Effects of screening for psychological distress on patient outcomes in cancer: a systematic review

Suicide risk among cancer survivors: Head and neck versus other cancers

BACKGROUND

Cancer survivors face psychosocial issues that increase their risk of suicide. This study examined the risk of suicide across cancer sites, with a focus on survivors of head and neck cancer (HNC).

METHODS

The Surveillance, Epidemiology, and End Results 18-registry database (from 2000 to 2014) was queried for the top 20 cancer sites in the database, including HNC. The outcome of interest was suicide as a cause of death. The mortality rate from suicide was estimated for HNC sites and was compared with rates for 19 other cancer sites that were included in the study. Poisson regression was used to estimate adjusted rate ratios (aRRs) and 95% confidence intervals (CIs) for 1) HNC versus non-HNC sites (the other 19 cancer sites combined), and 2) HNC versus each individual cancer site. Models were stratified by sex, controlling for race, marital status, age, year, and stage at diagnosis.

RESULTS

There were 404 suicides among 151,167 HNC survivors from 2000 to 2014, yielding a suicide rate of 63.4 suicides per 100,000 person-years. In this timeframe, there were 4493 suicides observed among 4219,097 cancer survivors in the study sample, yielding an incidence rate of 23.6 suicides per 100,000 person-years. Compared with survivors of other cancers, survivors of HNC were almost 2 times more likely to die from suicide (aRR, 1.97; 95% CI, 1.77-2.19). There was a 27% increase in the risk of suicide among HNC survivors during the period from 2010 to 2014 (aRR, 1.27; 95% CI, 1.16-1.38) compared with the period from 2000 to 2004.

CONCLUSIONS

Although survival rates in cancer have improved because of improved treatments, the risk of death by suicide remains a problem for cancer survivors, particularly those with HNC.

A Distress Thermometer Intervention for Patients With Head and Neck Cancer

OBJECTIVES

To investigate the feasibility of an intervention using the National Comprehensive Cancer Network Distress Thermometer and Problem List with nurse-guided follow-up and the effect on depressive symptoms, health-related quality of life, and worry of cancer in patients with head and neck cancer.
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SAMPLE & SETTING

110 patients with head and neck cancer in a two-arm randomized, controlled trial in an outpatient clinic of a university hospital. 
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METHODS & VARIABLES

Patients were randomized to usual care (n = 57) or the intervention group (n = 53), which consisted of screening with the Distress Thermometer and Problem List plus nurse-guided follow-up lasting about 20 minutes three to four times during 12 months. Intention-to-treat analysis was performed using linear mixed models with outcomes at 6 and 12 months and baseline adjustment.
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RESULTS

The intervention showed moderate compliance and acceptable session duration. Intervention participants were satisfied with nurses' care. Depressive symptoms, health-related quality of life, and worry of cancer were not significantly different in the two treatment groups. The intervention seemed feasible in clinical practice, but no effects on patient outcomes were seen.
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IMPLICATIONS FOR NURSING

Patients with head and neck cancer appreciated the opportunity to discuss their problems and challenges with a nurse. Nurses supported patients with basic psychosocial care, minor interventions, and referral possibilities.

Optimal primary care management of clinical osteoarthritis and joint pain in older people: a mixed-methods programme of systematic reviews, observational and qualitative studies, and randomised controlled trials

Background

Osteoarthritis (OA) is the most common long-term condition managed in UK general practice. However, care is suboptimal despite evidence that primary care and community-based interventions can reduce OA pain and disability.

Objectives

The overall aim was to improve primary care management of OA and the health of patients with OA. Four parallel linked workstreams aimed to (1) develop a health economic decision model for estimating the potential for cost-effective delivery of primary care OA interventions to improve population health, (2) develop and evaluate new health-care models for delivery of core treatments and support for self-management among primary care consulters with OA, and to investigate prioritisation and implementation of OA care among the public, patients, doctors, health-care professionals and NHS trusts, (3) determine the effectiveness of strategies to optimise specific components of core OA treatment using the example of exercise and (4) investigate the effect of interventions to tackle barriers to core OA treatment, using the example of comorbid anxiety and depression in persons with OA.

Data sources

The North Staffordshire Osteoarthritis Project database, held by Keele University, was the source of data for secondary analyses in workstream 1.

Methods

Workstream 1 used meta-analysis and synthesis of published evidence about effectiveness of primary care treatments, combined with secondary analysis of existing longitudinal population-based cohort data, to identify predictors of poor long-term outcome (prognostic factors) and design a health economic decision model to estimate cost-effectiveness of different hypothetical strategies for implementing optimal primary care for patients with OA. Workstream 2 used mixed methods to (1) develop and test a ‘model OA consultation’ for primary care health-care professionals (qualitative interviews, consensus, training and evaluation) and (2) evaluate the combined effect of a computerised ‘pop-up’ guideline for general practitioners (GPs) in the consultation and implementing the model OA consultation on practice and patient outcomes (parallel group intervention study). Workstream 3 developed and investigated in a randomised controlled trial (RCT) how to optimise the effect of exercise in persons with knee OA by tailoring it to the individual and improving adherence. Workstream 4 developed and investigated in a cluster RCT the extent to which screening patients for comorbid anxiety and depression can improve OA outcomes. Public and patient involvement included proposal development, project steering and analysis. An OA forum involved public, patient, health professional, social care and researcher representatives to debate the results and formulate proposals for wider implementation and dissemination.

Results

This programme provides evidence (1) that economic modelling can be used in OA to extrapolate findings of cost-effectiveness beyond the short-term outcomes of clinical trials, (2) about ways of implementing support for self-management and models of optimal primary care informed by National Institute for Health and Care Excellence recommendations, including the beneficial effects of training in a model OA consultation on GP behaviour and of pop-up screens in GP consultations on the quality of prescribing, (3) against adding enhanced interventions to current effective physiotherapy-led exercise for knee OA and (4) against screening for anxiety and depression in patients with musculoskeletal pain as an addition to current best practice for OA.

Conclusions

Implementation of evidence-based care for patients with OA is feasible in general practice and has an immediate impact on improving the quality of care delivered to patients. However, improved levels of quality of care, changes to current best practice physiotherapy and successful introduction of psychological screening, as achieved by this programme, did not substantially reduce patients’ pain and disability. This poses important challenges for clinical practice and OA research.

