Depressive Symptom Profiles and Survival in Older Patients with Cancer: Latent Class Analysis of the ELCAPA Cohort Study

Abstract

Background The expression of depressive symptoms in older people with cancer is heterogeneous because of specific features of age or cancer comorbidity. We aimed to identify depressive symptom profiles in this population and describe the associated features including survival. Materials and Methods Patients ≥70 years who were referred to geriatric oncology clinics were prospectively included in the ELCAPA study. In this subanalysis, depressive symptoms were used as indicators in a latent class analysis. Multinomial multivariable logistic regression and Cox models examined the association of each class with baseline characteristics and mortality. Results For the 847 complete‐case patients included (median age, 79 years; interquartile range, 76–84; women, 47.9%), we identified five depressive symptom classes: “no depression/somatic only” (38.8%), “no depression/pauci‐symptomatic” (26.4%), “severe depression” (20%), “mild depression” (11.8%), and “demoralization” (3%). Compared with the no depression/pauci‐symptomatic class, the no depression/somatic only and severe depression classes were characterized by more frequent comorbidities with poorer functional status and higher levels of inflammation. “Severe” and “mild” depression classes also featured poorer nutritional status, more medications, and more frequent falls. Severe depression was associated with poor social support, inpatient status, and increased risk of mortality at 1 year (adjusted hazard ratio, 1.62, 95% confidence interval, 1.06–2.48) and 3 years (adjusted hazard ratio, 1.49; 95% confidence interval, 1.06–2.10). Conclusion A data‐driven approach based on depressive symptoms identified five different depressive symptom profiles, including demoralization, in older patients with cancer. Severe depression was independently and substantially associated with poor survival. Implications for Practice Older patients with cancer present with distinct profiles of depressive symptomatology, including different severity levels of depression and the demoralization syndrome. Clinicians should use a systematic assessment of depressive symptoms to adequately highlight these distinct profiles. Geriatric and oncological features are differently associated with these profiles. For instance, severe depression was associated with more frequent comorbidities with poorer functional, poor nutritional status, polypharmacy, frequent falls, inpatient status and poor social support. Also, severe depression was independently and substantially associated with poor survival so that the identification and management of depression should be considered a high priority in this population.

Diagnostic Performance of the 4-Item Geriatric Depression Scale for Depression Screening in Older Patients with Cancer: The ELCAPA Cohort Study

“…One of the three methods was an LCA, which can be used to assess diagnostic performance in the absence of a "gold standard" [35]. Considering the measure of depression based on LCA, a latent class (labeled as "no depression/ somatic only") was defined by a high probability of somatic symptoms of depression and a low probability of psychological symptoms of depression, and only the latent class "severe depression" was considered as indicating the presence of depression, thus optimizing the specificity of the diagnosis [4]. Similar results were found whatever the measure considered.…”

“…The LCA also include somatic symptoms such as insomnia, fatigue, decreased appetite, pain complaints, and gastrointestinal symptoms. In the present study, five classes of depressive symptoms were identified: “somatic only,” “paucisymptomatic,” “severe depression,” “mild depression,” and “demoralization” [4]. We considered that “severe depression” was the third measure of depression.…”

“…The third measure was based on a latent class analysis (MMSE), a method that can be used to identify homogeneous classes of patients. Our team has developed an LCA for identifying depressed older patients with cancer [4]. The LCA's indicators include psychological symptoms like sadness (self-reported or assessed by a clinician), anhedonia (feeling empty or blunted positive affect), negative thoughts (feelings of worthlessness or hopelessness), and anxiety.…”

“…Depression is also reportedly associated with a longer hospital stay for patients with colorectal cancer [3]. Moreover, depression was found to be associated with worse survival in older patients with cancer [4][5][6][7]. The higher mortality rate might be partially explained by a delayed diagnosis, poorer quality of care, and/or poor treatment adherence [8,9].…”

The course of depressive symptoms and mortality in older patients with cancer

“…Depression is the most common mental health condition in older patients with cancer, and the reported prevalence varies from 13 to 45% between studies (Atag et al, 2018;Duc et al, 2017;Saracino et al, 2017;Weiss Wiesel et al, 2015). Whereas some longitudinal studies of older patients with cancer have shown an association between depression and increased mortality (Gouraud et al, 2019;Lloyd-Williams et al, 2009), others have not (Ferrat et al, 2015). Depression in older patients with cancer is reportedly associated with more pain, reduced quality of life, greater disability, and increased costs to the health care system (Anguiano et al, 2012;Atag et al, 2018;Gouraud et al, 2019;Kristjansson et al, 2010;Lloyd-Williams et al, 2009).…”