Screening for cancer-related distress: Summary of evidence from tools to programmes

Figures & data

Table I. Proposed grades of psychosocial distress.

Grade	DT Score	Functional Impairment
Minimal	0–2	None
Mild	3–4	Slight
Moderate	5–6	Moderate
Severe	7–10	Moderate-severe

Table II. Stages in evaluation of screening tools.

Stage	Purpose	Description
Preclinical	Tool development	Aim is to develop a screening method that is likely to help in detection of an underlying disorder, in either a specific setting or all settings. The acceptability of the tool to both patients and staff must be considered.
Phase-I screen	Early diagnostic validity testing in a selected sample; refinement of tool	Aim is to evaluate early design of screening method against a known (ideally accurate) standard, the criterion reference. In early testing, the tool can be refined, by selecting most useful aspects and deleting redundant aspects, in order to make the tool as efficient (brief) as possible while retaining its value.
Phase-II screen	Diagnostic validity in a representative sample	Aim is to assess the refined tool against a criterion (gold standard) in a real sample, in which the comparison group may have several competing conditions that could complicate differential diagnosis.
Phase-III screen	Randomized controlled trial; clinicians using vs not using the screening tool	The tool is evaluated clinically in one group with access to the new method which is compared with a second group (ideally selected in a randomized fashion) who make assessments without the tool. The outcome of interest is the number of additional cases correctly diagnosed or ruled out over that with assessment as usual.
Phase-IV screen	Studies with real outcomes	The screening tool is introduced clinically but monitored to determine the effect on patient outcomes, such as identification of new patients, new cases treated and new cases entering remission and also how well the tool accepted by clinicians (uptake).

Table originally presented in abstract format (Mitchell AJ, IPOS, 2008 [42]).

Table III. Randomized controlled trials of the effect of screening for distress on psychological well-being.

