Psycho-Oncology

Psycho-Oncology (2012)
Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/pon.3228

A longitudinal study of distress (depression and anxiety) up to

18 months after radiotherapy for head and neck cancer
Kate Neilson1*, Annabel Pollard1, Ann Boonzaier1, June Corry2,3, David Castle4,5, David Smith6, Tom Trauer3,4,5
and Jeremy Couper1,4,5
1

Psycho-Oncology Research Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
Head and Neck Cancer Service, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
3
Monash University, Melbourne, Victoria, Australia
4
Department of Psychiatry, St Vincents Hospital, Melbourne, Victoria, Australia
5
University of Melbourne, Melbourne, Victoria, Australia
6
Department of Psychology, RMIT University, Melbourne, Victoria, Australia
2

*Correspondence to:
Clinical Psychology, Peter
MacCallum Cancer Centre,
Locked Bag 1 A'Beckett Street,
Melbourne, Victoria 8006,
Australia. E-mail: Kate.Neilson@
petermac.org

Received: 2 February 2012

Revised: 26 October 2012
Accepted: 27 October 2012

Abstract
Objective: The aim of the study was to assess symptoms of depression and anxiety in patients with head
and neck cancer up to 18 months after radiotherapy.
Methods: Prospective observational study of consecutive head and neck outpatients was conducted
at a tertiary cancer centre (n = 101). Eligibility included diagnosis of cancer in the head and neck
region, where the patient agreed to radiotherapy with curative intent. Data were collected before
commencement of radiotherapy and 3 weeks and 18 months after completion. Symptoms of depression
and anxiety were assessed by the Hospital Anxiety and Depression Scale. Tumour/treatment-related
physical symptoms were assessed using the Additional Concerns subscale of the Functional Assessment
of Chronic Illness Therapy for Head and Neck Cancer.
Results: The prevalence of identied probable cases of depression was 15% at baseline, increasing
to 29% 3 weeks post-treatment, falling to 8% at 18-month follow-up. The number of probable cases
of anxiety was 20% at baseline, 17% at 3 weeks post-treatment and 22% at 18-month follow-up.
Depression scores signicantly increased from baseline to 3 weeks post-treatment and decreased at
18-month follow-up. Variability in depression scores was accounted for by tumour/treatment-related
physical symptoms. Anxiety scores signicantly decreased between baseline and 3-week post-treatment
and increased at 18-month follow-up. Younger age and more tumour/treatment-related physical
symptoms predicted anxiety scores.
Conclusions: The rates of depression in head and neck cancer patients increase following cancer
treatment and are related to tumour/treatment-related physical symptoms. Anxiety levels are higher
pre-treatment, lower immediately following cancer treatment but rise to near pre-treatment levels
more than a year after completion of cancer treatment.
Copyright 2012 John Wiley & Sons, Ltd.

Introduction
Head and neck cancer (HNC) patients are required to
undergo some of the most distressing and disguring
treatments among all cancers. Rates of 5-year survival
range between 23% and 64% depending on the site and
type of cancer [1]. Patients often live with chronic functional impairment and disgurement. Functional changes
associated with the disease, resulting from the acute
effects of radiation can include difculties with speaking,
swallowing and breathing, as well as pain [24]. For these
reasons, HNC has been described as more emotionally
traumatic than any other form of cancer [5].
Studies have shown that patients diagnosed with an
HNC display clinically signicant levels of psychological
distress. Psychological distress can be described as a
combination of symptoms including anxiety, depression,
cognitive and behavioural impairments [6]. Psychological
distress extends along a continuum ranging from transient,
normal feelings of vulnerability, sadness and fear to
problems that can become disabling such as symptoms
of depression and anxiety. More severe symptoms of
Copyright 2012 John Wiley & Sons, Ltd.

