Incorporating the Distress Thermometer into preoperative vital signs in patients undergoing ambulatory oncology surgery: a pilot feasibility study

BACKGROUND

Despite the extensive literature supporting distress screening at relevant transitions of care, the implementation of distress screening remains limited in ambulatory surgery settings. Our multidisciplinary team completed a pilot study to assess the feasibility and acceptability of including a standardized psychosocial assessment, the Distress Thermometer (DT), with the collection of admission vital signs by Patient Care Technicians (PCTs) in patients undergoing oncology surgery.

METHODS

We assessed feasibility by the response rate and acceptability through discussions with the PCTs.

RESULTS

Of the 189 men who underwent radical prostatectomy at our center, 71 were approached with the DT scale, and all patients who were approached completed the DT with no missing data. The staff reported no issues with data collection. A total of 21/71 (30%; 95% CI 19%, 42%) reported a clinically relevant distress DT ≥ 4.

CONCLUSION

Our results demonstrated that incorporating the DT into vital sign collection was feasible, acceptable, and provided a valuable assessment.

Diving deeper into distress screening implementation in oncology care

BACKGROUND

Responding to calls for additional research that identifies effective distress screening (DS) processes, including referral practices subsequent to screening and receipt of recommended care, we engaged in qualitative research as part of a larger (mixed methods) study of distress screening. This qualitative inquiry of oncology professionals across different facilities in the United States examined routine DS implementation, facilitators and challenges staff encounter with DS processes, and staff members' perceived value of DS.

PARTICIPANTS AND METHODS

We conducted key informant interviews and focus groups with staff in 4 Commission on Cancer (CoC)-accredited oncology facilities (a total of 18 participants) to understand implementation of routine DS within oncology care. We used a rigorous data analysis design, including inductive and deductive approaches.

RESULTS

Respondents believe DS enhances patient care and described ways to improve DS processes, including administering DS at multiple points throughout oncology care, using patient-administrated DS methods, and enhancing electronic health records infrastructure to better collect, record, and retrieve DS data. Respondents also identified the need for additional psychosocial staff at their facilities to provide timely psychosocial care.

CONCLUSIONS

Results reinforce the value of DS in cancer care, including the importance of follow-up to screening with psychosocial oncology providers. Understanding and resolving the barriers and facilitators to implementing DS are important to ensure appropriate psychosocial care for people with cancer. Insights from oncology staff may be used to enhance the quality of DS and subsequent psychosocial care, which is an essential component of oncology care.

Self-reliance, Social Norms, and Self-stigma as Barriers to Psychosocial Help-Seeking Among Rural Cancer Survivors With Cancer-Related Distress: Qualitative Interview Study

Background

Even when technology allows rural cancer survivors to connect with supportive care providers from a distance, uptake of psychosocial referrals is low. Fewer than one-third of participants in a telemedicine intervention for identifying rural survivors with high distress and connecting them with care accepted psychosocial referral.

Objective

The purpose of this research was to examine the reasons for which rural cancer survivors did not accept a psychosocial referral.

Methods

We utilized a qualitative design to address the research purpose. We interviewed participants who had been offered psychosocial referral. Semistructured interviews were conducted 6 weeks later (n=14), and structured interviews were conducted 9 months later (n=6). Data were analyzed descriptively using an inductive approach.

Results

Ultimately, none of the rural cancer survivors (0/14, 0%) engaged with a psychosocial care provider, including those who had originally accepted referrals (0/4, 0%) for further psychosocial care. When explaining their decisions, survivors minimized their distress, emphasizing their self-reliance and the need to handle distress on their own. They expressed a preference for dealing with distress via informal support networks, which was often limited to close family members. No survivors endorsed public stigma as a barrier to accepting psychosocial help, but several suggested that self-stigma associated with not being able to handle their own distress was a reason for not seeking care.

Conclusions

Rural cancer survivors’ willingness to accept a psychosocial referral may be mediated by the rural cultural norm of self-reliance and by self-stigma. Interventions to address referral uptake may benefit from further illumination of these relationships as well as a strength-based approach that emphasizes positive aspects of the rural community and individual self-affirmation.

Documentation of Psychosocial Distress and Its Antecedents in Children with Rare or Life-Limiting Chronic Conditions

Children with rare or life-limiting chronic conditions and their families are at high risk of psychosocial distress. However, despite its impact on patient and family health and functioning, psychosocial distress and its antecedents may not routinely be captured in medical records. The purpose of this study was to characterize current medical record documentation practices around psychosocial distress among children with rare or life-limiting chronic conditions and their families. Medical records for patients with rare or life-limiting chronic conditions (n = 60) followed by a pediatric complex care program were reviewed. Study team members extracted both structured data elements (e.g., diagnoses, demographic information) and note narratives from the most recent visit with a clinician in the program. Psychosocial topics were analyzed using a mixed quantitative (i.e., frequency counts of topics) and qualitative approach. Topics related to psychosocial distress that were documented in notes included child and parent emotional problems, parent social support, sibling emotional or physical problems, family structure (e.g., whether parents were together), and financial concerns. However, 35% of notes lacked any mention of psychosocial concerns. Although examples of psychosocial concerns were included in some notes, none were present in over one-third of this sample. For both patients with rare or life-limiting chronic conditions and their caregivers, more active elicitation and standard documentation of psychosocial concerns may improve the ability of healthcare providers to identify and intervene on psychosocial concerns and their risk factors.

