NCRI - Latest Evidence For Screening In Cancer (March08)

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

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0.60

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All Case ProportionDepressed ProportionNon-Depressed Proportion

Mitchell, Zimmerman et al MIDAS Database. Psychol Med 2007 Submitted

N=1500

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0.1

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0.5

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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%



Cancer Staff Psychiatrists

Mitchell, Kaar, Poster APA 2007Current Method



ICD10/DSMIV24%

Short QQ24%

Long QQ8%

Algorithm26%

Short QQ23%

ICD10/DSMIV0%



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

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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

0

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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

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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

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15

20

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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

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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?

Help

Algorithms

NCRI - Latest Evidence For Screening In Cancer (March08)

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