SMaRT Oncology-3 Trial Reports Collaborative Care Program Reduces Major Depression in Patients With Lung Cancer
In the SMaRT Oncology-3 study reported in The Lancet Oncology, Walker et al found that an integrated collaborative treatment program for depression (‘depression care for people with cancer’) was associated with significantly reduced severity of depression compared with usual care in lung cancer patients with major depression, as well as significant improvements in anxiety, perceived quality of care, and quality of life.
Study Details
In the trial, 142 lung cancer patients with major depression and predicted survival of ≥ 3 months from three cancer centers and associated clinics in Scotland were randomly assigned between January 2009 and September 2011 to the depression care for people with cancer intervention (n = 68) or usual care (n = 74), with stratification by trial center and minimization by age, sex, and lung cancer type. The primary outcome measure was depression severity on the Symptom Checklist Depression Scale (SCL-20; range, 0–4) averaged over the patient’s time in the trial up to a maximum of 32 weeks.
Program Description
Depression care for people with cancer is a manualized, multicomponent collaborative care treatment that is delivered systematically by a team of cancer nurses and psychiatrists in collaboration with patients’ oncology teams and primary care physicians. The nurses established a therapeutic relationship with the patient, provided information about depression and treatment, delivered brief psychological interventions (problem-solving therapy and behavioral activation), and monitored patient progress using the Patient Health Questionnaire (PHQ)-9 depression severity scale. Psychiatrists supervised treatment with the aim of achieving a treatment target of PHQ-9 score < 10 and ≥50% below baseline score, advised primary care physicians on prescribing antidepressants, and provided direct consultations with patients not exhibiting improvement. The initial treatment phase consisted of a maximum of 10 sessions with the nurse over 4 months, after which PHQ-9 scores were monitored monthly by telephone for 8 months, with additional nurse sessions being provided for patients not meeting treatment targets. Usual care was provided by patients’ oncologists and primary care physicians.
The intervention and usual care groups were generally balanced for age (mean 64 years in both, > 60 years in 60% and 66%), sex (65% women in both), marital status (spouse/partner for 53% and 65%), employment status (41% and 38% not working), duration of current depressive episode (1–6 months in 62% and 54%, ≥ 12 months in 19% and 22%), number of previous depressive episodes (0 in 49% and 42%, > 1 in 19% and 28%), antidepressant use at trial entry (31% and 35% at any dose, 24% and 24% at ≥ minimum effective dose), time since most recent cancer diagnosis (mean 7.4 and 6.5 months), primary cancer (small cell in 22% and 19%, non–small cell in 63% and 66%), cancer treatment (palliative in 51% and 57%), and perceived quality of depression care (poor for 26% and 35%, fair for 43% and 34%, good for 19% and 23%, very good for 6% and 5%, and excellent for 6% and 3%). Baseline scores for the SCL-20, SCL-10 anxiety scale, and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ-C30) subscales were similar in the two groups.
Reduced Severity
Overall, 43 patients (30%) had died by 32 weeks, all from cancer-related causes. Outcome data were available for 131 patients, including 59 in the intervention group and 72 in the usual care group. Among these patients, average depression severity was significantly lower in the intervention group (mean SCL-20 score = 1.24 [standard deviation = 0.64] vs 1.61 [SD = 0.58]), difference = −0.38; 95% confidence interval [CI] = −0.58 to −0.18, P = .0003); the difference was equivalent to a standardized mean difference of −0.62 (95% CI = −0.94 to −0.29), exceeding the difference of 0.5 indicative of a moderate size effect and clinical significance.
Additional Benefits
The intervention group also had significantly better SCL-10 anxiety score (P = .046), perceived quality of care (2.75 vs 1.97 on 5-point scale ranging from 0 = poor to 4 = excellent, P < .0001), and self-rated improvement of depression (2.97 vs 2.17 on 5-point scale ranging from 0 = much worse to 4 = much better, P < .0001). The intervention group had significant improvements on the role functioning (P = .0019) and quality-of-life (P = .018) EORTC-QLQ-C30 subscales but not on the pain, fatigue, physical functioning, social functioning, or overall health subscales.
In an exploratory analysis, 51% of intervention group patients vs 15% of usual care patients had response defined as a ≥ 50% reduction in SCL-20 score from baseline at 12 weeks, a degree of improvement considered comparable to no longer meeting diagnostic criteria for major depression. In interviews, 41 of 45 intervention group patients said that the treatment had been helpful, and 46 of 48 said that they would recommend it to a friend in a similar situation.
No intervention-related serious adverse events were observed.
The investigators concluded: “Our findings suggest that major depression can be treated effectively in patients with a poor prognosis cancer; integrated depression care for people with lung cancer was substantially more efficacious than was usual care. Larger trials are now needed to estimate the effectiveness and cost-effectiveness of this care programme in this patient population, and further adaptation of the treatment will be necessary to address the unmet needs of patients with major depression and even shorter life expectancy.”
Jane Walker, PhD, of University of Oxford Department of Psychiatry, is the corresponding author for The Lancet Oncology article.
The study was funded by Cancer Research UK and the Chief Scientist Office of the Scottish Government. The study authors reported no potential conflicts of interest.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
