NCCN Distress Thermometer Problem List Update

Common patient-reported sources of cancer-related distress in adults with cancer: A systematic review

BACKGROUND

Cancer-related distress (CRD) is widely experienced by people with cancer and is associated with poor outcomes. CRD screening is a recommended practice; however, CRD remains under-treated due to limited resources targeting unique sources (problems) contributing to CRD. Understanding which sources of CRD are most commonly reported will allow allocation of resources including equipping healthcare providers for intervention.

METHODS

We conducted a systematic review to describe the frequency of patient-reported sources of CRD and to identify relationships with CRD severity, demographics, and clinical characteristics. We included empirical studies that screened adults with cancer using the NCCN or similar problem list. Most and least common sources of CRD were identified using weighted proportions computed across studies. Relationships between sources of CRD and CRD severity, demographics, and clinical characteristics were summarized narratively.

RESULTS

Forty-eight studies were included. The most frequent sources of CRD were worry (55%), fatigue (54%), fears (45%), sadness (44%), pain (41%), and sleep disturbance (40%). Having enough food (0%), substance abuse (3%), childbearing ability (5%), fevers (5%), and spiritual concerns (5%) were infrequently reported. Sources of CRD were related to CRD severity, sex, age, race, marital status, income, education, rurality, treatment type, cancer grade, performance status, and timing of screening.

CONCLUSIONS

Sources of CRD were most frequently emotional and physical, and resources should be targeted to these sources. Relationships between sources of CRD and demographic and clinical variables may suggest profiles of patient subgroups that share similar sources of CRD. Further investigation is necessary to direct intervention development and testing.

Dedicated financial hardship screening adds value to routine distress screening among gynecologic cancer patients

OBJECTIVES

To evaluate existing distress screening to identify patients with financial hardship (FH) compared to dedicated FH screening and assess patient attitudes toward FH screening.

METHODS

We screened gynecologic cancer patients starting a new line of therapy. Existing screening included: (1) Moderate/severe distress defined as Distress Thermometer score ≥ 4, (2) practical concerns identified from Problem Checklist, and (3) a single question assessing trouble paying for medications. FH screening included: (1) Comprehensive Score for Financial Toxicity (COST) tool and (2) 10-item Financial Needs Checklist to guide referrals. FH was defined as COST score < 26. We calculated sensitivity (patients with moderate/severe distress + FH over total patients with FH) and specificity (patients with no/mild distress + no FH over total patients with no FH) to assess the extent distress screening could capture FH. Surveys and exit interviews assessed patient perspectives toward screening.

RESULTS

Of 364 patients screened for distress, average age was 62 years, 25% were Black, 45% were Medicare beneficiaries, 32% had moderate/severe distress, 15% reported ≥1 practical concern, and 0 reported trouble paying for medications. Most (n = 357, 98%) patients also completed FH screening: of them, 24% screened positive for FH, 32% reported ≥1 financial need. Distress screening had 57% sensitivity and 77% specificity for FH. Based on 79 surveys and 43 exit interviews, FH screening was acceptable with feedback to improve the timing and setting of screening.

CONCLUSIONS

Dedicated FH screening was feasible and acceptable, but sensitivity was low. Importantly, 40% of women with FH would not have been identified with distress screening alone.

Developing a Collaborative Agenda-Setting Intervention (CASI) to promote patient-centered communication in ovarian cancer care: A design thinking approach

OBJECTIVES

Patient-centered communication (PCC) occurs when clinicians respond to patients' needs, preferences, and concerns. While PCC is associated with better health-related quality of life in patients with cancer, patients with ovarian cancer have reported unmet communication needs. We used design thinking to develop an intervention to promote PCC in ovarian cancer care.

METHODS

Following the steps of design thinking, we empathized with stakeholders by reviewing the literature, then created stakeholder and journey maps to define the design challenge. To ideate solutions, we developed a challenge map. Finally, we developed wireframe prototypes and tested them with stakeholders.

RESULTS

Empathizing revealed that misaligned visit priorities precipitated suboptimal communication. Defining the design challenge and ideating solutions highlighted the need to normalize preference assessments, promote communication self-efficacy, and enhance visit efficiency. The Collaborative Agenda-Setting Intervention (CASI) elicits patients' needs and preferences and delivers communication guidance at the point of care. Stakeholders approved of the prototype.

CONCLUSION

Design thinking provided a systematic approach to empathizing with stakeholders, identifying challenges, and innovating solutions.

PRACTICE IMPLICATIONS

To our knowledge, the CASI is the first intervention to set the visit agenda and support communication from within the electronic health record. Future research will assess its usability and acceptability.

Effects of an urban forest healing program on cancer-related fatigue in cancer survivors

PURPOSE

This study aimed to examine the effects of an eight-session structured urban forest healing program for cancer survivors with fatigue.

BACKGROUND

Cancer-related fatigue (CRF) is a complex and multifactorial common symptom among cancer survivors that limits quality of life (QoL). Although health benefits of forest healing on physiological, physical, and psychological aspect as well as on the immune system have been reported in many studies, there is limited evidence on the efficacy of specialized forest program for cancer survivors.

METHOD

A single-blinded, pre-test and post-test control group clinical trial was conducted with -75 cancer survivors assigned to either the forest healing group or the control group. The intervention was an eight-session structured urban forest program provided at two urban forests with easy accessibility. Each session consists of three or four major activities based on six forest healing elements such as landscape, phytoncides, anions, sounds, sunlight, and oxygen. Complete data of the treatment-adherent sample (≥ 6 sessions) was used to examine whether sociodemographic, clinical, physiological (respiratory function, muscle strength, balance, 6-min walking test) and psychological (distress, mood state, sleep quality, QoL) characteristics at baseline moderated the intervention effect on fatigue severity at 9 weeks.

