Anxiety and Depression in Metastatic Cancer: A Critical Review of Negative Impacts on Advance Care Planning and End-of-Life Decision Making With Practical Recommendations

Abstract

PURPOSE

Providers treating adults with advanced cancer increasingly seek to engage patients and surrogates in advance care planning (ACP) and end-of-life (EOL) decision making; however, anxiety and depression may interfere with engagement. The intersection of these two key phenomena is examined among patients with metastatic cancer and their surrogates: the need to prepare for and engage in ACP and EOL decision making and the high prevalence of anxiety and depression.

METHODS

Using a critical review framework, we examine the specific ways that anxiety and depression are likely to affect both ACP and EOL decision making.

RESULTS

The review indicates that depression is associated with reduced compliance with treatment recommendations, and high anxiety may result in avoidance of difficult discussions involved in ACP and EOL decision making. Depression and anxiety are associated with increased decisional regret in the context of cancer treatment decision making, as well as a preference for passive (not active) decision making in an intensive care unit setting. Anxiety about death in patients with advanced cancer is associated with lower rates of completion of an advance directive or discussion of EOL wishes with the oncologist. Patients with advanced cancer and elevated anxiety report higher discordance between wanted versus received life-sustaining treatments, less trust in their physicians, and less comprehension of the information communicated by their physicians.

CONCLUSION

Anxiety and depression are commonly elevated among adults with advanced cancer and health care surrogates, and can result in less engagement and satisfaction with ACP, cancer treatment, and EOL decisions. We offer practical strategies and sample scripts for oncology care providers to use to reduce the effects of anxiety and depression in these contexts.

A critical review finds that anxiety and depression have multiple negative effects on advance care planning (ACP) and end-of-life decision making by patients with cancer and their caregiver surrogates. The review leverages the evidence base on anxiety, depression, and their treatment to offer recommendations to cancer care providers for how to reduce the negative effects of anxiety and depression in ACP and end-of-life contexts.

INTRODUCTION

Anxiety and depression, which are the most common mental health symptoms and disorders worldwide,^1,2 are highly prevalent among patients with cancer,^3,4 including about one in three adults with metastatic cancer^5-11 and their caregivers.^6,12 One of the leading causes of death worldwide,^13,14 metastatic cancer is associated with multiple experiences (difficult symptoms, treatments, and losses; threatened sources of identity and meaning^15,16; and fear of dying⁵) that contribute to or co-occur with anxiety and depression.^17-19 Anxiety and depression can also have a negative impact on advance care planning (ACP) and end-of-life (EOL) decision making—both of which are critical to the care of patients with metastatic cancer and typically involve patients and/or caregivers who serve as health care surrogates.

ACP refers to a process that supports adults in understanding and sharing their personal values, life goals, and preferences regarding future medical care,²⁰ and specifically facilitates their ability to discuss their goals and preferences with loved ones and health care providers, and to review and document their preferences, if appropriate, in the form of advance directives.²¹ EOL decision making is the process in which individuals and families make decisions about the care they will receive before death²² in collaboration with their health care team, sometimes significantly ahead of time during the ACP process, and often in the moment, when an urgent decision is necessary. Such decisions can include symptom management, suspension or continuation of treatments, and feeding and hydration procedures.^23,24

In studies of patients with advanced cancer and/or critical illness and their health care surrogates, ACP and EOL decision making and communication interventions have often failed to affect meaningful outcomes such as goal-concordant care, length of intensive care unit (ICU) stays, resource use, or surrogate's satisfaction with patient care or mental health outcomes.^25-30 Emerging research that more directly investigates the effects of anxiety and depressive symptoms and disorders on ACP and EOL decision making has the potential to inform more impactful interventions and help oncology providers to navigate the complex intersection of mental health and cancer care decision making.

