Anxiety and depression after cancer

diagnosis: Prevalence rates by cancer type,

gender, and age

Wolfgang Lindena, b, , 1, ,

Andrea Vodermaiera, c, , 1,

Regina MacKenzieb,

Duncan Greiga

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doi:10.1016/j.jad.2012.03.025

Abstract
Background
Reported prevalence of emotional distress in cancer patients varies widely across studies.
The present study determined prevalence of anxiety and depression (separated for presence
of symptoms versus clinical levels) in a large, representative sample of cancer patients after
diagnosis.
Method
During the years 20042009, 10,153 consecutive patients were routinely screened with the
Psychosocial Screen for Cancer questionnaire at two major cancer centers.
Results
Patients' mean age was 59 years and 45% were men. Across cancer types, 19.0% of patients
showed clinical levels of anxiety and another 22.6% had subclinical symptoms. Further,
12.9% of patients reported clinical symptoms of depression and an additional 16.5%
described subclinical symptoms. Analyses by cancer type revealed significant differences
such that patients with lung, gynecological, or hematological cancer reported the highest
levels of distress at the time point of cancer diagnosis. As expected, women showed higher
rates of anxiety and depression, and for some cancer types the prevalence was two to three
times higher than that seen for men. In some cancer types emotional distress was inversely

related to age. Patients younger than 50 and women across all cancer types revealed either
subclinical or clinical levels of anxiety in over 50% of cases.
Limitations
Findings describe levels of emotional distress after diagnosis but cannot inform about
trajectories of anxiety and depression over time.
Conclusion
Given that levels of anxiety and depression varied widely by cancer type, gender, and age,
these results inform which cancer patients are most likely in need of psychosocial support.

Keywords

Anxiety;

Depression;

Cancer diagnosis;

Cancer type;

Gender;

Age

1. Introduction
Emotional distress in cancer patients (operationally defined here as anxiety or depression)
reduces patients' quality of life, negatively impacts compliance with medical treatment
(DiMatteo et al., 2000 and Greer et al., 2008), and carries an elevated risk of mortality
(Pinquart and Duberstein, 2010 and Satin et al., 2009). For this reason, emotional distress is
recognized as the sixth vital sign in cancer care (Bultz and Carlson, 2005), calling for
systematic allocation of supportive resources. Cost-effective resource allocation, however,
requires precise knowledge of the extent of a problem. Correspondingly, researchers have
reported the prevalence rates of anxiety and depression in the cancer population but this
literature can be difficult to interpret because:
[a]
researchers do not always clarify whether an actual clinical diagnosis has been made
or whether symptoms were present;

[b]
diagnostic cut-offs are sometimes not empirically validated and diagnoses are at
times based on different diagnostic systems, with the latter resulting in prevalence
estimates that range from 25% to 38% in the same sample (Kathol et al., 1990);
[c]
the quality of measurement tools varies greatly (Vodermaier et al., 2009); and
[d]
prevalence rates are often assessed at varying time points in the trajectory of the
disease although emotional distress is known to change as patients transition
through stages of diagnosis, acute treatment, and post-treatment (Stommel et al.,
2004). Prevalence rates for distress also depend on whether or not patients have
responded positively to treatment or not (Hopwood et al., 2009 and van't Spijker et
al., 1997).
When researchers report on the prevalence of emotional distress they frequently
acknowledge a wide range of observed prevalence rates. Massie (2004) reported that major
depression in cancer patients ranged from 0 to 38%. Variability in reported prevalence rates
is echoed in a meta-analysis (van't Spijker et al., 1997) where prevalence rates ranged from
0% to 46% for depression and 1% to 49% for anxiety. Reporting such wide ranges is not
helpful to administrators who must allocate finite resources to help alleviate emotional
distress in patients. A more recent meta-analysis restricted to cancer inpatients and highquality prevalence estimates based on structured clinical interviews (as compared to selfreport scales or physician judgment) demonstrated that one third of cancer patients suffer
from some type of mental disorder during active treatment (Singer et al., 2010).
We posit that large-sample studies are more likely to sample broadly and to reveal
replicable findings and as shown in Table 1, a number of large sample studies of distress
prevalence exist (where large is arbitrarily defined as n > 1000) (Brintzenhofe-Szoc et al.,
2009, Caminiti et al., 2004, Carlson et al., 2004, Hinz et al., 2010, Hopwood et al., 2009,
Sharpe et al., 2004 and Zabora et al., 2001). Together, these studies possess many strengths,
including the noted large samples, no restrictions regarding cancer types (except for one
study), and use of standardized tools. Noted weaknesses, however, include non-consecutive
recruitment and variable timing of assessment within the disease and treatment trajectory.
Table 1.
Prevalence studies of patients with cancer, N > 1000.

