Validation of the Distress Thermometer with bone marrow transplant patients

Validity, specificity, feasibility and acceptability of a brief pediatric distress thermometer in outpatient clinics

OBJECTIVE

Psychosocial distress is under-recognized in children with cancer and other serious medical illnesses because of a focus on pressing medical concerns.

AIMS

This study assessed the validity, inter-rater reliability, sensitivity/specificity, acceptability, and feasibility of administration of a pediatric distress thermometer (DT) designed to screen for the presence of psychosocial distress in youth with serious medical illnesses.

MATERIALS & METHODS

Two hundred eighty-one patient-caregiver-provider triads were enrolled from two hospital outpatient clinics. Patients diagnosed with cancer and other life-threatening diseases, caregivers, and providers completed the DT and a DT acceptability rating. Patients and caregivers completed standardized measures of anxiety, depression, pain, and fatigue. Providers completed a measure of disease severity. Data collectors completed a feasibility rating.

RESULTS

The DT was significantly correlated with both caregiver and patient reports of depression, anxiety, pain, and fatigue, exhibiting concurrent validity. Parent, child, and caregiver report demonstrated significant, moderate inter-rater reliability, with lower concordance between raters in the youngest age group. The DT is a sensitive instrument for screening of psychosocial distress when compared with the selected gold standard (Brief Symptom Inventory 18 depression subscale and the Children's Depression Inventory). The DT is not highly specific but quickly identifies those in need of further psychosocial assessment.

DISCUSSION

Screening, using an adapted pediatric DT, is valid, feasible, and acceptable to patients, caregivers, and medical providers across chronic medical illnesses.

CONCLUSION

As patient and caregiver reports are not always concordant, both patient and caregiver report of distress are important for the provider to obtain clinically meaningful information to guide interventions. Published 2015. This article is a U.S. Government work and is in the public domain in the USA.

Physical Exercise Training versus Relaxation in Allogeneic stem cell transplantation (PETRA Study) - Rationale and design of a randomized trial to evaluate a yearlong exercise intervention on overall survival and side-effects after allogeneic stem cell transplantation

Background

Allogeneic stem cell transplantation (allo-HCT) is associated with high treatment-related mortality and innumerable physical and psychosocial complications and side-effects, such as high fatigue levels, loss of physical performance, infections, graft-versus-host disease (GvHD) and distress. This leads to a reduced quality of life, not only during and after transplantation, but also in the long term. Exercise interventions have been shown to be beneficial in allo-HCT patients. However, to date, no study has focused on long-term effects and survival. Previous exercise studies used ‘usual care’ control groups, leaving it unclear to what extent the observed effects are based on the physical effects of exercise itself, or rather on psychosocial factors such as personal attention. Furthermore, effects of exercise on and severity of GvHD have not been examined so far. We therefore aim to investigate the effects and biological mechanisms of exercise on side-effects, complications and survival in allo-HCT patients during and after transplantation.

Methods/design

The PETRA study is a randomized, controlled intervention trial investigating the effects of a yearlong partly supervised mixed exercise intervention (endurance and resistance exercises, 3–5 times per week) in 256 patients during and after allogeneic stem cell transplantation. Patients in the control group perform progressive muscle relaxation training (Jacobsen method) with the same frequency. Main inclusion criterion is planned allo-HCT. Main exclusion criteria are increased fracture risk, no walking capability or severe cardiorespiratory problems. Primary endpoint is overall survival after two years; secondary endpoints are non-relapse mortality, median survival, patient reported outcomes including cancer related fatigue and quality of life, physical performance, body composition, haematological/immunological reconstitution, inflammatory parameters, severity of complications and side-effects (e.g. GvHD and infections), and cognitive capacity.

Discussion

The PETRA study will contribute to a better understanding of the physiological and psychological effects of exercise training and their biological mechanisms in cancer patients after allo-HCT. The ultimate goal is the implementation of optimized intervention programs to reduce side-effects and improve quality of life and potentially prognosis after allogeneic stem cell transplantation.

Trial registration

ClinicalTrials.gov Identifier: NCT01374399.

Psychiatric considerations in the oncology setting

An aging population and advances in diagnostics and treatment have resulted in a rapidly growing population of people impacted by cancer. People live longer after a cancer diagnosis and tolerate more aggressive treatments than in the past. Younger patients struggle with diversions from the normal developmental milestones in career and relationships, while older patients deal with the dual challenges of aging and cancer. Cancer's transition from likely death to survival has increased interest in its impact on psychosocial issues and quality of life, rather than just longevity. In this article, the authors review the psychiatric diagnosis and management of the mental health issues most often encountered in oncology. Oncology treatment teams, including oncologists, nurses, social workers, and other ancillary staff, are often on the front lines of addressing psychiatric distress and clinical syndromes when psychiatrists are not easily available. The purpose of this review article is to highlight opportunities for nonpsychiatrists to improve identification and treatment of psychosocial distress and psychiatric syndromes and to request formal psychiatric consultation in appropriate situations. Psychotherapeutic, psychopharmacologic, cognitive, and behavioral-oriented interventions, as well as supportive interventions, are discussed for treating patients who are facing challenges during active cancer treatment, survivorship, and at the end of life. This review is not exhaustive but highlights the more common psychosomatic medicine and palliative care scenarios that impact cancer patient care. The importance of recognizing and addressing burnout and compassion fatigue in multidisciplinary professionals who care for those treated for cancer is also discussed given the secondary impact this can have on patient care.

Psychometric properties of the Cancer and Treatment Distress (CTXD) measure in hematopoietic cell transplantation patients

BACKGROUND

This study examines the psychometric properties of a measure of distress specific to cancer and its treatment, as tested in patients receiving hematopoietic cell transplantation (HCT).

METHODS

With multicenter enrollment, the Cancer and Treatment Distress (CTXD) measure was administered to adults beginning HCT as part of an assessment that included the Center for Epidemiologic Studies Depression (CESD), Profile of Mood States, and Medical Outcomes Study Short Form 36 (SF-36).

RESULTS

From eight transplant centers, 176 of 219 eligible patients completed the assessment. Average age was 46.7 years (SD = 11.9), 59% were male, and the majority were identified as Caucasian (93%). Principal components analysis with the CTXD identified 22 items that loaded onto six factors explaining 69% of the variance: uncertainty, health burden, identity, medical demands, finances, and family strain. Internal consistency reliability for the 22 items was 0.91. The receiver operating characteristic area under the curve was 0.85 (95% CI [0.79, 0.91]), with a cut point of 1.1 resulting in a sensitivity rate of 0.91 and a specificity rate of 0.58. Convergent validity and divergent validity were confirmed with large correlations of the CTXD total score with the CESD, Profile of Mood States, and SF-36 mental health; and a smaller correlation with the SF-36 physical function (r = -0.30).

CONCLUSIONS

The CTXD is a reliable and valid measure of distress for HCT recipients and captures nearly all cases of depression on the CESD in addition to detecting distress in those who are not depressed. It has potential value as both a research and clinical screening measure for distress.

Seventeen years of progress for supportive care services: A resurvey of National Cancer Institute-designated comprehensive cancer centers

OBJECTIVE

We replicated a 1994 study that surveyed the state of supportive care services due to changes in the field and the increased need for such services. We provide an updated assessment, comparing the changes that have occurred and describing the current status of supportive care services in comprehensive cancer settings.

METHOD

We used Coluzzi and colleague's 60-question survey from their 1995 Journal of Clinical Oncology article to frame the 98-question survey employed in the current study. Medical and palliative care directors for the 2011 National Cancer Institute (NCI) comprehensive cancer centers were surveyed regarding their supportive care services and their subjective review of the overall effectiveness of the services provided.

RESULTS

We achieved a 76% response rate (n = 31). The data revealed increases in the number of cancer beds in the hospitals, the degree of integration of supportive care services, the availability of complementary services, and the number of pain and palliative care services offered. There was also an overall shift toward centers becoming more patient centered, as 65% reported now having a patient and family advisory council. Our findings revealed a growing trend to offer distress screening for both outpatients and inpatients. Medical and palliative care directors' evaluations of the supportive care services they offered also significantly improved. However, the results revealed an ongoing gap in services for end-of-life care and timely referrals for hospice services.

SIGNIFICANCE OF RESULTS

Overall, both the quantity and quality of supportive care services in the surveyed NCI-designated cancer centers has improved.

A correlational study of suicidal ideation with psychological distress, depression, and demoralization in patients with cancer

PURPOSE

This study aims to study the effects of depression and demoralization on suicidal ideation and to determine the feasibility of the Distress Thermometer as a screening tool for patients with cancer who experience depression and demoralization, and thus to establish a model screening process for suicide prevention.

METHODS

Purposive sampling was used to invite inpatients and outpatients with lung cancer, leukemia, and lymphoma. Two hundred participants completed the questionnaire, which included the Distress Thermometer (DT), Patient Health Questionnaire-9 (PHQ-9), Demoralization Scale-Mandarin Version (DS-MV), and Beck Scale for Suicide Ideation. All data obtained were analyzed using SPSS 18.0 and SAS 9.3.

RESULTS

Tobit regression analysis showed that demoralization influenced suicidal ideation more than depression did (t = 2.84, p < 0.01). When PHQ-9 ≥ 10 and DS-MV ≥42 were used as criteria for the DT, receiver operating characteristic analysis revealed that the AUC values were 0.77-0.79, with optimal cutoff points for both of DT ≥5; sensitivity 76.9 and 80.6 %, respectively; and specificity of 73.9 and 72.2 %, respectively.

CONCLUSIONS

Demoralization had more influence on suicidal ideation than depression did. Therefore, attention should be paid to highly demoralized patients with cancer or high demoralization comorbid with depression for the purposes of suicide evaluation and prevention. The DT scale (with a cutoff of ≥5 points) has discriminative ability as a screening tool for demoralization or depression and can also be used in clinical settings for the preliminary screening of patients with cancer and high suicide risk.

Measurement of distress and its alteration during treatment in patients with nasopharyngeal carcinoma

BACKGROUND

We examined the criterion-related validity of the Distress Thermometer (DT) for screening distress in patients with nasopharyngeal carcinoma (NPC) and investigated prospectively how distress changes.

METHODS

In the cross-sectional study, the DT was tested against the Hospital Anxiety and Depression Scale (HADS) in 295 patients with NPC. In the prospective study, 61 newly diagnosed patients with NPC completed the DT and HADS 6 times.

RESULTS

Adopting HADS as the standard tool for screening distress, 31.5% of the patients with NPC had distress. A DT cutoff score ≥ 4 had best sensitivity (0.73) and specificity (0.85). In the prospective study, the proportion of patients with distress rose significantly during treatment.

CONCLUSION

Receiver operating characteristic (ROC) findings provide initial support for the validity of the DT among patients with NPC. Nearly one third of patients with NPC exceeded cutoff values for distress in the cross-sectional study. In the prospective study, the level of distress increased significantly during concurrent chemoradiotherapy for patients with NPC.

Monitoring patient distress and related problems before and after hematopoietic stem cell transplantation

Hematopoietic Stem Cell Transplantation (HSCT) is standard treatment for many high risk hematologic malignancies and non-malignant diseases either as part of overall treatment or after relapse. Both autologous and allogeneic transplant numbers are increasing worldwide (Storb, 2004). The procedure for transplantation is complex, can cause intense psychological distress, and extreme social strain on the patient, family members, and friends. There are times when the psychological and social issues can be more challenging for the health care team than the medical issues. Because HSCT is an intense and distinctive experience for patients and families and has the potential to cause prolonged psychological distress unlike other experiences with oncology patients, the issues unique to this population warrant special attention (Andrykowski, Brady, Henslee-Doeney, 1994, Andrykowski, 1994).

Hematopoietic stem cell transplant candidate and designated proxy distress levels prior to hematopoietic stem cell transplantation

Hematopoietic stem cell transplantation (HCT) is associated with a high risk of morbidity, making advance care planning (ACP) essential. The purpose of this study was to assess and compare proxy and HCT candidate distress levels (Distress Thermometer) before (T1) and after (T2) ACP question completion. 79 participants (40 HCT candidates, 39 proxies) rated their distress. The T1, T2 mean distress scores (SD) for HCT candidates were 3.13(2.27), 2.96(2.10); 43% and 38% endorsed clinically significant distress (≥4). Proxies reported 4.21(2.48), 4.33 (2.46); 62% endorsed significant distress at T1, T2. The majority of proxies endorsed distress levels that were clinically significant and comparatively higher (T1 (p = 0.047) and T2 (p = 0.009)) than their paired HCT recipients. Responding to questions about ACP did not increase overall distress ratings.

Mindfulness-based cancer stress management: impact of a mindfulness-based programme on psychological distress and quality of life

Within the area of cancer care, mindfulness-based therapeutic interventions have been found to be efficacious in reducing psychological distress related to a cancer diagnosis; however, the impact of mindfulness-based interventions on quality of life is unclear. This study explores the impact of a Mindfulness-Based Cancer Stress Management programme on psychological distress and quality of life. Research methodology included a single-group quasi-experimental study of 26 participants experiencing distress related to a cancer diagnosis, including carers, who completed an MBCSM programme and all assessments. Participants completed the Functional Assessment of Cancer Therapy - General version 4 (FACT-G) and its associated spirituality index (FACIT-Sp-Ex), Hospital Anxiety and Depression Scale (HADS), Freiburg Mindfulness Inventory (FMI), and the Distress Thermometer at baseline, post-intervention, and three months after programme completion. Significant improvements were observed on all measures (ranges: P ≤ 0.001 to 0.008, r = -0.53 to -0.79) following the intervention, which were maintained at 3-month follow-up. Mindfulness was significantly correlated with all main outcome measures at post-intervention (range: r = -0.41 to 0.67) and 3-month follow-up (range: r = -0.49 to 0.73), providing evidence for the internal validity of the study. Our findings indicate that the MBCSM programme is effective in reducing psychological distress and improving quality of life, including spiritual well-being.

Distress, problems and supportive care needs of patients treated with auto- or allo-SCT

Hematological malignancies and treatment with hematopoietic SCT are known to affect patients' quality of life. The problem profile and care needs of this patient group need clarification, however. This study aimed to assess distress, problems and care needs after allo- or auto-SCT, and to identify risk factors for distress, problems or care needs. In this cross-sectional study, patients treated with allo-SCT or auto-SCT for hematological malignancies completed the Distress Thermometer and Problem List. Three patient groups were created: 0-1, 1-2.5 and 2.5-5.5 years after transplantation. After allo-SCT, distress and the number of problems tended to be lower with longer follow-up. After auto-SCT, distress was highest at 1-2.5 year(s). Patients mainly reported physical problems, followed by cognitive-emotional and practical problems. A minority reported care needs. Risk factors for distress as well as problems after allo-SCT included younger age, shorter time after transplantation and GVHD. A risk factor for distress as well as problems after auto-SCT was the presence of comorbid diseases. Up to 5 years after auto-SCT or allo-SCT, patients continue to experience distress and problems. Judged by prevalence, physical problems are first priority in supportive care, followed by cognitive-emotional and practical problems.

Education for cancer-related fatigue: could talking about it make people more likely to report it?

PURPOSE

Education-based interventions for cancer-related fatigue have shown promise in adults undergoing radiotherapy. Research on the cancer-related fatigue intervention trial (CAN-FIT) programme found that pre-radiotherapy fatigue information and support (pre-RFES) did not improve levels of fatigue, but was associated with improvements in activity-based outcomes. We aimed to measure whether pre-RFES resulted in greater participant self-ratings of their performance of daily living activities, fatigue, quality of life and distress.

METHODS

Thirty people undergoing radiotherapy and/or chemotherapy were randomly allocated to either a 1-h RFES session from the CAN-FIT programme (delivered individually to participants and modified where necessary for patients undergoing chemotherapy) or standard care. Measures were taken pre- and post-treatment and 6 weeks after completing treatment.

RESULTS

There was no significant difference between groups on performance of daily living activities or ratings of distress. Further analysis found a significant difference between the control and treatment groups for EQ-5D health state visual analogue scale (-9.05 [-18.09; -0.018]; p < 0.05) and physical fatigue (2.86 [0.58; 5.14]; p < 0.02) with the treatment group rating their overall health state worse and their physical fatigue higher than the controls.

CONCLUSIONS

Pre-RFES delivered individually did not significantly improve participants' ratings of their performance of daily occupations and was unexpectedly associated with worse overall health state and higher physical fatigue. Future trials, ideally comparing individual and group education to exercise programmes or cognitive-behavioural approaches, are recommended to examine the broader question of whether discussing fatigue might actually make participants feel worse.

What to do with screening for distress scores? Integrating descriptive data into clinical practice

Objective:

Implementation of routine Screening for Distress constitutes a major change in cancer care, with the aim of achieving person-centered care.

Method:

Using a cross-sectional descriptive design within a University Tertiary Care Hospital setting, 911 patients from all cancer sites were screened at the time of their first meeting with a nurse navigator who administered a paper questionnaire that included: the Distress Thermometer (DT), the Canadian Problem Checklist (CPC), and the Edmonton Symptom Assessment System (ESAS).

Results:

Results showed a mean score of 3.9 on the DT. Fears/worries, coping with the disease, and sleep were the most common problems reported on the CPC. Tiredness was the most prevalent symptom on the ESAS. A final regression model that included anxiety, the total number of problems on the CPC, well-being, and tiredness accounted for almost 50% of the variance of distress. A cutoff score of 5 on the DT together with a cutoff of 5 on the ESAS items represents the best combination of specificity and sensitivity to orient patients on the basis of their reported distress.