Limitations

The key limitation in this work is the lack of improvement in patient-reported pain and disability despite clear evidence of enhanced delivery of evidence-based care.

Future work recommendations

(1) New thinking and research is needed into the achievable and desirable long-term goals of care for people with OA, (2) continuing investigation into the resources needed to properly implement clinical guidelines for management of OA as a long-term condition, such as regular monitoring to maintain exercise and physical activity and (3) new research to identify subgroups of patients with OA as a basis for stratified primary care including (i) those with good prognosis who can self-manage with minimal investigation or specialist treatment, (ii) those who will respond to, and benefit from, specific interventions in primary care, such as physiotherapy-led exercise, and (iii) develop research into effective identification and treatment of clinically important anxiety and depression in patients with OA and into the effects of pain management on psychological outcomes in patients with OA.

Trial registration

Current Controlled Trials ISRCTN06984617, ISRCTN93634563 and ISRCTN40721988.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research Programme and will be published in full inProgramme Grants for Applied Research Programme; Vol. 6, No. 4. See the NIHR Journals Library website for further project information.

Use of a self-reported psychosocial distress screening tool as a predictor of need for psychosocial intervention in a general medical setting

This study describes the development of a self-reported psychosocial distress screening tool for a general medical population and criteria to predict the need for psychosocial intervention. The objectives were to develop criteria to determine which patients need in-person screening and establish criteria identifying patients who are more likely to require psychosocial interventions. The outcomes have bearing on reducing initial psychosocial screening workload for medical social workers in high volume medical settings. Furthermore, a criterion for scoring the self-reported tool can predict which patients will need further social work intervention. The results suggest criteria are a score on the adapted Distress Thermometer of five or greater, at least two negative emotions, and a lack of health insurance. The optimal criterion identified 36% (446/1228) of patients in need of in-person screening with the remaining 64% (782/1228) screened low risk through the tool, representing a significant workload reduction.

Interventions to improve screening and appropriate referral of patients with cancer for psychosocial distress: systematic review

OBJECTIVES

The primary aim of the review was to determine the effectiveness of strategies to improve clinician provision of psychosocial distress screening and referral of patients with cancer.

DESIGN

Systematic review.

DATA SOURCES

Electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PsycINFO and Cumulative Index to Nursing and Allied Health Literature (CINAHL)) were searched until July 2016.

INCLUSION CRITERIA

Population: adult patients with cancer and clinical staff members.

INTERVENTION

any strategy that aimed to improve the rate of routine screening and referral for detected distress of patients with cancer. Comparison: no intervention controls, 'usual' practice or alternative interventions.

OUTCOME

(primary) any measure of provision of screening and/or referral for distress, (secondary) psychosocial distress, unintended adverse effects.

DESIGN

trials with or without a temporal comparison group, including randomised and non-randomised trials, and uncontrolled pre-post studies.

DATA EXTRACTION AND ANALYSIS

Two review authors independently extracted data. Heterogeneity across studies precluded quantitative assessment via meta-analysis and so a narrative synthesis of the results is presented.

RESULTS

Five studies met the inclusion criteria. All studies were set in oncology clinics or departments and used multiple implementation strategies. Using the Grades of Recommendation, Assessment, Development and Evaluation, the overall rating of the certainty of the body of evidence reported in this review was assessed as very low. Three studies received a methodological quality rating of weak and two studies received a rating of moderate. Only one of the five studies reported a significant improvement in referrals.

CONCLUSIONS

The review identified five studies of predominantly poor quality examining the effectiveness of strategies to improve the routine implementation of distress screening and referral for patients with cancer. Future research using robust research designs, including randomised assignment, are needed to identify effective support strategies to maximise the potential for successful implementation of distress screening and referral for patients with cancer.

PROSPERO REGISTRATION NUMBER

CRD42015017518.

Contributions and Limitations of National Cervical Cancer Screening Program in Korea: A Retrospective Observational Study

PURPOSE

The purpose of this study was to evaluate the contributions and limitations of the cervical cancer screening test with accuracy in Korea.

METHODS

This was a retrospective observational study. The study population consisted of all participants who underwent cervical cancer screening test from 2009 to 2014. The data were obtained from National Health Information Database (NHID) which represents medical use records of most Koreans. As the indices for contributions and limitations of the screening test, crude detection rate, incidence rate of interval cancer, sensitivity, specificity, and positive predictive value were used.

RESULTS

The crude detection rate of screening test per 100,000 participants increased from 100.7 in 2009 to 102.1 in 2014. The incidence rate of interval cancer per 100,000 negatives decreased from 13.0 in 2009 to 10.2 in 2014. The sensitivities of screening test were 88.7% in 2009 and 91.2% in 2014, and the specificities were 98.5% in 2009 and 97.7% in 2014. The positive predictive value of screening decreased from 6.2% in 2009 to 4.3% in 2014.

CONCLUSION

The Korean national cervical cancer screening program has improved in accuracy and has contributed to detection of early stage of cervical cancer over the years. Along with efforts to promote participation in cancer screening programs, quality control over the screening program should be enhanced.

Psychological distress among Indigenous Australian cancer survivors

PURPOSE

The purpose of this study is to identify the level of and factors associated with distress in 155 Indigenous Australian cancer survivors approximately 6 months post-diagnosis.

METHODS

The distress thermometer (DT) was used to assess clinically significant distress (defined as having a DT score ≥ 4). Logistic regression was used to identify sociodemographic and clinical factors associated with clinically significant distress.

RESULTS

The mean distress score was 2.7 (SD 2.9), with about one in three Indigenous cancer survivors reporting clinically significant distress (35%; n = 54). After adjusting for age and sex, clinically significant distress was more likely among those who were separated/divorced/widowed than those who were married (odds ratio (OR) = 2.99, 95% confidence intervals (95% CI) 1.21-7.35, p = 0.017) and less likely among those residing in remote areas than those in major cities (OR = 0.23, 95% CI 0.08-0.71, p = 0.001) and in those receiving non-surgical treatment only compared with surgery only (OR = 0.24, 95% CI 0.08-0.68, p = 0.008).