A systematic review³¹ shows that about one in three patients with metastatic cancer experience clinically significant anxiety and depression symptoms, with anxiety symptoms in particular remaining high at EOL. Cancer caregivers report even higher rates, with nearly half reporting clinically significant anxiety or depression symptoms.^19,32 Finally, death anxiety,³³ the worry and apprehension generated by death awareness, is common in metastatic cancer,^34,35 and is strongly linked to higher anxiety and depression symptoms among patients.^36-38

Using a critical review framework to synthesize diverse findings across numerous literatures,³⁹ the present goal is to develop a comprehensive understanding of the impacts of anxiety and depression on ACP and EOL decisions. We conducted a critical review rather than a meta-analysis or systematic review because a critical review involves integrating across literatures with an emphasis on conceptual synthesis and innovation. In addition, the modest empirical literature on anxiety and depression within ACP and EOL cancer care decision making is not yet large enough for a meta-analysis or systematic review. As the current topic is relatively new, it required synthesizing across multiple empirical literatures, including the sizable literature on the influence of anxiety and depression in decision making broadly with the more modest literature on their role in decision making in metastatic cancer specifically—an approach best reflected in a critical review. We predicted that both anxiety and depression among patients with metastatic cancer and their surrogates would have negative impacts on ACP and EOL decision making. On the basis of the review findings and informed by empirically supported behavioral interventions for anxiety and depression,^40-44 in the discussion, we offer provider-friendly recommendations and sample scripts for reducing the negative effects of anxiety and depression on ACP and EOL decision making among individuals with late-stage cancer and their health care surrogates.

METHODS

Literature Search

We used a critical review framework³⁹ to identify the most significant literature in the field. In October 2022, we searched three databases: PubMed, PsycINFO, and Web of Science. These databases were selected after consulting with a research librarian specializing in reviews, on the basis that they covered oncology (PubMed, Web of Science), psycho-oncology (all), and anxiety and depression (all, especially PsycINFO), providing good coverage and breadth for the relevant literatures. The Data Supplement (online only) details the terms and criteria of the search, with article flow summarized in Figure 1. Search terms were generated in consultation with the research librarian and articles were not restricted by year. We conducted two separate searches in each of three databases (PubMed, PsycINFO, and Web of Science) and pulled the first 100 articles that were listed in order of relevance in the output for each search, yielding 600 total papers (300 per search; 496 total unique records after removing duplicates; Fig 1). The first search targeted conceptual or review articles on decision making in the context of anxiety or depression; only English-language, peer-reviewed, topically relevant reviews, meta-analyses, and conceptual syntheses/models were selected for inclusion. The second search targeted health care and ACP decision making in the context of cancer and anxiety or depression; only English-language, peer-reviewed empirical studies were considered. The title and abstract of each article were reviewed for relevance by L.B.F., J.J.A., and E.E.B. on the basis of the aims of the critical review. Additional references were identified by hand-searching the bibliographies of relevant articles.

FIG 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram of database search.

Synthesizing and Building on the Findings

The Results section is organized into the three empirical foci that the search strategies identified: Empirically based reviews and models of the influence of anxiety and depression on broad decision making; the role of anxiety and depression in health behavior adherence (as ACP can be conceptualized as a series of health behaviors^45-47); and most specifically, their role in ACP and EOL decision making in care for patients with metastatic cancer. Following critical review recommendations,³⁹ the most methodologically rigorous and evidence-based review and conceptual papers in the first two literatures were leveraged to inform a more comprehensive understanding of the potential negative impacts of anxiety and depression on ACP and EOL decision making in metastatic cancer, as empirical research on the latter remains comparatively modest. Analysis of the literature was conducted by a multidisciplinary team with many decades of relevant research and clinical experience across academic and community care settings, with principal analysis led by J.J.A. (clinical psychologist) and secondarily by E.E.B. (health psychologist), in close consultation with D.J.A. (medical oncologist), J.S.K. (palliative care physician), R.M.F. (palliative care nurse), and J.L.M. (oncology social worker).

