Are depressive symptoms associated with cancer screening and cancer stage at diagnosis among postmenopausal women? The Women's Health Initiative observational cohort.
ABSTRACT Women with depressive symptoms may use preventive services less frequently and experience poorer health outcomes. We investigated the association of depressive symptoms with breast and colorectal cancer screening rates and stage of cancer among a cohort of postmenopausal women.
In The Women's Health Initiative Observational Study, 93,676 women were followed on average for 7.6 years. Depressive symptoms were measured at baseline and at 3 years using the 6-item scale from the Center for Epidemiological Studies Depression scale (CES-D). We calculated a cancer screening rate expressed as a proportion of the years that women were current with recommended cancer screening over the number of follow-up visits in the study. Breast and colorectal cancers were staged based on Surveillance, Epidemiology and End Results (SEER) classification.
At baseline, 15.8% (12,621) women were positive for depressive symptoms, and 6.9% (4,777) were positive at both baseline screening and at 3 years. The overall average screening rate was 71% for breast cancer and 53% for colorectal cancer. The breast cancer screening rate was 1.5% (CI 0.9%-2.0%) lower among women who reported depressive symptoms at baseline than among those who did not. Depressive symptoms were not a predictor for colorectal cancer screening. Stage of breast and colorectal cancer was not found to be associated with depressive symptoms after adjusting for covariates.
Among a healthy and self-motivated cohort of women, self-reported depressive symptoms were associated with lower rates of screening mammography but not with colorectal cancer screening.
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ABSTRACT: Depression is common among patients with chronic medical illness. We explored the impact of depressive symptoms in primary care patients with diabetes on diabetes self-care, adherence to medication regimens, functioning, and health care costs. We administered a questionnaire to 367 patients with types 1 and 2 diabetes from 2 health maintenance organization primary care clinics to obtain data on demographics, depressive symptoms, diabetes knowledge, functioning, and diabetes self-care. On the basis of automated data, we measured medical comorbidity, health care costs, glycosylated hemoglobin (HbA(1c)) levels, and oral hypoglycemic prescription refills. Using depressive symptom severity tertiles (low, medium, or high), we performed regression analyses to determine the impact of depressive symptoms on adherence to diabetes self-care and oral hypoglycemic regimens, HbA(1c) levels, functional impairment, and health care costs. Compared with patients in the low-severity depression symptom tertile, those in the medium- and high-severity tertiles were significantly less adherent to dietary recommendations. Patients in the high-severity tertile were significantly distinct from those in the low-severity tertile by having a higher percentage of days in nonadherence to oral hypoglycemic regimens (15% vs 7%); poorer physical and mental functioning; greater probability of having any emergency department, primary care, specialty care, medical inpatient, and mental health costs; and among users of health care within categories, higher primary (51% higher), ambulatory (75% higher), and total health care costs (86% higher). Depressive symptom severity is associated with poorer diet and medication regimen adherence, functional impairment, and higher health care costs in primary care diabetic patients. Further studies testing the effectiveness and cost-effectiveness of enhanced models of care of diabetic patients with depression are needed. Arch Intern Med. 2000;160:3278-3285.Archives of Internal Medicine 12/2000; 160(21):3278-85. · 11.46 Impact Factor
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ABSTRACT: To fuel advocacy for improved health care for mentally ill persons, the authors reviewed the literature that describes excess mortality and underrecognition and undertreatment of comorbid medical conditions in this population. Barriers to optimal primary medical care for psychiatric patients are discussed. A MEDLINE search focusing on mortality and medical problems in psychiatric patients yielded 66 papers in English published between 1934 and 1996. These studies and a German paper from 1912 are included in the review. Standardized mortality ratios for psychiatric patients, derived from comparisons with the general population and matched control groups, have repeatedly demonstrated excess mortality from both natural and unnatural causes among psychiatric patients. Several large studies that have attempted to clarify the issues underlying increased death rates are discussed. Although no single diagnostic group emerges as being at particularly high risk, substance abuse disorders alone or in combination with other psychiatric disorders have been repeatedly found to lead to increased mortality rates. Other studies have also repeatedly demonstrated that psychiatric patients suffer a high rate of comorbid medical illnesses, which are largely undiagnosed and untreated and which may cause or exacerbate psychiatric symptoms. Atypical presentations are common, and changes in vision are the symptoms most predictive of medical illness. Elderly patients and those with diagnoses of organic brain syndromes are at highest risk for comorbid medical illness. Parity in the medical and mental health treatment of psychiatric patients requires both political advocacy and development of primary care programs capable of efficiently meeting their needs.Psychiatric Services 01/1997; 47(12):1356-63. · 2.01 Impact Factor
