Preexisting Mental Health Disorders Worsen DLBCL Prognosis

Patients with depression, anxiety, or both in the 2 years before a diffuse large B-cell lymphoma (DLBCL) diagnosis have a worse prognosis, highlighting the need for a universal and systematic mental health screening for these patients, according to a study published in Lancet Haematology.

The median age of patients when they are diagnosed with DLBCL is 66 years, and the malignancy is aggressive. Many of the factors that affect survival are cannot be modified, such as age and stage of disease, but comorbidities, such as mental health disorders, are potentially modifiable, the authors explained.

“The psychological burden of haematological malignancies is high, and this can exacerbate pre-existing mental illness to increase psychiatric comorbidity,” they added.

The retrospective cohort study used Surveillance, Epidemiology, and End Results cancer registry linked to Medicare claims. A total of 13,244 patients were eligible for the study. They were diagnosed with DLBCL between January 1, 2001, and December 31, 2013, and the median age at diagnosis was 79 years. The patients were mostly White (94.1%). Slightly less than half (48.1%) of patients had stage III or IV disease.

Overall, 15.8% of patients had pre-existing depression (8.9%, n = 1176), anxiety (4.6%, n = 608), or both (2.3%, n = 310) at the time of their DLBCL diagnosis. Compared with patients who did not have pre-existing anxiety, depression, or both, patients with these mental health disorders were more likely to be female (66.0%), not married (47.9%), and have more comorbidities (40.4% with a Charlson Comorbidity Index score of ≥ 2).

The median follow-up for the total cohort was 2.0 years and for those alive at the end of the study it was 8.5 years. The researchers found:

• 5-year overall survival (OS) for patients with depression, anxiety, or both was 27.0% compared with 37.4% for those without (HR 1.37, 95% CI; 1.29-1.44)
• Patients with pre-existing depression had the worst 5-year OS (23.4%) compared with patients with no mental health disorder (38.0%), anxiety (34.0%), or both depression and anxiety (29.1%).
• Results were similar across sexes
• Income significantly moderated the effect pre-existing mental health disorders had on OS

There were similar findings for the 5-year lymphoma-specific survival:

1. Patients with mental health disorders had a 5-year survival of 42.0% vs 51.3% for patients without
2. Pre-existing depression had the worst lymphoma-specific survival (39.0%) compared with no mental health disorder (51.3%), anxiety (47.3%) or both (42.3%).
3. Income did not significantly moderate the effect pre-existing mental health disorders had on lymphoma-specific survival

The findings were consistent with previous studies of the impact mental health disorders had on patients with solid malignancies. Other literature has found patients have worse OS when they develop mental health disorders after being diagnosed with Hodgkin lymphoma or leukemia.

What still isn’t clear is why pre-existing mental health disorders result in a decreased OS and lymphoma-specific survival. The authors noted that it’s possible patients with anxiety and/or depression may have delayed treatment for their lymphoma. Another possibility is that patients with mental health disorders might have reduced medication adherence due to barriers such as financial constraints and limited social support.

“Identifying and treating pre-existing mental health disorders as a prognostic factor for patients with DLBCL is clinically important, as they are potentially modifiable,” the authors wrote.

Among the limitations to the study that the authors noted was the claims-based approach to measure depression and anxiety, which probably underestimates the rate of mental health disorders, and that the cohort only included patients 67 years and older and was predominantly White.

Based on the findings of the study, the authors suggest conducting a comprehensive psychosocial assessment at the time of DLBCL diagnosis.

“Knowledge of depression, anxiety, or both would lead to more accurate prognostication, and would help oncologists appropriately deploy necessary resources to affected patients,” they concluded. “Moreover, attention to, and improvement of, these conditions have the potential benefit of improving survival.”

Reference

Kuczmarski TM, Tramontano AC, Mozessohn L, et al. Mental health disorders and survival among older patients with diffuse large B-cell lymphoma in the USA: a population-based study. Lancet Haematol. Published online June 1, 2023. doi:10.1016/S2352-3026(23)00094-7