RESULTS

Anxiety and Depression in the Context of Broader Decision Making

Affect and Decision Making

Decades of research^48-53 show that affect—particularly in the form of immediate gut feelings experienced at the moment of decision making⁵¹ and quick judgments of good/bad or gain/loss,⁵⁰ which can occur unconsciously⁵³—serves as a foundation for decision making. Anxiety and depression, however, introduce affective and cognitive biases that can negatively affect such decisions.⁵⁴

Anxiety-Related Biases

Anxious states, traits, and related disorders entail two principal information-processing biases⁵⁵ that function to avoid threat: (1) a bias toward threat-related information⁵⁶ (avoiding it at low levels of threat and hyperattending to it at moderate to high levels of threat⁵⁷) and (2) a tendency to interpret ambiguous or uncertain situations negatively.^56,57 Thus, anxiety heightens attention to negative information, increases the likelihood that uncertain options will be viewed negatively, heightens reactivity to uncertainty, and intensifies the motivation to avoid potential negative outcomes (even low-probability negative outcomes),^56,58,59 often at the cost of missing potential benefits. Anxiety also leads people to inflate the likelihood of poor outcomes and to catastrophize the consequences of these outcomes if they occur.^56,60-62 Furthermore, highly anxious patients typically seek more reassurance⁶³ and greater intensity/frequency of health care visits⁶⁴ than less anxious patients. To the extent that ACP and EOL decision making focus on an uncertain future, engaging in these processes may be particularly anxiety-provoking for patients and surrogates who are already anxious, and require more provider time, discussion, and deliberation.

Depression-Related Biases

Depression decreases action toward seeking benefits or rewards.^60,65 A large body of evidence indicates that people who have depression or are in depressed states underestimate the value of rewarding outcomes (eg, patients with metastatic cancer may undervalue the physical relief from palliative radiation and thus choose not to pursue it), their ability to influence or control outcomes (“no matter what I do, my disease course won't improve”), and the likelihood of rewarding outcomes occurring (“the treatment may work for others, but it won't work for me”).^60,66 Depressed patients may also overestimate the effort required to take action (“this treatment seems impossible to do”). These biases result in low motivation to invest attention or energy to addressing challenges,⁶⁰ particularly when potential rewards or benefits require effort⁶⁷ or can be realized only in the future, not immediately,⁶⁸ as typically is the case with cancer treatment and ACP. Given that depressed patients tend to view rewarding future outcomes as weak, unlikely, and difficult to pursue,^60,66,69 inaction often follows.

Attention, Memory, and Processing Information

Anxiety- and depression-related biases are driven by numerous neural mechanisms including poor attentional control and selective attention,^70-73 working memory,^72-74 and executive functioning^72,73,75,76 (the ability to monitor and maintain goals, plans, and other task-relevant information⁷⁷). Together, these functional challenges make it more difficult for patients and surrogates to focus and recall information in a balanced manner (eg, balanced recalling of risks and benefits), engage in complex tasks (eg, thinking through the relevant dimensions of ACP), and maintain focus on the goals and decisions at hand (eg, weighing different EOL care options to arrive at a care decision).

The Impact of Anxiety and Depression on Health Behavior Adherence

ACP as a Health Behavior

ACP involves a nuanced and progressive series of health behaviors,^45-47 and thus is linked to the vast literature on health behavior adherence.^45-47 Health behaviors (actions and routines that target well-being through health maintenance, restoration, and improvement) that are part of the ACP process reflect the need for patients and caregivers/surrogates to engage in a series of conversations and documentations that clarify the patient's health care and EOL-related values and preferences.⁷⁸ These conversations can involve caregiver values and preferences too.⁷⁸ Common ACP behaviors include learning about EOL care options; clarifying patient and caregiver surrogate values regarding quality of life and EOL care; appointing, documenting, and communicating with a health care surrogate; discussing with the health care team the patient's preferences and the appointment of the surrogate; documenting health care preferences if appropriate; and updating these conversations and documents as health and personal circumstances change. Although studies have not yet evaluated the direct effects of anxiety and depression on adherence to ACP or engagement in EOL decision making, the broader literature showcases how anxiety and depression affect adherence to other health behaviors in ways that have implications for ACP and EOL decision making.