'Patients with Cancer are Distressed!' Indian Healthcare Provider Perspectives on Distress Screening and Referrals to Psycho-oncology Services - A Mixed Methods Study

Objectives:

Routine screening for distress is a guideline prescribed by the National Comprehensive Cancer Network (NCCN) to adequately assess distress in a cancer setting. Our centre conducted routine screening but failed to utilize psycho-oncology services. Our aim was to assess the extent of self-reported distress, referrals to psycho-oncology services and healthcare provider perspectives about the existing distress management system and psycho-oncology services.

Materials and Methods:

We conducted a record review of adult patients (n=372) who reported to the Out-patient department of the tertiary cancer centre. Semi-structured interviews were conducted with fourteen healthcare providers. We used a concurrent mixed methods study design. Adult patients were screened for distress using NCCN-Distress Thermometer and problem checklist. Healthcare providers from different oncology specialties were interviewed and the data was analysed using descriptive thematic analysis.

Results:

Patients screened for distress were found to report moderate to extreme levels of distress (53.5%). The total referrals to psycho-oncology support services were low (8.6%). Interviews with healthcare providers revealed three major themes: Enablers, barriers and solutions for utilization of distress management system and psycho-oncology services.

Conclusions:

Moderate to extreme distress was found among patients routinely screened for distress, although there was poor utilization of distress management system and psycho-oncology support services due to time constraints, patient’s negative attitudes towards mental health referrals, generic screening tools and use of own clinical judgement to make referrals by healthcare providers. Future research warrants implementation of strategies to integrate psycho-oncology services into routine cancer care by focusing on improving visibility of services.

Prevalence of Depression and Cancer - A systematic review

Objective: While comorbidity of different forms of cancer and clinical depression is reported for many single studies, representative and global overviews are scarce. Methods: A systematic review was carried out (mainly based on Medline, Embase, Cochrane, PsychLit, and Psyndex) to identify studies in adult cancer patients from 2007 to 2019. Studies with noncancer populations and cancer survivors were excluded. Assessment methods of depression were chart-based diagnoses, interview-based and self-report questionnaires. Quality and plausibility were checked using the adapted Downs & Black checklist. Results: For all 210 included studies the prevalence rate of clinical depression varied from 7.9 % to 32.4 %, with a mean of 21.2 % depression for different (mixed) cancer entities. The different methods of assessment have led to under- (especially charts-based diagnoses) as well as overreporting for some forms of cancer. In general, the different assessment forms show an acceptable variation in prevalence. Conclusions: The risk for a cancer patient to suffer a clinical depression during the first year after diagnoses is 15 % to 20 %, meaning every fifth or sixth patients. Different cancer entities, stage of cancer and treatments as well as different cultural and medical backgrounds show only slight variation in prevalence rates.

From Distress Screening to Uptake: An Italian Multicenter Study of Cancer Patients

INTRODUCTION

Little consideration is given to the referral and uptake of available supportive services after distress screening. However, identifying the reasons for accepting or refusing help is mandatory for implementing a screening policy. The present study explored the practical usefulness of and potential barriers to the application of distress management.

METHODS

406 cancer patients were consecutively selected and asked to complete the Distress Thermometer (DT) and Problem Check List (PL). All patients with a DT score ≥6 were invited for a post-DT telephone interview with a trained psychologist.

RESULTS

The 112 patients who refused to take part were more often older, retired, at a more advanced stage of illness, and with no previous experience of psychological intervention with respect to those who accepted. Of the 78 patients with a score ≥6 who were referred to the Psycho-Oncology Service, 65.4% accepted the telephone interview. Twenty-two patients rejected the initial invitation immediately for various reasons including logistic difficulties, physical problems, and feeling embarrassed about opening up to a psychologist.

CONCLUSIONS

Our study confirms that screening per sé is insufficient to deal with the problem of distress and that more emphasis should be placed on implementing referral and treatment.

Improving access to cancer information and supportive care services: A systematic review of mechanisms applied to link people with cancer to psychosocial supportive care services

OBJECTIVE

Previous research has described the low uptake of psychosocial support services in people living with cancer. While characteristics of individuals using services have been examined, mechanisms applied to link individuals to support services are less frequently considered. This review aims to identify the mechanisms used to link people with cancer to support services and assess their impact.

