Psychological Problems among Head and Neck Cancer Patients in Relation to Utilization of Healthcare and Informal Care and Costs in the First Two Years after Diagnosis

Round 1

Reviewer 1 Report

Thank you for the opportunity to review Psychological problems among head and neck cancer patients in relation to utilization of healthcare and informal care and costs in the first two years after diagnosis. In this study, the authors utilize a longitudinal cohort (NET-QUBIC) in a retrospective analysis examining healthcare utilization and its association with various psychological distress markers. While this is an incredibly important topic, I have several key concerns with the paper:

 

1. The patient reported outcome measures, while each individually validated, may not have undergone appropriate psychometric testing in the specific format used in the study (longitudinal, in head and neck cancer patients, etc).

 

2. Given the set-up of the analysis, with the use of forward logistic regression, this is largely an exploratory study and is not framed as such (and is instead framed as an epidemiological study).

 

3. There is no correction for multiplicity. While often thought of when there are multiple univariate analyses, the abundance of multivariable models presented also necessitates a multiplicity correction. The results of the study are highly suspect without this, which is further evidenced by some models showing an association between exposures of interest and the outcomes of interest, and others not.

 

4. There is no true primary or secondary outcome, instead there are a series of outcomes (various healthcare utilizations) measured at various time points. Further, this is an also an issue for the exposure of interest, as there are many (several forms of psychological problems).

 

Overall, while this is an important topic that deserves more research, the design and analysis carried out in this study are several limiting and should instead be either reconsidered or reframed to be purely exploratory.

 

Author Response

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Reviewer 2 Report

Thanks you for your submission entitled 'Psychological problems among head and neck cancer patients in relation to utilization of healthcare and informal care and costs in the first two years after diagnosis'. 

I read the study with interest and felt the methodology and results to be appropriate for the study. The data source was well powered and robust, and the author's discussion and conclusions are also well written and derived from the literature and their own data. 

 

 

Author Response

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Reviewer 3 Report

The authors analyzed the relationship between psycological distress and healthcare costs, finding higher costs in patients with psycological disorders.

The manuscript is well written.

The authors should report medical and psycological treatments for anxiety and depression and analyze their impact on healthcare system.

Author Response

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Reviewer 4 Report

This is a study about psychological problems among head and neck cancer patients in relation to utilization of healthcare and informal care and costs in the first two years after diagnosis.

The authors evaluated 558 patients by means of anxiety and depression disorder (diagnostic interview), distress, symptoms of anxiety and depression (HADS) and fear of cancer recurrence (FCR), that were measured at baseline and 12-months follow-up. Care use and costs (questionnaire) were measured at baseline, 3-, 6-, 12- and 24-months follow-up.

The paper is well written. However, some issues remain.

Please specify if any patients had recurrence during follow up. If yes, it must be included in the analyses.

Medical treatments (drugs) for psychological disorders must be added.

Some graphs about significant results may help the readers.

Author Response

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Reviewer 5 Report

The authors van Beek et al. present a study on correlations between mental health disorders and health care costs in head and neck cancer patients. In a prospective cohort, they found that mental health disorders, especially anxiety and depression are correlated to increased health care costs, regardless of cancer outcomes. 

The manuscript is overall an interesting read and highlights the importance to focus on mental health disorders and mental health care early on in the cancer treatment. One might hypothesize that overall health care costs might be reduced if HNC patients with anxiety/depression are early detected and properly treated. Nevertheless, there are minor points of criticism:

1. Could the authors please state and describe in more detail why/how patients of the cohort dropped out of the study? What is especially meant with psychological and physical reasons?
2. It seems that some health care costs of anxious/depressed patients, after being initially increased, are eventually at later follow up lower than in non-anxious/non-depressed patients. What is the explanation for this? Are there effects like this in later follow ups >24 months as well?
3. HNC patients are a special subcohort of cancer patients,  as stated in the introduction, and substance abuse is a major risk factor. Is there a perspective on HPV negative cancer patients or a subgroup with higher substance abuse and the levels of mental disorders in these patients? I think that these demographic and anamnestic/clinical specifications should at least be more addressed in the discussion. 

Author Response

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Round 2

Reviewer 1 Report

Thank you for revising after multiple reviewer comments.

Author Response

We are glad to read that our revisions meet the requirements of reviewer 1.