Feasibility and usefulness of the ‘Distress Screening Program in Ambulatory Care’ in clinical oncology practice

Usability and Preliminary Efficacy of an Adaptive Supportive Care System for Patients With Cancer: Pilot Randomized Controlled Trial

BACKGROUND

Using an iterative user-centered design process, our team developed a patient-centered adaptive supportive care system, PatientCareAnywhere, that provides comprehensive biopsychosocial screening and supportive cancer care to patients across the continuum of care adaptively. The overarching goal of PatientCareAnywhere is to improve health-related quality of life (HRQOL) and self-efficacy of patients with cancer by empowering them with self-management skills and bringing cancer care support directly to them at home. Such support is adaptive to the patient's needs and health status and coordinated across multiple sources in the forms of referrals, education, engagement of community resources, and secure social communication.

OBJECTIVE

This study aims to assess the usability of the new web-based PatientCareAnywhere system and examine the preliminary efficacy of PatientCareAnywhere to improve patient-reported outcomes compared with usual care.

METHODS

For phase 1, usability testing participants included patients with cancer (n=4) and caregivers (n=7) who evaluated the software prototype and provided qualitative (eg, interviews) and quantitative (eg, System Usability Scale) feedback. For phase 2, participants in the 3-month pilot randomized controlled trial were randomized to receive the PatientCareAnywhere intervention (n=36) or usual care control condition (n=36). HRQOL and cancer-relevant self-efficacy were assessed at baseline (preintervention assessment) and 12 weeks from baseline (postintervention assessment); mean differences between pre- and postintervention scores were compared between the 2 groups.

RESULTS

Participants were highly satisfied with the prototype and reported above-average acceptable usability, with a mean System Usability Scale score of 84.09 (SD 10.02). Qualitative data supported the overall usability and perceived usefulness of the intervention, with a few design features (eg, "help request" function) added based on participant feedback. With regard to the randomized controlled trial, patients in the intervention group reported significant improvements in HRQOL from pre- to postintervention scores (mean difference 6.08, SD 15.26) compared with the control group (mean difference -2.95, SD 10.63; P=.01). In contrast, there was no significant between-group difference in self-efficacy (P=.09).

CONCLUSIONS

Overall, PatientCareAnywhere represents a user-friendly, functional, and acceptable supportive care intervention with preliminary efficacy to improve HRQOL among patients diagnosed with cancer. Future studies are needed to further establish the efficacy of PatientCareAnywhere as well as explore strategies to enhance user engagement and investigate the optimal intensity, frequency, and use of the intervention to improve patient outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02408406; https://clinicaltrials.gov/study/NCT02408406.

Implementing an Inclusive, Multidisciplinary Supportive Care Model to Provide Integrated Care to Breast and Gynaecological Cancer Survivors: A Case Study at an Asian Ambulatory Cancer Centre

Introduction

Supportive care models considering inclusivity and community services to improve integrated care for cancer survivors are limited. In this case study, we described the implementation of a multidisciplinary care model employing routine distress screening and embedded integrated care pathways to integrate care across disciplines and care sectors, while remaining inclusive of the multi-ethnic and multilingual population in Singapore. We reported implementation outcomes after 18 months of implementation.

Description

We reviewed the model's process indicators from September 2019 to February 2021 at the largest public ambulatory cancer centre. Outcomes assessed included penetration, fidelity to screening protocol, and feasibility in three aspects - inclusiveness of different ethnic and language groups, responsiveness to survivors reporting high distress, and types of community service referrals.

Discussion/conclusion

We elucidated opportunities to promote access to community services and inclusivity. Integration of community services from tertiary settings should be systematic through mutually beneficial educational and outreach initiatives, complemented by their inclusion in integrated care pathways to encourage systematic referrals and care coordination. A hybrid approach to service delivery is crucial in ensuring inclusivity while providing flexibility towards external changes such as the COVID-19 pandemic. Future work should explore using telehealth to bolster inclusiveness and advance community care integration.

Evaluation of a Routine Psychosocial Screening for Patients Receiving Inpatient Specialist Palliative Care: Feasibility and Outcomes

This prospective one-year cohort study aimed to assess the feasibility and outcomes of a routine psychosocial screening at patients' admittance to specialist inpatient palliative care. Patients admitted to an academic palliative care ward were routinely screened for self-reported distress and psychological morbidity, psychosocial stress factors, and subjective need for help from psychosocial professions. Cognitive impairments were the most common patient barrier to screening. Screenings were completed in 138 of 428 patients (32%). Based on established cutoffs, distress was indicated in 89%, depression in 51%, and anxiety in 50% of these patients. The burden on next-of-kin emerged as the most prevalent stress factor (73%). One-half of the patients disclosed a subjective need for help (53%). Possible depression (p = .023), anxiety (p < .001), and subjective need for help (p < .001) correlated positively with a higher amount of time spent by psychologists and creative arts-based therapists with small to moderate effects. Patients who completed the screening were attributed with a higher amount of time by social workers than patients who did not (p = .004), but there were no relationships between screening results and social work. Results suggest the potential of screenings for the allocation of specialist psychosocial care during specialist palliative care; however, barriers to screening do exist.

Predictive value of the Distress Thermometer score for risk of suicide in patients with cancer

PURPOSE

This study aimed to assess the association between the Distress Thermometer (DT) score and risk of suicide in patients with cancer. In addition, we aimed to determine the best cutoff score to predict patients at risk of suicide.

METHODS

From 2015 to 2016, we retrospectively collected data on patients with cancer. DT scores were collected, and the association between DT score and risk of suicide (suicide ideation or death ideation) was analyzed. Furthermore, receiver operating characteristic (ROC) analysis was performed to identify the appropriate cutoff score for predicting risk of suicide.

