Screening for distress can predict loss of follow-up and treatment in cancer patients: results of development and validation of the Distress Inventory for Cancer Version 2

Factors Associated with Choosing the Kerala Model of Palliative Care versus Standard Care among Indian Cancer Patients

Patients who opt for the Kerala Model of Palliative Care (KMPC) report favorable psychological outcomes. Still, not all patients in Kerala prefer this treatment's approach. Hence, this study is aimed to examine the demographical, medical, pain, and psychological factors associated with cancer patients who choose the KMPC versus standard care (SC). Using a cross-sectional design and purposive sampling, 87 patients (SC = 40; KMPC = 47) residing in Kerala, India, responded to questionnaires on pain, anxiety, and depression, and quality of life (QoL). Data analysis was conducted using chi-squared and independent sample t-tests. Findings revealed that KMPC (vs. SC) patients had lower levels of education, were self-employed or homemakers, belonged to a middle or low socioeconomic status, received government aid or were financially self-supported, and were diagnosed for less than 1 year or less than 5 years. KMPC patients reported higher levels of pain, lower levels of anxiety and depression, better overall total QoL, physical health, social health, functionality capacity, and emotional health. These findings suggest the need for community awareness programs regarding the benefits of opting for the KMPC. Patients who chose KMPC reported higher levels of pain than SC patients, highlighting the need for the KMPC to improve its approach to pain management.

An EAPC white paper on multi-disciplinary education for spiritual care in palliative care

BACKGROUND

The EAPC White Paper addresses the issue of spiritual care education for all palliative care professionals. It is to guide health care professionals involved in teaching or training of palliative care and spiritual care; stakeholders, leaders and decision makers responsible for training and education; as well as national and local curricula development groups.

METHODS

Early in 2018, preliminary draft paper was written by members of the European Association for Palliative Care (EAPC) spiritual care reference group inviting comment on the four core elements of spiritual care education as outlined by Gamondi et al. (2013) in their paper on palliative care core competencies. The preliminary draft paper was circulated to experts from the EAPC spiritual care reference group for feedback. At the second stage feedback was incorporated into a second draft paper and experts and representatives of national palliative care organizations were invited to provide feedback and suggest revisions. The final version incorporated the subsequent criticism and as a result, the Gamondi framework was explored and critically revised leading to updated suggestions for spiritual care education in palliative care.

RESULTS

The EAPC white paper points out the importance of spiritual care as an integral part of palliative care and suggests incorporating it accordingly into educational activities and training models in palliative care. The revised spiritual care education competencies for all palliative care providers are accompanied by the best practice models and research evidence, at the same time being sensitive towards different development stages of the palliative care services across the European region.

CONCLUSIONS

Better education can help the healthcare practitioner to avoid being distracted by their own fears, prejudices, and restraints and attend to the patient and his/her family. This EAPC white paper encourages and facilitates high quality, multi-disciplinary, academically and financially accessible spiritual care education to all palliative care staff.

Distress Management in Patients With Head and Neck Cancer Before Start of Palliative Chemotherapy: A Practical Approach

Purpose

This study reports the incidence of distress, the factors associated with distress, and a practical strategy to resolve distress in patients with head and neck cancer who are starting palliative chemotherapy.

Methods

Adult patients with head and neck cancer planned for palliative chemotherapy underwent distress screening before the start of treatment as part of this single-arm prospective study. Patients who had a distress score > 3 on the National Comprehensive Cancer Network (NCCN) distress thermometer were counseled initially by the clinician. Those who continued to have high distress after the clinician-led counseling were referred to a clinical psychologist and were started on palliative chemotherapy. After counseling, distress was measured again. The relation between baseline distress and compliance was tested using Fisher's exact test.

Results

Two hundred patients were enrolled, and the number of patients with high distress was 89 (44.5% [95% CI, 37.8% to 51.4%]). The number of patients who had a decrease in distress after clinician-led counseling (n = 88) was 52 (59.1% [95% CI, 48.6% to 68.8%]) and after psychologist-led counseling (n = 32) was 24 (75.0% [95% CI, 57.6% to 72.2%]; P = .136). Compliance rates did not differ between the patients with or without a high level of distress at baseline (74.2% v 77.4%, P = .620).