Significance of results:

These descriptive data will provide valuable feedback to answer practical questions for the purpose of effectively implementing and managing routine screening in cancer care.

The Distress Thermometer in Spanish cancer patients: convergent validity and diagnostic accuracy

PURPOSE

International organizations such as National Comprehensive Cancer Network and NICE recommend implementation of routine screening programs for detecting and managing psychosocial distress among cancer patients. The selection of an adequate screening tool is crucial to the effectiveness of these programs. The present study examines the emotional symptomatology captured by the Distress Thermometer (DT) and its accuracy and validity as a screening tool in cancer. It also explores the possible discrepancy between patient distress and the use of psycho-oncology resources.

METHODS

A heterogeneous sample of 962 adult cancer patients completed the DT, the Problem List (PL), the Brief Symptom Inventory-18 (BSI-18), and the Psychosocial Questionnaire.

RESULTS

The DT was significantly correlated with BSI-18 symptoms and the emotional problems listed on the PL. Receiver Operating Characteristic analysis showed good diagnostic accuracy for the DT (area under the curve = .82, 95 %CI [.79-.85]). For a selected DT cutoff of 5, standard measures (sensitivity = 90 %, specificity = 64 %, predictive positive value = 35 %, and negative predictive value = 97 %) and Clinical Utility Indexes (utility index negative = .62 and utility index positive = .32) indicated that the DT was adequate for "screening" while it was limited for "case finding." Finally, 81.30 % of patients with clinical distress had not sought or were not receiving professional psychosocial support at the time of the study.

CONCLUSION

The DT is appropriate for use as a rapid screening instrument for cancer patients in a Spanish population because it assesses a broad concept of distress including both anxiety and depression symptoms. The diagnostic accuracy of the DT could be improved with minor proposed modifications to the DT and the inclusion of nonemotional ultrashort measures.

Representativeness of two sampling procedures for an internet intervention targeting cancer-related distress: a comparison of convenience and registry samples

Internet interventions often rely on convenience sampling, yet convenience samples may differ in important ways from systematic recruitment approaches. The purpose of this study was to evaluate potential demographic, medical, and psychosocial differences between Internet-recruited and registry-recruited cancer survivors in an Internet-based intervention. Participants were recruited from a cancer registry (n = 80) and via broad Internet outreach efforts (n = 160). Participants completed a set of self-report questionnaires, and both samples were compared to a population-based sample of cancer survivors (n = 5,150). The Internet sample was younger, better educated, more likely to be female, had longer time since diagnosis, and had more advanced stage of disease (p's < .001), and the registry-sample was over-represented by men and those with prostate or other cancer types (p's < .001). The Internet sample also exhibited lower quality of life and social support and greater mood disturbance (p's < .001). Understanding how convenience and systematic samples differ has important implications for external validity and potential for dissemination of Internet-based interventions.

Distress screening remains important during follow-up after primary breast cancer treatment

BACKGROUND

To improve psychosocial care, the National Comprehensive Cancer Network recommends the use of the Distress Thermometer (DT) to detect distress among cancer patients.

OBJECTIVES

The objectives of this study were to describe the prevalence of distress in breast cancer survivors (BCSs) and to investigate demographic, treatment, and psychosocial variables associated with distress and problems most often reported on the problem list. Moreover, we assessed how many BCSs requested referral to a professional for additional support.

METHODS

In a cross-sectional study, 258 BCSs identified at an outpatient clinic of a university hospital were asked to complete the following questionnaires: DT, Quality of Life Questionnaire, Hospital Anxiety and Depression Scale, and Illness Cognition Questionnaire.

RESULTS

Of the 258 identified BCSs, 129 (50 %) completed all questionnaires. After a mean follow-up period of 5.6 (SD, 10) years, 47 (36 %) of these 129 BCSs experienced distress as assessed by the DT. BCSs experienced significantly more distress in the first 2 years than in the period between 2 and 5 years after surgery. Also, more distress was experienced in BCSs treated with surgery, radiotherapy, and chemotherapy compared to those treated with surgery only. Problems most frequently encountered were fatigue (57 %), decrease in muscle strength (47 %), and lack of physical fitness (42 %). Thirty one (69 %) of the distressed BCSs requested or considered referral to a professional. Regression analysis showed that reduced quality of life, reduced cognitive function, and fatigue were predictors of distress.

CONCLUSION

The current study found that more than one third of all BCSs experienced distress. Screening remains an important part of BCSs' care. The professional should be aware of the potential problems and distress patients may experience.

The Distress Thermometer and its validity: a first psychometric study in Indonesian women with breast cancer

Purpose

This study aims to translate the Distress Thermometer (DT) into Indonesian, test its validity in Indonesian women with breast cancer and determine norm scores of the Indonesian DT for clinically relevant distress.

Methods

First, the original version of the DT was translated using a forward and backward translation procedure according to the guidelines. Next, a group of 120 breast cancer patients who were treated at the Outpatient Surgical Oncology Clinic in Hasan Sadikin Hospital in Indonesia completed a standard socio-demographic form, the DT and the Problem List, the Hospital Anxiety and Depression Scale (HADS) and the WHO Quality of Life (WHOQOL-BREF).

Results

Receiver operating characteristic (ROC) curve analyses identified an area under the curve = 0.81 when compared to the HADS cutoff score of 15. A cutoff score of 5 on the DT had the best sensitivity (0.81) and specificity (0.64). Patients who scored above this cutoff reported more problems in the practical, family, emotional, spiritual/religious and physical domains (30 out of 36 problems, p-value<0.05) than patients below the cutoff score. Patients at advanced stages of cancer experienced more emotional and physical problems. Patient's distress level was negatively correlated with overall quality of life, general health and all quality of life domains.

Conclusions

The DT was found to be a valid tool for screening distress in Indonesian breast cancer patients. We recommend using a cutoff score of 5 in this population.

