Validation of the Distress Thermometer with bone marrow transplant patients

Use of the Distress Thermometer to discern clinically relevant quality of life differences in women with breast cancer

PURPOSE

The purpose of this study was to explore the ability of Distress Thermometer (DT) scores to discern important differences in quality of life scores among women with breast cancer.

METHODS

The National Comprehensive Cancer Network's DT, the Functional Assessment of Cancer Therapy-Breast (FACT-B), and a demographic questionnaire were completed by 111 women recently diagnosed with breast cancer.

RESULTS

Patients considered moderately to severely distressed (score ≥ 4 on DT) scored significantly lower on FACT-B QOL scales and subscales when compared to those in the group scoring 3 or below. For those scales for which minimally important differences (MIDs) have been established, differences between the two groups were 2-3 and a half times the established MID.

CONCLUSIONS

Moderately to severely distressed patients have significantly lower QOL than those with expected or mild distress. The DT provides a quick and easy screening tool to alert the healthcare team to clinically relevant alterations in patients' QOL.

Routine screening for psychological distress on an Australian inpatient haematology and oncology ward: impact on use of psychosocial services

OBJECTIVE

To describe the outcomes and clinical experience of a 12-week pilot study of routine distress screening of newly admitted patients to an acute haematology and oncology ward.

DESIGN, PATIENTS AND SETTING

Bedside measurement of psychological distress, and collection of demographic and clinical data for 115 newly admitted patients in an acute haematology and oncology ward of The Alfred hospital in Melbourne between 5 June and 25 August 2006.

MAIN OUTCOME MEASURES

Psychosocial distress as measured by the Distress Thermometer and Problem Checklist, and 18-item Brief Symptom Inventory; rate of referral to psychology and social work services in the 12 weeks before and 12 weeks during the pilot study; ward staff feedback on the benefits and challenges associated with routine distress screening.

RESULTS

51% of patients were identified as being significantly distressed, of whom 47% had not received psychosocial support before screening. A significantly higher number of emotional and physical problems were reported by significantly distressed patients. Referrals to psychology and social work services during the pilot study increased, highlighting that screening directed more patients into care. Staff were generally positive about the ability of routine screening to help them care for their patients, and most agreed that some form of routine screening should continue.

CONCLUSION

The use of routine distress screening by inpatient cancer services can significantly improve their capacity to offer psychosocial care.

Distress in patients with newly diagnosed brain tumours

OBJECTIVE

Patients with intracranial tumours often suffer from clinically relevant psychological distress. However, levels of distress and contributing factors have not been systematically evaluated for the early course of the disease. Using the National Comprehensive Cancer Network's Distress Thermometer (DT), we evaluated the extent and sources of distress within a population of patients with intracranial neoplasms.

METHODS

One hundred and fifty-nine patients were included who underwent craniotomy for newly diagnosed intracranial tumours at our department. All patients completed the DT questionnaire, a single-item 11-point visual analogue scale measuring psychological distress. The appendant problem list (PL) consists of 40 items representing problems commonly experienced by cancer patients. Patients were asked to mark any experienced sources of distress.

RESULTS

Percentage of patients suffering from relevant distress was 48.4% (cut-off ≥6). DT-scores were significantly associated with depression and anxiety as well as reported number of concerns. On average, patients reported 6.9 sources of cancer-related distress. Objective medical data (e.g. tumour stage) as well as sociodemographic data (e.g. gender, IQ) were not associated with psychological distress at this early phase.

CONCLUSIONS

Prevalence of elevated distress is high shortly after primary neurosurgical treatment in patients with intracranial tumours and cannot be predicted by objective data. As a consequence, sources of distress can and should be routinely assessed and targeted in these individuals in this particular period. Further studies are needed to help to identify patients who are at risk of suffering from long-term emotional distress in order to enable targeted psychosocial intervention.

Breast cancer patients receiving postoperative radiotherapy: distress, depressive symptoms and unmet needs of psychosocial support

BACKGROUND AND PURPOSE

The diagnosis and treatment of breast cancer can cause considerable psychological consequences, which may remain unrecognized and untreated. In this study, the prevalence of depressive symptoms and distress, and unmet needs for psychosocial support were assessed among breast cancer patients receiving postoperative radiotherapy.

MATERIAL AND METHODS

Out of 389 consecutive patients, 276 responded and comprised the final study group. Depressive symptoms were assessed with the Beck Depression Inventory. Distress was measured with the Distress Thermometer. Hospital records of the patients were examined for additional information.

RESULTS

Nearly one third of patients (32.1%) displayed depressive symptoms, and more than a quarter of patients (28.4%) experienced distress. Younger age (p=0.001) and negative hormone receptor status (p=0.008) were independent factors associated with distress. One quarter of the patients expressed an unmet need for psychosocial support, which was independently associated with depressive symptoms and/or distress (p=0.001) and younger age (p=0.006).

CONCLUSIONS

During radiotherapy for breast cancer, the staff should have awareness of the higher risk of depression and distress in their patients and should consider screening tools to recognise distress and depressive symptoms. Special attention should be paid to younger patients.

Distress screening in allogeneic hematopoietic stem cell (HSCT) caregivers and patients

Family caregivers of allogeneic hematopoietic stem cell transplant (HSCT) patients are at risk for experiencing significant psychological distress yet screening caregivers has not been well studied.

