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ASSESSMENT OF PERIOPERATIVE PSYCHOLOGICAL DISTRESS IN PATIENTS UNDERGOING RADICAL CYSTECTOMY FOR BLADDER CANCER
0022-5347/04/1725-1814/0 THE JOURNAL OF UROLOGY® Copyright © 2004 by AMERICAN UROLOGICAL ASSOCIATION
Vol. 172, 1814 –1817, November 2004 Printed in U.S.A.
DOI: 10.1097/01.ju.0000141245.08456.1a
ASSESSMENT OF PERIOPERATIVE PSYCHOLOGICAL DISTRESS IN PATIENTS UNDERGOING RADICAL CYSTECTOMY FOR BLADDER CANCER GANESH S. PALAPATTU, MARY ELLEN HAISFIELD-WOLFE, JOANNE M. WALKER, KARLYNN BRINTZENHOFESZOC, BRUCE TROCK, JAMES ZABORA AND MARK SCHOENBERG* From The James Buchanan Brady Urological Institute (GSP, MEH-W, BT, MS), Johns Hopkins Bladder Cancer Research Program (GSP, MS), Department of Surgical Nursing (JMW) and Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins (KB, JZ), Baltimore, Maryland
ABSTRACT
Purpose: Despite a recent growth in our understanding of the impact of psychosocial factors on the outcome of patients with cancer there is still relatively little known about the effect of these issues on patients with genitourinary malignancies. We determined the prevalence of psychological distress in patients with bladder cancer prior to and following radical cystectomy. Materials and Methods: A total of 74 consecutive patients with clinically organ confined bladder cancer were prospectively surveyed preoperatively using the Basic Symptom Inventory18, a validated instrument that measures the psychological domains of general distress, anxiety, depression and somatization. Of the initial 74 patients 62 were available for postoperative assessment 1 month following cystectomy. Preoperative and postoperative distress scores were evaluated with respect to age, sex, marital status, type of surgical reconstruction and tumor stage. Results: The preoperative prevalence of psychological distress in patients diagnosed with bladder cancer was 45% and it remained somewhat increased at 34% approximately 4 weeks after cystectomy. Demographic factors such as gender, age, and marital status were not significantly associated with the overall prevalence of distress. In the entire study group there was a statistically significant decrease in general distress (p ⫽ 0.028), depression (p ⫽ 0.034) and anxiety (p ⫽ 0.0004) from the preoperative to the postoperative assessments. Pathological stage was significantly associated with post-cystectomy anxiety (p ⫽ 0.040) and general distress (p ⫽ 0.042). Conclusions: Our findings indicate that a large proportion of patients with bladder cancer undergoing radical cystectomy experience psychological distress during the perioperative period. The identification of psychological distress in this population has the potential to influence health related quality of life as well as recovery in all individuals with bladder cancer. KEY WORDS: bladder, bladder neoplasms, cystectomy, anxiety, depression
High levels of psychological distress expressed as depression or excessive anxiety have been identified in patients with advanced cancer.1 The prevalence of psychological distress in patients with cancer of various organs at diverse disease stages is 30% to 70%.2, 3 Patients with bladder cancer who are advised to undergo cystectomy are faced with multiple stressors, such as the possibility of experiencing major surgery, dealing with the prospect of significant body changes, coping with the impending loss of the bladder and confronting issues with respect to altered sexual and urinary function.4, 5 In addition, the cancer diagnosis itself creates unique psychological distress that can affect how a patient relates to pain and how a patient is able to recover from treatment.6, 7 Psychological distress by definition is integrally related to quality of life and, if untreated, it can manifest a relatively high frequency of somatic complaints.8, 9 In the current study we prospectively administered the Basic Symptom Inventory-18 (BSI-18) (Pearson Assessments, Inc., Bloomington, Minnesota) to patients with blad-
der cancer preoperatively and 1 month postoperatively. Our research hypothesis was that patients with a diagnosis of bladder cancer scheduled to undergo radical cystectomy experience levels of psychological distress that persist in the postoperative period. We assessed the psychological distress of patients with a known diagnosis of bladder cancer and evaluated what effect, if any, radical cystectomy may have on this. METHODS
Study design and sample population. This was a prospective, descriptive study. All patients were diagnosed with clinically organ confined, muscle invasive or carcinoma in situ bladder cancer and were evaluated at the adult urology clinic at our institution. Institutional review board approval and individual patient consent were obtained as set forth in The Johns Hopkins Hospital guidelines for human subject research. A total of 74 consecutive patients were enrolled in the study and completed the preoperative psychological assessment. Of the patients 12 did not complete the postoperative questionnaire, leaving 62 for whom preoperative and postoperative data were available. Nine of the 12 patients who did not complete the postoperative psychological assessment did not complete the study because they elected not to undergo surgery as
Accepted for publication June 11, 2004. Study received institutional review board approval. * Correspondence: Urologic Oncology, The James Buchanan Brady Urological Institute, 600 North Wolfe St., Marburg 150, Baltimore, Maryland 21287-2101 (telephone: 410-502-3803; FAX: 410-955-0833; e-mail: [email protected]). 1814
1815
PSYCHOLOGICAL DISTRESS AND BLADDER CANCER