METHODS

Systematic searches of Pubmed, CINAHL, EMBASE and PsycINFO were conducted up to May 2020. Studies reporting service use associated with mechanisms to link adults with cancer to support services targeting emotional, informational, practical or social support needs were eligible. Eligible study designs included controlled trials, pre-post designs and observational studies. Study quality was assessed and a narrative synthesis of findings undertaken.

RESULTS

A total of 10 papers (from 8,037 unique titles) were eligible. Testing the feasibility of the linkage mechanism was the primary aim in five (50%) studies. Three linkage mechanisms were identified: (a) outreach from the support service; (b) clinician recommendation/referral; (c) mailed invitation. Outreach was the most successful in connecting people with cancer to services (52%-90% use); clinician recommendation/referral was least successful (3%-28%). The impact of different linkage mechanisms for different demographic groups was not assessed.

CONCLUSIONS

Outreach from services shows the most potential for increasing access to support services. However, the limited number of studies and limitations in the types of support services people with cancer were linked to, demonstrated the need for further work in this area. Identifying mechanisms that are effective for underserved, high-needs patient groups is also needed.

Examination of a distress screening intervention for rural cancer survivors reveals low uptake of psychosocial referrals

Purpose

To determine the impact of a telemedicine-delivered intervention aimed at identifying unmet needs and cancer-related distress (CRD) following the end of active treatment on supportive care referral patterns.

Methods

We used a quasi-experimental design to compare supportive care referral patterns between a group of rural cancer survivors receiving the intervention and a control group (N = 60). We evaluated the impact of the intervention on the number and type of referrals offered and whether or not the participant accepted the referral. CRD was measured using a modified version of the National Comprehensive Cancer Network Distress Thermometer and Problem List.

Results

Overall, 30% of participants received a referral for further post-treatment supportive care. Supporting the benefits of the intervention, the odds of being offered a referral were 13 times higher for those who received the intervention than those in the control group. However, even among the intervention group, only 28.6% of participants who were offered a referral for further psychosocial care accepted.

Conclusions

A nursing telemedicine visit was successful in identifying areas of high distress and increasing referrals. However, referral uptake was low, particularly for psychosocial support. Distance to care and stigma associated with seeking psychosocial care may be factors. Further study to improve referral uptake is warranted.

Implications for Cancer Survivors

Screening for CRD may be inadequate for cancer survivors unless patients can be successfully referred to further supportive care. Strategies to improve uptake of psychosocial referrals is of high importance for rural survivors, who are at higher risk of CRD.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11764-021-01052-4.

Internet-delivered Mindfulness-Based Cognitive Therapy for anxiety and depression in cancer survivors: Predictors of treatment response

BACKGROUND

The present study investigates possible predictors of treatment response in an Internet-delivered Mindfulness-Based Cognitive Therapy (iMBCT) intervention with therapist support. This iMBCT program, a fully online delivered intervention with asynchronous therapist support, has previously been shown to be efficacious in reducing symptoms of anxiety and depression in women treated for breast cancer and men treated for prostate cancer.

METHODS

Eighty-two breast- and prostate cancer survivors experiencing psychological distress received 8 weeks of therapist-guided iMBCT. Primary outcomes were improvement in anxiety and depression scores from baseline to post-treatment and from baseline to six-months follow-up. Clinical predictors included levels of depression and anxiety at the time of screening and at baseline, as well as time since diagnosis. Demographic predictors included age and educational level. Therapy-related predictors included working alliance, self-compassion, and five facets of mindfulness. Mixed Linear Models were employed to test the prediction effects over time.

RESULTS

Higher levels of baseline depression were associated with increased treatment response in anxiety at post-treatment, and lower levels of self-compassion were associated with increased treatment response in depression at post-treatment. None of the proposed predictors significantly predicted treatment response at six-months follow-up.

CONCLUSION

The findings suggest that iMBCT can be provided for cancer survivors regardless of their age, educational level, and time since diagnosis (up to five years) and that therapeutic alliance is not crucial for treatment response. We did not identify characteristics predicting treatment response, although many factors were tested. Still, other characteristics may be predictors, and given the relatively small sample size and a large number of statistical tests, the results should be interpreted with caution.

Clinical management of emotions in patients with cancer: introducing the approach "emotional support and case finding"

The current approach to the management of emotions in patients with cancer is “distress screening and referral for the provision of psychosocial care.” Although this approach may have certain beneficial effects, screening and referral programs have shown a limited effect on patient psychological well-being. We argue that this limited effect is due to a mismatch between patient needs and the provision of care, and that a fundamental reconceptualization of the clinical management of emotions in patients with cancer is needed. We describe the rationale and characteristics of “emotional support and case finding” as the approach to the management of emotions in patients with cancer. The two main principles of the approach are: (1) Emotional support: (a) The treating team, consisting of doctors, nurses, and allied health staff, is responsive to the emotional needs of patients with cancer and provides emotional support. (b) The treating team provides information on external sources of emotional support. (2) Case finding: The treating team identifies patients in need of mental health care by means of case finding, and provides a referral to mental health care as indicated. We present a novel perspective on how to organize the clinical management of emotions in patients with cancer. This is intended to contribute to a fruitful discussion and to inform an innovative research agenda on how to manage emotions in patients with cancer.