OBJECTIVE

This analysis explored the psychometric characteristics of the Distress Thermometer (DT) by examining its relationship, sensitivity, and specificity relative to the Brief Symptom Inventory 18 (BSI-18) and the Multidimensional Fatigue Symptom Inventory (MFSI) in a sample of allogeneic HSCT caregivers and patients.

METHODS

Longitudinal data were drawn from an ongoing intervention study for HSCT caregivers and patients. Data from one hundred and fifty-six English-speaking adults where patients (n = 65) were receiving their first allogeneic HSCT with at least one adult caregiver (n = 91) were eligible for this analysis. Study questionnaires were administered at baseline, initial discharge, and 6 weeks following discharge.

RESULTS

Construct validity was supported by significant relationships (p<0.001) between the DT and the BSI-18 GSI and the MFSI-Emotional subscales for caregivers and patients. The diagnostic utility of the DT for patients was good (AUC = 0.85±0.05, p = 0.001), while for caregivers it was poor (AUC = 0.61±0.08, p = 0.28). A DT cut point of 5 was supported for patients (sensitivity = 1.0, specificity = 0.68), while for caregivers there was less confidence (sensitivity = 0.70, specificity = 0.52). Caregivers and patients reporting a higher number of problems had a greater level of distress (p<0.001).

CONCLUSIONS

These findings support the validity of the DT in screening for distress in HSCT caregivers and patients. Although the diagnostic utility of the DT for HSCT caregivers may be limited, understanding factors associated with distress can guide practice for this understudied population.

A randomised trial of a psychosocial intervention for cancer patients integrated into routine care: the PROMPT study (promoting optimal outcomes in mood through tailored psychosocial therapies)

BACKGROUND

Despite evidence that up to 35% of patients with cancer experience significant distress, access to effective psychosocial care is limited by lack of systematic approaches to assessment, a paucity of psychosocial services, and patient reluctance to accept treatment either because of perceived stigma or difficulties with access to specialist psycho-oncology services due to isolation or disease burden. This paper presents an overview of a randomised study to evaluate the effectiveness of a brief tailored psychosocial Intervention delivered by health professionals in cancer care who undergo focused training and participate in clinical supervision.

METHODS/DESIGN

Health professionals from the disciplines of nursing, occupational therapy, speech pathology, dietetics, physiotherapy or radiation therapy will participate in training to deliver the psychosocial Intervention focusing on core concepts of supportive-expressive, cognitive and dignity-conserving care. Health professional training will consist of completion of a self-directed manual and participation in a skills development session. Participating health professionals will be supported through structured clinical supervision whilst delivering the Intervention. In the stepped wedge design each of the 5 participating clinical sites will be allocated in random order from Control condition to Training then delivery of the Intervention. A total of 600 patients will be recruited across all sites. Based on level of distress or risk factors eligible patients will receive up to 4 sessions, each of up to 30 minutes in length, delivered face-to-face or by telephone. Participants will be assessed at baseline and 10-week follow-up. Patient outcome measures include anxiety and depression, quality of life, unmet psychological and supportive care needs. Health professional measures include psychological morbidity, stress and burnout. Process evaluation will be conducted to assess perceptions of participation in the study and the factors that may promote translation of learning into practice.

DISCUSSION

This study will provide important information about the effectiveness of a brief tailored psychological Intervention for patients with cancer and the potential to prevent development of significant distress in patients considered at risk. It will yield data about the feasibility of this model of care in routine clinical practice and identify enablers and barriers to its systematic implementation in cancer settings.

TRIAL REGISTRATION

ACTRN12610000448044.

Acceptability of the Distress Thermometer and Problem List to community-based telephone cancer helpline operators, and to cancer patients and carers

BACKGROUND

Cancer can be a distressing experience for cancer patients and carers, impacting on psychological, social, physical and spiritual functioning. However, health professionals often fail to detect distress in their patients due to time constraints and a lack of experience. Also, with the focus on the patient, carer needs are often overlooked. This study investigated the acceptability of brief distress screening with the Distress Thermometer (DT) and Problem List (PL) to operators of a community-based telephone helpline, as well as to cancer patients and carers calling the service.

METHODS

Operators (n = 18) monitored usage of the DT and PL with callers (cancer patients/carers, >18 years, and English-speaking) from September-December 2006 (n = 666). The DT is a single item, 11-point scale to rate level of distress. The associated PL identifies the cause of distress.

RESULTS

The DT and PL were used on 90% of eligible callers, most providing valid responses. Benefits included having an objective, structured and consistent means for distress screening and triage to supportive care services. Reported challenges included apparent inappropriateness of the tools due to the nature of the call or level of caller distress, the DT numeric scale, and the level of operator training.

CONCLUSIONS

We observed positive outcomes to using the DT and PL, although operators reported some challenges. Overcoming these challenges may improve distress screening particularly by less experienced clinicians, and further development of the PL items and DT scale may assist with administration. The DT and PL allow clinicians to direct/prioritise interventions or referrals, although ongoing training and support is critical in distress screening.