RESULTS

A total of 260 patients with cancer were included, and suicidal ideation was identified in 33 cases referred for psychological intervention. The DT scores of the patients with suicidal ideation were significantly higher than those of patients without suicidal ideation (6.30±2.11 vs. 4.29±1.72, p<0.05). In addition, the area under the ROC curve for predicting risk for suicide was 0.758. The cutoff DT score of 3 had the highest sensitivity of 1.00 to rule out suicidal ideation, while 9 had the highest specificity of 1.00 to rule in suicidal ideation. Moreover, the appropriate cutoff DT score to predict patients with suicidal ideation was 5, with a sensitivity of 0.52, specificity of .84, positive likelihood ratio of 3.24, and negative likelihood ratio of 0.58.

CONCLUSION

The DT score may be a helpful clinical tool to evaluate emotional distress and risk of suicide in patients with cancer. Clinically, for DT scores greater than 5 in patients with cancer, the risk of suicide greatly increases. In view of the DT's widespread use internationally by non-mental health clinicians in cancer to guide the need for specialist mental health interventions, its potential utility in also predicting suicide risk is of great interest.

Addressing distress management challenges: Recommendations from the consensus panel of the American Psychosocial Oncology Society and the Association of Oncology Social Work

Distress management (DM) (screening and response) is an essential component of cancer care across the treatment trajectory. Effective DM has many benefits, including improving patients' quality of life; reducing distress, anxiety, and depression; contributing to medical cost offsets; and reducing emergency department visits and hospitalizations. Unfortunately, many distressed patients do not receive needed services. There are several multilevel barriers that represent key challenges to DM and affect its implementation. The Consolidated Framework for Implementation Research was used as an organizational structure to outline the barriers and facilitators to implementation of DM, including: 1) individual characteristics (individual patient characteristics with a focus on groups who may face unique barriers to distress screening and linkage to services), 2) intervention (unique aspects of DM intervention, including specific challenges in screening and psychosocial intervention, with recommendations for resolving these challenges), 3) processes for implementation of DM (modality and timing of screening, the challenge of triage for urgent needs, and incorporation of patient-reported outcomes and quality measures), 4) organization-inner setting (the context of the clinic, hospital, or health care system); and 5) organization-outer setting (including reimbursement strategies and health-care policy). Specific recommendations for evidence-based strategies and interventions for each of the domains of the Consolidated Framework for Implementation Research are also included to address barriers and challenges.

Understanding help-seeking behaviour in relation to psychosocial support services among Japanese cancer patients

BACKGROUND

There are various psychosocial support services for cancer patients in Japan; however, their utilization rate is lower than in Western countries. The aim of this study was to investigate the actual status of the utilization of such services and the related factors of their use, using the transtheoretical model.

METHODS

We conducted an Internet survey of cancer outpatients. They were asked for information on their demographics, physical status and the usage of and intention to use psychosocial support services, and to answer the Hospital Anxiety and Depression Scale.

RESULTS

Data of 712 participants were analyzed; 111 had made use of psychosocial support services (15.6%). Participants who were younger, female, had breast cancer, experience with hormone therapy and did not have a good performance status (Karnofsky Performance Scale) more often used such services when comparing users/experiencers with non-users/inexperienced. Of the inexperienced, 538 were in the Precontemplation stage (89.5%), 62 were in the Contemplation stage (10.3%) and one was in the Preparation stage (0.2%). Approximately 35% of those in the Precontemplation stage would correspond to adjustment disorders or major depression.

CONCLUSIONS

We showed the degree of cancer patients who have used the psychosocial support services and its contents and revealed the factors related to the utilization of such services in Japan. Our study supports previous reports that cancer patients with high levels of distress do not necessarily seek support, and thus future studies should also examine other modifiable factors considering the medical settings.

Examination of factors contributing to help-seeking behavior in accessing psychosocial support services among Japanese cancer patients: An application of the segmentation approach

OBJECTIVE

Various psychosocial support services for cancer patients are available in Japan; however, their utilization rate is low. The present study aimed to examine factors contributing to help-seeking behavior in the use of psychosocial support services among cancer outpatients at three stages: Precontemplation (without adjustment disorder or major depression), Precontemplation (with adjustment disorder or major depression), and Contemplation.

METHODS

We conducted a web-based questionnaire survey at two points with a panel of cancer outpatients. We collected data on demographic information, physical status, the use of and intention to use psychosocial support services, psychological distress, attitude toward using psychosocial support services for cancer patients, and social support.

RESULTS

In total, 395 cancer patients were analyzed. In the Precontemplation (without adjustment disorder or major depression) stage, resistance to help-seeking (OR = 0.726, P = .011) and future prospects of the Brief Cancer-Related Worry Inventory (OR = 1.012, P = .019) were significant. In the Precontemplation (with adjustment disorder or major depression) stage, only recommendation by medical staff or family (OR = 0.000, P = .026) had a significant effect. In the Contemplation stage, only social and interpersonal problems (OR = 0.942, P = .080) showed a significant (negative) trend.

CONCLUSIONS

This study showed that contributing factors differed by stage. To encourage the use of psychosocial support services, it is desirable to recommend the use and to develop interventions for promoting, with responding to patients' conditions and intentions rather than responding to everyone in the same way.

Economic evaluation of a combined screening and stepped-care treatment program targeting psychological distress in patients with metastatic colorectal cancer: A cluster randomized controlled trial

BACKGROUND

Psychological distress is highly prevalent among patients with metastatic colorectal cancer.

AIMS

To perform an economic evaluation of a combined screening and treatment program targeting psychological distress in patients with metastatic colorectal cancer in comparison with usual care.

DESIGN

Societal costs were collected alongside a cluster randomized controlled trial for 48 weeks. A total of 349 participants were included.

SETTING

Participants were recruited from oncology departments at 16 participating hospitals in the Netherlands.

METHODS

Outcome measures were the Hospital Anxiety and Depression Scale and quality-adjusted life-years. Missing data were imputed using multiple imputation. Uncertainty was estimated using bootstrapping. Cost-effectiveness planes and cost-effectiveness acceptability curves were estimated to show uncertainty surrounding the cost-effectiveness estimates. Sensitivity analyses were performed to check robustness of results.