Conclusion

The incidence of baseline distress is high in patients awaiting the start of palliative chemotherapy. It can be resolved in a substantial number of patients using the strategy of clinician-led counseling, with additional referral to a clinical psychologist as required. Patients with a greater number of emotional problems usually require psychologist-led counseling.

Validation of Malayalam Version of National Comprehensive Cancer Network Distress Thermometer and its Feasibility in Oncology Patients

Context

This study was designed to translate and validate the National Comprehensive Cancer Network (NCCN) distress thermometer (DT) in regional language " Malayalam" and to see the feasibility of using it in our patients.

Aims

(1) To translate and validate the NCCN DT. (2) To study the feasibility of using validated Malayalam translated DT in Malabar Cancer center.

Settings and Design

This is a single-arm prospective observational study. The study was conducted at author's institution between December 8, 2015, and January 20, 2016 in the Department of Cancer Palliative Medicine.

Materials and Methods

This was a prospective observational study carried out in two phases. In Phase 1, the linguistic validation of the NCCN DT was done. In Phase 2, the feasibility, face validity, and utility of the translated of NCCN DT in accordance with QQ-10 too was done.

Statistical Analysis Used

SPSS version 16 (SPSS Inc. Released 2007. SPSS for Windows, Version 16.0. Chicago, SPSS Inc.) was used for analysis.

Results

Ten patients were enrolled in Phase 2. The median age was 51.5 years and 40% of patients were male. All patients had completed at least basic education up to the primary level. The primary site of cancer was heterogeneous. The NCCN DT completion rate was 100%. The face validity, utility, reliability, and feasibility were 100%, 100%, 100%, and 90%, respectively.

Conclusion

It can be concluded that the Malayalam validated DT has high face validity, utility, and it is feasible for its use.

State of the Science of Spirituality and Palliative Care Research Part II: Screening, Assessment, and Interventions

The State of the Science in Spirituality and Palliative Care was convened to address the current landscape of research at the intersection of spirituality and palliative care and to identify critical next steps to advance this field of inquiry. Part II of the SOS-SPC report addresses the state of extant research and identifies critical research priorities pertaining to the following questions: 1) How do we assess spirituality? 2) How do we intervene on spirituality in palliative care? And 3) How do we train health professionals to address spirituality in palliative care? Findings from this report point to the need for screening and assessment tools that are rigorously developed, clinically relevant, and adapted to a diversity of clinical and cultural settings. Chaplaincy research is needed to form professional spiritual care provision in a variety of settings, and outcomes assessed to ascertain impact on key patient, family, and clinical staff outcomes. Intervention research requires rigorous conceptualization and assessments. Intervention development must be attentive to clinical feasibility, incorporate perspectives and needs of patients, families, and clinicians, and be targeted to diverse populations with spiritual needs. Finally, spiritual care competencies for various clinical care team members should be refined. Reflecting those competencies, training curricula and evaluation tools should be developed, and the impact of education on patient, family, and clinician outcomes should be systematically assessed.

Compliance With Neoadjuvant Chemotherapy in T4 Oral Cancers: Place, Person, Socioeconomic Status, or Assistance

PURPOSE

Approximately 15% to 20% of our patients with head and neck cancer receiving neoadjuvant chemotherapy (NACT) discontinue therapy because of various nonmedical reasons. We sought to analyze the factors associated with treatment default and noncompliance among these patients.

PATIENTS AND METHODS

We performed a retrospective analysis of patients with T4 oral cancer treated with NACT between January 2011 and December 2012. We included patients who discontinued treatment for nonmedical reasons before the second cycle of NACT. The factors analyzed were income, education, socioeconomic status, age, sex, place of residence, habits, and payment pattern (government supported or personal capacity). Pearson χ² test was used to identify significant factors associated with noncompliance.

