Two-Step Screening for Depression and Anxiety in Patients with Cancer: A Retrospective Validation Study Using Real-World Data

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

I would like to thank you for the opportunity to review this manuscript. This study is interesting for publication, as it addresses the important relationship between screening for depression and anxiety in cancer patients, a relevant area for both mental health and oncology. The results have practical implications for improving the diagnosis and treatment of these disorders in a vulnerable population, and the use of tools such as PHQ-9 and GAD-7 provides evidence applicable to clinical practice. In this regard, I will now comment on some aspects that the authors could consider modifying to improve the understanding of the study:

The INTRODUCTION is well-structured and clearly addresses the relevance of the topic. It presents an appropriate context, discussing the prevalence of depression and anxiety in cancer patients and the importance of psychosocial screening. However, the following recommendations should be taken into account:

- The introduction of the DART tool could be described in more detail before discussing its implementation and characteristics.

- The text generally flows well and follows a logical reasoning. Nevertheless, the transition between the paragraphs discussing screening barriers and the introduction of two-step screening tools could be smoother. A connecting sentence could be added to make the relationship between the need for more efficient tools and the adoption of a two-step screening more explicit.

- Some specific terms, such as "specificity" and "sensitivity," could be briefly clarified to facilitate understanding of the importance of balancing them in screening.

In general, this METHODS section provides a solid foundation but could benefit from greater precision in certain aspects to improve the clarity and reproducibility of the study. These aspects are discussed below:

- The study population, inclusion criteria, and assessment tools are clearly described, which is essential for the reproducibility of the study. While the time frame of the study (October 2009 to February 2011) is well specified, it would be useful to clarify why this period was chosen and whether the data are representative of the entire population at the center during those years. Additionally, it is not mentioned if there were any exclusions or reasons why some patients were not included in the final analysis. This information is crucial to understanding the generalizability of the results.

- The section could benefit from more details on how patient data confidentiality was ensured.

- The explanation of each tool is well structured, but the section becomes dense due to the amount of information on each of the measures. It would be advisable to simplify or summarize the key characteristics of the tools. Additionally, it could be useful to mention if these tools were previously validated in the oncology population, which would strengthen the study's rigor.

- Although the two-step approach is well justified, the section could benefit from a more detailed explanation of how specific thresholds for each tool were defined and how the values of 1 to 6 for the ESAS and 11 to 18 for the PHQ-9 and GAD-7 were chosen.

The RESULTS section provides a solid and well-structured overview of the study's findings. However, some aspects are commented on below that could improve the understanding of the results:

- The description of the study population is clear and concise. Relevant demographic information is provided. It is mentioned that 172 patients were included. It would be useful to indicate whether this sample size is adequate for the analysis being performed and whether any statistical power calculations were conducted to justify it.

- The inclusion of anxiety and depression disorder diagnoses is relevant. However, more context could be provided on how the psychiatric evaluation was conducted and what criteria were used to make these diagnoses.

- PHQ-9 performance in detecting depression: The results for PHQ-9 cutoff points, as well as its positive likelihood ratio and AUC, are reported. It is important to briefly explain the methods used to determine these results and their clinical significance.

- The significant differences in scores between patients diagnosed and not diagnosed with depression are adequately mentioned. However, it would be beneficial to include the means and standard deviations of PHQ-9 scores to provide more complete context.

- The presentation of the C-index is adequate, although a brief explanation of its interpretation in the context of depression detection would help readers less familiar with this type of analysis.

- The improvement in performance when using sequential screening is a relevant finding. However, it should be discussed why a significant improvement was observed only with the PHQ-9 and not with the GAD-7.

- Two-step screening for anxiety using ESAS-A and GAD-7: The conclusion that there was no improvement in anxiety predictability is a critical point. It should be explored whether there are factors that may have influenced the effectiveness of the screening methods used and how they could be improved in future studies.

The DISCUSSION seems very appropriate and enriching. However, it would be interesting to consider the following aspects:

- It would be useful to address possible confounding factors that may have influenced the results. For example, it could be considered how the patients' physical condition, the type of oncology treatment received, or psychosocial support might have affected the anxiety and depression scores.

- It is suggested to include more recommendations for future research. For instance, longitudinal studies that evaluate the effectiveness of interventions based on screening results in this population would be valuable to advance knowledge in the area.

The CONCLUSION effectively summarizes the most important findings of the study. Despite this, it would be useful to include specific recommendations for clinical practice or future research at the end of the conclusion. This would provide clear guidance on how the findings can be applied and what next steps could be taken.

Author Response

Please see the attachment. 

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for this well written, interesting article.  Some minor edits are needed, 1) on table 1 you have only listed Male, typically both should be listed, 2) on page 3, you should describe the scoring of both the PHQ-9 and GAD-7 for the reader, including a description of the sum total scoring strategy for both tools. 

I agree that there are many barriers to the routine use of distress screening in Ambulatory Oncology, with the most common being a lack of time in the clinic, however, this research does little to convince me that a 2 step symptom screening approaches is required. As the authors point out, improving the acceptability and implementation within busy oncology clinics requires that a distress screening tool achieves accurate results, while avoiding long surveys.  The purpose of using a distress screening tool is to identify patients who need further assessment, support and interventions. This may include psychiatric care, but it may also include receiving education, coping and self-management resources, participation in group sessions or counselling.  Not all patients will end up with a psychiatric diagnosis, even though by participating in a distress screening program, they may have received the appropriate targeted support to help them cope better with the emotional impact that cancer and its treatment was having on them.  The use of psychiatry assessment and the presence of psychiatric disorders as the gold standard to predict clinical utility may not have been the most relevant to the busy ambulatory clinic setting, although it could assist within the Psychosocial oncology setting to ensure the patient gets triaged to the right level of care within that specialty setting.  As a result it may be helpful for the authors to include some commentary in the background section that the purpose of the secondary screen is to refine the type of intervention and the intensity of support that the patient would benefit from.  There is no mention of the busy nature of the psychosocial oncology setting, and that 2-step screening is more about increased efficiency in that setting than in the busy clinical ambulatory outpatient setting.  As the volume of cancer patients receiving disease modifying treatments in the ambulatory setting increases, so too does the volume of patients seeking psychosocial care.  Effective triage to the right level of clinical care within Psychosocial would be helpful to help that department be most efficient with their limited resources.  Adding literature in about this into the paper and into the discussion would strengthen this paper.

Comments on the Quality of English Language

excellent English language readability

Author Response

Please see the attachment. 

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

I would like to thank the authors for taking into account all the suggestions made. I think the authors have done a good job and the study is ready for publication. Thank you very much and best regards