Distress evaluation in a veteran affairs oncology clinic

Distress in oncology patients (pts) has a negative impact on quality of life, survival, and healthcare satisfaction. Higher distress leads to lower compliance with treatment and follow-up [1-8]. The 2012 American College of Surgeons Commission on Cancer (CoC) standard of care for oncology pts included an assessment for distress [1]. A screening process for distress allows the healthcare team to address these issues early and refer to appropriate resources [2-9]. This project was initiated to meet National Comprehensive Cancer Network (NCCN) and CoC standard of care, identify distress in veterans with cancer, and address these concerns. Patients who attended the Tuesday oncology clinic at the Dayton VAMC were given the NCCN Distress Thermometer (DT) during triage. The treating physician addressed problems identified. The Wilcoxon signed rank test and the Friedman test were used. DTs were completed by 296 pts from March to December 2016. Mean age was 68, 93% male, 83% white, 55% married, and 93% without PTSD. The distress level was not different from T1 through T3. Number of problems decreased over three time periods. Referrals to nutrition, mental health, and social work services increased over time. Although over time periods we found no decrease in distress scores, there was a decline in number of problems. The mean distress score at all but time 4 was < 4, which is considered mild distress. The mean distress score at T4 was 4.36 (n = 14), suggesting that the few pts who return to clinic more than three times may be experiencing more difficult personal and environmental circumstances. Patient sample ranged from those undergoing intensive cancer treatment (e.g., chemotherapy) to less intensive treatment (e.g., hormone injections) to those who completed treatment.

How Interdisciplinary Teamwork Contributes to Psychosocial Cancer Support

BACKGROUND

The organization of psychosocial care is rather complex, and its provision diverse. Access is affected by the acceptance and attitude of patients and professional caregivers toward psychosocial care.

OBJECTIVES

The aims of this study were to examine when patients with cancer experience quality psychosocial care and to identify circumstances in collaboration that contribute to patient-perceived positive psychosocial care.

METHODS

This study used a qualitative design in which semistructured interviews were conducted with patients, hospital workers, and primary health professionals.

RESULTS

Psychosocial care is often requested but also refused by patients with cancer. Based on this discrepancy, a distinction is made between psychosocial support and psychosocial interventions. Psychosocial support aims to reduce the chaos in patients' lives caused by cancer and is not shunned by patients. Psychosocial interventions comprise the formal care offered in response to psychosocial problems. Numerous patients are reluctant to use psychosocial interventions, which are often provided by psychologists.

CONCLUSION

Psychosocial care aims to assist patients in bearing the difficulties of cancer and its treatment. Patients prefer informal support, given often in conjunction with physical care.

IMPLICATIONS FOR PRACTICE

This study confirms the important role of nurses in promoting psychosocial care. Patients perceive much support from nurses, although nurses are not considered to be professional psychosocial caregivers. Being perceived as approachable and trustworthy offers nurses a significant opportunity to bring more intense psychosocial interventions within reach of cancer patients.

Clinical assessment of emotions in patients with cancer: Diagnostic accuracy compared with two reference standards

BACKGROUND

Previous research has suggested that clinical assessment of emotions in patients with cancer is suboptimal. However, it is a possibility that well-trained and experienced doctors and nurses do recognize emotions but that they do not evaluate all emotions as necessitating professional mental health care. This implies that the sensitivity of clinical assessment should be tested against the need for professional mental health care as reference standard, instead of emotional distress. We hypothesized that the observed sensitivity of clinical assessment of emotions would be higher when tested against need for professional mental health care as reference standard, compared with emotional distress as reference standard.

PATIENTS AND METHODS

A consecutive series of patients starting with chemotherapy were recruited during their routine clinical care, at a department of medical oncology. Clinical assessment of emotions by medical oncologists and nurses was derived from the patient file. Emotional distress and need for professional mental health care were assessed using the Distress Thermometer and Problem List.

RESULTS

Clinical assessment resulted in notes on emotions in 42.2% of the patient files with 36.2% of patients experiencing emotional distress and 10.8% expressing a need for professional mental health care (N = 185). As expected, the sensitivity of clinical assessment of emotions was higher with the reference standard "need for professional mental health care" compared with "emotional distress" (P < .001). For specificity, equivalent results were obtained with the two reference standards (P = .63).

CONCLUSIONS

Clinical assessment of emotions in patients with cancer may be more accurate than previously concluded.