References	Primary outcome	Secondary outcome	Study design	Management plan/staff training	Sample	Measures	Results	Conclusion	Comments
Boyes et al. 2006 [20]	Level of depression, anxiety, physical symptoms	Desire for help	Intervention (n=42)/control (n=38). Screening in both groups; results available to oncologist in intervention group only. All patients had four screenings	Plan included suggestions for referral based on reported symptoms. No staff training	Patients (n=80); oncologists (n=4). Eligibility (58%): mixed cancer sites, ≥ 18 years, first consultation at outpatient clinic, in treatment, read English, emotionally and physically capable of participating. Response rate: 75%. Baseline distress: mean HADS anxiety, 6.48; HADS depression, 4.41	Screening tool: Physical symptoms: 12 items related to chemo-therapy, HADS, SCNS	Mood changes: mean HADS anxiety 6.83–4.80 in intervention group, 6.13–5.17 in control group. Mean HADS depression 4.98–4.20 in intervention group and 3.84–3.91 in control group. No significant difference in anxiety (p=0.09), depression (p=0.20) between intervention and control group	No effect on psychological well-being	Small sample, large attrition. Patients functioned well at baseline. Only 3 patients in intervention group reported that oncologist discussed screening results. Half of oncologists reported discussing results. No protection against contamination
Carlson et al. 2010 [21]	Level of distress	Level of anxiety and depression. Effect of referral to resources on distress, anxiety and depression	Minimal screening: not available to physician or patients (n=365)/full screening: available to physician and patient (n=391)/triage: full screening plus optional phone triage with referral (n=378). All groups had one screening and one follow-up after 3 months	Detailed triage algorithm used, including optional appointment with psychosocial staff. Patients wanting referral were contacted by staff. No staff training	Patients (n=1134): lung (n=549), breast (n=585). Eligibility (97%): ≥ 18 years, patients at outpatient clinic newly diagnosed or new to clinic or oncologist. Response rate, 89%. Baseline distress: mean DT score, 4.86 for lung and 3.79 for breast cancer	DT, PCL, PSSCAN, medical charts. Screening tool: DT, PCL, PSSCAN	Overall: Marginally significant difference between triage and minimal screening groups (F=2.47, p < 0.10). Distress: mean DT 4.26–3.16 in triage and 4.33–3.72 with minimal screening Lung: triage, 20% fewer patients with continued high distress. Breast: triage and full screening, significantly less distress than minimal screening at follow-up. No significant group differences for anxiety and depression	Effect on psychological well-being	No protection against contamination. Accepting referral was predictor of decreased anxiety and depression in full screening and triage. Treatment as usual not well described in any arm
Detmar et al. 2002 [22]	Discussion of QoL issues	Oncologists’ awareness of QoL, management activities, patient and physician satisfaction, level of QoL	Cross-over: Intervention (n=100)/control (n=114). Both groups screened; only intervention group had three screenings with results available to physician and patient Cross-over: randomization of physicians who switched condition midway through. All patients had baseline questionnaire at first and follow-up at fourth visit	No plan. 30 min training of staff	Patients (n=214)/oncologists (n=10). Eligibility (%?): mixed cancer group, in palliative chemotherapy, after two cycles of chemotherapy, ≥ 18 years, proficient in Dutch. Response rate: physicians (80%), patients (71%). Baseline distress: mean QLQ-C30 mental health, 73	QLQ-C30, SF-36, COOP, WONCA, Patient Satisfaction Questionnaire C, audio-taped consultation and review of medical records. Screening tool: QLQ-C30	No significant difference in QoL in intervention vs. control group at fourth visit (SF 36 mental health (p=0.41), but significantly more persons in intervention group improved over time in mental health (43% vs. 30%, p=0.04) and role functioning (22% vs 11%, p=0.05)	Effect on psychological well-being	Multiple statistical testing, potential carry-over effect from cross-over design
Maunsell et al. (1996) [23]	Distress	QoL including previous and current depression and anxiety, physical health, return to usual activities, employment, marital satisfaction	Intervention (n=123)/control (n=127). No screening in control group. Only intervention group had 12 monthly telephone screenings: patients with high distress contacted by social worker within 2 weeks. All patients had brief psychosocial intervention from social worker at initial treatment. All patients had telephone follow-up at baseline and 3 and 12 months	Plan: highly distressed patients contacted by social worker. No report of staff training	Patients (n=250). Eligibility (93%): women newly diagnosed with first primary breast cancer, no distant disease, not participating in competing studies, access to telephone, no hearing or severe health problems. Response rate: 89%. Baseline distress: mean PSI of 20.5	PSI, GHQ, LES, LWMAT, DIS, SSQ, employment. Screening tool: GHQ.	No significant difference in distress between intervention vs. control group (p=0.65). Distress changes: mean PSI, 20.4–13.5 in intervention group, 20.7–14.6 in control group. Distress level in both groups decreased over time (p=0.0001)	No effect on psychological well-being	Minimal psychosocial intervention provided to all patients may have made it difficult to show effect of intervention
McLachlan et al. (2001) [24]	Level of QoL, needs and satisfaction	Level of depression	Intervention (n=296)/control (n=154). Both groups screened; results for intervention group only available to oncologist. All patients had one screening. A nurse formulated an individual plan including referrals. Follow-ups at 2 and 6 months	Individual plan based on predefined guideline. No staff training	Patients (n=450). Eligibility (22%): mixed cancer group at outpatient clinic, > 1 visit, follow-up scheduled at clinic, English proficiency, ≥ 18 years, Eastern Cooperative Oncology Group Performance status ≤ 2 completion of ≥ 90% of pre-study questionnaire. Response rate, 59%. Baseline distress: mean not reported	Screening tool: CNQ, QLQ-C30, BDI	No overall difference in QoL between intervention and control group after 2 months (1.6, p=0.45). Significant difference in depression decrease (mean, 5.1) in intervention group at 6 months in subgroup of patients who were depressed at baseline (p=0.001)	Possible effect on psychological well-being	Eligibility criteria may have resulted in well-functioning patients. 41% of eligible patients were not randomized. No protection against contamination
Rosenbloom et al. (2007) [25]	Level of QoL and satisfaction		Control: Usual care (n=71)/screening (n=73)/screening and interview (n=69). Only intervention group was screened. All patients had baseline and 6-month follow-up. ‘Screening’ and ‘screening + interview’ also assessed after 1, 2 and 3 months. In ‘screening + interview’, research nurse interviewed patients about symptoms and reported them to treating nurse	No plan. No staff training	Patients (n=213). Eligibility (?): Advanced breast, lung and colorectal cancer, in chemotherapy, 18–75 years, life expectancy ≥ 6 months, English proficiency, no brain metastases or major CNS complication, no psychosis or mania/depression with psychotic symptoms. Response rate: ? Baseline distress: mean POMS of 7.3	FACT-G, FLIC, POMS-17, PSQ-III. Screening tool: FACT-G and structured interview	No significant differences in QoL (measured by FLIC) among the three groups. Distress changes: mean POMS of 9.1–8.3 in control group, 6.3–8.1 in screening group, 6.3–8.1 in screening + interview group	No effect on psychological well-being	Screening results not provided to treating nurse directly, but through a research nurse to protect against contamination, but this may have decreased an effect. No information on response rate
Velikova et al. (2004) [26]	Level of and management of QoL	Level of depression	Screening results: available to oncologist (n=144)/ not available to oncologist (n=70)/no screening (n=72). Two groups screened and one not. All patients had outcome questionnaires at home at baseline, 2, 4 and 6 months. Screenings performed at all visits to clinic	No plan. Staff received training in interpretation of screening results	Patients (n=286); oncologists (n=28). Eligibility (95%): mixed cancer group at oncology clinic starting treatment, expected to attend ≥ 3 times, proficiency in English, not taking part in other QoL studies, not exhibiting overt psychopathology. Response rate: 68%. Baseline distress: mean of 71.7 on FACT-G	QLQ-C30, HADS, FACT-G, audio-taped consultations. Primary outcome: Issues on QLQ-C30 identified as discussed in audio-taped sessions. Screening tool: QLQ-C30, HADS	Both screening groups had significantly different FACT-G scores from no-screening group (p=0.006 and p=0.01). Significant difference in proportion of patients experiencing improved QoL in group with results available to oncologist than in other groups	Effect on psychological well-being	No protection against contamination. Oncologist explicitly used screening results in only 64% of third sessions