[a]
Standardized Differentiation
Types of
Study
and
measure?
of disorder from Consecutive
cancer
sample size
[b]
Cut-offs presence
of recruitment
included
empirically
symptoms
determined?
[a] Yes, BSI
Zabora et al.
No,
caseness
53
(2001)
All
was defined as T- No
[b] Not in
N = 4496
score > 62
cancer patients
Carlson et al.
No,
caseness
[a] Yes, BSI-18
(2004)
All
was defined as T- No
[b] Yes
N = 3095
score > 62
Caminiti et al.
No, only clinical
[a]
HADS
(2004)
All
caseness
No
[b] Yes
N = 3293
reported
Brintzenhofe[a]
BSI-53
Szoc et al.
All
[b] Not in No
No
(2009)
cancer patients
N = 8265
Early
Hopwood et al.
stage
[a] Yes, HADS
(2009)
Yes
Yes
breast
[b] Yes
N = 2208
cancer
Hinz et al.
No,
only
[a] Yes, HADS
(2010)
All
caseness was No
[b] Yes
N = 1529
reported
Sharpe et al.
[a] Yes, HADS.
(2004)
All
Yes
Yes
[b] Yes
N = 5613
Linden et al.
[a]
Yes,
(this
article) All
PSSCAN
Yes
Yes
N = 10,153
[b] Yes
Table options

Assessment
conducted at
fixed time in
disease
trajectory?
No

No
Yes,
during
chemotherapy
No
Yes, in acute
care,
before
radiation
No
No
Yes,
postdiagnosis but
pre-treatment

The present study adds data on subclinical and clinical symptoms of anxiety and depression
in another large sample and uses a standardized instrument with good psychometric
properties and empirically validated cut-offs. While acknowledging the substantial overlap
of these constructs, we chose not to aggregate data into a single distress index because
anxiety and depression may have different trajectories from diagnosis to end of first-line
treatment to long-term follow-up (Ando et al., 2009, Den Oudsten et al., 2010, Kangas et
al., 2007 and Thomas et al., 2011). Anxiety tends to reflect a reaction to the diagnosis and
the anticipated aversive treatment and is often transient, depression is more likely to reflect
a stable predisposition. Furthermore, given earlier reports that distress may vary not only by
cancer type but also by age and gender, we explicitly conducted analyses on these
moderator variables as well.

2. Methods
2.1. Procedures
In 2004, all British Columbia Cancer Agency centers implemented a routine screening
program for emotional distress. Since then, patients have routinely completed the
Psychosocial Screen for Cancer (PSSCAN) (Linden et al., 2005 and Linden et al., 2009)
during the first visit to a provincial cancer center, prior to beginning treatment. Patients are
free to refuse completion but record checks during data acquisition revealed that 73% of
eligible patients provided usable data. Unfortunately, the cancer clinics do not
systematically record reasons for non-completion, but clinicians report that an estimated
1015% of the total patient pool speak English as a second language and do not complete
standardized tests due to poor comprehension. Other prominent reasons for nonparticipation are a high level of medical crisis at arrival in the cancer clinic and/or lack of
lucidity typically due to old age (Linden et al., 2005).
For this study, the psychosocial data obtained at the two largest centers were merged with
electronically archived medical and demographic data. Given that breast cancer in men is a
very rare disease and difficult to compare with breast cancer in women, the few men were
excluded from analysis. Similarly, prostate cancer as a tumor type was distinguished from
the large genitourinary category given that it represents a highly prevalent disease in older
men and carries a different prognosis than other genitourinary cancers. Also, three age
groups were formed: [a] patients below 50 (where cancer is relatively rare), [b] 50 to 69
(where cancer is on the rise), and [c] > 70 (where cancer is often superimposed on preexisting health problems). This study was approved by the Institutional Review Board of
the British Columbia Cancer Agency.