primary treatment or elected surgery to be performed elsewhere. Three patients who underwent radical cystectomy at our institution did not complete a postoperative questionnaire. None of the study patients had a history of major mental illness. Systematic chart review was performed to obtain information on patient demographics, length of stay, diversion type, postoperative course and pathological findings. Psychological distress assessment. Numerous tools have been used to evaluate psychological distress in patients with cancer. The BSI-18 was developed for patients with cancer from the longer 53 item Brief Symptom Inventory.10, 11 The questionnaire measures 4 areas of distress, namely anxiety, depression, somatization (ie physical symptoms with a presumed psychological origin) and general distress. The BSI-18 has been validated as an effective instrument for assessing psychological distress in patients with cancer and it has been used widely in other areas of oncology.12 Notably, the BSI-18 requires only 1 to 5 minutes to answer, thus, making it relatively easy for patients to complete. Questionnaires were administered by one of the study nurse coordinators. Following each of the 18 formulated statements (ie problems) that make up the questionnaire the patient is asked to specify how much each particular problem has caused distress or bother (ie not at all, a little bit, moderately, quite a bit or extremely) in the last 7 days. Point values for each response range from 0 —not at all to 4 — extremely. Three psychological distress domains (ie depression, anxiety and somatization) comprise 6 statements each. Therefore, the maximum score for each domain is 24. The general distress score is obtained by summing the scores from the 3 other domains (ie 72). Subscale gender specific classification of each psychological distress domain into high or low distress was performed according to previously established cutoff points.10 Patients were asked to complete the BSI-18 during the preoperative visit on an occasion that was separate from when they had been advised of the diagnosis and treatment options. The BSI-18 was administered a second time to subjects during postoperative visit 1 approximately 4 to 6 weeks after cystectomy. The majority of patients were given the pathological information before the second psychological assessment during a separate physician visit. Patients with scores consistent with high levels of distress on the postoperative administration of the BSI-18 were referred for appropriate psychological consultation. Statistical analysis. Distributions of categorical variables were compared with the chi-square test. Mean values of continuous scaled distress variables were compared across categories of preoperative demographic and clinical variables using the t tests and ANOVA. Paired t tests were used to compare preoperative vs postoperative changes in distress variables. Linear regression was used to correlate levels of preoperative and postoperative distress variables with patient age. Distress variables were dichotomized as high vs low. Factors predicting high distress after surgery were evaluated using logistic regression to allow adjustment for preoperative levels and potential confounding factors. All analyses were performed using SAS software (SAS Institute, Cary, North Carolina). RESULTS
Patient characteristics. Of the original 74 consecutive patients who completed the preoperative BSI-18, 62 (84%) were available for postoperative assessment. Mean patient age in the group was 64 years (range 34 to 84) (table 1). There was no significant difference with respect to age or clinical stage between those who had only preoperative vs those who had preoperative and postoperative psychological distress data available (data not shown). Of the study sample 80% were married and 72% were white. Average hospital stay was 7
TABLE 1. Study population characteristics of all patients with bladder cancer who completed BSI-18 prior to planned cystectomy No. Pts (%) Sex: Male 62 (83.8) Female 12 (16.2) Reconstruction type:* Ileal conduit 34 (46) Continent pouch 4 (5.4) Orthotopic neobladder 25 (33.8) Ureterostomy 2 (10.8) Pathological stage:* T0 2 (3.1) Ta 2 (3.1) Tis 11 (16.9) T1 4 (6.2) T2 21 (32.3) T3 21 (32.3) T4 4 (6.2) Data available: Preop only 12 (16.2) Preop ⫹ postop 62 (83.8) * Because 3 patients who underwent surgery did not complete a postoperative survey, the totals in these columns are 65.
days. Of the patients 11% showed signs and symptoms consistent with prolonged postoperative ileus. Of the study group 23% required re-admission to the hospital following discharge home. No patient required a second operation due to complications from cystectomy. Overall 66% of the patients had an uncomplicated postoperative course. Prevalence and assessment of psychological distress before and after cystectomy. The prevalence of psychological distress in the pre-cystectomy patient group was 49% (30 with high general distress of the total preoperative population of 62 who went on to cystectomy). If one includes the patients who did not go on to cystectomy, the prevalence of psychological distress in patients diagnosed with bladder cancer was 45% (33 with high general distress of the total of 74 with the diagnosis of bladder cancer). In the 62 patients evaluated postoperatively the prevalence rate of psychological distress was 34% (21 with high general distress patients of the total postoperative population of 62). These findings were not significantly associated with age, gender, marital status or reconstruction type. Comparing the psychological distress scores of patients who completed only the preoperative assessment with those who completed the preoperative and postoperative questionnaires showed a statistically significant difference across all distress parameters (table 2). Table 3 lists preoperative and postoperative psychological distress scores separated by gender. When separated in this way, only anxiety in males was associated with a statistically significant change from preopTABLE 2. Age and mean preoperative BSI-18 domain scores in 12 patients who completed only the preoperative survey vs 62 with preoperative and postoperative psychological assessment data No. Pts
Mean ⫾ SD
Age: Preop only 12 65.3 ⫾ 11.1 Preop ⫹ postop 62 63.1 ⫾ 10.7 Preop depression: Preop only 12 2.3 ⫾ 2.1 Preop ⫹ postop 62 4.1 ⫾ 4.4 Preop anxiety: Preop only 12 3.0 ⫾ 2.6 Preop ⫹ postop 62 6.1 ⫾ 5.9 Preop somatization: Preop only 12 0.6 ⫾ 1.2 Preop ⫹ postop 62 2.3 ⫾ 2.7 Preop general distress: Preop only 12 6.4 ⫾ 3.9 Preop ⫹ postop 62 12.3 ⫾ 11.4 Scale 0 to 24 for depression, anxiety and somatization, and general distress.