Systematic screening and assessment of psychosocial well-being and care needs of people with cancer

BACKGROUND

Receiving a diagnosis of cancer and the subsequent related treatments can have a significant impact on an individual's physical and psychosocial well-being. To ensure that cancer care addresses all aspects of well-being, systematic screening for distress and supportive care needs is recommended. Appropriate screening could help support the integration of psychosocial approaches in daily routines in order to achieve holistic cancer care and ensure that the specific care needs of people with cancer are met and that the organisation of such care is optimised.

OBJECTIVES

To examine the effectiveness and safety of screening of psychosocial well-being and care needs of people with cancer. To explore the intervention characteristics that contribute to the effectiveness of these screening interventions.

SEARCH METHODS

We searched five electronic databases in January 2018: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO, and CINAHL. We also searched five trial registers and screened the contents of relevant journals, citations, and references to find published and unpublished trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and non-randomised controlled trials (NRCTs) that studied the effect of screening interventions addressing the psychosocial well-being and care needs of people with cancer compared to usual care. These screening interventions could involve self-reporting of people with a patient-reported outcome measures (PROMs) or a semi-structured interview with a screening interventionist, and comprise a solitary screening intervention or screening with guided actions. We excluded studies that evaluated screening integrated as an element in more complex interventions (e.g. therapy, coaching, full care pathways, or care programmes).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data and assessed methodological quality for each included study using the Cochrane tool for RCTs and the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool for NRCTs. Due to the high level of heterogeneity in the included studies, only three were included in meta-analysis. Results of the remaining 23 studies were analysed narratively.

MAIN RESULTS

We included 26 studies (18 RCTs and 8 NRCTs) with sample sizes of 41 to 1012 participants, involving a total of 7654 adults with cancer. Two studies included only men or women; all other studies included both sexes. For most studies people with breast, lung, head and neck, colorectal, prostate cancer, or several of these diagnoses were included; some studies included people with a broader range of cancer diagnosis. Ten studies focused on a solitary screening intervention, while the remaining 16 studies evaluated a screening intervention combined with guided actions. A broad range of intervention instruments was used, and were described by study authors as a screening of health-related quality of life (HRQoL), distress screening, needs assessment, or assessment of biopsychosocial symptoms or overall well-being. In 13 studies, the screening was a self-reported questionnaire, while in the remaining 13 studies an interventionist conducted the screening by interview or paper-pencil assessment. The interventional screenings in the studies were applied 1 to 12 times, without follow-up or from 4 weeks to 18 months after the first interventional screening. We assessed risk of bias as high for eight RCTs, low for five RCTs, and unclear for the five remaining RCTs. There were further concerns about the NRCTs (1 = critical risk study; 6 = serious risk studies; 1 = risk unclear).Due to considerable heterogeneity in several intervention and study characteristics, we have reported the results narratively for the majority of the evidence.In the narrative synthesis of all included studies, we found very low-certainty evidence for the effect of screening on HRQoL (20 studies). Of these studies, eight found beneficial effects of screening for several subdomains of HRQoL, and 10 found no effects of screening. One study found adverse effects, and the last study did not report quantitative results. We found very low-certainty evidence for the effect of screening on distress (16 studies). Of these studies, two found beneficial effects of screening, and 14 found no effects of screening. We judged the overall certainty of the evidence for the effect of screening on HRQoL to be very low. We found very low-certainty evidence for the effect of screening on care needs (seven studies). Of these studies, three found beneficial effects of screening for several subdomains of care needs, and two found no effects of screening. One study found adverse effects, and the last study did not report quantitative results. We judged the overall level of evidence for the effect of screening on HRQoL to be very low. None of the studies specifically evaluated or reported adverse effects of screening. However, three studies reported unfavourable effects of screening, including lower QoL, more unmet needs, and lower satisfaction.Three studies could be included in a meta-analysis. The meta-analysis revealed no beneficial effect of the screening intervention on people with cancer HRQoL (mean difference (MD) 1.65, 95% confidence interval (CI) -4.83 to 8.12, 2 RCTs, 6 months follow-up); distress (MD 0.0, 95% CI -0.36 to 0.36, 1 RCT, 3 months follow-up); or care needs (MD 2.32, 95% CI -7.49 to 12.14, 2 RCTs, 3 months follow-up). However, these studies all evaluated one specific screening intervention (CONNECT) in people with colorectal cancer.In the studies where some effects could be identified, no recurring relationships were found between intervention characteristics and the effectiveness of screening interventions.

AUTHORS' CONCLUSIONS

We found low-certainty evidence that does not support the effectiveness of screening of psychosocial well-being and care needs in people with cancer. Studies were heterogeneous in population, intervention, and outcome assessment.The results of this review suggest a need for more uniformity in outcomes and reporting; for the use of intervention description guidelines; for further improvement of methodological certainty in studies and for combining subjective patient-reported outcomes with objective outcomes.