RESULTS

Between treatment arms, no significant differences were found in Hospital Anxiety and Depression Scale score (mean difference: -0.058; 95% confidence interval: -0.13 to 0.011), quality-adjusted life-years (mean difference: 0.042; 95% confidence interval: -0.015 to 0.099), and societal costs (mean difference: -1152; 95% confidence interval: -5058 to 2214). Cost-effectiveness acceptability curves showed that the probability of cost-effectiveness was 0.64 and 0.74 at willingness-to-pay values of €0 and €10,000 per point improvement on the Hospital Anxiety and Depression Scale, respectively. The probability that the intervention was cost-effective compared to usual care for quality-adjusted life-years was 0.64 and 0.79 at willingness-to-pay values of €0 and €20,000 per quality-adjusted life-year, respectively.

CONCLUSION

The intervention is dominant over usual care, primarily due to lower costs in the intervention group. However, there were no statistically significant differences in clinical effects and the uptake of the intervention was quite low. Therefore, widespread implementation cannot be recommended.

Does a regular nurse-led distress screening and discussion improve quality of life of breast cancer patients treated with curative intent? A randomized controlled trial

OBJECTIVE

We performed a randomized controlled trial (RCT) to investigate whether regular screening with the distress thermometer (DT) by a nurse improved global quality of life (QOL) of patients with breast cancer (BC) treated with curative intent.

METHODS

BC patients were randomized between regular screening for distress with a nurse-led DT intervention (NDTI) and usual care (UC). Both groups filled out questionnaires at baseline, after each received treatment modality and at follow-up visits up to 2 years. At these points, the intervention group received also the NDTI. The primary outcome was the global QOL of the EORTC QLQ C30 at 2 years after the end of treatment. Analyses were done on an intention-to-treat basis, using analysis of covariance (ANCOVA), generalized least squares, and interaction analyses.

RESULTS

Of 194 randomized patients, 153 filled out the questionnaires up to 2 years after treatment. There was no significant difference between NDTI and UC in global QOL 2 years after the end of treatment (mean diff. = -1∙273, P = .610; 95% CI [-6.195; 3.649]). Subgroup analysis of patients who received multimodality treatment (surgery, radiotherapy, and chemotherapy, n = 66) showed a significant between-group difference in global QOL over time (mean diff. = -10, P < .001; 95% CI [-14.835; -5.167]) together with other secondary outcome measures in favor of the NDTI.

CONCLUSION

NDTI did not lead to a significant improvement in global QOL 2 years after the end of treatment for patients with BC. However, the findings indicate that BC patients who received multimodality treatment may benefit from NDTI.

Development of an e-learning prototype for assessing occupational stress-related disorders: a qualitative study

BACKGROUND

Occupational stress-related disorders are complex to diagnose and prevent, due to their multifactorial origin. We developed an e-learning programme aimed at supporting occupational physicians when diagnosing and preventing occupational stress-related disorders. In order to explore the extent to which a developed e-learning prototype was perceived as useful and feasible by occupational physicians, we executed a qualitative study.

METHODS

We conducted semi-structured, face-to-face interviews with fifteen occupational physicians, who were recruited using a combination of convenience and purposive sampling. Participants were shown a hard copy prototype of the e-learning programme, on which they were invited to comment in terms of perceived usefulness and feasibility. The interview data was transcribed verbatim and coded by two researchers using a content analysis approach.

RESULTS

Occupational physicians perceived e-learning as useful when it contributed to creating a full clinical picture and supported the diagnosis. Its structure had to support occupational physicians to work systematically. The programme had to be applicable to their daily practice and had to incorporate learning tools in order to increase the competences of occupational physicians. Feasibility was perceived to increase when the e-learning programme took less time to complete, when the quantity of written text was not too high, and when the user was guided and recertification points provided.

CONCLUSIONS

An e-learning programme can be an asset in continuing medical education for occupational physicians when assessing occupational stress-related disorders. Perceived usefulness depended on the clinical picture, structure, practicality and the increasing of competences. Feasibility depended on text, time, structure and reward.

Effectiveness of clinical practice change strategies in improving dietitian care for head and neck cancer patients according to evidence-based clinical guidelines: a stepped-wedge, randomized controlled trial

Best practice guidelines make a number of recommendations regarding dietitian management of head and neck cancer (HNC) patients. Randomized trials assessing the effectiveness of clinical practice change strategies for improving the nutritional management of HNC patients have not previously been conducted. The purpose of this study was to evaluate the effect of practice change strategies on improving the implementation of best practice guideline recommendations for the nutritional management of HNC patients. Four Australian radiotherapy departments participated in a stepped-wedge, randomized controlled trial. Baseline data were collected across all sites simultaneously, and the intervention was then introduced to each site sequentially, in a randomly determined order. During the intervention phase, sites received a range of supportive clinical practice change strategies to facilitate dietitian adherence to clinical practice guidelines. To assess the associated practice change by dietetic staff, we evaluated the change in implementation of six guideline recommendations for dietitians from preintervention to postintervention periods. Adherence to the clinical practice guidelines during the preintervention period was generally very low. The clinical practice change strategies significantly improved the odds of provision of four of the six guideline recommendations. The study found the intervention significantly enhanced dietitian provision of recommended care for HNC patients during the postintervention period. This finding holds clinical importance for clinician and health service effective implementation of guideline recommendations as well as HNC patient treatment outcomes. Trial registration number ACTRN12613000320752, https://www.anzctr.org.au.

Focusing on cancer patients' intentions to use psychooncological support: A longitudinal, mixed-methods study

OBJECTIVE

Distress screening programs aim to ensure appropriate psychooncological support for cancer patients, but many eligible patients do not use these services. To improve distress management, we need to better understand patients' supportive care needs. In this paper, we report the first key finding from a longitudinal study that focused on patients' intentions to use psychooncological support and its association with distress and uptake of the psychooncology service.