Measurement of psychological distress in patients with intracranial tumours: the NCCN distress thermometer

Identification of patients suffering from elevated psychosocial distress, the sources of the distress, and the necessary treatment of the distress can be rather difficult within the neurosurgical setting (e.g., lack of time, cognitive or aphasic disorders of the patients). The distress thermometer (DT) is a single-item rapid distress screening tool by use of which these difficulties can be minimized. The objective of this study was to determine the optimum DT cut-off score that would identify significant distress in patients with intracranial tumours thus validating its use in the neurosurgical setting. In all, 150 patients were tested either during in-patient stay or during a follow-up examination before and after the neurosurgical removal of a primary intracranial neoplasm. Patients were administered the DT with the hospital anxiety and depression scale (HADS), the gold standard against which the DT was compared. The area under the receiver operating characteristics curve (ROC) was ≥0.82. Thus, the ability of the DT to correctly identify patients as significantly distressed was excellent. The DT ranges from 0 to 10. Its optimum cut-off score for identifying distressed patients was at or above 6 (sensitivity ≥ 88%; specificity ≥ 53%). The DT is a valid and practicable screening instrument for assessment of levels and sources of distress in patients with intracranial tumours in the neurosurgical setting.

Assessing the risk for suicide in patients with cancer

The Joint Commission publishes its annual National Patient Safety Goals to guide accredited organizations in addressing high-risk, low-volume concerns related to patient safety. The 2010 list includes a goal to identify patients at risk for suicide, but do oncology nurses need to be concerned about the risk of suicide in patients with cancer?

The sequelae of anxiety in breast cancer: a human response to illness model

PURPOSE/OBJECTIVES

To provide a critical review of the empirical literature on anxiety in women with breast cancer using the physiologic, pathophysiologic, behavior, and experiential perspectives of the Human Response to Illness (HRTI) Model.

DATA SOURCES

Research articles, clinical articles, and Internet sources on breast cancer and anxiety. Literature sources included CINAHL, PubMed, and PsycINFO, incorporating English language reports through March 2009.

DATA SYNTHESIS

Patients with breast cancer experience fluctuating levels of anxiety throughout their diagnosis and treatment trajectory. Anxiety may influence an individual's response to treatment, treatment decision making, and overall quality of life.

CONCLUSIONS

Research consistently demonstrates that anxiety in patients with breast cancer can have a negative effect on patient outcomes.

IMPLICATIONS FOR NURSING

The insight gained from exploring anxiety within the context of the four interrelated perspectives of the HRTI model fosters the provision of optimal care for patients suffering with anxiety throughout their breast cancer illness trajectory.

Evaluation of psychosocial distress in patients treated in a community-based oncology group practice in Germany

Background: Systematic evaluation of psychosocial distress in oncology outpatients is an important issue. We assessed feasibility and benefit of standardized routine screening using the Distress Thermometer (DT) and Problem List (PL) in all patients of our community-based hematooncology group practice.

Patients and methods: One thousand four hundred forty-six patients were screened between July 2008 and September 2008. Five hundred randomly selected patients were sent a feedback form.

Results: The average distress level was 4.7, with 37% indicating a distress level >5. Patients with nonmalignant diseases (81% autoimmune diseases or hereditary hemochromatosis) showed the highest distress level of 5.2. Most distressed were patients who just learned about relapse or metastases (6.4), patients receiving best supportive care (5.4) and patients receiving adjuvant antihormonal therapy (5.4). Ninety-seven percent of patients appreciated to speak to their doctor about their distress. Fifty-six percent felt better than usual after this consultation.

Conclusion: DT and PL are feasible instruments to measure distress in hematooncology outpatients receiving routine care. DT and PL are able to improve doctor–patient communication and thus should be implemented in routine patient care. The study shows that distress is distributed differently between individuals, disease groups and treatment phases.

Identification of patient-reported distress by clinical nurse specialists in routine oncology practice: a multicentre UK study

BACKGROUND

There is uncertainty regarding how well clinical nurse specialists are able to identify distress in cancer settings.

METHODS

We examined recognition of patient-reported distress by nurse specialists across three sites in the East Midlands (UK). Clinicians were asked to report on their clinical opinion regarding the presence of distress or any mental health complication after routine assessment of 401 mixed cancer patients. Patient-reported distress was defined by the distress thermometer at a cut-off of 4 or higher.

RESULTS

We found that the prevalence of patient-reported distress was 45.4%. The rates for mild, moderate and severe distress were: 23.4, 13.7 and 8.2, respectively. When looking for distress (or any mental health complication) nurse practitioners had a detection sensitivity of 50.5% and specificity 80.0%. Cohen's kappa suggested fair agreement between staff and patients. Examining predictors of distress, clinicians were better able to recognise higher severities of distress (adjusted R(2) =0.87 P=0.001). There was lower sensitivity in palliative stages but no differences according to the type of cancer. There was also higher sensitivity but lower specificity in those clinicians with high self-rated confidence.

CONCLUSIONS

Nurses working in cancer settings have difficulty identifying distress using their routine clinical judgement and tend to make more false-negative than false-positive errors. Evidence-based strategies that improve detection of mild and moderate distress are required in routine cancer care.

Feasibility of brief psychological distress screening by a community-based telephone helpline for cancer patients and carers

Background

Up to one-third of people affected by cancer experience ongoing psychological distress and would benefit from screening followed by an appropriate level of psychological intervention. This rarely occurs in routine clinical practice due to barriers such as lack of time and experience. This study investigated the feasibility of community-based telephone helpline operators screening callers affected by cancer for their level of distress using a brief screening tool (Distress Thermometer), and triaging to the appropriate level of care using a tiered model.

Methods

Consecutive cancer patients and carers who contacted the helpline from September-December 2006 (n = 341) were invited to participate. Routine screening and triage was conducted by helpline operators at this time. Additional socio-demographic and psychosocial adjustment data were collected by telephone interview by research staff following the initial call.

