Abstract
Background/Aim: When assigned to radiotherapy (RT), elderly patients may experience distress. We investigated distress during RT and potential risk factors in these patients. Patients and Methods: Six-hundred-and-nineteen patients completed pre-RT and post-RT distress thermometers. Seven characteristics were investigated including age, sex, Karnofsky performance score (KPS), grouped KPS, tumor type, intent of RT, and previous RT. Additional analyses were performed in 358 patients with pre-RT scores ≤5. Results: Mean change of distress was −0.5 (±2.7) points and associated with KPS (p=0.005) and grouped KPS (p<0.001). Male sex (p=0.035), KPS 90-100 (p=0.001), and curative intent (p=0.037) were associated with increased distress on univariable analyses, and KPS 90-100 (odds ratio=1.92, p=0.004) on multivariable analysis. In patients with baseline scores ≤5, mean change was +0.5 (±2.5) points and associated with KPS (p=0.040) and grouped KPS (p=0.025). Conclusion: Psychological assistance should be considered for all patients including those with baseline scores ≤5 and KPS 90-100. Patients with risk factors for increased distress would especially benefit.
Many cancer patients assigned to a course of radiotherapy (RT) experience significant distress (1-5). However, little is known about the development of distress during the course of RT (6-8). The levels of distress may decrease due to habituation with the daily sessions of RT or increase, for example due to symptoms caused by RT-related adverse events or a treatment effect below the patient’s expectations. In our pilot study including 200 patients receiving RT, the mean distress score decreased in the majority of patients (8). These results were confirmed in our recent study of 927 patients (9). Both studies included patients of any age and did not focus on elderly or very elderly patients (8).
As patients continue to live longer, outcomes in the elderly population require particular attention (10-12). Due to comorbidities, many elderly patients are unable to tolerate aggressive standard therapies. According to the Organization for Economic Co-operation and Development (OECD), the elderly population is defined as aged ≥65 years (13). Moreover, very elderly patients are defined as aged ≥80 years in several studies (14-18). Our present study focused on elderly patients and additionally considered very elderly patients irradiated for a malignant disease. We investigated the course of distress during RT and aimed to identify risk factors for increased distress. High-risk patients may particularly benefit from psychological assistance before and during their course of RT.
Patients and Methods
Data from 619 elderly cancer patients aged ≥65 years including 134 very elderly patients (≥80 years) were included in this retrospective study, which was approved by the leading ethics at the University of Lubeck (file 2022-486). The patients, who received curative or palliative RT for their malignant disease between November 2021 and November 2022, completed the Distress Thermometer of the National Comprehensive Cancer Network (NCCN) prior to the start of RT (baseline) and at the end of RT (19). Distress scores on the thermometer range between zero (no distress during the past week) and ten points (extreme distress during the past week).
We investigated the course of distress scores during the series of RT by subtracting the score at baseline from the score at the end of RT. In addition to the entire cohort, seven characteristics (Table I) were evaluated for associations with the change in distress scores, including age at start of RT (65-79 vs. ≥80 years), sex (female vs. male), Karnofsky performance score (KPS) (50 vs. 60 vs. 70 vs. 80 vs. 90 vs. 100), grouped KPS (≤80 vs. 90-100), primary tumor type (breast cancer vs. lung cancer vs. prostate cancer vs. head-and-neck cancer vs. other types), intent of RT (curative vs. palliative), and history of previous RT (no vs. yes). We calculated mean values and standard deviations of the change in distress scores and the rates of decrease (by 2 or more points), no change (difference ranging between −1 and +1 point), and increase (by 2 or more points) in distress.
Patient characteristics of the entire cohort (n=619).
Statistical analyses regarding associations between the seven characteristics and the mean changes of distress scores was performed using the Wilcoxon two-sample test (2 subgroups compared) and the Kruskal-Wallis test (≥3 subgroups compared). The same tests were applied for potential associations between the seven characteristics and decrease, no change, or increase in distress scores. In addition, we investigated the binary variable “increase vs. no increase in distress” using the Chi-square test for univariable analyses and a logistic regression model for multivariable analyses. For all statistical analyses, p-values of <0.05 were considered indicating significance and p-values <0.10 indicating a trend.
In addition to the entire cohort, all analyses indicated above were performed in the subgroup of 358 patients with a baseline distress score of ≤5, in order to identify the need for psychological assistance in this group. The rationale for the additional analyses was that physicians are generally more inclined to offer psychological assistance to patients who feel more distressed.