psychological distress may meet the criteria for a

psychiatric diagnosis. Psychiatric co-morbidity involves
a diagnosis of a mental disorder such as mood (e.g.
depression) or anxiety disorders. Symptoms of depression
include less enjoyment of usual activities, feeling sad and
less energy, whereas symptoms of anxiety include feeling
tense, frightened, worried, unable to relax and/or panic
[7,8]. Percentages of HNC patients with signicant levels
of distress range from 11% to 52% [913].
Changes in distress levels over time have been demonstrated in a few studies of HNC patients, suggesting that
these patients may experience a reduced quality of life
(QOL) and increased symptoms of distress at different
points in the treatment process. Studies have shown
increased distress at the time of diagnosis, as well as
during and immediately following radiotherapy and/or
chemotherapy [12,1419]. Kohda et al. [18] found that
there was a signicant decline in QOL and increase in
symptoms of depression during radiotherapy, and that
depressive symptoms persisted after completion of radiotherapy. Some studies have demonstrated that a proportion
of patients with HNC continue to struggle with lower

K. Neilson et al.

QOL and more symptoms of depression up to 1 year

after treatment [20,21].
Undetected and untreated psychological needs are
associated with reductions in patient QOL, extended
hospital stays, malnutrition, more complications with
treatment and treatment non-compliance [2224]. One
study has also found that the suicide rate for HNC
patients is more than four times the rate in the general
US population [25]. Recognition of anxiety and depressive disorders in cancer patients is therefore important
because effective psychotherapeutic and pharmacologic
treatments exist which can improve QOL and reduce
psycho-morbidity [2628].
Investigating predictive factors for psychological distress
helps to identify vulnerable patient groups early, in order to
target these groups with services/interventions to prevent
severe and persistent symptoms of distress and facilitate
long-term adjustment and recovery. Demographic factors
that have been reported to be predictive of psychological
distress in HNC include living alone, being male, lacking
social support, employed at start of treatment, younger
age and having a lower educational level [9,12,15,2931].
Cancer-related physical symptoms and advanced stage
cancer have also been associated with increased distress
and lower QOL [9,23,30,32].
Although this past research contributes to understanding
the experiences of HNC patients, many studies have included
only short follow-up periods (most 3 months following
treatment) [14,15,1719], focused only on depression
[9,11,12], did not examine predictors [14,19] and/or
included mixed HNC treatment groups [9,11,16,21].
The aim of this longitudinal study was to follow the
psychological trajectory of an Australian HNC population
up to 18 months after receiving radiotherapy. A previous
paper has summarised the 3-week post-treatment followup data [33]. This paper extends our ndings with this
patient group up to 18 months after radiotherapy. This
study specically aimed to: identify rates of depression
or anxiety cases; identify trends in depression and anxiety
symptom before and up to 18 months after radiotherapy;
and explore what bio-psychosocial factors predict depression
and anxiety scores up to 18 months following radiotherapy.
On the basis of past research, factors such as the physical
symptoms associated with HNC tumour and treatments
(e.g. chemotherapy), age, gender, living alone and other
medical treatments for cancer were expected to predict
depression and anxiety post-treatment.

Method
Procedure
This was a prospective longitudinal observational study of
HNC outpatients attending the Peter MacCallum Cancer
Centre (Melbourne, Australia) between May 2008 and
May 2009. Clinic oncologists assessed patient eligibility.
Eligibility criteria were a diagnosis for the rst time of
HNC, age >17 years, where the patient agreed to undertake cancer treatment involving radiotherapy with curative
intent. Exclusion criteria included inability to give informed
consent (including active psychosis, intellectual disability
or dementia), receiving treatment for another cancer, or
Copyright 2012 John Wiley & Sons, Ltd.

minimal understanding of English. Participants were

recruited by two student researchers and a research
ofcer. All follow-up contact, including posting out
questionnaires and contacting participants to remind to
complete questionnaires were completed by the research
ofcer. Each patient gave written consent to participate.
Ethics approval was obtained from the hospital human
research ethics committee.
Questionnaire measures were collected at three time
points: (i) pre-treatment (before radiotherapy); (ii) 3 weeks
post-treatment (approximately 3 weeks after completing
radiotherapy); and (iii) 18 months post-treatment.
Eighteen months after treatment was chosen as the nal
follow-up as it was expected that the majority of patients
would have recovered from most of the physical effects
of radiotherapy.

