AIM: A study was performed to investigate the impact of comorbid anxiety and depression (CAD) on quality of life (QOL) and cellular immunity changes in patients with digestive tract cancers.

METHODS: One hundred and fifty-six cases of both sexes with cancers of the digestive tract admitted between March 2001 and February 2004 in the Department of Medical Oncology, First Affiliated Hospital of Xi’an Jiaotong University were randomly enrolled in the study. Depressive and anxiety disorder diagnoses were assessed by using the Structured Clinical Interview for DSM-IV. All adult patients were evaluated with the Hamilton depressive scale (HAMD, the 24-item version), the Hamilton anxiety scale (HAMA, a modified 14-item version), quality of life questionnaire-core 30 (QLQ-C30), social support rating scale (SSRS), simple coping style questionnaire (SCSQ), and other questionnaires, respectively. In terms of HAMD ≥ 20 and HAMA ≥ 14, the patients were categorized, including CAD (n = 31) in group A, anxiety disorder (n = 23) in group B, depressive disorder (n = 37) in group C, and non-disorder (n = 65) in group D. Immunological parameters such as T-lymphocyte subsets and natural killer (NK) cell activities in peripheral blood were determined and compared among the four groups.

RESULTS: The incidence of CAD was 21.15% in patients with digestive tract cancers. The average scores of social support was 43.67±7.05 for 156 cases, active coping 20.34±7.33, and passive coping 9.55±5.51. Compared with group D, subjective support was enhanced slightly in group A, but social support, objective support, and utilization of support reduced, especially utilization of support with significance (6.16 vs 7.80, P<0.05); total scores of active coping decreased, while passive coping reversed; granulocytes proliferated, monocytes declined, and lymphocytes declined significantly (32.87 vs 34.00, P<0.05); moreover, the percentage of CD3, CD4, CD8 and CD56 in T lymphocyte subsets was in lower level, respectively, and CD56 showed a significant decline in group A (26.02 vs 32.20, P<0.05), however, CD4/CD8 ratio increased. Physical function, role function, fatigue, sleeplessness and constipation had significant changes among different groups by one-way ANOVA, and group A was in poor QOL. It revealed that global health-related quality of life (QL) were positively correlated with active coping and CD56; CAD was negatively correlated with QL, active coping and CD56. Furthermore, the step-wise regression analysis suggested that utilization of support, CD56, active coping, fatigue, sleeplessness and depression were significant factors contributing to QOL.

CONCLUSION: CAD, which can impair QOL and cellular immunity, occurs with a higher incidence in patients with digestive tract cancers. Hence, it is essential to improve mental health for them with specifically tailored interventions.

Comorbid anxiety and depression (CAD) occurs at a high rate in primary care, and is costly to both the individual and society. CAD is significantly associated with special conditions, such as severe symptom, chronic course, social functional lesion, suicidal ideation, bad prognosis, and so on. When severe enough, it may cause negative effects on the antitumor therapy, immunological function, as well as the quality of life[1-4]. Distress, social support, and coping style are the most important psychosocial factors in this approach. As a psychotic or neurotic condition, doctors and mental-health professionals have increasingly recognized the effects of CAD, however, to date, few studies have systematically examined the clinical correlates of CAD or its effect on patients with digestive tract cancers. Cancers of the digestive tract pose complicated public health problems worldwide[5-7]. These cancers are associated with high morbidity and mortality[8-11], in which esophageal, gastric, colorectal and liver cancers are among the top 10 malignant tumors in China and account for 63% of total cancer mortality[12-14]. In this study, we therefore tested the data on the changes of QOL aspects and immunological parameters in patients with digestive tract cancer suffering from CAD. The Hamilton rating scales and other questionnaires, as well as the immunological parameters were investigated in an attempt to provide guidelines for the means of psychological therapy in the clinical practice and for the evaluation, diagnosis, and management of CAD in the primary care setting.

Increasing evidence suggests that psychosocial factors such as stress and depression may have a harmful impact on the course of many diseases, such as cardiovascular disease[25,26], functional disorder and cancer[27-30], and may heighten susceptibility to infectious diseases[31,32]. As psychosocial stress has been suspected as a risk factor for cancer, an association between mental disorders and cancer has been reported in many clinical studies within patients. In this research, we have used data gathered in a 3-year consecutive study to examine the comorbidity in adult patients. The findings both confirm and extend the previous results.