p Value 0.511 0.035 0.006 0.002 0.002 0 to 72 for
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PSYCHOLOGICAL DISTRESS AND BLADDER CANCER
TABLE 3. Preoperative and postoperative mean BSI-18 scores in 51 men, 11 women and whole study population Mean ⫾ SD
p Value
Men Depression: Preop Postop Anxiety: Preop Postop Somatization: Preop Postop General distress: Preop Postop
3.5 ⫾ 3.5 2.9 ⫾ 3.5
0.092
5.2 ⫾ 5.0 3.2 ⫾ 4.0
0.002
1.7 ⫾ 2.4 2.7 ⫾ 3.2
0.123
10.5 ⫾ 9.2 9.0 ⫾ 9.2
0.098
Women Depression: Preop Postop Anxiety: Preop Postop Somatization: Preop Postop General distress: Preop Postop
5.2 ⫾ 6.6 3.2 ⫾ 4.3
0.220
7.6 ⫾ 7.8 4.8 ⫾ 6.2
0.087
3.3 ⫾ 3.4 2.8 ⫾ 3.4
0.536
16.1 ⫾ 16.6 10.8 ⫾ 12.5
0.166
ther statistical analysis was performed to address the question of whether patients who were in a high category within a specific domain preoperatively remained in the high category after surgery. This assessment revealed that a statistically significant number of patients changed from the high classification preoperatively to the low category postoperatively within the depression, anxiety and general distress domains (p ⫽ 0.003, 0.004 and 0.022, respectively). No other changes showed statistical significance. Neither gender nor reconstruction type significantly influenced the change from high to low distress in any variable. High (pathological T3 or T4) vs low (pathological T1 or T2) tumor stage was the only statistically significant predictor of any distress domain, namely high postoperative anxiety and general distress (OR ⫽ 4.2, 95% CI 1.1 to 16.4, p ⫽ 0.040 and OR ⫽ 3.9, 95% CI 1.05 to 14.2, p ⫽ 0.042, respectively). High tumor stage was also associated with high postoperative depression but the effect was not statistically significant (OR ⫽ 3.4, 95% CI 0.9 to 12.9, p ⫽ 0.076). These ORs were adjusted for preoperative levels. Age, gender, marital status and surgical reconstruction type were not significantly predictive of high distress in any domain. In addition, while it was not statistically significant, it should be noted that men with higher stage tumors (T3 or T4) had no change in depression after surgery compared to a decrease in depression in men with lower stage tumors postoperatively (p ⫽ 0.090).
Study population Depression: Preop 3.8 ⫾ 4.2 0.034 Postop 2.9 ⫾ 3.6 Anxiety: Preop 5.6 ⫾ 5.6 0.0004 Postop 3.5 ⫾ 4.4 Somatization: Preop 2.0 ⫾ 2.6 0.313 Postop 2.7 ⫾ 3.2 General distress: Preop 11.4 ⫾ 10.8 0.028 Postop 9.3 ⫾ 9.8 Scale range 0 to 24 for depression, anxiety and somatization, and 0 to 72 for general distress.
erative to postoperative levels (5.2 vs 3.2, p ⫽ 0.002). For all distress variables women had higher values preoperatively and postoperatively, in addition to higher preoperative vs postoperative differences than men. When the 2 sexes were combined, a statistically significant difference between preoperative and postoperative scores for depression, anxiety and general distress was seen (table 3). Apart from the association of age with preoperative depression (ie 74 younger patients reported higher operative depression scores, p ⫽ 0.018) neither age, marital status, sex or reconstruction type was significantly associated with preoperative, postoperative or preoperative vs postoperative differences for any distress domains. Of note, in 5 unmarried women (including widowed and divorced women) there was a postoperative increase in somatization related distress (1.8), while scores in 6 married women decreased by 3.0 postoperatively. This difference approached statistical significance despite the small sample size (p ⫽ 0.055). Table 4 shows the application of sex specific cutoff points to dichotomize distress variables into high and low scores. Fur-
DISCUSSION
In the current study we found a 44.6% preoperative prevalence of psychological distress in all patients diagnosed with bladder cancer. This is slightly higher than in previous reports of other cancers in the medical oncology literature.1–3 This suggests that patients with bladder cancer have one of the highest observed rates of cancer related psychological distress, approximating that of patients with lung cancer.12 Recently Henningsohn et al evaluated psychological wellbeing and subjective quality of life in patients at varying intervals following radical cystectomy for bladder cancer.13 At a minimum followup of 1 year they found no significant differences in the 2 parameters between age matched controls and the study group. A major difference between our study and this report is that we assessed various domains of psychological distress before and after radical cystectomy. Repeat assessment of psychological distress in our study population at later time points, such as 1 year as suggested by Kulaksizoglu et al,14 may yield different results. These and other reports cogently describe the link between bladder cancer diagnosis and treatment with psychosocial distress and quality of life.15–18 Even so, to our knowledge the recognition of psychological distress in patients with a diagnosis of muscle invasive bladder cancer and the variation of such distress in response to radical cystectomy is a novel observation. Separation of the psychological distress data by gender was performed in an attempt to consider the varying ways in which men and women respond to psychological stress. This analysis showed that only male anxiety changed significantly (decreased) preoperatively to postoperatively. These results seem to indicate that after cystectomy males are less anxious. More complete psychological assessment would be
TABLE 4. BSI-18 high subscale scores in 62 patients with preoperative and postoperative data
High High High High
depression anxiety somatization general distress
No. Preop (%)
No. Postop (%)
26 (42) 34 (55) 15 (24) 30 (48)
18 (29) 18 (29) 16 (26) 21 (34)
Domain Score Men
Women 4 or Greater
4 or Greater 4 or Greater 10 or Greater
6 or Greater 5 or Greater 13 or Greater
PSYCHOLOGICAL DISTRESS AND BLADDER CANCER