CONCLUSIONS

Despite increased screening for distress in cancer care, this is, to our knowledge, the first published assessment of distress among Indigenous Australian cancer survivors. The characteristics of Indigenous cancer survivors associated with greater likelihood of clinically significant distress indicate at-risk subgroups who would benefit from screening and early intervention. Further research is required to identify the specific aetiologies of distress. Our findings indicate a need to identify psychological distress and for survivorship care to include culturally sensitive and tailored psychological support for Indigenous cancer survivors.

The effects of individually tailored nurse navigation for patients with newly diagnosed breast cancer: a randomized pilot study

AIM

Our aim was to determine the feasibility and effectiveness of an individual, nurse-navigator intervention for relieving distress, anxiety, depression and health-related quality of life in women who have been treated for breast cancer (BC) and are experiencing moderate-to-severe psychological and physical symptoms.

METHODS

Fifty women with newly diagnosed BC who reported distress (score ≥7 on distress thermometer) before surgery were included consecutively in a pilot study and randomized 1:1 to the intervention or the control group. The intervention comprised repeated screening with patient reported outcome measures and nurse navigation. A total of 66 women who were not distressed (score <7) were followed longitudinally as an observational group. Participants filled in four questionnaires, at baseline, after 6 months and 12 months. The primary outcome was psychological distress and the secondary outcomes were anxiety, depression, health-related quality of life and feasibility of the intervention.

RESULTS

Women in the intervention group reported significantly greater satisfaction with treatment and rehabilitation and lower levels of distress (mean 2.7 vs. 5.1, p<.01), anxiety (mean 5.1 vs. 7.8, p = .02) and depression (mean 2.2 vs. 4.4, p = .04) after 12 months compared to the control group. No significant effects were seen on health-related quality of life.

CONCLUSIONS

The study shows promising feasibility of the individually tailored nurse-navigation intervention and while no significant effects were observed after 6 months, we did find statistically significant effects on distress, anxiety and depression 12 months after diagnosis. Our results will assist in developing rehabilitation to the most vulnerable patients.

Evaluation of a specialized oncology nursing supportive care intervention in newly diagnosed breast and colorectal cancer patients following surgery: a cluster randomized trial

BACKGROUND

Better coordination of supportive services during the early phases of cancer care has been proposed to improve the care experience of patients. We conducted a randomized trial to test a community-based nurse-led coordination of care intervention in cancer patients.

METHODS

Surgical practices were cluster randomized to a control group involving usual care practices or a standardized nursing intervention consisting of an in-person supportive care assessment with ongoing support to meet identified needs, including linkage to community services. Newly diagnosed breast and colorectal cancer patients within 7 days of cancer surgery were eligible. The primary outcome was the patient-reported outcome (PRO) of continuity of care (CCCQ) measured at 3 weeks. Secondary outcomes included unmet supportive care needs (SCNS), quality of life (EORTC QLQ-C30), health resource utilization, and level of uncertainty with care trajectory (MUIS) at 3 and/or 8 weeks.

RESULTS

A total of 121 breast and 72 colorectal patients were randomized through 28 surgical practices. There was a small improvement in the informational domain of continuity of care (difference 0.29 p = 0.05) and a trend to less emergency room use (15.8 vs 7.1%) (p = 0.07). There were no significant differences between groups on unmet need, quality of life, or uncertainty.

CONCLUSION

We did not find substantial gaps in the PROs measured immediately following surgery for breast and colorectal cancer patients. The results of this study support a more targeted approach based on need and inform future research focused on improving navigation during the initial phases of cancer treatment. ClinicalTrials.gov Identifier: NCT00182234. SONICS-Effectiveness of Specialist Oncology Nursing.

Dealing with cancer: a meta-synthesis of patients' and relatives' experiences of participating in psychosocial interventions

The aim was to synthesise patients' and relatives' experiences of participating in a psychosocial intervention related to having cancer. The study was a meta-synthesis inspired by Noblit & Hare's 'meta-ethnography' approach. We systematically searched six databases and included 33 studies in the meta-synthesis. Inclusion criteria were qualitative studies with relevance to the synthesis topic. The meta-synthesis conceptualised the way in which participants develop their way of living with cancer, and the role psychosocial interventions play in helping them to live through the illness. Five themes symbolising the participants' core experiences were identified: (1) Emotional relief and a sense of well-being, (2) normalisation of experiences and a sense of control, (3) shared experience and a sense of community, (4) a safe place and (5) transformation and adaptability. The findings indicated that psychosocial interventions were used to try to deal with the changes in the human conditions caused by cancer. Sharing their experiences and forming social relationships helped the participants adapt to cancer. An existential perspective may provide a nuanced understanding of patients' and relatives' experiences of participating in psychosocial interventions.

A Prevalence Study of Psychosocial Distress in Adolescents and Young Adults With Cancer

BACKGROUND

Psychosocial distress is common among cancer patients. Significant associations between coping and social support with distress and quality of life in adult cancer patients have been identified before, but little is known about the interrelationships between distress, medical coping, and social support in adolescents and young adults (AYAs).

OBJECTIVE

The aims of this study are to investigate the prevalence of psychological distress in Chinese AYAs with cancer and examine the associations among distress, anxiety and depression, medical coping, and social support in the same population.

METHODS

A total of 610 AYA patients were recruited for this study; 551 patients completed the Chinese version of the National Comprehensive Cancer Network Distress Thermometer (DT), the Hospital Anxiety and Depression Scale, the Medical Coping Modes Questionnaire, and the Social Support Rating Scale.

RESULTS

The prevalence of psychological distress was 89.1% in Chinese AYAs with cancer. The DT scores were the highest in the 21- to 25-year-old patients; the DT scores were positively correlated with anxiety and depression (P < .01) but negatively correlated with medical coping and social support (P < .01).

CONCLUSION

The prevalence of psychological distress in AYA cancer patients was higher than that in the general cancer population. Medical coping and social support can lower the prevalence of psychological distress in AYA cancer patients.

IMPLICATIONS FOR PRACTICE

Findings suggest the need for evidence-based intervention strategies to enhance medical coping and social support in AYA cancer patients. Nurses are crucial to implementing psychological interventions in AYA cancer patients.

