Published online Feb 14, 2018. doi: 10.3748/wjg.v24.i6.671
Peer-review started: October 27, 2017
First decision: November 21, 2017
Revised: December 11, 2017
Accepted: December 20, 2017
Article in press: December 20, 2017
Published online: February 14, 2018
Psychological issues in patients with gastroenteropancreatic neuroendocrine tumours (GEPNETs), with or without carcinoid syndrome (CS), are rarely studied. There is a physician perception of higher levels of psychological distress amongst patients with CS. There is some data to support this in the form of case reports, but not large comparative studies and it is unclear whether this takes the form of anxiety, depression or even impulsivity. The aim of this study was therefore to compare health-related quality of life, anxiety, depression, and impulsivity in patients with advanced GEPNET, with and without CS, and to correlate with biochemical markers of disease activity.
An improved understanding of the psychological issues for these patients will help better inform management of their symptoms.
To assess whether patients with advanced GEPNET and CS have increased levels of anxiety, depression, impulsivity or worse quality of life than patients with advanced GEPNET, but non-functioning tumours.
Patients with advanced GEPNET with and without CS were invited to fill out questionnaires at outpatient clinics at The Christie NHS Foundation Trust, which is a European centre of excellence for neuroendocrine tumours. Patients completed the hospital anxiety and depression scale (HADS), the EORTC QLQ-C30 and GINET-21 quality of life scales and the Barrett Impulsivity scale (BIS) at a single time point. Demographic information with regards to gender, time from diagnosis and treatment history was collected from casenotes, as were serum markers of disease [5-hydroxyindoleacetic acid (5-HIAA)].
Fifty patients were included; 25 each with and without CS (CS). Median serum 5-HIAA in patients with and without CS was 367nmol/L and 86nmol/L, respectively (P = 0.003). Scores related to endocrine symptoms were significantly higher amongst patients with CS (P = 0.04) and scores for disease-related worries approached significance in the group without CS, but no other statistically-significant differences were reported between patients with and without CS in responses on QLQ-C30 or QLQ-GI.NET21. Fifteen patients (26%) scored ≥ 8/21 on anxiety scale, and 6 (12%) scored ≥ 8/21 on depression scale. There was no difference in median 5-HIAA between those scoring < or ≥ 8/21 on anxiety scale (P = 0.53). There were no statistically significant differences between groups in first or second-order factors (BIS) or total sum (P = 0.23).
There were no significant differences between groups with regards to anxiety, depression or impulsivity. Serum 5-HIAA and endocrine symptoms were more prevalent in the group with CS as would be expected. Disease-related worries were higher in the group without CS. Results may have been impacted by a long time from diagnosis in the CS group or limited sensitivity of screening tools to detect subtle differences in mental state. Results may also have been impacted by small sample size however in this rare disease group the sample size is robust in a comparative study. Levels of anxiety and depression were high in both groups and may be higher in patients with GEPNET than with other solid tumours. This is one of few comparative prospective studies in this patient group and established methods of assessment were used and correlated with serum biochemistry. More sensitive tools need to be developed to assess psychological symptoms in these patients.
This prospective comparative study included single time point assessment of symptoms. Studies with questionnaires distributed at varying times would be helpful to assess the impact of changes throughout the patient journey.
Futures prospective studies are needed, ideally involving multiple centres with considered methodology such as psychiatric interviews including the use and development of more selective psychological assessment tools.