METHODS

We conducted a prospective, observational study in an Oncology Outpatient Clinic and assessed distress, intention to use psychooncological support, and uptake of the psychooncology service by using the Distress Thermometer, a semistructured interview, and hospital records. We analyzed data with a mixed-methods approach.

RESULTS

Of 333 patients (mean age 61 years; 55% male; 54% Distress Thermometer ≥ 5), 25% intended to use the psychooncology service (yes), 33% were ambivalent (maybe), and 42% reported no intention (no). Overall, 23% had attended the psychooncology service 4 months later. Ambivalent patients reported higher distress than patients with no intention (odds ratio = 1.18, 95% confidence interval [1.06-1.32]) but showed significantly lower uptake behavior than patients with an intention (odds ratio = 14.04, 95% confidence interval [6.74-29.24]). Qualitative analyses revealed that ambivalent patients (maybe) emphasized fears and uncertainties, while patients with clear intentions (yes/no) emphasized knowledge, attitudes, and coping concepts.

CONCLUSIONS

We identified a vulnerable group of ambivalent patients with high distress levels and low uptake behavior. To optimize distress screening programs, we suggest addressing and discussing patients' supportive care needs in routine clinical practice.

Feasibility of Psychosocial Distress Screening and Management Program for Hospitalized Cancer Patients

OBJECTIVE

Although the diagnosis and treatment of cancer is associated with psychosocial distress, routine distress screening is difficult in hospitalized oncology settings. We developed a consecutive screening program for psychosocial distress to promote psychiatric treatment of cancer patients and evaluated the feasibility of our program by Distress Thermometer (DT) and Hospital Anxiety and Depression Scale (HADS).

METHODS

Among 777 cancer inpatients recruited from the Catholic Comprehensive Institute of Seoul St. Mary's Hospital, 499 agreed to complete primary distress screening through DT. We conducted secondary distress screening through HADS in 229 patients who had high scores of DT.

RESULTS

Of the 499 participants, 270 patients with low scores of DT were included in the distress education program. 229 patients with high scores of DT received secondary distress screening through HADS. Among 115 patients with low scores of HADS, 111 patients received distress management. Among 114 patients with high scores in the secondary distress screening, 38 patients received psychiatric consultation service whereas 76 patients refused psychiatric consultation.

CONCLUSION

Using consecutive screening for psychosocial distress appeared to be feasible in an inpatient oncology setting. Nevertheless, the low participation rate of psychiatric consultation service in cancer patients with high distress level should be improved.

Distress During Radiation Therapy: Assessment Among Patients With Breast or Prostate Cancer

BACKGROUND

Distress is regarded as the sixth vital sign in cancer care, but few studies describe distress in patients undergoing radiation therapy.

OBJECTIVES

The purpose of this study was to assess distress levels among patients with breast or prostate cancer undergoing radiation therapy and investigate which problems contribute to patients' distress levels.

METHODS

A retrospective medical record review was conducted for 217 patients with breast or prostate cancer at a midwestern community cancer center. Demographic data, distress scores, and problems or concerns from the patient-completed Distress Thermometer and associated Problem List were collected. Descriptive and bivariate statistics were calculated.

FINDINGS

The average distress of patients with breast cancer was significantly higher than that of patients with prostate cancer, and patients with breast cancer reported more problems than those with prostate cancer.

Development of anxiety, depression and health-related quality of life in oncology patients without initial symptoms according to the Hospital Anxiety and Depression Scale - a comparative study

BACKGROUND

Depression and anxiety are associated with decreased health-related quality of life (HRQoL). The knowledge about the development of anxiety, depression and HRQoL in cancer patients without depression or anxiety, that is initially scoring as non-cases (cutoff <8) according to the Hospital Anxiety and Depression Scale (HADS), is sparse. The objectives were: (1) to evaluate changes in anxiety, depression and HRQoL over 6 months in two independent cohorts of oncology patients initially scoring as non-cases by the HADS, (2) to compare stable non-case patients with the general population regarding HRQoL and (3) to explore the outcomes using >4 rather than >7 as cutoff on any of HADS subscales.

METHODS

The study group (SG) included 245 and the validation group (VG), a previous cohort, included 281 non-cases. Patients who were non-cases (HADS <8) at all completed assessments were categorized as stable non-cases (stable-NC); those who were doubtful/clinical cases (HADS >7) in at least one follow-up were categorized as unstable-NC. Questionnaires were completed at baseline, and after 1, 3 and 6 months. Age- and sex-matched EORTC QLQ-C30 data from the general population were used for HRQoL comparisons.

RESULTS

One hundred ninety-six (80%) SG and 244 (87%) VG patients were stable-NC and 49 (20%) SG and 37 (13%) VG patients were unstable-NC. SG and VG were similar in all outcomes. Anxiety, depression and HRQoL deteriorated over 6 months for unstable-NC (p < .05). HRQoL for stable-NC was comparable to that in the general population. If >4 had been used as cutoff, most unstable-NC (36/49 and 25/37, respectively) would have been identified at baseline.

CONCLUSIONS

Most non-cases are stable-NC with a high stable HRQoL, indicating no need for re-assessment. A minority develop anxiety or depression symptoms and impaired HRQoL; for these a cutoff >4 rather than >7 on HADS subscales may be useful for early detection.

Prevalence, risk factors, and the desire for help of distressed newly diagnosed cancer patients: A large-sample study

Objective:

Beginning in 2007, all newly diagnosed cancer patients at the Koo Foundation Sun Yat-Sen Cancer Center (KF–SYSCC) were screened for psychosocial distress. Our social workers, as part of the psychosocial care team (PCT), have engaged in proactive outreach with patients identified as distressed. The goal of the present study was to assess the prevalence of psychosocial distress and the extent of contact between the PCT and distressed patients.