Anxiety and Health Behavior

Anxiety has a bimodal relationship with health behavior adherence, such that very low and high levels of anxiety interfere with engagement in health behaviors, but moderate levels of anxiety often facilitate engagement.^79,80 In addition, certain symptoms of anxiety, such as avoidance, make engagement in health behaviors difficult, whereas other symptoms, such as increased vigilance, can increase engagement in health behaviors, reflecting the finding that anxiety can motivate action to prevent future threat or harm,⁸¹ including in health domains.^82,83 Given this variation, it is not surprising that studies of the relationship between anxiety and engagement in health behaviors have been mixed.⁸⁴ For example, studies of the association between anxiety and likelihood of engaging in breast cancer screenings (mammography) have shown both positive^85-87 and negative relationships.^88,89 Furthermore, a more limited body of research has found support for a curvilinear relationship between anxiety and mammography such that moderate levels of anxiety are associated with keeping scheduled mammogram appointments but low and high levels of anxiety are not.^90,91 Finally, among colorectal cancer survivors, greater worry and anxiety were associated with intentions to make healthy behavior changes.⁹² These findings suggest that moderate levels of worry and anxiety may promote engagement in ACP and EOL decision making while lower and higher levels may interfere.

Depression and Health Behavior

Symptoms of depression, such as reduced energy and hopelessness, hinder patient engagement in health behaviors.^84,93 Patients with depression have more difficulty communicating with their medical team and understanding their care plans,⁹⁴ which present potential barriers to ACP and EOL decision making.⁹⁵ Furthermore, depression symptoms and disorders are associated with noncompliance to medical treatment.⁸⁴ In a meta-analysis of 31 studies, depressed patients had 1.76 times greater estimated odds of being nonadherent to medication than nondepressed patients.⁹³ Among adults with cancer, depression is negatively associated with adherence to anticancer medication,⁹⁶ and engagement in cancer-preventing health behaviors such as exercise^97,98 and smoking cessation.^99,100 Given the active steps that ACP and EOL decision making entails, findings indicate that an elevation of depression symptoms would likely reduce engagement in ACP and EOL decision making.

The Role of Anxiety and Depression in EOL and Cancer-Related Decision Making

An emerging group of studies evaluate the impact of anxiety and depression on decision making related to EOL and to cancer treatment generally. Because no meta-analyses or reviews have yet summarized this modest literature, we discuss relevant individual studies.

Decisional Conflict and Regret

Patients and surrogates are often asked to make EOL decisions in highly activated emotional states, such as when they feel scared or overwhelmed.^101-103 People prone to anxiety or depression may become activated more easily than others, and are likely to experience anxiety- and depression-related biases in this state. Thus, predisposition toward anxiety or depression, or emotional contexts such as at initial cancer diagnosis or EOL, can place patients and health care surrogates at particular risk for making care decisions that do not resonate once they return to less-activated emotional states. A 2015 systematic review of decisional regret in prostate cancer treatment¹⁰⁴ identified anxiety or depression as a predictor of decisional regret. In one large study, higher trait anxiety at baseline (ie, a general tendency to be anxious) was one of the most robust predictors of decisional regret 6 months later¹⁰⁵ (depression was not examined). A more recent large study of urology outpatients,¹⁰⁶ including 42% with a uro-oncologic diagnosis, found that clinically elevated levels of anxiety or depression reported immediately before a urologic consult predicted greater decisional conflict immediately after the consultation (ie, feeling uncertain, unsupported, uninformed, ineffective, and unclear of values regarding a medical decision¹⁰⁷). Finally, a systematic review of breast reconstruction after mastectomy for breast cancer¹⁰⁸ found that higher levels of patient depression, anxiety, and distress were associated with greater decisional regret. The review included one longitudinal study showing that anxiety during treatment predicted greater decisional regret 5 years later among young breast cancer survivors.¹⁰⁹ It also included another study of patients with early-stage breast cancer considering breast surgery, which showed that preconsult patient depression predicted subsequent decisional conflict and preconsult patient anxiety predicted subsequent lower satisfaction with the medical consult and decisional regret.¹¹⁰ Together, these studies suggest that in the context of cancer care, anxiety and depression increase subsequent decisional conflict and regret.

