Gustetic, Elaine

Abstract Purpose The devastation and impact of a new cancer diagnosis can be compounded by psychosocial challenges that can significantly affect patient outcomes. Historically at Mayo Clinic Florida, social work contact with newly diagnosed hematology oncology patients occurred at various and inconsistent times during treatment. Baseline data revealed that 2.16% of these patients received social work contact ranging from 2 to 43 days after diagnosis. Referrals were typically initiated following elevated distress screening or provider-identified needs. This quality improvement initiative explored the impact of embedding early clinical social work services to increase timely social work support for patients and awareness of the role of social work and resources. Methods All patients newly diagnosed with hematological malignancy were scheduled for first contact with social work within two weeks of meeting with their medical provider. During the first social work appointment, psychosocial screening was performed and social work role and resource education was provided. A follow-up consultation was scheduled if needs were identified. Results 96 out of 122 (78.6%) newly diagnosed patients had social work contact for an initial screen during this quality improvement project. There was a 76.44% increase from baseline in the number of patients receiving social work support as a result of this initiative. 52.08% of the newly diagnosed patients proceeded from this initial screening to a scheduled social worker consult. Conclusion Early and proactive social work outreach through a Responsive Practical Proactive (RPP) approach improved access to psychosocial care and helped address gaps between distress screening and timely intervention.

Abstract Background: Cancer diagnosis and treatment are important risk factors for developing clinical depression. Validated tools for screening distress and depression, such as Cancer Distress Thermometer (DT) and PHQ9 (Patient Health Questionnaire), are underutilized, despite endorsement by NCCN and Institute of Medicine. We investigated patient and treatment characteristics as well as patient endorsement of depression or anhedonia to predict those at risk of having depression. Methods: The PHQ9 and/or DT were administered prospectively to patients with hematologic malignancies (HM) before they started antineoplastic therapy at Mayo Clinic in Florida. Patient endorsement of depression or anhedonia was collected from the current visit information survey. Patient demographics, disease and treatment characteristics, chronic medication burden, Charlson comorbidity index, living situation, clinic/hospital visit burden in the month prior to screening and number of psychiatric medications for every patient were recorded. Intergroup comparison of categorical and continuous variables was done by Chi-square and Wilcoxon rank-sum tests, respectively. Linear or logistic regression models were used to compare PHQ9 score with DT (continuous) or endorsing depression or anhedonia (categorical) respectively. Multivariate models were constructed using the stepwise selection technique using all potential variables in the models. All analyses were completed using SAS v9.3. Results: Final analysis included 246 patients with a median age at diagnosis 64.5 (range: 18-94) years, diagnosed between 6/30/93-10/9/14 and screened between 1/13/11-2/13/15. PHQ9 score of ≥9 and DT score ≥5 suggested a high risk of depression and distress, respectively, as per published literature. Patient characteristics at time of survey and analysis are noted in table 1. PHQ9, DT and answers to two questions about depression and anhedonia were available on 129, 129 and 246 patients, respectively. 63% of patients were chemotherapy naïve. In multivariate analysis, PHQ9 score ≥9 was associated with living alone (p=0.003) (Fig.1a) and non-White race (p=0.043) (Fig.1b), while a DT score ≥5 was associated with being currently married (p=0.048) and female gender (p=0.02). The only characteristic significant on univariate but not on multivariate analysis being chemotherapy naive, associated with a DT score ≥5 (p=0.049). Answering "no" to both the questions regarding depression or anhedonia was significantly associated with a low score on PHQ9 (p=0.007). Age at diagnosis, Charlson comorbidity score, chronic medication or visit burden, daily psychiatric medication use or type of malignancy were not associated with scores on any screen. Conclusions: Causes of depression in patients with HM have not been fully explored. We validated previously known risk factors for depression, such as living alone. We also reported for the first time that non-White race independently predicts depression in these patients. Female patients and those currently married are at a higher risk of psychological distress, possibly due to fear of abandoning family. We also found that simply asking a patient two questions about feelings of depression or anhedonia significantly correlates with the well-established PHQ9. Our analysis provides simple tools and reveals at-risk patient subgroups with HM where depression and distress screening should be aggressively instituted for better resource utilization and survivorship. Table 1. Patient Characteristic N % Gender Male Female 146 100 59.4 40.6 Race White Non-White 216 30 87.8 12.2 Marital Status Married Not married* 180 66 73.2 26.8 Living Situation Alone With others 37 209 15 85 Type of Malignancy Aggressive lymphoid Indolent lymphoid Aggressive myeloid Indolent myeloid 124 94 25 3 50.4 38.2 10.2 1.2 Prior Cancer Treatment Yes No 91 155 37 63 Daily Psych Meds Yes No 52 194 21.1 78.9 Patient Status Alive Dead 191 55 77.6 22.4 *Not currently married=single, divorced, widowed or unknown Disclosures No relevant conflicts of interest to declare.

232 Background: Screening for distress in cancer patients (pts) is recommended by several national guidelines. High distress scores are associated with increased depression. We established universal depression screening and investigated its impact on cancer patient management. Methods: Patient Health Questionnaire (PHQ9) was administered to newly diagnosed cancer patients prior to receiving their first non-oral antineoplastic agent. Patient demographics, disease characteristics, chronic medication load, antidepressant use, treatment interruptions, weight change, referral and adherence to psychiatry were recorded. Pts with high (> 9) and low (< 4) PHQ9 scores were compared using Chi-square and Wilcoxon rank-sum tests. Results: Screening was performed in 1,190 consecutive pts over an 18 month period at Mayo Clinic. Responses were received from 1055 (89%) pts, of which 144 had high score (PHQ-H). These were compared with 99 randomly selected low score (PHQ-L) pts. The 243 pts (median age 65; range 18-92 years) in the final analysis included: 53.5% females, 90% Caucasians, 74% married and 77% living with others. Diagnosis was solid organ cancer in 81% and metastatic disease in 54% patients, and 13% were on antidepressants for preexisting depression. PHQ-H were more likely to be on antidepressants than PHQ-L (19% vs. 3%; p = 0.0002), be referred to psychiatry (69% vs. 12%; p < 0.0001), attend psychiatry appointment (45% vs. 12%; p < 0.0001) and require behavioral therapy (50% vs 8%; p = 0.0065). PHQ-H did not have a significantly increased antidepressant use, treatment interruptions (p = 0.5) or weight change (p = 0.4). Race, gender, chronic medication load, marital status, living situation, metastatic disease and type of cancer were not significantly different between PHQ-H and PHQ-L. Conclusions: We implemented a universal depression screening and management plan for cancer pts and noted that previously being on antidepressants was associated with higher patient distress. Higher score led to more frequent behavioral therapy, possibly preventing non-compliance or need for increased psychotropic medications. Our model identifies cancer pts with depression and implements an effective management plan for their care.