Article: Cancer statistics, 2005.[show abstract] [hide abstract]
ABSTRACT: Each year, the American Cancer Society estimates the number of new cancer cases and deaths expected in the United States in the current year and compiles the most recent data on cancer incidence, mortality, and survival based on incidence data from the National Cancer Institute and mortality data from the National Center for Health Statistics. Incidence and death rates are age-standardized to the 2000 US standard million population. A total of 1,372,910 new cancer cases and 570,280 deaths are expected in the United States in 2005. When deaths are aggregated by age, cancer has surpassed heart disease as the leading cause of death for persons younger than 85 since 1999. When adjusted to delayed reporting, cancer incidence rates stabilized in men from 1995 through 2001 but continued to increase by 0.3% per year from 1987 through 2001 in women. The death rate from all cancers combined has decreased by 1.5% per year since 1993 among men and by 0.8% per year since 1992 among women. The mortality rate has also continued to decrease from the three most common cancer sites in men (lung and bronchus, colon and rectum, and prostate) and from breast and colorectal cancers in women. Lung cancer mortality among women has leveled off after increasing for many decades. In analyses by race and ethnicity, African American men and women have 40% and 20% higher death rates from all cancers combined than White men and women, respectively. Cancer incidence and death rates are lower in other racial and ethnic groups than in Whites and African Americans for all sites combined and for the four major cancer sites. However, these groups generally have higher rates for stomach, liver, and cervical cancers than Whites. Furthermore, minority populations are more likely to be diagnosed with advanced stage disease than are Whites. Progress in reducing the burden of suffering and death from cancer can be accelerated by applying existing cancer control knowledge across all segments of the population.CA A Cancer Journal for Clinicians 01/2005; 55(1):10-30. · 153.46 Impact Factor
JOURNAL OF WOMEN’S HEALTH
Volume 17, Number 8, 2008
© Mary Ann Liebert, Inc.
Are Depressive Symptoms Associated with Cancer
Screening and Cancer Stage at Diagnosis
among Postmenopausal Women? The Women’s
Health Initiative Observational Cohort
Arpita Aggarwal, M.D., M.Sc.,1Karen Freund, M.D., M.P.H.,2Alicia Sato, M.S.,3
Lucille L. Adams-Campbell, Ph.D.,4Ana Maria Lopez, M.D., M.P.H., FACP,5
Lawrence S. Lessin, M.D., MACP,6Judith Ockene, Ph.D., M.Ed.,7Robert B. Wallace, M.D., M.Sc.,8
Carla D. Williams, Ph.D.,4and Denise E. Bonds, M.D., M.P.H.9
Background: Women with depressive symptoms may use preventive services less frequently and experience
poorer health outcomes. We investigated the association of depressive symptoms with breast and colorectal
cancer screening rates and stage of cancer among a cohort of postmenopausal women.
Methods: In The Women’s Health Initiative Observational Study, 93,676 women were followed on average for
7.6 years. Depressive symptoms were measured at baseline and at 3 years using the 6-item scale from the Cen-
ter for Epidemiological Studies Depression scale (CES-D). We calculated a cancer screening rate expressed as
a proportion of the years that women were current with recommended cancer screening over the number of
follow-up visits in the study. Breast and colorectal cancers were staged based on Surveillance, Epidemiology
and End Results (SEER) classification.
Results: At baseline, 15.8% (12,621) women were positive for depressive symptoms, and 6.9% (4,777) were pos-
itive at both baseline screening and at 3 years. The overall average screening rate was 71% for breast cancer
and 53% for colorectal cancer. The breast cancer screening rate was 1.5% (CI 0.9%–2.0%) lower among women
who reported depressive symptoms at baseline than among those who did not. Depressive symptoms were not
a predictor for colorectal cancer screening. Stage of breast and colorectal cancer was not found to be associated
with depressive symptoms after adjusting for covariates.
Conclusions: Among a healthy and self-motivated cohort of women, self-reported depressive symptoms were
associated with lower rates of screening mammography but not with colorectal cancer screening.
United States.1Early detection of these cancers can save lives,
reduce length of treatment, and increase quality of life
REAST AND COLORECTAL CANCER are the second and third
leading causes of cancer death among women in the
(QOL). Race, economic status, family history of cancer, med-
ical comorbidity, healthcare access, health behavior, and ed-
ucation have been recognized as major factors associated
with screening behavior.2,3Only a few studies have investi-
gated the role of psychiatric comorbidities in cancer screen-
ing behavior and mortality.
1Virginia Commonwealth University, Richmond, Virginia.
2Boston University, Boston, Massachusetts.
3Fred Hutchinson Cancer Research Center, Seattle, Washington.
4Howard University Cancer Center, Washington, DC.
