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Contact us. Please note you do not have access to teaching notes. Other access options You may be able to access teaching notes by logging in via your Emerald profile. Abstract Purpose The psycho-oncology and social work services recognised that a cancer diagnosis and treatment can result in considerable emotional consequences for patients, yet the referral rate to both services was extremely low. Conversely, studies have shown that when patients were screened and did not receive any referrals or assistance, their levels of distress increased Mitchell, Distress is considered the sixth vital sign in oncology care.
Research continues to determine the validity of the DT and Problem List in various cancer populations based on ethnicity, cancer type, language, and age. Research is needed to validate interventions used to manage distress. Because the NCCN DT is a tool with well-established validity and brevity that is available in multiple languages and easy for the provider to interpret, the use of the instrument is being studied in other patient populations, including those with chronic obstructive pulmonary disease and acquired immune deficiency syndrome.
The National Comprehensive Cancer Network makes no warranties of any kind whatsoever regarding their content, use or application and disclaims any responsibility for their application or use in any way.
The author has no conflicts of interest to disclose. National Center for Biotechnology Information , U. Search database Search term. J Adv Pract Oncol. Kristin K. Author information Copyright and License information Disclaimer.
Correspondence to: Kristin K. E-mail: kristin. This article is distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
This article has been cited by other articles in PMC. Abstract Distress is experienced by many cancer patients, adversely affecting quality of life and cancer care. Figure 1. Open in a separate window. Disclaimer The National Comprehensive Cancer Network makes no warranties of any kind whatsoever regarding their content, use or application and disclaims any responsibility for their application or use in any way.
Footnotes The author has no conflicts of interest to disclose. References 1. Abrahamson Kathleen. Dealing with cancer-related distress. The American journal of nursing. American College of Surgeons. Cancer Program Standards Version 1. Emotional distress in patients with cancer: The sixth vital sign. Community Oncology. Distress screening for oncology patients: Practical steps for developing and implementing a comprehensive distress screening program. High levels of untreated distress and fatigue in cancer patients.
British journal of cancer. Screening for distress and unmet needs in patients with cancer: review and recommendations. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. Incorporating patient-reported outcomes to improve emotional distress screening and assessment in an ambulatory oncology clinic.
Journal of oncology practice. Which items on the distress thermometer problem list are the most distressing? Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer. The MHADRO required participants to complete a baseline assessment during a chemotherapy or routine oncology appointment on a touch-screen tablet. Patients were recruited at all points during the cancer trajectory i. Patients were approached for enrollment during a chemotherapy infusion or an ambulatory care appointment with an oncologist.
Oncologists helped a research assistant to identify eligible participants. They were informed that participation would not delay their care, and that they could withdraw from the study or terminate the assessment at any time.
Individuals with nausea or pain which precluded enrollment were re-approached during later appointments. The participant was randomly assigned to one of two study conditions. Participants in the intervention group received three printed reports including details of their psychological adjustment: one was provided to the patient, one was shared with their oncologist, and one was placed in the electronic medical record.
Participants in the intervention group who scored high in distress automatically received the contact information for two appropriate mental health providers based on their zip code and insurance carrier as a part of their printed report. In addition, these participants were given the option to choose to automatically send a dynamic referral for an appointment with one of these providers at the completion of the MHADRO assessment.
Participants in the control group completed the same MHADRO assessment, and then received standard care for psychosocial issues. Participants were recruited, enrolled into the study, and then were randomized to the intervention or control group before completing the assessment. The consent form signed by all participants was explicit in that patients would be enrolled and then randomized to either intervention or control condition. Randomization into the intervention or control group was completed by an internal random number generator programmed into the software.
Follow-up assessments will be completed at 2, 6, and 12 months from baseline. The present investigation utilizes baseline data from the parent RCT. All of the longitudinal data will be used for future publications.
The Psychological symptoms subscale is further broken down into symptoms of anxiety and depression. Each of the subscales was validated against one or more established scales e. The composite BHS has good reliability. It was chosen as the foundation of the MHADRO assessment because the goal was to identify patients who would find most benefit from mental health services in conjunction with cancer treatment.
The BHS has been used clinically with college students, substance abuse outpatients, and cardiovascular disease patients. Using the BHS Grissom et al. Patients were appraised based on their ability to function emotionally as well as physically, given the distress they experience on a daily basis.
This BHS scale combined the scores of three subscales: psychological symptoms, functioning, and subjective well-being Grissom et al. The BHS score placed participants into one of three categories: those with low, moderate, or high distress. The cutoffs for low, moderate, and high distress were based on percentile scores comparing each patient to a normative database that consisted of other MHADRO patients at intake.
Because this normative data was gathered from a cancer patient population, it may represent this population of interest more closely than would normative data gathered from a general population. Higher scores signify more severe symptoms and worse functioning. Patients with scores in the 70 th percentile or above were considered clinically elevated in distress, patients who fell below the 30 th percentile were considered low in distress, and others in between the 30 th and 70 th percentiles were considered within normal limits.