The Effect of a Communicational Program on Psychological Distress in the Elderly Suffering from Cancer

BACKGROUND

Psychological distress is one of the most common psychological symptoms in elderly cancer patients. However, many of these patients do not receive any treatment for distress management. Therefore, we aimed to assess the effect of a communication program on the psychological distress of elderly cancer patients.

MATERIALS AND METHODS

This two-group clinical trial with a before and after design was conducted in Al-Zahra and Seyed-Al-Shohada hospitals affiliated to the Isfahan University of Medical Sciences in 2015. A total of 64 elderly patients were randomly assigned to two groups: experimental and control groups. A 3-week intervention (communicational program) consisting of distributing educational booklets, practices, and phone follow-ups was performed for the intervention group. All sessions were held during the 3-week period with sessions held twice per week both in the form of personal attendance and phone tracking, and the patients were encouraged to do the tasks assigned to them. The control group received routine care, and at the end of the study, the content of the sessions was explained to them. The demographic and clinical data of the participants were recorded, and all participants completed Kessler's Psychological Distress inventory at baseline and at the end of the 3-week intervention.

RESULTS

We found a significant difference in the psychological distress scores between the two groups before and after the intervention (P < 0.001, independent t-test). Moreover, the mean psychological distress scores decreased significantly in the experimental group after the intervention (P < 0.001, paired t-test).

CONCLUSIONS

Our communicational program had a positive effect on psychological distress in elderly patients with cancer. Therefore, this program could be used as an easy, cheap, and practical approach for reducing psychological distress in these patients.

Characterising the latent structure and organisation of self-reported thoughts, feelings and behaviours in adolescents and young adults

Little is known about the underlying relationships between self-reported mental health items measuring both positive and negative emotional and behavioural symptoms at the population level in young people. Improved measurement of the full range of mental well-being and mental illness may aid in understanding the aetiological substrates underlying the development of both mental wellness as well as specific psychiatric diagnoses. A general population sample aged 14 to 24 years completed self-report questionnaires on anxiety, depression, psychotic-like symptoms, obsessionality and well-being. Exploratory and confirmatory factor models for categorical data and latent profile analyses were used to evaluate the structure of both mental wellness and illness items. First order, second order and bifactor structures were evaluated on 118 self-reported items obtained from 2228 participants. A bifactor solution was the best fitting latent variable model with one general latent factor termed 'distress' and five 'distress independent' specific factors defined as self-confidence, antisocial behaviour, worry, aberrant thinking, and mood. Next, six distinct subgroups were derived from a person-centred latent profile analysis of the factor scores. Finally, concurrent validity was assessed using information on hazardous behaviours (alcohol use, substance misuse, self-harm) and treatment for mental ill health: both discriminated between the latent traits and latent profile subgroups. The findings suggest a complex, multidimensional mental health structure in the youth population rather than the previously assumed first or second order factor structure. Additionally, the analysis revealed a low hazardous behaviour/low mental illness risk subgroup not previously described. Population sub-groups show greater validity over single variable factors in revealing mental illness risks. In conclusion, our findings indicate that the structure of self reported mental health is multidimensional in nature and uniquely finds improved prediction to mental illness risk within person-centred subgroups derived from the multidimensional latent traits.

The effects of implementing a point-of-care electronic template to prompt routine anxiety and depression screening in patients consulting for osteoarthritis (the Primary Care Osteoarthritis Trial): A cluster randomised trial in primary care

BACKGROUND

This study aimed to evaluate whether prompting general practitioners (GPs) to routinely assess and manage anxiety and depression in patients consulting with osteoarthritis (OA) improves pain outcomes.

METHODS AND FINDINGS

We conducted a cluster randomised controlled trial involving 45 English general practices. In intervention practices, patients aged ≥45 y consulting with OA received point-of-care anxiety and depression screening by the GP, prompted by an automated electronic template comprising five questions (a two-item Patient Health Questionnaire-2 for depression, a two-item Generalized Anxiety Disorder-2 questionnaire for anxiety, and a question about current pain intensity [0-10 numerical rating scale]). The template signposted GPs to follow National Institute for Health and Care Excellence clinical guidelines for anxiety, depression, and OA and was supported by a brief training package. The template in control practices prompted GPs to ask the pain intensity question only. The primary outcome was patient-reported current pain intensity post-consultation and at 3-, 6-, and 12-mo follow-up. Secondary outcomes included pain-related disability, anxiety, depression, and general health. During the trial period, 7,279 patients aged ≥45 y consulted with a relevant OA-related code, and 4,240 patients were deemed potentially eligible by participating GPs. Templates were completed for 2,042 patients (1,339 [31.6%] in the control arm and 703 [23.1%] in the intervention arm). Of these 2,042 patients, 1,412 returned questionnaires (501 [71.3%] from 20 intervention practices, 911 [68.0%] from 24 control practices). Follow-up rates were similar in both arms, totalling 1,093 (77.4%) at 3 mo, 1,064 (75.4%) at 6 mo, and 1,017 (72.0%) at 12 mo. For the primary endpoint, multilevel modelling yielded significantly higher average pain intensity across follow-up to 12 mo in the intervention group than the control group (adjusted mean difference 0.31; 95% CI 0.04, 0.59). Secondary outcomes were consistent with the primary outcome measure in reflecting better outcomes as a whole for the control group than the intervention group. Anxiety and depression scores did not reduce following the intervention. The main limitations of this study are two potential sources of bias: an imbalance in cluster size (mean practice size 7,397 [intervention] versus 5,850 [control]) and a difference in the proportion of patients for whom the GP deactivated the template (33.6% [intervention] versus 27.8% [control]).

CONCLUSIONS

In this study, we observed no beneficial effect on pain outcomes of prompting GPs to routinely screen for and manage comorbid anxiety and depression in patients presenting with symptoms due to OA, with those in the intervention group reporting statistically significantly higher average pain scores over the four follow-up time points than those in the control group.

TRIAL REGISTRATION

ISRCTN registry ISRCTN40721988.

Use of the Distress Thermometer in a cancer helpline context: Can it detect changes in distress, is it acceptable to nurses and callers, and do high scores lead to internal referrals?