Results

The Distress Thermometer had good overall accuracy in detecting general psychosocial morbidity (Hospital Anxiety and Depression Scale cut-off score ≥ 15) for cancer patients (AUC = 0.73) and carers (AUC = 0.70). We found 73% of participants met the Distress Thermometer cut-off for distress caseness according to the Hospital Anxiety and Depression Scale (a score ≥ 4), and optimal sensitivity (83%, 77%) and specificity (51%, 48%) were obtained with cut-offs of ≥ 4 and ≥ 6 in the patient and carer groups respectively. Distress was significantly associated with the Hospital Anxiety and Depression Scale scores (total, as well as anxiety and depression subscales) and level of care in cancer patients, as well as with the Hospital Anxiety and Depression Scale anxiety subscale for carers. There was a trend for more highly distressed callers to be triaged to more intensive care, with patients with distress scores ≥ 4 more likely to receive extended or specialist care.

Conclusions

Our data suggest that it was feasible for community-based cancer helpline operators to screen callers for distress using a brief screening tool, the Distress Thermometer, and to triage callers to an appropriate level of care using a tiered model. The Distress Thermometer is a rapid and non-invasive alternative to longer psychometric instruments, and may provide part of the solution in ensuring distressed patients and carers affected by cancer are identified and supported appropriately.

Screening for emotional distress in cancer patients: a systematic review of assessment instruments

Screening for emotional distress is becoming increasingly common in cancer care. This systematic review examines the psychometric properties of the existing tools used to screen patients for emotional distress, with the goal of encouraging screening programs to use standardized tools that have strong psychometrics. Systematic searches of MEDLINE and PsycINFO databases for English-language studies in cancer patients were performed using a uniform set of key words (eg, depression, anxiety, screening, validation, and scale), and the retrieved studies were independently evaluated by two reviewers. Evaluation criteria included the number of validation studies, the number of participants, generalizability, reliability, the quality of the criterion measure, sensitivity, and specificity. The literature search yielded 106 validation studies that described a total of 33 screening measures. Many generic and cancer-specific scales satisfied a fairly high threshold of quality in terms of their psychometric properties and generalizability. Among the ultrashort measures (ie, those containing one to four items), the Combined Depression Questions performed best in patients receiving palliative care. Among the short measures (ie, those containing five to 20 items), the Center for Epidemiologic Studies–Depression Scale and the Hospital Anxiety and Depression Scale demonstrated adequate psychometric properties. Among the long measures (ie, those containing 21–50 items), the Beck Depression Inventory and the General Health Questionaire–28 met all evaluation criteria. The PsychoSocial Screen for Cancer, the Questionnaire on Stress in Cancer Patients–Revised, and the Rotterdam Symptom Checklist are long measures that can also be recommended for routine screening. In addition, other measures may be considered for specific indications or disease types. Some measures, particularly newly developed cancer-specific scales, require further validation against structured clinical interviews (the criterion standard for validation measures) before they can be recommended.

Distress in older patients with cancer

PURPOSE

To determine the predictors of distress in older patients with cancer.

PATIENTS AND METHODS

Patients age >or= 65 years with a solid tumor or lymphoma completed a questionnaire that addressed these geriatric assessment domains: functional status, comorbidity, psychological state, nutritional status, and social support. Patients self-rated their level of distress on a scale of zero to 10 using a validated screening tool called the Distress Thermometer. The relationship between distress and geriatric assessment scores was examined.

RESULTS

The geriatric assessment questionnaire was completed by 245 patients (mean age, 76 years; standard deviation [SD], 7 years; range, 65 to 95 years) with cancer (36% stage IV; 71% female). Of these, 87% also completed the Distress Thermometer, with 41% (n = 87) reporting a distress score of >or= 4 on a scale of zero to 10 (mean score, 3; SD, 3; range, zero to 10). Bivariate analyses demonstrated an association between higher distress (>or= 4) and poorer physical function, increased comorbid medical conditions, poor eyesight, inability to complete the questionnaire alone, and requiring more time to complete the questionnaire. In a multivariate regression model based on the significant bivariate findings, poorer physical function (increased need for assistance with instrumental activities of daily living [P = .015] and lower physical function score on the Medical Outcomes Survey [P = .018]) correlated significantly with a higher distress score.

CONCLUSION

Significant distress was identified in 41% of older patients with cancer. Poorer physical function was the best predictor of distress. Further studies are needed to determine whether interventions that improve or assist with physical functioning can help to decrease distress in older adults with cancer.

Beating the blues after cancer: randomised controlled trial of a tele-based psychological intervention for high distress patients and carers

BACKGROUND

The diagnosis and treatment of cancer is a major life stress such that approximately 35% of patients experience persistent clinically significant distress and carers often experience even higher distress than patients. This paper presents the design of a two arm randomised controlled trial with patients and carers who have elevated psychological distress comparing minimal contact self management vs. an individualised tele-based cognitive behavioural intervention.

METHODS/DESIGN

140 patients and 140 carers per condition (560 participants in total) will been recruited after being identified as high distress through caller screening at two community-based cancer helplines and randomised to 1) a single 30-minute telephone support and education session with a nurse counsellor with self management materials 2) a tele-based psychologist delivered five session individualised cognitive behavioural intervention. Session components will include stress reduction, problem-solving, cognitive challenging and enhancing relationship support and will be delivered weekly. Participants will be assessed at baseline and 3, 6 and 12 months after recruitment. Outcome measures include: anxiety and depression, cancer specific distress, unmet psychological supportive care needs, positive adjustment, overall Quality of life.