Evaluation of the adherence of distress screening with the distress thermometer in cancer patients 4 years after implementation

PURPOSE

Identifying and assessing psychosocial distress with an appropriate screening instrument is essential when caring for cancer patients. Since 2012, the distress thermometer (DT) has been used by nurses for all cancer inpatients at the Comprehensive Cancer Center Zurich. We wanted to identify nurses' adherence to the screening protocol, differences between screened and not screened patients and the relationship between screening rate and productivity.

METHODS

This retrospective descriptive study used screening and referral data as well as socioeconomic and disease-related data of inpatients at the Comprehensive Cancer Center Zurich. This was collected from the electronic patient documentation system. Additionally, data showing the productivity of all wards was used. All data were analyzed descriptive.

RESULTS

Since 2012, 40.6% (4541) of the 11,184 patients have been screened. The screening rate was initially significantly lower but settled at 40% after 2 years. There was a higher screening rate among Swiss, married, male, and emergency patients and patients with hematology diseases, brain tumors, or head and neck cancer (p < 0.001). Every fourth patient with a moderate to severe distress level requested referral to a psychosocial service. Significantly more screened patients were referred to the social service (44.7%) than to the psycho-oncology service (9.4%). Only 22.9% of all referrals were made on the day of screening or a day later. There were only two wards of 15 with a significant relationship between productivity and screening rate.

CONCLUSIONS

Screening is useful in recognizing distress among patients, but screening practice needs to be reconsidered.

Mental health treatment dose and annual healthcare costs in patients with cancer and major depressive disorder

OBJECTIVE

Depression in patients with cancer has been associated with increased annual health care use and costs relative to nondepressed patients. Little is known of the potential cost savings associated with receipt of mental health treatment. This study evaluated the association between number of mental health visits and annual health care costs in patients with cancer and comorbid major depression.

METHOD

Using a retrospective cohort study design, this study included 182 individuals with an ICD-9 chart diagnosis of cancer in 2014 and with comorbid major depressive disorder. The outcome of interest was annual health care charges 1 year from cancer diagnosis. Number of mental health visits was extracted from patients' electronic medical records for the year following cancer diagnosis. A generalized linear model with a log link function and gamma distribution was used to evaluate the association between number of mental health visits and annual health care charges, covarying for age, sex, race/ethnicity, cancer site, metastatic disease, insurance status, and severity of comorbid medical conditions.

RESULTS

A significant association was found between number of mental health visits and annual health care charges (exp(B) = 0.973, 95% CI [0.949, 0.999]; p = .043). Estimated annual health care costs were $99,073 for those receiving no mental health visits and $71,245 for those receiving the sample-based mean of 12 mental health visits, inclusive of mental health visits.

CONCLUSIONS

Greater dose of mental health visits was associated with lower annual health care costs. Improved screening and adequate treatment of depression has potential to reduce total health care costs among patients with cancer. Because this was a small study, few patients with exceptionally high costs could augment the results. Therefore, replication of these findings, particularly using a clinical trial design, is needed to confirm these effects. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Psychosocial Distress and Health Service Utilization in Patients Undergoing Hemodialysis: A Prospective Study

BACKGROUND

End-stage renal disease is associated with significant morbidity, high-symptom burden, and health care use. Studies have not yet assessed psychosocial distress and health care utilization in this population.

OBJECTIVE

This study examines psychosocial distress and its association with hospitalization and emergency room (ER) visits in patients on maintenance hemodialysis (HD).

METHODS

The Distress Assessment and Response Tool (DART) was administered to 80 adults on HD in a single treatment center. The DART assessed for anxiety, depression, and social distress. Health care utilization data were extracted prospectively from electronic medical charts. The time between psychosocial distress and hospitalization or ER visits during 12-month follow-up was examined using Cox proportional hazard models.

RESULTS

Overall 46% of the sample reported psychosocial distress, with 33% screening above the threshold for depression, 14% for anxiety, and 36% for significant social distress. In multivariable regression adjusting for age, sex, and comorbidity, the presence of psychosocial distress was associated with shorter time to hospitalization (hazard ratio: 2.4 [1.1, 5.0], p = 0.03) during 12-month follow-up. Psychosocial distress was not significantly associated with ER visits in either univariable (hazard ratio: 1.3 [0.7, 2.3], p = 0.5) or multivariable (hazard ratio: 1.4 [0.8, 2.6], p = 0.3) analyses.

CONCLUSION

Psychosocial distress is frequent in patients undergoing maintenance HD and is associated with shorter time to hospitalization. Future longitudinal studies should examine if health service use can be reduced through routine distress screening and psychosocial distress intervention.

Doctor's recommendations for psychosocial care: Frequency and predictors of recommendations and referrals

BACKGROUND

A significant number of oncological patients are heavily burdened by psychosocial stress. Doctors recommending or referring their patients to psycho-oncologists in the course of routine consultations can positively influence psycho-oncological care. The aim of this study was to analyze the frequency and predictors of such recommendations and to examine the use of these services by patients.