PURPOSE

To improve understanding about; (1) the validity of the Distress Thermometer (DT) as a measure of changes in distress after a cancer helpline call, (2) the impact of a helpline call on callers' distress, (3) caller and helpline nurses' comfort with use of the DT, and (4) the extent to which DT scores over the critical threshold, are associated with referral to internal support services for follow-up psychosocial care.

METHODS

Callers (people diagnosed with cancer and their family/friends: N = 100) completed a questionnaire that included DT ratings (three time-points), the Depression Anxiety and Stress Scale-21 (DASS-21) and measures of comfort with the DT tool. Nurses recorded referrals to internal services and their comfort in using the DT in each call.

RESULTS

The DT correlated with the DASS-21 depression (r = 0.45, p < 0.001), anxiety (r = 0.56, p < 0.001) and stress (r = 0.64, p < 0.001) subscales demonstrating validity. Callers' self-rated distress was significantly lower after the call, regardless of gender or caller type (F(2, 97) = 63.67, p < 0.01, partial eta squared = 0.57). Over 74% of people diagnosed with cancer, 80% family/friends and 89.3% of nurses felt comfortable with DT use. Only 16% of participants were referred on to follow-up internal support services despite 90% of people with cancer and 75% of family/friends' DT scores' suggesting they required follow-up care.

CONCLUSIONS

The DT is a valid and acceptable tool for use by cancer helplines. Improved documentation of referrals is required to better understand referral patterns.

Depression in cancer: The many biobehavioral pathways driving tumor progression

Major Depressive Disorder (MDD) is common among cancer patients, with prevalence rates up to four-times higher than the general population. Depression confers worse outcomes, including non-adherence to treatment and increased mortality in the oncology setting. Advances in the understanding of neurobiological underpinnings of depression have revealed shared biobehavioral mechanisms may contribute to cancer progression. Moreover, psychosocial stressors in cancer promote: (1) inflammation and oxidative/nitrosative stress; (2) a decreased immunosurveillance; and (3) a dysfunctional activation of the autonomic nervous system and of the hypothalamic-pituitaryadrenal axis. Consequently, the prompt recognition of depression among patients with cancer who may benefit of treatment strategies targeting depressive symptoms, cognitive dysfunction, fatigue and sleep disturbances, is a public health priority. Moreover, behavioral strategies aiming at reducing psychological distress and depressive symptoms, including addressing unhealthy diet and life-style choices, as well as physical inactivity and sleep dysfunction, may represent important strategies not only to treat depression, but also to improve wider cancer-related outcomes. Herein, we provide a comprehensive review of the intertwined biobehavioral pathways linking depression to cancer progression. In addition, the clinical implications of these findings are critically reviewed.

The effectiveness of a nurse-led intervention with the distress thermometer for patients treated with curative intent for breast cancer: design of a randomized controlled trial

Background

Distress in patients with cancer influences their quality of life. Worldwide, screening on distress with the Distress Thermometer (DT) in patients with cancer is recommended. However, the effects of the use of the DT on the psychosocial wellbeing of the patient are unknown. A study to assess the psychosocial consequences of the systematic use of the DT and its discussion by a nurse as compared to the usual care provided to outpatients who are treated for primary breast cancer is needed.

Methods/design

The effectiveness of a nurse-led intervention with the DT will be tested in a non-blinded randomized controlled trial. Patients treated with curative intent for breast cancer will be recruited from the Radboud University Medical Center. The intervention consists of the DT together with discussion of the results with the patient by a trained oncology nurse added to the usual care. Patients will be randomly allocated (1:1) to either receive usual care or the usual care plus the intervention. Primary outcome measure is global quality of life measured with the EORTC QLQ-C30. The functional and symptom scales of the EORTC QLQ-C30 and BR23, Hospital Anxiety and Depression Scale, Impact of Event Scale, Illness Cognition Questionnaire and DT (baseline and final measurement only) will be used to measure secondary outcomes. Questionnaires are obtained in both arms at baseline, after completion of each type of cancer treatment modality and during follow up, with a three and six months’ interval during the first and second year respectively.

Discussion

This study will be the first randomized controlled longitudinal study about the effectiveness of the DT as nurse led-intervention. In case of proven effectiveness, future implementation and standardization of use of the DT as part of routine care will be recommended.

Trial registration

This study is registered at clinicaltrial.gov march 17, 2010 (NCT01091584).

Replication initiatives will not salvage the trustworthiness of psychology

Replication initiatives in psychology continue to gather considerable attention from far outside the field, as well as controversy from within. Some accomplishments of these initiatives are noted, but this article focuses on why they do not provide a general solution for what ails psychology. There are inherent limitations to mass replications ever being conducted in many areas of psychology, both in terms of their practicality and their prospects for improving the science. Unnecessary compromises were built into the ground rules for design and publication of the Open Science Collaboration: Psychology that undermine its effectiveness. Some ground rules could actually be flipped into guidance for how not to conduct replications. Greater adherence to best publication practices, transparency in the design and publishing of research, strengthening of independent post-publication peer review and firmer enforcement of rules about data sharing and declarations of conflict of interest would make many replications unnecessary. Yet, it has been difficult to move beyond simple endorsement of these measures to consistent implementation. Given the strong institutional support for questionable publication practices, progress will depend on effective individual and collective use of social media to expose lapses and demand reform. Some recent incidents highlight the necessity of this.

Easier Said Than Done: Keys to Successful Implementation of the Distress Assessment and Response Tool (DART) Program

Purpose:

Systematic screening for distress in oncology clinics has gained increasing acceptance as a means to improve cancer care, but its implementation poses enormous challenges. We describe the development and implementation of the Distress Assessment and Response Tool (DART) program in a large urban comprehensive cancer center.

Method:

DART is an electronic screening tool used to detect physical and emotional distress and practical concerns and is linked to triaged interprofessional collaborative care pathways. The implementation of DART depended on clinician education, technological innovation, transparent communication, and an evaluation framework based on principles of change management and quality improvement.

Results:

There have been 364,378 DART surveys completed since 2010, with a sustained screening rate of > 70% for the past 3 years. High staff satisfaction, increased perception of teamwork, greater clinical attention to the psychosocial needs of patients, patient-clinician communication, and patient satisfaction with care were demonstrated without a resultant increase in referrals to specialized psychosocial services. DART is now a standard of care for all patients attending the cancer center and a quality performance indicator for the organization.