The 5-item depression subscale assessed patients on their symptoms of sadness, loss of pleasure from previously enjoyable activities, feelings of worthlessness, hopelessness, pessimism, and difficulty concentrating.
Each item presented a 4-point Likert scale with higher scores indicating better less severe outcomes. Each item presented a 4-point Likert scale with higher scores indicating better outcomes. The functional disability subscale converts 5 items to a 5-point Likert scale. Scores are coded so that higher scores indicate better functioning.
This 1-item measurement required participants to indicate how well they had been getting along psychologically and emotionally on a 5-point scale.
The responses range from 1 quite poorly, can barely manage to deal with things to 5 quite well, no important complaints. As described above, the DT has been validated using Receiver Operating Characteristic ROC analyses in numerous oncology populations and has held up against other validated and lengthier measures.
Basic descriptive statistics were used to characterize the sample. To characterize the association between DT scores and categorical characteristics of interest we used analysis of variance. When significance was achieved we further examined specific group differences by calculating least squares means. The least squares means approach is preferred because it both allows for adjustment for multiple comparison testing as well as unbalanced designs. Specifically, we used a Tukey-Kramer adjustment Kramer, that accommodates unequal sample sizes in groups.
We conservatively chose to calculate a Spearman correlation rather than a Pearson correlation because the former only requires the data to be measured at least at the ordinal scale rather than the interval scale requirement of Pearson correlation and makes no assumptions about the underlying distribution. Using a similar approach to that described above, we further investigated the relationship between the NCCN and the BHS using analysis of variance. Based on the categorization of low, moderate, and high distress as measured by the BHS and described earlier in the Methods, we determined if there was a difference in the NCCN score based on group membership.
When significance was achieved we further examined specific group differences by calculating least square means. Specifically, we were interested in determining if a cut-point with acceptable sensitivity and specificity could be defined on the NCCN that corresponded to higher distress on the more thoroughly examined and commonly used BHS score.
Several logistic regression models predicting the probability of high distress as measured by the BHS score with varying cut-points on the NCCN score were developed and the corresponding sensitivity, specificity, positive predictive and negative predictive values were calculated. All statistical analyses were performed using SAS 9.
A description of sample characteristics is presented in Table 1. A history of 11 mental health diagnoses were endorsed e. Further, least squares means analyses revealed that each category of BHS score was related to a significantly different DT score.
Specifically, we were interested in determining if a cut-point with acceptable sensitivity and specificity could be defined on the NCCN that corresponded to higher distress on the BHS score. Based on the cut-point for distress using the NCCN score, sensitivity ranged from 0. The current recommended cut-point on the NCCN scale, 4, had a sensitivity of 0. The corresponding positive and negative predictive values were 0. A cut-point of 3 on the NCCN scale was found to have higher sensitivity 0.
For example, at a thermometer score of 3 read from the top right corner , the average high distress score 0. A statistically significant difference in distress was found among patients, depending on the amount of time that had lapsed since the diagnosis of cancer.
Figure 2 demonstrates mean levels of distress at each of the four times since diagnosis. Oncology providers and governing bodies in oncology care agree that the psychosocial needs of individuals with cancer should be identified and addressed. Efficient and accurate screening tools are helpful to providers who are attempting to accomplish these goals.
The present study examined the DT as a brief screening tool for distress and was compared to a psychometrically validated assessment of distress. In accordance with previous research, scores on the brief DT were significantly associated with scores on the lengthier BHS index Chambers et al. Also, time since diagnosis was related to scores on the DT. Specifically, patients who were in the period of time weeks after receiving the diagnosis endorsed more distress than patients at any other time in the cancer trajectory, even those patients who were in the first week post-cancer diagnosis.
This poses an immediate need to ensure that patients receive the option for psychosocial services when they are diagnosed with cancer as this may help them navigate the difficult journey on which they are about to embark.
Figure 2 illustrates distress levels among patients who received their diagnoses at varying intervals of time. The findings in Figure 2 are consistent with previous research that has demonstrated the fluctuation of distress levels over the course of coping with cancer, which may be due to the uncertainty surrounding cancer treatment Chambers et al. During the first week, patients may be feeling numb or in a state of derealization before they have fully processed the diagnosis National Cancer Institute, Once the diagnosis has sunk in, but before treatment plans have been determined, patients may experience heightened distress, which could explain the high levels of distress during that week post-diagnosis interval.
Providers may need to screen for distress symptoms in patients during this phase, and it may be helpful to offer mental health services as well. These proactive measures may serve to help patients transition through the different phases of coping with cancer. This study may have implications for the clinical use of brief screeners of psychosocial distress in cancer populations. Our analyses indicated that using a cutoff of 3 to indicate high levels of distress may maximize sensitivity and be a more useful option in some heterogeneous clinical settings.
Because this score is lower than the one recommended by the NCCN Guidelines, it raises the issue of over-diagnosing distress in a clinical setting, using valuable provider time and resources. Indeed, another option would be to use multiple cutoff points depending on the situation. For example, in situations where distress may not be as prevalent e.
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