In the Journals Plus

Supportive therapy alleviates depression associated with advanced cancer

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September 14, 2018

Patients with advanced cancer experienced alleviated depressive symptoms and a reduction in end-of-life distress after taking part in a brief, tailored psychotherapeutic intervention called Managing Cancer and Living Meaningfully, or CALM, according to a randomized controlled trial published in Journal of Clinical Oncology.

“Findings suggest that CALM is an effective intervention that provides a systematic approach to alleviating depressive symptoms in patients with advanced cancer and addresses the predictable challenges these patients face,” Gary Rodin, MD, joint University of Toronto/University Health Network Harold and Shirley Lederman chair in psychosocial oncology and palliative care and head of the department of supportive care at Princess Margaret Cancer Centre in Toronto, and colleagues wrote.

“The diagnosis of advanced cancer may trigger enormous distress and the challenge of living meaningfully in the face of progressive disease,” the researchers added. “Individuals in this situation face the burden of physical suffering, the threat of dependency and impending mortality, and the difficulty of making treatment decisions that have life-and-death implications while navigating a complex health care system.”

The analysis included 305 patients with advanced cancer who were recruited from outpatient oncology clinics at a comprehensive cancer center between February 2012 and March 2016. Researchers randomly assigned patients to receive CALM intervention plus usual care (n = 151) or usual care alone (n = 154).

“CALM provides a therapeutic relationship and reflective space, with attention to the following domains: symptom management and communication with health care providers, changes in self and relations with close others, spiritual well-being and the sense of meaning and purpose, and mortality and future-oriented concerns,” the researchers wrote. “The CALM domains are addressed for each patient in a tailored, individualized manner that allows for variation in the number of sessions and time spent on each domain on the basis of the patient’s needs and health status. CALM can be delivered by a wide range of trained psychosocial oncology clinicians and cancer care providers.”

Assessments of depressive symptoms at 3 months — measured using PHQ-9 of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition — served as the primary outcome. Death-related distress and other measures served as secondary outcomes. Researchers assessed all outcomes at baseline, 3 months and 6 months.

Among those assigned CALM intervention, 54.3% had participated in at least three sessions by 3 months (mean, 3 sessions; range, 0-7) and 77.5% had done so by 6 months (mean, 4 sessions; range 0-10). Most sessions occurred in outpatient clinics, with a small number delivered to very ill patients by telephone or in the inpatient palliative care unit.

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CALM participants reported less-severe depressive symptoms than usual care participants at 3 months (Cohen’s d = 0.23; 95% CI, 0.04 to 2.13), with a more profound effect observed at 6 months (Cohen’s d = 0.29; 95% CI, 0.24 to 2.35).

To clarify the clinical meaning of effects on the primary outcome, researchers conducted post hoc analyses on the emergence and remission rates of depressive symptoms of at least threshold severity, defined by an increase in PHQ-9 by eight or more points.

CALM participants appeared more likely to demonstrate remission of symptoms of at least threshold severity at 6 months (OR = 3.29; P = .005) and were less likely to develop depressive symptoms of at least threshold severity at 3 months (OR = 0.36; P = .02).

Greater end-of-life preparation at 6 months also favored the CALM group.

Limitations of the study include that it was conducted at a single site with primarily English-speaking, white, well-educated participants, who may not be representative of other settings.

“Additional research is needed to explore the optimal timing of CALM, the specific mechanisms of therapeutic action, the most appropriate and meaningful outcome measures, and feasibility and effectiveness of CALM in diverse cultural and clinical settings,” Rodin and colleagues wrote. – by Trudi Gilfillian

Disclosures: The authors report no relevant financial disclosures.