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Psychooncology

Journal Article Annotations
2021, 2nd Quarter

Psychooncology

Annotations by Elie Isenberg-Grzeda, MD, Carlos Fernandez Robles, MD
March, 2021

  1. Mirtazapine in cancer-associated anorexia and cachexia: A double-blind placebo-controlled randomized trial.
  2. Hospital Contacts for Psychiatric Disorders in Parents of Children With Cancer in Denmark.
  3. Use of psychotropic drugs among older patients with bladder cancer in the United States.

    PUBLICATION #1 — Psychooncology

    Mirtazapine in cancer-associated anorexia and cachexia: A double-blind placebo-controlled randomized trial.
    Catherine N Hunter, Hesham H Abdel-Aal, Wessam A Elsherief, Dina E Farag, Nermine M Riad, Samy A Alsirafy

    Annotation

    The finding:
    15 mg of mirtazapine nightly over four weeks was as effective as a placebo in improving appetite in patients with Cancer-Associated Anorexia and Cachexia (CAC). Patients taking mirtazapine were more likely to discontinue the medication because of somnolence and delirium.

    Strength and weaknesses:
    This was a placebo-controlled, double-blind, randomized trial on advanced cancer patients that appropriately excluded patients with other non-cancer related causes of anorexia. The most significant limitation is the use of patient reported scales on appetite improvement as the primary endpoint instead of using other objective measures such as change in handgrip strength or change in weight.

    Relevance:
    Mirtazapine is frequently prescribed to cancer patients, both with and without co-occurring depression. Because of mirtazapine's reported side effects/benefits (increased sedation and appetite), clinicians favor it as an all-in-one solution for cancer patients. The results of this trial and the evidence obtained from previous non-randomized trials show no justification for recommending mirtazapine for CAC in routine practice. Furthermore, it calls for further research regarding the actual value of mirtazapine in clinically depressed patients over that of the more traditional first-line agent such as serotonin-reuptake inhibitors, if appetite enhancement is the deciding factor favoring it.

    Type of study (EBM guide):
    Randomized controlled trial


    PUBLICATION #2 — Psychooncology

    Hospital Contacts for Psychiatric Disorders in Parents of Children With Cancer in Denmark.
    Luzius Mader, Line Elmerdahl Frederiksen, Pernille Envold Bidstrup, Marie Hargreave, Susanne K Kjær, Claudia E Kuehni, Thomas Tjørnelund Nielsen, Anja Krøyer, Jeanette Falck Winther, Friederike Erdmann

    Annotation

    The finding:
    Mothers, but not fathers, of children diagnosed with cancer, have a 23% higher risk of hospital contact for any psychiatric disorder. Individual risk factors included employment within one year of children’s diagnosis, age younger than 30, lower education, and immigrant status. Mothers of children diagnosed with leukemia and CNS tumors, as well as younger child’s age at diagnosis, were at a higher risk. Only fathers of children diagnosed with lymphoid leukemia, CNS tumor, and a bone tumor or soft tissue sarcoma were at increased risk of psychiatric disorders in the diagnostic period from 1982 to 1999.

    Strength and weaknesses:
    This study derives its principal strength from its large sample size with over 12,000 case parents and over 123,000 control parents. The study was vastly inclusive, encompassing contacts of patients with any psychiatric encounter. Additionally, researchers compared mothers and fathers separately and stratified for cancer type, inpatient and outpatient psychiatric contacts, and meaningful time windows concerning the child’s diagnosis date. Finally, the risk analysis tried to account for advances in cancer care that could have impacted outcomes. The results must be examined in light of increased surveillance for psychiatric distress in parents of children with cancer compared to controls, potential misclassification on the medical record, and lack of control for pre-existing psychiatric diagnoses.

    Relevance:
    Having a child diagnosed with cancer is a calamitous event for any family. It impacts family routines, responsibilities, finances, and parental and marital dynamics. Unfortunately, studies on this topic are small and focus on specific psychiatric diagnoses and most prominently on mothers. This large population-based study provides a better framework for C-L Psychiatrists to identify parents at risk for psychiatric distress and argues for developing programs that focus on supporting parents during child medical crises. Recognizing and addressing the mental health needs of this population can mitigate the negative impact on health problems and the associated costs related to healthcare utilization, productivity loss, and sick leave.

    Type of study (EBM guide):
    Cohort study


    PUBLICATION #3 — Psychooncology

    Use of psychotropic drugs among older patients with bladder cancer in the United States.
    Usama Jazzar, Cristiane D Bergerot, Yong Shan, Christopher J D Wallis, Stephen J Freedland, Ashish M Kamat, Douglas S Tyler, Jacques Baillargeon, Yong-Fang Kuo, Zachary Klaassen, Stephen B Williams

    Annotation

    The finding:
    Among patients with bladder cancer, the majority (53%) were prescribed one or more psychiatric drugs following their diagnosis. Stage of disease was associated with increased rate of prescribing (except for stage IV). 37% of patients were prescribed psychiatric drugs prior to the diagnosis, and this was also the strongest predictor of being prescribed psychiatric drugs following the diagnosis. Sedative/hypnotics and antidepressants were most commonly prescribed, with 21% of patients prescribed each. Adherence rates were generally low (around one-third at 3-months post diagnosis) and continued to decrease over time.

    Strength and weaknesses:
    The study’s main strengths are that it pulled data from a large American cancer database (SEER) and used neuroscience-based nomenclature (e.g., serotonin reuptake inhibitor) to classify medications. The limitations of this type of study pertain to its methodology. It is a cohort study. Although the authors analyzed a large dataset, we are unable to make conclusions about causality. Close to 90% of the cohort identified as white (non-Hispanic white); while this mirrors SEER data for bladder cancer, it also potentially limits generalizability to non-white populations.

    Relevance:
    There is a dearth of literature on the rates of psychiatric drug prescription in cancer patients in general, but more specifically in bladder cancer. The findings suggest that more attention must be paid to psychiatric needs of patients with bladder cancer. While the rate of prescribing seems high, the non-adherence may have a number of different implications: perhaps there is over-prescribing of psychiatric drugs initially; perhaps there is a need to better target who is prescribed drugs versus non-pharmacologic treatments; perhaps the rate of prescribing is appropriate but more attention is needed to help patients adhere to medications.

    Type of study (EBM guide):
    Cohort study
     


    Also of interest - PUBLICATION #4 — Psychooncology

    The Impact of an Unconventional Elective in Narrative Medicine and Pediatric Psycho-oncology on Humanism in Medical Students.
    F Jeffrey Lorenz, Matthew C Darok, Lisa Ho, Maria S Holstrom-Mercader, Andrew S Freiberg, Cheryl A Dellasega
    Annotation (unstructured)

    Annotation (unstructured):
    The authors describe a medical elective in narrative medicine whereby medical students journaled their reflections after time spent shadowing pediatric psycho-oncology patients. The authors encouraged meaningful reflection as a tool to help students connect or reconnect with the inherent empathy that led them towards medicine in the first place. On the surface, this article chronicles an interesting and unconventional elective which any academic clinician in psycho-oncology ought to consider offering. More deeply, though, and read through the lens of a world stricken by COVID, it serves to inspire, as a recipe to reignite our own empathic behaviors at a time in history when this is deeply needed.

    Type of study (EBM guide):
    Other (enter a free text description on the document)