The point prevalence of major depression following a cancer diagnosis is approximately 15 % but major depression is only one of several important mood complications. Minor depression is also common and comprises two to four key symptoms along with the same criterion as MDD. Those with minor and sub-syndromal depressions are at risk of major depression but also suffer high co-morbidity and distress in their own right. We recently carried out a study to try and tease out which somatic symptoms (if any) are indicative of depression in the cancer setting [14]. We approached 279 patients up to three times within 9 months of the first presentation of the diagnosis of cancer. In total there were 559 contacts of which 176 (31 %) were treated with palliative intent. Patients completed PHQ-9 and the HADS-D scales and these scales were analysed to assess the diagnostic value of individuals’ somatic and non-somatic symptoms in attempting to diagnosis depression in these cancer patients. Using DSM-IV criteria the prevalence of major depression was 12.7 and 29.6 % had major or minor depression. A single question ‘are you feeling down, depressed or hopeless?’ had a positive predictive value of 61.9 % but did have excellent screening utility and could be used as a first step screening question with follow-up questions addressed to those who answered positively. The least discriminatory question was the complaint of fatigue or low energy (see next section) as 27.9 % of non-depressed cancer patients complained of this symptom. The answers to three questions “trouble concentrating on such things as reading” combined with either feeling “down, depressed or hopeless” or feeling “bad about yourself or that you are a failure” give very good accuracy. We found that the most useful symptom in terms of clinical utility was sleep disturbance (or falling or staying asleep or sleeping too much). Sleep disturbance should alert the busy urological oncologist to the possibility of depression and further questions should be asked. Identification of psychiatric complications of cancer can often be improved by the use of a suitable diagnostic scale provided the scale is acceptable to both staff and patients. The Hospital Anxiety and Depression Scale (HADS) developed by Zigmund and Snaith in 1982 [15] is the most widely used scale in clinical practice. This has anxiety (HADS-A) and depression (HADS-D) subscales. In a meta-analysis of 50 studies using the depression subscale (HADS-D) the anxiety subscale (HADS-A) or combined scales (HADS-T) and a semi-structured psychiatric interview showed that the scale was a good initial screening instrument [16]. In the identification of depression the HADS-T, HADS-D and HADS-A had a pooled sensitivity of specificity of 82 %, 77 %; 71.6 %, 82.6 % and 85 %, 77.8 % respectively. When assessing anxiety the HADS-T and HADS-A had a pooled sensitivity of specificity of 83.9 %, 69.9 % and 48.7 %, 78.7 %. Many consider the HADS to be a rather cumbersome tool for routine use. We developed a simple visual-analogue scale consisting of a total of five domains (the emotion thermometers) which is much less laborious to use. The patient just marks a point on each of the visual analogue scales for distress, anxiety, depression, anger and the need for help (see Fig. 16.2). Studies in our Department have shown that this gives comparable results to the HADS-D scale but in a simpler to understand format [17, 18].

Fatigue is increasingly recognised as the most common symptom associated with cancer and its treatment [19]. It has also been reported to be strongly associated with emotional distress [20]. Cancer related fatigue has been described by Hickok et al. [21] as pervasive, unusual or excessive tiredness that involves the whole body, is disproportionate to or unrelated to activity or exertion and is usually not relieved by rest or sleep. Excessive fatigue may be present prior to treatment, be worsened by treatment and persist well after successful treatment when patients are tumour free.

Moderate fatigue was reported in over 66 % of a group of 1,397 patients with advanced cancer prior to radiotherapy. Fatigue was assessed using the ESAS [22]. A larger study of cancer fatigue was carried out in Edinburgh on a group of 3,424 consecutive patients attending for follow-up visits between June 2003 and December 2004 in outpatient clinics specialising in the following cancer types: colorectal, breast, gynaecological, genitourinary, sarcoma, melanoma and miscellaneous cancers (including Phase I trials). Fatigue was measured using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-30) fatigue sub-scale. Emotional distress was measured using the Hospital Anxiety and Depression Scale. Clinically relevant fatigue (CRF) was found in 32 % of patients. Variables independently associated with clinically relevant fatigue were primary cancer site, having disease present, type of cancer, treatment and emotional distress [19]. Emotional distress (total HADS score ≥ (greater than or equal to) 15) had a strong association with fatigue but half of the patients with clinically relevant fatigue were not distressed. Radiotherapy treatment can worsen levels of fatigue in patients especially those with pre-existing fatigue prior to treatment. Hickok from the University of Rochester in the USA [21] assessed fatigue in a group of 372 patients undergoing radical radiotherapy (5 weeks’ treatment) using an adaptation of a scale developed at the MD Anderson Hospital. The most common diagnosis was breast cancer (42 % of patients) followed by prostate cancer (22 %) of patients. Prostate cancer patients were the least likely to report fatigue at the beginning of treatment with only 42 % having some degree of fatigue at baseline measurements. The highest degree of fatigue (76 %) was in patients with brain tumours and this is certainly consistent with the author’s experience. Fatigue worsened during radiotherapy with the frequency and severity of fatigue being increased by approximately 30 % by the end of treatment.

Fatigue can certainly persist well after the end of treatment. Storey and colleagues in Edinburgh [23] recently assessed prostate cancer patients on follow-up greater than a year after treatment using the Brief Fatigue Inventory. These patients also filled in the Hospital Anxiety and Depression scale, the International Prostate Symptom Score, the EORTC QLQ-30 Quality of Life Questionnaire and the HADS score. Data was available for a total of 377 patients, 240 had been treated by radical radiotherapy and 133 by radical prostatectomy. The results in this group of patients were compared to a group of non-cancer controls. Interestingly the frequency of urinary symptoms was greater in the non-cancer controls than in the patients treated for prostate cancer. However, the prevalence of Clinically Relevant Fatigue (CRF) was 29 % in the prostate cancer patients versus 16 % of controls (p = 0.31). CRF was more common post-radiotherapy than post-prostatectomy (33 % versus 22 % p = 0.024). However, when other factors (current depression, anxiety, urinary symptoms, medical co-morbidities, pain and insomnia) were controlled for previous treatment did not predict CRF. Depression (HADS scale ≥ (greater than or equal to) 8) was by far the strongest association (OR 9.9 95 % CL 4.2–23.5).

There is some evidence that our advice to patients suffering from cancer fatigue in the past was detrimental. Typical advice given to such patients has been that they should rest and avoid physical effort. A study from Windsor and colleagues from Dundee [24] suggests this advice is wrong. Sixty six men receiving radical radiotherapy for prostate cancer were randomised to either an exercise group or another group who were not discouraged from performing normal activities but were advised to rest and take things easy if they became fatigued. Patients were assessed using the Brief Fatigue Inventory and walking distance was measured in a modified shuttle test before and after radiotherapy. The control group had a significant increase in fatigue scores from baseline at the end of radiotherapy (p = 0.013) with no significant increase observed in the exercise group (p = 0.203). A non-significant reduction (2.4 %) in shuttle test distance at the end of radiotherapy was observed in the control group, however in the exercise group there was a significant increase (13.2 %) in distance walked (p = 0.0003). Patients suffering from cancer fatigue should be screened for depression which is likely to be present in about half of these patients. A graded aerobic exercise programme should be considered for these patients rather than the classical advice of rest which could be detrimental.