Method:

Newly diagnosed patients who were treated at KF–SYSCC between 2007 and 2010 for cancer were eligible if there were at least 100 patients with the same type of cancer. Before treatment began, they were screened with the Pain Scale and the Distress Thermometer (DT) and had the option to specify a desire for help. The rates of distress were analyzed by cancer type and by probable related factors. Information regarding contact with the PCT was retrieved from computerized databases.

Results:

Overall, some 5,335 cancer patients representing 12 major cancer types were included in our study. Of these, 1,771 (33.20%) were significantly distressed. By multivariate logistic regression, younger age, female gender, higher pain score, and disease stage, but not cancer type, were found to be associated with higher rates of distress. Among these distressed patients, 628 (36%) had some contact with the PCT.

Significance of results:

This Taiwanese study with a large sample size revealed a prevalence rate of psychosocial distress similar to rates found in Western countries. Contact with the PCT was established in only 36% of significantly distressed patients, despite a proactive outreach program. It is very important to have screening results made available in a timely fashion to the psycho-oncology team so that appropriate care can be offered promptly.

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.

Psychological intervention targeting distress for cancer patients: a meta-analytic study investigating uptake and adherence

OBJECTIVE

Although cancer care guidelines recommend screening for distress among cancer patients and offering psychological support when indicated, many patients decline offers of such support. This study aimed to quantify uptake and adherence to psychological support and to identify predictors of each.

METHODS

Searches were conducted in Embase, Medline, PsychInfo and Scopus to identify studies reporting uptake or adherence rates for individual psychological interventions targeting distress, anxiety or depression for cancer patients or survivors.

RESULTS

Across the 53 included studies reporting uptake and/or adherence rates for 12 323 cancer patients, the uptake and adherence rates were 60.1% and 90.4%, respectively. Patients screened and identified as distressed were less likely to accept intervention than unselected patients (50.3% compared with 66.3%, Q(1) = 4.66, P = 0.031). Uptake of therapy was higher for interventions delivered by telephone rather than face-to-face (71.2% compared with 53.8%, Q(1) = 4.91, P = 0.027) and when therapy was offered prior to medical treatment compared with later (72.9% compared with 56.8%, Q(1) = 5.60, P = 0.018). Patients were more likely to accept intervention from nurses than other allied health professionals (68.3% compared with 50.5%, Q(1) = 5.76, P = 0.016).

CONCLUSIONS

Patients appeared more receptive to interventions offered near diagnosis, over the telephone and by nurses. Although this suggests higher acceptability of such interventions, evidence of their greater efficacy is lacking, and this merits further investigation. Research is needed to understand barriers to acceptance of psychological support, particularly because uptake rates were lower for distressed patients. Copyright © 2016 John Wiley & Sons, Ltd.

What happens after distress screening? Patterns of supportive care service utilization among oncology patients identified through a systematic screening protocol

PURPOSE

While distress screening is important for identifying unmet needs of cancer patients, less is known about referral and uptake of supportive care services among distressed patients. The current analysis examined screen-based rates of referral to supportive care and explored demographic and clinical correlates of referral uptake.

METHODS

We tracked distress screens completed by a varied group of cancer patients receiving outpatient care at a National Cancer Institute (NCI)-designated cancer center during a 1-month period. Electronic medical record review was used to examine the rates of supportive care referral and uptake among distressed patients.

RESULTS

Out of 644 unique screens, 195 (30 %) patients reported significant distress; distressed patients were more likely to be non-white (odds ratio (OR) = 1.71, p < 0.01), prescribed psychiatric medication (OR = 1.92, p < 0.00), and have no previous contact with the cancer center's supportive care staff (OR = 1.62, p = 0.01). Thirty-four of these patients pre-emptively declined supportive care contact; thus, 161 were referred for supportive care. Among the 99 patients who received initial assessments by a team member, only 19 (19 %) requested and completed at least one follow-up appointment.

CONCLUSIONS

Findings from this analysis support earlier work demonstrating significant supportive care needs in cancer patients. However, it challenges the assumption that screening will result in increased uptake of supportive care services beyond initial assessment. Further work should focus on facilitating engagement and reducing barriers for patients with continuing post-assessment supportive care needs.

Routine depression screening and diagnosing strategy for cancer inpatients

BACKGROUND

Clinical practice guidelines frequently recommend systematic screening for depression in cancer patients to improve recognition and prompt appropriate management. We aimed to screen major depressive disorder (MDD) in cancer inpatients using a structured tool and explore its applicability.

METHODS

Cancer inpatients were routinely screened by nurses using the Taiwanese Depression Questionnaire (TDQ), and for those screened positive, this was followed by a non-mandated referral to a psychiatrist for clinical evaluation and diagnosis. Patients who completed this two-stage procedure comprised the analysis sample.

RESULTS

Routine screening of 8800 patients in a period of 27 months yielded 1087 (26.9%) positive first-time screens. Of them, 298 (27.4%) completed the psychiatric consultation. Depressive disorders were diagnosed in 185 patients (62.1%), mainly adjustment disorder (23.8%) and MDD (21.5%). The estimated prevalence of MDD was 21.5%. Area under the curve was 0.72, a result produced by the receiver operating characteristic curve of the TDQ scores relative to the clinical psychiatric diagnoses of MDD. A TDQ cutoff score of ≧26 provided an optimal diagnostic accuracy for MDD.

CONCLUSIONS

This two-stage depression screening and diagnosing strategy is practical for improving recognition of MDD and other depressive disorders in cancer patients and could be routinely applied, rather than selectively, in a comprehensive cancer care system.

Recommendations for the implementation of distress screening programs in cancer centers: report from the American Psychosocial Oncology Society (APOS), Association of Oncology Social Work (AOSW), and Oncology Nursing Society (ONS) joint task force

In 2015, the American College of Surgeons (ACoS) Commission on Cancer will require cancer centers to implement screening programs for psychosocial distress as a new criterion for accreditation. A joint task force from the American Psychosocial Oncology Society, the Association of Oncology Social Work, and the Oncology Nursing Society developed consensus-based recommendations to guide the implementation of this requirement. In this review, the authors provide recommendations regarding each of the 6 components necessary to meet the ACoS standard: 1) inclusion of psychosocial representation on the cancer committee, 2) timing of screening, 3) method/mode of screening, 4) tools for screening, 5) assessment and referral, and 6) documentation.

