Effective treatment for depression in patients with cancer

Menés au Royaume-Uni auprès de patients atteints d'un cancer du poumon, ces deux essais multicentriques randomisés analysent l'efficacité d'un programme thérapeutique destiné à traiter les dépressions sévères

Résumé en anglais

The studies by Michael Sharpe and colleagues in The Lancet and by Jane Walker and colleagues in The Lancet Oncology show a rigorous approach to the implementation and assessment of a complex intervention to alleviate depression in people with cancer. This research is timely, since the risk of depression has been shown to be two-to-three-times higher in patients with cancer than in the general population, and could contribute to the poorer quality of life and increased risk of suicide in such individuals. Neurobiological factors might play a part in the link between cancer and depression, but much evidence suggests that depression in this population represents a final common pathway of distress that results from the interaction of several diverse risk and vulnerability factors.
Substantial advances in the treatment of cancer have been made during the past few decades, but attention to the physical and psychological symptoms of this disease and its treatment has been given lower priority in clinical settings. To address this imbalance, professional bodies have mandated that routine distress screening be a standard of practice in cancer treatment settings Such screening needs to be linked to an effective intervention programme for it to be clinically effective, although only sparse evidence has shown the benefit of such interventions in patients with cancer. In other medical populations, positive outcomes in the treatment of depression have been shown to be achievable by a collaborative care approach that links care managers or nurses with primary care physicians and psychiatrists to provide and adjust psychological or pharmacological treatment, to monitor outcomes, and to ensure treatment compliance.
Sharpe and colleagues have developed a collaborative care intervention for depression, which is referred to as depression care for people with cancer. This is a complex intervention involving both antidepressant medication and psychological treatment that makes available for each patient contact with, or input from, a nursing case manager trained in problem-solving therapy and behavioural activation, a primary care physician, a psychiatrist, and liaison with the patient's oncologist. The SMaRT Oncology-2 multicentre phase 3 trial of depression care for people with cancer is a major study in which 500 patients from three cancer centres in Scotland, UK, all with an expected survival of at least 12 months and a diagnosis of major depression, were randomly assigned to depression care for people with cancer or to usual care. 90% of the study population were women, and a participation rate of 47% was achieved among eligible patients. The primary outcome was treatment response at 24 weeks, defined by a 50% or greater reduction in depression severity on a self-reported measure (the Symptom Checklist Depression Scale [SCL-20]), although patients were followed for up to 48 weeks. Several other secondary and tertiary outcomes were also assessed, including depression, anxiety, physical distress, functional capacity, and quality of life.
The treatment effect in SMaRT Oncology-2 is impressive, with 62% (143 of 231) of the depression care for people with cancer group having a response at 24 weeks, compared with only 17% (40 of 231) of those in the usual care group (adjusted odds ratio 8·5 [95% CI 5·5—13·4]). Statistically significant differences were also recorded between the two groups on all the secondary and tertiary outcomes. These benefits, which persisted throughout the trial, are greater than those reported by this group in their 2008 efficacy trial of this intervention.11 In the present study, patients in the depression care treatment group received up to ten sessions with a nurse and were more likely to receive an effective dose of antidepressant medication than were those in the usual care group. Very few patients in the usual care group received counselling or a formal psychological intervention. The depression care intervention in this study was estimated to cost an additional £613 per patient, based on the cost of the treatment sessions, telephone contacts, and treatment supervision, although implementation in other cancer settings would incur further setup costs. How such a system of care could be implemented or modified to be feasible in lower resource settings that do not have ready access to primary care physicians, nurses, psychiatrists, and oncologists is a challenge that is yet to be addressed