Decision-Making Roles in Intensive Care Settings (ICU)

In the context of metastatic cancer, discussions about goals of care ideally occur before hospitalization or ICU admission, when there is less urgency. Nonetheless, for many people with metastatic cancer, EOL discussions and decisions take place in the ICU. These discussions often involve family members or surrogates as patients are frequently too ill to participate. Family members and surrogates are highly prone to anxiety and depression symptoms in ICU contexts.¹⁰³ A study of 50 family members of patients in the ICU, including but not limited to patients with cancer, found that elevated anxiety and depression symptoms were each strongly linked to greater preference for a passive decision-making role over an active or shared role¹¹¹ (although findings were cross-sectional and could not establish causality). Importantly, passive decision making is associated with worse anxiety and depression outcomes for the family members of patients treated in the ICU,¹¹² risking a vicious cycle.

Decision Making in Outpatient Cancer Care Settings

In a large sample of adults with advanced cancer, worrying about dying, a form of death anxiety, was associated with significantly lower likelihood of completing a living will/advance directive or discussing EOL wishes with the oncologist.¹¹³ Furthermore, anxious adults with advanced cancer were more likely to experience discordance between their preferences and their actual receipt of life-sustaining treatments,¹¹⁴ suggesting less communication of EOL wishes.

Communication and the Patient-Physician Relationship

Dozens of studies evaluating EOL communication interventions,^30,115 most aimed at health care professionals, have identified communication as an important facet of EOL decision making.^115,116 Adults with advanced cancer who met criteria for an anxiety disorder (specifically, generalized anxiety disorder, panic disorder, or post-traumatic stress disorder [PTSD]) had less trust in their physicians, felt less comfortable asking questions, and felt less likely to understand information that their physician communicated, and were more likely to believe their physician would offer them futile treatments and would not sufficiently control their symptoms,¹¹⁷ suggesting an important relationship between these anxiety disorders and difficulties in the physician-patient relationship. A longitudinal study of patients with advanced cancer showed that higher levels of patient anxiety, but not patient depression, longitudinally predicted significantly fewer patient-physician EOL care discussions,¹¹⁸ suggesting avoidance of such discussions. The findings suggest that anxious patients' bias for avoiding contexts perceived as threatening translates into less trust in physicians and fewer EOL care discussions. Physicians may also avoid such discussions with anxious patients, suggesting that this relationship may be bidirectional. Future studies should directly investigate this possibility.

DISCUSSION

The purpose of this critical review was to provide a more comprehensive understanding of the role of anxiety and depression in ACP and EOL decision making. We predicted that both would exert negative (or largely negative) effects on decision making in these contexts, and found strong evidence in support of this prediction.

Discussion of Critical Review Findings

The review identified extensive evidence that anxiety and depression often bias and affect engagement with decision making, and a subset of studies supported this conclusion in the context of health care and specifically cancer care. As EOL decision making for patients with metastatic cancer frequently involves health care surrogates or caregivers, many current findings are relevant for both patients and surrogates. Key findings include evidence that depression reduces compliance with recommended health care treatment, reduces motivation and engagement in decision making, and is associated with surrogates adopting a more passive decision-making role in acute care settings, which further increases their depression. Depression also predicts greater decisional conflict and regret in the context of cancer treatment. The overall picture that emerges is that depression predicts lower engagement in the process of decision making followed by enduring conflict and regret.