needed to explain this finding accurately. In addition, longer followup with psychological distress assessment may be helpful for determining if this result is durable. Depression, somatization and general distress did not change significantly in either gender following surgery. Our study included only 12 women (16%) and, thus, it did not have the statistical power with respect to gender to make accurate associations based only on sex. However, when male and female distress data were combined, statistically significant changes preoperatively to postoperatively were noted in all distress variables except somatization. The increase in distress scores from preoperative to postoperative levels noted after combining data on the 2 genders was likely due to our relatively small sample size and must be corroborated by larger studies. Our study also shows that younger age at presentation was significantly associated with the degree of preoperative depression. Younger patients may be impacted more by a cancer diagnosis, and its implications and ramifications on quality of life (ie sexual and/urinary function and body image) than older patients. Interestingly the association of age with depression scores was not maintained after surgery. One may hypothesize that this may have been the result of the realization postoperatively that surgery and its aftereffects were not as dire as once thought. A larger study of younger patients faced with bladder cancer is needed to clarify this finding. No other significant association was found between age, marital status, sex or reconstruction type with preoperative, postoperative or preoperative vs postoperative differences for any distress domains. After splitting the distress variables into high and low groups according to previously established gender specific cutoff points we found that despite a baseline level of depression in the study group as a whole there was a significant decrease in depression and general distress in all patients in the postoperative period. Why this was observed for these variables and not the others is unclear. We also found that high pathological tumor stage was significantly associated with high postoperative anxiety and general distress. Intuitively one can draw the conclusion that patients with higher stage disease who are apprised of this and of its implications are likely to be more anxious and distressed than those with low stage tumors. Again, why this logic did not apply to the other domains is unclear. As opposed to what is sometimes seen in other cancers, marital status did not have a significant role in affecting our results.19 The decision to use the BSI-18 as our instrument of choice was based on its common use in oncology and the short time that is required to complete it. An important aspect that we did not explore is the effect of perioperative complications (ie ileus) and postoperative morbidity (ie altered sexual and urinary function) on psychological distress. These factors undoubtedly influence psychological issues. In addition, it should be noted that the 1 month postoperative psychological assessment was administered to a minority of patients at the same time a discussion was held regarding the final pathological findings. Thus, the impact of the knowledge of prognosis on the assessed psychological factors could not be fully quantified in our study. However, one may speculate that scores for all domains of psychological distress would increase with adverse pathological findings if the survey were administered in this fashion. A similarly designed study of larger proportion with longer followup is needed to further explore these questions. The precise reasons why 12 of the original 74 patients (12%) chose not to undergo surgery at our institution or complete a postoperative assessment (3) and, thus, participate in the postoperative aspect of our study are unknown. What is clear is that these 12 patients represent a significantly different group with relation to preoper-
1817
ative psychological distress across all domains than the cohort that completed the postoperative survey. CONCLUSIONS
In this study we found that the prevalence of psychological distress in patients with bladder cancer is relatively high and this level slightly decreases in the early postoperative period. The identification of psychological distress in patients with bladder cancer before and after cystectomy may provide a rational basis for psychological interventional strategy design and implementation. Such approaches may not only impact patient quality of life, but also may influence patient recovery. REFERENCES
1. Parker, P. A., Baile, W. F., de Moor, C. and Cohen, L.: Psychosocial and demographic predictors of quality of life in a large sample of cancer patients. Psychooncology, 12: 183, 2003 2. Kaasa, S., Malt, U., Hagen, S., Wist, E., Moum, T. and Kvikstad, A.: Psychological distress in cancer patients with advanced disease. Radiother Oncol, 27: 193, 1993 3. Spiegel, D.: Health caring. Psychosocial support for patients with cancer. Cancer, 74: 1453, 1994 4. Mansson, A. and Mansson, W.: When the bladder is gone: quality of life following different types of urinary diversion. World J Urol, 17: 211, 1999 5. Hart, S., Skinner, E. C., Meyerowitz, B. E., Boyd, S., Lieskovsky, G. and Skinner, D. G.: Quality of life after radical cystectomy for bladder cancer in patients with an ileal conduit, cutaneous or urethral Kock pouch. J Urol, 162: 77, 1999 6. Thielking, P. D.: Cancer pain and anxiety. Curr Pain Headache Rep, 7: 249, 2003 7. Patrick, D. L., Ferketich, S. L., Frame, P. S., Harris, J. J., Hendricks, C. B., Levin, B. et al: National Institutes of Health State-of-the-Science Conference Statement: Symptom Management in Cancer: Pain, Depression, and Fatigue, July 15– 17, 2002. J Natl Cancer Inst, 95: 1110, 2003 8. Ferrell, B., Smith, S. L., Cullinane, C. A. and Melancon, C.: Psychological well being and quality of life in ovarian cancer survivors. Cancer, 98: 