Background 

It is estimated that the 12-month prevalence of depression in the United States is 8.6%, and for anxiety it is 2.9%. Although prior studies have evaluated depression and anxiety in patients with carcinoma, few have specifically evaluated patients with sarcoma, who often have unique treatment considerations such as mobility changes after surgery.

Questions/purposes 

We evaluated patients with sarcoma seen in our orthopaedic oncology clinic to determine (1) the proportion of patients with depression symptoms, symptom severity, how many patients triggered a referral to mental health professionals based upon our prespecified cutoff scores on the nine-item Patient Health Questionnaire (PHQ-9), and if their symptoms varied by disease state; (2) the proportion of patients with anxiety symptoms, symptom severity, how many patients triggered a referral to mental health professionals based upon our prespecified cutoff scores on the seven-item Generalized Anxiety Disorder Scale (GAD-7), and if they symptoms varied by disease state; (3) whether other factors were associated with the proportion and severity of symptoms of anxiety or depression, such as tumor location in the body (axial skeleton, upper extremity, or lower extremity), general type of tumor (bone or soft tissue), specific diagnosis, use of chemotherapy, length of follow-up (less than 1 year or greater than 1 year), and gender; and (4) what proportion of patients accepted referrals to mental health professionals, when offered.

Methods 

This study was a cross-sectional survey study performed at a single urban National Cancer Institute–designated Comprehensive Cancer Center from April 2021 until July 2021. All patients seen in the orthopaedic clinic 18 years of age and older with a diagnosis/presumed diagnosis of sarcoma were provided the PHQ-9 as well as the GAD-7 in our clinic. We did not track those who elected not to complete the surveys. Surveys were scored per survey protocol (each question was scored from 0 to 3 and summed). Specifically, PHQ-9 scores the symptoms of depression as 5 to 9 (mild), 10 to 14 (moderate), 15 to 19 (moderately severe), and 20 to 27 (severe). The GAD-7 scores symptoms of anxiety as 5 to 9 (mild), 10 to 14 (moderate), and 15 to 21 (severe). Patients with PHQ-9 or GAD-7 scores of 10 to 14 were referred to social work and those with scores 15 or higher were referred to psychiatry. Patients with thoughts of self-harm were referred regardless of score. Patients were divided based on disease state: patients during their initial management; patients with active, locally recurrent disease; patients with active metastatic disease; patients with prior recurrence or metastatic lesions who were subsequently treated and now have no evidence of disease (considered to be patients with discontinuous no evidence of disease); patients with no evidence of disease; and patients with an active, noncancerous complication but otherwise no evidence of disease. We additionally looked at the association of gender, chemotherapy administration, and tumor location on survey responses. Data are summarized using descriptive statistics. Differences across categories of disease state were tested for statistical significance using Kruskal-Wallis tests for continuous variables and Fisher exact tests for categorical variables as well as pairwise Wilcoxon rank sum tests.

Results 

Overall, symptoms of depression were seen in 35% (67 of 190) of patients, at varying levels of severity: 19% (37 of 190) had mild symptoms, 9% (17 of 190) had moderate symptoms, 6% (12 of 190) had moderately severe symptoms, and 1% (1 of 190) had severe symptoms. Depresssion symptoms severe enough to trigger a referral were seen in 17% (32 of 190) of patients overall. Patients scored higher on the PHQ-9 during their initial treatment or when they had recurrent or metastatic disease, and they were more likely to trigger a referral during those timepoints as well. The mean PHQ-9 was 5.7 ± 5.8 during initial treatment, 6.1 ± 4.9 with metastatic disease, and 7.4 ± 5.2 with recurrent disease as compared with 3.2 ± 4.2 if there was no evidence of disease (p = 0.001). Anxiety symptoms were seen in 33% (61 of 185) of patients: 17% (32 of 185) had mild symptoms, 8% (14 of 185) had moderate symptoms, and 8% (15 of 185) had severe symptoms. Anxiety symptoms severe enough to trigger a referral were seen in 16% (29 of 185) of patients overall. Patients scored higher on the GAD-7 during initial treatment and when they had recurrent disease or an active noncancerous complication. The mean GAD-7 was 6.3 ± 3.2 in patients with active noncancerous complications, 6.8 ± 5.8 in patients during initial treatment, and 8.4 ± 8.3 in patients with recurrent disease as compared with 3.1 ± 4.2 in patients with no evidence of disease (p = 0.002). Patients were more likely to trigger a referral during initial treatment (32% [9 of 28]) and with recurrent disease (43% [6 of 14]) compared with those with no evidence of disease (9% [9 of 97]) and those with discontinuous no evidence of disease (6% [1 of 16]; p = 0.004). There was an increase in both PHQ-9 and GAD-7 scores among patients who had chemotherapy. Other factors that were associated with higher PHQ-9 scores were location of tumor (upper extremity versus lower extremity or axial skeleton) and gender. Another factor that was associated with higher GAD-7 scores included general category of diagnosis (bone versus soft tissue sarcoma). Specific diagnosis and length of follow-up had no association with symptoms of depression or anxiety. Overall, 22% (41 of 190) of patients were offered referrals to mental health professionals; 73% (30 of 41) accepted the referral.

Conclusion 

When treating patients with sarcoma, consideration should be given to potential concomitant psychiatric symptoms. Screening, especially at the highest-risk timepoints such as at the initial diagnosis and the time of recurrence, should be considered. Further work should be done to determine the effect of early psychiatric referral on patient-related outcomes and healthcare costs.

Level of Evidence 

Level III, therapeutic study.

