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Running Head: Depressive Symptoms and Endometrial Cancer 1 Depressive Symptoms, Length of Hospitalization, and Post Operation Complications in Endometrial Cancer Daniel Elgut University of Florida
Depressive Symptoms and Endometrial Cancer 2 Acknowledgements This research was supported by an American Cancer Society Institutional Gra nt Award to the University of Florida (#IRG 01 188 01), PI, William Stratford May, MD, PhD and the National Cancer Institute R03CA117480, PI, Deidre B. Pereira, PhD.
Depressive Symptoms and Endometrial Cancer 3 Abstract Endometrial cancer (EC) is the most common and second most deadly gynecologi c cancer in the US. Women with EC experience impairment in physical and emotional quality of life. Psychosocial factor s have been associated with length of hospitalization and post operative complications. This study examined the relationships among depres sive symptoms, length of hospitalization, and post operative complications among women undergoing surgery ( total abdominal hysterectomy and bilateral salpingo oophorectomy [ TAH BSO ] ) for suspected EC. It was hypothesized that w omen with greater depressive symptoms would have longer lengths of hospitalization and more post operative complications. One hundred thirty four women scheduled to undergo TAH BSO were recruited and enrolled from the UF & Shands Gynecologic Oncology Clinic prior to surgery. Depress ive symptoms were assessed using the Beck Depression Inventory 2 nd Edition ( N = 56) and the Structured Interview Guide for the Hamilton Anxiety and Depression Scales ( N = 106) Length of hospitalization and post operative complications were obtained via me dical record abstraction. After controlling for relevant control variables, n o significant correlations emerged between depressive symptoms and length of hospitalization or depressive symptoms and number of post operative complications. Given these null findings, future research should examine whether other psychosocial factors, such as anxiety, are associated with these outcomes in endometrial cancer patients.
Depressive Symptoms and Endometrial Cancer 4 Literature Review Introduction Endometrial carcinoma is a cancer of endometrium, the lini ng of the uterus. Endometrial adenocarcinoma is the most common form of endometrial cancer, and e ndometrioid adenocarcinoma is the most common type of endometrial adenocarcinoma ( Seffrin 2009). Endometrial cancer is the most common gynecological malignan cy in the United States and represents approximately 6% of all cancers in women. In 2008, an estimated 40,100 women were newly diagnosed with endometrial cancer, and an estimated 7,4 70 women died from endometrial cancer (American Cancer Society, 2008) The most common presenting problem of women with endometrial cancer is abnormal vaginal bleeding ( Lieberman McFarland & Boetes 2008). Endometrial Cancer & Depression Anxiety and depression are common ly experienced among individuals with cancer (Deroga tis et al., 1983; Stark et al., 2002). Many women with endometrial cancer experience clinically significant distress and other psychological symptoms. Commonly, women may experience fears of recurrence, including a se nse of doubt over their future, as we ll as isolation, separation, anxiety or depression. Y ounger endometrial cancer survivors may have the most distress, including symptoms such as f rustration, tension, depression, and difficulty relaxing (Li, Samsioe, & Iosif, 1999). In addition, low socio economic status and ethnic minority status are associated with risk for depression in female specific cancers (i.e., breast and gynecologic cancers ) (Ell, Sanchez, & Vourlekis, 2005) Unemployment and living alone are additional risk factors for negative mood states and health problems, particularly among long term survivors of endometrial cancer (Bradley, Rose, Lutgendorf, Costanzo, & Anderson, 2006)
Depressive Symptoms and Endometrial Cancer 5 Depression & Length of Hospitalization Research demonstrates an association between depression and l onger length of hospitalization. In a study examining the relationship between depression and length of stay in the hospital, individuals with depression had a mean length of hospitalization that was 10 days longer than those without depression Furthermo re, p atients treated with antidepressants had a mean length of hospitalization that was 31.8 days shorter than those with major depression who were not treated (Verbosky, Franco, & Zrull, 1993) A study of patients who suffered from depression and anxiety after cardiac surgery found that symptoms of depression and anxiety after surgery led to between two and 15 extra days in the hospital (Lane, Carroll, Ring, Beevers, & Lip, 2000) Depression Length of Hospitalization & Postoperative complications In d iverse medical populations, psychiatric morbidity has been associated with a greater length of hospitalization (Jesus et al., 2002) In one study, predictors of postoperative complications and length of hospitalization in gynecologic cancer were assessed. The number of co morbid mental disorders such as depression and anxiety, can help predict length of hospital stay and prevalence of postoperative complications (Dean, Finan, & Kline, 2001) Women with more co morbid medical conditions had a greater lengt h of hospital stay. The same relationship was established with the number of postoperative complications, such that women with more co morbid medical conditions had a higher frequency of postoperative complications. Study Aim and Hypothesis The purpose of the presemt study wa s t o examine the relationship s among depressive symptoms, length of hospitalization, and post operative complications among women undergoing surgery for suspected endometrial cancer. The followed hypotheses were generated:
