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Majumdar JR, Assel M, Dannaoui A, Fatata-Haim A, Fromkin J, Nelson C, Laudone V, Carlsson SV. Incorporating the Distress Thermometer into preoperative vital signs in patients undergoing ambulatory oncology surgery: a pilot feasibility study. J Psychosoc Oncol 2024:1-6. [PMID: 38757449 DOI: 10.1080/07347332.2024.2351038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
BACKGROUND Despite the extensive literature supporting distress screening at relevant transitions of care, the implementation of distress screening remains limited in ambulatory surgery settings. Our multidisciplinary team completed a pilot study to assess the feasibility and acceptability of including a standardized psychosocial assessment, the Distress Thermometer (DT), with the collection of admission vital signs by Patient Care Technicians (PCTs) in patients undergoing oncology surgery. METHODS We assessed feasibility by the response rate and acceptability through discussions with the PCTs. RESULTS Of the 189 men who underwent radical prostatectomy at our center, 71 were approached with the DT scale, and all patients who were approached completed the DT with no missing data. The staff reported no issues with data collection. A total of 21/71 (30%; 95% CI 19%, 42%) reported a clinically relevant distress DT ≥ 4. CONCLUSION Our results demonstrated that incorporating the DT into vital sign collection was feasible, acceptable, and provided a valuable assessment.
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Affiliation(s)
- Jennifer Ross Majumdar
- Department of Nursing, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Hunter-Bellevue School of Nursing, City University of New York, New York, NY, USA
| | - Melissa Assel
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Aimee Dannaoui
- Department of Nursing, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alexandria Fatata-Haim
- Department of Digital Informatics and Technology Solutions, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jillian Fromkin
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Christian Nelson
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vincent Laudone
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sigrid V Carlsson
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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Chau YF, Zhou H, Chen B, Ren H, Ma Z, Zhang X, Duan J. Screening for depression and anxiety in lung cancer patients: A real-world study using GAD-7 and HADS. Thorac Cancer 2024; 15:1041-1049. [PMID: 38523362 PMCID: PMC11062860 DOI: 10.1111/1759-7714.15287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 03/03/2024] [Accepted: 03/06/2024] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND The psychological well-being of lung cancer patients is critical in-patient care but frequently overlooked. METHODS This study, employing a cross-sectional, questionnaire-based design, aimed to elucidate the prevalence of depressive and anxiety symptoms among lung cancer patients and identify associated risk factors. Participants' demographic, medical history, disease stage, and pathology were systematically collected. Psychological assessment was conducted using the general anxiety disorder-7 (GAD-7), patient health questionnaire-9 (PHQ-9), and hospital anxiety and depression scale (HADS). Statistical analyses were performed using SPSS software (version 25.0). RESULTS Out of 294 distributed questionnaires, 247 lung cancer patients were included in the final analysis, with an average completion time of 9.08 min. Notably, 32.4% exhibited depressive symptoms, while 30% displayed signs of anxiety. A significant correlation was found between both depressive and anxiety symptoms and a history of tobacco and alcohol consumption. Specifically, increased nicotine dependence and greater cumulative tobacco use were linked to higher rates of depressive symptoms, whereas cumulative alcohol consumption was associated with increased risks of anxiety symptoms. CONCLUSION The study affirms the feasibility of GAD-7, PHQ-9, and HADS as screening tools for depressive and anxiety symptoms in lung cancer patients. It further highlights tobacco and alcohol consumption as significant risk factors for poor psychological health in this population.
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Affiliation(s)
- Yi Fung Chau
- CAMS Key Laboratory of Translational Research on Lung Cancer, State Key Laboratory of Molecular Oncology, Department of Medical OncologyNational Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical CollegeBeijingChina
| | - Huixia Zhou
- CAS Key Laboratory of Mental HealthInstitute of Psychology, Chinese Academy of SciencesBeijingChina
- Department of PsychologyUniversity of Chinese Academy of SciencesBeijingChina
| | | | - Hengqin Ren
- CAS Key Laboratory of Mental HealthInstitute of Psychology, Chinese Academy of SciencesBeijingChina
- Department of PsychologyUniversity of Chinese Academy of SciencesBeijingChina
| | - Zixiao Ma
- CAMS Key Laboratory of Translational Research on Lung Cancer, State Key Laboratory of Molecular Oncology, Department of Medical OncologyNational Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical CollegeBeijingChina
| | - Xiangyang Zhang
- CAS Key Laboratory of Mental HealthInstitute of Psychology, Chinese Academy of SciencesBeijingChina
- Department of PsychologyUniversity of Chinese Academy of SciencesBeijingChina
| | - Jianchun Duan
- CAMS Key Laboratory of Translational Research on Lung Cancer, State Key Laboratory of Molecular Oncology, Department of Medical OncologyNational Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical CollegeBeijingChina
- Department of Medical OncologyShanxi Province Cancer Hospital/Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical UniversityTaiyuanChina
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Prendergast H, Stratton R, Butler N, Mannan N, Khosla S. Understanding Barriers and Distress Experienced Among Cancer Patients: Analysis from an Urban Academic Emergency Department. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2024:10.1007/s13187-024-02435-8. [PMID: 38619797 DOI: 10.1007/s13187-024-02435-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/29/2024] [Indexed: 04/16/2024]
Abstract
The purpose of this study was to examine barriers and facilitators to compliance for cancer care in patients utilizing an emergency department (ED)-based assessment. Adult ED patients who either had active cancer or a history of cancer were enrolled between August 2020 and Jan 2022 for this prospective cohort study. We piloted the National Comprehensive Cancer Network (NCCN) Distress Thermometer. Multivariable regression analyses were used to assess the predictors of high distress. Of the 152 patients enrolled, 73% were Black patients, 11% were non-Hispanic White, and 16% included patients from other racial and ethnic groups (including 10.5% Hispanic patients); 73% of the sample had active cancer. The current ED visit was cancer related for 44%. The mean score on the Distress Thermometer was 4 (SD = 2; range 0-8) with 30% having a high distress level of ≥ 6. Having an active cancer and race/ethnicity were significant predictors of high distress. Patients who had active cancer had three times (aOR = 3.01; 95% CI 1.12-8.10) higher odds of experiencing high distress in the past week compared to those who did not have active cancer, after adjusting for race/ethnicity and reason for visit. Practical problems and physical problems were the most common, with 43% (n = 66) and 40% (n = 61) of the patients reporting these problems, respectively. Despite significant progress in cancer care, cancer patients/survivors face difficulty in transitioning between care environments and end up seeking episodic care in the ED and experience a high level of distress.
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Affiliation(s)
- Heather Prendergast
- Department of Emergency Medicine, University of Illinois Chicago, 808 S. Wood St., Chicago, IL, 60612, USA
| | - Ryan Stratton
- Department of Emergency Medicine, University of Illinois Chicago, 808 S. Wood St., Chicago, IL, 60612, USA
| | - Nia Butler
- Department of Emergency Medicine, University of Illinois Chicago, 808 S. Wood St., Chicago, IL, 60612, USA
| | - Nasima Mannan
- University of Illinois Cancer Center, Chicago, IL, USA
| | - Shaveta Khosla
- Department of Emergency Medicine, University of Illinois Chicago, 808 S. Wood St., Chicago, IL, 60612, USA.
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Vencill JA, Kirsch JL, McPherson K, Sprankle E, Patten CA, Campana K, Brockman T, Bronars C, Hughes C, Gastineau D, Ehlers SL. Prospective Association of Psychological Distress and Sexual Quality of Life Among Hematopoietic Stem Cell Transplant Survivors. J Clin Psychol Med Settings 2024:10.1007/s10880-024-10013-9. [PMID: 38615280 DOI: 10.1007/s10880-024-10013-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2024] [Indexed: 04/15/2024]
Abstract
Sexual health concerns are one of the most common late effects facing hematopoietic stem cell transplant (HSCT) survivors. The current study tested whether self-reported depression and anxiety symptoms before transplant were associated with embedded items assessing two specific areas of sexual health-sexual interest and sexual satisfaction-one year post-HSCT. Of the 158 study participants, 41% were diagnosed with a plasma cell disorder (n = 60) and most received autologous transplantation (n = 128; 81%). At post-HSCT, 21% of participants reported they were not at all satisfied with their sex life, and 22% were not at all interested in sex. Greater pre-HSCT depressive symptomology was significantly predictive of lower sexual interest (β = -.27, p < .001) and satisfaction (β = -.39, p < .001) at post-HSCT. Similarly, greater pre-HSCT trait anxiety was significantly predictive of lower sexual interest (β = -.19, p = .02) whereas higher levels of state and trait anxiety were both predictive of lower satisfaction (β = -.22, p = .02 and β = -.29, p = .001, respectively). Participant sex significantly moderated the relationship between state anxiety and sexual satisfaction (b = -.05, t = -2.03, p = .04). Additional research examining the factors that contribute to sexual health post-HCST is needed to inform and implement clinical interventions to address these commonly overlooked survivorship concerns.
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Affiliation(s)
- Jennifer A Vencill
- Department of Psychiatry & Psychology, Mayo Clinic, 200, 1st Street SW, Rochester, MN, 55905, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Janae L Kirsch
- Department of Psychiatry & Psychology, Mayo Clinic, 200, 1st Street SW, Rochester, MN, 55905, USA
| | - Keagan McPherson
- Department of Psychiatry & Psychology, Mayo Clinic, 200, 1st Street SW, Rochester, MN, 55905, USA
- Minnesota State University, Mankato, MN, USA
| | | | - Christi A Patten
- Department of Psychiatry & Psychology, Mayo Clinic, 200, 1st Street SW, Rochester, MN, 55905, USA
| | | | - Tabetha Brockman
- Department of Psychiatry & Psychology, Mayo Clinic, 200, 1st Street SW, Rochester, MN, 55905, USA
| | - Carrie Bronars
- Department of Psychiatry & Psychology, Mayo Clinic, 200, 1st Street SW, Rochester, MN, 55905, USA
| | - Christine Hughes
- Department of Psychiatry & Psychology, Mayo Clinic, 200, 1st Street SW, Rochester, MN, 55905, USA
| | - Dennis Gastineau
- Department of Psychiatry & Psychology, Mayo Clinic, 200, 1st Street SW, Rochester, MN, 55905, USA
| | - Shawna L Ehlers
- Department of Psychiatry & Psychology, Mayo Clinic, 200, 1st Street SW, Rochester, MN, 55905, USA.
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You W, Pilehvari A, Shi R, Cohn W, Sheffield C, Chow PI, Krukowski BA, Anderson R. A multi-dimensional assessment of financial hardship of cancer patients using existing health system data. Cancer Med 2023; 12:22263-22277. [PMID: 37987094 PMCID: PMC10757134 DOI: 10.1002/cam4.6731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 10/19/2023] [Accepted: 11/07/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Existing financial hardship screening does not capture the multifaceted and dynamic nature of the problem. The use of existing health system data is a promising way to enable scalable and sustainable financial hardship screening. METHODS We used existing data from 303 adult patients with cancer at the University of Virginia Comprehensive Cancer Center (2016-2018). All received distress screening and had a valid financial assistance screening based solely on household size-adjusted income. We constructed a composite index that integrates multiple existing health system data (Epic, distress screening, and cancer registry) to assess comprehensive financial hardship (e.g., material conditions, psychological responses, and coping behaviors). We examined differences of at-risk patients identified by our composite index and by existing single-dimension criterion. Dynamics of financial hardship over time, by age, and cancer type, were examined by fractional probit models. RESULTS At-risk patients identified by the composite index were generally younger, better educated, and had a higher annual household income, though they had lower health insurance coverage. Identified periods to intervene for most patients are before formal diagnosis, 2 years, and 6 years after diagnosis. Within 2 years of diagnosis and more than 4 years after diagnosis appear critical for subgroups of patients who may suffer from financial hardship disparities. CONCLUSION Existing health system data provides opportunities to systematically measure and track financial hardship in a systematic, scalable and sustainable way. We find that the dimensions of financial hardship can exhibit different patterns over time and across patient subgroups, which can guide targeted interventions. The scalability of the algorithm is limited by existing data availability.