5Arizona Cancer Center, University of Arizona, Tucson, Arizona.
6Washington Hospital Center, Washington, DC.
7University of Massachusetts Medical School, Worcester, Massachusetts.
8University of Iowa, Iowa City, Iowa.
9University of Virginia, Charlottesville, Virginia.
Preliminary results of this study were published in abstract format and subsequently presented as a poster at the annual meeting of the
Society for General Internal Medicine in April 2006.
The WHI study was supported by the National Heart, Lung and Blood Institute and the General Clinical Research Center program of
the National Center for Research Resources, Department of Health and Human Services.
In the United States, about 1 in 8 women can expect to de-
velop clinical depression during her lifetime,4,5a condition
that may cause considerable impairment, suffering, and dis-
ruption of personal, family, and work in one’s life. Although
depressed women are more likely to experience functional
impairment,5,6less than half seek medical care.7Several stud-
ies have addressed the association of chronic mental ill-
nesses, such as depression, with use of general medical
care.8–12These studies indicate poor adherence to medical
treatment and follow-up as well as worse outcome in the
population with psychiatric illness or substance use disor-
der or dual diagnoses. Few of these studies looked specifi-
cally at preventive care and cancer screening among patients
with chronic mental illnesses.8,13Although each of these
studies shows lower cancer screening rates among patients
with chronic mental illnesses, they did not study depression
as a factor independent of substance abuse. The inclusion of
individuals with dual diagnoses does not allow us to un-
derstand the independent effect of the mental illness.
Moreover, these studies included a broad spectrum of psy-
chiatric illnesses, such as depression and schizophrenia, that
are significantly different in their prevalence, latency, course
of disease, and, most importantly, their effect on patient
functioning. It may not be reasonable to study them as a sin-
gle group of diseases. Furthermore, most studies were per-
formed on veterans,8–10who exhibit higher rates of multiple
mental illnesses and may experience a more serious course
of disease compared with nonveterans.14–16There are no data
available on the association of depression with cancer stage
at initial presentation. We hypothesize that depressive symp-
toms may be associated with lower cancer screening rates as
a result of reduced motivation for use of preventive services,
less receipt of recommendations for screening by providers
who are focusing on depression treatment, or reduced com-
pliance with screening recommendations. These lower rates
of early cancer screening may result in a more advanced
stage of cancer at the initial presentation. On the other hand,
depression itself might affect on the growth of cancer cells,
leading to higher incidence of advanced stage cancers. Ad-
vanced stage of breast and colorectal cancers is associated
with increased cancer morbidity, mortality, and healthcare
costs. To better understand the association of depressive
symptoms with cancer screening rates and stage of cancer at
clinical presentation, we analyzed data from the Women’s
Health Initiative Observational Study (WHI-OS).
Materials and Methods
The WHI-OS is a cohort of 93,676 women with an average
follow-up time of 7 years. Postmenopausal women aged 50–79
years who gave written informed consent were recruited into
the WHI study at 40 clinical centers in the United States,
mostly through mass mailings to age-eligible women. The
WHI cohort is multiethnic, with 83.3% white, 8.2% African
American, 3.9% Hispanic, 2.9% Asian/Pacific Islander, 0.5%
American Indian/Alaskan Native, and 1.4% unknown eth-
nicity. Details of the WHI study design are reported else-
where.17Exclusions for WHI-OS were participation in other
randomized trials, survival prediction of ?3 years, alcohol
abuse, dementia, drug dependency, documented diagnosis of
a serious mental illness (which includes schizophrenia,
schizoaffective disorder, bipolar-affective disorder, and other
nonorganic psychotic disorders), or other conditions making
women unable to participate in the study. Because individu-
als with a prior history of cancer often have increased sur-
veillance and sometimes have different screening guidelines,
this analysis excluded all subjects with a history of cancer at
baseline, except nonmelanoma skin cancer. Previous research
has shown an increased incidence of depression among pa-
tients diagnosed with cancer.18Women with cancer diagnosed
within the first year of the study were also excluded to reduce
the bias of a causal association of cancer and depression.
Participants were assessed for their current and past his-
tory of depressive symptoms using the Burnam screen19for
depression. This screen consists of 6 items from the 20-item
Center for Epidemiological Studies Depression scale (CES-
D) and 2 items from the National Institute of Mental Health’s
Diagnostic Interview Schedule (DIS).20
The 6-item CES-D and DIS scale was administered at base-
line and again at the 3-year follow-up visit. Current depres-
sive symptoms were assessed using 6 items from the CES-D
in the Burnam scale, which is highly correlated with the 20-
item CES-D scale (correlation coefficient r ? 0.88, p ?
