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Emotional Distress: The Sixth Vital Sign in Cancer Care

Department of Psychosocial Resources, Tom Baker Cancer Centre/Alberta Cancer Board, and the Department of Oncology, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada

To the Editor:

Along with the vital signs of temperature, respiration, heart rate, blood pressure, and pain,¹ it is time for health care professionals to recognize emotional distress as a core indicator of a patient's health and well-being. In June 2004, the Canadian Strategy for Cancer Control elected to do just that.²

Here was the rationale:

Cancer is well known to be a difficult disease, affecting cancer patients and their families both emotionally and physically. Despite biomedical progress, cancer is still often considered synonymous with death, pain, and suffering.³ Research has demonstrated that across the trajectory of the illness—from the time of diagnosis to treatment, termination of treatment, survivorship, or recurrence and palliation—the incidence of emotional distress in North America ranges from 35% to 45%.^4-6 Up to 58% of patients in palliative care experience significant levels of emotional distress,⁷ and in a Jordanian sample of cancer inpatients, the prevalence of distress was 70%.⁸ Similar overall rates to those in North America were recently reported in several European countries,^9-11 the Middle East,^12-14 South America,¹⁵ and Asia.^16,17 Large studies at Johns Hopkins Kimmel Cancer Center (Baltimore, MD)¹⁸ and the Tom Baker Cancer Centre (Alberta, Canada)¹⁹ found high levels of fatigue (in 49% of all patients), pain (26%), anxiety (24%), and depression (24%), along with significant financial hardship and material challenges in a representative cross section of patients screened for emotional distress.

Despite medicine's acknowledgment of the emotional side of cancer, there has been little effort to modify clinical practice, expand relevant hospital budgets, or implement third-party coverage for this core component of patient care. In Canada, where health care is publicly funded and delivered, a 1999 survey of provincial cancer agencies found that less than 3% of cancer center direct operating dollars were channeled to psychosocial care of cancer patients.²⁰ In contrast, the same survey found that no less than 5% of cancer center operating dollars were directed to cleaning of cancer facilities. Does more need to be said?

Insurance companies in the United States and healthcare administrators in Canada will say "the system" cannot afford more health care. We suggest this is not the case: we cannot afford to neglect this problem. The literature is clear: high prevalence of emotional distress is commonplace in cancer populations globally; when the emotional needs of cancer patients remain unresolved, they are more likely to use community health services and to visit emergency facilities.²¹ Such patients place higher demands on scarce care-provider time and are also more likely to be offered expensive third- and fourth-line chemotherapy,²² inappropriately applying limited resources in an attempt to relieve anxiety—usually, without extending life.

Voluminous clinical studies have repeatedly demonstrated that patients benefit from psychosocial care.²³ If the current discussion around distress prevalence and benefit of psychosocial care does not provide a compelling enough argument for attending to the emotional and psychosocial needs of cancer patients, the economic argument around medical cost offset might. Studies have demonstrated benefit of psychosocial care with no increased cost,²⁴ whereas Simpson et al showed a 25% decrease in billings to the medical system as a result of a psychosocial intervention in breast cancer patients, compared with a randomized control group,²⁵ and a meta-analysis of 90 studies by Chiles²⁶ showed that medical cost offset of psychosocial care averages 20% of overall health care expenditures—a significant benefit to the system.

Given the high prevalence rates of psychosocial and emotional distress in a rapidly expanding cancer population—cancer prevalence is expected to double within the next 15 years in developed countries²⁷—and the demonstrated benefit to patients and families, it is no wonder that on compassionate grounds alone, the Canadian Strategy for Cancer Control supported the proposition that Emotional Distress be considered the sixth vital sign—implying that monitoring of emotional distress should be undertaken as routinely as monitoring of the other vital signs.²

In reducing the emotional burden of cancer care, we can also reduce the economic burden. To put patient needs squarely at the center of the healthcare model involves a fundamental shift in our approach to patient care. Full recognition that the "people part" of cancer care is vital to a well-managed and compassionate cancer system makes ethical, emotional and economic sense.²⁰ Is it not time for all patient care providers to consider emotional distress as an essential component in the care of their patients—and therefore screen, routinely monitor, and treat its symptoms?

Authors' Disclosures of Potential Conflicts of Interest

The authors indicated no potential conflicts of interest.

REFERENCES

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17. Shimizu K, Akechi T, Okamura M, et al: Feasibility and usefulness of the distress and impact thermometer as a brief screening tool to detect psychological distress in clinical oncology practice. Psychooncology 13:S68-S69, 2004 (suppl)

18. Zabora J, BrintzenhofeSzoc K, Curbow B, et al: The prevalence of psychological distress by cancer site. Psychooncology 10:19-28, 2001

19. Carlson LE, Angen M, Cullum J, et al: High levels of untreated distress and fatigue in cancer patients. Br J Cancer 90:2297-2304, 2004

20. Bultz BD: Changing the face of cancer care for patients, community and the health care system: A report to the government of Canada. Comission on the Future of Health Care in Canada, 2002

21. Carlson LE, Bultz BD: Efficacy and medical cost offset of psychosocial interventions in cancer care: Making the case for economic analyses. Psychooncology 13:837-849, 2004[CrossRef][Medline]

22. Ashbury FD, Findlay H, Reynolds B, et al: A canadian survey of cancer patients' experiences: Are their needs being met? J Pain Symptom Manage 16:298-306, 1998[CrossRef][Medline]

23. Newell SA, Sanson-Fisher RW, Savolainen NJ: Systematic review of psychological therapies for cancer patients: Overview and recommendations for future research. J Natl Cancer Inst 94:558-584, 2002[Abstract/Free Full Text]

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