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Affiliation(s)
- Wen You
- University of Virginia Comprehensive Cancer CenterCharlottesvilleVirginiaUSA
| | - Asal Pilehvari
- University of Virginia Comprehensive Cancer CenterCharlottesvilleVirginiaUSA
| | - Ruoding Shi
- University of Virginia Comprehensive Cancer CenterCharlottesvilleVirginiaUSA
| | - Wendy Cohn
- University of Virginia Comprehensive Cancer CenterCharlottesvilleVirginiaUSA
| | - Christina Sheffield
- University of Virginia Comprehensive Cancer CenterCharlottesvilleVirginiaUSA
| | - Philip I‐Fon Chow
- University of Virginia Comprehensive Cancer CenterCharlottesvilleVirginiaUSA
| | | | - Roger Anderson
- University of Virginia Comprehensive Cancer CenterCharlottesvilleVirginiaUSA
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Pirl W, Nekhlyudov L, Rowland JH, Lacchetti C, Andersen BL. Management of Anxiety and Depression in Adult Survivors of Cancer: ASCO Guideline Update Q&A. JCO Oncol Pract 2023; 19:714-717. [PMID: 37406256 DOI: 10.1200/op.23.00324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 06/07/2023] [Indexed: 07/07/2023] Open
Affiliation(s)
| | - Larissa Nekhlyudov
- Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA
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Parmet T, Yusufov M, Braun IM, Pirl WF, Matlock DD, Sannes TS. Willingness toward psychosocial support during cancer treatment: a critical yet challenging construct in psychosocial care. Transl Behav Med 2023; 13:511-517. [PMID: 36940406 PMCID: PMC10465092 DOI: 10.1093/tbm/ibac121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023] Open
Abstract
Psychosocial distress screening, mandated by the American College Surgeons' Commission on Cancer, continues to be implemented across cancer centers nationwide. Although measuring distress is critical to identifying patients who may benefit from additional support, several studies suggest that distress screening may not actually increase patients' utilization of psychosocial services. While various investigators have identified barriers that may impede effective implementation of distress screening, we posit that patients' intrinsic motivation, which we term patients' willingness, may be the biggest predictor for whether cancer patients choose to engage with psychosocial services. In this commentary, we define patient willingness towards psychosocial services as a novel construct, distinct from the intention toward a certain behavior described across pre-existing models of health behavior change. Further, we offer a critical perspective of models of intervention design that focus on acceptability and feasibility as preliminary outcomes thought to encompass the willingness construct described herein. Finally, we summarize several health service models that successfully integrate psychosocial services alongside routine oncology care. Overall, we present an innovative model that acknowledges barriers and facilitators and underscores the critical role of willingness in health behavior change. Consideration of patients' willingness toward psychosocial care will move the field of psychosocial oncology forward in clinical practice, policy initiatives, and study design.
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Affiliation(s)
- Tamar Parmet
- Harvard Medical School, Boston, MA, 02215, USA
- Division of Adult Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, 02215, USA
- Adult and Child Consortium for Outcomes Research and Delivery Science, Aurora, CO, USA
| | - Miryam Yusufov
- Harvard Medical School, Boston, MA, 02215, USA
- Division of Adult Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, 02215, USA
| | - Ilana M Braun
- Harvard Medical School, Boston, MA, 02215, USA
- Division of Adult Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, 02215, USA
| | - William F Pirl
- Harvard Medical School, Boston, MA, 02215, USA
- Division of Adult Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, 02215, USA
| | - Daniel D Matlock
- Adult and Child Consortium for Outcomes Research and Delivery Science, Aurora, CO, USA
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Veteran Affairs (VA) Eastern Colorado Geriatric Research Education and Clinical Center, Denver, CO, USA
| | - Timothy S Sannes
- Harvard Medical School, Boston, MA, 02215, USA
- Division of Adult Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, 02215, USA
- University of Massachusetts Medical School/UMass Memorial Hospital, Worcester, MA, USA
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8
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Potter AL, Haridas C, Neumann K, Kiang MV, Fong ZV, Riddell CA, Pope HG, Yang CFJ. Incidence, Timing, and Factors Associated With Suicide Among Patients Undergoing Surgery for Cancer in the US. JAMA Oncol 2023; 9:308-315. [PMID: 36633854 PMCID: PMC9857808 DOI: 10.1001/jamaoncol.2022.6549] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/22/2022] [Indexed: 01/13/2023]
Abstract
Importance The risk and timing of suicide among patients who undergo surgery for cancer remain largely unknown, and, to our knowledge, there are currently no organized programs in place to implement regular suicide screening among this patient population. Objective To evaluate the incidence, timing, and factors associated with suicide among patients undergoing cancer operations. Design, Setting, and Participants This retrospective population-based cohort study used data from the Surveillance, Epidemiology, and End Results Program database to examine the incidence of suicide, compared with the general US population, and timing of suicide among patients undergoing surgery for the 15 deadliest cancers in the US from 2000 to 2016. A Fine-Gray competing risks regression model was used to identify factors associated with an increased risk of suicide among patients in the cohort. Data were analyzed from September 2021 to January 2022. Exposures Surgery for cancer. Main Outcomes and Measures Incidence, compared with the general US population, timing, and factors associated with suicide after surgery for cancer. Results From 2000 to 2016, 1 811 397 patients (74.4% female; median [IQR] age, 62.0 [52.0-72.0] years) met study inclusion criteria. Of these patients, 1494 (0.08%) committed suicide after undergoing surgery for cancer. The incidence of suicide, compared with the general US population, was statistically significantly higher among patients undergoing surgery for cancers of the larynx (standardized mortality ratio [SMR], 4.02; 95% CI, 2.67-5.81), oral cavity and pharynx (SMR, 2.43; 95% CI, 1.93-3.03), esophagus (SMR, 2.25; 95% CI, 1.43-3.38), bladder (SMR, 2.09; 95% CI, 1.53-2.78), pancreas (SMR, 2.08; 95% CI, 1.29-3.19), lung (SMR, 1.73; 95% CI, 1.47-2.02), stomach (SMR, 1.70; 95% CI, 1.22-2.31), ovary (SMR, 1.64; 95% CI, 1.13-2.31), brain (SMR, 1.61; 95% CI, 1.12-2.26), and colon and rectum (SMR, 1.28; 95% CI, 1.16-1.40). Approximately 3%, 21%, and 50% of suicides were committed within the first month, first year, and first 3 years after surgery, respectively. Patients who were male, White, and divorced or single were at greatest risk of suicide. Conclusions and Relevance In this cohort study, the incidence of suicide among patients undergoing cancer operations was statistically significantly elevated compared with the general population, highlighting the need for programs to actively implement regular suicide screening among such patients, especially those whose demographic and tumor characteristics are associated with the highest suicide risk.
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Affiliation(s)
- Alexandra L. Potter
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston
| | - Chinmay Haridas
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston
| | - Krista Neumann
- Division of Epidemiology, School of Public Health, University of California, Berkeley
| | - Mathew V. Kiang
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California
| | - Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Boston
| | - Corinne A. Riddell
- Division of Epidemiology, School of Public Health, University of California, Berkeley
- Division of Biostatistics, School of Public Health, University of California, Berkeley
| | - Harrison G. Pope
- Biological Psychiatry Laboratory and Psychiatric Epidemiology Research Program, McLean Hospital, Belmont, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Chi-Fu Jeffrey Yang
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston
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Azizoddin DR, Allsop M, Farah S, Salim F, Hauser J, Baltazar AR, Molokie R, Weber J, Weldon C, Feldman L, Martin JL. Oncology distress screening within predominately Black Veterans: Outcomes on supportive care utilization, hospitalizations, and mortality. Cancer Med 2022; 12:8629-8638. [PMID: 36573460 PMCID: PMC10134375 DOI: 10.1002/cam4.5560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/08/2022] [Accepted: 12/10/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND We evaluated whether patients' initial screening symptoms were related to subsequent utilization of supportive care services and hospitalizations, and whether patient-level demographics, symptoms, hospitalizations, and supportive care service utilization were associated with mortality in primarily low-income, older, Black Veterans with cancer. METHODS This quality improvement project created collaborative clinics to conduct cancer distress screenings and refer to supportive care services at an urban, VA medical center. All patients completed a distress screen with follow-up screening every 3 months. Supportive care utilization, hospitalization rates, and mortality were abstracted through medical records. Poisson regression models and cox proportional hazard models were utilized. RESULTS Five hundred and eighty five screened patients were older (m = 72), mostly Black 70% (n = 412), and had advanced cancer 54%. Fifty-eight percent (n = 340) were screened only once with 81% (n = 470) receiving ≥1 supportive care service and 51.5% (n = 297) being hospitalized ≥1 time 18 months following initial screen. Symptom severity was significantly related to number of hospitalizations. Low mood was significantly related to higher supportive services (p < 0.001), but not hospitalizations (p ≥ 0.52). Pain, fatigue, physical function, nutrition, and physical symptoms were significantly associated with more supportive services and hospitalizations (p < 0.01). Twenty percent (n = 168) died; Veterans who were Black, had lower stage cancers, better physical health, and utilized less supportive care services had lower odds of mortality (p ≤ 0.01). CONCLUSION Individuals with elevated distress needs and those reporting lower physical function utilized more supportive care services and had higher hospitalization rates. Lower physical function, greater supportive care use, higher stage cancer, and being non-Black were associated with higher odds of death.
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Affiliation(s)
- Desiree R. Azizoddin
- Health Promotion Research Center, Stephenson Cancer Center University of Oklahoma Health Sciences Center Oklahoma City Oklahoma USA
- Department of Psychosocial Oncology and Palliative Care Dana‐Farber Cancer Institute Boston Massachusetts USA
| | - Matthew Allsop
- Academic Unit of Palliative Care Leeds Institute of Health Sciences, University of Leeds Leeds UK
| | - Subrina Farah
- Center for Clinical Investigation Brigham and Women's Hospital Boston Massachusetts USA
| | - Farah Salim
- Department of Medicine Jesse Brown VA Medical Center Chicago Illinois USA
| | - Joshua Hauser
- Department of Medicine Jesse Brown VA Medical Center Chicago Illinois USA
- Northwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Ashton R. Baltazar
- Health Promotion Research Center, Stephenson Cancer Center University of Oklahoma Health Sciences Center Oklahoma City Oklahoma USA
| | - Robert Molokie
- Department of Medicine Jesse Brown VA Medical Center Chicago Illinois USA
- University of Illinois Hospital and Health Sciences System Chicago Illinois USA
| | - Jane Weber
- Department of Medicine Jesse Brown VA Medical Center Chicago Illinois USA
| | | | - Lawrence Feldman
- Department of Medicine Jesse Brown VA Medical Center Chicago Illinois USA
- University of Illinois Hospital and Health Sciences System Chicago Illinois USA
| | - Joanna L. Martin
- Department of Medicine Jesse Brown VA Medical Center Chicago Illinois USA
- Northwestern University Feinberg School of Medicine Chicago Illinois USA
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10
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Kissane DW, Appleton J, Lennon J, Michael N, Chye R, King T, William L, Poon P, Kanathigoda S, Needham K, Bobevski I. Psycho-Existential Symptom Assessment Scale (PeSAS) Screening in Palliative Care. J Pain Symptom Manage 2022; 64:429-437. [PMID: 35961431 DOI: 10.1016/j.jpainsymman.2022.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 07/21/2022] [Accepted: 08/02/2022] [Indexed: 12/24/2022]
Abstract
CONTEXT Psycho-existential symptoms are common yet often missed or neglected in palliative care. Screening can be an effective way to recognize and respond to this need. OBJECTIVES We aimed to implement routine use of the Psycho-existential Symptom Assessment Scale (PeSAS) as a screening tool in Australian palliative care services and discern the symptom prevalence identified. METHODS In a multi-site rolling design, we established implementation site committees and embarked on experiential workshops to train clinicians in the tool's efficient use. Patient symptom prevalence data were collected to compare uptake across sites. Descriptive statistics were applied. RESULTS Over one year, we trained 216 clinicians across six palliative care services in the use of the PeSAS as a screening tool and collected data from 1405 patients. Clinicians reported significant growth in their sense of efficacy in assessing psycho-existential wellness. Services using electronic records implemented most easily. Psycho-existential symptoms with clinically significant prevalence (scores ≥ 4/10) included anxiety 41.1%, discouragement 37.6%, hopelessness 35.8%, pointlessness 26.9%, depression 30.3%, and the wish to die 17%. The precision of measurement within 3% was found for severe ratings (score ≥ 8/10) including anxiety 10.6%, depression 10.2%, the wish to die 7.6%, and confusion 3.6%. CONCLUSION Clinicians can be trained to screen with the Psycho-existential Symptom Assessment Scale, which serves as a valuable measure to better recognize symptoms of psycho-existential distress among palliative care patients. Implementation barriers included the prior ethos of the service, confidence in talking about these themes, electronic data entry, and perceived time pressures.