Results
At baseline, 430 patients (69.5%) had distress scores ≥4 indicating moderate to severe distress according to version 3.2019 of the NCCN practice guideline for distress management (20). Moreover, 261 patients (42.2%) had distress scores ≥6, which according to a recent study was the optimal cut-off point to identify highly distressed cancer patients (21). In the subgroup of very elderly patients, 97 patients (72.4%) had distress scores ≥4 and 53 patients (39.6%) distress scores ≥6, respectively.
In the entire cohort of 619 patients, the mean distress score was 5.0 (±2.7) points prior to RT compared to 4.4 (±2.6) points at the end of RT. The mean change in distress scores was −0.5 (±2.7) points. Significant associations with the mean change were found for KPS (p=0.005, Figure 1) and grouped KPS (p<0.001, Figure 2) (Table II). When considering decrease, no change, and increase in distress scores, significant associations were identified for KPS (p=0.001) and grouped KPS (p<0.001) (Table III).
Changes in distress levels stratified according to Karnofsky performance score (50 vs. 60 vs. 70 vs. 80 vs. 90 vs. 100) in the entire cohort (n=619). The p-value was calculated with the Kruskal-Wallis test.
Changes in distress levels stratified according to the grouped Karnofsky performance score (≤80 vs. 90-100) in the entire cohort (n=619). The p-value was calculated with the Kruskal-Wallis test.
Mean changes in distress scores during the radiotherapy course in the entire cohort (n=619).
Rates of decrease, no change, and increase in distress scores during the radiotherapy course in the entire cohort (n=619).
When evaluating the seven characteristics with respect to the binary variable “increase vs. no increase in distress”, significant associations on univariable analyses were found for male sex (p=0.035), grouped KPS 90-100 (p=0.001), and curative intent of RT (p=0.037), and a trend was found for higher ungrouped KPS (p=0.052) (Table III). On multivariable analysis, grouped KPS 90-100 was significantly associated with increase in distress (odds ratio=0.52, 95% Wald confidence interval=0.34-0.82, p=0.004), and male sex showed a trend (odds ratio=0.59, 95% Wald confidence interval=0.32-1.08, p=0.085) (Table IV). When comparing very elderly patients aged ≥80 years to patients 65-79 years of age, the results were not significantly different (Table II, Table III, and Table IV).
Results of the multivariable analysis regarding the binary variable “increase vs. no increase in distress” in the entire cohort (n=619).
In the 358 patients with a baseline distress score of ≤5 (characteristics shown in Table V), the mean distress scores were 3.1 (±1.8) points prior to RT and 3.6 (±2.5) points at the end of RT, and the mean change was +0.5 points (±2.5) points. Like in the entire cohort, significant associations with the mean change were found for KPS (p=0.040) and grouped KPS (p=0.025) (Table VI). When considering decrease, no change, and increase in distress scores, significant associations were identified for male sex (p=0.030), KPS (p=0.028), and grouped KPS (p=0.013) (Table VII). When considering the binary variable “increase in vs. no increase in distress”, a significant association was found for male sex (p=0.034) on univariable analysis (Table VII). On multivariable analysis, grouped KPS of 90-100 showed a trend (odds ratio=0.64, 95% Wald confidence interval=0.39-1.07, p=0.091) (Table VIII). Like in the entire cohort, the results were not significantly different in very elderly patients and patients aged 65-79 years of age (Table VI, Table VII, and Table VIII).
Characteristics of patients with baseline distress scores ≤5 points (n=358).
Mean changes in distress scores during the radiotherapy course in patients with baseline distress scores ≤5 points (n=358). p-Values were calculated with Wilcoxon two-sample test (2 subgroups) or Kruskal-Wallis test (≥3 subgroups).
Rates of decrease, no change, and increase in distress scores during the radiotherapy course in patients with baseline distress scores ≤5 points (n=358).
Results of the multivariable analysis regarding the binary variable “increase vs. no increase in distress” in patients with baseline distress scores ≤5 points (n=358).