Psychosocial aspects of hereditary cancer (PAHC) questionnaire: development and testing of a screening questionnaire for use in clinical cancer genetics

BACKGROUND

Up to three-quarters of individuals who undergo cancer genetic counseling and testing report psychosocial problems specifically related to that setting. The objectives of this study were to develop and evaluate the screening properties of a questionnaire designed to assess specific psychosocial problems related to cancer genetic counseling.

METHODS

We adopted the European Organisation for Research and Treatment of Cancer Quality of Life Group guidelines to develop the Psychosocial Aspects of Hereditary Cancer (PAHC) questionnaire, a 26-item questionnaire organized into six problem domains: genetics, practical issues, family, living with cancer, emotions, and children. The Distress Thermometer and a question per domain on the perceived need for extra psychosocial services were included as well. We administered the questionnaire and the Hospital Anxiety and Depression Scale to 127 counselees at the time of genetic counseling and 3 weeks after DNA test disclosure. As a gold standard to evaluate the screening properties of the questionnaire, participants underwent a semi-structured interview with an experienced social worker who assessed the presence and severity of problems per domain.

RESULTS

A cutoff score representing responses of 'quite a bit' or 'very much' to one or more items within a given problem domain yielded moderate to high sensitivity across domains. A cutoff of 4 on the Distress Thermometer yielded high sensitivity. The questions regarding the perceived need for extra psychosocial services yielded high specificity and negative predictive values.

CONCLUSION

The Psychosocial Aspects of Hereditary Cancer questionnaire in combination with the Distress Thermometer can be used as a first-line screener for psychosocial problems within the cancer genetic counseling setting.

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

OBJECTIVE

Several practice guidelines recommend routine screening for psychological distress in cancer care. The objective was to evaluate the effect of screening cancer patients for psychological distress by assessing the (1) effectiveness of interventions to reduce distress among patients identified as distressed; and (2) effects of screening for distress on distress outcomes.

METHODS

CINAHL, Cochrane, EMBASE, ISI, MEDLINE, PsycINFO, and SCOPUS databases were searched through April 6, 2011 with manual searches of 45 relevant journals, reference list review, citation tracking of included articles, and trial registry reviews through June 30, 2012. Articles in any language on cancer patients were included if they (1) compared treatment for patients with psychological distress to placebo or usual care in a randomized controlled trial (RCT); or (2) assessed the effect of screening on psychological distress in a RCT.

RESULTS

There were 14 eligible RCTs for treatment of distress, and 1 RCT on the effects of screening on patient distress. Pharmacological, psychotherapy and collaborative care interventions generally reduced distress with small to moderate effects. One study investigated effects of screening for distress on psychological outcomes, and it found no improvement.

CONCLUSION

Treatment studies reported modest improvement in distress symptoms, but only a single eligible study was found on the effects of screening cancer patients for distress, and distress did not improve in screened patients versus those receiving usual care. Because of the lack of evidence of beneficial effects of screening cancer patients for distress, it is premature to recommend or mandate implementation of routine screening.

Use of psychosocial services increases after a social worker-mediated intervention in gynecology oncology patients

The purpose of this study was to determine whether the introduction of psychosocial services to gynecologic oncology outpatients by a social worker increases service use. During the initial six weeks (phase I), patients were referred for psychosocial services by clinic staff. During the second six weeks (phase II), a nurse introduced available services to each patient with a brochure. During the final 12 weeks (phase III), a social worker introduced services to each patient. The authors then compared psychosocial service referral rates. The sample included 196 patients. During phase III, the probability of a patient-initiated referral increased 3.4-fold (95 percent confidence interval [CI] [1.1, 10.4], p = .04) compared with baseline; the probability of any referral rose 2.7-fold (95 percent CI [1.1, 6.3], p = .03). The mean time to referral decreased from 79.4 days at baseline to 3.9 days during phase III (p < .001). The phase III intervention was accomplished only in 34 patients (39 percent) because of scheduling conflicts. Of these, eight requested referral, resulting in a 24 percent patient-initiated referral rate after meeting with a social worker. The introduction of psychosocial services by a social worker to gynecologic oncology outpatients increases referral rates and expedites evaluation.

Effects of integrated psychosocial care for distress in cancer patients

BACKGROUND

Despite some clinical guidelines for incorporating integrated psychosocial care (combining psychological screening and psychological intervention, including adequate collaboration with mental health specialists) into routine oncology practice, definitive empirical evidence regarding the effectiveness of such care remains unavailable. Here the findings of recent experimental studies are reviewed to provide guidance regarding this issue.

METHODS

Comparative studies examining integrated psychosocial care were reviewed.

RESULTS

Studies examining interventions that include both screening and psychological care have produced contradictory results regarding effectiveness, but all the studies that have examined the effect of psychological care after the identification of distress using systematic screening have shown positive results.

CONCLUSIONS

Integrated psychosocial care may affect patients with significant distress, but the adequacy of introducing such care into routine oncology practice remains debatable.

Screening for cancer-related distress: when is implementation successful and when is it unsuccessful?

OBJECTIVE

Screening for distress is controversial with many advocates and detractors. Previously it was reasonable to assert that there was a lack of evidence but this position is no longer tenable. The question is now: what does the evidence show and, in particular, when is screening successful and when is screening unsuccessful? The aim of this paper is to review the most up-to-date recent findings from randomized and non-randomized trials regarding the merits of screening for distress in cancer settings.

METHODS

A search was made of the Embase/Medline and Web of knowledge abstract databases from inception to December 2012. Online theses and experts were contacted. Inclusion criteria were interventional (randomized and non-randomized) trials concerning screening for psychological distress and related disorders. Studies screening for quality of life were included.