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Affiliation(s)
- David W Kissane
- School of Medicine (D.W.K, J.A., J.L., N.M., K.N., I.B.), University of Notre Dame Australia; St. Vincent's Hospital (D.W.K., J.A., J.L., R.C., K.N.), Sydney, NSW; Cabrini Health (D.W.K., N.M., I.B.), Melbourne, Victoria; School of Clinical Sciences (D.W.K., N.M., L.W., P.P., I.B.), Monash University, Victoria; Monash Health (D.W.K., P.P.), Melbourne, Victoria.
| | - Jane Appleton
- School of Medicine (D.W.K, J.A., J.L., N.M., K.N., I.B.), University of Notre Dame Australia; St. Vincent's Hospital (D.W.K., J.A., J.L., R.C., K.N.), Sydney, NSW
| | - Jonathon Lennon
- School of Medicine (D.W.K, J.A., J.L., N.M., K.N., I.B.), University of Notre Dame Australia; St. Vincent's Hospital (D.W.K., J.A., J.L., R.C., K.N.), Sydney, NSW
| | - Natasha Michael
- School of Medicine (D.W.K, J.A., J.L., N.M., K.N., I.B.), University of Notre Dame Australia; Cabrini Health (D.W.K., N.M., I.B.), Melbourne, Victoria; School of Clinical Sciences (D.W.K., N.M., L.W., P.P., I.B.), Monash University, Victoria
| | - Richard Chye
- St. Vincent's Hospital (D.W.K., J.A., J.L., R.C., K.N.), Sydney, NSW
| | - Tania King
- Eastern Palliative Care (T.K.), Victoria
| | - Leeroy William
- School of Clinical Sciences (D.W.K., N.M., L.W., P.P., I.B.), Monash University, Victoria; Eastern Health (L.W.), Melbourne, Victoria
| | - Peter Poon
- School of Clinical Sciences (D.W.K., N.M., L.W., P.P., I.B.), Monash University, Victoria; Monash Health (D.W.K., P.P.), Melbourne, Victoria
| | | | - Katarina Needham
- School of Medicine (D.W.K, J.A., J.L., N.M., K.N., I.B.), University of Notre Dame Australia; St. Vincent's Hospital (D.W.K., J.A., J.L., R.C., K.N.), Sydney, NSW
| | - Irene Bobevski
- School of Medicine (D.W.K, J.A., J.L., N.M., K.N., I.B.), University of Notre Dame Australia; Cabrini Health (D.W.K., N.M., I.B.), Melbourne, Victoria; School of Clinical Sciences (D.W.K., N.M., L.W., P.P., I.B.), Monash University, Victoria
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11
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Emotional Distress and Financial Toxicity in Younger Adult Patients Undergoing Oncologic Surgery. Ann Surg 2022; 276:694-700. [PMID: 35838403 DOI: 10.1097/sla.0000000000005593] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There has been an alarming increase in the number of young adults diagnosed with cancer. The emotional, psychosocial, and financial distress experienced by newly diagnosed young adults undergoing cancer surgery remains largely unknown. METHODS A validated biopsychosocial distress screening tool (SupportScreen®) was administered to patients diagnosed with cancer prior to surgery between 2009 and 2017 in a National Cancer Institute Comprehensive Cancer Center. Patients were stratified into younger adults ≤45 years (YA) and older adults >45 years (OA). Descriptive statistics and logistic regression were used to analyze distress outcomes. RESULTS In total, 4,297 patients were identified, with YA comprising 13.3% (n=573) of the cohort. YA reported higher emotional distress, including increased anxiety (33.8% vs. 27.4%, P=0.002), greater fear of procedures (26.7% vs. 22%, P=0.018), and difficulty managing emotions (26% vs. 20.7%, P=0.006). YA struggled more frequently to manage work/school (29.5% vs. 19.3%, P<0.001), finding resources (17.8% vs. 11.8%, P<0.001), changes in physical appearance (22.2% vs. 13.4%, P<0.001), fatigue (36% vs. 27.3%, P<0.001), and ability to have children (18.4% vs. 3%, P<0.001). Financial toxicity was significantly higher in the YA group (40.5% vs. 28%, P<0.001). While income level was strongly protective against emotional distress and financial toxicity in OAs, it was less protective against the risk of financial toxicity in YA. Younger age was an independent predictor of financial toxicity in a model adjusted to income (OR-1.52, P=0.020). CONCLUSION Younger adults in the prime of their personal and professional years of productivity require special attention when undergoing surgical evaluation for cancer. Resource allocation and counseling interventions should be integrated as part of their routine care to expedite their return to optimal physical and holistic health and mitigate psychosocial distress and financial toxicity.
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12
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Sutton TL, Koprowski MA, Gold JA, Liu B, Grossblatt-Wait A, Macuiba C, Lehman A, Hedlund S, Rocha FG, Brody JR, Sheppard BC. Disparities in Electronic Screening for Cancer-Related Psychosocial Distress May Promote Systemic Barriers to Quality Oncologic Care. J Natl Compr Canc Netw 2022; 20:765-773.e4. [PMID: 35830889 DOI: 10.6004/jnccn.2022.7015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 03/25/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Screening for cancer-related psychosocial distress is an integral yet laborious component of quality oncologic care. Automated preappointment screening through online patient portals (Portal, MyChart) is efficient compared with paper-based screening, but unstudied. We hypothesized that patient access to and engagement with EHR-based screening would positively correlate with factors associated with digital literacy (eg, age, socioeconomic status). METHODS Screening-eligible oncology patients seen at our Comprehensive Cancer Center from 2014 through 2019 were identified. Patients with active Portals were offered distress screening. Portal and screening participation were analyzed via multivariable logistic regression. Household income in US dollars and educational attainment were estimated utilizing zip code and census data. RESULTS Of 17,982 patients, 10,279 (57%) had active Portals and were offered distress screening. On multivariable analysis, older age (odds ratio [OR], 0.97/year; P<.001); male gender (OR, 0.89; P<.001); Black (OR, 0.47; P<.001), Hawaiian/Pacific Islander (OR, 1.54; P=.007), and Native American/Alaskan Native race (OR, 0.67; P=.04); Hispanic ethnicity (OR, 0.76; P<.001); and Medicare (OR, 0.59; P<.001), Veteran's Affairs/military (OR, 0.09; P<.01), Medicaid (OR, 0.34; P<.001), or no insurance coverage (OR, 0.57; P<.001) were independently associated with lower odds of being offered distress screening; increasing income (OR, 1.05/$10,000; P<.001) and educational attainment (OR, 1.03/percent likelihood of bachelor's degree or higher; P<.001) were independently associated with higher odds. In patients offered electronic screening, participation rate was 36.6% (n=3,758). Higher educational attainment (OR, 1.01; P=.03) was independently associated with participation, whereas Black race (OR, 0.58; P=.004), Hispanic ethnicity (OR, 0.68; P=.01), non-English primary language (OR, 0.67; P=.03), and Medicaid insurance (OR, 0.78; P<.001) were independently associated with nonparticipation. CONCLUSIONS Electronic portal-based screening for cancer-related psychosocial distress leads to underscreening of vulnerable populations. At institutions using electronic distress screening workflows, supplemental screening for patients unable or unwilling to engage with electronic screening is recommended to ensure efficient yet equal-opportunity distress screening.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Flavio G Rocha
- 4Knight Cancer Institute.,5Division of Surgical Oncology, Department of Surgery, and
| | - Jonathan R Brody
- 1Department of Surgery.,6Brenden-Colson Center for Pancreatic Care, Oregon Health & Science University, Portland, Oregon
| | - Brett C Sheppard
- 1Department of Surgery.,6Brenden-Colson Center for Pancreatic Care, Oregon Health & Science University, Portland, Oregon
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13
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Hahn EE, Munoz-Plaza CE, Pounds D, Lyons LJ, Lee JS, Shen E, Hong BD, La Cava S, Brasfield FM, Durna LN, Kwan KW, Beard DB, Ferreira A, Padmanabhan A, Gould MK. Effect of a Community-Based Medical Oncology Depression Screening Program on Behavioral Health Referrals Among Patients With Breast Cancer: A Randomized Clinical Trial. JAMA 2022; 327:41-49. [PMID: 34982119 PMCID: PMC8728610 DOI: 10.1001/jama.2021.22596] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
IMPORTANCE Implementation of guideline-recommended depression screening in medical oncology remains challenging. Evidence suggests that multicomponent care pathways with algorithm-based referral and management are effective, yet implementation of sustainable programs remains limited and implementation-science guided approaches are understudied. OBJECTIVE To evaluate the effectiveness of an implementation-strategy guided depression screening program for patients with breast cancer in a community setting. DESIGN, SETTING, AND PARTICIPANTS A pragmatic cluster randomized clinical trial conducted within Kaiser Permanente Southern California (KPSC). The trial included 6 medical centers and 1436 patients diagnosed with new primary breast cancer who had a consultation with medical oncology between October 1, 2017, through September 30, 2018. Patients were followed up through study end date of May 31, 2019. INTERVENTIONS Six medical centers in Southern California participated and were randomized 1:1 to tailored implementation strategies (intervention, 3 sites, n = 744 patients) or education-only (control, 3 sites, n = 692 patients) groups. The program consisted of screening with the 9-item Patient Health Questionnaire (PHQ-9) and algorithm-based scoring and referral to behavioral health services based on low, moderate, or high score. Clinical teams at tailored intervention sites received program education, audit, and feedback of performance data and implementation facilitation, and clinical workflows were adapted to suit local context. Education-only controls sites received program education. MAIN OUTCOMES AND MEASURES The primary outcome was percent of eligible patients screened and referred (based on PHQ-9 score) at intervention vs control groups measured at the patient level. Secondary outcomes included outpatient health care utilization for behavioral health, primary care, oncology, urgent care, and emergency department. RESULTS All 1436 eligible patients were randomized at the center level (mean age, 61.5 years; 99% women; 18% Asian, 17% Black, 26% Hispanic, and 37% White) and were followed up to the end of the study, insurance disenrollment, or death. Groups were similar in demographic and tumor characteristics. For the primary outcome, 7.9% (59 of 744) of patients at tailored sites were referred compared with 0.1% (1 of 692) at education-only sites (difference, 7.8%; 95% CI, 5.8%-9.8%). Referrals to a behavioral health clinician were completed by 44 of 59 patients treated at the intervention sites (75%) intervention sites vs 1 of 1 patient at the education-only sites (100%). In adjusted models patients at tailored sites had significantly fewer outpatient visits in medical oncology (rate ratio, 0.86; 95% CI, 0.86-0.89; P = .001), and no significant difference in utilization of primary care, urgent care, and emergency department visits. CONCLUSIONS AND RELEVANCE Among patients with breast cancer treated in community-based oncology practices, tailored strategies for implementation of routine depression screening compared with an education-only control group resulted in a greater proportion of referrals to behavioral care. Further research is needed to understand the clinical benefit and cost-effectiveness of this program. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02941614.
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Affiliation(s)
- Erin E. Hahn
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | | | - Dana Pounds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
- Now with Southern California Permanente Medical Group Performance Assessment team, Pasadena
| | - Lindsay Joe Lyons
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Janet S. Lee
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Ernest Shen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Benjamin D. Hong
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | | | - Farah M. Brasfield
- Department of Medical Oncology, Southern California Permanente Medical Group, Anaheim
| | - Lara N. Durna
- Department of Medical Oncology, Southern California Permanente Medical Group, South Bay
| | - Karen W. Kwan
- Department of Medical Oncology, Southern California Permanente Medical Group, Los Angeles
| | - David B. Beard
- Department of Medical Oncology, Southern California Permanente Medical Group, Woodland Hills
| | - Alexander Ferreira
- Department of Medical Oncology, Southern California Permanente Medical Group, West Los Angeles
| | - Aswini Padmanabhan
- Department of Medical Oncology, Southern California Permanente Medical Group, Baldwin Park
| | - Michael K. Gould
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
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14
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Rivest J, Desbeaumes Jodoin V, Martineau JT, Folch N, Charpentier D. “I Want to Help Others Like Me”: A Pilot Qualitative Study on Patients’ Participation in a Screening for Distress Program. J Patient Exp 2022; 9:23743735221106593. [PMID: 35719417 PMCID: PMC9203945 DOI: 10.1177/23743735221106593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Screening for distress was implemented in our academic hospital with the engagement of patients as partners. Little is known about how they appreciate such participation. This pilot qualitative study aimed to explore their experience. Six participants completed a semi-structured interview, which was transcribed verbatim. Thematic analysis was performed on the transcripts. Four themes emerged: “opinions about their participation”, “working with others”, “role of patient partners”, and “barriers encountered”. Mean global satisfaction reported on a Likert scale reached 8.92 over 10. Our preliminary findings suggest that patients-as-partners appreciated their participation, and also identified barriers that should be explored in future quality improvement (QI) projects.
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Affiliation(s)
- Jacynthe Rivest
- Department of Psychiatry, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Canada
| | | | | | - Nathalie Folch
- Nursing Directorate (ND), Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Danielle Charpentier
- Department of Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Canada
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15
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Implementation of Commission on Cancer Operative Standards: A Deceptively Complex Process. Ann Surg 2021; 275:e673-e675. [PMID: 34966065 DOI: 10.1097/sla.0000000000005361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Not seeing the forest for the trees: a systematic review of comprehensive distress management programs and implementation strategies. Curr Opin Support Palliat Care 2021; 14:220-231. [PMID: 32657813 DOI: 10.1097/spc.0000000000000513] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Clinically significant distress is common in patients with cancer and if untreated can be associated with adverse outcomes. This article offers a review of current approaches to implementing and reporting the minimum components of distress screening and management interventions in cancer services. RECENT FINDINGS Twenty-two relevant published articles were identified from January 2018 to February 2020. The reporting of recommended minimum components of distress screening and management interventions in these articles was not consistent. The majority of studies used validated tools to conduct initial screening. However, recommendations were either not reported or not followed regarding subsequent pathway components, secondary assessment, referral pathways linked to screening results and rescreening. The majority of studies did not include a description of the implementation of the distress screening program. A small number of studies described a comprehensive set of implementation strategies. SUMMARY Distress screening and management interventions in cancer are an important component of comprehensive cancer care. To improve patient outcomes and guide researchers and services to identify effective models, studies must include and evaluate minimum recommended components and implementation strategies. Addressing these limitations with high-quality, robust interventions is vital for advancing the implementation of effective distress management.