Discussion
A considerable proportion of cancer patients assigned to a course of RT experience significant distress due to the upcoming treatment (1-5, 22-24). Distress can lead to sleep disorders and decreased quality of life (1, 25-28). Until now, only a few studies have evaluated the development of distress during the course of RT (6-9). In 2001, Mose et al. presented a study of breast cancer patients receiving adjuvant RT following breast-conserving surgery (6). Forty-eight per-cent of the 111 women indicated that they were afraid of the planned RT. In 36% of these women, anxiety did not improve during their RT-course. In another study, 37% of 71 patients with different types of primary tumor, who completed a Distress Thermometer every day during their RT-course, had distress scores ≥4 at least once. Remarkably, distress improved during the first five weeks of RT but increased afterwards, even beyond pre-RT distress scores. Moreover, after completion of RT, distress did not reduce in 47% of the patients (7). In our pilot study from 2022 of 200 patients irradiated for different types of malignancy, the mean distress score at the end of RT was slightly lower (decrease by 0.5 points) compared to that at baseline prior to RT (8). This result was recently confirmed in a larger cohort of 927 patients (decrease by 0.3 points) (9). However, these studies were performed in patients of any age (6-9). A subgroup analysis in elderly patients was performed only in our pilot study (8). Since elderly and very elderly patients should be considered separate groups, it appeared reasonable to perform an additional study focusing on these age groups.
Our present study was conducted in a total of 619 elderly patients aged ≥65 years including 134 very elderly patients aged ≥80 years. The prevalence of moderate to severe distress according to NCCN (scores ≥4) was high for both elderly (69.5%) and very elderly (72.4%) patients (20). Moreover, 42.2% and 39.6% of patients, respectively, experienced very high levels of distress (scores ≥6) (21). These data demonstrate the importance of distress for these age groups. During the RT-course, the mean distress score slightly decreased in both the entire cohort and the subgroup of very elderly patients. The values in the present study were similar to the mean change of −0.5 (±2.6) and −0.3 (±2.8) found in our previous studies in patients of any age (8, 9). The mean distress scores at baseline were also similar when compared to the previous studies (8, 9). These data suggest that the need of psychological support of elderly and very elderly patients is similar to that of younger patients. This suggestion is supported by the fact that in our pilot study, results in the subgroup of elderly patients regarding the mean change of distress scores and potential risk factors were similar to the results in the entire cohort (8).
In the present study, increase in distress was associated with male sex, KPS 90-100, and curative intent of RT. These results partly agree with our previous study of 927 patients (9). In that study, increased distress was associated with KPS 90-100 and curative intent of RT. However, male sex did not have a significant impact on the course of distress in the previous study. This may be explained to some extent by the fact that in the present study, the proportion of prostate cancer patients was greater than that in the previous study. In both studies, prostate cancer patients did non-significantly worse with respect to the course of distress during RT when compared to patients with other investigated tumor entities (9).
Moreover, in the present study, patients with baseline scores ≤5 experienced a mean increase in distress by 0.5 (±2.5) points, which was also found in our previous study. These results suggest that, although patients with higher distress scores at baseline appear to have a greater need for psychological assistance, those patients with scores of ≤5 points would also significantly benefit from such support. However, when following our recommendations, one should be aware that the results were obtained from retrospective data and, therefore, may have been influenced by a hidden selection bias.
In conclusion, high proportions of elderly and very elderly cancer patients assigned to RT have significant distress due to the upcoming treatment. Although the distress score decreases in many patients during the course of RT, a considerable number of patients experiences increased distress. Particularly for these high-risk patients early psychological assistance should be provided. This accounts also for patients with lower pre-RT distress scores (≤5 points) and good performance status, who are usually not considered for psychological assistance at their first presentation at a radiation oncology department.
Acknowledgements
As part of the project TreaT (148-1.1-21), the study received funding form the European Regional Development Fund through the Interreg Deutschland-Danmark program.
Footnotes
Authors’ Contributions
The study was designed by C.D., S.J., and D.R. The data were collected by C.D. and analyzed by a professional statistician. The article was drafted by D.R. with the support of N.Y.Y. The final version of the article was reviewed and approved by all Authors.
Conflicts of Interest
On behalf of all Authors, the corresponding Author states that there are no conflicts of interest related to this study.
- Received August 3, 2023.
- Revision received August 28, 2023.
- Accepted August 29, 2023.
- Copyright © 2024 The Author(s). Published by the International Institute of Anticancer Research.
This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international license (https://creativecommons.org/licenses/by-nc-nd/4.0).
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