The findings for anxiety are more nuanced in that moderate levels of anxiety can motivate adaptive responses to threat,⁸¹ including higher engagement in cancer prevention behaviors.^90,91 In the context of ACP and EOL decision making, however, moderate to high anxiety is likely to create biases toward decisions or care options perceived as threatening in such a manner that promotes catastrophizing, overwhelm, strong averseness to pursuing decisions or care options that entail any risk, and avoidance of engaging in EOL decision making and ACP. Indeed, among patients with advanced cancer, higher anxiety or anxiety disorders predict lower completion of advance directives, less trust in and less comprehension of information conveyed by their physicians, and less discussion of EOL wishes. Thus unsurprisingly, anxiety among patients with advanced cancer predicts a larger gap between desired versus received life-sustaining treatments and higher decisional conflict and regret. The overall picture is that anxiety predicts negative reactivity toward anything perceived as uncertain or (at all) risky and predicts avoidance of ACP and EOL decision making, followed by enduring decisional conflict and regret. In that many decisions in metastatic cancer entail risks and uncertainty, anxious patients and surrogates are more likely to require significant oncologist time and reassurance.

Practical Recommendations for Providers

On the basis of research findings, ASCO recommends early integration of palliative care as a gold standard for patients with advanced cancer, citing benefits of improved quality of life, decreased symptom burden, reduced anxiety and depression, and goal-concordant care.^119,120 Multiple authors^121-124 have explored the importance of promoting health care provider education for facilitating ACP and EOL decision-making communication. Recommended strategies include establishing trust, providing respect, recognizing patient concerns, attending to patient affect, acknowledging emotions, expressing empathy, and reframing hope.^121,122 Providing prompts and scripts can help to overcome barriers in having these important discussions,^123,124 and represent tools and strategies that we integrate next.

Given the review findings, it may prove beneficial for cancer care providers to use brief, scalable strategies for shifting the immediate negative emotional and cognitive state of a patient or surrogate before engaging in sensitive health care discussions or decisions regarding ACP or EOL. As a recent review on anxiety and decision making concluded,⁵⁵ “techniques for altering fear and anxiety may also change decisions (p. 113), with similar findings for depression.”¹²⁵

In the context of care for persons with metastatic cancer, cancer care providers are aware that some degree of anxiety and depression is normal and expected and there is no correct ACP or EOL decision, with many sociocultural, familial, and spiritual factors to consider together with the prognosis, functional status, and treatment options. Given current findings, it remains important to assess the nature, severity, and source of patient or surrogate anxiety and depression symptoms at the point of decision making—a task with which supportive care providers (eg, clinical social workers, psychologists, and spiritual care providers) can assist.

Table 1 presents common effects of anxiety and depressive symptoms relevant to ACP and EOL decision making, derived from scientific models on anxiety and depression and their influence on decision making reviewed currently.^{56,60,61,69,76} The table provides practical recommendations and sample scripts for how to reduce these symptoms and biases in the context of ACP and EOL decision making, on the basis of empirically supported behavioral intervention models for anxiety and depression,^40-44,126 with scripts further refined by our collective clinical experience in medical oncology, palliative care medicine, palliative care nursing, clinical/health psychology, and clinical social work. These recommendations aim to help providers manage these symptoms in the moment, toward the goal of facilitating better conditions for ACP and EOL decision-making discussions. Specifically, they focus on helping anxious and depressed patients and surrogates engage more fully in ACP and EOL decision making, maintain a more balanced cognitive and emotional state, reduce or better tolerate the anxiety and overwhelm that such decision processes can trigger, clarify their values and goals, and become motivated to act on them. Table 1 emphasizes core relevant symptoms of common forms of elevated anxiety and depression. Tables 2 and 3 provide recommendations for responding to social anxiety and phobia (Table 2) and PTSD symptoms (Table 3) that are relevant for ACP and EOL decision making (PTSD was classified as an anxiety disorder in the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5), and shares many neurobiologic features and empirical treatment approaches with the anxiety disorders; thus, it is included here). These recommendations are not intended to replace established treatment approaches for anxiety or depressive symptoms or disorders. However, in the context of ACP and EOL decision making, there are at least three possible barriers to effective treatment of anxiety and depression.