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17
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Rose S, Boyes A, Kelly B, Cox M, Palazzi K, Paul C. Lung cancer stigma is a predictor for psychological distress: A longitudinal study. Lung cancer stigma is a predictor for psychological distress. Psychooncology 2021; 30:1137-1144. [PMID: 33624377 DOI: 10.1002/pon.5665] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 02/11/2021] [Accepted: 02/18/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To examine if baseline stigma predicts psychological distress at 3 and 6 months follow-up among patients newly diagnosed with lung cancer. METHODS This longitudinal study was nested within a larger randomised controlled trial. Eligible participants were recruited via respiratory and oncology out-patient clinics in Australia (n = 194). Consenting participants were asked to complete surveys at baseline, 3 and 6 months post-recruitment. Measures included lung cancer stigma (Cataldo Lung Cancer Stigma Scale) and psychological distress (General Health Questionnaire-12 [GHQ-12]). RESULTS One-hundred and ninety-four participants were included for analysis. Most were male (57.7%) with a mean age of 68 years (SD = 8.8). A significant relationship between baseline lung cancer stigma and psychological distress at 6 months was found, where a one unit increase in lung cancer stigma increases psychological distress by 0.044 when adjusting for age, gender, smoking status, baseline GHQ-12 scores and intervention allocation (as part of the larger trial; p = 0.001; β = 0.044, 95% CI = 0.010, 0.079). CONCLUSION Temporal links between lung cancer stigma and psychological distress was found at 6 months, suggesting stigma-related experiences may have a delayed impact. Development of routine lung cancer stigma assessments is recommended to identify those at risk of psychological distress.
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Affiliation(s)
- Shiho Rose
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Allison Boyes
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Brian Kelly
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia.,Centre for Brain and Mental Health Research, School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Martine Cox
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Kerrin Palazzi
- Clinical Research, Information Technology and Statistical Support Unit, Hunter Medical Research Institute, New Lambton, New South Wales, Australia
| | - Christine Paul
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia.,Hunter Cancer Research Alliance, University of Newcastle, Callaghan, New South Wales, Australia
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18
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Patel JN, Boselli D, Jandrisevits EJ, Hamadeh IS, Salem A, Meadors P, Walsh D. Potentially actionable pharmacogenetic variants and symptom control medications in oncology. Support Care Cancer 2021; 29:5927-5934. [PMID: 33758969 DOI: 10.1007/s00520-021-06170-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 03/18/2021] [Indexed: 01/26/2023]
Abstract
PURPOSE We estimated the prevalence of potentially actionable pharmacogenetic (PGx) variants related to symptom control medications (SCMs) based on institutional prescribing patterns and correlated presenting symptoms with SCM prescribing. METHODS This was a retrospective study of adult ambulatory cancer patients undergoing electronic distress screening (EDS) within 90 days of intake to the cancer hospital. We estimated the proportion prescribed SCM(s) with PGx evidence within 90 days of intake. Those with potentially actionable variants were estimated using population frequency data from 1000 genomes. The expected number at risk of altered drug response was estimated. The associations between symptom scores and SCM(s) were estimated with logistic regression and threshold analyses performed with receiver operating characteristic (ROC) curves. RESULTS Of 6985 patients, 3222 (46%) received ≥ one SCM. Of these, 2760 (86%) received SCM(s) with PGx evidence for CYP2B6, CYP2C19, CYP2D6, or SLC6A4; 2719 (84%) received a drug metabolized by CYP2D6, most commonly hydrocodone (40.4%), ondansetron (35.6%), oxycodone (24.2%), and/or tramadol (7.1%). Based on this, about one quarter were expected to have altered metabolism and/or drug response. One third were prescribed two or more SCMs with PGx evidence. About half reported at least one severe symptom, which significantly correlated with SCM prescribing (p < 0.001). Threshold scores were identified that highly correlated with SCM prescribing for anxiety, depression, nausea, neuropathy, pain, and sleep. CONCLUSION About half presented with significant symptom burden, which highly correlated with SCM prescribing. Most received SCMs with PGx evidence. Preemptive PGx testing for these variants should be evaluated in prospective trials to evaluate the impact on symptom control.
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Affiliation(s)
- Jai N Patel
- Department of Cancer Pharmacology & Pharmacogenomics, Atrium Health Levine Cancer Institute, 1021 Morehead Medical Drive, Charlotte, NC, 28204, USA.
| | - Danielle Boselli
- Department of Biostatistics, Atrium Health Levine Cancer Institute, Charlotte, NC, USA
| | - Elizabeth J Jandrisevits
- Department of Cancer Pharmacology & Pharmacogenomics, Atrium Health Levine Cancer Institute, 1021 Morehead Medical Drive, Charlotte, NC, 28204, USA
| | - Issam S Hamadeh
- Department of Cancer Pharmacology & Pharmacogenomics, Atrium Health Levine Cancer Institute, 1021 Morehead Medical Drive, Charlotte, NC, 28204, USA
| | - Ahmed Salem
- Department of Cancer Pharmacology & Pharmacogenomics, Atrium Health Levine Cancer Institute, 1021 Morehead Medical Drive, Charlotte, NC, 28204, USA
| | - Patrick Meadors
- Section of Psycho-oncology, Center for Supportive Care and Survivorship, Atrium Health Levine Cancer Institute, Charlotte, NC, USA
| | - Declan Walsh
- Department of Supportive Oncology, Atrium Health Levine Cancer Institute, Charlotte, NC, USA
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Götz A, Kröner A, Jenewein J, Spirig R. Wie erleben und beurteilen Pflegende das Screening von stationären onkologischen Patient_innen mit dem Belastungsthermometer? Pflege 2021; 34:71-79. [PMID: 33535833 DOI: 10.1024/1012-5302/a000790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
How do nurses experience and interpret the screening of hospitalised cancer patients by means of the distress thermometer? - A qualitative study Abstract. Background: People with cancer experience distress and may need professional support. In 2012, the University Hospital Zurich introduced its distress thermometer (DT) screening, whereby all inpatients were to be screened to gauge their support need. However, after five years, the screening rate was 40 % and the referral rate to psycho oncology was 7.9 %, surprisingly low. Aim: The aim of this qualitative study was to describe how nurses experience the screening and how they interpret the screening and referral rate. Methods: The evaluation of three focus group interviews with 14 nurses followed the principles of qualitative content analysis according to Mayring. Results: The analysis revealed four main categories. The first category "Trying to perform useful screening in a complex daily routine" comprises three subcategories: "Using the benefits of screening for comprehensive care", "The best way to recognize the individuality of the counterpart" and "Failing due to structural and personal barriers". Three further main categories addressing nurses' personal attitudes complete the screening experience: "Experiencing fewer difficulties due to competence and experience", "Being careful due to hesitations", and "Reflecting one's responsibility". Conclusions: Nurses want to use the DT. However, they need more practical and scientific support to usefully integrate screening into their everyday life.
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Affiliation(s)
- Anna Götz
- Comprehensive Cancer Center Zürich, Universitätsspital Zürich.,PhD Programm, Department für Pflegewissenschaft, Universität Witten / Herdecke
| | | | - Josef Jenewein
- Triaplus Ag - Integrierte Psychiatrie Uri, Schwyz und Zug
| | - Rebecca Spirig
- PhD Programm, Department für Pflegewissenschaft, Universität Witten / Herdecke.,Institut für Pflegewissenschaft, Universität Basel
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20
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Azizoddin DR, Lakin JR, Hauser J, Rynar LZ, Weldon C, Molokie R, Enzinger AC, Payvar S, Martin JL. Meeting the guidelines: Implementing a distress screening intervention for veterans with cancer. Psychooncology 2020; 29:2067-2074. [PMID: 33009712 DOI: 10.1002/pon.5565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 09/02/2020] [Accepted: 09/29/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Guidelines recommend systematic evaluation of distress screening and referral for cancer patients. Implementation remains a notable gap for cancer centers serving disadvantaged communities. We present the implementation of a distress screening program within a Veterans Affairs hospital oncology clinic, serving a majority African American (AA) male population of low socioeconomic status (SES). METHODS The Coleman Foundation funded this program supporting a palliative care physician and psychologist to implement screening in a phased approach as follows: (1) Organizing key stakeholders, (2) educating clinical staff, (3) delivering distress screening, (4) generating documentation, and (5) implementing clinical action and referral pathways. We utilized validated measures in the "Patient Screening Questions for Supportive Care" screening tool. RESULTS This program was unsuccessful in screening all veterans with cancer; however, we were able to implement 3 years of longitudinal screening. In distress screens from the initial program period (n = 253), patients were primarily males (95.6%) of older age (m = 70, standard deviation = 9.45), AA (76.4%), with various cancers of advanced disease (69%). Males reported moderate psychosocial distress and elevated financial needs. For males with elevated psychosocial distress (n = 63, PHQ-4 ≥3), 36% were previously connected with psychosocial services. Following screening, engagement increased as the majority (77%) established psychosocial care. CONCLUSIONS This screening program had mixed success. Centralized program staff and available supportive care referrals were critical for program implementation. Screening may have increased engagement in social work/mental health services for males of low SES. Screening programs should be tailored to the needs of underserved communities with accessible housing/food subsidies.
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Affiliation(s)
- Desiree R Azizoddin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychiatry, Jesse Brown VA Medical Center, Chicago, Illinois, USA
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua Hauser
- Section of Palliative Care, Department of Medicine, Jesse Brown VA Medical Center, Chicago, Illinois, USA.,Section of Palliative Care, Department of Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lauren Z Rynar
- Department of Psychiatry, Jesse Brown VA Medical Center, Chicago, Illinois, USA.,Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Christine Weldon
- Department of Medicine, Hematology and Oncology, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA.,The Center for Business Models in Healthcare, Glencoe, Illinois, USA
| | - Robert Molokie
- Hematology/Medical Oncology, Department of Medicine, Jesse Brown VA Medical Center, Chicago, Illinois, USA.,Department of Hematology, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Andrea C Enzinger
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Susan Payvar
- Department of Psychiatry, Jesse Brown VA Medical Center, Chicago, Illinois, USA
| | - Joanna L Martin
- Section of Palliative Care, Department of Medicine, Jesse Brown VA Medical Center, Chicago, Illinois, USA.,Section of Palliative Care, Department of Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
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Ratcliff CG, Deavers F, Tullos EA, Christensen MR, Ricardo MM, Dindo L, Cully JA. Brief Behavioral Intervention for Distressed Patients Undergoing Cancer Surgery: A Case Series. COGNITIVE AND BEHAVIORAL PRACTICE 2020. [DOI: 10.1016/j.cbpra.2020.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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22
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Götz A, Kröner A, Jenewein J, Spirig R. Adherence to the distress screening through oncology nurses and integration of screening results into the nursing process to adapt psychosocial nursing care five years after implementation. Eur J Oncol Nurs 2020; 45:101725. [DOI: 10.1016/j.ejon.2020.101725] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 09/16/2019] [Accepted: 01/28/2020] [Indexed: 01/30/2023]
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Abstract
BACKGROUND The organization of psychosocial care is rather complex, and its provision diverse. Access is affected by the acceptance and attitude of patients and professional caregivers toward psychosocial care. OBJECTIVES The aims of this study were to examine when patients with cancer experience quality psychosocial care and to identify circumstances in collaboration that contribute to patient-perceived positive psychosocial care. METHODS This study used a qualitative design in which semistructured interviews were conducted with patients, hospital workers, and primary health professionals. RESULTS Psychosocial care is often requested but also refused by patients with cancer. Based on this discrepancy, a distinction is made between psychosocial support and psychosocial interventions. Psychosocial support aims to reduce the chaos in patients' lives caused by cancer and is not shunned by patients. Psychosocial interventions comprise the formal care offered in response to psychosocial problems. Numerous patients are reluctant to use psychosocial interventions, which are often provided by psychologists. CONCLUSION Psychosocial care aims to assist patients in bearing the difficulties of cancer and its treatment. Patients prefer informal support, given often in conjunction with physical care. IMPLICATIONS FOR PRACTICE This study confirms the important role of nurses in promoting psychosocial care. Patients perceive much support from nurses, although nurses are not considered to be professional psychosocial caregivers. Being perceived as approachable and trustworthy offers nurses a significant opportunity to bring more intense psychosocial interventions within reach of cancer patients.