0.001).20,21Burnam et al.19showed that this screen has ade-
quate psychometric properties for detecting current depres-
sive disorder (major depression and dysthymia), with 86%
sensitivity and 95% specificity for detecting depression in a
primary care population. Participants are asked how often
they felt the depressive symptoms during the past week.
Each item is scored as 0 (rarely or none of the time ?1 day),
1 (some or a little of the time 1–2 days), 2 (occasionally or a
moderate amount of the time 3–4 days), or 3 (most or all of
the time 5–7 days). The items included: (1) you felt de-
pressed, (2) your sleep was restless, (3) you enjoyed life (re-
versed scoring), (4) you had crying spells, (5) you felt sad,
and (6) you felt that people disliked you.
The DIS scale consists of two questions used to assess de-
pressive symptoms20,21over the previous 2 years. These di-
chotomous response questions are (1) In the past year, have
you had 2 weeks or more during which you felt sad, blue,
or depressed or lost pleasure in things that you usually cared
about or enjoyed? (2) Have you had 2 years or more in your
life when you felt depressed or sad most days, even if you
felt okay sometimes? If yes, have you felt depressed or sad
much of the time in the past year?”
A score of ?5 on the short form of the CES-D at baseline
was used as the primary definition for depressive symptoms.
This definition represents depressive symptoms over the
previous week at study baseline. During this longitudinal
study, depressive symptoms were also assessed using an-
other measure (DIS scale) and at a different time point (3
years). We used additional definitions for depressive symp-
toms to assess the correlation of depressive symptoms with
cancer screening and stage at initial presentation. The three
additional definitions in this sensitivity analysis used to
strengthen our results are (1) depressive symptoms defined
as both a score of ?5 on the CES-D and a positive DIS score
(score of 2) at baseline, (2) a score of ?2 on the DIS, and (3)
depressive symptoms defined as a score of ?5 at both the
baseline visit and 3 years later on the CES-D.
AGGARWAL ET AL.1354
Current breast cancer screening was defined as a mam-
mogram within the last 12 months.22,23Current colorectal
screening was defined as an annual fecal occult blood test
(FOBT) or lower endoscopy or double-contrast barium en-
ema within the last 5 years.22,23This information was col-
lected during the baseline and annual follow-up question-
naires. We calculated a screening rate expressed as a
proportion of the years that women were current with rec-
ommended screening over the number of follow-up visits in
Breast and colorectal cancers were staged based on the
Surveillance Epidemiology and End Results (SEER) classifi-
cation.24All in situ and localized cancers were classified as
early stage cancers, and regional and distant cancers were
classified as late stage cancers. Unstaged cancers and women
diagnosed with cancer during the first year of the study were
not included in this analysis, but there was little difference
in the incidence rates for this subset of cancers between de-
pressed and nondepressed cohorts (data not shown).
Sociodemographic characteristics, past medical history,
and information about known breast and colorectal cancer
risk factors were self-reported on the baseline questionnaire.
Descriptive characteristics included age, ethnicity, educa-
tion, income, insurance type, physical activity, age at menar-
che, age at first pregnancy, number of children breastfed,
family history of breast or colorectal cancer, history of breast
biopsy, history of ulcerative colitis or Crohn’s disease, use
of hormone therapy (HT) (estrogen only or estrogen and pro-
gesterone combination therapy), aspirin use, smoking and
alcohol use status, and use of a primary care provider. Body
mass index (BMI) was calculated based on weight and height
measurements taken by study nurses at baseline. New med-
ical problems and changes in treatment were reported dur-
ing follow-up questionnaires. Comorbidity burden was cal-
culated using a modified version of the Charlson Index
(unpublished WHI data by R. Gold et al.), a commonly used
and validated25,26comorbidity index composed of 19 dis-
eases weighted based on how well they predict mortality,
with a maximum possible score of 37. Charlson Index scores
were calculated using WHI baseline data from each study
subject’s self-reported medical history. Use of antidepressant
medication was not included in the model because of the va-
riety of other indications for these classes of medication.
Baseline sociodemographic characteristics and cancer risk
factors of the study cohort were compared among women
who screened positive for depression vs. those who did not.
Simple linear regression was used to determine the associa-
tion between depressive symptoms and subsequent breast
or colorectal cancer screening rates. To control for potential
confounding factors, the estimates and corresponding 95%
confidence intervals (95% CI) for depression status in the
breast cancer screening model were adjusted for sociode-
mographic characteristics, family history of breast cancer,
history of previous breast biopsy, HT, alcohol intake, BMI,
comorbidity index, insurance, and having a primary care
provider. Adjustment factors for the colorectal cancer screen-
ing analysis included sociodemographic characteristics; fam-
ily history of colorectal cancer, ulcerative colitis, or Crohn’s
disease; alcohol intake; comorbidity index; and having a pri-
mary care provider.
