Deidre B. Pereira, PhD

Associate Professor

Licensed Psychologist

Psychosocial Rep., UFHCC Joint Oncology Program

Department of Clinical & Health Psychology

College of Public Health & Health Professions

Distress Screening & Management in Cancer

Definition of Distress in Cancer: NCCN Distress Management Guidelines Version 2.2014

An unpleasant emotional experience of a psychological (cognitive, behavioral, emotional), social, and/or spiritual nature MultifactorialInterferes with the ability to manage cancerExists on a continuum:– Common feelings of sadness and fear– Disabling panic, depression, anger

Distress Screening Requirement

American College of Surgeons (ACoS) Commission on Cancer (CoC) 2012 Cancer Program Standards

Hospital Cancer Committee must develop and implement a process to integrate and monitor on-site psychosocial distress screening and referral for treatment as standard of care

Overseen by psychosocial representative on cancer committee

Method of assessment can be determined by the program

CoC RequirementsAssessed at least once during a pivotal medical visit

Preference for assessment methods that are standardized, validated, and have clinical cut-offs

Individuals with moderate/severe distress must be referred to appropriate resources for management

Assessment, referral, follow-up must be documented in the medical record

Distress as the 6th Vital Sign (Howell & Olsen, 2011)

Assessment of distress via Distress Thermometer or Visual Analog Scale (0 [No distress] – 10 [Worst distress imaginable] ) parallel to assessment of other vitals, such as temperature and pain

Cancer-Related Distress & Disability

Years Lost due to Disability in cancer: – 270 years per 100,000 population

Clinically-significant distress: Epi research– 5.7% of cancer survivors– 4.3% of patients with other health conditions– 0.7% of healthy individuals

Clinically-significant distress: Acute care– 31.3% of cancer patients, self-reported– 56.3% of cancer patients, expert-rated

Distress Screening & Management: A Stepped Care Model

Health & Behavior Assessment &

Intervention

Distress Screening

Low

-In

tens

ity

Mo

de

rate

-In

ten

sity

Mental Health Assessment

& Intervention

Patient-Centered Oncology

Care

Oncology Nurse

Navigators

Oncology Social Work

Integrative Medicine

Palliative Care &

Symptom Management

Psycho-Oncology Service

Psychiatry

Distress Screening Participants

Patient-Centered Oncology

Care

Oncology Nurse

Navigators

Oncology Social Work

Integrative Medicine

Palliative Care &

Symptom Management

Psycho-Oncology Service

Health & Behavior Assessment/Intervention Participants

Patient-Centered Oncology

Care

Oncology Social Work

Integrative Medicine

Psycho-Oncology Service

Psychiatry

Mental Health Assessment/Intervention Participants

Distress is an unpleasant emotional state that may affect how you feel, think, and act. It can include feelings of unease, sadness, worry, anger, helplessness, guilt, and so forth. It is common to feel sad, fearful, and helpless.

Feeling distressed may be a minor problem or it may be more serious. You may be so distressed that you can't do the things you used to do. Serious or not, it is important that your treatment team knows how you feel.

The Distress Thermometer is a tool that you can use to talk to your health care providers about your distress. It has a scale on which you circle your level of distress. It also asks about the parts of life in which you are having problems. The Distress Thermometer has been tested in many studies and found to work well.

The Distress Thermometer and the other questions below will help your treatment team know if you need supportive services. You may be referred to supportive services at UF or in your community. Supportive services can include help from support groups, chaplains, social workers, mental health counselors, psychologists, or psychiatrists.