1. In EOL contexts, patients must often make decisions in the moment on an urgent time scale, and thus there is not enough time to treat the underlying anxiety or depression.

2. For acutely or seriously ill patients, recommended behavioral treatments may be impractical and psychiatric medications can negatively affect the cognitive functioning^127,128 and alertness¹²⁹ required for ACP and EOL discussions, or interfere with anticancer medications such as tamoxifen.¹³⁰

3. For about half of the adults (without cancer), the evidence-based pharmacologic and psychological treatments for anxiety and depression are ineffective or only partially effective.^131-134

4. If the anxious or depressed individual is the surrogate rather than the patient, providers can offer resources, information, and support,¹³⁵ but it may fall outside of their purview to suggest treatment.

TABLE 1.

Common Anxiety and Depression Symptoms in the Context of ACP and EOL Decision Making and Practical Recommendations

TABLE 2.

Additional Recommendations in the Context of ACP and EOL Decision Making for Supporting Patients and Surrogates With Specific Concerns Because of Social Anxiety or Phobia Symptoms

TABLE 3.

Additional Recommendations in the Context of ACP and EOL Decision Making for Supporting Patients and Surrogates With Specific Concerns Because of History of Trauma or PTSD

In conclusion, people with metastatic cancer and their health care surrogates commonly experience anxiety and depression, both of which are characterized by symptoms and biases that can negatively affect ACP and EOL decision-making engagement, content, and satisfaction. If providers recognize that patients or surrogates are experiencing anxiety or depression symptoms, they can use a range of brief strategies to reduce the extent and influence of these symptoms in the context of ACP and EOL decision making. Research to evaluate the effectiveness of these strategies in the context of ACP and EOL decision making, and how best to train providers in their provision, represent important next steps toward the goal of increasing patient and surrogate engagement and satisfaction with cancer care decisions.

AUTHOR CONTRIBUTIONS

Conception and design: Joanna J. Arch, Emma E. Bright, Regina M. Fink, Jill L. Mitchell, David J. Andorsky, Jean S. Kutner

Collection and assembly of data: Joanna J. Arch, Lauren B. Finkelstein

Data analysis and interpretation: Joanna J. Arch, Emma E. Bright, Jill L. Mitchell, David J. Andorsky, Jean S. Kutner

Manuscript writing: All authors

Final approval of manuscript: All authors

Accountable for all aspects of the work: All authors

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Anxiety and Depression in Metastatic Cancer: A Critical Review of Negative Impacts on Advance Care Planning and End-of-Life Decision Making With Practical Recommendations

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/op/authors/author-center.

Open Payments is a public database containing information reported by companies about payments made to US-licensed physicians (Open Payments).

Joanna J. Arch

Consulting or Advisory Role: AbbVie/Genentech (I), Bristol Meyers Squibb (I)

Research Funding: NCCN/AstraZeneca

Jill L. Mitchell

Employment: Rocky Mountain Cancer Centers/USON, Meru Health

Stock and Other Ownership Interests: Teladoc Health stock, Walgreens Boots Alliance stock, FSPHX (ETF), XLV (etf)

Research Funding: Cancer Support Community, University of Colorado—Boulder/NIH grant funding

David J. Andorsky

Consulting or Advisory Role: Bristol Myers Squibb/Celgene, AstraZeneca, AbbVie/Genentech, Novartis

Research Funding: Bristol Myers Squibb/Celgene, AbbVie, Epizyme, Novartis

No other potential conflicts of interest were reported.