High level of distress in long-term survivors of thyroid carcinoma: results of rapid screening using the distress thermometer

CONTEXT

Cancer patients are at increased risk for distress. The Distress Thermometer (DT) and problem list (PL) are short-tools validated and recommended for distress screening in cancer patients.

OBJECTIVE

To investigate the level of distress and problems experienced by survivors of differentiated non-medullary thyroid carcinoma (DTC), using the DT and PL and whether this correlates with clinical and demographical variables.

PARTICIPANTS, DESIGN AND SETTING

All 205 DTC patients, under follow-up at the outpatient clinic of our university hospital, were asked to fill in the DT and PL, hospital anxiety and depression scale (HADS), illness cognition questionnaire (ICQ) and an ad hoc questionnaire. Receiver Operator Characteristic analysis (ROC) was used to establish the optimal DT cut-off score according to HADS. Correlations of questionnaires scores with data on diagnosis, treatment and follow-up collected from medical records were analyzed.

RESULTS

Of the 159 respondents, 145 agreed to participate [118 in remission, median follow-up 7.2 years (range 3 months-41 years)]. Of these, 34.3% rated their distress score ≥5, indicating clinically relevant distress according to ROC analysis. Patients reported physical (86%) over emotional problems (76%) as sources of distress. DT scores correlated with HADS scores and ICQ subscales. No significant correlations were found between DT scores and clinical or demographical characteristics except for employment status.

CONCLUSION

Prevalence of distress is high among patients with DTC even after long-term remission and cannot be predicted by clinical and demographical characteristics. DT and PL are useful screening instruments for distress in DTC patients and could easily be incorporated into daily practice.

Screening for psychosocial risk in pediatric cancer

Major professional organizations have called for psychosocial risk screening to identify specific psychosocial needs of children with cancer and their families and facilitate the delivery of appropriate evidence-based care to address these concerns. However, systematic screening of risk factors at diagnosis is rare in pediatric oncology practice. Subsequent to a brief summary of psychosocial risks in pediatric cancer and the rationale for screening, this review identified three screening models and two screening approaches [Distress Thermometer (DT), Psychosocial Assessment Tool (PAT)], among many more articles calling for screening. Implications of broadly implemented screening for all patients across treatment settings are discussed.

Do cancer and treatment type affect distress?

OBJECTIVE

We examined differences in distress levels and Distress Thermometer (DT) cutoff scores between different cancer types. The effect of socio-demographic and illness-related variables on distress was also examined.

METHODS

One thousand three hundred fifty patients (response = 51%) completed questions on socio-demographic and illness-related variables, the Dutch version of the DT and Problem List, and the Hospital Anxiety and Depression Scale. Receiver operating characteristics analyses were performed to determine cancer specific cutoff scores. Univariate and multivariate effects of socio-demographic and illness-related variables (including cancer type) on distress were examined.

RESULTS

Prostate cancer patients reported significantly lower DT scores (M = 2.5 ± 2.5) and the cutoff score was lower (≥ 4) than in patients with most other cancer types (M varied between 3.4 and 5.1; cutoff ≥ 5). Multivariate analyses (F = 10.86, p < .001, R(2) = 0.08) showed an independent significant effect of four variables on distress: intensive treatment (β = .10, any (combination of) treatment but surgery only and 'wait and see'); a non-prostate cancer type (β = -.17); the interaction between gender and age (β = -.12, highest distress in younger women as compared with older women and younger and older men); and the interaction between cancer type and treatment intensity (β = .08, lowest scores in prostate cancer patients receiving non-intensive treatment as compared with their counterparts).

CONCLUSIONS

Distress and cutoff score in prostate cancer patients were lower than in patients with other cancer types. Additionally, younger women and patients receiving treatment other than surgery only or 'wait and see' are at risk for higher distress. These results can help identify patients possibly in need of referral to professional psychosocial and/or allied health care.

Screening for distress, the 6th vital sign: common problems in cancer outpatients over one year in usual care: associations with marital status, sex, and age

BACKGROUND

Very few studies examine the longitudinal prevalence of problems and the awareness or use of clinical programs by patients who report these problems. Of the studies that examine age, gender and marital status as predictors of a range of patient outcomes, none examines the interactions between these demographic variables. This study examined the typical trajectory of common practical and psychosocial problems endorsed over 12 months in a usual-care sample of cancer outpatients. Specifically, we examined whether marital status, sex, age, and their interactions predicted these trajectories. We did not actively triage or refer patients in this study in order to examine the natural course of problem reports.

METHODS

Patients completed baseline screening (N = 1196 of 1707 approached) and the sample included more men (N = 696) than women (N = 498), average age 61.1 years. The most common diagnoses were gastrointestinal (27.1%), prostate (19.2%), skin (11.1%) and gynecological (9.2%). Among other measures, patients completed a Common Problem Checklist and Psychosocial Resources Use questions at baseline, 3, 6, and 12 months using paper and pencil surveys.

RESULTS

Results indicated that patients reported psychosocial problems more often than practical and both decreased significantly over time. Younger single patients reported more practical problems than those in committed relationships. Younger patients and women of all ages reported more psychosocial problems. Among a number of interesting interactions, for practical problems, single older patients improved more; whereas among married people, younger patients improved more. For psychosocial problems we found that older female patients improved more than younger females, but among males, it was younger patients who improved more. Young single men and women reported the most past-and future-use of services.

CONCLUSIONS

Younger women are particularly vulnerable to experiencing practical and psychosocial problems when diagnosed with cancer, but being married protects these younger women. Marriage appeared to buffer reports of both practical and psychosocial problems, and led to less awareness and use of services. Unexpectedly, young men reported the highest use of psychosocial services. This study informs clinical program development with information on these risk groups.