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Riba MB, Donovan KA, Andersen B, Braun II, Breitbart WS, Brewer BW, Buchmann LO, Clark MM, Collins M, Corbett C, Fleishman S, Garcia S, Greenberg DB, Handzo RGF, Hoofring L, Huang CH, Lally R, Martin S, McGuffey L, Mitchell W, Morrison LJ, Pailler M, Palesh O, Parnes F, Pazar JP, Ralston L, Salman J, Shannon-Dudley MM, Valentine AD, McMillian NR, Darlow SD. Distress Management, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2019; 17:1229-1249. [PMID: 31590149 PMCID: PMC6907687 DOI: 10.6004/jnccn.2019.0048] [Citation(s) in RCA: 328] [Impact Index Per Article: 65.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Distress is defined in the NCCN Guidelines for Distress Management as a multifactorial, unpleasant experience of a psychologic (ie, cognitive, behavioral, emotional), social, spiritual, and/or physical nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment. Early evaluation and screening for distress leads to early and timely management of psychologic distress, which in turn improves medical management. The panel for the Distress Management Guidelines recently added a new principles section including guidance on implementation of standards of psychosocial care for patients with cancer.
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Affiliation(s)
| | | | - Barbara Andersen
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - IIana Braun
- Dana-Farber/Brigham and Women's Cancer Center
| | | | | | | | | | | | | | | | - Sofia Garcia
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | - Laura Hoofring
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | | | | | | | | | | | | | | | | | - Janice P Pazar
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | - Laurel Ralston
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
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Ciambella CC, Taneja C, Dizon DS, Wiggins DL, Emmick CM, Leonard KL, Lopresti ML, Witherby S, Cabral D, Snow S, Graves TA. Distress: Characterizing What Causes the Thermometer to Shift in Patients with Newly Diagnosed Breast Cancer Attending a Multidisciplinary Clinic. Ann Surg Oncol 2019; 26:3204-3209. [PMID: 31342366 DOI: 10.1245/s10434-019-07544-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND A diagnosis of breast cancer (BC) can result in multifactorial stress. If not addressed, distress can have a negative impact on outcomes. The experience of patients with newly diagnosed BC has not been sufficiently investigated. This study characterizes distress among new patients in a multidisciplinary care (MDC) clinic. The study aimed to determine the degree of distress at presentation, to characterize the sources, and to evaluate the impact of an MDC visit. METHODS A retrospective review was performed from January 2015 to November 2017. Charts were accessed for demographics, tumor characteristics, and treatment data. Distress scores (DS) and problems as captured using the National Comprehensive Cancer Network (NCCN) Distress Thermometer were completed before evaluation and in a subgroup after an MDC visit. Predictors of severe distress (DS ≥4) were investigated using multivariable logistic regression. The paired t test was used to determine the impact of an MDC visit. RESULTS The mean initial DS (n = 474) was 4.98. The top four sources of distress were worry, anxiety, fears, and sadness. Age younger than 65 years was significantly associated with a higher DS at presentation (p < 0.003). Among the patients queried before and after MDC (n = 137), a significant reduction in distress was identified (5.58-2.94; p < 0.0005). CONCLUSIONS Severe distress was found in 66 % of the patients with a recent diagnosis of BC, with younger age related to higher distress scores at presentation. Emotional stressors were the predominant factors accounting for distress. A same-day MDC visit was associated with a significant reduction in DS. These data indicate the importance and feasibility of proactively screening patients. Our research lends support to the value of multidisciplinary evaluation in this setting.
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Affiliation(s)
- Chelsey C Ciambella
- Department of Surgery, Brown University Warren Alpert Medical School, Providence, RI, USA. .,Rhode Island Hospital, Providence, RI, USA.
| | - Charu Taneja
- Rhode Island Hospital, Providence, RI, USA.,Lifespan Health System, Providence, RI, USA
| | - Don S Dizon
- Rhode Island Hospital, Providence, RI, USA.,Lifespan Health System, Providence, RI, USA
| | - Doreen L Wiggins
- Rhode Island Hospital, Providence, RI, USA.,Lifespan Health System, Providence, RI, USA
| | - Christine M Emmick
- Rhode Island Hospital, Providence, RI, USA.,Lifespan Health System, Providence, RI, USA
| | - Kara L Leonard
- Rhode Island Hospital, Providence, RI, USA.,Lifespan Health System, Providence, RI, USA
| | - Mary L Lopresti
- Rhode Island Hospital, Providence, RI, USA.,Lifespan Health System, Providence, RI, USA
| | - Sabrina Witherby
- Rhode Island Hospital, Providence, RI, USA.,Lifespan Health System, Providence, RI, USA
| | - Diana Cabral
- Rhode Island Hospital, Providence, RI, USA.,Lifespan Health System, Providence, RI, USA
| | - Serena Snow
- Rhode Island Hospital, Providence, RI, USA.,Lifespan Health System, Providence, RI, USA
| | - Theresa A Graves
- Rhode Island Hospital, Providence, RI, USA.,Lifespan Health System, Providence, RI, USA
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A cross-sectional audit of current practices and areas for improvement of distress screening and management in Australian cancer services: is there a will and a way to improve? Support Care Cancer 2019; 28:249-259. [PMID: 31030278 DOI: 10.1007/s00520-019-04801-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Accepted: 04/03/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND It is unknown how many distressed patients receive the additional supportive care recommended by Australian evidence-based distress management guidelines. The study identifies the (1) distress screening practices of Australian cancer services; (2) barriers to improving practices; and (3) implementation strategies which are acceptable to service representatives interested in improving screening practices. METHOD Clinic leads from 220 cancer services were asked to nominate an individual involved in daily patient care to complete a cross-sectional survey on behalf of the service. Questions related to service characteristics; screening and management processes; and implementation barriers. Respondents indicated which implementation strategies were suitable for their health service. RESULTS A total of 122 representatives participated from 83 services (51%). The majority of respondents were specialist nurses or unit managers (60%). Approximately 38% of representatives' services never or rarely screen; 52% who screen do so for all patients; 55% use clinical interviewing only; and 34% follow referral protocols. The most common perceived barriers were resources to action screening results (74%); lack of time (67%); and lack of staff training (66%). Approximately 65% of representatives were interested in improving practices. Of the 8 implementation strategies, workshops (85%) and educational materials (69%) were commonly selected. Over half (59%) indicated a multicomponent implementation program was preferable. CONCLUSIONS Although critical gaps across all guideline components were reported, there is a broad support for screening and willingness to improve. Potential improvements include additional services to manage problems identified by screening, more staff time for screening, additional staff training, and use of patient-report measures.
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27
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Buzaglo JS, Zaleta AK, McManus S, Golant M, Miller MF. CancerSupportSource®: validation of a revised multi-dimensional distress screening program for cancer patients and survivors. Support Care Cancer 2019; 28:55-64. [PMID: 30980258 PMCID: PMC6882761 DOI: 10.1007/s00520-019-04753-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 03/18/2019] [Indexed: 11/26/2022]
Abstract
Purpose To facilitate access to and provision of psychosocial care to cancer patients in the community, the Cancer Support Community (CSC) developed CancerSupportSource® (CSS), an evidence-based psychosocial distress screening program. The current study examined the psychometric properties and multi-dimensionality of a revised 25-item version of CSS, and evaluated the scale’s ability to identify individuals at risk for clinically significant levels of depression and anxiety. Methods CSS development and validation were completed in multiple phases. Exploratory factor analysis was completed with 1436 individuals diagnosed with cancer to examine scale dimensionality, and nonparametric receiver operating characteristic (ROC) curve analyses were used to determine scoring thresholds for depression and anxiety risk scales. Internal consistency reliability and convergent and discriminant validity were also examined. Confirmatory factor analysis and intraclass correlation coefficients were subsequently calculated with a separate sample of 1167 individuals to verify the scale factor structure and examine test–retest reliability. Results Five factors were identified and confirmed: (1) emotional well-being, (2) symptom burden and impact, (3) body image and healthy lifestyle, (4) health care team communication, and (5) relationships and intimacy. Psychometric evaluation of the total scale and factors revealed strong internal consistency reliability, test–retest reliability, and convergent and divergent validity. Sensitivity of CSS 2-item depression and 2-item anxiety risk scales were .91 and .92, respectively. Conclusions Results indicate that CancerSupportSource is a reliable, valid, multi-dimensional distress screening program with the capacity to screen for those at risk for clinically significant levels of depression and anxiety.
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Affiliation(s)
- Joanne S Buzaglo
- Cancer Support Community, Research and Training Institute, 520 Walnut Street, Suite 1170, Philadelphia, PA, 19106, USA
- Concerto HealthAI, 501 Boylston Street 10th Floor, Boston, MA, 02116, USA
| | - Alexandra K Zaleta
- Cancer Support Community, Research and Training Institute, 520 Walnut Street, Suite 1170, Philadelphia, PA, 19106, USA.
| | - Shauna McManus
- Cancer Support Community, Research and Training Institute, 520 Walnut Street, Suite 1170, Philadelphia, PA, 19106, USA
| | - Mitch Golant
- Cancer Support Community, Research and Training Institute, 520 Walnut Street, Suite 1170, Philadelphia, PA, 19106, USA
| | - Melissa F Miller
- Cancer Support Community, Research and Training Institute, 520 Walnut Street, Suite 1170, Philadelphia, PA, 19106, USA
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Ehlers SL, Davis K, Bluethmann SM, Quintiliani LM, Kendall J, Ratwani RM, Diefenbach MA, Graves KD. Screening for psychosocial distress among patients with cancer: implications for clinical practice, healthcare policy, and dissemination to enhance cancer survivorship. Transl Behav Med 2019; 9:282-291. [PMID: 30566662 PMCID: PMC6610173 DOI: 10.1093/tbm/iby123] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Accreditation standards are at the forefront of evolving healthcare systems, setting metrics for high-quality care. Healthcare outcomes (health, experience, cost, provider satisfaction/burn out) are becoming mutual goals of the patient, provider, payer, and healthcare system. Achieving high-quality outcomes in cancer care necessitates collaboration among interdisciplinary teams of clinical providers, administrators, patient advocates, caregivers, and researchers. Dissemination and implementation science provides necessary frameworks to organize the efforts of these implementation teams, inclusive of identifying facilitators and barriers to implementation of accreditation standards. Since 2015, cancer distress screening has been mandated for continued cancer center accreditation by the American College of Surgeon's Commission on Cancer. Cancer centers have thus become real world implementation laboratories. We present the current context of distress screening, highlighting prior research and key areas of future research. We consider multiple levels of cancer care delivery and the use of interdisciplinary teams to help cancer center teams adopt, implement, and maintain efficient distress screening programs. Finally, we present a case study to identify methods for successful implementation of distress screening at one cancer center and then describe efficiencies that can be introduced using elements from human factors engineering, e- and m-health screening platforms, and community partnerships.
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Affiliation(s)
- Shawna L Ehlers
- Department of Psychiatry and Psychology, Mayo College of Medicine and Science, Rochester, MN, USA
| | - Kimberly Davis
- Departments of Oncology and Psychiatry, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Shirley M Bluethmann
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - Lisa M Quintiliani
- Section of General Internal Medicine, School of Medicine, Boston University, MA, USA
| | - Jeffrey Kendall
- Oncology Service Line, University of Minnesota Cancer Care, Minneapolis, MN, USA
| | - Raj M Ratwani
- National Center for Human Factors in Healthcare, MedStar Health, Washington, DC, USA
| | - Michael A Diefenbach
- Feinstein Institute for Medical Research, Center for Health Innovation and Outcomes Research, Manhasset, NY, USA
| | - Kristi D Graves
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
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29
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Check DK, Kwan ML, Chawla N, Dusetzina SB, Valice E, Ergas IJ, Roh JM, Kolevska T, Rosenstein DL, Kushi LH. Opportunities to Improve Detection and Treatment of Depression Among Patients With Breast Cancer Treated in an Integrated Delivery System. J Pain Symptom Manage 2019; 57:587-595. [PMID: 30508637 PMCID: PMC6386165 DOI: 10.1016/j.jpainsymman.2018.11.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 11/23/2018] [Accepted: 11/26/2018] [Indexed: 01/07/2023]
Abstract
CONTEXT Patients with cancer commonly experience depression. If not addressed, depression can lead to reduced quality of life and survival. OBJECTIVE Given the introduction of national initiatives to improve management of psychiatric symptoms among patients with cancer, we examined patterns of depression detection and treatment over time, and with respect to patient characteristics. METHODS This cross-sectional study linked data from the Pathways Study, a prospective cohort study of women diagnosed with breast cancer at Kaiser Permanente Northern California between 2005 and 2013, with data from Kaiser Permanente Northern California's electronic medical record. Pathways participants eligible for this analysis had no known prior depression but reported depressive symptoms at baseline. We used modified Poisson regression to assess the association of cancer diagnosis year and other patient characteristics with receipt of a documented clinician response to depressive symptoms (depression diagnosis, mental health referral, or antidepressant prescription). RESULTS Of the 725 women in our sample, 34% received a clinician response to depression. We observed no statistically significant association of breast cancer diagnosis year with clinician response. Characteristics associated with clinician response included Asian race (adjusted risk ratio, Asian vs. white: 0.44, 95% CI: 0.29-0.68) and depression severity (adjusted risk ratio, mild-moderate vs. severe depression: 1.45, 95% CI: 1.11-1.88). CONCLUSION Most patients in our sample did not receive a clinician response to their study-reported depression, and rates of response do not appear to have improved over time. Asian women, and those with less severe depression, appeared to be at increased risk of having unmet mental health care needs.
