Selected Bibliography of Psychosocial Screening Literature

Our current ability to identify all patients feeling distress is not possible. Limitations in our screening tools and constrained financial resources may lead to one-time clinic screening procedures rather than routine screening. Likewise, we cannot be sure that we will identify clinically relevant and measurable effects of the screening activity if we do not have access to a system of referral and treatment for patients screened positive for distress 34. This all demonstrates the growing need for more trials investigating the effects of screening and treatments for distress. With the endorsement of distress as the 6th Vital Sign we are at a new threshold of comprehensive cancer care. The current challenge for Psycho-Oncology is how to use our science to improve patient care. Palmer SC, Coyne JC. Clinical Trial Did Not Demonstrate Benefits of Screening Patients With Cancer for Distress. Editorial, J Clin Oncol, April 1, 2011, 29: 10, e277-78. This letter to the editor discusses the study by Carlson et al (see above) regarding routine distress screening for breast and lung cancer patients. The letter states that the study did not demonstrate that screening cancer patients for distress reduced their distress, but this result was not reported in the article. According to Palmer and Coyne, “there was no difference in mean distress at 3 months between patients with cancer who were simply screened for distress, those whose screening results generated a personalized report that was provided to them and placed in an electronic medical record, and those who, in addition to the report, received an offer to discuss any issues with psychosocial staff regardless of their level of distress.” The authors note that this raises potentially important clinical and policy questions. They suggest that instead of screening, patients could be asked if they would like to discuss any psychosocial concerns that they might have with oncologic or psychosocial staff regardless of level of distress. This would allow the additional resources and staffing required for screening to be directed to facilitating better patient-staff communication. The authors acknowledge that screening for distress is widely advocated, but there is a lack of evidence that screening actually leads to reduced distress. They state that screening proponents of screening often “do not cite evidence, mis-cite null findings as supportive, or cite post hoc secondary and subgroup analyses as though they carry the same weight as primary outcomes, without noting that these are null findings.” The letter notes that those who advocate universal routine screening for distress of cancer patients should look at evaluations of evidence for the efficacy of screening for depression in general as well as in specialty medical settings. For instance, the US Preventive Services Task Force Recommendation Statement recommends against screening in settings in which staff-assisted depression care is not in place, a situation that characterizes most oncology care settings. The authors encourage advocates (and they count themselves as such) to “look beyond the simple solution that screening offers and has yet to demonstrate, and to focus on the message that offering patients the chance to discuss their concerns, regardless of screening, may make a more substantial contribution to their well-being.” Loscalzo MJ, Clark KL, Holland J. Commentary: Successful Strategies for Implementing Biopsychosocial Screening. Psycho-Oncology 2011:20 455-462 This commentary discusses strategies to utilize in setting up a screening program. It begins with a review of why screening is important and goes on to explore the need to engage key stakeholders at the outset with policies that meet their needs and that avoid control and turf issues. The commentary highlights the importance of providing information as to the value of screening for stakeholders i.e. physicians, nurses, administrators. Implementing screening involves understanding the culture of the clinic and then providing in-service education complete with food and thank you notes t ensure staff feel appreciated as they undertake the process. The importance of securing physician champions was stressed as was the value of having a member of the screening team present during all screenings for the first week of the roll-out. The article concludes with a reminder that to ensure success key stakeholders must perceive the direct benefits to them as well as to patients and families. Linda E. Carlson, Shannon L. Groff, Olga Maciejewski, and Barry D. Bultz. Screening for Distress in Lung and Breast Cancer Outpatients: A Randomized Controlled Trial. J Clin Oncol. 28: Nov. 20, 2010. 4884-4891. High levels of distress have been detected in patients in many countries, and recommendations to routinely screen for and treat distress have been published by a number of agencies, including the National Comprehensive Cancer Network. The primary objective of this study was to compare the efficacy of three versions of screening on subsequent distress (using the distress thermometer [DT]) in a population-based cohort of outpatients with breast and lung cancer. Other objectives were: to assess the impact of the three conditions on measures of anxiety and depression; and to assess the impact of receiving referrals to resources on changes in distress, anxiety, and depression across conditions. High prevalence of distress was detected in these patients with lung and breast cancer, with almost two thirds of the patients with lung and half of the patients with breast cancer scoring over the cutoff for high distress at baseline. The authors noted that these levels are higher than previous reports of general outpatients using other assessment tools, but similar to results in a lung patient clinic that also used the DT. The authors primary hypotheses were partially confirmed in each tumor group. Mean distress scores for patients with breast cancer were lower at follow-up for those in both the full screening and triage groups compared to minimal screening, but the proportions in the high distress category did not differ across groups. In patients with lung cancer, although mean distress scores did not differ at follow-up, the proportion of patients with lung cancer with high distress was 20% lower in the triage condition than the other two. This indicates that those patients with lung cancer with the highest levels of initial distress benefited most from personalized triage, while those with low or moderate levels to begin with may have slightly increased. This randomized controlled trial found that routine online screening is feasible in a large cancer center and that intensive screening including feedback to patients and care providers followed by personalized triage may help to reduce future distress levels, particularly when coupled with the uptake of appropriate resources. International Pscho-Oncology Society. International Psycho-Oncology Statement on Standards and Clinical Practice Guidelines in Cancer Care. July 2010. http://www.ipossociety.org/about/news/standards_news.aspx In July 2010, IPOS adopted a statement