Depressive Symptoms and Endometrial Cancer 6 Hypothesis 1 a : W omen with greater depressive symptoms will have longer lengths of stay in the hospital. Hypothesis 1b : Women with greater depressive symptoms will have more post operative complications Methods This study utilized a non experimental, longitudinal, s urvey method design. This design examined the associations between psychosocial factors and clinical variables in a sample of women undergoing a total abdominal hysterectomy and bilateral salpingo o opherectomy (TAH BSO) for Stages I III a endometrial aden ocarcinoma. Exclusion criteria included recurrent or stage IIIb, II Ic, or IV endometrial carcinoma ; pre surg ical chemotherapy or radiation therapy ; metastasis to the uterine corpus from another site ; current psychotic disorder ; and current suicidal intent/ plan. Participants were recruited from the UF & Shands Gynecologic Oncology Clinic. Women were recruited prior to undergoing surgery for endometrial cancer. Women were considered eligible for the study after an initial screening and a meeting with the res earcher where the women were presented with relevant study procedures and rationale. If the women agreed to participate in the study, they read and signed a University of Florida Institutional Review Board approved informed consent form indicating their in tent to participate. The data recorded was psychosocial data and was gathered via face to face administration of structured interviews and questionnaires both pre and post operatively. Psychosocial Assessment Depressive symptoms were assessed using the B eck Depression Inventory 2 nd Edition (BDI II; 0 [no depressive symptoms] to 63 [severe depressive symptoms] (Beck, Steer, &
Depressive Symptoms and Endometrial Cancer 7 Brown, 1996). This assessment is a 21 question multiple choice survey that is self report. Each question is scored on a scale from 0 to 3. There are four choices, for example, ranging from: (0) I do not feel sad (1) I feel sad (2) I am sad all the time (3) I have considered suicide. Depressive symptoms were also assessed using an abbreviated form of the Structured Interview Guide fo r the Hamilton Anxiety and Depression Scales (SIGH AD; 0 [no depressive symptoms] to 44 [severe depressive symptoms]) (Shear et al., 2001; Williams, 1988) described elsewhere (Pereira et al., 2010) This questionnaire uses 21 multiple choice questions that range in intensity. The first 18 questions go towards the total score while the rest of the questions go towards further questions have 3 options e.g. : (0) Absent (1) Mild (2) Severe while other questions have 5 options e.g. : (0) Not present (1) Self absorption (2) Preoccupation with health (3) Frequent complaints (4) Hypochondriacal delusions Assessment of Control and Outcome Variables Length of hospitalizatio n and post operative complications were obtained via medical record abstraction. Age, body mass index (BMI), and Charlson Comorbidity Index (Charlson, Pompei, Ales, & MacKenzie, 1987) scores were examined as possible control variables. This data was studie d against the 134 women who were eligible to participate in this study. It was concluded that the controls examined had no relationship with post operative complications and length of hospitalization for women suffering from depressi ve symptoms with susp ected endometrial cancer. Results A total of 134 women met the requirements for eligibility for participation and were enrolled in the study following completion of the informed consent process. In the total sample
Depressive Symptoms and Endometrial Cancer 8 of 134 participants, participants ranged in age from 35 to 84 years ( M =61.3 yrs, SD =9.0 yrs). The majority of participants identify themselves as White (92.1%); however other races were represented (Black/African American [7.1%] and Mixed [0.8%]). Also, 91.4% of the women identified themselves a s non Hispanic/Latino. One hundred six of the 134 women in the parent study provided SIGH AD depression data. The 106 women provided all the necessary data to compare variables within the SIGH AD Among these 106 women, neither age nor BMI was associate d with either length of hospitalization or number of post operative complications 1 (Table 1). G reater Charlson Comorbidity Index scores were significantly correlated with greater length of hospitalization, r = .336, p < .001 and marginally correlated wi th number of post operative complications, r = .173 p = .078 (Table 1) However, controlling for Charlson Comorbidity Index scores, SIGH AD depression scores were not correlated with either length of hospitalization, r = .07 0 p = .483, or number of post operative complications, r = .076, p = .448 (not shown). As expected, greater number of post operative complications was significantly correlated with greater length of hospitalization E ven after controlling for Charlson Comorbidity Index scores post operative complications were significantly correlated with greater length of hospitalization r = .518, p < .00 1 (Table 1) Fifty six of the 134 women in the parent study provided BDI II depression data. Among these 56 women, age and Charlson Comorbidity Index scores were not associated with length of hospitalization or number of post operative complications (Table 2). However, greater BMI was marginally associated with greater length of hospitalization, r = .245, p = .080 (Table 2). After controlling fo r BMI, pre operative BDI II scores were not significantly associated with either 1 Length of hospitalization and number of post operative complications were not normally distributed. Therefore, each variable was log10 transformed in order to impose a normal distribution on the data so that parametric statistics could be used.