Logistic regression was used to assess the correlation of
depressive symptoms with late vs. early stage at presenta-
tion of subsequent breast and colorectal cancers. To control
for potential confounding, odds ratios (ORs) and 95% CIs for
depression status in the breast cancer model were adjusted
for sociodemographic characteristics, insurance type, breast
biopsy, number of relatives with breast cancer, moderate or
strenuous physical activity, BMI, age at first birth, number
of children breastfed, parity, and aspirin use. Depression sta-
tus in the colorectal cancer model was adjusted for sociode-
mographic characteristics, insurance type, BMI, moderate or
strenuous physical activity, and smoking status. We ran ad-
ditional multivariate models with different measurements of
depressive symptoms at baseline and 3-year follow-up. All
analyses were conducted using SAS (version 9.1.3) (SAS In-
stitute, Cary, NC) software. Analyses were statistically sig-
nificant at alpha of 0.05.
There were 12,621 (15.8%) women (Table 1) with current
depressive symptoms and a mean CES-D score of ?5 at base-
line. The mean CES-D score for those above the cutoff of 5
was 7.0 (standard deviation [SD] 2.4), compared with 1.45
(SD 1.33) for women scoring below the cutoff. Using our al-
ternative definitions, 5,152 (7.4%) women had both positive
CES-D and DIS scores at baseline, 9,760 (12.1%) had positive
DIS scores, and 4,777 (6.9%) women had positive CES-D at
baseline and at the 3-year follow-up.
Table 2 compares the sociodemographic and health char-
acteristics of women with and without depressive symptoms
at baseline in the WHI-OS cohort. Women with depressive
symptoms were younger (aged 50–59 years); had lower ed-
ucational attainment; and were less likely to be white, have
a ?$20,000 annual income, and be insured. Women with de-
pressive symptoms were more likely to have BMI ?30, were
less physically active, used more alcohol in the past, and
were more likely to be current smokers.
The overall average screening rate was 71% for breast can-
DEPRESSION AND CANCER SCREENING1355
TABLE 1.PREVALENCE OF DEPRESSIVE SYMPTOMS REPORTED BY WOMEN: WOMEN’S HEALTH INITIATIVE OBSERVATIONAL COHORT
%Mean depressive score SDa
CES-D ? 5 at baseline
DIS ? 2 at baseline
CES-D ? 5 and DIS ? 2 at baseline
CES-D ? 5 at baseline and 3-year follow-up
aCES-D, Center for Epidemiological Studies Depression scale; DIS: Diagnostic Interview Schedule; SD, standard deviation.
AGGARWAL ET AL.1356
TABLE 2.BASELINE CHARACTERISTICS OF WOMEN WITH AND WITHOUT DEPRESSIVE
SYMPTOMS: WOMEN’S HEALTH INITIATIVE OBSERVATIONAL COHORTa
n ? 12,623
n ? 67,368
Age group, at screening, years
High school diploma or less
Posthigh school/some college
College degree or more
Annual household income
Body mass index (kg/m2)
2–?4 episodes per week
4? episodes per week
Primary care provider
Age at menarache, years
Age at first birth, years
Never pregnant/no term pregnancy
2,676 21 14,81722
cer and 53% for colorectal cancer. Of women with current de-
pressive symptoms at baseline, 61% reported screening for
breast cancer compared with 65% of women without depres-
sive symptoms. Differences in these rates persisted even when
the rates were adjusted for factors associated with breast can-
cer screening (Table 3). Breast cancer screening rates during
the average 7.6 years of follow-up among women with cur-
rent depressive symptoms at baseline were 1.5 percentage
points lower (?1.5 % difference, 95% CI ?0.9, ?2.0) compared
with women without depressive symptoms, after adjustment
for risk factors and differences between the two groups.
Screening rates were even lower among women with a posi-
tive DIS at baseline (?3.6% difference, CI ?2.9, ?4.2) and
among those with positive CES-D at both baseline and 3-year
follow up (?2.2% difference, CI ?1.3, ?3.0) during the study.
Depressive symptoms at baseline or any other time dur-
ing the follow-up were not associated with colorectal screen-
ing (Table 3). Neither breast cancer nor colorectal cancer
stage at diagnosis (Table 4) was associated with current de-
pressive symptoms, past depressive symptoms at baseline,
or depressive symptoms at baseline and at the 3-year follow-
up in unadjusted or adjusted analysis.
