ASCO 2023: Hospital Anxiety and Depression Scale Score Trends Among Testicular Cancer Survivors: A Longitudinal Study

( The 2023 ASCO annual meeting included a testicular cancer session, featuring a presentation by Dr. Khalid Alkhatib discussing a longitudinal study of Hospital Anxiety and Depression Scale (HADS) score trends among testicular cancer survivors. The rarity of testicular germ cell tumors, in conjunction with the young age of its patients, makes it challenging to study its long-term adverse effects. It is believed that the psychosocial state of testicular cancer patients is adversely impacted during treatment and survivorship. As such, Dr. Alkhatib and colleagues sought to investigate the changes in HADS scores over time in our institutional cohort of testicular cancer survivors, hypothesizing that anxiety and depression indices will improve over time, and specifically after treatment completion.

This study was a longitudinal analysis of testicular cancer survivors at the University of Pennsylvania between 2013 and 2020, with quality of life metrics measured annually during routine clinic visits. A validated HADS score was utilized to calculate indices of anxiety and depression. Multivariable linear mixed-effects regression models adjusted for pathology type, stage, treatment type, age, marital status, education, income, insurance, employment status, living situation, and time from diagnosis to first survey administration were used to calculate the mean predicted HADS, HADS-Anxiety, and HADS-Depression scores. ANOVA was used to test for parallelism and changes between survey scores. Each item was rated on a 4-point scale (ranging from 0 = no not at all, to 3 = yes definitely), for a total score ranging from 0-21 for each sub-scale with a cut-off point of 8/21 for anxiety or depression.

 There were a total of 353 patients included in the study. Baseline characteristics and demographics are included the following table:

HADS scores.jpg

The mean age was 40.5 years, pathology was nearly evenly split between seminoma and non-seminoma, and 2/3 of patients were stage I with 40% of men undergoing orchiectomy alone. The majority of patients were married, had at least college education, had an income of $100,000 or greater, had private insurance, and lived with others. Baseline mean scores were 7.3, 4.9, and 2.4 for HADS overall, HADS-Anxiety, and HADS-Depression, respectively. Unadjusted mean HADS indices appeared to decrease over time though adjusted predicted mean scores had no statistically significant change over time: ANOVA testing of p=0.84 for overall HADS, p=0.78 for HADS-Anxiety, and p=0.65 for HADS-Depression 

HADS scores ASCO.jpg

Clustering by pathology, stage, and treatment showed no statistically significant interaction with results indicating little influence of these variables. 

Dr. Alkhatib concluded his presentation by discussing a longitudinal study of HADS score trends among testicular cancer survivors with the following take-home points:

  • Contrary to the hypothesis, after adjusting for disease and patient characteristics, the data did not show a change in anxiety or depression indices over time in testis cancer patients
  • Considering the risks associated with depression and anxiety, such as suicide, it is essential to consider early referrals to psychiatric services
  • Limitations include these results isolated to a single institution, limited by a small sample size, and data lacks granularity, including mental health history
  • Nonetheless, these findings serve as a framework for future prospective studies of testicular cancer survivors

Presented by: Khalid Y. Alkhatib, MD, MMSc, University of Pennsylvania, Philadelphia, PA

Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Associate Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, @zklaassen_md on Twitter during the 2023 American Society of Clinical Oncology (ASCO) Annual Meeting, Chicago, IL, Fri, June 2 – Tues, June 6, 2023.