中文翻译：

---

有多少比例的肌肉骨骼肉瘤患者出现抑郁或焦虑症状？

背景 

据估计，美国 12 个月抑郁症患病率为 8.6%，焦虑症患病率为 2.9%。尽管之前的研究已经评估了癌症患者的抑郁和焦虑情况，但很少有专门评估肉瘤患者，这些患者通常有独特的治疗考虑因素，例如手术后活动能力的变化。

问题/目的 

我们评估了在我们的骨科肿瘤诊所就诊的肉瘤患者，以确定 (1) 有抑郁症状的患者比例、症状严重程度、根据我们预先设定的九项患者健康的截止分数，有多少患者触发转诊给心理健康专业人员调查问卷 (PHQ-9)，以及他们的症状是否因疾病状态而异；(2) 有焦虑症状的患者比例、症状严重程度、根据我们在七项广泛性焦虑症量表 (GAD-7) 上预先指定的截止分数，有多少患者触发转诊给心理健康专业人员，以及他们的症状是否有所不同按疾病状态；(3)其他因素是否与焦虑或抑郁症状的比例和严重程度相关，例如肿瘤在体内的位置(中轴骨骼、上肢或下肢)、肿瘤的一般类型(骨或软组织)、具体诊断、化疗的使用、随访时间（少于 1 年或超过 1 年）和性别；(4) 有多少比例的患者接受心理健康专业人士的转介（如果有）。

方法 

这项研究是一项横断面调查研究，于 2021 年 4 月至 2021 年 7 月在国家癌症研究所指定的一个城市综合癌症中心进行。所有在骨科诊所就诊的 18 岁及以上诊断/推定诊断为肉瘤的患者我们诊所提供了 PHQ-9 和 GAD-7。我们没有追踪那些选择不完成调查的人。调查按照调查协议进行评分（每个问题从 0 到 3 进行评分并求和）。具体来说，PHQ-9 将抑郁症状评分为 5 至 9（轻度）、10 至 14（中度）、15 至 19（中重度）和 20 至 27（重度）。GAD-7 对焦虑症状的评分为 5 至 9 分（轻度）、10 至 14 分（中度）和 15 至 21 分（重度）。PHQ-9或GAD-7得分为10至14的患者被转诊至社会工作，得分为15或更高的患者被转诊至精神病科。无论评分如何，有自残想法的患者都会被转诊。根据疾病状态将患者分为：初始治疗期间的患者；患有活动性、局部复发性疾病的患者；患有活动性转移性疾病的患者；既往有复发或转移病灶，随后接受治疗但现在没有疾病证据的患者（被认为是不连续无疾病证据的患者）；无疾病证据的患者；以及患有活动性非癌性并发症但没有疾病证据的患者。我们还研究了性别、化疗给药和肿瘤位置与调查反应之间的关系。使用描述性统计总结数据。使用连续变量的 Kruskal-Wallis 检验和分类变量的 Fisher 精确检验以及成对 Wilcoxon 秩和检验来测试疾病状态类别之间差异的统计显着性。

结果 

总体而言，35%（190 人中的 67 人）的患者出现抑郁症状，其严重程度各不相同：19%（190 人中的 37 人）有轻度症状，9%（190 人中的 17 人）有中度症状，6%（190 人中的 12 人）有中度症状。 190 人中的 1 人有中度严重症状，190 人中的 1 人有严重症状。总体而言，17%（190 名患者中有 32 名）的抑郁症状严重到足以触发转诊。患者在初次治疗期间或患有复发或转移性疾病时在 PHQ-9 上得分较高，并且他们也更有可能在这些时间点触发转诊。初始治疗期间的平均 PHQ-9 为 5.7 ± 5.8，转移性疾病为 6.1 ± 4.9，复发性疾病为 7.4 ± 5.2，而没有疾病证据时为 3.2 ± 4.2 (p = 0.001)。33%（185 人中的 61 人）出现焦虑症状：17%（185 人中的 32 人）有轻度症状，8%（185 人中的 14 人）有中度症状，8%（185 人中的 15 人）有严重症状。总体而言，16% 的患者（185 名患者中有 29 名）出现了严重到足以触发转诊的焦虑症状。患者在初始治疗期间以及患有复发性疾病或活动性非癌性并发症时的 GAD-7 得分较高。患有活动性非癌性并发症的患者的平均 GAD-7 为 6.3 ± 3.2，初始治疗期间的患者为 6.8 ± 5.8，复发性疾病患者的平均 GAD-7 为 8.4 ± 8.3，而无疾病证据的患者的平均 GAD-7 为 3.1 ± 4.2（p = 0.002）。与没有疾病证据的患者（9% [97 中的 9]）相比，初始治疗期间（32% [28 中的 9]）和疾病复发患者（43% [14 中的 6]）更有可能触发转诊以及那些不连续没有疾病证据的患者（6% [16 中的 1]；p = 0.004）。接受化疗的患者的 PHQ-9 和 GAD-7 评分均有所增加。与较高 PHQ-9 评分相关的其他因素包括肿瘤位置（上肢与下肢或中轴骨骼）和性别。与较高 GAD-7 评分相关的另一个因素包括一般诊断类别（骨与软组织肉瘤）。具体诊断和随访时间与抑郁或焦虑症状无关。总体而言，22%（190 名患者中的 41 名）被转介给心理健康专业人员；73%（41 人中的 30 人）接受了推荐。

结论 

治疗肉瘤患者时，应考虑潜在的伴随精神症状。应考虑进行筛查，尤其是在风险最高的时​​间点，例如初次诊断时和复发时。应该做进一步的工作来确定早期精神病转诊对患者相关结果和医疗费用的影响。

证据水平 

III级，治疗研究。