DEPRESSION AND CANCER SCREENING1357
Number of children breastfed
No term pregnancy
Hormone therapy use
First degree relatives with breast cancer
History of benign breast disease
No breast biopsy
Mammogram last year
No mammogram ever
No mammogram last year
Mammogram last year
Ulcerative colitis or Crohn’s disease
First-degree relatives with
?5 years ago
5? years ago
Antidepressant use (at baseline)
Antidepressant use (at 3-year follow-up)
History of depression—DISc(at baseline)
aAll analyses were statistically significant (p ? 0.0001).
bDepressive symptoms: CES-D ? 5 at baseline.
cDIS, Diagnostic Interview Schedule.
SYMPTOMS: WOMEN’S HEALTH INITIATIVE OBSERVATIONAL COHORTa(CONT’D)
BASELINE CHARACTERISTICS OF WOMEN WITH AND WITHOUT DEPRESSIVE
n ? 12,623
n ? 67,368
This study examined whether depressive symptoms are
associated with breast and colorectal cancer screening rates
and stage of diagnosis among postmenopausal women. To
examine this hypothesis, we used WHI-OS data from 1991
to 1998, the largest (93,676) longitudinal study of healthy
postmenopausal women. Among this large cohort, we found
a high prevalence (15.8%) of women who screened positive
for depressive symptoms at baseline, and almost half of them
continued to have depressive symptoms at 3-year follow-up.
Women with depressive symptoms at baseline had 1.5%
lower breast cancer screening rates during the study period,
controlling for other known predictors for screening. Breast
cancer screening rates were even lower (?2.2% difference)
among women reporting a past history of depression at base-
line. This difference in breast cancer screening among
women with depressive symptoms was not associated with
presentation at a later stage of breast cancer. Depressive
symptoms in the past, at baseline, or at 3-year follow-up had
no association with adequate colorectal cancer screening rate
or stage of colorectal cancer.
The incidence of cancer-related deaths in the year 2005 was
the same as that in 1950.22Significant effort and resources
have gone toward promoting early detection of cancer to re-
duce mortality and improve QOL. One possible barrier to
early detection is co-morbid mental illness, such as depres-
sion. Numerous studies describe greater physical illness,
functional impairment, and morbidity among patients with
depression.11,27–29Patients with depression use more health-
care resources, including clinician visits and hospital ad-
missions.30,31However, despite higher utilization rates, rou-
tine care such as screening may be overlooked. Patients and
providers may be overly focused on managing the depres-
sion, or they may assume it is a natural consequence of
events associated with aging, such as the loss of loved ones
or medical illness, and appropriate proper treatment may not
be considered. Additional barriers to seeking care include
the social stigma associated with depression and social stres-
sors, such as lack of social or financial support.4
Our results confirm that depressed women have modestly
lower breast cancer screening rates, but we found no asso-
ciation with colorectal cancer screening rates. Pirraglia et al.32
found similar results in a small cohort of younger women,
aged 42–52 years, for whom high depressive symptom bur-
den was a modest barrier for breast cancer screening but not
for cervical cancer screening. Druss et al.8,9found that vet-
erans with any mental illness or a dual diagnosis of mental
illness and substance abuse were less likely to receive opti-
mal cancer screening, including colorectal and prostate
screening. Our study results differ from their studies for col-
orectal cancer screening. One possible reason for this differ-
AGGARWAL ET AL. 1358
TABLE 3.CHANGE IN CANCER SCREENING WITH DEPRESSIVE SYMPTOMS: WOMEN’S HEALTH INITIATIVE OBSERVATIONAL COHORT
Breast cancer screeninga
Colorectal cancer screeningb
Depressive symptoms 95% CI 95% CI
CES-Dd? 5 at baseline
DIS ? 2 at baseline
CES-D ? 5 and DIS ? 2 at baseline
CES-D ? 5 at baseline and 3-year follow-up
aAdjusted for sociodemographic characteristics, family history of breast cancer, history of previous breast biopsy, HT, alcohol intake, BMI,
comorbidity index, insurance, and having a primary care provider.
bAdjusted for sociodemographic characteristics, family history of colorectal cancer, ulcerative colitis, or Crohn’s disease; alcohol intake; co-
morbidity index; and having a primary care provider.
cDifference in percentage, %, comparing women with variable listed as reference group.
dCES-D, Center for Epidemiological Studies Depression scale; DIS: Diagnostic Interview Schedule.