RESULTS

Significant time-group interactions were observed muscle strength, balance, 6-min walking test, distress, fatigue, moods, and QoL. The mean difference in fatigue between pre- and post-forest healing program was 9.1 (95% CI 6.2 to 11.9), 11.9 (95% CI 7.6 to 16.1) in moods, and -93.9 (95% CI -123.9 to -64.0) in QoL, showing significant improvements in forest healing group, but no significant improvements in the control group.

CONCLUSION

This study suggests that a forest healing program positively impacts the lives of cancer survivors, by addressing both physical and psychological challenges associated with CRF.

TRIAL REGISTRATION NUMBER

KCT0008447 (Date of registration: May 19, 2023).

Implementing process improvements to enhance distress screening and management

INTRODUCTION

While distress is prevalent among individuals living with cancer, distress management has not been optimized across cancer care delivery despite standards for screening. This manuscript describes the development of an enhanced Distress Thermometer (eDT) and shares the process for deploying the (eDT) across a cancer institute by highlighting improvements at the provider, system, and clinic levels.

METHODS

Focus groups and surveys were used at the provider-level to outline the problem space and to identify solutions to improve distress screening and management. Through stakeholder engagement, an eDT was developed and rolled out across the cancer institute. Technical EHR infrastructure changes were implemented at the system-level to improve the use of the distress screening findings and generate automated referrals for specialty services. Clinic workflows were adapted to improve screening and distress management using the eDT.

RESULTS

Stakeholder focus group participants (n=17) and survey respondents (n=13) found the eDT to be feasible and acceptable for distress identification and management. System-level technical EHR changes resulted in high accuracy with patient identification for distress management, and 100% of patients with moderate to severe distress were connected directly to an appropriate specialty provider. Clinic-level workflow changes to expand eDT use improved compliance rates with distress screening from 85% to 96% over a 1-year period.

CONCLUSIONS

An eDT that provides more context to patient-reported problems improved identification of referral pathways for patients experiencing moderate to high distress during cancer treatment. Combining process improvement interventions across multiple levels in the cancer care delivery system enhanced the success of this project. These processes and tools could support improved distress screening and management across cancer care delivery settings.

Financial toxicity: A practical review for gynecologic oncology teams to understand and address patient-level financial burdens

Financial toxicity describes the adverse impact patients experience from the monetary and time costs of cancer care. The financial burden patients experience comes from substantially increased out-of-pocket spending that often occurs concurrent with reduced income due to sick leave from work. Financial toxicity is common affecting approximately half of patients with a gynecological cancer depending on the validated instrument used for measurement. Financial toxicity is experienced by patients in three domains: economic hardship affecting patients' material conditions (i.e., medical debt), psychological response (i.e., distress), and health-related coping behaviors that patients adopt (i.e., foregoing care due to costs). Higher financial toxicity among cancer patients has been associated with decreased quality of life, impaired adherence to recommended care, and worse overall survival. In this review, we describe the current literature on financial toxicity, including how it can be assessed with validated tools, the downstream impact on patients, risk factors, and employment concerns of survivors. Whenever possible, we highlight data from research featuring patients with gynecologic cancer specifically. We also review studies with interventions aimed to mitigate financial toxicity and offer the reader real world examples of interventions currently being used. Lastly, we provide an overview of health policy developments relevant to financial toxicity and advocate for innovation in the development and implementation of strategies to decrease the financial toxicity patients experience following a diagnosis of gynecologic cancer.

Simultaneous care in oncology: Assessment of benefit in relation to symptoms, sex, and age in 753 patients

BACKGROUND

Early activation of palliative care for patients with advanced cancer is central in the treatment trajectory. At the Veneto Institute of Oncology, a simultaneous-care outpatient clinic (SCOC) has been active since 2014, where patients are evaluated by an oncologist together with a palliative care team. Recently, we reported on consecutive patients admitted at SCOC from 2018 to 2021 in terms of appropriateness, process, and outcome indicators. Here, we report further analysis in the same group of 753 patients, evaluating other parameters and the correlation between symptom intensity, gender, age, and survival.

METHODS

SCOC data were retrieved from a prospectively maintained database.

RESULTS

Among the patients, 42.2% were women, and the median age was 68 years, with 46.7% of patients aged ≥70 years. The most prevalent disease type was gastrointestinal cancer (75.2%), and 90.9% of the patients had metastatic disease. The median score for the distress thermometer was 4; the vast majority of the patients (98.6%) reported physical problems, and 69.4% presented emotional issues. Younger women demonstrated a significantly greater median distress than other patients (p=0.0018). Almost all symptoms had a higher prevalence on the 0-3 Edmonton Symptom Assessment Scale (ESAS) score, except for fatigue. About 43.8% of the patients received systemic anticancer treatment (SAT) in the last 60 days of life, 15.0% of whom received SAT in the last month and 3.1% in the last 2 weeks. For some symptoms, women frequently had more ESAS >3. Pain and nausea were significantly less reported by older patients compared with younger adults. Men had a lower risk of having MUST score ≥ 2 (p=0.0311). Men and older patients showed a lower prognosis awareness (p=0.0011 and p=0.0049, respectively). Older patients received less SAT within the last 30 days of life (p=0.0006) and had death risk decreased by 20.0%.

CONCLUSION

Our study identified two subgroups of patients with advanced cancer who require special attention and support due to important symptoms' burden detected by Patient Reported Outcome Measures tests: women and younger adults. These categories of patients require special attention and should be provided early access at SCOC. The role of an oncologist remains crucial to intercept all patients in need of early palliative care and balancing trade-offs of anticancer treatment in advanced metastatic disease.