Cancer History

• Primary diagnosis• Date of diagnosis• Type(s) of treatment completed to date• Type(s) of treatment under

consideration• Dates and brief descriptions of any

cancer-related inpatient hospitalizations to date

• Previous cancer diagnosis• Medications and any side effects

experienced• Changes in quality of life due to

cancer/cancer treatment (including pain)

• Other significant medical problems

Health & Behavior Assessment Components

Mood Screening

• Sadness/Depressed mood• Anhedonia• Crying spells• Fatigue/loss of energy• Appetite disturbance• Sleep disturbance• Psychomotor agitation or retardation• Irritability• Feelings of

guilt/worthlessness/hopelessness/helplessness

• Changes in libido• Suicidal ideation• Homicidal ideation• Anxiety• Mania/hypomania

Behavioral

Screening

• Current/past psychopharmacologic medications

• Current/recent/past alcohol use• Current/recent/past tobacco use• Current/recent/past illicit

substance use

Cognitive Screening

• Getting lost in familiar places• Misplacing belongings• Inability to concentrate• Short- or long-term memory

impairments• Confusion or disorientation

Psychosis Screening

• Hallucinations• Delusions• Dissociation• Depersonalization• Unusual beliefs

Stress and Coping Screening

• Other current stressors• History of trauma• Main problem- and/or emotion-

focused coping mechanisms used, including their efficacy

Brief Psychosocial History

• Age• Date and location of birth• Location of current residence• Education• Marital status• Number of children• Brief description of quality of family

(including spouse/partner) relationships• Employment status, including job

satisfaction if employed• Hobbies, activities that bring enjoyment• Plans for the future

Self-Report Testing

• Patient Health Questionnaire - 9 (PHQ-9)

• Past/current depressive symptoms• Current hopelessness• Past/recent/current suicidal ideation, intent, plan,

gestures, or behavior• Significant current, exacerbating stressors

(including relational)• Past/current anxious symptoms• Trauma history• Significant previous stressors and effectiveness of

skills used to cope with these• Past/current alcohol, tobacco, and illicit substance

use• Patient's strengths• Nature of social support network• Cancer-related quality of life (e.g., pain, fatigue,

nausea/vomiting, anorexia/cachexia, sleep, sexual functioning)

• Cancer-related concerns (e.g., end of life concerns, body image concerns, fears of recurrence, thoughts about death, spiritual/religious crisis, sexuality/intimacy concerns, reproductive health/fertility concerns)

Men

tal H

ealth

A

sses

smen

t

Current Distress Screening & Management at UFHCC

Routine Distress Screening– Multidisciplinary GI Oncology Clinic (2009 –

Present)– Inpatient Medical Oncology (January 2015 -

Present)– Outpatient Medical Oncology (June 2015)– Outpatient Radiation Oncology (August 2015)

Registration staff provides distress

screening form to patient

Patient completes form in waiting room

Medical Assistant (MA) gathers form

and enters data into “Vitals” in

EHR

If Distress Thermometer > 4 or PHQ-2 > 3, MA alerts

HCP

HCP discusses results with patient and

offers appropriate

referrals

If patient desires, referrals to Oncology Social Work and/or Psycho-Oncology Service provided

Oncology Social Work and Psycho-Oncology

Service document receipt of referral and any follow-

up care in EHR

Offered at every clinic visit but no more than once a week. Patient may decline to participate.

…Current Distress Screening & Management at UFHCC

Routine Psychological Evaluation– Hematopoietic Stem Cell Transplant patients– Prophylactic Mastectomy patients

Referral-Based Psychological Evaluation (2003 – Present)– Evaluation and treatment of mental and

behavioral health issues in the context of cancer survivorship

Range of Mental Health Issues Treated at UFHCC

Adjustment D/O

Health Behaviors

Nonadherence

Relational Issues

Anxiety D/O

Depressive D/O

Posttraumatic

Stress D/O

Delirium

Personality D/O

Psychosis

Substance D/O

Suicidality

Integration of Distress Screening Practice and Research

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

“Screening is resource intensive, and questions can be raised as to what alternative purposes the resources consumed by screening could be put…apply the resources that would otherwise go to screening instead to facilitating completion of referrals for the minority of patients who want services, particularly those who are having low income or otherwise disadvanged…screening for distress should not be implemented without demonstration that it actually improves patient outcomes over routine care and that benefits exceed costs at patient and system levels.”

Thank you!