DISCUSSION

The study will provide recommendations about the efficacy and potential economic value of minimal contact self management vs. tele-based psychologist delivered cognitive behavioural intervention to facilitate better psychosocial adjustment and mental health for people with cancer and their carers.

TRIAL REGISTRATION

ACTRN12609000301268.

Amazon heart: an exploration of the role of challenge events in personal growth after breast cancer

High-profile events where in response to the experience of breast cancer women take on adventure activities to raise awareness and/or funds for breast cancer are increasing. These activities offer physical and psychological challenges within a peer support group setting. We investigated the experiences of 21 breast cancer survivors who participated in a 7-day breast cancer awareness motorcycle ride. Assessments included a qualitative pre/postinterview, solicited diary, pre-6-month follow-up survey. Measures included satisfaction with life, distress, happiness, global well being, meaning in life. Motivators were a desire for peer support, to promote breast cancer awareness, enjoyment, and personal growth. The ride incorporated physical and emotional challenge. A positive peer support experience led to feelings of inner peace, accomplishment, self-learning, a positive perspective, and improved social support. For a minority of women peer support or recreational expectations were not met resulting in negative feelings. No significant changes were observed over time in adjustment measures. Adventure events where women undertake emotional and physical challenge in an environment of group peer support provide opportunity for personal growth. In this context, peer support may provide the catalyst for the experience to become transformational and so is critical to generating positive outcomes. Realistic expectations of the ride are also influential.

Affective syndromes and their screening in cancer patients with early and stable disease: Italian ICD-10 data and performance of the Distress Thermometer from the Southern European Psycho-Oncology Study (SEPOS)

BACKGROUND

The assessment of mood and anxiety disorders secondary to cancer by using easy-to-administer instruments has been the object of recent research.

METHODS

The aim of this study was to examine the accuracy of the short screening tool developed by the National Comprehensive Cancer Network Clinical Practice Guidelines for Distress Management, (0-10 point-scale Distress Thermometer) (DT) in detecting affective syndrome disorders in Italian cancer patients. The sample consisted of 109 cancer outpatients who were administered the ICD-10 psychiatric interview (CIDI), the DT and the Hospital Anxiety Depression Scale (HADS).

RESULTS

Forty-four patients (40.4%) met the criteria for an ICD-10 diagnosis of affective syndromes. The DT was significantly associated with HADS-Total score (r=0.66, p=0.001). A cut-off > or = 4 on the DT showed a sensitivity of 79.5% and a specificity of 75.4% (positive predictive value--PPV = 68.6%; negative predictive value--NPV = 84.5%). The cut-off score > or = 10 on the HADS was associated with a sensitivity of 86% and a specificity of 81.5% (PPV = 76%; NPV = 89.9%). A cut-off score > or = 5 on DT and > or = 15 on HADS maximized sensitivity (78.6% and 85%, respectively) and specificity (83.1% and 96%, respectively) for patients with more severe affective syndromes (major depression, persistent depressive disorders).

CONCLUSIONS

The results suggest that simple instruments can be used as feasible tools in the screening of mood and anxiety disorders among cancer patients.

Screening cancer patients' families with the distress thermometer (DT): a validation study

Although family members of cancer patients are at great risk of experiencing psychological distress, clinical tools to assist with recognizing and intervening with appropriate psychosocial care are sparse. This study reports on the first validation of the distress thermometer (DT) as a screening instrument for symptoms of depression and anxiety in family members of cancer patients. The DT was administered with the Hospital Anxiety and Depression Scale (HADS) in a sample of 321 family members. Receiver operating characteristics (ROC) demonstrated that the DT has good diagnostic utility relative to the HADS (area under the curve= 0.88 relative to the HADS anxiety scale; 0.84 relative to the HADS depression scale, respectively). The ROC curves indicate that using a cut-off of 4/5 maximizes sensitivity (86.2% HADS anxiety scale; 88.2% HADS depression scale) and specificity (71.2% HADS anxiety scale; 67.6% HADS depression scale); however, the alternative lower cut-off of 3/4 increases sensitivity (94.1% for both scales) and hence reduces the risk of missing distressed family members (specificity is 62.9% for HADS anxiety scale; 59.1% for HADS depression scale). The results offer validation of the DT for screening family members of cancer patients and support its use for clinical assessment. Distress screening with DT for family members of cancer patients is a promising and efficient approach to integrating family members in the program of care and provides the first step toward meeting their unmet needs with referral for supportive services.