Conclusion:

Key factors in the success of DART implementation were the adoption of a programmatic approach, strong institutional commitment, and a primary focus on clinic-based response. We have demonstrated that large-scale routine screening for distress in a cancer center is achievable and has the potential to enhance the cancer care experience for both patients and staff.

Living an everyday life with head and neck cancer 2-2.5 years post-diagnosis - A qualitative prospective study of 56 patients

RATIONALE

There are many studies available describing how patients are affected by head and neck cancer (HNC) and its treatment. Usually these studies are quantitative and focus on assessing patients' quality of life or distress post-treatment. These studies are important, but they are of limited value if we are interested in understanding more about HNC in an everyday life context.

OBJECTIVE

The purpose was to determine how life was lived and valued during and after treatment for HNC and to detect different transitions in returning to everyday life.

METHODS

During 2009-2012, 56 patients with HNC were consecutively included, and interviewed at 6, 12, and 24 months post-treatment about how they lived their lives. All patients received primary treatment at a tertiary referral university hospital in Sweden.

RESULTS

Four different trajectories and transitions emerged. The first group (n = 15) evaluated their illness experience as a past parenthesis in their life suggesting that they had psychologically left the illness behind. In the second group (n = 9), the impact of the disease seemed to be diluted by other strains in their life, and although these patients to some extent were still hampered by side effects, they regarded them as 'no big deal'. The cancer really made a difference in the third group (n = 12) in both positive and negative ways and seemed to reflect a balance between such effects. In the fourth group (n = 20), the physical and/or psychological problems predominated and the patients' lives had changed for the worse.

CONCLUSION

The narratives showed that being afflicted by HNC has different impacts depending on how the patients live their lives - it is a matter of individual transition in an everyday life context. This idiosyncrasy challenges the meaningfulness of screening efforts to identify vulnerable groups for psychosocial intervention.

ReCAP: Would Women With Breast Cancer Prefer to Receive an Antidepressant for Anxiety or Depression From Their Oncologist?

PURPOSE

Patient treatment preferences for the management of anxiety and depression influence adherence to treatment and treatment outcomes, yet the preferences of patients with breast cancer for provider-specific pharmacologic management of anxiety and depression is unknown. This study examined the antidepressant prescriber preferences of patients with breast cancer and their preferences for treatment by a mental health professional.

METHODS

Patients with breast cancer (stages 0 to IV) were asked two questions: “Would you be willing to have your oncologist treat your depression or anxiety with an antidepressant medication if you were to become depressed or anxious at any point during your treatment?” and “Would you prefer to be treated by a psychiatrist or mental health professional for problems with either anxiety or depression?” In addition, the Distress Thermometer and Problem List, Hospital Anxiety and Depression Scale, Risky Families Questionnaire, and demographic information were assessed.

RESULTS

One hundred twenty-five participants completed the study. A total of 60.4% were willing to accept an antidepressant from an oncologist, and 26.3% preferred treatment by a mental health professional. The 77.3% who were willing to receive an antidepressant from their oncologist reported either no preference or that treatment by a mental health professional did not matter (P = .01). Participants taking antidepressants (P = .02) or reporting high chronic stress (P = .03) preferred a mental health professional.

CONCLUSION

The majority of patients accepted antidepressant prescribing by their oncologist; only a minority preferred treatment by a mental health professional. These findings suggest that promoting education of oncologists to assess psychological symptoms and manage anxiety and depression as a routine part of an outpatient visit is beneficial

Psychosocial Follow-Up in Survivorship as a Standard of Care in Pediatric Oncology

Childhood cancer survivors (CCS) have a high risk of medical late effects following cancer therapy. Psychosocial late effects are less often recognized. Many CCS do not receive long-term follow-up (LTFU) care, and those who do are rarely screened for psychosocial late effects. An interdisciplinary team conducted a systematic review of qualitative and quantitative studies to assess social, educational, vocational, psychological, and behavioral outcomes along with factors related to receipt of LTFU care. We propose that psychosocial screening be considered a standard of care in long-term follow-up care and that education be provided to promote the use LTFU care starting early in the treatment trajectory.

Interventions to improve screening and appropriate referral of patients with cancer for distress: systematic review protocol

INTRODUCTION

It is estimated that 35-40% of patients with cancer experience distress at some stage during their illness. Distress may affect functioning, capacity to cope, treatment compliance, quality of life and survival of patients with cancer. Best practice clinical guidelines recommend routine psychosocial distress screening and referral for further assessment and/or psychosocial support for patients with cancer. However, evidence suggests this care is not provided consistently.

METHODS AND ANALYSIS

We developed our methods following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. The review is registered with PROSPERO and any amendments to the protocol will be tracked. The primary aim of this systematic review is to examine the impact of interventions delivered in healthcare settings that are aimed at (1) improving routine screening of patients for psychosocial distress and (2) referral of distressed patients with cancer for further assessment and/or psychosocial support. The effectiveness of such interventions in reducing psychosocial distress, and any unintended adverse effect of the intervention will also be assessed in patients with cancer. Data sources will include the bibliographic databases Cochrane Central Register of Controlled trials (CENTRAL) in the Cochrane Library, MEDLINE, EMBASE, PsycINFO and CINAHL. Eligible studies must compare an intervention (or two or more interventions) in a healthcare setting to improve the rate of screening for psychosocial distress and/or referral for further assessment and/or psychosocial support for patients with cancer with no intervention or 'usual' practice. Two investigators will independently review titles and abstracts, followed by full article reviews and data extraction. Disagreements will be resolved by consensus and if necessary, a third reviewer. Where studies are sufficiently homogenous, trial data will be pooled and meta-analyses performed.

ETHICS AND DISSEMINATION

No ethical issues are foreseen. The findings of this study will be disseminated widely via peer-reviewed publications and conference presentations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD4 2015017518.

Supportive care needs and distress in patients with non-melanoma skin cancer: Nothing to worry about?