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Affiliation(s)
- Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Marilyn L Kwan
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Neetu Chawla
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Stacie B Dusetzina
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Emily Valice
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Isaac J Ergas
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Janise M Roh
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Tatjana Kolevska
- Kaiser Permanente Northern California Vallejo Medical Center, Vallejo, California, USA
| | - Donald L Rosenstein
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lawrence H Kushi
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
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30
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Ercolano E, Hoffman E, Tan H, Pasacreta N, Lazenby M, McCorkle R. Managing Psychosocial Distress: Lessons Learned in Optimizing Screening Program Implementation. ONCOLOGY (WILLISTON PARK, N.Y.) 2018; 32:488-493. [PMID: 30334237 PMCID: PMC6727845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The estimated prevalence of psychosocial distress in cancer patients is 29.6% to 43.4%. Psychosocial distress is associated with depression, a common comorbidity in cancer patients. Untreated distress can contribute to early morbidity and mortality and can worsen other comorbidities. In 2012, the American College of Surgeons (ACoS) Commission on Cancer (CoC) required accredited cancer centers to integrate psychosocial distress screening into cancer care by the end of 2015. Uptake of screening has been minimal, with only 47% to 73% of eligible patients being screened. The Screening for Psychosocial Distress Program (SPDP) is a 2-year educational and implementation-support program designed to help cancer care clinicians meet the ACoS CoC mandate. Through the SPDP, we have trained cancer care clinicians on how to optimize the distress screening process to increase the likelihood that patients' distress will be detected, evaluated, and triaged. We report here on our "lessons learned" and the optimal strategies to promote institutions' adoption of distress screening.
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Affiliation(s)
| | - Emma Hoffman
- Yale University School of Nursing, West Haven, Connecticut
| | - Hui Tan
- Yale University School of Nursing, West Haven, Connecticut
| | | | - Mark Lazenby
- Yale University School of Nursing, West Haven, Connecticut
| | - Ruth McCorkle
- Yale University School of Nursing, West Haven, Connecticut
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31
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El-Majzoub S, Mucsi I, Li M, Moussaoui G, Lipman ML, Looper KJ, Novak M, Rej S. Psychosocial Distress and Health Service Utilization in Patients Undergoing Hemodialysis: A Prospective Study. PSYCHOSOMATICS 2018; 60:385-392. [PMID: 30396686 DOI: 10.1016/j.psym.2018.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 10/02/2018] [Accepted: 10/03/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND End-stage renal disease is associated with significant morbidity, high-symptom burden, and health care use. Studies have not yet assessed psychosocial distress and health care utilization in this population. OBJECTIVE This study examines psychosocial distress and its association with hospitalization and emergency room (ER) visits in patients on maintenance hemodialysis (HD). METHODS The Distress Assessment and Response Tool (DART) was administered to 80 adults on HD in a single treatment center. The DART assessed for anxiety, depression, and social distress. Health care utilization data were extracted prospectively from electronic medical charts. The time between psychosocial distress and hospitalization or ER visits during 12-month follow-up was examined using Cox proportional hazard models. RESULTS Overall 46% of the sample reported psychosocial distress, with 33% screening above the threshold for depression, 14% for anxiety, and 36% for significant social distress. In multivariable regression adjusting for age, sex, and comorbidity, the presence of psychosocial distress was associated with shorter time to hospitalization (hazard ratio: 2.4 [1.1, 5.0], p = 0.03) during 12-month follow-up. Psychosocial distress was not significantly associated with ER visits in either univariable (hazard ratio: 1.3 [0.7, 2.3], p = 0.5) or multivariable (hazard ratio: 1.4 [0.8, 2.6], p = 0.3) analyses. CONCLUSION Psychosocial distress is frequent in patients undergoing maintenance HD and is associated with shorter time to hospitalization. Future longitudinal studies should examine if health service use can be reduced through routine distress screening and psychosocial distress intervention.
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Affiliation(s)
- Salam El-Majzoub
- Geri-PARTy Research Group, Jewish General Hospital, Department of Psychiatry, McGill University, Montreal, Canada.
| | - Istvan Mucsi
- Multiorgan Transplant Program and Division of Nephrology, University Health Network, University of Toronto, Toronto, Canada
| | - Madeline Li
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; Centre for Mental Health, University Health Network and Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Ghizlane Moussaoui
- Geri-PARTy Research Group, Jewish General Hospital, Department of Psychiatry, McGill University, Montreal, Canada
| | - Mark L Lipman
- Division of Nephrology, Jewish General Hospital, Montreal, Canada
| | - Karl J Looper
- Geri-PARTy Research Group, Jewish General Hospital, Department of Psychiatry, McGill University, Montreal, Canada
| | - Marta Novak
- Centre for Mental Health, University Health Network and Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Soham Rej
- Geri-PARTy Research Group, Jewish General Hospital, Department of Psychiatry, McGill University, Montreal, Canada
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Khushalani JS, Qin J, Cyrus J, Lunsford NB, Rim SH, Han X, Yabroff KR, Ekwueme DU. Systematic review of healthcare costs related to mental health conditions among cancer survivors. Expert Rev Pharmacoecon Outcomes Res 2018; 18:505-517. [PMID: 29869568 PMCID: PMC6103822 DOI: 10.1080/14737167.2018.1485097] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 06/03/2018] [Indexed: 01/18/2023]
Abstract
INTRODUCTION This systematic review examines healthcare costs associated with mental health conditions among cancer survivors in the United States. AREAS COVERED Ten published studies were identified. Studies varied substantially in terms of population, mental health conditions examined, data collection methods, and type of cost reported. Cancer survivors with mental health conditions incurred significantly higher total medical costs and costs of most service types compared to cancer survivors without a mental health condition. Additionally, the total healthcare expenditure related to mental health was higher among cancer survivors compared with people without history of cancer. EXPERT COMMENTARY Mental health conditions are associated with increased healthcare costs among cancer survivors. Future examination of other components of economic burden, including patient out-of-pocket costs, nonmedical costs, such as transportation, childcare, and productivity losses for patients and their caregivers, will be important. Additionally, evaluation of economic burden by cancer site, stage at diagnosis, duration of survivorship, and treatment(s) will increase understanding of the overall impact of mental health conditions on cancer survivors and on the healthcare system.
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Affiliation(s)
| | - Jin Qin
- Division of Cancer Prevention and Control, CDC, Atlanta, United States
| | - John Cyrus
- Tompkins-McCaw Library, Virginia Commonwealth University, Richmond, Virginia, United States
| | | | - Sun Hee Rim
- Division of Cancer Prevention and Control, CDC, Atlanta, United States
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Rodin G. From evidence to implementation: The global challenge for psychosocial oncology. Psychooncology 2018; 27:2310-2316. [DOI: 10.1002/pon.4837] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 06/27/2018] [Accepted: 06/27/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Gary Rodin
- Department of Supportive Care; Princess Margaret Cancer Centre; Toronto Canada
- Department of Psychiatry; University of Toronto; Toronto Canada
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McLeod D, Esplen MJ, Wong J, Hack TF, Fillion L, Howell D, Fitch M, Dufresne J. Enhancing clinical practice in the management of distress: The Therapeutic Practices for Distress Management (TPDM) project. Psychooncology 2018; 27:2289-2295. [PMID: 29956392 DOI: 10.1002/pon.4831] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 06/16/2018] [Accepted: 06/19/2018] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The Therapeutic Practices for Distress Management (TPDM) project was carried out to support clinicians in integrating recommendations from four clinical practice guidelines (CPGs) in routine care at five Pan Canadian cancer care sites. METHODS Using a concurrent, mixed-method study design and knowledge translation (KT) activities, this project included two phases: phase I-a baseline/preparation phase and phase II-an intervention phase plus evaluation. The intervention phase (the focus of this report) included a one-year education and supervision program (24 hours in virtual class; 12-hour group supervision). Primary outcomes were knowledge and self-efficacy in practicing CPGs as measured by a Knowledge and Self-Efficacy Survey (KSES). A secondary outcome was observer-rated performances with standardized patients (objective structured clinical exams). Participants included 80 (90%) nurses, and 9 (10%) social workers (N = 89). RESULTS The TPDM program was effective in accomplishing change in knowledge, self-efficacy, and performance. All measures demonstrated significant change pre and post module, with evidence of increasing knowledge (P < .01) and confidence (P < .01) over time. Further, there was evidence of a shift in barriers and enablers to practicing in alignment with the CPGs. CONCLUSIONS A tailored education program using case-based learning and supervision over time improves knowledge and practice among front line clinicians. The findings have implications for quality improvement in cancer care.
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Affiliation(s)
- Deborah McLeod
- Psychosocial Oncology, NS Health Authority, School of Nursing, Dalhousie University, Halifax, NS, Canada
| | - Mary Jane Esplen
- de Souza Institute, University Health Network, Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada.,Clinical and Basic Sciences, Department of Psychiatry, University of Toronto, Toronto, Canada.,Princess Margaret Cancer Centre, Toronto, Canada
| | - Jiahui Wong
- de Souza Institute, University Health Network, Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada.,Clinical and Basic Sciences, Department of Psychiatry, University of Toronto, Toronto, Canada.,Princess Margaret Cancer Centre, Toronto, Canada
| | - Thomas F Hack
- College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnepeg, Canada.,Research Institute in Oncology and Hematology, CancerCare Manitoba, Winnepeg, Canada.,Psychosocial Oncology & Cancer Nursing Research, I.H. Asper Clinical Research Institute, Winnepeg, Canada
| | - Lise Fillion
- Nursing Research Unit, Centre de Recherche du CHU de Québec, L'Hôtel Dieu de Québec, Quebec, Canada
| | - Doris Howell
- Oncology Nursing Research and Education, University Health Networks, Toronto, Canada.,Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Margaret Fitch
- Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.,Canadian Association of Nurses in Oncology, Toronto, Canada
| | - Julie Dufresne
- Yukon Chamber of Commerce, Whitehorse, Yukon, Canada.,Touché Consulting, Whitehorse, Yukon, Canada
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35
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Barriers and facilitators to implementing the commission on cancer's distress screening program standard. Palliat Support Care 2018; 17:253-261. [PMID: 29880068 DOI: 10.1017/s1478951518000378] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Many cancer centers struggle to implement standardized distress screening despite the American College of Surgeons' Commission on Cancer 2012 mandate for a distress screening program standard of care by 2015. This paper presents outcomes for the first cohort of participants (n = 36) of a Screening for Psychosocial Distress Program (SPDP), a 2-year training program designed to assist clinicians in implementing routine distress screening as mandated by the American College of Surgeons Commission on Cancer. Specifically, participants' success with distress screening implementation, institutional barriers and facilitators to implementation, and the role of the SPDP are described. METHOD This research followed a longitudinal pre- and posttest mixed methods design. An investigator-developed questionnaire collected qualitative (distress screening goals, institutional barriers and facilitators, facilitators associated with participation in the SPDP) and quantitative (level of goal achievement) data at 6, 12, and 24 months of participation in the SPDP. Conventional content analysis was applied to qualitative data. Mixed methods data analysis in Dedoose evaluated (1) types and number of distress screening goals, barriers, and facilitators, and (2) goal achievement at 6, 12, and 24 months of participation.ResultNinety-five percent of distress screening implementation goals were completed after 2 years of participation. Most common institutional barriers to distress screening implementation were "lack of staff," "competing demands," and "staff turn-over." Most common institutional facilitators were "buy-in," "institutional support," and "recognition of participants' expertise." The number of reported facilitators associated with SPDP participation was higher than the number associated with any institutional factor, and increased over time of participation.Significance of resultsParticipating in training programs to implement distress screening may facilitate successful achievement of the Commission on Cancer's distress screening standard, and benefits seem to increase with time of participation. Training programs are needed to promote facilitators and overcome barriers to distress screening.
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36
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Lazenby M, Ercolano E, Knies A, Pasacreta N, Grant M, Holland JC, Jacobsen PB, Badger T, Jutagir DR, McCorkle R. Psychosocial Distress Screening: An Educational Program's Impact on Participants' Goals for Screening Implementation in Routine Cancer Care. Clin J Oncol Nurs 2018; 22:E85-E91. [PMID: 29781464 DOI: 10.1188/18.cjon.e85-e91] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Psychosocial distress screening is a quality care standard in cancer care. Screening implementation may be facilitated by an educational program that uses goals to evaluate progress over time. OBJECTIVES This article describes the content and design of the Screening for Psychosocial Distress Program (SPDP), reports on its delivery to 36 paired participants, and evaluates its effects on distress screening activities and goals. METHODS The SPDP used a one-group pre-/post-test design. It was delivered at 2 workshops and 10 conference calls during a two-year period. Data on screening and goal achievement were collected at 6, 12, and 24 months. Data on the quality of dyads' relationships were collected at 24 months. FINDINGS At 24 months, all 18 dyads had begun screening. Dyads reported working effectively together and being supportive of the other member of the dyad while achieving their goals for implementing psychosocial distress screening.