Measures
A Demographic Questionnaire asked participants to
record their gender, age, marital status, employment,
education, current tobacco use and mental health
history.
Cancer information such as diagnosis, tumour histology and treatment were obtained from reviewing
patients medical records.
The Hospital Anxiety and Depression Scale (HADS)
[7] is a well validated and reliable self-report measure designed to detect the presence and severity of
anxiety and depression [34,35]. The questionnaire
items exclude somatic symptoms and therefore
avoid symptom overlap between somatic illnesses
and mood disorders. Respondents are asked to rate
their symptoms over the previous week. Higher
scores on the two subscales (depression and anxiety)
indicate more severe symptoms. Scores >7 can be
used as a threshold for identifying probable cases
of depression. Normative data for the HADS is
available in a non-clinical sample and show a mean
score of 6.14 for the anxiety subscale and 3.68 for
the depression subscale [36]. A large study of oncology patients (n = 3035) demonstrated a mean anxiety
subscale score 6.76 and depression 4.3 [37].
The Functional Assessment of Chronic Illness
Therapy-Head and Neck Version [38] is a 39-item
scale developed to measure quality of life in
patients undergoing cancer treatment for HNC. An
Additional Concerns subscale assesses physical
symptoms specic to HNC tumours and treatment
(ability to eat, dry mouth, difculty breathing,
difculty speaking or communicating, unhappiness
with physical appearance). Respondents are asked
to report their symptoms over the previous week.
The subscale score is the sum of the respondents
ratings for the nine items. Higher subscale scores
denote higher QOL and less physical symptoms. It
is a valid and reliable measure [38].

Statistical analyses
Baseline characteristics of the study sample were summarised using means and standard deviations for continuous
variables, and frequencies and percentages for categorical
Psycho-Oncology (2012)
DOI: 10.1002/pon

Distress 18 months after radiotherapy for head and neck cancer

variables. Differences in baseline characteristics between

study completers and non-completers were analysed using
t-tests.
Multilevel mixed-effects linear regressions estimated
the association between predictors and symptoms of (i)
depression and (ii) anxiety. This approach recognises the
multilevel nature (assessments clustered within patients)
of the data and accommodates missing data from patients
who withdrew or became ineligible to continue the study.
Predictors included in the models were time (measured in
months), age, sex, living alone, received chemotherapy,
pain and physical symptoms associated with HNC tumours
and treatment.
Analyses were performed using STATA Version 12
(StataCorp, Texas, USA) and SPSS Version 16 (SPSS
Inc, Chicago, Ill USA).

Results
Participants
In total, 172 patients were referred for the study; of these,
71 declined to participate and 101 patients completed
baseline measures.
Pre-treatment demographic characteristics and cancer
type and treatment of participants are presented in detail
in Table 1. Participants consisted of 85 men and 16
women. The average age of participants was 63 years
(range 3785 years). Most participants were diagnosed with
squamous cell carcinoma, and all received radiotherapy as
part of treatment. The average duration of radiotherapy +/
chemotherapy was 6 weeks. Most participants had
surgery and radiotherapy (35%). One participant reported
a pre-treatment psychiatric condition (depression).
Of the 101 eligible patients who completed pre-treatment
questionnaires, 75 completed the 3-week post-treatment
questionnaires (26 withdrew from the study at 3 weeks
post-treatment). Of the post-treatment participants who
completed questionnaires, 23 patients were excluded from
the 18-month follow-up because of diagnosis of recurrence
or metastases during the rst 18 months after treatment
(n = 10), diagnosis and current treatment for another cancer
(n = 3), or death (n = 10). Patients with recurrent disease or
current treatment for other cancers were excluded to reduce
the inuence of these events on self-reported symptoms. A
further n = 15 withdrew at 18-month follow-up. Thus, a
total of 37 participants completed 18-month follow-up.
Participants who completed the study did not differ from
non-completers (either excluded or withdrew) on age,
sex or baseline anxiety. Completers did tend to be less
depressed at baseline compared with non-completers
(t(20) = 2.19, p = .04).

