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Originally published as JCO Early Release 10.1200/JCO.2007.13.1367 on September 10 2007 © 2007 American Society of Clinical Oncology.
Screening for Psychological Distress in Cancer Patients: Challenges and Opportunities
H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL A number of governmental and professional organizations have recommended that cancer patients be screened routinely for the presence of heightened psychological distress.1-3 For example, the National Comprehensive Cancer Network (NCCN) initially published guidelines in 1999, recommending that all patients be screened for distress at their initial visit and at appropriate intervals thereafter.1 Several arguments can be made for implementation of routine screening for distress. First, evidence suggests that heightened distress is associated with a number of negative outcomes that include poorer adherence to treatment recommendations,4 worse satisfaction with care,5 and worse quality of life.6 Relationships have also been reported between heightened distress (such as greater depressive symptomatology) and poorer survival in people with cancer.7 Second, heightened distress is treatable. Numerous randomized controlled trials show that psychological distress, including anxiety and depression, can be alleviated by pharmacologic and nonpharmacologic interventions.8 Third, heightened distress is common. Prevalence estimates derived from large-scale studies typically exceed 30%.9,10 Fourth, and perhaps most important, evidence indicates that heightened distress often goes unrecognized by oncology professionals. In one of the largest studies examining this issue, Fallowfield et al9 evaluated the ability of 143 physicians to detect heightened distress in 2,297 cancer patients. Only 29% of patients with scores exceeding the cutoff on an established screening measure were identified by their physicians as having heightened distress. Despite evidence that heightened distress is under-recognized, clinicians seem reluctant to use screening tools routinely.11 The format and length of many existing tools may be a barrier, in that the time required for administering, scoring, and interpreting these measures favors use of more informal methods. To address this issue, several ultrashort screening tools have been developed. The most widely studied of these is the Distress Thermometer,1 a single-item measure that asks respondents to rate their distress during the last week on an 11-point scale ranging from "no distress" (0) to "extreme distress" (10). Although they possess greater potential for routine clinical use than longer measures, the accuracy of these ultrashort tools in detecting heightened distress could be too low to recommend them. The article by Mitchell12 in the this issue of the Journal of Clinical Oncology represents the first comprehensive evaluation of the accuracy of ultrashort methods in detecting heightened distress in people with cancer. The study is notable for the use of systematic search and pooled analysis methods, similar to those used in a comprehensive evaluation of the results of randomized controlled trials. That is, the investigator used replicable methods to identify all relevant studies and then used quantitative methods to summarize findings across studies. The results of these efforts indicate that ultrashort methods possess both strengths and weaknesses that need to be considered when they are used in the clinic. The principal strength of these methods is their accuracy in ruling out the presence of heightened distress relative to longer methods; the principal weakness is their generally poor accuracy in confirming the presence of heightened distress. An example provided by the author12 illustrates these qualities. Findings summarized across studies suggest that if 100 people were screened for heightened distress using the Distress Thermometer and the cutoff currently recommended by NCCN,13 distress would be correctly ruled out (ie, patients identified as not distressed would be classified accurately) in 51 of 60 patients, but correctly confirmed (ie, patients identified as distressed would be classified accurately) in just 22 of 40 patients. Based on these findings, should ultrashort methods be recommended as screening tools? Their poor accuracy in ruling in heightened distress is a liability. If used consistent with NCCN guidelines to decide whether patients should be referred for mental health, social work, or pastoral services,1 implementation of ultrashort screening measures is likely to result in many patients who are not distressed receiving inappropriate referrals. The primary consequence of this would be the needless use of generally scarce resources available for psychosocial care. The mislabeling of some patients as distressed might also have the unintended consequence of causing distress where it was not present previously. Conversely, the generally good accuracy of ultrashort methods in ruling out heightened distress can be viewed as a major asset that outweighs the previously identified liability. As noted by Mitchell,12 this feature means that "... one simple screen could be used to exclude most cases of distress and mood disorder." Given that ultrashort methods are unlikely to possess the same accuracy as longer methods, it seems preferable to have brevity come at the expense of making more false-positive errors than false-negative errors. Of the two types of errors, incorrectly identifying a patient as not distressed is likely to have more severe consequences for an individual's quality of life and quality of care than incorrectly identifying him or her as distressed. Progress in implementing routine screening for distress has been slow. A survey conducted of NCCN member institutions in 200514 found that, of 18 responding centers, only eight (53%) conducted any routine screening as recommended by NCCN distress management guidelines.1 Among these eight institutions, three routinely screened all patients