Changes in quality-of-life and psychosocial adjustment among multiple myeloma patients treated with high-dose melphalan and autologous stem cell transplantation

High-dose melphalan and autologous hematopoietic stem cell transplantation (HSCT) is a standard treatment for myeloma, but very little is known about the psychosocial or quality-of-life difficulties that these patients encounter during treatment. Data regarding older patients is particularly scarce. Using a prospective design, this investigation evaluated 94 patients at stem cell collection and again after high-dose therapy and transplantation. Outcomes included quality-of-life (FACT-BMT) and psychosocial adjustment (ie, Brief Symptom Inventory, Impact of Events Scale, and Satisfaction with Life Scale). Findings were compared with age- and sex-adjusted population norms and with transplantation patient norms. At stem cell collection, physical deficits were common, with most patients scoring 1 standard deviation below population norms for physical well-being (70.2%) and functional well-being (57.5%), and many reporting at least moderate fatigue (94.7%) and pain (39.4%). Clinically meaningful levels of anxiety (39.4%), depression (40.4%), and cancer-related distress (37.0%) were evident in a notable proportion of patients. After transplantation, there was a worsening of transplant-related concerns (P < .05), depression (P < .05), and life-satisfaction (P < .001); however, pain improved (P < .01), and social functioning was well preserved. Overall, the declines in functioning after transplantation were less pronounced than anticipated. Older patients were not more compromised than younger ones; in multivariate analyses, they reported better overall quality of life (P < .01) and less depression (P < .05) before transplantation. Our findings emphasize the importance of early screening and intervention.

Effects of a nursing intervention on quality of life outcomes in post-surgical women with gynecological cancers

OBJECTIVE

Women with gynecological cancers have reported poor health-related quality of life (QOL), with complex physical and psychological needs post-surgery and during chemotherapy treatment. There are no studies reporting interventions addressing these needs post-hospital discharge in this population.

METHODS

Patients were randomized into two groups. The intervention group received 6 months of specialized care by an Advanced Practice Nurse (APN); in addition, women with high distress were evaluated and monitored by a psychiatric consultation-liaison nurse (PCLN). The attention control group was assisted with symptom management by a research assistant. The effects of the 6-month intervention were evaluated using self-report questionnaires at baseline (24-48 h after surgery), 1, 3, and 6 months post- surgery. QOL assessments included the Center for Epidemiological Studies-Depression Scale , the ambiguity subscale of the Mishel Uncertainty in Illness Scale , the Symptom Distress Scale, and the Short-Form Health Survey (SF-12). The sample for the longitudinal analysis included 123 who completed QOL outcome measures across three occasions post-surgery.

RESULTS

The APN intervention resulted in significantly less uncertainty than the attention control intervention 6 months after surgery. When the sub-group who received the APN plus PCLN intervention was compared with the total attention control group, the sub-group had significantly less uncertainty, less symptom distress, and better SF-12 mental and physical QOL over time.

CONCLUSION

Nurse tailored interventions that target both physical and psychological aspects of QOL in women recovering from cancer surgery and undergoing chemotherapy produce stronger outcomes than interventions that target solely one QOL aspect.

The measure of psychological distress in cancer patients: the use of Distress Thermometer in the Oncological Rehabilitation Center of Florence

GOALS OF WORK

Distress in cancer patients is common. In the last years, several studies have used the single-item Distress Thermometer (DT) as a screening tool for psychological distress in cancer patients. The primary objective of this study was to determine the optimal cutoff score on the DT for detecting psychological distress in cancer patients attending a rehabilitation center, by comparing the DT's scores with those of the Psychological Distress Inventory (PDI). The second aim was to explore the effectiveness of the DT as a screening tool for psychological distress in rehabilitative oncological setting.

PATIENTS AND METHODS

The sample study totaled 290 patients who were recruited from patients attending the Oncological Rehabilitation Center of Florence for the first time between January and December 2007. Patients were administered the DT along with the Problem List (PL) and the PDI as the gold standard against which the DT was compared.

MAIN RESULTS

The area under the receiver operating characteristics curve was 0.84 [95%CI 0.80-0.89]. The optimal DT cutoff score for identifying distressed cancer patients would be at or above 7 (sensitivity = 0.73; specificity = 0.82). Patients whose DT score was 7 or above were more likely to report problems in all issues on the PL.

CONCLUSIONS

The combination of DT and PL could be a practicable screening instrument for assessing the extent and the kind of distress also in rehabilitative oncological patients. On the other hand, the choice of the DT should be evaluated by clinicians.

Screening for psychological distress in two French cancer centers: feasibility and performance of the adapted distress thermometer

OBJECTIVE

Little is known about the prevalence of psychiatric disorders in French cancer patients. This study aimed to assess the feasibility of a screening procedure using the Psychological Distress Scale (PDS). The PDS is a French adaptation of the National Comprehensive Cancer Network Distress Thermometer. The screening performance of the PDS was assessed by comparison with the established clinical case threshold on the Hospital Anxiety and Depression Scale (HADS).

METHODS

Among 598 consecutive cancer outpatients recruited in two cancer centers in Paris, 561 (94%) agreed to complete the PDS, the HADS, the European Organisation for Research and Treatment of Cancer core quality of life questionnaire (EORTC QLQ-C30), and study-specific psychosocial questions.

RESULTS

A receiver operating characteristic (ROC) analysis was performed, using a HADS cutoff score of 15 or greater to identify patients with psychological distress. This yielded a PDS cutoff score of 3, giving 76% sensitivity and 82% specificity. With this cutoff score, the prevalence of psychological distress was 38%. PDS scores were significantly related to scores from the HAD total scale (r=.64), HAD anxiety (r=.61) and HAD depression (r=.39) subscales, and EORTC QLQ-C30 emotional functioning (r=.56) and global health state (r=.44). In multivariate analyses, factors associated with psychological distress were female gender, taking analgesics, receiving professional psychological help, perceived psychosocial difficulties and lack of social support.

SIGNIFICANCE OF RESULTS

Using the PDS appeared feasible, acceptable and effective for psychological distress screening in French ambulatory cancer care settings.