Depressive Symptoms and Endometrial Cancer 9 length of hospitalization, r = .098, p = .500, or number of postoperative complications, r = .081, p = .577 (not shown). Once again, as expected, greater number of post ope rative complications was significantly correlated with greater length of hospitalization, even after controlling for BMI, r = .498, p < .001. Although null findings were obtained on the primary analyses, several other noteworthy results emerged. Older age was marginally associated with the lower SIGH AD depression scores, r = .214 p =.026 and lower BMI, r = .190 p =.050 (Table 1). In addition, greater BDI II scores were significantly correlated with greater Charlson Comorbidity Index scores r = .3 27 p =.016 (Table 2) This latter finding is of interest given that, among the 106 women with complete SIGH AD data, greater Charlson Comorbidity Index scores were significantly associated with greater length of hospitalization and marginally associated with greater number of post operative complications (Table 1). Table 1. Pearson correlation coefficients (p values) among SIGH AD depression scores, select control variables, and outcome variables ( N 1. 2. 3. 4. 5. 6. 1. Age --.190** (.050) .011 (.914) .214** (.026) .095 (.333) .030 (.764) 2. BMI ----.030 (.762) .122 (.212) .103 (.294) .090 (.361) 3. Charlson Comorbidity Index Score ------.035 (.721) .336*** (.000) .173* (.078) 4. SIGH AD Depression Score --------.055 (.574) .066 (.501) 5. Length of Hospitalization ----------.539*** (.000) 6. Number of Post Operative Complications ------------*p < .10, **p < .050, ***p < .001
Depressive Symptoms and Endometrial Cancer 10 Table 2. Pearson cor relation coefficients (p values) among BDI II depression scores, select control variables, and outcome variables ( N 1. 2. 3. 4. 5. 6. 1. Age --.166 (.230) .100 (.470) .119 (.387) .151 (.279) .143 (.306) 2. BMI ----.010 (.946) .039 (.778) .245* (.080) .058 (.681) 3. Charlson Comorbidity Index Score ------.327** (.016) .178 (.201) .015 (.914) 4. BDI II Score --------.038 (.786) .052 (.710) 5. Length of Hospitalization ----------.492*** (.000) 6. Number of Post Operative Complications ------------*p < .10, **p < .050, ***p < .001 Discussion In the present study, it was hypothesized that women with greater depressive symptoms would have (a) longer lengths of stay in the hospital and (b) more post operative complications. However, in contrast to hypotheses and prior literature, results revealed that d epressive symptoms w ere not associated with either length of hospitalization or number of post operative complications. In spite of these null findings, a relationship emerged between greater depressive symptoms and (1) greater medical co morbidity and (2) younger age. The former finding is interesting given that greater medical co moribidty was associated with greater length of hospitalization and greater number of post operative complications. A limitation of the study that may have infl uenced the results obtained or int erpretation is the small sample size particularly for the BDI 2 analyses. Exclusion criteria included recurring or stage IIIb, IIIc, or IV endometrial carcinoma; pre surgical chemotherapy or radiation therapy;
Depressive Symptoms and Endometrial Cancer 11 metastasis to the uterine corpus from a diffe rent site; current psychotic disorder; and current suicidal intent/plan. Small sample sizes may lead to low statistical power or spurious findings, both of which threaten study validity. An additional limitation is the unknown validity of the post operati ve complication data. Specifically, the physician differences in documenting the type and presence of post operative complications may have impacted the ability to detect a significant relationship between depression and this particular outcome variable. Furthermore, multiple individuals were not used to abstract and code the post operative complication data; thus, inter rater reliability could not be determined. In light of the null findings of this study, f uture research should examine associations am ong other relevant psychosocial factors, length of hospitalization and post operative complications in this population. Anxiety is highly prevalent in both cancer and surgical samples; thus, anxiety would be an important psychosocial factor to target in t his future research. In addition, a study on depression and anxiety and how it affects specific co morbidities could give further information on its effects with length of hospitalization. References American Cancer Society (2007). Cancer facts and figu res 2007 Atlanta, GA: American Cancer Society. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). The Beck Depression Inventory Second Edition San Antonio: The Psychological Corporation. Bradley, S., Rose, S., Lutgendorf, S., Costanzo, E., & Anderson, B. (2006). Quality of life and mental health in cervical and endometrial cancer survivors. Gynecologica Oncology 100(3), 479 486. Charlson, M. E., Pompei, P., Ales, K. L., & MacKenzie, C. R. (1987). A new method of classifying prognostic comorbidity i n longitudinal studies: development and validation. Journal of Chronic Disease, 40, 373 383. Dean, M., Finan, M., & Kline, R. (2001). Predictors of complications and hospital stay in gynecologic cancer surgery. Obstetrics and Gynecology 97(5), 721 724.
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