Management of Cancer Related Distress in Patients with a Hematological Malignancy

Patients with hematologic malignancies often require urgent, aggressive, and lengthy chemotherapy treatment. These treatment regimens, divided into cycles, result in extended, often isolating periods of hospitalization where any direct clinical benefit for the patient, such as remission or "no evidence of disease" is not immediately declared. Consequently, this population is at a high risk of experiencing severe levels of cancer related distress. Cancer related distress is a complex psychosocial phenomenon that has consequences for patients, their families as well as the healthcare staff. Thus the importance of prevention, early recognition, treatment and management is unquestionable. Nurses have an important role to help identify and manage the presence of cancer related distress in these patients, as well as their family's. Nurses should work proactively in close partnership with an interdisciplinary team to effectively provide the necessary support for patients experiencing or who are at risk for high levels of cancer related distress. This case study and subsequent discussion illustrates the symptom management needs and challenges related to cancer related distress in the patient with a hematologic malignancy. Current evidence-based practice guidelines for the assessment and management of cancer related distress will be presented.

Measurement of distress in Chinese inpatients with lymphoma

PURPOSE

The aim of this study was to assess the levels and sources of distress in patients with lymphoma. This study also focused on the influence of factors of the level of distress and the cutoff score using the Distress Thermometer (DT) relative to the Hospital Anxiety and Depression Scale (HADS).

METHOD

DT and HADS were used to estimate the psychological status of 323 eligible lymphoma patients. The DT was evaluated against the HADS for its sensitivity and specificity.

RESULTS

One hundred and ninety-three (59.7%) lymphoma patients experienced overall distress on the HADS, with 137 (42.4%) experiencing anxiety and 114 (35.3%) suffering from depression. There were 199 (61.6%) and 163 (50.5%) patients with distress score ≥ 4 and ≥ 5, respectively. DT was significantly correlated with the HADS-total (T) (r=0.820, p<0.001), HADS-depression (D) (r=0.763, p<0.001), and HADS-anxiety (A) (r=0.738, p<0.001). The consistency of the DT and HADS was favorable (coherence index=0.6030, p<0.01) when the cutoff score was 5 for the DT. Referring to the cutoff of 15 on HADS, 5 on DT yielded optimal specificity (0.869, p<0.001) and sensitivity (0.756, p<0.001). In multiple logistic regression analysis, patients with 'B symptoms' were more likely to have a distress score ≥ 5 [OR=4.512, p<0.05, 95% CI 1.953-10.467].

CONCLUSION

DT is efficacious for screening for anxiety and depression in lymphoma patients.

Characterizing distress, the 6th vital sign, in an oncology pain clinic

CONTEXT

The delineation of populations of cancer patients with complex symptoms can inform the planning and delivery of supportive care services.

OBJECTIVES

We explored the physical, psychosocial, and practical concerns experienced by patients attending an ambulatory oncology symptom control clinic.

METHODS

Patients attending a Pain Clinic at a large tertiary cancer centre were invited to complete screening measures assessing distress, pain, fatigue, anxiety, depression, and practical and psychosocial problems. A matched sample of patients who did not attend the Pain Clinic were selected as a comparison group.

RESULTS

Of all eligible Pain Clinic patients, 46 (77%) completed the measures; so did 46 comparison group patients. The percentages of patients reporting distress (78.3%), pain (93.5%), and fatigue (93.5%) were higher among Pain Clinic patients than among the comparison patients. A higher percentage of Pain Clinic patients also reported multiple, severe, concurrent symptoms: 87% scored 7 or higher in at least one of the pain, fatigue, or distress scales, and 30.4% of the patients scored 7 or higher on all three. The most common problem areas were feeling a burden to others, trouble talking with friends and family, spirituality, and sleep difficulties.

CONCLUSIONS

Higher levels of multiple, concurrent symptoms and psychosocial problems were found in Pain Clinic patients than in a group of patients who did not attend the Pain Clinic. Routine screening and triaging of cancer patients using a comprehensive and standardized panel of questions can facilitate symptom assessment and management, and can inform program planning.

Quality of life, social challenges, and psychosocial support for long-term survivors after allogeneic hematopoietic stem-cell transplantation

Over the last two decades quality of life (QoL) and the social challenges of allogeneic hematopoietic stem cell transplant (allo-HSCT) survivors have been emerging as subjects of extensive research and are now considered as very important aspects in the pretransplant evaluation and management of allo-HSCT recipients. Recognition of QoL challenges in allo-HSCT survivors allows timely interventions leading to improvement of post-transplant outcomes. It needs to be recognized that long-lasting life changes associated with survivorship after allo-HSCT also significantly affect QoL of partners of allo-HSCT survivors. Currently, resources should be focused on how research findings can be used by patients, their partners, and physicians to optimize QoL and psychosocial adjustment.

Validation of Malaysian translated distress thermometer with problem checklist among the breast cancer survivors in Malaysia

INTRODUCTION

Distress thermometer (DT) is a single-item measure generated to assess the psychological distress among cancer patients. The aim of this study was to validate the translated DT as a tool to determine the psychological distress level and assess the factors associated with distress among the working breast cancer survivors and also to compare with the Hospital Anxiety and Depression Scale (HADS).

METHODS

150 working breast cancer survivors were interviewed using the Malay and Chinese language translated version of DT and HADS.

RESULTS

Based on HADS, 23.3% were anxious, 19.3% were depressed whereas 15.3% experienced both anxiety and depression. About 14.7% of the respondents reported distress (cutoff≥5) on DT. A significant association was found between the DT and HADS which indicated that both were measuring the same construct, Hospital Anxiety and Depression Scale-T (F=71.34, p<0.001), Hospital Anxiety and Depression Scale-A (F=65.81, p<0.001), Hospital Anxiety and Depression Scale-D (F=74.28, p<0.001). This study also showed that a cut-off of ≥5 on DT yielded an area under Receiver analysis characteristic curve (AUC) of 0.95 with a sensitivity of 90.9% and specificity of 89.8% for HADS-T score defined as cases. On the problem checklist, respondents scoring above the cut-off of 5 on DT had a greater number of problems with family (70.0%), emotional (65.0%), physical (60.0%), practical (50.0%) and spiritual/religious (15.0%) issues.