2.2. Measure
The 21-item Psychosocial Screen for Cancer assesses anxiety and depressive symptoms,
perceived social support, desired social support, and quality of life. The scale was
specifically developed and validated for use with cancer patients and was designed to serve
as a clinical as well as a research tool. The anxiety and depression subscales were
developed to map onto DSM-IV TR defined disorders, i.e., major depression and
generalized anxiety disorder and these scales were of particular interest for the present
study. Both subscales are comprised of 5 items each. Items are scaled on a 5-point Likert
scale (from 1 = not at all to 5 = very much so), with a potential range of scores from 5 to
25. An example item of the anxiety subscale is I felt nervous and shaky inside. And for
depression a sample is In the past year I have had 2 weeks or more during which I felt sad,
blue or depressed. These subscales have satisfactory internal consistency ( = .83, for
anxiety; = .79 for depression), and are sensitive to change (testretest reliability over
2 months: r = .67 for anxiety, r = .61 for depression). The anxiety and depression subscales
were highly sensitive and specific when compared to the Hospital Anxiety and Depression
Scale (sensitivity 92% and specificity 98%, for anxiety; sensitivity 100% and specificity
86%, for depression; Zigmond and Snaith, 1983). As well, normative data comparing
cancer patients with healthy controls exist (Linden et al., 2009). Results regarding

discriminant validity indicate that scores of 11 and greater are suggestive of a clinical
diagnosis, and scores greater than 8 but less than 11 indicate the presence of symptoms for
both the anxiety and depression subscales alike. PSSCAN psychometrics were also judged
to meet a satisfactory standard in a comprehensive comparison of screening tools and
available data indicate that it is suitable as a research tool and not just a screening tool
(Vodermaier et al., 2009).

3. Results
3.1. Sample description
Patient mean age was 58.9 (14.6) years. 4553 (44.8%) patients were male, and 5600
(55.2%) were female. Absolute and relative probabilities by cancer types were n = 2430
(23.9%) breast, n = 1598 (15.7) prostate, n = 1334 (13.1%) gastrointestinal, n = 949 (9.3%)
gynecological, n = 673 (6.6%) lung, n = 550 (5.4%) neuroendocrine, n = 501 (4.9%) skin,
n = 454 (4.5%) head and neck, n = 302 (3.0%) genitourinary (excluding prostate), n = 211
(2.1%) bone, n = 180 (1.8%) hematological, and n = 971 (9.6%) other unclassified primary
tumors.

3.2. Anxiety mean scores

As shown in Fig. 1, on average cancer patients experienced anxiety just above the
subclinical threshold (8.1(3.8)). Relative to the total sample, aggregated across cancer
types, patients with gynecological (d = .29***), hematological (d = .15) and lung cancer
(d = .22***) reported the highest levels of anxiety, whereas patients with skin
(d = .23***) and prostate (d = .43***) cancer were less anxious than the average cancer
patient (Fig. 1). These differences were partially attributable to gender effects (d = .38***),
indicating that female patients with gynecological, hematological, head and neck, and lung
cancers report the highest levels of anxiety (Fig. 3).

Fig. 1.
Levels of anxiety by cancer type.