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Smith SK, Loscalzo M, Mayer C, Rosenstein DL. Best Practices in Oncology Distress Management: Beyond the Screen. Am Soc Clin Oncol Educ Book 2018; 38:813-821. [PMID: 30231391 DOI: 10.1200/edbk_201307] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The field of psychosocial oncology is a young discipline with a rapidly expanding evidence base. Over the past few decades, several lines of research have established that psychosocial problems, such as anxiety, depression, post-traumatic stress, fatigue, sexual dysfunction, and cognitive complaints, are common and consequential in patients with cancer. The word "distress" was chosen deliberately to capture a broad concept; consequently, distress screening is meant to function as an initial step in the more targeted evaluation of the source(s) of the patient's distress. In 2015, the American College of Surgeons' Commission on Cancer mandated psychosocial distress screening as part of their accreditation process. Similar screening requirements are in place internationally, including in Canada, where screening for distress is endorsed as the sixth vital sign and a standard of care that must be met by any Canadian health care organization providing cancer services that seeks to be accredited. Over the past few years, cancer centers around the world have been exploring optimum ways to implement and evaluate distress screening initiatives. This paper presents three approaches to distress screening implementation: (1) a model that incorporates the importance of shared values, perceived benefits, and relevant outcomes in the implementation of distress management protocols; (2) a Canadian knowledge translation application to distress screening, including triage considerations and interventions; and (3) a novel approach to distress management via the use of a mobile application to manage post-traumatic stress symptoms. In closing, future opportunities and challenges associated with the emergence of technology will be discussed.
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Affiliation(s)
- Sophia K Smith
- From the Duke University School of Nursing, Durham, NC; Sheri & Les Biller Patient and Family Resource Center, Department of Supportive Care Medicine, Department of Population Sciences, City of Hope, Duarte, CA; Supportive Care Oncology Program, Northeast Cancer Centre, Sudbury, ON, Canada; Departments of Psychiatry and Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Matthew Loscalzo
- From the Duke University School of Nursing, Durham, NC; Sheri & Les Biller Patient and Family Resource Center, Department of Supportive Care Medicine, Department of Population Sciences, City of Hope, Duarte, CA; Supportive Care Oncology Program, Northeast Cancer Centre, Sudbury, ON, Canada; Departments of Psychiatry and Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Carole Mayer
- From the Duke University School of Nursing, Durham, NC; Sheri & Les Biller Patient and Family Resource Center, Department of Supportive Care Medicine, Department of Population Sciences, City of Hope, Duarte, CA; Supportive Care Oncology Program, Northeast Cancer Centre, Sudbury, ON, Canada; Departments of Psychiatry and Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Donald L Rosenstein
- From the Duke University School of Nursing, Durham, NC; Sheri & Les Biller Patient and Family Resource Center, Department of Supportive Care Medicine, Department of Population Sciences, City of Hope, Duarte, CA; Supportive Care Oncology Program, Northeast Cancer Centre, Sudbury, ON, Canada; Departments of Psychiatry and Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Cartmell KB, Sterba KR, Pickett K, Zapka J, Alberg AJ, Sood AJ, Esnaola NF. Availability of patient-centered cancer support services: A statewide survey of cancer centers. PLoS One 2018; 13:e0194649. [PMID: 29584744 PMCID: PMC5870953 DOI: 10.1371/journal.pone.0194649] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 03/07/2018] [Indexed: 12/05/2022] Open
Abstract
The Institute of Medicine recommended in their landmark report “From Cancer Patient to Cancer Survivor: Lost in Transition” that services to meet the needs of cancer patients should extend beyond physical health issues to include functional and psychosocial consequences of cancer. However, no systems exist in the US to support state-level data collection on availability of support services for cancer patients. Developing a mechanism to systematically collect these data and document service availability is essential for guiding comprehensive cancer control planning efforts. This study was carried out to develop a protocol for implementing a statewide survey of all Commission on Cancer (CoC) accredited cancer centers in South Carolina and to implement the survey to examine availability of patient support services within the state. We conducted a cross-sectional survey of CoC-certified cancer centers in South Carolina. An administrator at each center completed a survey on availability of five services: 1) patient navigation; 2) distress screening; 3) genetic risk assessment and counseling, 4) survivorship care planning; and 5) palliative care. Completed surveys were received from 16 of 17 eligible centers (94%). Of the 16 centers, 44% reported providing patient navigation; 31% reported conducting distress screening; and 44% reported providing genetic risk assessment and counseling. Over 85% of centers reported having an active palliative care program, palliative care providers and a hospice program, but fewer had palliative outpatient services (27%), palliative inpatient beds (50%) or inpatient consultation teams (31%). This was a small, yet systematic survey in one state. This study demonstrated a practical method for successfully monitoring statewide availability of cancer patient support services, including identifying service gaps.
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Affiliation(s)
- Kathleen B. Cartmell
- College of Nursing, Medical University of South Carolina, Charleston, SC, United States of America
- Hollings Cancer Center, Medical University of South Carolina, Charleston, SC, United States of America
- * E-mail:
| | - Katherine R. Sterba
- Hollings Cancer Center, Medical University of South Carolina, Charleston, SC, United States of America
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, United States of America
| | - Kim Pickett
- College of Nursing, Medical University of South Carolina, Charleston, SC, United States of America
| | - Jane Zapka
- College of Nursing, Medical University of South Carolina, Charleston, SC, United States of America
- Hollings Cancer Center, Medical University of South Carolina, Charleston, SC, United States of America
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, United States of America
| | - Anthony J. Alberg
- Arnold School of Public Health, University of South Carolina, Columbia, SC, United States of America
| | - Amit J. Sood
- Hollings Cancer Center, Medical University of South Carolina, Charleston, SC, United States of America
| | - Nestor F. Esnaola
- Department of Surgery, Fox Chase Cancer Center, Philadelphia, PA, United States of America
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Clover K, Lambert SD, Oldmeadow C, Britton B, King MT, Mitchell AJ, Carter G. PROMIS depression measures perform similarly to legacy measures relative to a structured diagnostic interview for depression in cancer patients. Qual Life Res 2018; 27:1357-1367. [DOI: 10.1007/s11136-018-1803-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2018] [Indexed: 12/18/2022]
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McFarland DC, Shaffer KM, Polizzi H, Mascarenhas J, Kremyanskaya M, Holland J, Hoffman R. Associations of Physical and Psychologic Symptom Burden in Patients With Philadelphia Chromosome-Negative Myeloproliferative Neoplasms. PSYCHOSOMATICS 2018; 59:472-480. [PMID: 29506868 DOI: 10.1016/j.psym.2018.01.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 01/14/2018] [Accepted: 01/16/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND The physical symptom burden of patients with myeloproliferative neoplasms (MPNs) may last for extended periods during their disease trajectories and lead to psychologic distress, anxiety, or depression or all of these. OBJECTIVE This study evaluated the relationship between physical symptom burden captured by the Physical Problem List (PPL) on the Distress Thermometer and Problem List and psychologic outcomes (distress, anxiety, and depression) in the MPN setting. METHODS Patients (N = 117) with MPNs completed questionnaires containing the Distress Thermometer and Problem List and the Hospital Anxiety and Depression Scale in a dedicated MPN clinic within an academic medical center. They reported symptoms from any of 22 physical problems on the PPL. Items endorsed by more than 10% of participants were assessed for their associations with distress (Distress Thermometer and Problem List), anxiety (Hospital Anxiety and Depression Scale-Anxiety), and depression (Hospital Anxiety and Depression Scale-Depression). The total number of endorsed PPL items per participant was also evaluated. RESULTS Nine of 22 PPL items (fatigue, sleep, pain, dry skin/pruritus, memory/concentration, feeling swollen, breathing, and sexual) were reported by >10% of participants. In univariate analyses, all PPL items but one were associated with distress and depression, and all but 2 were associated with anxiety. In multivariate analyses, the total number of PPL items was associated with depression only (p < 0.001) when controlling for covariates. CONCLUSION Physical symptom burden in MPN patients was clearly associated with psychologic symptoms. Depression was uniquely associated with overall physical symptom burden. As such, the endorsement of multiple PPL items on the Distress Thermometer and Problem List should prompt an evaluation for psychologic symptoms to improve MPN patients' overall morbidity and quality of life.
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Affiliation(s)
- Daniel C McFarland
- Department of Medicine, Memorial Sloan Kettering Cancer Center, West Harrison, NY.
| | - Kelly M Shaffer
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Heather Polizzi
- Division of Hematology/Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai Hospital, New York, NY
| | - John Mascarenhas
- Division of Hematology/Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai Hospital, New York, NY
| | - Marina Kremyanskaya
- Division of Hematology/Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai Hospital, New York, NY
| | - Jimmie Holland
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ronald Hoffman
- Division of Hematology/Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai Hospital, New York, NY
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McCarter K, Britton B, Baker AL, Halpin SA, Beck AK, Carter G, Wratten C, Bauer J, Forbes E, Booth D, Wolfenden L. Interventions to improve screening and appropriate referral of patients with cancer for psychosocial distress: systematic review. BMJ Open 2018; 8:e017959. [PMID: 29306881 PMCID: PMC5988073 DOI: 10.1136/bmjopen-2017-017959] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Revised: 11/06/2017] [Accepted: 11/16/2017] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES The primary aim of the review was to determine the effectiveness of strategies to improve clinician provision of psychosocial distress screening and referral of patients with cancer. DESIGN Systematic review. DATA SOURCES Electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PsycINFO and Cumulative Index to Nursing and Allied Health Literature (CINAHL)) were searched until July 2016. INCLUSION CRITERIA Population: adult patients with cancer and clinical staff members. INTERVENTION any strategy that aimed to improve the rate of routine screening and referral for detected distress of patients with cancer. Comparison: no intervention controls, 'usual' practice or alternative interventions. OUTCOME (primary) any measure of provision of screening and/or referral for distress, (secondary) psychosocial distress, unintended adverse effects. DESIGN trials with or without a temporal comparison group, including randomised and non-randomised trials, and uncontrolled pre-post studies. DATA EXTRACTION AND ANALYSIS Two review authors independently extracted data. Heterogeneity across studies precluded quantitative assessment via meta-analysis and so a narrative synthesis of the results is presented. RESULTS Five studies met the inclusion criteria. All studies were set in oncology clinics or departments and used multiple implementation strategies. Using the Grades of Recommendation, Assessment, Development and Evaluation, the overall rating of the certainty of the body of evidence reported in this review was assessed as very low. Three studies received a methodological quality rating of weak and two studies received a rating of moderate. Only one of the five studies reported a significant improvement in referrals. CONCLUSIONS The review identified five studies of predominantly poor quality examining the effectiveness of strategies to improve the routine implementation of distress screening and referral for patients with cancer. Future research using robust research designs, including randomised assignment, are needed to identify effective support strategies to maximise the potential for successful implementation of distress screening and referral for patients with cancer. PROSPERO REGISTRATION NUMBER CRD42015017518.
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Affiliation(s)
- Kristen McCarter
- School of Psychology, University of Newcastle, Callaghan, Australia
| | - Ben Britton
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Amanda L Baker
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Sean A Halpin
- School of Psychology, University of Newcastle, Callaghan, Australia
| | - Alison K Beck
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Gregory Carter
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Chris Wratten
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Waratah, Australia
| | - Judith Bauer
- Centre for Dietetics Research, University of Queensland, St Lucia, Australia
| | - Erin Forbes
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Debbie Booth
- University Library, University of Newcastle, Callaghan, Australia
| | - Luke Wolfenden
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
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Weldon CB, Friedewald SM, Kulkarni SA, Simon MA, Carlos RC, Strauss JB, Bunce MM, Small A, Trosman JR. Radiology as the Point of Cancer Patient and Care Team Engagement: Applying the 4R Model at a Patient's Breast Cancer Care Initiation. J Am Coll Radiol 2017; 13:1579-1589. [PMID: 27888945 DOI: 10.1016/j.jacr.2016.09.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 09/13/2016] [Accepted: 09/15/2016] [Indexed: 12/11/2022]
Abstract
Radiologists aspire to improve patient experience and engagement, as part of the Triple Aim of health reform. Patient engagement requires active partnerships among health providers and patients, and rigorous teamwork provides a mechanism for this. Patient and care team engagement are crucial at the time of cancer diagnosis and care initiation but are complicated by the necessity to orchestrate many interdependent consultations and care events in a short time. Radiology often serves as the patient entry point into the cancer care system, especially for breast cancer. It is uniquely positioned to play the value-adding role of facilitating patient and team engagement during cancer care initiation. The 4R approach (Right Information and Right Care to the Right Patient at the Right Time), previously proposed for optimizing teamwork and care delivery during cancer treatment, could be applied at the time of diagnosis. The 4R approach considers care for every patient with cancer as a project, using project management to plan and manage care interdependencies, assign clear responsibilities, and designate a quarterback function. The authors propose that radiology assume the quarterback function during breast cancer care initiation, developing the care initiation sequence, as a project care plan for newly diagnosed patients, and engaging patients and their care teams in timely, coordinated activities. After initial consultations and treatment plan development, the quarterback function is transitioned to surgery or medical oncology. This model provides radiologists with opportunities to offer value-added services and solidifies radiology's relevance in the evolving health care environment. To implement 4R at cancer care initiation, it will be necessary to change the radiology practice model to incorporate patient interaction and teamwork, develop 4R content and local adaption approaches, and enrich radiology training with relevant clinical knowledge, patient interaction competence, and teamwork skill set.