TABLE 4.ODDS RATIO OF LATER STAGE OF CANCER AT DIAGNOSIS:
WOMEN’S HEALTH INITIATIVE OBSERVATIONAL COHORT
OR, (95% CI)c
OR, (95% CI)c
CES-Dd? 5 at baseline
DIS ? 2 at baseline
CES-D ? 5 and DIS ? 2 at baseline
CES-D ? 5 at baseline and 3-year follow-up
0.93 (0.71, 1.21)
1.03 (0.77, 1.37)
0.97 (0.66, 1.44)
1.17 (0.78, 1.74)
1.01 (0.61, 1.69)
1.10 (0.63, 1.92)
1.22 (0.59, 2.52)
0.84 (0.34, 2.04)
aAdjusted for sociodemographic characteristics, insurance type, breast biopsy, number of relatives with
breast cancer, moderate or strenuous physical activity, BMI, age at first birth, number of children breastfed,
parity, and aspirin use.
bAdjusted for sociodemographic characteristics, insurance type, BMI, moderate or strenuous physical
activity, and smoking status.
cOR, odds ratio; CI, confidence interval; CES-D, Center for Epidemiological Studies Depression scale; DIS:
Diagnostic Interview Schedule.
ence may be that we examined the effect of depression in-
dependently from other mental illness, such as psychotic or
anxiety disorders, which were combined in previous stud-
ies. As these mental illnesses differ significantly from de-
pression in their severity impact on the patient, they may
also differ in their relationship to obtaining cancer screen-
ing. WHI participants tended to be relatively healthy and
self-motivated, as women with the most severe forms of
mental illness were excluded from the study.
Although we found a moderate association of depressive
symptoms and breast cancer screening, we found no associ-
ation with colorectal cancer screening. Several possible rea-
sons may account for this difference. Colorectal cancer
screening can be adequate with less frequent screening mo-
dalities, such as endoscopy, which is repeated every 3–5
years. Because the severity of depressive symptoms can vary
widely over time, it is possible that individuals may obtain
screening during their symptom-free periods and thus
achieve adequate colorectal cancer screening. On the other
hand, breast cancer screening requires yearly mammogra-
phy. A depressed woman may have difficulty adhering to
annual appointments because of lack of interest in cancer
screening, or she may have difficulty remembering appoint-
ments. Colorectal cancer screening is not as widely accepted
as breast cancer screening. In our study, only 53% of all
women received adequate colorectal cancer screening vs.
71% for breast cancer. Given the relatively lower rate of col-
orectal screening, the influence of depression may not be ev-
We did not find any association of depressive symptoms
with breast or colorectal cancer in early stage or late stage at
initial presentation. The results were consistent when all can-
cer stages were analyzed independently. One explanation for
the lack of a finding may be that our cohort included fewer
women with chronic, severe, or untreated depression. Sec-
ond, this cohort may have had different baseline screening
practices related to other factors, including their personal
risk of cancer. The incidence rates of both breast and col-
orectal cancer were 3-fold and 1.5 fold higher, respectively,
in the WHI-OS cohort than nationally reported by SEER
data.24In the WHI-OS cohort, approximately 80% of the in-
cident breast cancer cases diagnosed were in early stages
compared with 60% nationally. Among colorectal cancer in-
cident cases, 44% were diagnosed at the early stages, which
is similar to national rates.
There are limitations to our study. The depression screen-
ing instrument (Burnam screen) may also reflect anxiety or
psychological distress, and when it is used clinically, any pa-
tient with positive screening would generally be referred for
further psychiatric evaluation. Although the positive screen-
ing result has high sensitivity and specificity for diagnosing
clinical depression, it is only an indicator of depressive
symptoms. The association between depressive symptoms
and breast cancer screening might be stronger among sub-
jects with severe or untreated depressive illness than is re-
ported in this cohort of women. We were unable to verify
the self-reported mammogram and colorectal cancer screen-
ing among these women. The literature supports high accu-
racy in self-reported screening data, 75% for breast33and 85%
for colorectal screening,34if asked within 2 years. In the WHI
study, women were queried about their health habits annu-
ally. Because of the limited data regarding the purpose of
medication use, we could not control for antidepressant use
and adherence to medications. The WHI was not designed
to study the association of depressive symptoms with can-
One of the strengths of this study is the large number of
participants, allowing us to adjust for most covariables with-
out overfitting the multivariate models. Depression was
measured at two different times during the study period us-
ing an instrument with reasonably high sensitivity and speci-
ficity for clinical depression. Sensitivity analysis by using a
variety of definitions for depression, ranging from current
depression to depression at multiple time points, was an
added strength to the methodology. Additionally, stronger
association of depressive symptoms with lower breast can-
cer screening rates among women with long-standing de-
pressive symptoms also strengthened our results; we had
enough power to study the effect of depressive symptoms
on stage of cancer at presentation, which previous studies
had been unable to do. Although our study is the first to
study and show no effect of depressive symptoms on stage
of breast and colorectal cancer, this association may be dif-
ferent among patients with severe refractory depression or
other chronic mental illnesses. It is hoped that our study will
help researchers to design additional studies looking at can-
cer screening and chronic mental illnesses.