Figure options

Fig. 2.
Levels of depression by cancer type.
Figure options

Fig. 3.
Levels of anxiety by cancer type and gender.
Figure options
The visual display of age effects in Fig. 5 was supplemented with inferential testing via
computation of Pearson-Product moment correlations given that age is a continuous
variable. Overall, age was not strongly linked to differences in distress levels, never
explaining more than 2.5% of the variance. Nevertheless, younger patients (below 50)
reported higher anxiety than older patients (70 and above). Within tumor groups, visual
inspection of graphed data indicates that middle-aged patients with genitourinary cancers
were most anxious. No age differences for anxiety were evident for lung, bone, skin and
genitourinary cancers. Older age was on average associated with less anxiety (r = .15).

Fig. 4.
Levels of depression by cancer type and gender.
Figure options

Fig. 5.
Levels of anxiety by cancer type and age.
Figure options

3.3. Prevalence rates of anxiety

On average, 19.0% of patients showed levels of anxiety in the clinical range, and another
22.6% reported subclinical symptoms (Fig. 1). Female cancer patients were almost two
times more likely than males (24.0% versus 12.9%) to report clinical levels of anxiety
(Fig. 3). Prevalence rates of clinical anxiety exceeding 30% were evident for females with
hematological and lung cancers. In terms of age, prevalence rates varied across cancer
types; they were 25.7% for the youngest, 18.9% for the middle, and 11.8% for the oldest
age group (Fig. 5). Within tumor groups, younger patients with bone cancer, breast cancer
and prostate cancer were almost three times more likely to report clinically relevant anxiety
than the oldest age group. Patients with gastrointestinal, hematological and neuroendocrine

cancers were more than two times more likely to report clinical levels of anxiety than their
older counterparts.

3.4. Depression mean scores

As shown in Fig. 2, cancer patients on average experienced levels of depression below
subclinical thresholds. Patients with lung (d = .21***), hematological (d = .20*) and
gynecological (d = .18***) cancers were the most distressed, whereas patients with skin
(d = .37***) and prostate (d = .18***) cancers were less depressed than the average
cancer patient. Women scored higher than men (d = .33***; Fig. 4). Women with
genitourinary, hematological, and lung cancers reported levels of depression at or above the
subclinical threshold.
In terms of age differences across cancer types, there emerged again a linear but weak
relationship such that younger cancer patients experienced the highest and older cancer
patients the lowest levels of depressive symptoms across all cancers when aggregated
(r = .12), but visual inspection suggested that patients with genitourinary, gynecological,
and hematological cancer types were the most depressed when they fell into the middleaged group (Fig. 6). Middle-aged patients with unspecified primary tumors seemed less
depressed than both their older and younger counterparts.

Fig. 6.
Levels of depression by cancer type and age.
Figure options

3.5. Prevalence rates of depression

On average, 12.9% of patients showed levels of depression in the clinical range. Another
16.5% reported subclinical symptoms. Similarly, female cancer patients were almost two
times more likely than males (16.4% versus 8.6%) to report clinical levels of depression.
Female patients with lung cancer demonstrated the highest prevalence rate of depression
with 24.7% being clinically depressed, followed by hematological (23.2%), and bone
cancers (19.4%). Regarding age, younger age was associated with higher rates of
depression but within lung cancer no age differences emerged. Again, for genitourinary,
gynecological, and hematological cancers an inverse U-shaped relationship emerged with
the middle-aged group being the most depressed.

