Palliative Care in Pancreatic Cancer

Frank J. Brescia, MD, MA, FACP

Disclosures

Cancer Control. 2004;11(1) 

In This Article

Depression

It has long been known that depression is more common in patients with pancreatic cancer than in those with other malignancies. A well-described study of 139 patients who were admitted for possible colon or pancreatic cancer reported that 76% of patients with pancreatic cancer had depressive symptoms prior to surgery compared to 17% of patients with colon cancer.[30] A small National Cancer Institute study also revealed major depressive symptoms in half of the patients with pancreatic cancer compared with none in patients with gastric cancer.[31] A large literature of retrospective reviews has tried to connect the issue of unrelieved pain and misdiagnosis to depressive symptoms in this illness.[32] Foley[33] noted that pain was a presenting symptom in 80% of patients and occurred sometime in their illness in 90% of patients. Because of the widely held belief that pain and depression are common with pancreatic cancer, Kelsen et al[34] prospectively evaluated these symptoms in 130 newly diagnosed patients: 83 patients prior to a surgical procedure and 47 before their first chemotherapy treatment. All patients had excellent performance status and were being treated at a major tertiary cancer center. The Beck Depression Inventory (BDI) and Beck Hopelessness Scale (BHS) were utilized, as well as other validated tools, to measure pain and symptom distress. Only 29% of these patients complained of moderate to severe pain. The patients receiving chemotherapy reported more pain than did preoperative patients. BDI scores were ≥15 in 38%, suggesting high levels of depressive symptoms. There was a strong correlation between increasing pain and depressive symptoms among those with pain. However, the authors concluded that moderate or severe pain and symptoms of depression were less prevalent than originally thought. This study examined patients earlier in their disease where severity of depression and pain would be less prevalent. The patients receiving chemotherapy who were more likely to be depressed may have seen themselves as less likely to be cured. It is difficult to be sure since the number of cases in this treatment arm was small.

Some data suggest that patients with a prior history of depression have a worse survival when cancer occurs than would be expected on the basis of their cancer diagnosis alone.[35] If prior depression affects life expectancy among patients with cancer, effective intervention should be studied to substantiate survival outcomes. Brief psychotherapy (ie, fewer than six sessions with a psychiatrist) and cognitive therapy appear to be beneficial for patients in a palliative setting by addressing depressive symptoms, anxiety, and adjustment of patients to their illness (D. Schuyler, MD, personal communication, 2003). Interestingly, there is evidence that depressive symptoms may abate in patients with pancreatic cancer when the malignancy has been surgically excised.[36]

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