on the standards and clinical practice for oncology care:  Quality cancer care must integrate the psychosocial domain into routine care  Distress should be measured as the 6th Vital Sign after temperature, blood pressure, pulse, respiratory rate and pain. Paul B. Jacobsen, David Shibata, Erin M. Siegel, Ji-Hyun Lee, William J. Fulp, Carlos Alemany, Guillermo Abesada-Terk, Jr., Richard Brown, Thomas Cartwright, Douglas Faig, George Kim, Richard Levine, Merry-Jennifer Markham, Fred Schreiber, Philip Sharp and Mokenge Malafa. Evaluating the quality of psychosocial care in outpatient medical oncology settings using performance indicators. Psycho-Oncology. DOI: 10.1002/pon.1849 An American Psychosocial Oncology Society workgroup developed indicators of quality of psychosocial care that may be measured through medical records review. This article describes the first large-scale use of these indicators to evaluate psychosocial care in outpatient medical oncology settings. The medical records of 1660 colorectal, breast and non-small cell cancer patients first seen by a medical oncologist in 2006 at 11 practice sites in Florida were reviewed for performance on indicators of the quality of psychosocial care. Medical records were abstracted for numerous indicators of the quality of cancer care; however, thist report focuses on two indicators of the quality of psychosocial care: (1) there should be evidence in the medical record that the patient’s current emotional well-being was assessed within 1 month of the patient’s first visit with a medical oncologist; and (2) if a problem with emotional wellbeing was identified, there should be evidence in the patient’s medical record that action was taken to address the problem or an explanation provided for why no action was taken. The findings showed that assessment of emotional well-being was significantly less likely to be documented than assessment of pain. A problem with emotional well-being was documented in 13% of records and evidence of action taken was documented in 58% of these records. Ten of eleven practice sites performed below an 85% threshold on each indicator of psychosocial care. Variability in assessment of emotional-well being was associated with practice site, and patient gender and age, while variability in assessment of pain was associated with practice site and cancer type. This illustrates how use of the psychosocial care indicators allows identification of specific practice sites and processes of care that should be targeted for quality improvement efforts. Additionally, findings demonstrate the extent to which routine assessment of emotional wellbeing lags behind routine assessment of pain in cancer patients. Paul Jacobsen. Improving Psychosocial Care in Outpatient Oncology Settings. Journal of the National Comprehensive Cancer Network. 8: No. 4. April 2010. 368-370. Clinical Practice Guidelines in Oncology: Distress Management were first issued by the NCCN in 1994 and are updated annually. These guidelines were developed based on the recognized need for better management of distress and with the intent of promoting best practices for the psychosocial care of patients with cancer. NCCN guidelines recommend that all patients undergo screening routinely to identify the level and source of their distress. The specific services and resources recommended are intended to be appropriate to the nature and severity of the problems identified through screening and, if indicated, further evaluation. This article describes the efforts of the APOS work group to develop quality indicators and their testing as part of the Florida Initiative for Quality Cancer Care (FIQCC) and the Quality Oncology Practice Initiative of ASCO. The findings from these evaluations consistently indicate that, to date, efforts to promote routine symptom assessment have been more successful for pain than for emotional well-being. In addition, findings show considerable variability in quality of psychosocial care across practices. Most importantly, findings provide information that can be used by individual practices to make decisions about the need to improve the quality of psychosocial care they provide. Practices participating in these evaluations were provided feedback showing how its performance compared with the average of all practices and to every practice individually. Evidence suggests that providing feedback in this manner can yield improvements in the quality of psychosocial care provided to patients. Although provision of feedback alone may yield improvements in the quality of psychosocial care, a more deliberate approach seems more likely to achieve the desired results. Dr. Jacobsen offers potential strategies for more deliberate approaches. Barbara L. Andersen, Lisa M. Thornton, Charles L. Shapiro, William B. Farrar, Bethany L. Mundy, Hae-Chung Yang, and William E. Carson, III. Biobehavioral, Immune, and Health Benefits following Recurrence for Psychological Intervention Participants. Clin Cancer Res 16(12) June 15, 2010. A clinical trial was designed to test the hypothesis that a psychological intervention could reduce the risk of cancer recurrence. Newly diagnosed regional breast cancer patients (n = 227) were randomized to the intervention-with-assessment or the assessment-only arm. The intervention had positive psychological, social, immune, and health benefits, and after a median of 11 years the intervention arm was found to have reduced the risk of recurrence (hazard ratio, 0.55; P = 0.034). In follow-up, we hypothesized that the intervention arm might also show longer survival after recurrence. If observed, we then would examine potential biobehavioral mechanisms. Hazards analyses augment previous findings in showing improved survival for the intervention arm after recurrence. Follow-up analyses showing biobehavioral advantages for the intervention arm contribute to our understanding of how improved survival was achieved. Beesley V, Eakin E, Steginga S, Aitken J, Dunn J, Battistutta D. Unmet needs of gynaecological cancer survivors: implications for developing community support services. Psycho-Oncology. 2008;17(4):392–400. Abstract: Eight hundred and two women participated in a population-based mail survey in 2004 Eight hundred and two women participated in a population-based mail survey in 2004 (56% response rate). The questionnaire included a validated instrument to assess 45 need items across multiple supportive care domains, and a range of measures to evaluate related correlates consistent with a social–ecological perspective. Forty-three per cent of respondents reported having at least one moderateor high-level unmet need. The five highest included needing help with fear about the cancer spreading (17%), concerns about the worries of those close to them (15%), uncertainty about the future (14%), lack of energy/tiredness (14%), and not being able to do things they used to do (14%). Espie C, Fleming L, Cassidy J, Samuel L, Taylor L, White C, Douglas N, Engleman H, Kelly H, Paul J. Randomized Controlled Effectiveness Trial of Cognitive Behavior Therapy Compared With Treatment As Usual for Persistent Insomnia in Patients With Cancer. J Clin Oncol. Oct. 2008, Vol.