RESULTS

Twenty-four valid interventional studies of distress/QoL screening were identified, 14 being randomized controlled trials (RCTs). Six of 14 screening RCTs reported benefits on patient well-being and an additional three showed benefits on secondary outcomes such as communication between clinicians and patients. Five randomized screening trials failed to show any benefits. Only two of 10 non-randomized sequential cohort screening studies reported benefits on patient well-being but an additional six showed secondary benefits on quality of care (such as receipt of psychosocial referral). Two non-randomized screening trials failed to show benefits. Of 24 studies, there were 17 that reported some significant benefits of screening on primary or secondary outcomes, six that reported no effect and one that reported a non-significantly deleterious effect upon communication. Across all studies, barriers to screening success were significant. The most significant barrier was receipt of appropriate aftercare. The proportion of cancer patients who received psychosocial care after a positive distress screen was only one in three. Screening was more effective when it was linked with mandatory intervention or referral.

CONCLUSIONS

Screening for distress/QoL is likely to benefit communication and referral for psychosocial help. Screening for distress has the potential to influence patient well-being but only if barriers are addressed. Quality of care barriers often act as a rate limiting step. Key barriers are lack of training and support, low acceptability and failure to link treatment to the screening results.

Anxiety and depression in oncology patients; a longitudinal study of a screening, assessment and psychosocial support intervention

BACKGROUND

Anxiety and depression in cancer patients are associated with poor health-related quality of life (HRQOL). Clinical interventions to detect and support patients with these symptoms need to be developed and evaluated. We investigated the feasibility of screening with the Hospital Anxiety and Depression Scale (HADS) in a clinical oncology setting. In patients with anxiety or depression symptoms (HADS >7) we explored the use of clinical assessment and psychosocial support and described the development of anxiety, depression and HRQOL during a six-month period.

MATERIAL AND METHODS

Four hundred and ninety-five consecutive patients were screened for anxiety and depression at the time of their first visit at an oncology department (baseline). Half of the patients with HADS >7 on any of the two HADS subscales were referred to clinical assessment and psychosocial support (intervention group, IG) and half received standard care (SCG) using a historical control group design. HADS and EORTC QLQ-C30 were completed at baseline and after one, three and six months.

RESULTS

One hundred and seventy-six (36%) of 495 patients had anxiety or depression symptoms at screening, HRQOL at baseline was clearly impaired for them. Thirty-six (43%) of 84 IG patients attended clinical assessment, resulting in subsequent psychosocial support for 20 (24%) of them. In the SCG, only five (5%) patients attended clinical assessment after self referral, two received subsequent psychosocial support. Anxiety and depression decreased and HRQOL increased statistically significantly over time although anxiety was frequent and HRQOL impaired during the entire six month period. There were no differences between the SCG and IG regarding anxiety, depression or HRQOL at any time point.

CONCLUSION

Systematic screening with HADS is feasible for oncology patients in clinical settings; it identifies patients with persistent symptoms and increases referral to clinical assessment and utilisation of psychosocial support.

Screening for Distress and Unmet Needs in Patients With Cancer: Review and Recommendations

Purpose

This review summarizes the need for and process of screening for distress and assessing unmet needs of patients with cancer as well as the possible benefits of implementing screening.

Methods

Three areas of the relevant literature were reviewed and summarized using structured literature searches: psychometric properties of commonly used distress screening tools, psychometric properties of relevant unmet needs assessment tools, and implementation of distress screening programs that assessed patient-reported outcomes (PROs).

Results

Distress and unmet needs are common problems in cancer settings, and programs that routinely screen for and treat distress are feasible, particularly when staff are supported and links with specialist psychosocial services exist. Many distress screening and unmet need tools have been subject to preliminary validation, but few have been compared head to head in independent centers and in different stages of cancer. Research investigating the overall effectiveness of screening for distress in terms of improved recognition and treatment of distress and associated problems is not yet conclusive, but screening seems to improve communication between patients and clinicians and may enhance psychosocial referrals. Direct effects on quality of life are uncertain, but screening may help improve discussion of quality-of-life issues.

Conclusion

Involving all stakeholders and frontline clinicians when planning screening for distress programs is recommended. Training frontline staff to deliver screening programs is crucial, and continuing to rigorously evaluate outcomes, including PROs, process of care, referrals, and economic costs and benefits is essential.

Validation of simple visual-analogue thermometer screen for mood complications of cardiovascular disease: the Emotion Thermometers

OBJECTIVE

Conventional scales may help with the identification of depression but are generally too lengthy for clinical practice and perform poorly against anxiety and distress. We therefore examined the value of a single item NCCN Distress Thermometer and an enhanced visual-analogue method (Emotion Thermometers, ET) that incorporates four emotion thermometers.

METHODS

We examined 228 patients with mixed cardiovascular conditions of whom 200 completed questionnaires. 64.5% suffered from cardiomyopathy/congestive heart failure, 9.5% had coronary artery disease, 4.5% had multiple cardiac diagnoses, 3% suffered from hypertension, 2% had rhythm problem, 2% had valve problems and 1.5% were diagnosed with atrial fibrillation. We used DSM-IV criteria to define current depression, the GAD7 to define current anxiety and the HADS-T to define distress. 13% had DSM-IV MDD and 19.1% had major or minor depression using DSM-IV (any depression). There were also 59 people (29.6%) with clinically significant distress and 46 with clinically significant anxiety (23.1%).

RESULTS

The optimal accuracy for major depression was either the Depression thermometer (DepT) or the Help thermometer (HelpT), as both performed well. They had a sensitivity and specificity of 73.1%, 89.7% and 84.6%, 85.6%, respectively. The DepT was also best for detecting any DSM-IV depression (sensitivity 68.4% and specificity 93.2%) and HAD-T based distress (sensitivity 79.7% and specificity 82.9%). The Anxiety thermometer (AnxT) performed best against the GAD7 (sensitivity 84.8% and specificity 83.7%).