1061, 2003 9. Erbil, P., Razavi, D., Farvacques, C., Bilge, N., Paesmans, M. and Van Houtte, P.: Cancer patients psychological adjustment and perception of illness: cultural differences between Belgium and Turkey. Support Care Cancer, 4: 455, 1996 10. Zabora, J., BrintzenhofeSzoc, K., Jacobsen, P., Curbow, B., Piantadosi, S., Hooker, C. et al: A new psychosocial screening instrument for use with cancer patients. Psychosomatics, 42: 241, 2001 11. Derogatis, L. R. and Melisaratos, N.: The Brief Symptom Inventory: an introductory report. Psychol Med, 13: 595, 1983 12. Zabora, J., BrintzenhofeSzoc, K., Curbow, B., Hooker, C. and Piantadosi, S.: The prevalence of psychological distress by cancer site. Psychooncology, 10: 19, 2001 13. Henningsohn, L., Steven, K., Kallestrup, E. B. and Steineck, G.: Distressful symptoms and well-being after radical cystectomy and orthotopic bladder substitution compared with a matched control population. J Urol, 168: 168, 2002 14. Kulaksizoglu, H., Toktas, G., Kulaksizoglu, I. B., Aglamis, E. and Unluer, E.: When should quality of life be measured after radical cystectomy? Eur Urol, 42: 350, 2002 15. Mansson, A., Davidsson, T., Hunt, S. and Mansson, W.: The quality of life in men after radical cystectomy with a continent cutaneous diversion or orthotopic bladder substitution: is there a difference? BJU Int, 90: 386, 2002 16. Mansson, A., Colleen, S., Hermeren, G. and Johnson, G.: Which patients will benefit from psychosocial intervention after cystectomy for bladder cancer? Br J Urol, 80: 50, 1997 17. Hardt, J., Filipas, D., Hohenfellner, R. and Egle, U. T.: Quality of life in patients with bladder carcinoma after cystectomy: first results of a prospective study. Qual Life Res, 9: 1, 2000 18. Henningsohn, L., Wijkstrom, H., Dickman, P. W., Bergmark, K. and Steineck, G.: Distressful symptoms after radical cystectomy with urinary diversion for urinary bladder cancer: a Swedish population-based study. Eur Urol, 40: 151, 2001 19. Pistrang, N. and Barker, C.: The partner relationship in psychological response to breast cancer. Soc Sci Med, 40: 789, 1995
Vol. 172, 1814 –1817, November 2004 Printed in U.S.A.
DOI: 10.1097/01.ju.0000141245.08456.1a
ASSESSMENT OF PERIOPERATIVE PSYCHOLOGICAL DISTRESS IN PATIENTS UNDERGOING RADICAL CYSTECTOMY FOR BLADDER CANCER GANESH S. PALAPATTU, MARY ELLEN HAISFIELD-WOLFE, JOANNE M. WALKER, KARLYNN BRINTZENHOFESZOC, BRUCE TROCK, JAMES ZABORA AND MARK SCHOENBERG* From The James Buchanan Brady Urological Institute (GSP, MEH-W, BT, MS), Johns Hopkins Bladder Cancer Research Program (GSP, MS), Department of Surgical Nursing (JMW) and Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins (KB, JZ), Baltimore, Maryland
ABSTRACT
Purpose: Despite a recent growth in our understanding of the impact of psychosocial factors on the outcome of patients with cancer there is still relatively little known about the effect of these issues on patients with genitourinary malignancies. We determined the prevalence of psychological distress in patients with bladder cancer prior to and following radical cystectomy. Materials and Methods: A total of 74 consecutive patients with clinically organ confined bladder cancer were prospectively surveyed preoperatively using the Basic Symptom Inventory18, a validated instrument that measures the psychological domains of general distress, anxiety, depression and somatization. Of the initial 74 patients 62 were available for postoperative assessment 1 month following cystectomy. Preoperative and postoperative distress scores were evaluated with respect to age, sex, marital status, type of surgical reconstruction and tumor stage. Results: The preoperative prevalence of psychological distress in patients diagnosed with bladder cancer was 45% and it remained somewhat increased at 34% approximately 4 weeks after cystectomy. Demographic factors such as gender, age, and marital status were not significantly associated with the overall prevalence of distress. In the entire study group there was a statistically significant decrease in general distress (p ⫽ 0.028), depression (p ⫽ 0.034) and anxiety (p ⫽ 0.0004) from the preoperative to the postoperative assessments. Pathological stage was significantly associated with post-cystectomy anxiety (p ⫽ 0.040) and general distress (p ⫽ 0.042). Conclusions: Our findings indicate that a large proportion of patients with bladder cancer undergoing radical cystectomy experience psychological distress during the perioperative period. The identification of psychological distress in this population has the potential to influence health related quality of life as well as recovery in all individuals with bladder cancer. KEY WORDS: bladder, bladder neoplasms, cystectomy, anxiety, depression
High levels of psychological distress expressed as depression or excessive anxiety have been identified in patients with advanced cancer.1 The prevalence of psychological distress in patients with cancer of various organs at diverse disease stages is 30% to 70%.2, 3 Patients with bladder cancer who are advised to undergo cystectomy are faced with multiple stressors, such as the possibility of experiencing major surgery, dealing with the prospect of significant body changes, coping with the impending loss of the bladder and confronting issues with respect to altered sexual and urinary function.4, 5 In addition, the cancer diagnosis itself creates unique psychological distress that can affect how a patient relates to pain and how a patient is able to recover from treatment.6, 7 Psychological distress by definition is integrally related to quality of life and, if untreated, it can manifest a relatively high frequency of somatic complaints.8, 9 In the current study we prospectively administered the Basic Symptom Inventory-18 (BSI-18) (Pearson Assessments, Inc., Bloomington, Minnesota) to patients with blad-