PURPOSE

There is a paucity of psychosocial research on non-melanoma skin cancer (NMSC) despite the fact that these malignancies mainly develop on the head and neck, frequently recur, and are associated with an increased risk for other cancers. The current study aims to respond to this gap in the scholarship by determining the prevalence of supportive care needs and examining the relationship between patients' needs and distress.

METHOD

A cross-sectional research protocol included a consecutive sample of 60 patients with squamous and/or basal cell carcinomas who completed a survey comprised of the Skin Cancer Index (SCI), the Hospital Anxiety and Depression Scale (HADS), the Supportive Care Needs (SCNS) Survey, an inquiry about informational needs regarding skin cancer prevention, and a socio-demographic questionnaire.

RESULTS

More than half of the patients indicated unmet needs, most frequently endorsing moderate and high needs for help with: the prevention of future skin cancers, the health system and informational matters. Psychological needs were strongly associated with skin cancer-specific and general distress. Higher levels of anxious and depressive symptoms were related to greater patient needs across all domains.

CONCLUSIONS

Despite NMSC not being life threatening in most cases, there is a significant proportion of patients, who have unmet supportive care needs and experience heightened distress levels. This study raises awareness for health care professionals to be vigilant about the supportive care needs and the psychological health of patients with non-melanoma skin cancer.

Correlates of oncologist-issued referrals for psycho-oncology services: what we learned from the electronic voluntary screening and referral system for depression (eVSRS-D)

OBJECTIVE

Depression in cancer patients is under-recognized and under-treated. To better identify depression, we designed a voluntary depression screening system. Based on its data, we examined trends in oncologist-issued referrals for the psycho-oncology service (POS).

METHODS

The Electronic Voluntary Screening and Referral System for Depression (eVSRS-D) comprises self-screening, automated reporting, and referral guidance. Using touch-screen kiosks at a tertiary hospital in Korea, participants with cancer completed the Patient Health Questionnaire-9 at their convenience, received the results, and reported their willingness to participate in POS. At oncology appointments, oncologists received the screening reports and issued referrals following pre-recommended guidelines. The correlates of actual referrals were examined across all participants and within the willing and non-willing groups.

RESULTS

Among the 838 participants, 56.3% reported severe depression symptoms, 30.5% wanted a referral, and 14.8% were actually referred. The correlates of participants' desire for referral were more severe depression symptoms, being unmarried, and being metastasis and recurrence free. Among all participants, the correlates of actual referrals were unemployment, less severe depression symptoms, poorer performance, treatment status, and wanting a referral. The sole correlate of actual referrals within the non-willing group was poorer performance, and no significant correlates existed within the willing group. The non-referrals were mostly (87.1%) because of postponed decisions.

CONCLUSIONS

The eVSRS-D cannot definitively diagnose major depression but may efficiently self-select a population with significant depression symptoms. The patients' willingness to engage the POS most strongly predicted the actual referrals. Oncologist reviews of screening reports may not result in further depression severity-specific referrals.

Effective, clinically feasible and sustainable: Key design features of psycho-educational and supportive care interventions to promote individualised self-management in cancer care

As the global burden of cancer increases healthcare services will face increasing challenges in meet the complex needs of these patients, their families and the communities in which they live. This raises the question of how to meet patient need where direct clinical contact may be constrained or not readily available. Patients and families require resources and skills to manage their illness outside of the hospital setting within their own communities.

AIM

To propose a framework for the development and delivery of psycho-educational and supportive care interventions drawing on theoretical principles of behaviour change and evidence-based interventions, and based on extensive experience in developing and testing complex interventions in oncology.

APPROACH

At the core of this intervention framework are considerations of efficiency: interventions are designed to cater for individuals' unique needs; to place minimal demands on the health system infrastructure and to be rapidly disseminated into usual care if successful. There are seven key features: 1) Targeting cancer type and stage; 2) Tailoring to unique individual needs; 3) Promotion of patient self-management of their disease and treatment side effects; 4) Efficient delivery of the intervention; 5) Training and adherence to protocol; 6) Ensuring the intervention is evidence-based; 7) Confirming stakeholder acceptability of the intervention.

APPLICATION

A case study of a randomised controlled trial which tested psycho-educational oncology interventions using this framework is presented. These interventions were designed to cater for individuals' unique needs and promote self-management while placing minimal demands on the acute health care setting.

DISCUSSION

Innovative ways to realise the potentially major impact that psycho-educational and supportive care interventions can have on psychological morbidity, coping, symptoms and quality of life in serious and chronic illness are needed. This framework, which is driven by theory, evidence, and experience, is designed to ensure that interventions are effective, clinically feasible and sustainable.

Developing a clinical pathway for the identification and management of anxiety and depression in adult cancer patients: an online Delphi consensus process

PURPOSE

People with cancer and their families experience high levels of psychological morbidity. However, many cancer services do not routinely screen patients for anxiety and depression, and there are no standardized clinical referral pathways. This study aimed to establish consensus on elements of a draft clinical pathway tailored to the Australian context.

METHODS

A two-round Delphi study was conducted to gain consensus among Australian oncology and psycho-oncology clinicians about the validity of 39 items that form the basis of a clinical pathway that includes screening, assessment, referral and stepped care management of anxiety and depression in the context of cancer. The expert panel comprised 87 multidisciplinary clinician members of the Australian Psycho-oncology Co-operative Research Group (PoCoG). Respondents rated their level of agreement with each statement on a 5-point Likert scale. Consensus was defined as >80% of respondents scoring within 2 points on the Likert scale.

RESULTS

Consensus was reached for 21 of 39 items, and a further 15 items approached consensus except for specific contextual factors, after two Delphi rounds. Formal screening for anxiety and depression, a stepped care model of management and recommendations for inclusion of length of treatment and time to review were endorsed. Consensus was not reached on items related to roles and responsibilities, particularly those not applicable across cancer settings.

CONCLUSIONS

This study identified a core set of evidence- and consensus-based principles considered essential to a stepped care model of care incorporating identification, referral and management of anxiety and depression in adult cancer patients.

Everybody wants it done but nobody wants to do it: an exploration of the barrier and enablers of critical components towards creating a clinical pathway for anxiety and depression in cancer

BACKGROUND

This study aimed to explore barriers to and enablers for future implementation of a draft clinical pathway for anxiety and depression in cancer patients in the Australian context.