Table 1. Participants pre-treatment demographic characteristics

(n = 101)
Characteristic
Age
3544
4554
5564
6574
7584
85+
Cancer histology type
SCC
Other
Primary tumour site
Oral cavity
Oropharynx
Larynx/hypopharynx
Parotid gland
Paranasal sinus/nasal cavity
Nasopharynx
Thyroid
Cancer treatment/s
Radiation therapy only
Chemo + radiation therapy
Surgery + radiation therapy
Surgery + chemo + radiation
Marital status
Married
De facto
Never married
Divorced
Widowed
Lives alone
Alone
Not alone
Education
Primary
Secondary
Apprenticeship
Undergraduate
Postgraduate
Employment status
Full-time
Part-time
Casual
Unemployed
Retired
Pension/sickness benets
Income (annual household)
$0$15,599
$15,600$36,399
$35,400$78,000
$78,001 or more
Current smoking
No
Yes
Did not respond

5
24
29
26
15
2

5
24
28
26
15
2

82
19

81
19

33
29
23
7
4
3
2

32
29
23
7
4
3
2

13
29
35
24

13
28
35
24

65
7
10
11
8

64
7
10
11
8

25
76

25
75

8
44
19
9
18

8
44
19
9
18

30
6
4
7
46
6

30
6
4
7
46
6

23
22
28
20

23
22
28
20

89
10
2

88
10
2

SCC, squamous cell carcinoma.

the cut-off pre-treatment, 17% at 3 weeks post-treatment

and nearly 22% at 18-month follow-up.

Rates of depression and anxiety cases

The proportion of participants scoring above the clinical
threshold (>7) on HADS depression and anxiety subscales is shown in Figure 1. In terms of HADS depression
scores, 15% of participants reported symptoms above the
cut-off for depression pre-treatment, rising to nearly 30%
3 weeks post-treatment and dropping to 8% at 18-month
follow-up. On the anxiety scale, nearly 20% were above
Copyright 2012 John Wiley & Sons, Ltd.

Changes in depression and anxiety over time

A multilevel mixed-effects linear regression analysed predictors of depression scores. Depression scores did change
signicantly over time; however, this effect disappeared
when physical symptoms associated with HNC tumours
and treatment was included. The severity of physical
symptoms associated with HNC tumours and treatment
Psycho-Oncology (2012)
DOI: 10.1002/pon

K. Neilson et al.
6

50
5.49
5.16

45

40
35
30

4.04

4.02

29.3

3.54

25
20

3
21.6

19.8

17.3

15

14.9

10

Mean subscale score (lines)

% of participants above cut-off (bars)

5.32

HADS Anxiety % above

cut off
HADS Depression %
above cut-off
HADS Anxiety mean
HADS Depression mean

1
8.1

5
0

0
Pre-treatment

3-weeks posttreatment

18-months posttreatment

Time

Figure 1. Percentage of participants scoring above threshold (>7) and means for Hospital Anxiety and Depression Scale (HADS) depression
and anxiety subscales

was the only signicant predictor of depression scores

(b = .24; 95% CI: ( .30, .17); p < .01) with more
reported physical symptoms associated with higher
depression scores. Change in physical symptoms over time
is presented in Figure 2. No other predictors (time, pain,
chemotherapy, age, sex or living alone) were signicantly
related to depression scores.
Anxiety scores also changed signicantly over time,
with both time (b = .86; 95% CI: ( 1.19, .53); p < .01)
and time squared (b = .05; 95% CI: .03, .07; p < .01) being
statistically signicant, indicating a decrease in anxiety
scores between baseline and 3 weeks post-treatment and
an increase in anxiety between 3 weeks post-treatment
and 18-month follow-up. Although mean anxiety scores
signicantly change over time, these means appear to
vary less dramatically than depression (refer to Figure 1).
Age of participants also predicted anxiety, where anxiety
30
26.29