der cancer preoperatively and 1 month postoperatively. Our research hypothesis was that patients with a diagnosis of bladder cancer scheduled to undergo radical cystectomy experience levels of psychological distress that persist in the postoperative period. We assessed the psychological distress of patients with a known diagnosis of bladder cancer and evaluated what effect, if any, radical cystectomy may have on this. METHODS
Study design and sample population. This was a prospective, descriptive study. All patients were diagnosed with clinically organ confined, muscle invasive or carcinoma in situ bladder cancer and were evaluated at the adult urology clinic at our institution. Institutional review board approval and individual patient consent were obtained as set forth in The Johns Hopkins Hospital guidelines for human subject research. A total of 74 consecutive patients were enrolled in the study and completed the preoperative psychological assessment. Of the patients 12 did not complete the postoperative questionnaire, leaving 62 for whom preoperative and postoperative data were available. Nine of the 12 patients who did not complete the postoperative psychological assessment did not complete the study because they elected not to undergo surgery as
Accepted for publication June 11, 2004. Study received institutional review board approval. * Correspondence: Urologic Oncology, The James Buchanan Brady Urological Institute, 600 North Wolfe St., Marburg 150, Baltimore, Maryland 21287-2101 (telephone: 410-502-3803; FAX: 410-955-0833; e-mail: [email protected]). 1814
1815
PSYCHOLOGICAL DISTRESS AND BLADDER CANCER
primary treatment or elected surgery to be performed elsewhere. Three patients who underwent radical cystectomy at our institution did not complete a postoperative questionnaire. None of the study patients had a history of major mental illness. Systematic chart review was performed to obtain information on patient demographics, length of stay, diversion type, postoperative course and pathological findings. Psychological distress assessment. Numerous tools have been used to evaluate psychological distress in patients with cancer. The BSI-18 was developed for patients with cancer from the longer 53 item Brief Symptom Inventory.10, 11 The questionnaire measures 4 areas of distress, namely anxiety, depression, somatization (ie physical symptoms with a presumed psychological origin) and general distress. The BSI-18 has been validated as an effective instrument for assessing psychological distress in patients with cancer and it has been used widely in other areas of oncology.12 Notably, the BSI-18 requires only 1 to 5 minutes to answer, thus, making it relatively easy for patients to complete. Questionnaires were administered by one of the study nurse coordinators. Following each of the 18 formulated statements (ie problems) that make up the questionnaire the patient is asked to specify how much each particular problem has caused distress or bother (ie not at all, a little bit, moderately, quite a bit or extremely) in the last 7 days. Point values for each response range from 0 —not at all to 4 — extremely. Three psychological distress domains (ie depression, anxiety and somatization) comprise 6 statements each. Therefore, the maximum score for each domain is 24. The general distress score is obtained by summing the scores from the 3 other domains (ie 72). Subscale gender specific classification of each psychological distress domain into high or low distress was performed according to previously established cutoff points.10 Patients were asked to complete the BSI-18 during the preoperative visit on an occasion that was separate from when they had been advised of the diagnosis and treatment options. The BSI-18 was administered a second time to subjects during postoperative visit 1 approximately 4 to 6 weeks after cystectomy. The majority of patients were given the pathological information before the second psychological assessment during a separate physician visit. Patients with scores consistent with high levels of distress on the postoperative administration of the BSI-18 were referred for appropriate psychological consultation. Statistical analysis. Distributions of categorical variables were compared with the chi-square test. Mean values of continuous scaled distress variables were compared across categories of preoperative demographic and clinical variables using the t tests and ANOVA. Paired t tests were used to compare preoperative vs postoperative changes in distress variables. Linear regression was used to correlate levels of preoperative and postoperative distress variables with patient age. Distress variables were dichotomized as high vs low. Factors predicting high distress after surgery were evaluated using logistic regression to allow adjustment for preoperative levels and potential confounding factors. All analyses were performed using SAS software (SAS Institute, Cary, North Carolina). RESULTS
Patient characteristics. Of the original 74 consecutive patients who completed the preoperative BSI-18, 62 (84%) were available for postoperative assessment. Mean patient age in the group was 64 years (range 34 to 84) (table 1). There was no significant difference with respect to age or clinical stage between those who had only preoperative vs those who had preoperative and postoperative psychological distress data available (data not shown). Of the study sample 80% were married and 72% were white. Average hospital stay was 7
TABLE 1. Study population characteristics of all patients with bladder cancer who completed BSI-18 prior to planned cystectomy No. Pts (%) Sex: Male 62 (83.8) Female 12 (16.2) Reconstruction type:* Ileal conduit 34 (46) Continent pouch 4 (5.4) Orthotopic neobladder 25 (33.8) Ureterostomy 2 (10.8) Pathological stage:* T0 2 (3.1) Ta 2 (3.1) Tis 11 (16.9) T1 4 (6.2) T2 21 (32.3) T3 21 (32.3) T4 4 (6.2) Data available: Preop only 12 (16.2) Preop ⫹ postop 62 (83.8) * Because 3 patients who underwent surgery did not complete a postoperative survey, the totals in these columns are 65.
