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Pain and emotional distress in leukemia patients at diagnosis
Leukemia Research 34 (2010) e67–e68
Contents lists available at ScienceDirect
Leukemia Research journal homepage: www.elsevier.com/locate/leukres
Letter to the editor Pain and emotional distress in leukemia patients at diagnosis The few available studies on leukemia patients have so far addressed only the issue of physical pain and emotional distress in terminally ill patients [1,2] The prevalence of pain during the last 3 months of life of Italian cancer patients was reported to be 83% in lymphoma and leukemia patients, according to what reported by their caregivers [3]. This result is much higher compared with other studies [4] reporting a prevalence of 5% in leukemia [4] and 38% in lymphoma patients [5]. We used the Edmonton Symptoms Assessment System (ESAS) to investigate the frequency of physical pain and both ESAS and Hospital Anxiety and Depression Scale (HADS) to assess emotional distress in 53 patients (36 male, 17 female; median age 50 years-range 32–72) with acute leukemia (40 myeloid and 13 lymphoblastic), at diagnosis (T0), during the neutropenia phase (T15), and at discharge, as well as in 76 patients with solid cancers (47 male, 29 female; median age 65 years-range 42–83), as control group. The diagnosis of depression and/or anxiety was made with a score of eight of 21 or more in the HADS questionnaire [6]. In the ESAS analysis, depression and anxiety were considered present with a score of two of 10 or more [6]. During the induction chemotherapy phase, mild pain (from 1 to 3 of the Numerical Rating Scale-NRS of the ESAS) was reported in 39.5%, 27%, and 16.6%, while moderate (from 4 to 6) to severe pain (from 7 to 10) was reported in 11.6%, 20.4% and 5.5% of the cases, at T0, T15 and discharge, respectively. According to the HADS score, depression was reported in 21%, 36% and 33%, at T0, T15 and discharge, respectively, while anxiety in 30%, 40%, 36% of the cases, at the same time intervals, respectively. Depression was reported in 32% while anxiety in 38% of all questionnaires, respectively, collected at all time intervals, during all clinical phases. According to the ESAS score, depression was reported in 45%, 38.6% and 27.7%, at T0, T15 and discharge, while anxiety in 46.5%, 40.4%, 41.6% of the cases, at the same time intervals, respectively. ESAS showed a sensitivity of 57% and 74%, and a specificity of 67% and 67% for depression and anxiety, respectively, when all questionnaires were considered. In solid cancer patients, mild to moderate to severe pain was reported in 38% of the cases, at diagnosis. HADS score was positive for depression in 25% while for anxiety in 19.7% of the cases. ESAS score was positive for depression in 28.9% while for anxiety in 40.7% of the cases, showing a sensitivity of 63% and 86.6% and a specificity of 82% and 70% for depression and anxiety, respectively. Symptom severity appeared similar or even higher in leukemia compared with solid cancer patients, at diagnosis, as reported for patients referred to palliative care (Table 1) [2,4]. We suggest that, contrary to what is generally accepted, leukemia patients may suffer from physical pain and emotional distress since the time of diagnosis. Further studies are warranted to confirm and extend these findings.
0145-2126/$ – see front matter © 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.leukres.2009.08.008
Table 1 Comparison of symptom burden between leukemia and solid cancer patients at diagnosis. ESAS symptoms
Pain Fatigue Nausea Depression Anxiety Drowsiness Appetite Well-being Dyspnea
Leukemia
Solid cancer
p
Median
Range
Median
Range
1 3 0 1 1 2 1 0.5 0
0–7 0–10 0–8 0–8 0–10 0–10 0–9 0–7 0–8
0 1 0 0 2 0 0 0 0
0–7 0–9 0–9 0–10 0–10 0–10 0–9 0–10 0–10
0.1306 0.0370 0.0042 0.7243 0.4477 0.002 0.0039 0.0692 0.8096
Conflict of interest The authors declare no conflict of interest. Acknowledgements MM, EB, RZ equally contributed to the study. EB, ML, CR designed the study. MM, EB, CR, ML wrote the paper. RZ, LB, FF, AP, LP, AB, GC, AM, LG collected clinical data. RD, MM, RZ performed the statistical analysis. FA, CR, EB, GT revised the paper. This study was grant supported by A.I.L. Modena, ONLUS and AMO 9 Comuni Area Nord ONLUS Modena, Italy. References [1] Stalfelt AM, Brodin H, Petterson S, Eklöf A. The final phase in acute myeloid leukaemia (AML): a study on bleeding, infection and pain. Leuk Res 2003;27:481–8. [2] Fadul NA, El Osta B, Dalal S, Poulter VA, Bruera E. Comparison of symptom burden among patients referred to palliative care with hematologic malignancies versus those with solid tumors. J Palliat Med 2008;11:422–7. [3] Costantini M, Ripamonti C, Beccaro M, et al. Prevalence, distress, management, and relief of pain during the last 3 months of cancer patients’ life. Results of an Italian mortality follow-back survey. Ann Oncol 2009;20:729–35. [4] Foley KM. The treatment of cancer pain. N Engl J Med 1985;313:84–94. [5] Lidstone V, Butters E, Seed PT, Sinnott C, Beynon T, Richards M. Symptoms and concerns amongst cancer outpatients: identifying the need for specialistic palliative care. Palliat Med 2003;17:588–95. [6] Vignaroli E, Pace EA, Willey J, Palmer JL, Zhang TL, Bruera E. The Edmonton symptom assessment system as a screening tool for depression and anxiety. J Palliat Med 2006;9:296–303.
