Elsevier

The Lancet Oncology

Volume 14, Issue 8, July 2013, Pages 721-732
The Lancet Oncology

Articles
Depression and anxiety in long-term cancer survivors compared with spouses and healthy controls: a systematic review and meta-analysis

https://doi.org/10.1016/S1470-2045(13)70244-4Get rights and content

Summary

Background

Cancer survival has improved in the past 20 years, affecting the long-term risk of mood disorders. We assessed whether depression and anxiety are more common in long-term survivors of cancer compared with their spouses and with healthy controls.

Methods

We systematically searched Medline, PsycINFO, Embase, Science Direct, Ingenta Select, Ovid, and Wiley Interscience for reports about the prevalence of mood disorders in patients diagnosed with cancer at least 2 years previously. We also searched the records of the International Psycho-oncology Society and for reports that cited relevant references. Three investigators independently extracted primary data. We did a random-effects meta-analysis of the prevalences of depression and anxiety in cancer patients compared with spouses and healthy controls.

Findings

Our search returned 144 results, 43 were included in the main analysis: for comparisons with healthy controls, 16 assessed depression and ten assessed anxiety; of the comparisons with spouses, 12 assessed depression and five assessed anxiety. The prevalence of depression was 11·6% (95% CI 7·7–16·2) in the pooled sample of 51 381 cancer survivors and 10·2% (8·0–12·6) in 217 630 healthy controls (pooled relative risk [RR] 1·11, 95% CI 0·96–1·27; p=0·17). The prevalence of anxiety was 17·9% (95% CI 12·8–23·6) in 48 964 cancer survivors and 13·9% (9·8–18·5) in 226 467 healthy controls (RR 1·27, 95% CI 1·08–1·50; p=0·0039). Neither the prevalence of depression (26·7% vs 26·3%; RR 1·01, 95% CI 0·86–1·20; p=0·88) nor the prevalence of anxiety (28·0% vs 40·1%; RR 0·71, 95% CI 0·44–1·14; p=0·16) differed significantly between cancer patients and their spouses.

Interpretation

Our findings suggest that anxiety, rather than depression, is most likely to be a problem in long-term cancer survivors and spouses compared with healthy controls. Efforts should be made to improve recognition and treatment of anxiety in long-term cancer survivors and their spouses.

Funding

None.

Introduction

Survival after cancer has improved over the past 20 years, thanks to advances in diagnosis and targeted treatment. As a result, cancer is increasingly thought of as a chronic disease—about 70% of patients live for at least 5 years after diagnosis.1, 2 GLOBOCAN estimates3 that by 2030, more than 21 million new cases will be diagnosed yearly worldwide. Prevalence estimates suggest that at least 20 million people in the USA will have cancer by 2030, and perhaps 50 million worldwide.4 Several studies have shown that mood disorders are common in patients with cancer. In a meta-analysis of interview-based studies, Mitchell and colleagues5 reported that the point prevalence of major depression was about 16% and that of anxiety was 10%. In most of the studies, patients were interviewed early in the course of illness, during which time the distress of diagnosis and treatment is probably most intense. The prevalence of mood disorders in long-term cancer survivors has been much less extensively investigated and is widely debated,6 partly because of uncertainty about the definition of long term. Conventionally, oncologists define long-term survivors as those who are alive 5 years after diagnosis.7 However, the US Centers for Disease Control and National Coalition for Cancer Survivorship both define a cancer survivor as any person living with cancer from the time of diagnosis to the time of death.8 We consider 2 years or more to be long term because many cancer relapses occur within 2 years.9 Interpretation of the prevalence of mood disorders is also affected by methodological difficulties—eg, uncertainty about the best diagnostic method, heterogeneity in setting, and cancer type. A key question for clinicians is whether the prevalence of mood disorders is significantly different in patients compared with spouses. Relatives of patients with cancer can often have mood disorders including anxiety and depression. In some cases, the level of distress in spouses can exceed that of patients.10, 11 A meta-analysis12 has reported a positive association between patient and carer psychological distress (r=0·35; p<0·0001) and that the severity of distress is of roughly equal magnitude. However, this study did not report on specific mood disorders such as depression or anxiety. A second question is whether the prevalence of mood disorders is different in long-term cancer survivors compared with the general population—ie, do the initially high rates of depression and anxiety after cancer return to baseline? Large, general population surveys13 suggest that the 30-day prevalence of depression is roughly 5% and the 12-month prevalence is about 9% in Europe and the USA. Anxiety disorders are about twice as common as depression, with a 12-month prevalence of about 18%.14 Several well-powered studies have attempted to measure depression prevalence in people with cancer compared with the general population. Rasic and coworkers15 reported that diagnosis of cancer was significantly associated with 12-month prevalence of major depression (15·5% vs 5·4% in healthy controls) based on Composite International Diagnostic Interviews with 36 984 people aged 15–54 years in the Canadian Community Health Survey. Similarly, Dalton and colleagues16 assessed linked data from 608 591 adults with cancer in the Danish Cancer Registry and reported a relative risk (RR) for depression of 1·16–3·08 in the first year after diagnosis, which seemed to increase at 10-year follow-up.

Longitudinal studies of depression and anxiety after cancer suggest that the high early prevalence of mood disorders falls slowly with time, suggesting that anxiety or depression in long-term cancer survivors is more common than in healthy controls.17, 18 Long-term cancer survivors face prolonged uncertainty about their prognosis,19, 20 although many—particularly those in remission—make good psychological progress. In one study,21 almost 50% of patients had cancer-related intrusive thoughts, 3 years or more after surgery for breast cancer. However, other studies22, 23, 24, 25 have documented low rates of depression, good quality of life, and low distress in long-term cancer survivors. Health-related quality of life is often much the same in long-term cancer survivors and age-matched individuals in the general population.26, 27, 28, 29, 30, 31 Further work is needed to assess the prevalence of specific mood disorders and to test whether the prevalence of depression or anxiety in long-term cancer survivors is the same as in healthy controls. How rates compare between patients and their spouses is also unclear. We did a systematic review and meta-analysis of depression and anxiety in long-term cancer survivors compared with their spouses and healthy controls.

Section snippets

Study selection and procedures

The protocol for the systematic review was based on the PRISMA statement.32 We did a systematic search of Medline, PsycINFO, and Embase, from inception to March 31, 2013, for publications in English. We also searched four full-text collections (Science Direct, Ingenta Select, Ovid Full text, Wiley Interscience), and theses and meeting abstracts from the International Psycho-oncology Society. When necessary, authors were contacted directly for primary data. We also searched for reports that

Results

Our systematic review returned 1886 results, of which 304 publications investigated mood disorders in long-term cancer survivors and 144 mentioned a comparison sample. Of these, most were unsuitable and we identified only 68 comparisons that contained primary data. 25 were comparisons in the period soon after cancer diagnosis and were therefore excluded, leaving 43 studies for the main analyses (figure 1, table 1).50

We identified 43 comparative analyses (extracted from 27 publications)

Discussion

We did four meta-analyses comparing depression and anxiety in long-term cancer survivors with healthy controls and spouses. After 2 years or more, cancer patients had much the same prevalence of depression as did spouses and healthy controls. The prevalence of anxiety was higher in cancer patients than in healthy controls. Anxiety was also high in spouses, indeed it was significantly higher in spouses than in patients if one outlier was removed. To our knowledge, our study is the first

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