days. Of the patients 11% showed signs and symptoms consistent with prolonged postoperative ileus. Of the study group 23% required re-admission to the hospital following discharge home. No patient required a second operation due to complications from cystectomy. Overall 66% of the patients had an uncomplicated postoperative course. Prevalence and assessment of psychological distress before and after cystectomy. The prevalence of psychological distress in the pre-cystectomy patient group was 49% (30 with high general distress of the total preoperative population of 62 who went on to cystectomy). If one includes the patients who did not go on to cystectomy, the prevalence of psychological distress in patients diagnosed with bladder cancer was 45% (33 with high general distress of the total of 74 with the diagnosis of bladder cancer). In the 62 patients evaluated postoperatively the prevalence rate of psychological distress was 34% (21 with high general distress patients of the total postoperative population of 62). These findings were not significantly associated with age, gender, marital status or reconstruction type. Comparing the psychological distress scores of patients who completed only the preoperative assessment with those who completed the preoperative and postoperative questionnaires showed a statistically significant difference across all distress parameters (table 2). Table 3 lists preoperative and postoperative psychological distress scores separated by gender. When separated in this way, only anxiety in males was associated with a statistically significant change from preopTABLE 2. Age and mean preoperative BSI-18 domain scores in 12 patients who completed only the preoperative survey vs 62 with preoperative and postoperative psychological assessment data No. Pts
Mean ⫾ SD
Age: Preop only 12 65.3 ⫾ 11.1 Preop ⫹ postop 62 63.1 ⫾ 10.7 Preop depression: Preop only 12 2.3 ⫾ 2.1 Preop ⫹ postop 62 4.1 ⫾ 4.4 Preop anxiety: Preop only 12 3.0 ⫾ 2.6 Preop ⫹ postop 62 6.1 ⫾ 5.9 Preop somatization: Preop only 12 0.6 ⫾ 1.2 Preop ⫹ postop 62 2.3 ⫾ 2.7 Preop general distress: Preop only 12 6.4 ⫾ 3.9 Preop ⫹ postop 62 12.3 ⫾ 11.4 Scale 0 to 24 for depression, anxiety and somatization, and general distress.
p Value 0.511 0.035 0.006 0.002 0.002 0 to 72 for
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PSYCHOLOGICAL DISTRESS AND BLADDER CANCER
TABLE 3. Preoperative and postoperative mean BSI-18 scores in 51 men, 11 women and whole study population Mean ⫾ SD
p Value
Men Depression: Preop Postop Anxiety: Preop Postop Somatization: Preop Postop General distress: Preop Postop
3.5 ⫾ 3.5 2.9 ⫾ 3.5
0.092
5.2 ⫾ 5.0 3.2 ⫾ 4.0
0.002
1.7 ⫾ 2.4 2.7 ⫾ 3.2
0.123
10.5 ⫾ 9.2 9.0 ⫾ 9.2
0.098
Women Depression: Preop Postop Anxiety: Preop Postop Somatization: Preop Postop General distress: Preop Postop
5.2 ⫾ 6.6 3.2 ⫾ 4.3
0.220
7.6 ⫾ 7.8 4.8 ⫾ 6.2
0.087
3.3 ⫾ 3.4 2.8 ⫾ 3.4
0.536
16.1 ⫾ 16.6 10.8 ⫾ 12.5
0.166
ther statistical analysis was performed to address the question of whether patients who were in a high category within a specific domain preoperatively remained in the high category after surgery. This assessment revealed that a statistically significant number of patients changed from the high classification preoperatively to the low category postoperatively within the depression, anxiety and general distress domains (p ⫽ 0.003, 0.004 and 0.022, respectively). No other changes showed statistical significance. Neither gender nor reconstruction type significantly influenced the change from high to low distress in any variable. High (pathological T3 or T4) vs low (pathological T1 or T2) tumor stage was the only statistically significant predictor of any distress domain, namely high postoperative anxiety and general distress (OR ⫽ 4.2, 95% CI 1.1 to 16.4, p ⫽ 0.040 and OR ⫽ 3.9, 95% CI 1.05 to 14.2, p ⫽ 0.042, respectively). High tumor stage was also associated with high postoperative depression but the effect was not statistically significant (OR ⫽ 3.4, 95% CI 0.9 to 12.9, p ⫽ 0.076). These ORs were adjusted for preoperative levels. Age, gender, marital status and surgical reconstruction type were not significantly predictive of high distress in any domain. In addition, while it was not statistically significant, it should be noted that men with higher stage tumors (T3 or T4) had no change in depression after surgery compared to a decrease in depression in men with lower stage tumors postoperatively (p ⫽ 0.090).
Study population Depression: Preop 3.8 ⫾ 4.2 0.034 Postop 2.9 ⫾ 3.6 Anxiety: Preop 5.6 ⫾ 5.6 0.0004 Postop 3.5 ⫾ 4.4 Somatization: Preop 2.0 ⫾ 2.6 0.313 Postop 2.7 ⫾ 3.2 General distress: Preop 11.4 ⫾ 10.8 0.028 Postop 9.3 ⫾ 9.8 Scale range 0 to 24 for depression, anxiety and somatization, and 0 to 72 for general distress.
