Screening for Psychosocial Distress in Patients with Hematological Malignancies and Identifying Specific Factors That Cause Distress throughout Stage of Disease

Studies incorporating measurement tools for emotional distress into clinical care for hematology patients are rare. We previously reported that distress levels of >5 on the National Comprehensive Cancer Network (NCCN) distress thermometer (DT) were significantly more likely to occur in patients who were seen within the first 30 day of presentation, women, younger patients, those with previous depression/anxiety, and those who are unmarried. However, the diagnosis of malignant or non-malignant hematologic disorder was not associated with DT levels >5. Since this report, the DT indicator of distress was adjusted to ≥4.

To assess and measure psychosocial distress in adult patients with hematological malignancies pertaining to Hodgkin's Lymphoma (HL), Non-Hodgkin's Lymphoma (NHL), Multiple Myeloma (MM), and Chronic Lymphocytic Leukemia (CLL) at a multidisciplinary community-based hematology/oncology clinic, and identify the specific factors of these subjects associated with the most distress.

Consecutive adult subjects with HL, NHL, MM, and CLL (n=302) seen at the Gundersen Lutheran Center for Cancer and Blood Disorders were approached over a period from September 2010 to March 2011. Study subjects consented to a one-time assessment of two prospective surveys that included the DT (scale of 0–10) and the Hospital Anxiety and Depression Scale (HADS), which indicates the specific factors that cause distress in daily life. Subjects were excluded for incomplete surveys. The Charlson Comorbidity Index (CCI) was utilized to assess comorbid conditions at the time of consent and is predictive of mortality within one year. Additional medical information including history of anxiety/depression, as well as disease related information and disease state (diagnosed, observation, remission, treatment) were collected by chart review. A score ≥4 was used an indicator of distress for the DT, and a score of ≥8 was used as a positive indicator of anxiety/depression for the HADS. All prospective surveys were completed prior to the subject's clinic appointment.

A total of 190 subjects (63%) consented and completed both the DT and HADS (mean age 65.8±13.4 yrs; 62% men). Subjects were grouped into hematological malignancy cohorts, with 31% having NHL, 25% CLL, 11% HL and MM 20%. The mean DT score was 2.8±2.5 and the mean CCI was 4.5±1.4, with 34% of subjects rating distress ≥4 and 31% of subjects having a positive HADS result. No differences between hematological malignancy cohorts were found for subjects with a history of anxiety/depression (p=0.079), DT ≥4 (p=0.468) or positive HADS results (p=0.079); however, the percentage of subjects with a positive HADS result trended higher in HL subjects (52%). When stratified by DT score (≥4 vs. 0–3), no differences were found for hematological malignancy cohorts, disease state, sex, age, marital status or CCI. However, a positive HADS result was associated with a DT score ≥4 (p=0.001), thereby validating DT as a screening tool for anxiety/depression. Women were more likely to have a history of depression (p=0.008), but a history of anxiety/depression or medication usage was strongly associated with a DT score ≥4 (p=0.001) for the entire population.

In subjects with common hematologic malignancies, a history of anxiety/depression was a very strong indicator of distress. Degree of comorbid illness, disease status and type of hematologic malignancy were not associated with distress. Based on these results, patients with hematologic malignancies who have a DT score ≥4 and/or a positive HADS result should be considered for aggressive management of prior anxiety and depression to ensure treatment that encompasses patient-centered care.

No relevant conflicts of interest to declare.