METHODS

4,020 cancer patients (mean age 58 years; 51% women) were evaluated in a multicenter, cross-sectional study in Germany. Data was gathered about doctors' referral practices, patients' utilization of psycho-oncological care services, and disease-related symptoms. The PHQ-9 depression scale and the GAD-7 anxiety scale were used to measure psychological burden. Descriptive data analysis was conducted on the basis of subgroup comparisons and multivariable analysis was done using binary logistical regression.

RESULTS

21.9% of the respondents reported having been given a recommendation or referral for psycho-oncological care by a doctor within the course of their cancer diagnosis and treatment. This comprises 29.5% of the patients identified by screening as being psychologically burdened. Nearly half of the patients who received a recommendation or referral (49.8%) acted on it. Predictors for seeking out psycho-oncological care included: patient desire (OR = 2.0), previous experience with psycho-oncological care (OR = 1.59), and female gender (OR = 1.57). Multivariable analysis indicated that patients' level of psychological burden (depression, anxiety) had no effect on whether doctors gave them a recommendation or referral.

CONCLUSIONS

Along with examining the degree to which patients are burdened (e.g. using screening instruments), determining whether or not patients would like to receive psycho-oncological care is an important aspect of improving referral practices and, by extension, will allow important progress in the field of psycho-oncological care to be made.

A Distress Thermometer Intervention for Patients With Head and Neck Cancer

OBJECTIVES

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

SAMPLE & SETTING

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

METHODS & VARIABLES

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

RESULTS

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

IMPLICATIONS FOR NURSING

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

Cancer patients' wish for psychological support during outpatient radiation therapy : Findings from a psychooncological monitoring program in clinical routine

BACKGROUND

Cancer patients frequently suffer from physical and psychosocial impairments due to their disease and its treatment. Psychooncology (PO) can help to cope with stress resulting from outpatient radiotherapy (RT) treatment. There are currently few data regarding patients' wishes for PO support. The aim of this study was to investigate the number of patients with a wish for PO, treatment paths, and predictors of the wish for PO among cancer patients at the beginning of RT.

METHODS

The results of routine psychological stress screening (Hornheide screening instrument; cut-off  ≥ 4) of 944 cancer patients between 2015 and 2017 were analyzed in a retrospective cross-sectional study. Predictors for a wish for PO support were identified by stepwise binary logistic regression, in which sociodemographic and treatment data were included in addition to the screening items.

RESULTS

Around 20% of patients had above-average stress levels and 13% expressed a wish for PO support (participation rate was approximately 55%). Low emotional wellbeing (OR = 11.3) and lack of social support (OR = 9.4) were strong predictors for this treatment wish. Among patients with pancreatic cancer, head and neck tumors, and hematologic disease, there was a substantial difference between the degree of psychological stress and the wish for treatment. Patients with urological (23.5%) and lung tumors (20.9%) most frequently expressed a wish for PO support.

CONCLUSION

Patient-reported psychosocial problems were better predictors of a wish for PO support than sociodemographic or clinical data. Stress screening should thus be implemented in clinical routine.

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

OBJECTIVES

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

DESIGN

Systematic review.

DATA SOURCES

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

INCLUSION CRITERIA

Population: adult patients with cancer and clinical staff members.

INTERVENTION

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

OUTCOME

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

DESIGN

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

DATA EXTRACTION AND ANALYSIS

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

RESULTS

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

CONCLUSIONS

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

PROSPERO REGISTRATION NUMBER

CRD42015017518.

[Psychosocial stress in patients with prostate cancer : Experiences by using psychooncological screening questionnaires]

BACKGROUND

Prostate cancer is the most common malignancy in men and accounts for most surgical procedures in uro-oncology. Stressful sequelae of radical prostatectomy are incontinence and erectile dysfunction. Hormone ablation and radiation therapy are also known stressors. Mental stress has a low prevalence compared to other tumor entities. It is highly probable that there is an underexpression of verbally reported emotional experiences. Therefore, a low-threshold access to psycho-oncological services and accurate identification of patients with mental comorbidities is important. The aim of this study was to identify the distress level with clarification of the stress in patients with prostate cancer.

MATERIALS AND METHODS

Prospective evaluation of prostate cancer patients (n = 81, mean age 69 years) with regard to stress level, stress factors and the need for care using the Distress Thermometer, a standardized ultrashort stress-screening questionnaire.

RESULTS

The mean stress level was 4.4 points. In total, 56% of patients indicated a stress level ≥5, i. e. a clinically relevant psychological burden was indicated. Main stressors were sexual problems (35%), reduced mobility (30%), pain (27.5%), tingling paresthesia (26%) and worries (26%).

CONCLUSION

The psychological burden of prostate cancer patients is not as high as in other solid organ malignancies. However, some patients have a significantly increased psychosocial stress level. Identifying this subgroup and clarifying the correlation with specific stress and risk factors are important tasks of clinical care.