4. Discussion
The present study adds a large sample of patients with all types of cancers to the extant
literature on the prevalence of anxiety and depression but is the first to provide
representative data on anxiety and depressive symptoms for all cancer types at the same
time point in the disease trajectory, namely after diagnosis but prior to treatment. The
sample is larger than the samples in either one of three earlier meta-analyses (Mitchell et
al., 2011, Singer et al., 2010 and van't Spijker et al., 1997), or another large systematic
review (Ng et al., 2010). Comparison of observed prevalence rates between the current
study and previous studies calls for cautious interpretation because no other study using all
cancer types had assessed patients at a standard point in the cancer trajectory. On the other
hand, the prevalence rates reported here do fit well into the range of prevalence rates
reported elsewhere (Brintzenhofe-Szoc et al., 2009, Caminiti et al., 2004, Carlson et al.,
2004, Hinz et al., 2010, Hopwood et al., 2009, Mitchell et al., 2011, Ng et al.,
2010 and Zabora et al., 2001) indicating that roughly 19% and 13% respectively met the
threshold for a level of anxiety or depression within the clinical range.
Also of interest is that mean levels of anxiety and depression were on average not much
greater than those of a healthy population sample (Linden et al., 2009), but that they varied
considerably as a function of cancer type, gender, and age. This implies that there are
distinct risk groups covering a full range of prevalence rates from essentially population
norm for prostate and skin cancer to majority depressed or anxious for lung and
hematological cancer. In contrast to van't Spijker et al.'s meta-analytic findings (1997),
where women had lower rates of emotional distress, our results showed that across all
cancer types female cancer patients showed higher prevalence rates of anxiety and
depression than men. This finding is consistent with higher rates of anxiety and depression
in the general healthy female population as compared to men (Piccinelli and Wilkinson,
2000). This gender difference may reflect a gender difference in willingness to report
distress but could also arise because women tend to use emotional approach coping
(Goldzweig et al., 2009, Jacobs-Lawson et al., 2010 and Stanton et al., 2000). Our data
suggest that men initially experience cancer as less threatening and this may arise in part
from the high prevalence of prostate cancer which indeed has a good overall prognosis.
Given the timing of our participant recruitment, we do not, however, know how men
respond when cancer progresses and a prognosis may worsen.
Interestingly, a clear inverse relationship between emotional distress and age was seen.
Prevalence rates of anxiety and depression were higher in the youngest age group and
lowest in older adults, likely due to more disruption of everyday living in younger cancer
patients, whereas older patients may already have impairments in physical function and are
cognitively and emotionally better prepared to accept illness. However, for a number of
cancer types no age effect emerged suggesting that cancers with unfavorable prognosis (i.e.,
gynecological, hematological, lung) affect all age groups equally. This, in turn, may reflect
a ceiling effect.
Which factors account for divergent levels of emotional distress between cancer groups?
The highest levels of emotional distress were reported from women patients with lung and

hematological cancer and this confirms results of smaller studies (Castelli et al.,
2009 and Nron et al., 2007), which showed very high prevalence rates of depression.
Advanced stage, poor prognosis, and invasive treatment, therefore, are plausible sources for
elevated levels of emotional distress (Vodermaier et al., 2011). To illustrate the range of
varying prognoses, 5-year survival rates are 25% for lung cancer and 57% for leukemia in
British Columbia (www.bccancer.bc.ca).
What do psychological symptoms at the time point of cancer diagnosis represent? For most
patients they are a natural reaction to what the patient perceives to be great uncertainty and
thus a severe stressor. In others, the larger emotional reaction may be superimposed upon a
latent vulnerability, e.g., preexisting mental disorders. Also, anxiety may be more of a
reaction to acute events and is likely to decrease after completion of primary treatment
(Thomas et al., 2011) once patients have become familiar with the side effects of treatment
and also may have received positive prognostic information. Depressive symptoms on the
other hand appear to be more stable and indicative of a trait-type disposition (Ando et al.,
2009, Den Oudsten et al., 2010 and Kangas et al., 2007).
Study strengths are very large sample, and separately reported prevalence rates of reporting
of symptoms versus more severe range. The sample is representative of a multi-ethnic,
urban population served by a publicly funded, equal-access health care system. Finally, the
data represent consecutive recruitment of patients conducted at the same time point in the
disease trajectory whereas other large-scale studies that include different cancer types only
report on convenience samples measured at varying points in the course of cancer.
Furthermore, this dataset has also allowed us to study the effect of disease stage on distress
levels, and these data are already published elsewhere (Vodermaier et al., 2011).
One of the study's strengths is at the same time also a limitation. The current data describe
levels of emotional distress at the time of diagnosis and cannot speak to changes in
emotional distress over the disease trajectory. Therefore, findings do not reflect treatmentinduced emotional disturbance or emotional adjustment during survivorship or palliation.
Lastly, the findings need to be seen in light of their representativeness for the entire cancer
population.
It is a strength that recruiting was based on routinely collected clinical data and consecutive
recruiting and as such has no known major selection bias (except English language
proficiency). Nevertheless, it is worth comparing this sample to its underlying population,
and for this effort we were able to draw on recent data for British Columbia
(www.bccancer.bc.ca) and for all of Canada (www.cancer.ca/Canada-wide/Cancer
research/Cancer statistics.aspx?sc_lang=en). The rank ordering of most to least prevalent
cancer types for our sample reflects those for the province and the whole country, however,
our data set has a notably lower prevalence of lung cancer cases than does the province and
the country (6% versus 13% and 14%, respectively) and also has a somewhat higher
prevalence of prostate cancer cases (36% versus 25% and 27%). We attribute these
deviations to regional differences in how care is provided and where records are kept. For a
number of years now, the charts of deceased patients are moved to a warehouse and are
kept by a private company contracted by the regional health authority. These charts are not
directly accessible to researchers and, given the high mortality associated with lung cancer,