erative to postoperative levels (5.2 vs 3.2, p ⫽ 0.002). For all distress variables women had higher values preoperatively and postoperatively, in addition to higher preoperative vs postoperative differences than men. When the 2 sexes were combined, a statistically significant difference between preoperative and postoperative scores for depression, anxiety and general distress was seen (table 3). Apart from the association of age with preoperative depression (ie 74 younger patients reported higher operative depression scores, p ⫽ 0.018) neither age, marital status, sex or reconstruction type was significantly associated with preoperative, postoperative or preoperative vs postoperative differences for any distress domains. Of note, in 5 unmarried women (including widowed and divorced women) there was a postoperative increase in somatization related distress (1.8), while scores in 6 married women decreased by 3.0 postoperatively. This difference approached statistical significance despite the small sample size (p ⫽ 0.055). Table 4 shows the application of sex specific cutoff points to dichotomize distress variables into high and low scores. Fur-
DISCUSSION
In the current study we found a 44.6% preoperative prevalence of psychological distress in all patients diagnosed with bladder cancer. This is slightly higher than in previous reports of other cancers in the medical oncology literature.1–3 This suggests that patients with bladder cancer have one of the highest observed rates of cancer related psychological distress, approximating that of patients with lung cancer.12 Recently Henningsohn et al evaluated psychological wellbeing and subjective quality of life in patients at varying intervals following radical cystectomy for bladder cancer.13 At a minimum followup of 1 year they found no significant differences in the 2 parameters between age matched controls and the study group. A major difference between our study and this report is that we assessed various domains of psychological distress before and after radical cystectomy. Repeat assessment of psychological distress in our study population at later time points, such as 1 year as suggested by Kulaksizoglu et al,14 may yield different results. These and other reports cogently describe the link between bladder cancer diagnosis and treatment with psychosocial distress and quality of life.15–18 Even so, to our knowledge the recognition of psychological distress in patients with a diagnosis of muscle invasive bladder cancer and the variation of such distress in response to radical cystectomy is a novel observation. Separation of the psychological distress data by gender was performed in an attempt to consider the varying ways in which men and women respond to psychological stress. This analysis showed that only male anxiety changed significantly (decreased) preoperatively to postoperatively. These results seem to indicate that after cystectomy males are less anxious. More complete psychological assessment would be
TABLE 4. BSI-18 high subscale scores in 62 patients with preoperative and postoperative data
High High High High
depression anxiety somatization general distress
No. Preop (%)
No. Postop (%)
26 (42) 34 (55) 15 (24) 30 (48)
18 (29) 18 (29) 16 (26) 21 (34)
Domain Score Men
Women 4 or Greater
4 or Greater 4 or Greater 10 or Greater
6 or Greater 5 or Greater 13 or Greater
PSYCHOLOGICAL DISTRESS AND BLADDER CANCER
needed to explain this finding accurately. In addition, longer followup with psychological distress assessment may be helpful for determining if this result is durable. Depression, somatization and general distress did not change significantly in either gender following surgery. Our study included only 12 women (16%) and, thus, it did not have the statistical power with respect to gender to make accurate associations based only on sex. However, when male and female distress data were combined, statistically significant changes preoperatively to postoperatively were noted in all distress variables except somatization. The increase in distress scores from preoperative to postoperative levels noted after combining data on the 2 genders was likely due to our relatively small sample size and must be corroborated by larger studies. Our study also shows that younger age at presentation was significantly associated with the degree of preoperative depression. Younger patients may be impacted more by a cancer diagnosis, and its implications and ramifications on quality of life (ie sexual and/urinary function and body image) than older patients. Interestingly the association of age with depression scores was not maintained after surgery. One may hypothesize that this may have been the result of the realization postoperatively that surgery and its aftereffects were not as dire as once thought. A larger study of younger patients faced with bladder cancer is needed to clarify this finding. No other significant association was found between age, marital status, sex or reconstruction type with preoperative, postoperative or preoperative vs postoperative differences for any distress domains. After splitting the distress variables into high and low groups according to previously established gender specific cutoff points we found that despite a baseline level of depression in the study group as a whole there was a significant decrease in depression and general distress in all patients in the postoperative period. Why this was observed for these variables and not the others is unclear. We also found that high pathological tumor stage was significantly associated with high postoperative anxiety and general distress. Intuitively one can draw the conclusion that patients with higher stage disease who are apprised of this and of its implications are likely to be more anxious and distressed than those with low stage tumors. Again, why this logic did not apply to the other domains is unclear. As opposed to what is sometimes seen in other cancers, marital status did not have a significant role in affecting our results.19 The decision to use the BSI-18 as our instrument of choice was based on its common use in oncology and the short time that is required to complete it. An important aspect that we did not explore is the effect of perioperative complications (ie ileus) and postoperative morbidity (ie altered sexual and urinary function) on psychological distress. These factors undoubtedly influence psychological issues. In addition, it should be noted that the 1 month postoperative psychological assessment was administered to a minority of patients at the same time a discussion was held regarding the final pathological findings. Thus, the impact of the knowledge of prognosis on the assessed psychological factors could not be fully quantified in our study. However, one may speculate that scores for all domains of psychological distress would increase with adverse pathological findings if the survey were administered in this fashion. A similarly designed study of larger proportion with longer followup is needed to further explore these questions. The precise reasons why 12 of the original 74 patients (12%) chose not to undergo surgery at our institution or complete a postoperative assessment (3) and, thus, participate in the postoperative aspect of our study are unknown. What is clear is that these 12 patients represent a significantly different group with relation to preoper-
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ative psychological distress across all domains than the cohort that completed the postoperative survey. CONCLUSIONS
In this study we found that the prevalence of psychological distress in patients with bladder cancer is relatively high and this level slightly decreases in the early postoperative period. The identification of psychological distress in patients with bladder cancer before and after cystectomy may provide a rational basis for psychological interventional strategy design and implementation. Such approaches may not only impact patient quality of life, but also may influence patient recovery. REFERENCES
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