DISCUSSION

Overall, DT was a useful and simple screening tool to indicate psychological distress. The translated DT has a good sensitivity and specificity for screening psychological distress among the Malaysian breast cancer survivors.

Removing the stress from selecting instruments: arming social workers to take leadership in routine distress screening implementation

Quality cancer care requires identifying and addressing the psychosocial needs of cancer patients. Oncology social workers have long been on the forefront of this endeavor. Although there has been longstanding interest in screening cancer patients for distress, it has recently been included as a quality of care metric in institutions accredited by the American College of Surgeons. Implementing routine screening for distress in oncology settings requires thoughtful planning, including assessing various screening instruments and considering a host of variables within each practice setting. Oncology social workers are best positioned to provide leadership in operationalizing this mandate and to lead their team in the choice of a distress measure for compliance with the screening guideline. This article highlights the most popular distress screening measures used in oncology and their psychometric properties.

'Open Window': a randomized trial of the effect of new media art using a virtual window on quality of life in patients' experiencing stem cell transplantation

OBJECTIVES

To measure the psychological effect of an art intervention on hospitalized patients and explore benefits to their quality of life.

METHODS

We conducted a large prospective randomized trial between July 2006 and August 2009 of an art intervention, Open Window (OW), in patients undergoing stem cell transplantation for a hematological malignancy compared with a control group. The primary endpoint measured the effect of an art intervention on levels of anxiety, depression, and stress using the Hospital Anxiety and Depression Scale and the Distress Thermometer. The secondary endpoint measured the influence of OW on patients' experiences of stem cell transplantation using the OW survey and expectations questionnaires.

RESULTS

Of the 199 patients in the study, 96 were randomized to the intervention group and 103 to the control group. Participants in the intervention group had significantly reduced levels of anxiety on the day before transplant (p = 0.001), at day 7 (p = 0.041), and day 60 (p = 0.035). There was a significant reduction in depression before transplant (p = 0.022). Participants in the intervention group reported better experiences (p < 0.005). Qualitative data showed that those in the intervention group commented freely on their likes and dislikes about OW and how it made them feel.

CONCLUSION

An art intervention, OW, had a positive influence on health-related quality of life and patients' experiences of having a stem cell transplant.

Screening for distress, the sixth vital sign: examining self-referral in people with cancer over a one-year period

PURPOSE

Although research has indicated a diagnosis of cancer is most often distressing for patients and their families, few studies have examined which patients access resources to manage distress or how distress levels affect resource utilization. This study explored psychosocial and supportive care resource utilization in a large cancer population at a Canadian tertiary cancer centre over a 12-month period in a usual care setting.

METHODS

Patients who were new to the Tom Baker Cancer Centre completed the Distress Thermometer, the Pain and Fatigue Thermometers, the Psychological Screen for Cancer (Part C) that measures anxiety and depression, self-report questions on resources accessed and a demographic form at baseline, 3, 6 and 12 months. No feedback or specific triage to services was provided in order to observe usual care practices.

RESULTS

A total of 714 patients provided baseline data with 505 retained at 12 months. Twenty-four percent indicated they accessed at least one service (e.g. individual counselling, nutritionist or resource social worker) over the 12 months. Patients who were older, less educated and with lower income were less likely to access services. People who reported higher symptom burden were more likely to access services at each time point.

CONCLUSIONS

Overall levels of access of psychosocial services were relatively low in this population and varied by socio-demographic variables and symptom burden. Routine monitoring of psychosocial, practical and physical concerns is a potential strategy for targeting individuals who may require additional information or support in accessing available services to manage their concerns.

Sensitivity and specificity of the Distress Impact Thermometer for the detection of psychological distress among CRC survivors

This study assessed the relative screening performance of the Distress Impact Thermometer (DIT) and cutoff levels with the established clinical case threshold of the Hospital Anxiety and Depression Scale (HADS) among a sample of colorectal cancer (CRC) survivors. Fifty-nine CRC survivors completed the DIT, HADS, and provided demographic information at baseline, and 45 of these patients completed the same measures at follow-up, giving a total of 104 participant data. Receiver operating characteristic (ROC) analysis was performed to determine the accuracy of the DIT compared to the HADS, with a cutoff score ≥8 on each HADS subscale (depression and anxiety) and ≥15 on the HADS total scale used to identify patients with psychological distress. The sample comprised slightly more males (63%) than females, with an average age of 59 years (SD = 9.53) and ranging from 33 to 77 years. The optimum DT cutoff score of ≥5 yielded a sensitivity of 60% and specificity of 86.1%; the area under the curve was 0.771 (95% confidence interval [CI] [0.646, 0.896]). For the depression subscale, the DT performed better on specificity than sensitivity, however the opposite was true for the anxiety subscale. The addition of an impact thermometer did not enhance screening performance. The results of this study provide support for a DT score of ≥5 for detecting psychological distress among CRC survivors and do not support the addition of an impact thermometer. The use of the DT might underestimate depression but overestimate anxiety.

Can the distress thermometer (DT) identify significant psychological distress in long-term cancer survivors? A comparison with the Brief Symptom Inventory-18 (BSI-18)

BACKGROUND

As the number of cancer survivors continues to grow, identification of brief, valid psychological screening measures is critical for providing these survivors with appropriate psychosocial care. The distress thermometer (DT) is a one-item distress screening recommended by the National Comprehensive Cancer Network (NCCN) for screening cancer patients during their treatment.

METHOD

In this study, the validity of the DT for identifying psychological distress in cancer survivors was evaluated by comparing results of the DT to the Brief Symptom Inventory-18 (BSI-18) in a sample of 120 survivors of adult onset cancer.

RESULTS

Results indicated that when using the NCCN suggested cutoff score of 5, the DT only identified 10 of the 21 BSI-18 positive cases of psychological distress (sensitivity 47.6%; specificity 90.9%). Using an alternative DT cutoff score of 4, 12 of the 21 BSI-18 positive cases were identified (sensitivity 51.7%; specificity 89.9%).

