diagnosis. The stage and prognosis of the cancer. Loss of function related to the cancer. Disfigurement, often seen in head-neck, or esophageal cancers, for example. And persistent cancer related physical symptom such as pain, fatigue, cognitive dysfunction, or sleep disturbance. Other risk factors for depression include lack of social support. Such as having few family members, friends, lack of a social structure. Not being involved with a religious organization or a spiritual organization. Alcohol or drug abuse issues. Other major medical conditions such as diabetes, heart disease arthritis, as examples. A family history of depression or anxiety. And then other life stressors. Such as financial issues, relationship issues, and other losses that the patient might have encountered. In terms of other risk factors for depression anxiety. There are behavioral risk factors, such as smoking. So, in the example of patients with lung cancer or esophageal cancers. Even though patients can who end up having lung or esophageal cancers not related to smoking, as an example. There may be family dynamics where the family wanted the patient who was smoking to have stopped. And may be very upset when the patient now gets lung or esophageal cancer. Where it is related to smoking, but often it's not. Alcohol consumption can be a behavioral risk factor, drug abuse, nutrition, obesity, physical activity or inactivity. Adherence to screening or treatment so that the patient may not have been going to the doctor regularly or getting screened appropriately. And then chronic stress is an important behavioral risk factor. What about anxiety? We talked about depression. What about an anxiety? Well, patients can have a lot of anxiety related to treatment decisions. They can worry about treatment failures. And it may be so overwhelming. That it's hard for them to get through the day, to think about what they need to do in the here and now. Because they're worried about what happens if that drug doesn't work? Or is there going to be another drug to use? Or other treatment to use if the current drug they're on fails. They could be worried about family issues, jobs. Will they be able to go back to their job? Or what happens if the cancer impedes on their ability to function at their job, or workplace? Finances are a big worry for patients with cancer. Especially if they have to go on disability. And if they are the primary breadwinner, or an important aspect of the family's financial health. Transportation to and from cancer care. And what happens to the transportation for their children or other members of their family. And then,medical costs in general. Co-pays are really sometimes very difficult for patients and their families. And sometimes they're embarrassed to talk about it with their doctors, about the high co-pays. And sometimes patients often take less of a drug. They'll cut it in half, or take it every other day. Because they worry about the high co-pays. Patients worry about a number of the big Ds. Being dependent, being disabled, having destruction in their lives, death, and disfigurement. And so all of these are important aspects for us when we screen for and then treat patients for anxiety. Pain is an important aspect and sometimes people are afraid to talk about that. And so, it's important for us to anticipate that and try to help address that. And then side effects of medications. People generally want to be brave and tough it out. But sometimes the side effects of medications are very noxious for patients. And we need to ask about that and try to help with these kinds of side effects. The specific types of anxiety that patients with lung or esophageal cancers have could be panic. Where they feel like their heart is racing. They're about to die. They're short of breath. They don't know if they can stand this terrible anxiety they may have. Autonomic nervous symptoms, problems. They may sweat and be diaphoretic, feel like they're choking. There can be generalized anxiety. I have that twice. So they could have generalized feeling anxious throughout the day, most of the day. And it just never goes away. They can't pinpoint why they're feeling anxious. They could have post traumatic stress. Where they feel like they're on edge and they have remembrances. They feel like they are triggers, and they're on the alert. They have trouble sleeping. And they can have both acute and chronic PTSD. They can have OCD, which they've had before. Obsessive Compulsive Disorder. And they get even more anxious with the onset of cancer. And then they could have anxiety specifically due to the medical condition or the medication. And that could be related to the specific medication. Such as, we use the example of steroids. But there are many other medications that make people feel anxious. The location of the tumor itself. Such as an adrenal tumor. But we see anxiety for patients with esophageal cancer. Where they worry about eating, choking, not being able to swallow, something getting stuck. Or with lung cancer patients, where they're worried about breathing. Patients have a lot of worries and concerns, which may be normal for the type of cancer and their stage. But it also could be abnormal as well and need to be treated. So, patients worry about tolerating when you're recovering from the treatment. What will life be like? Again, they worry about the cancer progressing and recurring. They're worried about the uncertainty of their future. A lot of us like to be controlling and plan. And not being able to do that is sometimes really troubling for patients and makes them anxious. Will they be able to adapt to this interruption in their life plans? For many patients their role and their family and at work and their social structure changes. So that is really difficult to be able to change their lifestyle. Fertility and sexual health are really important. So we have young or a younger type patient who. We have to start talking about fertility and banking the ova or sperm. And having these very difficult conversations. And people worry about if they can conceive later on. And they do worry about their sexual health at all ages. Patients worry about their financial health and the stability of their jobs. And in fact, many people worry about getting promoted or whether in a small organization whether the increased cost. Because of their cancer will impact on their employers keeping them. Patients worry about their relationships with their children, with their significant others, with neighbors, friends. Not wanting to impose themselves on others. But knowing that they may need help. And most probably importantly, people start feeling very vulnerable when they have cancer. So anxiety can manifest in a number of ways. And everybody's quite different. But if it's generalized anxiety. They may have problems sleeping. They may have problems concentrating. And they may be worrying constantly. Which often makes people worry about their cognitive functions. Whether they can do their job. Whether they can drive. And so there's a lot of unintended consequences of this anxiety. Their anxiety may be disease specific. Specifically related for example, to the lung or esophageal cancer. Again, they may have panic attacks, or claustrophobia. We see this with patients for example, who need MRI scans. And they worry about going into the machine and how we can help. It's important for us to try to figure out how to help them with that. So what's the course of symptoms of depression and anxiety? Well, in this study by Alex Mitchell. The question was, how do rates of depression and anxiety after cancer compare to rates in the general population? And in terms of depression. In the two years from the diagnosis of cancer. It's pretty high and then it goes down in the two to ten years from diagnosis. And if you're ten years out the depression's even less. But it's interesting in terms of anxiety. In the two years after the diagnosis it's high. And then two to ten years from the diagnosis it goes down lower, but ten years after it goes back higher. And a lot of patients tell me that they're waiting for the other shoe to fall. So survivorship and anxiety are really quite difficult for many patients. So in terms of dealing with feelings, depression, anxiety, and stress affect a very large percentage of patients with lung and esophageal cancer. The good news is that depression and anxiety are very treatable with both antidepressant medication and other kinds of medication. Which we'll talk about and various forms of psychotherapy, or counseling, or other modifications. Treatments for depression and anxiety may affect disease progression as well as the quality of life. So this is really an important area for us to work on, and do research in. And why we need to treat people. Because it may impact on the disease progression and quality of life. And then, it's important because people feel better when they're dealing with their feelings. And that may lead to healing better from their cancer. In our next lecture we will be talking about treatments for distress in lung and esophageal cancers. Focusing on depression and anxiety.