METHODS

Health professionals reviewed a draft clinical pathway and participated in qualitative interviews about the delivery of psychosocial care in their setting, individual components of the draft pathway, and barriers and enablers for its future implementation.

RESULTS

Five interrelated themes were identified: ownership; resources and responsibility; education and training; patient reluctance; and integration with health services beyond oncology.

CONCLUSIONS

The five themes were perceived as both barriers and enablers and provide a basis for an implementation plan that includes strategies to overcome barriers. The next steps are to design and deliver the clinical pathway with specific implementation strategies that address team ownership, endorsement by leaders, education and training modules designed for health professionals and patients and identify ways to integrate the pathway into existing cancer services.

Reliability and validity of depression assessment among persons with HIV in sub-Saharan Africa: systematic review and meta-analysis

OBJECTIVE

The aim of this study was to systematically review the reliability and validity of instruments used to screen for major depressive disorder or assess depression symptom severity among persons with HIV in sub-Saharan Africa.

DESIGN

Systematic review and meta-analysis.

METHODS

A systematic evidence search protocol was applied to 7 bibliographic databases. Studies examining the reliability and/or validity of depression assessment tools were selected for inclusion if they were based on the data collected from HIV-positive adults in any African member state of the United Nations. A random-effects meta-analysis was used to calculate pooled estimates of depression prevalence. In a subgroup of studies of criterion-related validity, the bivariate random-effects model was used to calculate pooled estimates of sensitivity and specificity.

RESULTS

Of 1117 records initially identified, I included 13 studies of 5373 persons with HIV in 7 sub-Saharan African countries. Reported estimates of Cronbach alpha ranged from 0.63 to 0.95, and analyses of internal structure generally confirmed the existence of a depression-like construct accounting for a substantial portion of variance. The pooled prevalence of probable depression was 29.5% [95% confidence interval (CI): 20.5 to 39.4], whereas the pooled prevalence of major depressive disorder was 13.9% (95% CI: 9.7 to 18.6). The Center for Epidemiologic Studies Depression scale was the most frequently studied instrument, with a pooled sensitivity of 0.82 (95% CI: 0.73 to 0.87) for detecting major depressive disorder.

CONCLUSIONS

Depression-screening instruments yielded relatively high false positive rates. Overall, few studies described the reliability and/or validity of depression instruments in sub-Saharan Africa.

Psychiatric pathology and suicide risk in patients with cancer

The aims of the study were to assess sociodemographic and clinical factors associated with suicidal ideation in patients with cancer who required a psycho-oncological support. Among 504 participants, there were 136 (23 men and 113 women) cancer patients who completed psychological assessment when admitted to the Psycho-oncology Outpatient Clinic between 2006 and 2011. Suicidal ideation was assessed by Item 9 of the Brief Symptom Inventory, Hopelessness was assessed by the hopelessness subscale of the Mini-Mental Adjustment to Cancer Scale, and Depression was assessed by the depression subscale of the Hospital and Anxiety Depression Scale. Around 30% of this sample reported affective symptoms and around 20% reported suicidal ideation and hopelessness. Patients who reported suicidal ideation were more hopeless (18.8 ± 6.7 vs. 15.7 ± 5.2; t(134) = 2.54; p < 0.05) and reported more depression (11.8 ± 4.8 vs. 6.8 ± 4.1; t(134) = 5.30; p < 0.001). It is evident that cancer can result in a strong psychological distress in the patient. It is important, therefore, that cancer patients receive a proper assistance and psychological support and that both the possible presence of depression and suicidal ideation are constantly monitored.

American Cancer Society prostate cancer survivorship care guidelines

Prostate cancer survivors approach 2.8 million in number and represent 1 in 5 of all cancer survivors in the United States. While guidelines exist for timely treatment and surveillance for recurrent disease, there is limited availability of guidelines that facilitate the provision of posttreatment clinical follow-up care to address the myriad of long-term and late effects that survivors may face. Based on recommendations set forth by a National Cancer Survivorship Resource Center expert panel, the American Cancer Society developed clinical follow-up care guidelines to facilitate the provision of posttreatment care by primary care clinicians. These guidelines were developed using a combined approach of evidence synthesis and expert consensus. Existing guidelines for health promotion, surveillance, and screening for second primary cancers were referenced when available. To promote comprehensive follow-up care and optimal health and quality of life for the posttreatment survivor, the guidelines address health promotion, surveillance for prostate cancer recurrence, screening for second primary cancers, long-term and late effects assessment and management, psychosocial issues, and care coordination among the oncology team, primary care clinicians, and nononcology specialists. A key challenge to the development of these guidelines was the limited availability of published evidence for management of prostate cancer survivors after treatment. Much of the evidence relies on studies with small sample sizes and retrospective analyses of facility-specific and population databases.

Beyond treatment - Psychosocial and behavioural issues in cancer survivorship research and practice

The population of cancer survivors has grown steadily over the past several decades. Surviving cancer, however, is not synonymous with a life free of problems related to the disease and its treatment. In this paper we provide a brief overview of selected physical and psychosocial health problems prevalent among cancer survivors, namely pain, fatigue, psychological distress and work participation. We also address issues surrounding self-management and e-Health interventions for cancer survivors, and programmes to encourage survivors to adopt healthier lifestyles. Finally, we discuss approaches to assessing health-related quality of life in cancer survivors, and the use of cancer registries in conducting psychosocial survivorship research. We highlight research and practice priorities in each of these areas. While the priorities vary per topic, common themes that emerged included: (1) Symptoms should not be viewed in isolation, but rather as part of a cluster of interrelated symptoms. This has implications for both understanding the aetiology of symptoms and for their treatment; (2) Psychosocial interventions need to be evidence-based, and where possible should be tailored to the needs of the individual cancer survivor. Relatively low cost interventions with self-management and e-Health elements may be appropriate for the majority of survivors, with resource intensive interventions being reserved for those most in need; (3) More effort should be devoted to disseminating and implementing interventions in practice, and to evaluating their cost-effectiveness; and (4) Greater attention should be paid to the needs of vulnerable and high-risk populations of survivors, including the socioeconomically disadvantaged and the elderly.