Monica Morselli a Elena Bandieri b,c Roberta Zanin a Loredana Buonaccorso b Roberto D’Amico a Fabio Forghieri a
e68
Letter to the editor / Leukemia Research 34 (2010) e67–e68
Alessandra Pietramaggiori d Leonardo Potenza a Andrea Berti a Giovanna Cacciapaglia a Antonio Molitierno a Lisa Galli a Fabrizio Artioli d Carla Ripamonti e Eduardo Bruera f Giuseppe Torelli a Mario Luppi a,∗ a Department of Oncology, Hematology and Respiratory Diseases, Azienda Ospedaliera Universitaria, University of Modena and Reggio Emilia, Via del Pozzo 71, 41100, Modena, Italy b Palliative Care Unit USL, Modena, Italy c Centre for the Evaluation of the Effectiveness of Health Care (CeVEAS), WHO Collaborating Centre, Modena, Italy
e
d D.H.O. Carpi-Mirandola Hospital, Modena, Italy Supportive Care in Cancer Unit, IRCCS Foundation, National Cancer Institute Milano, Italy f Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA ∗ Corresponding
author. Tel.: +39 059 4225570; fax: +39 059 4224549. E-mail address: [email protected] (M. Luppi) 7 August 2009 Available online 4 September 2009
Contents lists available at ScienceDirect
Leukemia Research journal homepage: www.elsevier.com/locate/leukres
Letter to the editor Pain and emotional distress in leukemia patients at diagnosis The few available studies on leukemia patients have so far addressed only the issue of physical pain and emotional distress in terminally ill patients [1,2] The prevalence of pain during the last 3 months of life of Italian cancer patients was reported to be 83% in lymphoma and leukemia patients, according to what reported by their caregivers [3]. This result is much higher compared with other studies [4] reporting a prevalence of 5% in leukemia [4] and 38% in lymphoma patients [5]. We used the Edmonton Symptoms Assessment System (ESAS) to investigate the frequency of physical pain and both ESAS and Hospital Anxiety and Depression Scale (HADS) to assess emotional distress in 53 patients (36 male, 17 female; median age 50 years-range 32–72) with acute leukemia (40 myeloid and 13 lymphoblastic), at diagnosis (T0), during the neutropenia phase (T15), and at discharge, as well as in 76 patients with solid cancers (47 male, 29 female; median age 65 years-range 42–83), as control group. The diagnosis of depression and/or anxiety was made with a score of eight of 21 or more in the HADS questionnaire [6]. In the ESAS analysis, depression and anxiety were considered present with a score of two of 10 or more [6]. During the induction chemotherapy phase, mild pain (from 1 to 3 of the Numerical Rating Scale-NRS of the ESAS) was reported in 39.5%, 27%, and 16.6%, while moderate (from 4 to 6) to severe pain (from 7 to 10) was reported in 11.6%, 20.4% and 5.5% of the cases, at T0, T15 and discharge, respectively. According to the HADS score, depression was reported in 21%, 36% and 33%, at T0, T15 and discharge, respectively, while anxiety in 30%, 40%, 36% of the cases, at the same time intervals, respectively. Depression was reported in 32% while anxiety in 38% of all questionnaires, respectively, collected at all time intervals, during all clinical phases. According to the ESAS score, depression was reported in 45%, 38.6% and 27.7%, at T0, T15 and discharge, while anxiety in 46.5%, 40.4%, 41.6% of the cases, at the same time intervals, respectively. ESAS showed a sensitivity of 57% and 74%, and a specificity of 67% and 67% for depression and anxiety, respectively, when all questionnaires were considered. In solid cancer patients, mild to moderate to severe pain was reported in 38% of the cases, at diagnosis. HADS score was positive for depression in 25% while for anxiety in 19.7% of the cases. ESAS score was positive for depression in 28.9% while for anxiety in 40.7% of the cases, showing a sensitivity of 63% and 86.6% and a specificity of 82% and 70% for depression and anxiety, respectively. Symptom severity appeared similar or even higher in leukemia compared with solid cancer patients, at diagnosis, as reported for patients referred to palliative care (Table 1) [2,4]. We suggest that, contrary to what is generally accepted, leukemia patients may suffer from physical pain and emotional distress since the time of diagnosis. Further studies are warranted to confirm and extend these findings.