26.15

Mean subscale score

25

20

19.14

15

10

0
Pre-treatment

3-weeks Posttreatment

18-months Posttreatment

Time

Figure 2. Mean Functional Assessment of Chronic Illness Therapy

(FACT)-Additional Concerns subscale scores at each time (lower
scores indicate more physical symptoms)
Copyright 2012 John Wiley & Sons, Ltd.

scores were higher for younger participants (b = .54;

95% CI: ( .10, .01); p = .03). Physical symptoms predicted anxiety (b = .09; 95% CI: ( .15, .02; p = .01),
with more physical symptoms also associated with higher
anxiety scores. Other predictors were not signicantly
related to anxiety scores (pain, chemotherapy, age, sex and
living alone).

Discussion
This is the rst prospective (up to 18 months) study of predictors of depression and anxiety symptoms for HNC
patients treated with radiotherapy. This longitudinal study
demonstrated risk factors and the change in symptoms
of psychological distress (depression and anxiety) over
the course of treatment and recovery for HNC, up to
18 months after radiotherapy.
Participants anxiety levels were lower at 3 weeks
post-treatment compared with baseline and 18 months
post-treatment. A number of risk factors for anxiety over
the course of treatment were identied, with younger age
and more severe physical symptoms associated with
higher anxiety levels.
Depression, when analysed alone, increased signicantly between baseline and 3 weeks post-treatment, and
then decreased at 18-month follow-up. However, further
analysis revealed that variability in depression scores
was accounted for by participants experience of physical
symptoms associated with HNC tumours and treatment
(ability to eat, dry mouth, difculty breathing, difculty
speaking or communicating, unhappiness with physical
appearance). Results suggest that as physical symptoms
associated with their cancer and treatment increased, so
did symptoms of depression. This highlights the important
relationship between HNC patients tumour/treatmentrelated physical symptoms and psychological distress.
This nding is supported by previous studies of HNC
patients [9,23].
The pattern of change observed in depression scores
over treatment is similar to other studies [15,1719].
Psycho-Oncology (2012)
DOI: 10.1002/pon

Distress 18 months after radiotherapy for head and neck cancer

However, contrary to the current study, many previous

studies have found no signicant change in anxiety over
time [17,19]. Other risk factors (such as pain, receiving
chemotherapy, sex and living alone) identied by previous studies for distress were not supported as risk factors
in the current study [10,18].
Compared with previous studies using the HADS,
patients in the current study reported fewer symptoms
of anxiety across time than the general population
and other oncology samples [36]. However, the
HNC sample in the current study scored higher on
the depression subscale 3 weeks post-treatment when
compared with a general population [36] and a general
oncology sample [37], with one third of patients reporting symptoms above the cut-off threshold for depression
at 3 weeks following radiotherapy. This indicates that
HNC patients experience more symptoms of depression
following radiotherapy than other oncology and general
populations.
Future studies in this area should investigate the role of
other risk factors to identify vulnerable patients, such as
coping style and social support that may also provide
valuable information. It would also be useful to gain a
broader understanding of participants experiences during
treatment and recovery using qualitative methods. This
would further elucidate the relationship between physical
symptoms and mood symptoms reported on the quantitative measures in the current study.
This high incidence of symptoms of depression associated with physical symptoms in this HNC patient group
points to the importance for ongoing and routine surveillance to monitor psychological distress (particularly
symptoms of depression) in this patient group as they
proceed through medical treatments and rehabilitation,
and to provide appropriate interventions. Furthermore,
designing interventions aimed at supporting patients
as they develop physical symptoms from treatments and
preventing additional suffering from symptoms of depression would presumably assist this patient group: this is an
area worthy of further scientic study.

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A number of limitations of our study should be kept

in mind when interpreting results. Over the course of
the study, 41.5% of participants either dropped out or
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In conclusion, the results of this study indicate that
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group as they undergo treatment for HNC.

Acknowledgements
This research was funded by beyondblue: The National Depression Initiative. Thank you also to Karen Mead and Marcelle Gray, who assisted
this project as part of their postgraduate (psychology) dissertations.

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