CONCLUSIONS

The results do not support the validity of the DT in survivors of adult cancers.

Validity of the Patient Generated Index as a quality-of-life measure in radiation oncology

PURPOSE/OBJECTIVES

To evaluate psychometric properties of an instrument designed to measure individualized health-related quality of life (HRQOL).

DESIGN

Repeated measures of self-reported quality of life.

SETTING

An outpatient radiation therapy department in the western part of the United States.

SAMPLE

86 adults with cancer receiving their first course of radiation therapy.

METHODS

The Patient Generated Index (PGI), the National Comprehensive Cancer Network's Distress Thermometer (DT), and the European Organisation for Research and Treatment of Cancer Quality-of-Life Questionnaire-Core-30 (QLQ-C30).

MAIN RESEARCH VARIABLES

Convergent validity, responsiveness, sensitivity, and response shift.

FINDINGS

PGI scores were inversely correlated with scores on the DT (r = -0.49, -0.55, -0.44; p < 0.001), as well as the role (r = 0.31, 0.4, 0.38; p < 0.01), emotional (r = 0.33, 0.41, 0.33; p < 0.01), social functioning (r = 0.27, 0.49, 0.42; p < 0.05), pain (r = -0.29, -0.39, -0.39; p < 0.01), and fatigue (r = -0.35, -0.25, -0.47; p < 0.05) QLQ-C30 subscales at all measurement times. The PGI was responsive to those reporting high or low DT scores (t = 4.42, 3.32, 2.9; p < 0.05). A small-to-moderate effect size was detected in those who had an increase (effect size = 0.51) or decrease (effect size = 0.38) in HRQOL over time. Participants reconceptualized HRQOL over time.

CONCLUSIONS

Data supported the PGI as a valid measure of individualized HRQOL.

IMPLICATIONS FOR NURSING

The PGI potentially provides a more patient-centered measure of HRQOL in patients with cancer. Additional testing is needed in larger, more diverse groups.

Use of the Distress Thermometer for the Elderly in the identification of distress and need in nursing and care homes

BACKGROUND

Previous studies have found high levels of undetected psychological distress and unaddressed need among care home residents. The aim of this study was to investigate the usability and usefulness of the Distress Thermometer for the Elderly (DTE; modified from a measure used in cancer care) in the identification of distress and need with older people in care homes.

METHOD

This was a single group, cross-sectional study. Staff in 12 nursing homes and one care home in England completed the DTE and a measure of depression with their older residents (n = 66). Quantitative methods were employed to investigate the relationship between the Distress Thermometer rating, depression scores and problems or needs selected on the DTE.

RESULTS

The DTE was found to be feasible for completion by residents with assistance from staff. The level of distress on the DTE was significantly related to depression, number of problems and practical-physical problems. Each of 50 problems in the checklist was checked by at least one of the respondents. More problem items and physical-practical problems were selected by individuals who reached clinical levels of depression.

CONCLUSIONS

In this preliminary study, results indicate promising potential for the use of the DTE as a simple screening tool for distress, as well as to enable residents to record their perceived needs as part of care-planning and a broader person-centred approach.

Psychological Distress during Ovarian Cancer Treatment: Improving Quality by Examining Patient Problems and Advanced Practice Nursing Interventions

Background/Significance. Ovarian cancer patients are prone to psychological distress. The clinical significance and best practices for distress among this population are poorly understood. Method. Secondary analysis of research records from a six month randomized control trial included 32 women with primary ovarian cancer. All received 18 advanced practice nurse (APN) visits over six months. Three sub-samples were determined by distress level (high/low) and mental health service consent for high distress. Demographic, clinical factors, patient problems and APN interventions obtained through content analysis and categorized via the Omaha System were compared. Results. Clinically-significant psychiatric conditions were identified in 8/18 (44%) high distress subjects consenting to mental health intervention. High distress subjects who refused mental health intervention had more income and housing problems than the other subjects, received the fewest interventions at baseline, and progressively more throughout the study, exceeding the other sub-samples by study completion. Conclusions. Highly-distressed women not psychologically ready to work through emotional consequences of cancer at treatment onset may obtain support from APNs to manage cancer problems as they arise. Additional studies may identify best practices for all highly-distressed women with cancer, particularly those who do not accept mental health services for distress, but suffer from its effects.

Using the Distress Thermometer and Hospital Anxiety and Depression Scale to screen for psychosocial morbidity in patients diagnosed with colorectal cancer

BACKGROUND

The Distress Thermometer (DT) and Hospital Anxiety and Depression Scale (HADS) are commonly used within oncology settings. However there is a paucity of research comparing these measures to gold standard structured clinical interviews assessing for clinical disorders. The aim of this study is to establish the sensitivity, specificity and optimal cut-off scores on these measures when compared to a clinical interview.

METHOD

Ninety-nine patients with colorectal cancer completed the DT and HADS and a psychologist-administered gold standard structured clinical interview (the Composite International Diagnostic Interview-CIDI). Receiver Operator Characteristic analyses (ROC) were conducted to establish the optimal cut-off score on the DT and HADS to identify clinical disorders based on the CIDI.

RESULTS

Seventeen patients met criteria for a clinical disorder in the sample. A cut-off score of 4 on the DT indicated acceptable sensitivity (60%) and specificity (67%) to detect a current clinical disorder, while the optimal cut-off for the HADS was 10 (sensitivity=73%, specificity=72%). The area under the ROC values were 0.66 for the DT (95% CI: 0.51, 0.82) and 0.78 for the HADS (95% CI: 0.67, 0.90). The difference in AUC between the two measures was not statistically significant.

LIMITATIONS

The limitations to the design and methodology of the study are discussed.

CONCLUSION

The single item DT performed fairly, however not as well as the longer HADS in identifying clinical disorders amongst oncology patients, particularly anxiety disorders.