CONCLUSION

Innovative visual-analogue screening tools for mood appear to perform well in cardiovascular settings.

Psychiatric disorders in cancer patients at a university hospital in Japan: descriptive analysis of 765 psychiatric referrals

OBJECTIVE

In cancer patients, adjustment disorders, delirium and depression have been identified as common psychiatric disorders. Although a comparable result was reported in the National Cancer Center in Japan, the nature of patients in that hospital may differ from that in local hospitals. There is a possibility to expand the findings of psycho-oncology by evaluation of the data from a local university hospital and comparison with the National Cancer Center data.

METHODS

We retrospectively reviewed the medical records of cancer patients who were referred to the Department of Psycho-Oncology at Saitama Medical University International Medical Center. We identified their characteristics and psychiatric diagnoses and compared these with the National Cancer Center data.

RESULTS

During the study period, 765 cancer patients were referred. The numbers of inpatients and outpatients were almost the same. The most common psychiatric diagnosis was adjustment disorders (24%), followed by delirium (16%) and then major depressive disorder (12%). The rank of these three was the same as that at the National Cancer Center. Outpatients constituted more than 80% of the patients with major depressive disorder. The proportion of cancer patients with schizophrenia in this study (4.3%) was higher than that in the National Cancer Center (1.6%).

CONCLUSIONS

This study revealed basic information about the consultation data of cancer patients at a local university hospital in Japan. The importance of communication with outpatients was suggested. It seems that cancer treatment for patients with schizophrenia in a local hospital is also important.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effectiveness of QUICATOUCH: a computerised touch screen evaluation for pain and distress in ambulatory oncology patients in Newcastle, Australia

OBJECTIVE

To describe the change in pain and distress over time to demonstrate the effectiveness of the QUICATOUCH program in an outpatient oncology population.

METHODS

Descriptive study of the first 29 months of the QUICATOUCH program (13 736 assessments for 5775 patients). A longitudinal cohort design was used to examine the patients with three or more assessments (8129 assessments for 1778 patients). Effectiveness of this complex intervention (repeated assessment, clinician report and referral to speciality psycho-oncology service) was examined using: reduction in proportion over threshold for pain and distress, predictors of mean pain and distress scores and comparison of the number of new patients treated by the psycho-oncology service during the study and in the preceding 29 months.

RESULTS

Pain and distress declined during the study. The risk of being over threshold at endpoint was reduced for pain (odds ratio (OR) 0.70, confidence interval (CI) 95% 0.60-0.81) and for distress (OR 0.58 CI 95% 0.49-0.68) with baseline as referent level. Three variables predicted the mean pain: clinic type, current radiotherapy treatment and distress score; and five predicted mean distress: time, gender, clinic type, age and pain score. There was an increase of 40% (533v747) in new patients treated by the psycho-oncology service.

CONCLUSIONS

The QUICATOUCH assessment for pain and distress was implemented into usual clinical practice with reasonable coverage of patients for modest cost. It was effective in monitoring the patients over time, contributed to a reduction in pain and distress, whilst appropriately increasing the number of new patients reaching psychological treatment as part of the clinical service.

Nutritional and psychosocial status of colorectal cancer patients referred to an outpatient oncology clinic

PURPOSE

Malnutrition and psychological distress are associated with poorer outcomes following treatment for colorectal cancer. Screening for issues such as malnutrition, depression, and anxiety is being adopted in some oncology settings, but its effectiveness or the relationship between these risk factors in this population are not well understood.

METHODS

A retrospective chart review was conducted of 836 health assessment forms provided to colorectal cancer patients referred to an outpatient oncology clinic. Nutritional (Patient-Generated Subjective Global Assessment) and psychological (Psychosocial Screen for Cancer) screening tools were included in the form. Demographic and screening tool information was obtained from completed forms. The prevalence of nutritional risk, depression, and anxiety were determined based on screening tool scores and clinical cutoffs. An ordinal regression model was fitted to determine which demographic and psychosocial factors best predicted nutritional risk.

RESULTS

Only 252 (30%) of the forms were completed enough for inclusion in analysis. The prevalence of nutritional risk, anxiety, and depression were determined to be 29%, 10%, and 7%, respectively. A regression model containing the variables depression, anxiety, gender, health coverage, and marital status was found to best explain the nutritional score. Depression was the most significant predictor, with odds of increased nutritional risk being 5.6 times greater for depressed individuals (P = 0.0005).

CONCLUSIONS

The use of nutritional and psychosocial screening tools is warranted and needs to be emphasized more in oncology settings. There appears to be a relationship between psychosocial issues and increased nutritional risk which should be taken into account when considering cancer care interventions.

Association of psychosocial risk screening in pediatric cancer with psychosocial services provided

OBJECTIVE

How screening for psychosocial risk in pediatric oncology may relate to the number and type of psychosocial services provided is a critical step in linking screening with treatment. We predicted that screening at diagnosis would be associated with the delivery of more psychosocial services over 8 weeks and that these services would be consistent with Universal, Targeted, or Clinical psychosocial risk level based on the Pediatric Psychosocial Preventative Health Model (PPPHM).

METHODS

Parents of children newly diagnosed with cancer received either the Psychosocial Assessment Tool (PAT; n = 49) or psychosocial care as usual (PAU; n = 47), based on their date of diagnosis and an alternating monthly schedule. Medical record review and surveys completed by social workers and child life specialists were used to determine psychosocial services provided to patients and their families over the first eight weeks of treatment.

RESULTS

As predicted, families in the PAT condition received more services than those in PAU based on social worker and child life specialist report and medical record review. Within the PAT group, families at the Targeted and Clinical levels of risk received more intensive services than those at the Universal level.

CONCLUSIONS

This initial report shows how psychosocial risk screening may impact psychosocial care in pediatric cancer, supporting the importance of screening as well as matching services to risk level.