BDI, Beck Depression Inventory short form; CNQ, Cancer Needs Questionnaire, short form; CNS, central nervous system; COOP, Dartmouth Primary Care Cooperative Information Functional Health Assessment; DIS, Diagnostic Interview Schedule; DT, Distress Thermometer; FACT-G, Functional Assessment of Cancer Therapy – General; FLIC, Functional Living Index, Cancer; GHQ, General Health Questionnaire; HADS, Hospital Anxiety and Depression Scale; LES, Life Experiences Survey; LWMAT, Locke-Wallace Marital Adjustment Test; PCL, Problem Check List; POMS-17, Profile of Mood States -brief; PSI, Psychiatric Symptom Index; PSQ-III, Medical Outcomes Study patient Satisfaction Questionnaire – III; PSSCAN, Psychological Screen for Cancer, part c; QLQ-C30, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30; QoL, quality of life; SF-36, Medical Outcomes Study 36-Item Short-Form Health Survey; SCNS, Supportive Care Needs Survey; SSQ, Social Support Questionnaire; WONCA, World Organization of National Colleges and Academics.

Mitchell AJ. Are one or two simple questions sufficient to detect depression in cancer and palliative care? A Bayesian meta-analysis. Br J Cancer 2008;98:1934–43.

 PubMed Web of Science ®Google Scholar

Boyes A, Newell S, Girgis A, McElduff P, Sanson-Fisher R. Does routine assessment and real-time feedback improve cancer patients’ psychosocial well-being? Eur J Cancer Care (Engl) 2006;15:163–71.

 PubMed Web of Science ®Google Scholar

Carlson LE, Groff SL, Maciejewski O, Bultz B. Screening for distress in lung and breast cancer outpatients: A randomized controlled trial. J Clin Oncol 2010; E-pub ahead of print october 12.

 Google Scholar

Detmar SB, Muller MJ, Schornagel JH, Wever LD, Aaronson NK. Health-related quality-of-life assessments and patient-physician communication: A randomized controlled trial. JAMA 2002;288:3027–34.

 PubMed Web of Science ®Google Scholar

Maunsell E, Brisson J, Deschenes L, Frasure-Smith N. Randomized trial of a psychologic distress screening program after breast cancer: Effects on quality of life. J Clin Oncol 1996;14:2747–55.

 PubMed Web of Science ®Google Scholar

McLachlan SA, Allenby A, Matthews J, Wirth A, Kissane D, Bishop M, . Randomized trial of coordinated psychosocial interventions based on patient self-assessments versus standard care to improve the psychosocial functioning of patients with cancer. J Clin Oncol 2001;19:4117–25.

 PubMed Web of Science ®Google Scholar

Rosenbloom SK, Victorson DE, Hahn EA, Peterman AH, Cella D. Assessment is not enough: A randomized controlled trial of the effects of HRQL assessment on quality of life and satisfaction in oncology clinical practice. Psychooncology 2007;16:1069–79.

 PubMed Web of Science ®Google Scholar

Velikova G, Booth L, Smith AB, Brown PM, Lynch P, Brown JM, . Measuring quality of life in routine oncology practice improves communication and patient well-being: A randomized controlled trial. J Clin Oncol 2004;22:714–24.

 PubMed Web of Science ®Google Scholar