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Affiliation(s)
- Christine B Weldon
- Center for Business Models in Healthcare, Glencoe, Illinois; Northwestern University, Feinberg School of Medicine, Chicago, Illinois.
| | - Sarah M Friedewald
- Northwestern University, Feinberg School of Medicine, Chicago, Illinois; Lynn Sage Comprehensive Breast Center, Northwestern University, Chicago, Illinois
| | - Swati A Kulkarni
- Northwestern University, Feinberg School of Medicine, Chicago, Illinois; Lynn Sage Comprehensive Breast Center, Northwestern University, Chicago, Illinois; Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - Melissa A Simon
- Northwestern University, Feinberg School of Medicine, Chicago, Illinois; Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - Ruth C Carlos
- University of Michigan Health System, Ann Arbor, Michigan; University of Michigan Medical School, Ann Arbor, Michigan
| | - Jonathan B Strauss
- Northwestern University, Feinberg School of Medicine, Chicago, Illinois; Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois; Department of Radiation Oncology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Mikele M Bunce
- Quality of Care and Outcomes Research, Genentech, South San Francisco, California
| | - Art Small
- Quality of Care and Outcomes Research, Genentech, South San Francisco, California
| | - Julia R Trosman
- Center for Business Models in Healthcare, Glencoe, Illinois; Northwestern University, Feinberg School of Medicine, Chicago, Illinois
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Reed SC, Bell JF, Whitney R, Lash R, Kim KK, Bold RJ, Joseph JG. Psychosocial outcomes in active treatment through survivorship. Psychooncology 2017; 27:279-285. [PMID: 28429466 DOI: 10.1002/pon.4444] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 02/26/2017] [Accepted: 04/14/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The objective of the study is to understand potential differences in psychosocial outcomes from active treatment to survivorship. METHODS Using the Medical Expenditure Panel Survey Experiences with Cancer Survivorship Supplement (n = 1360), we examined and compared psychosocial outcomes among respondents in active treatment with survivors by year(s) since treatment ended. Survey-weighted regression models were used to test associations between year(s) since treatment and depressive symptoms (Patient Health Questionnaire-2), psychological distress (K6), and cancer-specific worry related to recurrence. RESULTS Unadjusted estimates showed no significant differences in depressive symptoms or psychological distress between those in active treatment and cancer survivors at any time posttreatment. In contrast, the prevalence of cancer-specific worry was lowest among survivors more than 5 years since treatment (10%), slightly higher among those with less than 1 year since treatment (15%), and highest among those in active treatment (32%). In models controlled for sociodemographic and health-related covariates, the year(s) since treatment ended was inversely associated with the odds of cancer-specific worry but was not associated with depressive symptoms or psychological distress. CONCLUSIONS In this population-based sample, worry about cancer recurrence may diminish with years since treatment ended, while depressive symptoms and distress are persistent across the trajectory. These findings highlight unmet psychosocial needs among cancer survivors and demonstrate the importance of targeted interventions across the survivorship continuum.
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Affiliation(s)
- Sarah C Reed
- Betty Irene Moore School of Nursing, University of California, Davis, Sacramento, CA, USA.,Collaborative Cancer Care Research Group, University of California, Davis, Sacramento, CA, USA.,Jane Addams College of Social Work, University of Illinois at Chicago, Chicago, IL, USA
| | - Janice F Bell
- Betty Irene Moore School of Nursing, University of California, Davis, Sacramento, CA, USA.,Collaborative Cancer Care Research Group, University of California, Davis, Sacramento, CA, USA
| | | | - Rebecca Lash
- Department of Nursing Practice, Research, and Education, UCLA Health System, Los Angeles, CA, USA
| | - Katherine K Kim
- Betty Irene Moore School of Nursing, University of California, Davis, Sacramento, CA, USA.,Collaborative Cancer Care Research Group, University of California, Davis, Sacramento, CA, USA
| | - Richard J Bold
- Collaborative Cancer Care Research Group, University of California, Davis, Sacramento, CA, USA.,Comprehensive Cancer Center, University of California, Davis, Sacramento, CA, USA
| | - Jill G Joseph
- Betty Irene Moore School of Nursing, University of California, Davis, Sacramento, CA, USA.,Collaborative Cancer Care Research Group, University of California, Davis, Sacramento, CA, USA
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Clover K, Rogers K, Britton B, Oldmeadow C, Attia J, Carter G. Reduced prevalence of pain and distress during 4 years of screening with QUICATOUCH in Australian oncology patients. Eur J Cancer Care (Engl) 2017; 26. [DOI: 10.1111/ecc.12636] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 11/21/2016] [Accepted: 11/24/2016] [Indexed: 11/26/2022]
Affiliation(s)
- K.A. Clover
- Psycho-Oncology Service; Calvary Mater Newcastle; Hunter Regional Mail Centre NSW Australia
- Centre for Brain and Mental Health Research (CBMHR); University of Newcastle; Callaghan NSW Australia
| | - K.M. Rogers
- Psycho-Oncology Service; Calvary Mater Newcastle; Hunter Regional Mail Centre NSW Australia
| | - B. Britton
- Psycho-Oncology Service; Calvary Mater Newcastle; Hunter Regional Mail Centre NSW Australia
| | - C. Oldmeadow
- Hunter Medical Research Institute; New Lambton Heights NSW Australia
| | - J. Attia
- Hunter Medical Research Institute; New Lambton Heights NSW Australia
- School of Medicine and Public Health; University of Newcastle; Callaghan NSW Australia
- Department of Medicine; John Hunter Hospital; Newcastle NSW Australia
| | - G.L. Carter
- Centre for Brain and Mental Health Research (CBMHR); University of Newcastle; Callaghan NSW Australia
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Sullivan DR, Forsberg CW, Ganzini L, Au DH, Gould MK, Provenzale D, Slatore CG. Longitudinal Changes in Depression Symptoms and Survival Among Patients With Lung Cancer: A National Cohort Assessment. J Clin Oncol 2016; 34:3984-3991. [PMID: 27996350 DOI: 10.1200/jco.2016.66.8459] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Purpose Depression symptoms are common among patients with lung cancer; however, longitudinal changes and their impact on survival are understudied. Methods This was a prospective, observational study from the Cancer Care Outcomes Research and Surveillance Consortium from five US geographically defined regions from September 2003 through December 2005. Patients enrolled within 3 months of their lung cancer diagnosis were eligible. The eight-item Center for Epidemiologic Studies Depression scale was administered at diagnosis and 12 months' follow-up. The main outcome was survival, which was evaluated using Kaplan-Meyer curves and adjusted Cox proportional hazards modeling. Results Among 1,790 participants, 681 (38%) had depression symptoms at baseline and an additional 105 (14%) developed new-onset depression symptoms during treatment. At baseline, depression symptoms were associated with increased mortality (hazard ratio [HR], 1.17; 95% CI, 1.03 to 1.32; P = .01). Participants were classified into the following four groups based on longitudinal changes in depression symptoms from baseline to follow-up: never depression symptoms (n = 640), new-onset depression symptoms (n = 105), depression symptom remission (n = 156), and persistent depression symptoms (n = 254) and HRs were calculated. Using the never-depression symptoms group as a reference group, HRs were as follows: new-onset depression symptoms, 1.50 (95% CI, 1.12 to 2.01; P = .006); depression symptom remission, 1.02 (95% CI, 0.79 to 1.31; P = .89), and persistent depression symptoms, 1.42 (95% CI, 1.15 to 1.75; P = .001). At baseline, depression symptoms were associated with increased mortality among participants with early-stage disease (stages I and II; HR, 1.61; 95% CI, 1.26 to 2.04), but not late-stage disease (stages III and IV; HR, 1.05; 95% CI, 0.91 to 1.22). At follow-up, depression symptoms were associated with increased mortality among participants with early-stage disease (HR, 1.71; 95% CI, 1.27 to 2.31) and those with late-stage disease (HR, 1.32; 95% CI, 1.04 to 1.69). Conclusion Among patients with lung cancer, longitudinal changes in depression symptoms are associated with differences in mortality, particularly among patients with early-stage disease. Symptom remission is associated with a similar mortality rate as never having had depression.
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Affiliation(s)
- Donald R Sullivan
- Donald R. Sullivan, Christopher G. Slatore, and Linda Ganzini, Oregon Health & Science University; Donald R. Sullivan, Christopher W. Forsberg, Linda Ganzini, and Christopher G. Slatore, Veterans Affairs Portland Health Care System, Portland, OR; David H. Au, Veterans Affairs Puget Sound Health Care System David H. Au, University of Washington, Seattle, WA; Michael K. Gould, Kaiser Permanente Southern California, Pasadena; Michael K. Gould, University of Southern California, Los Angeles, CA; Dawn Provenzale, Durham VA Medical Center; and Dawn Provenzale, Duke University, Durham, NC
| | - Christopher W Forsberg
- Donald R. Sullivan, Christopher G. Slatore, and Linda Ganzini, Oregon Health & Science University; Donald R. Sullivan, Christopher W. Forsberg, Linda Ganzini, and Christopher G. Slatore, Veterans Affairs Portland Health Care System, Portland, OR; David H. Au, Veterans Affairs Puget Sound Health Care System David H. Au, University of Washington, Seattle, WA; Michael K. Gould, Kaiser Permanente Southern California, Pasadena; Michael K. Gould, University of Southern California, Los Angeles, CA; Dawn Provenzale, Durham VA Medical Center; and Dawn Provenzale, Duke University, Durham, NC
| | - Linda Ganzini
- Donald R. Sullivan, Christopher G. Slatore, and Linda Ganzini, Oregon Health & Science University; Donald R. Sullivan, Christopher W. Forsberg, Linda Ganzini, and Christopher G. Slatore, Veterans Affairs Portland Health Care System, Portland, OR; David H. Au, Veterans Affairs Puget Sound Health Care System David H. Au, University of Washington, Seattle, WA; Michael K. Gould, Kaiser Permanente Southern California, Pasadena; Michael K. Gould, University of Southern California, Los Angeles, CA; Dawn Provenzale, Durham VA Medical Center; and Dawn Provenzale, Duke University, Durham, NC
| | - David H Au
- Donald R. Sullivan, Christopher G. Slatore, and Linda Ganzini, Oregon Health & Science University; Donald R. Sullivan, Christopher W. Forsberg, Linda Ganzini, and Christopher G. Slatore, Veterans Affairs Portland Health Care System, Portland, OR; David H. Au, Veterans Affairs Puget Sound Health Care System David H. Au, University of Washington, Seattle, WA; Michael K. Gould, Kaiser Permanente Southern California, Pasadena; Michael K. Gould, University of Southern California, Los Angeles, CA; Dawn Provenzale, Durham VA Medical Center; and Dawn Provenzale, Duke University, Durham, NC
| | - Michael K Gould
- Donald R. Sullivan, Christopher G. Slatore, and Linda Ganzini, Oregon Health & Science University; Donald R. Sullivan, Christopher W. Forsberg, Linda Ganzini, and Christopher G. Slatore, Veterans Affairs Portland Health Care System, Portland, OR; David H. Au, Veterans Affairs Puget Sound Health Care System David H. Au, University of Washington, Seattle, WA; Michael K. Gould, Kaiser Permanente Southern California, Pasadena; Michael K. Gould, University of Southern California, Los Angeles, CA; Dawn Provenzale, Durham VA Medical Center; and Dawn Provenzale, Duke University, Durham, NC
| | - Dawn Provenzale
- Donald R. Sullivan, Christopher G. Slatore, and Linda Ganzini, Oregon Health & Science University; Donald R. Sullivan, Christopher W. Forsberg, Linda Ganzini, and Christopher G. Slatore, Veterans Affairs Portland Health Care System, Portland, OR; David H. Au, Veterans Affairs Puget Sound Health Care System David H. Au, University of Washington, Seattle, WA; Michael K. Gould, Kaiser Permanente Southern California, Pasadena; Michael K. Gould, University of Southern California, Los Angeles, CA; Dawn Provenzale, Durham VA Medical Center; and Dawn Provenzale, Duke University, Durham, NC
| | - Christopher G Slatore
- Donald R. Sullivan, Christopher G. Slatore, and Linda Ganzini, Oregon Health & Science University; Donald R. Sullivan, Christopher W. Forsberg, Linda Ganzini, and Christopher G. Slatore, Veterans Affairs Portland Health Care System, Portland, OR; David H. Au, Veterans Affairs Puget Sound Health Care System David H. Au, University of Washington, Seattle, WA; Michael K. Gould, Kaiser Permanente Southern California, Pasadena; Michael K. Gould, University of Southern California, Los Angeles, CA; Dawn Provenzale, Durham VA Medical Center; and Dawn Provenzale, Duke University, Durham, NC
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