0145-2126/$ – see front matter © 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.leukres.2009.08.008
Table 1 Comparison of symptom burden between leukemia and solid cancer patients at diagnosis. ESAS symptoms
Pain Fatigue Nausea Depression Anxiety Drowsiness Appetite Well-being Dyspnea
Leukemia
Solid cancer
p
Median
Range
Median
Range
1 3 0 1 1 2 1 0.5 0
0–7 0–10 0–8 0–8 0–10 0–10 0–9 0–7 0–8
0 1 0 0 2 0 0 0 0
0–7 0–9 0–9 0–10 0–10 0–10 0–9 0–10 0–10
0.1306 0.0370 0.0042 0.7243 0.4477 0.002 0.0039 0.0692 0.8096
Conflict of interest The authors declare no conflict of interest. Acknowledgements MM, EB, RZ equally contributed to the study. EB, ML, CR designed the study. MM, EB, CR, ML wrote the paper. RZ, LB, FF, AP, LP, AB, GC, AM, LG collected clinical data. RD, MM, RZ performed the statistical analysis. FA, CR, EB, GT revised the paper. This study was grant supported by A.I.L. Modena, ONLUS and AMO 9 Comuni Area Nord ONLUS Modena, Italy. References [1] Stalfelt AM, Brodin H, Petterson S, Eklöf A. The final phase in acute myeloid leukaemia (AML): a study on bleeding, infection and pain. Leuk Res 2003;27:481–8. [2] Fadul NA, El Osta B, Dalal S, Poulter VA, Bruera E. Comparison of symptom burden among patients referred to palliative care with hematologic malignancies versus those with solid tumors. J Palliat Med 2008;11:422–7. [3] Costantini M, Ripamonti C, Beccaro M, et al. Prevalence, distress, management, and relief of pain during the last 3 months of cancer patients’ life. Results of an Italian mortality follow-back survey. Ann Oncol 2009;20:729–35. [4] Foley KM. The treatment of cancer pain. N Engl J Med 1985;313:84–94. [5] Lidstone V, Butters E, Seed PT, Sinnott C, Beynon T, Richards M. Symptoms and concerns amongst cancer outpatients: identifying the need for specialistic palliative care. Palliat Med 2003;17:588–95. [6] Vignaroli E, Pace EA, Willey J, Palmer JL, Zhang TL, Bruera E. The Edmonton symptom assessment system as a screening tool for depression and anxiety. J Palliat Med 2006;9:296–303.
Monica Morselli a Elena Bandieri b,c Roberta Zanin a Loredana Buonaccorso b Roberto D’Amico a Fabio Forghieri a
e68
Letter to the editor / Leukemia Research 34 (2010) e67–e68
Alessandra Pietramaggiori d Leonardo Potenza a Andrea Berti a Giovanna Cacciapaglia a Antonio Molitierno a Lisa Galli a Fabrizio Artioli d Carla Ripamonti e Eduardo Bruera f Giuseppe Torelli a Mario Luppi a,∗ a Department of Oncology, Hematology and Respiratory Diseases, Azienda Ospedaliera Universitaria, University of Modena and Reggio Emilia, Via del Pozzo 71, 41100, Modena, Italy b Palliative Care Unit USL, Modena, Italy c Centre for the Evaluation of the Effectiveness of Health Care (CeVEAS), WHO Collaborating Centre, Modena, Italy
e
d D.H.O. Carpi-Mirandola Hospital, Modena, Italy Supportive Care in Cancer Unit, IRCCS Foundation, National Cancer Institute Milano, Italy f Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA ∗ Corresponding
author. Tel.: +39 059 4225570; fax: +39 059 4224549. E-mail address: [email protected] (M. Luppi) 7 August 2009 Available online 4 September 2009