In conclusion, we found that among a healthy and self-
motivated cohort of women, self-reported depressive symp-
toms were associated with moderately lower rates of screen-
ing for breast cancer. No association was noted between
depressive symptoms and adequacy of colorectal cancer
screening. We were unable to find any association of de-
pressive symptoms with stage of cancer at presentation. Can-
cer control programs might consider assessing psychiatric
comorbidities, such as depression, when planning strategies
to improve breast cancer screening rates.
Cordial thanks to R. Gold and colleagues for sharing the
modified Charlson Index scores.
Women’s Health Initiative Clinical Coordinating Center
Fred Hutchinson Cancer Research Center, Seattle, WA:
Ross Prentice, Garnet Anderson, Andrea LaCroix, Charles L.
Kooperberg, Ruth E. Patterson, Anne McTiernan; Wake For-
est University School of Medicine, Winston-Salem, NC: Sally
Shumaker; Medical Research Labs, Highland Heights, KY:
Evan Stein; University of California at San Francisco, San
Francisco, CA: Steven Cummings.
Women’s Health Initiative WHI Clinical Centers
Albert Einstein College of Medicine, Bronx, NY: Sylvia
Wassertheil-Smoller; Baylor College of Medicine, Houston,
TX: Jennifer Hays; Brigham and Women’s Hospital, Harvard
Medical School, Boston, MA: JoAnn Manson; Brown Uni-
versity, Providence, RI: Annlouise R. Assaf; Emory Univer-
sity, Atlanta, GA: Lawrence Phillips; Fred Hutchinson Can-
cer Research Center, Seattle, WA: Shirley Beresford; George
Washington University Medical Center, Washington, DC: Ju-
dith Hsia; Los Angeles Biomedical Research Institute at Har-
bor-UCLA Medical Center, Torrance, CA: Rowan Chle-
DEPRESSION AND CANCER SCREENING1359
bowski; Kaiser Permanente Center for Health Research, Port-
land, OR: Evelyn Whitlock; Kaiser Permanente Division of
Research, Oakland, CA: Bette Caan; Medical College of Wis-
consin, Milwaukee, WI: Jane Morley Kotchen; MedStar Re-
search Institute/Howard University, Washington, DC: Bar-
bara V. Howard; Northwestern University, Chicago/
Evanston, IL: Linda Van Horn; Rush Medical Center,
Chicago, IL: Henry Black; Stanford Prevention Research Cen-
ter, Stanford, CA: Marcia L. Stefanick; State University of
New York at Stony Brook, NY: Dorothy Lane; The Ohio State
University, Columbus, OH: Rebecca Jackson; University of
Alabama at Birmingham, Birmingham, AL: Cora E. Lewis;
University of Arizona, Tucson/Phoenix, AZ: Tamsen Bass-
ford; University at Buffalo, Buffalo, NY: Jean Wactawski-
Wende; University of California at Davis, Sacramento, CA:
John Robbins; University of California at Irvine, CA: F. Al-
lan Hubbell; University of California at Los Angeles, CA:
Howard Judd; University of California at San Diego, La-
Jolla/Chula Vista, CA: Robert D. Langer; University of
Cincinnati, Cincinnati, OH: Margery Gass; University of
Florida, Gainesville/Jacksonville, FL: Marian Limacher; Uni-
versity of Hawaii, Honolulu, HI: David Curb; University of
Iowa, Iowa City/Davenport, IA: Robert Wallace; University
of Massachusetts/Fallon Clinic, Worcester, MA: Judith Ock-
ene; University of Medicine and Dentistry of New Jersey,
Newark, NJ: Norman Lasser; University of Miami, FL: Mary
Jo O’Sullivan; University of Minnesota, Minneapolis, MN:
Karen Margolis; University of Nevada, Reno, NV: Robert
Brunner; University of North Carolina, Chapel Hill, NC: Ger-
ardo Heiss; University of Pittsburgh, Pittsburgh, PA: Lewis
Kuller; University of Tennessee, Memphis, TN: Karen C.
Johnson; University of Texas Health Science Center, San An-
tonio, TX: Robert Brzyski; University of Wisconsin, Madison,
WI: Gloria E. Sarto; Wake Forest University School of Med-
icine, Winston-Salem, NC: Denise Bonds; Wayne State Uni-
versity School of Medicine/Hutzel Hospital, Detroit, MI: Su-
No competing financial interests exist.
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Address reprint requests to:
Arpita Aggarwal, M.D., M.Sc.
Department of Internal Medicine
Virginia Commonwealth University
1200 East Broad Street
Richmond, VA 23298
DEPRESSION AND CANCER SCREENING1361