Distress and its correlates in Korean cancer patients: pilot use of the distress thermometer and the problem list

The distress thermometer (DT), a one-item measure for distress, provides a means for rapidly and effectively screening psychological distress in cancer patients. In this pilot study, a screening efficacy of the DT was investigated in a mixed cohort of 108 Korean cancer patients. Participants completed the DT, the problem list (PL), and the Hospital Anxiety and Depression Scale (HADS), and answered questions regarding supportive needs and their degree of satisfaction with several aspects of care. Receiver operating characteristic (ROC) curve analyses indicated that a DT cutoff score of 4 yielded an area under the ROC curve of 0.75 with a sensitivity of 0.83 and a specificity of 0.59 for HADS-total score defined cases (> or =15). HADS--Anxiety and Depression subscale scores explained 27% of the variability in the DT scores, implying that 'distress' is a broader concept that includes anxiety and depressive symptoms but has a more comprehensive meaning that encompasses multiple contributory factors. Regarding the PL, distressed patients (DT> or =4) reported significantly more problems (23 of 35) in all categories, suggesting, although degrees differ, that a wide variety of problems contribute to distress in cancer patients. Distress as defined by DT and HADS subscale scores was also significantly associated with higher supportive needs, a poor ECOG performance status (both physician and patient-rated), and a reduced level of satisfaction with treatment, staff, and communications. In conclusion, the DT and the PL were found to be simple yet effective screening instruments for detecting psychosocial distress in Korean cancer patients, and for identifying problems that warrant intervention.

Screening for distress in cancer patients: is the distress thermometer a valid measure in the UK and does it measure change over time? A prospective validation study

A prospective validation study was conducted in 171 consenting patients from oncology and palliative care outpatient clinics to validate the Distress Thermometer (DT) against the Hospital Anxiety and Depression Scale (HADS), General Health Questionnaire-12 (GHQ-12) and Brief Symptom Inventory-18 (BSI-18) at baseline, four weeks and eight weeks. Receiver Operating Characteristic analysis was used to examine the sensitivity and specificity of the DT scores against the clinically significant cut-off scores of the criterion measures reporting 95% confidence intervals. Standardised response means were used to compare DT scores with criterion measures over time. For a cut-off of 4 vs 5, sensitivity against HADS was 79%, specificity 81%; against GHQ-12, sensitivity was 63%, specificity 83%; and against BSI-18, sensitivity was 88%, specificity 74%. At both four and eight weeks, DT scores tended to change significantly in the same direction as the criterion measures. Ninety-five percent of patients found completing the DT acceptable. The DT is valid and acceptable for use as a rapid screening instrument for patients in the UK with cancer. Our results indicate that it can be used to monitor change in psychological distress over time, but further work is needed to confirm this.

Screening for mental disorders in laryngeal cancer patients: a comparison of 6 methods

OBJECTIVES

The aim of this study was to determine how accurate mental distress screening instruments are in identifying psychological sequelae in ambulatory laryngeal cancer patients who have undergone surgery.

METHODS

Two-hundred and fifty subjects were tested for mental disorders according to the guidelines defined in the Diagnostic Statistical Manual of Psychological Illnesses, Version 4. Screening instruments tested were: the 'Hospital Anxiety and Depression Scale' (HADS), the subscale 'Emotional Functioning' of the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30), the 'Hornheider Fragebogen' (HFB), and a single-item visual analogues scale (VAS). Accuracy was assessed by calculating the sensitivity rates, specificity rates, and areas under the curve from the receiver operating characteristic curves.

RESULTS

The relative frequency of mental disorders was 19.8%. All of the screening instruments tested were found to be highly accurate. The best levels of sensitivity and specificity were associated with the total score of the HADS.

CONCLUSIONS

These results confirm that a significant minority of laryngeal cancer patients suffer from severe mental distress, and that accurate screening for clinically significant mental disorders is possible using any of the instruments evaluated here.

The symptom experience in the first 100 days following allogeneic hematopoietic stem cell transplantation (HSCT)

GOALS OF WORK

Despite advances in allogeneic hematopoietic stem cell transplantation (HSCT), post-transplant complications are common, and patients' symptom experience has not been well documented.

PURPOSE

To characterize the symptom experience of adult patients pre-transplantation and days 0, 30, and 100 after allogeneic HSCT.

METHODS

Data from 76 participants enrolled in a prospective health-related quality of life (HRQL) study were used. Symptom occurrence, distress, and clusters were determined based on the 11 symptoms of the Symptom Distress Scale (SDS).

RESULTS

Participants were on average 40 years old (SD +/- 13.5). The majority (54%) received reduced intensity conditioning. Prevalent symptoms included fatigue (68%) and worry (68%) at baseline, appetite change (88%) at day 0, and fatigue at days 30 (90%) and 100 (81%). Participants reported the following symptoms as severely distressing: worry (16%) [baseline], insomnia (32%) [day 0], appetite change (22%) [day 30], and fatigue (11%) [day 100]. The total SDS score was highest at day 0 (M = 26.6 +/- 7.6) when the highest number of symptoms were reported [median = 8 (1-11)]. Symptoms formed clusters comprised of fatigue, appearance change, and worry at baseline, and fatigue, insomnia, and bowel changes at days 0 and 30. Compared to those with low symptom distress, participants with moderate/severe symptom distress reported poorer HRQL.

CONCLUSION

Allogeneic HSCT patients present for transplantation with low symptom distress yet experience multiple symptoms and high symptom distress after HSCT conditioning. Understanding the symptom experience of allogeneic HSCT patients can guide management strategies and improve HRQL.

New research in psychooncology

PURPOSE OF REVIEW

The objectives of this review are to identify new studies in the area of psychooncology, and ascertain the directions current studies are taking.

RECENT FINDINGS

New studies relate to the measurement of distress, which is being strongly proposed as the sixth vital sign in the assessment of patients with cancer. Attempts to use different scales and instruments to screen for depression and psychiatric morbidity in patients with cancer have also been made. Posttraumatic stress disorder, fatigue, somatization and cognitive dysfunctions have been studied. The field of psychoneuroimmunology has further strengthened our understanding of the impact of stress on immune function. Cancer survivors and their coping methods, sexual health, and suicidality have been the focus of research in the last year. Quality of life of caregivers has also been studied, as has spirituality. Cognitive behaviour group therapy in relatives of patients with cancer appears to be helpful.

SUMMARY

New studies in psychooncology have focused on the relationship between psychosocial factors and cancer, such as detection of distress and psychiatric morbidity, intervention, coping methods used by survivors, and psychoneuroimmunology. Research in psychooncology is an exciting area despite numerous challenges.

Screening adult survivors of childhood cancer with the distress thermometer: a comparison with the SCL-90-R

As the number of cancer survivors continues to grow, identification of brief, valid psychological screening measures will be a critical step in providing them with appropriate psychosocial care. The distress thermometer (DT) is a one-item distress screening that is recommended by the National Comprehensive Cancer Network (NCCN) for screening cancer patients, but has not been evaluated for cancer survivors. This study evaluated the validity of the DT compared to the Symptom Checklist-90-Revised (SCL-90-R) in a sample of 119 adult survivors of childhood cancer aged 18-45 (median=23.5). Results indicated that when using the NCCN suggested cut-off score of 5, the DT only identified 20 of the 36 SCL-90-R-positive cases of psychological distress (sensitivity 55.6%; specificity 80.7%). Using an alternative DT cut-off score of 4 identified 23 of the 36 SCL-90-R-positive cases (sensitivity 63.9%; specificity 65.1%). Receiver operating characteristics analysis indicated that the DT had only fair diagnostic utility relative to the SCL-90-R (AUC=0.72). Results do not support the validity of the DT in adult survivors of childhood cancer.

Surgical palliation of advanced gastrointestinal tumors

Patients with advanced gastrointestinal tumors suffer a spectrum of progressive symptoms that reduce their quality of life (QOL). Operative palliative strategies seeking to improve QOL and decrease symptom burden are poorly studied. This study seeks to measure the effect of operations on symptoms and QOL in patients with advanced gastrointestinal malignancies. Patients undergoing World Health Organization (WHO)-defined palliative operations for gastrointestinal cancers were prospectively followed with monthly QOL and Distress Thermometer surveys until 6 months post-operatively. Comparisons were made between preoperative and 3-month postoperative data. Parameters of physical, psychological, social, and spiritual QOL were measured on a scale of 0 (worst) to 5 (best). Frequency of occurrence and degree of distress caused by that specific symptom were scored from 0 (rarely/not at all) to 5 (most of the time/severely). Thirty-five patients had gastrointestinal cancer. The median age was 55.3 years. The most common symptoms were pain and obstruction. Thirty-three operations were abdominal. Ultimately, 34 patients (97%) were discharged home. When preoperative data were compared to 3 months postoperative, the frequency of the primary symptom improved by 2.22 (p = 0.001) and the distress it caused decreased by 1.82 (p = 0.004). Physical QOL decreased by 0.61 (p = 0.009), psychological QOL decreased by 0.50 (p = 0.015), social QOL decreased by 0.48 (p = 0.017), spiritual QOL decreased by 0.42 (p = 0.008), and overall QOL decreased by 0.50 (p = 0.012). Because of the unrelenting nature of gastrointestinal tumors, QOL over time will inevitably decrease. Palliative operations effectively improve symptom frequency and distress without greatly affecting the expected decline in QOL and its parameters.

Four weeks of daily assessments of anxiety, depression and activity compared to a point assessment with the Hospital Anxiety and Depression Scale

OBJECTIVES

To explore to what extent the daily reporting of anxiety, depression and activity in a diary mirrors scores on point assessments with the Hospital Anxiety and Depression scale (HADS).

METHODS

In a randomized intervention study consecutive breast cancer patients (n = 179) about to start adjuvant therapy were included. The HADS questionnaires were sent to patients 3 and 12 months after inclusion. Daily reporting of anxiety, depression and activity on Visual Analogue Scales (VAS) were completed during 4 weeks surrounding the HADS assessments.

RESULTS

The results showed moderate correlations (r = -0.36 to -0.67, P < 0.01) at both assessments. The daily reports were consistent over 4 weeks and did not differ between assessments. Mean scores on the HAD-Anxiety were 4.00 at the 3 months and 5.07 at the 12 months assessment. For the HAD-Depression the mean scores at the same assessment points were 3.61 and 3.23, respectively. The daily reports put more strain on the respondents and produced a larger attrition rate than the HADS.

CONCLUSION

A point assessment with the HADS captures the situation of breast cancer patients' equivalent to 4 weeks assessment in a diary, but is easier to complete and is therefore preferable to the diary.