our data likely under-represent lung cancer patients because the charts of those who have
died were likely removed from the hospital-based archives. Hence, the prevalence rates in
our sample differ for a few cancer types from provincial data, and this also accounts for the
fact that our sample has slightly more women than men (55% versus 45%) whereas the
entire population of cancer patients has a 48% to 52% ratio for women/men.
Although PSSCAN has satisfactory psychometrics, its anxiety and depression subscales are
each only 5 items long and the tool has not been validated using gold standard structured
interviews. We cannot rule out potential confounding of anxiety or depression with medical
problems and/or pharmacological treatment side effects (Holland and Alici, 2010).
Similarly, patient anxiety and depression need to be understood in the context of the
patient's knowledge about the disease, treatment, and probable outcomes as well as the
quality of the patients' social network. We also need to sensitize readers to the fact that the
data reflect the population of one limited geographical area in which all patients receive a
similar quality of universal, third-party paid health care. Cancer may be perceived as an
even greater threat when patients worry about medical bills that may exceed their resources,
or have reason to fear loss of a job if their country of residence does not provide illness
leaves and disability pensions.
The present study offers a clear picture of absolute prevalence rates of emotional distress
and it identifies distinct at-risk groups. Armed with these data, policy-makers can now use a
data-driven approach to allocate staffing resources to psychosocial care. Fortunately, many
cancer clinics already offer psycho-oncological services to which vulnerable patients can be
referred, but just because a referral was made does not mean that all patients will accept
this service offer. Also, patients who are not considered emotionally distressed as defined
by cutoffs on the PSSCAN (or any other sensitive screening tool) may still ask for
psychosocial support and this raises the thorny ethical question of whether or not, given
generally scarce resources, these lower-risk groups should be offered professional help on
demand.
For cost-effective implementation of screening and treatment, some questions remain
unresolved. What kind and how much treatment do subclinical levels of anxiety and
depression require compared to clinical anxiety and depressive disorder? Do we need
repeated screenings to assure that persistent anxiety and depression problems are treated?
Should anxiety treatments differ as a function of what patients are specifically afraid of?
They may have, for example, a longstanding, generalized anxiety disorder, or classically
conditioned phobic anxiety responses to aversive cancer treatment, or may have high levels
of fear of recurrence.

Role of funding source

Supported by CIHR Team for Supportive Cancer Care (#AQC83559).

Conflict of interest
There are no conflicts of interest or financial interests associated with this work.

Acknowledgments
We greatly appreciate the technical assistance of Colleen Wong, Leanne Fichtner, Tina
May, and Sylvie Roy.

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Previous presentations: presented in part at the World Congress for PsychoOncology, Quebec City, Canada, May 2629, 2010.
Corresponding authors: University of British Columbia, Department of Psychology,
2136 West Mall, Vancouver BC, Canada, V6T 1Z4. Tel.: + 1 604 822 4156; fax: + 1
604 822 6923.
1
Both Dr. Linden and Dr. Vodermaier share first authorship.