Cancer of the gastrointestinal tract is a major health problem in China, especially for the elderly. Results indicated that Chinese patients newly diagnosed with gastrointestinal tract cancer experienced a range of symptoms associated with cancer and its treatment that resulted in varying degrees of symptom distress, anxiety and depression[33,34]. More than 20% of the cancer patients have elevated scores on the Hospital Anxiety and Depression Scale (HADS) subscales depression and anxiety in Harter’s report[35]. In the present cohort, there were clear and consistent trends that the average age was 58±9 years and the rates of CAD are 21.15% in patients with digestive tract cancers.

High level of social support appears to play a protective role in psychological adjustment of cancer patients[36]. Social networks, including marital/partner status; number of children, relatives, and friends; and the frequency of religious and community participation, may have an important relation with HRQOL-particularly, mental health-among female long-term colorectal cancer survivors[37]. Indeed, social support in the form of marriage, frequent daily contact with others, and the presence of a confidante may all have protective values against cancer progression. The current study showed that utilization of support went down significantly in group A, but the total scores of social support were close in four groups. It is considered that the family pay attention to patients in need and highlight their problems.

Coping with cancer is multidimensional scaling. There is a significant association between patients who scored highly on the HADS and dissatisfaction with the information provided. Young patients, women, patients with advanced tumors and those who had been treated with both surgery and radiotherapy reported worse function. The worse the functional domain, the more likely it was to be associated with anxiety, depression and ineffective coping style[38]. Use of a logistic regression model showed that those patients most likely to be suffering from severe psychological distress had a worse coping style, measured by the Mental Adjustment to Cancer Scale (MACS)[39]. In this study, patients’ passive coping of their disease remained relatively stable, whereas their use of active coping strategies decreased remarkably.

Psychosocial factors influence disease-resistance capabilities via the neuroimmune connection. Some immunological parameters such as T lymphocyte subsets and NK cells are thought to play a central role in antitumour immunity[40-42]. For instance, the growth of malignancies was observed to be inhibited by the activated tumor-specific T cells and the depressed activity of NK cells was probably related to the tumor enlargement and dissemination[43,44]. Suppressive effects of CAD on immune function were well documented in our study, providing further evidence for the specificity of immune changes in psychiatric disorders. Granulocytes proliferated, monocytes declined, and lymphocytes declined significantly; moreover, the percentage of CD3, CD4, CD8 and CD56 in T lymphocyte subsets was in lower level. Thus, it is reasonable to hypothesize that CAD may contribute to impairing immunity, and thereby delay the recovery of immune mechanisms that may be important for cancer resistance.

In the last decade of clinical research, there has been increasing interest in the evaluation of quality of life. Accurate assessment of the QOL of patients can provide important clinical information to physicians, especially in the area of oncology[45-47]. Changes in QOL are important indicators of the impact of a new cytotoxic therapy, which can affect a patient’s willingness to continue treatment, and may aid in defining response in the absence of quantifiable endpoints such as tumor regression[48-51]. The results obtained from the validated QLQ-C30 were used to evaluate the physical role, emotional, cognitive and social functioning, global health status as well as energy and sleep[52]. Then, it revealed that QL were positively correlated with active coping and CD56; CAD was negatively correlated with QL, active coping and CD56. Furthermore, use of a step-wise regression model suggested that utilization of support, CD56, active coping, fatigue, sleeplessness and depression were significant factors contributing to QOL. Our findings were consistent with the reports that patients who showed high levels of anxiety or depression had more health problems[53-56].

Quality of life, symptom management, and social support are the traditional foci for the practise of psychosocial oncology. The current paradigm for research in this area primarily assesses patient responses to cancer-related CAD and illuminates the necessity of ameliorating the negative aspects of those responses. Findings from this research provides insight into the importance of ongoing QOL assessment, symptom management, and intervention to improve QOL of Chinese cancer patients. In brief, CAD, which can impair QOL and cellular immunity, occurs with a higher incidence in patients with digestive tract cancers. Hence, it is essential to improve mental health for them with specifically tailored interventions.