and five routinely screened only certain patients (eg, patients undergoing transplantation). Evidence that ultrashort measures possess acceptable properties for ruling out distress should encourage greater adoption of routine screening. However, even ultrashort methods may be too labor intensive to permit broad implementation if administered using paper-and-pencil methods. Automated methods, such as computer terminals or tablets positioned in waiting areas, would allow for collection and dissemination of information about distress with minimal staff involvement. Studies show that use of computers to collect quality of life data is acceptable to patients and yields information comparable to that collected using paper-and-pencil methods.15,16 Greater adoption of routine screening for distress might also be facilitated by stronger evidence that it results in better outcomes. Current NCCN distress management guidelines are consensus based and rely largely on lower level evidence, including clinical experience.13 Randomized controlled trials are needed to test the hypothesis that care delivered consistent with these guidelines (ie, routine screening followed by referral of distressed individuals to appropriate professionals) yields better control of distress than care delivered inconsistent with these guidelines. Screening alone is unlikely to improve outcomes. For example, a recently completed randomized trial found no difference in health-related quality of life compared with usual care when patient reports of health-related quality of life were just summarized and conveyed to the treating nurse.17 These and other studies18,19 suggest that information about heightened distress provided to treating clinicians must be accompanied by recommendations that lead to specific actions for screening to make a difference. AUTHOR'S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author(s) indicated no potential conflicts of interest. NOTES published online ahead of print at www.jco.org on September 17, 2007. REFERENCES 1. Anonymous: NCCN practice guidelines for the management of psychosocial distress. Oncology (Huntingt) 13:113-147, 1999[Medline] 2. NICE: Guidance on cancer services: Improving supportive and palliative care for adults with cancer. London, United Kingdom, National Institute for Clinical Excellence, 2004 3. Rebalance Action Focus Group: A position paper: Screening key indicators in cancer patients—Pain as a fifth vital sign & emotional distress as a sixth vital sign. Can Strategy Cancer Control Bull 7:4, 2004 4. Kennard BD, Smith SM, Olvera R, et al: Nonadherence in adolescent oncology patients: Preliminary data on psychological risk factors and relationships to outcome. J Clin Psychol Med Settings 11:30-39, 2004 5. Von Essen I, Larsson G, Oberg K, et al: ‘Satisfaction with care’: Associations with health-related quality of life and psychosocial function among Swedish patients with endocrine gastrointestinal tumours. Eur J Cancer Care 11:91-99, 2002[CrossRef] 6. Skarstein J, Aass N, Fossa SD, et al: Anxiety and depression in cancer patients: Relation between the Hospital Anxiety and Depression Scale and the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire. J Psychosom Res 49:27-34, 2000[Medline] 7. Steel JL, Geller DA, Gamblin TC, et al: Depression, immunity, and survival in patients with hepatobiliary carcinoma. J Clin Oncol 25:2397-2405, 2007 8. Jacobsen PB, Donovan KA, Swaine ZN, et al: Management of anxiety and depression in adult cancer patients: Toward an evidence-based approach, in Chang AE, Ganz PA, Hayes DF, et al (eds): Oncology: An Evidence-Based Approach. New York, NY, Springer-Verlag, 2006, pp 1552-1579 9. Fallowfield L, Ratcliffe D, Jenkins V, et al: Psychiatric morbidity and its recognition by doctors in patients with cancer. Br J Cancer 84:1011-1015, 2001[CrossRef][Medline] 10. Zabora J, BrintzenhofeSzoc K, Curbow B, et al: The prevalence of distress by cancer site. Psychooncology 10:19-28, 2001[CrossRef][Medline] 11. Mitchell AJ, Kaar S, Coggan C, et al: Acceptability of common screening methods used to detect distress and related mood disorders: preferences of cancer specialists and non-specialists. Psychooncology [epub ahead of print on June 18, 2007] 12. Mitchell AJ: Pooled results from 38 analyses of the accuracy of distress thermometer and other ultra-short methods of detecting cancer-related mood disorder J Clin Oncol 25:4670-4681, 2007 13. Holland JC, Breitbart WS, Andersen B, et al: The NCCN distress management clinical practice guidelines in oncology. J Natl Compr Cancer Network 5:66-98, 2007 14. Jacobsen PB, Ransom S: Implementation of NCCN distress management guidelines by member institutions. J Natl Compr Cancer Network 5:99-103, 2007 15. Gil KM, Frasure HE, Hopkins MP, et al: Effect of method of administration on longitudinal assessment of quality of life in gynecologic cancer: An exploratory study. Health Qual Life Outcomes 3:6, 2005[CrossRef][Medline] 16. Mullen KH, Berry DL, Zierler BK: Computerized symptom and quality of life assessment for patients with cancer. Part II: Acceptability and usability. Oncol Nurs Forum 31:E84-E89, 2004 17. Rosenbloom SK, Victorson DE, Hahn EA, et al: Assessment is not enough: A randomized controlled trial of the effects of HRQL assessment on quality of life and satisfaction in oncology clinical practice. Psychooncology [epub ahead of print on Match 7, 2007] 18. Boyes A, Newell S, Girgis A, et al: Does routine assessment and real-time feedback improve cancer patients' psychosocial well-being. Eur J Cancer Care 15:163-171, 2006[CrossRef] 19. McLachlan S, Allenby A, Matthews J, et al: Randomized trial of coordinated psychosocial interventions based on patient self-assessments versus standard care to improve the psychosocial functioning of patients with cancer. J Clin Oncol 19:4117-4125, 2001 Related Article
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Copyright © 2007 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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