More than 20% of patients with cancer had symptoms of post-traumatic stress disorder (PTSD) a month after diagnosis, and the symptoms persisted long-term a third of the time, a prospective study showed.
Overall, 44 of 203 patients met diagnostic criteria for PTSD (including subsyndromal PTSD) 6 months after diagnosis of cancer. At 4 years, 15 of the 45 patients had persistent or worsening symptoms of PTSD, as reported online in Cancer.
“Our data underscore the risk of developing persistent PTSD even years after cancer diagnosis and treatment,” said Lei Hum Wee, PhD, of the National University of Malaysia in Kuala Lumpur, and colleagues. “Approximately one-third of patients with cancer who are initially diagnosed with full or subsyndromal PTSD at 6 months went on to develop chronic or full PTSD at 4 years follow-up.”
“This highlights a need to monitor PTSD among long-term cancer survivors, especially because many of the symptoms of PTSD, such as avoidance and cognitive difficulties (as well as psychological distress), are enduring, which may potentially impact adherence to treatment,” they noted.
The findings are consistent with several recent studies showing that many patients with cancer have persistent fear of disease recurrence, even after successful treatment. For example, a study reported earlier this year at the American Society of Clinical Oncology (ASCO) meeting showed that more than half of cancer survivors had “emotional distress that is insufficiently addressed by survivor care planning and supportive services.”
Also at the 2017 ASCO meeting, investigators from Australia reported that cancer survivors who underwent a form of cognitive behavioral therapy had significant improvement in anxiety and distress associated with fear of cancer recurrence.
Previous studies of PTSD in patients with cancer have shown incidences ranging from 0% to 6% with use of structured diagnostic interviews, Wee’s group noted. The literature included six studies with at least 100 patients, most of whom were women with breast or gynecologic cancers. The only study with a longitudinal design showed that more than half the patients had at least one symptom of PTSD a year after cancer diagnosis.
“To the best of our knowledge, there are no studies examining PTSD in patients with cancer that have used gold-standard clinical interviews and followed a cohort for a period as long as 4 years,” the authors noted.
The study involved 469 consecutive patients who had cancer diagnoses within the previous month. All patients were evaluated by the Hospital Anxiety and Depression Scale (HADS). Patients with elevated HADS scores at 6 months were evaluated by the Structured Clinical Interview for DSM-IV Axis I disorders (SCID) module for PTSD, and all patients had SCID evaluations at 4 years.
A PTSD diagnosis required that a patient meet criteria specified by DSM-IV: traumatic exposure (cancer diagnosis) and response associated with at least one recurring symptom, three avoidance/numbing symptoms, and two arousal symptoms, all persisting for more than a month and resulting in significant distress or functional impairment.
Subsyndromal PTSD was defined as traumatic exposure and response leading to distress or functional impairment persisting more than a month, associated with the presence of at least six symptoms from three of four categories (recurring, avoidance/numbing, hyperarousal, and duration).
At the 6-month follow-up, 203 of 222 patients with elevated HADS scores completed the SCID. During follow-up, 210 of the 469 patients died, and two others were lost to follow-up, leaving 245 patients for the 4-year evaluation.
The data showed that 27 patients met criteria for a PTSD diagnosis and 17 met criteria for subsyndromal PTSD, resulting in a total PTSD incidence of 21.7%. At the 4-year follow-up, 10 of the 245 (4.1%) evaluable patients had overt PTSD and five (2%) had subsyndromal PTSD, resulting in a total prevalence of 6.1%.
Six of 27 (22.2%) patients with overt PTSD at 6 months still met diagnostic criteria for PTSD at 4 years, two (7.4%) had subsyndromal PTSD, three (11.1%) no longer met diagnostic criteria for PTSD, one patient was lost to follow-up (3.7%), and 15 (55.6%) had died. Of the 17 patients with subsyndromal PTSD at 6 months, three (17.6%) had overt PTSD, four (23.5%) no longer met PTSD diagnostic criteria, and 10 (58.8%) had died.
Overall, 15 of 44 (34.1%) patients who had PTSD diagnoses at 6 months (including subsyndromal PTSD) had overt PTSD at 4 years.
An analysis of potential predictors of PTSD showed that patients with breast cancer were significantly less likely to develop PTSD by the 6-month assessment (OR 0.272, 95% CI 0.089-0.834).
Study limitations included the fact that the patient population was from one academic medical center, and the small number of patients diagnosed with PTSD using SCID.
The study was funded by the National University of Malaysia (University Kebangsaan Malaysia).
Wee and co-authors disclosed no relevant disclosures with industry.
Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner