Rapid Diagnostic and Treatment Pathways

Rapid Diagnostic and Treatment Pathways

PEP Topic 
Anxiety
Description 

Rapid diagnostic and treatment pathways involve shortening the time for diagnosis and/or initiation of treatment of cancer. Receiving a diagnosis of cancer or awaiting results can be a major cause of distress and anxiety. Rapid pathways can shorten the period of uncertainty and have been examined for effects on anxiety.

Effectiveness Not Established

Systematic Review/Meta-Analysis

Brocken, P., Prins, J.B., Dekhuijzen, P.N., & van der Heijden, H.F. (2012). The faster the better? A systematic review on distress in the diagnostic phase of suspected cancer, and the influence of rapid diagnostic pathways. Psycho-Oncology, 21(1), 1-10.

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Purpose:

STUDY PURPOSE: To synthesize the evidence regarding the effect of rapid diagnostic approaches on anxiety in patients with cancer

TYPE OF STUDY: Systematic review

Search Strategy:

DATABASES USED: PubMed, PsycINFO, and Cochrane Collaboration
 
KEYWORDS: Neoplasm, anxiety, distress, stress, quality of life (QOL), and psychological
 
INCLUSION CRITERIA: Patients scheduled to undergo at least one invasive diagnostic procedure; suspicion of cancer; pre- and post-use of at least one validated measure for anxiety, QOL, or depression; follow-up within six weeks
 
EXCLUSION CRITERIA: Small pilot studies, abstracts, studies involving cancer screening, studies involving surgery, and editorials and letters

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: 1,846
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: No quality rating identified

Sample Characteristics:

  • FINAL NUMBER STUDIES INCLUDED: 23
  • TOTAL PATIENTS INCLUDED IN REVIEW: 3,663
  • SAMPLE RANGE ACROSS STUDIES: 27-583 patients
  • KEY SAMPLE CHARACTERISTICS: Most (16) studies involved patients with breast cancer.

Phase of Care and Clinical Applications:

PHASE OF CARE: Diagnostic

Results:

Patients receiving a benign diagnosis showed significant decreases in anxiety. Women eventually diagnosed with breast cancer had either increased or sustained anxiety levels; however, increases were not statistically significant in all but one study. Findings were mixed in this regard across studies involving prostate and ovarian cancer and melanoma. Among suspected breast cancer cases, 46%-73% had anxiety scores (Hospital Anxiety and Depression Scale [HADS] instrument) that were ≥ 8, indicating at least borderline clinically relevant anxiety. In studies using the State-Trait Anxiety Inventory (STAI) tool, suspected patients with breast cancer had mean STAI scores between 40.1 and 60, with a score of 44 being considered high anxiety. Three studies examined the effect of rapid diagnostic evaluation in breast cancer. One study found significantly larger reduction in anxiety after 24 hours in a one-stop evaluation versus two-stop evaluation; however, this difference disappeared after three weeks. In all studies, anxiety declined significantly among those who had benign result when results were obtained more quickly. In all studies, there were small numbers of patients who were diagnosed with benign disease.

Conclusions:

Rapid diagnostic pathways reduce anxiety in patients with benign disease.

Limitations:

No evaluation of the quality of studies was included.

Nursing Implications:

Findings that anxiety declines in patients with benign disease are not surprising. Findings confirm that the more quickly one receives a benign diagnosis, the more quickly related anxiety is reduced. The emotional impact during the diagnostic phase related to cancer can be substantial. Use of one-stop rapid diagnosis can result in a shorter period of uncertainty and related anxiety.

Research Evidence Summaries

Sharp, L., Cotton, S., Gray, N., Avis, M., Russell, I., Walker, L., . . . TOMBOLA Group. (2011). Long-term psychosocial impact of alternative management policies in women with low-grade abnormal cervical cytology referred for colposcopy: A randomised controlled trial. British Journal of Cancer, 104, 255-264. 

doi: 10.1038/sj.bjc.6606042
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Study Purpose:

To compare the psychosocial outcomes of two different approaches for management of women undergoing colposcopy: immediate large loop excision versus punch biopsies with recall

Intervention Characteristics/Basic Study Process:

In a larger study, women had been randomly assigned to cytological surveillance or colposcopy for low-grade abnormal cervical cytology. Women having colposcopy then were randomly assigned to either immediate large loop excision or to a group having punch biopsies and selective recall. Assessments were done at baseline, at six weeks post-procedure, and at 12,18, 24, and 30 months.

Sample Characteristics:

  • N (sample size) = 966 completed six-week assessments, and 594 completed 30-month assessments.
  • AGE: Mean and range were not provided. All patients were younger than 60 years; 71.6% were younger than 40 years.
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: 37.6% were high risk based on initial cytology.
  • OTHER KEY SAMPLE CHARACTERISTICS: 76.6% were employed full- or part-time.

Setting:

  • SITE: Mutli-site   
  • SETTING TYPE: Outpatient
  • LOCATION: United Kingdom

Phase of Care and Clinical Applications:

PHASE OF CARE: Diagnostic

 

Study Design:

Randomized controlled trial

Measurement Instruments/Methods:

  • Hospital Anxiety and Depression Scale (HADS)
  • Profile of Mood States (POMS) 
  • Spielberger State Trait Anxiety Inventory

Results:

There were no differences between groups in prevalence of significant depression at any study time-point. In all patients, the median POMS score fell significantly from recruitment to 12 months (p < .001) and remained stable thereafter. There were no significant differences in average scores at any time-point. In all patients, anxiety fell significantly from baseline to six weeks post-procedure (p < .001) and remained stable thereafter. There were no significant differences between groups at any time point in the study.

Conclusions:

There were no differences in symptoms of anxiety and depression based on the type of management examined here for women undergoing colposcopy. In all patients, anxiety and depression declined significantly shortly after the procedure and then remained stable over the next 24 months. However, the prevalence of significant depression (HADS depression subscale ≥ 8 ) increased from 6% precolcoscopy to 9.6% at 30 months.

Limitations:

  • No subgroup analysis was performed based upon whether or not patient had clinically relevant anxiety or depression at baseline.
  • No information is provided regarding use of medications or any other interventions aimed at these symptoms.
  • The study fails to take into consideration the many variables that can impact changes in anxiety and depression symptoms over time.

Nursing Implications:

Findings suggest that the specific approach to management with colposcopy does not significantly impact anxiety and depression in women with low-risk abnormal cervical cytology. The timing of depression increase seen here might suggest that extended follow-up after colposcopy and treatment may be associated with depression for some women. Which of the strategies examined here offers the best balance between benefits and harms is a matter of continuing debate.


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