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.

Validation of the flemish CARES, a quality of life and needs assessment tool for cancer care

BACKGROUND

The Cancer Rehabilitation Evaluation System (CARES) is a quality of life (QOL) and needs assessment instrument of US origin that was developed in the 90's. Since November 2012 the copyright and user fee were abolished and the instrument became publicly available the present study aims to reinvestigate the psychometric properties of the CARES for the Flemish population in Belgium.

METHODS

The CARES was translated into Flemish following a translation-back translation process. A sample of 192 cancer patients completed the CARES, concurrent measures, and questions on socio-demographic and medical data. Participants were asked to complete the CARES a second time 1 week later, followed by some questions on their experiences with the instrument. Internal consistency, test-retest reliability, content validity, construct validity, concurrent validity and feasibility of the CARES were subsequently assessed.

RESULTS

The Flemish CARES version demonstrated excellent reliability with high internal consistency (range .87-.96) and test-retest ratings (range .70-.91) for all summary scales. Factor analysis replicated the original factor solution of five higher order factors with factor loadings of .325-.851. Correlations with other instruments ranging from |.43|-|.75| confirmed concurrent validity. Feasibility was indicated by the low number of missing items (mean 2.3; SD 5.0) and positive feedback of participants on the instrument.

CONCLUSIONS

The Flemish CARES has strong psychometric properties and can as such be a valid tool to assess cancer patients' QOL and needs in research, for example in international comparisons. The positive feedback of participants on the CARES support the usefulness of this tool for systematic assessment of cancer patients' well-being and care needs in clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02282696 (July 16, 2014).

Assessing cancer patients' quality of life and supportive care needs: Translation-revalidation of the CARES in Flemish and exhaustive evaluation of concurrent validity

BACKGROUND

The prevalence of cancer increases every year, leading to a growing population of patients and survivors in need for care. To achieve good quality care, a patient-centered approach is essential. Correct and timely detection of needs throughout the different stages of the care trajectory is crucial and can be supported by the use of screening and assessment in a stepped-care approach. The Cancer Rehabilitation Evaluation System (CARES) is a valuable and comprehensive quality of life and needs assessment instrument. For use in Flemish research and clinical practice, the CARES tool was translated for the Dutch-speaking part of Belgium (Flanders) from its original English format. This protocol paper describes the translation and revalidation of this Flemish CARES version.

METHODS

After forward-backward translation of the CARES into Flemish we aim to recruit 150 adult cancer patients with a primary cancer diagnosis (stage I, II or III) for validation. In this study with a combination of qualitative and a quantitative approach, qualitative data will be collected through focus groups and supplemented by two phases of quantitative data collection: i) an initial patient survey containing questions on socio-demographic and medical data, the CARES and seven concurrent instruments; and ii) a second survey administered after 1 week containing the CARES and supplementary questions to explore their impressions on the content and the feasibility of the CARES.

DISCUSSION

With this extensive data collection process, psychometric validity of the Flemish CARES can be tested thoroughly using classical test theory. Internal consistency of summary scales, test-retest reliability, content validity, construct validity, concurrent validity and feasibility of the instrument will be examined. If the Flemish CARES version is found reliable, valid and feasible, it will be used in future research and clinical practice. Comprehensive assessment with the CARES in a stepped-care approach can facilitate timely identification of cancer patients' psychosocial concerns and care needs so it can contribute to efficient provision of patient-centered quality care.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02282696 (July 16, 2014).

Assessing the need for psychooncological support: screening instruments in combination with patients' subjective evaluation may define psychooncological pathways

BACKGROUND

Cancer patients suffer from severe distress. About one third show mental comorbidities. Nevertheless, there is no common agreement on how to measure distress or identify patients in need for psychooncological services using screening questionnaires.

PATIENTS AND METHODS

A sample of N = 206 patients with confirmed breast cancer, being inpatient for surgical treatment, filled in distress assessment instruments: Distress Thermometer, Hospital Anxiety and Depression Scale, Patient Health Questionnaire 2, Hornheider Screening Instrument and parts of the EORTC-QLQ-C30. Additionally, they were asked for their subjective need for psychooncological counselling.

RESULTS

The correlation between the assessment instruments is low to medium. The number of patients above the cut-off criteria varies quite a lot according to the instrument (10% to 66%). Therefore, the congruence between the instruments' indications is quite low. Patients with and without subjective need do not differ in personal data but in distress scores.

CONCLUSIONS

Recommended instruments for distress assessment in psychooncology measure different areas of distress. They do not sufficiently agree in indicating a patient's need for psychooncological treatment. Hence, one should neither compare results of studies using different assessment instruments nor implement a screening without reflecting the used instrument's characteristics compared to the others. The subjective need seems to provide additional information to the assessment. At present, the combination of an assessment instrument and patients' subjective need is seen as a best practice for identifying patients in need of psychooncological treatment.