RESULTS

Of 486 patients, 91 patients (18.7%) were noncompliant. Percentages of noncompliant patients in the age groups < 30, between 30 and 60, and > 60 years were 25.0%, 17.4%, and 25.5%, respectively (P = .27). Percentages of noncompliance in patients residing within the city, same state, or different state were 20.7%, 20.9%, and 17.1%, respectively (P = .44). Noncompliance rates were 20.3%, 15.7%, 18.1%, and 22.5% in upper middle, lower middle, upper lower, and lower economic strata, respectively (P = .60). Similarly, there was no significant difference in noncompliance according to occupation, education level, payment pattern, sex, or habits.

CONCLUSION

Our analysis failed to identify any specific significant factor associated with noncompliance with NACT among our patients with T4 oral cancers.

The influence of chemotherapy-induced neurotoxicity on psychological distress and sleep disturbance in cancer patients

PURPOSE

In the present study, we aimed to investigate the effects of chemotherapy-induced peripheral neurotoxicity (cipn) on psychological distress and sleep quality in cancer patients.

METHODS

A total of 706 cancer patients were interviewed for the study. In the 4th week of treatment, patient cipn was measured using the Patient Neurotoxicity Questionnaire (pnq). The sleep quality and psychological distress of patients were measured using the Pittsburgh Sleep Quality Index (psqi), the Distress Thermometer (dt), and the Hospital Anxiety and Depression Scale (hads). Multiple logistic regression was applied to determine the independent effects of cipn on psychological distress and sleep disturbance in the patients.

RESULTS

THESE CORRELATION COEFFICIENTS WERE OBTAINED: 0.387 (p < 0.0001) between the pnq total score and the dt score, 0.386 (p < 0.0001) between the pnq total score and the hads Depression score, 0.379 (p < 0.0001) between the pnq total score and the hads Anxiety score, and 0.399 (p < 0.0001) between the pnq total score and the psqi global score. The prevalence rates of distress, depression, anxiety, and poor sleep quality in the five pnq grades were statistically significantly different (p < 0.0001). After controlling for age, sex, education level, social supports, fatigue, disease stage, and tumour site, the pnq grades were found to be associated with depression (p < 0.0001), anxiety (p < 0.0001), and poor sleep quality (p < 0.0001).

CONCLUSIONS

Chemotherapy-induced peripheral neurotoxicity negatively affects psychological distress and sleep quality in cancer patients treated with chemotherapy. High pnq grades were significantly associated with poor psychological status and sleep quality. Our results emphasize the importance of assessing peripheral neuropathies during chemotherapy and of adjusting treatment plans based on assessment results.

Sensitivity and specificity of the Distress Thermometer in screening for distress in long-term nasopharyngeal cancer survivors

BACKGROUND

The Distress Thermometer (dt) is a screening tool recommended to quickly identify cancer patients with distress. Our study aimed to examine the sensitivity and specificity of the dt in detecting psychological distress in long-term Chinese nasopharyngeal cancer (npc) survivors.

METHODS

Data for the 442 participating npc survivors were collected through a self-administered questionnaire based on the dt and the Hospital Anxiety and Depression Scale (hads). The hads was used to define cases of psychological distress. Positive and negative groups were defined based on 4 hads criteria (Anxiety, Depression, Anxiety or Depression, and overall score). Receiver operating characteristic (roc) curves were used to examine the ability of all possible cut-off values of the dt to detect positive and negative cases. For each roc curve, the area under the curve (auc) was used as an indicator of the overall accuracy of the dt to identify positive cases of distress.

RESULTS

The positive auc values [with 95% confidence intervals (ci)] for the 4 hads criteria were 0.715 (95% ci: 0.667 to 0.764), 0.714 (95% ci: 0.661 to 0.768), 0.724 (95% ci: 0.677 to 0.771), and 0.724 (95% ci: 0.664 to 0.775) respectively. At a cut-off score of 4, the sensitivity of the dt to the four hads criteria was, respectively, 0.366 (95% ci: 0.296 to 0.436), 0.448 (95% ci: 0.364 to 0.532), 0.362 (95% ci: 0.299 to 0.425), and 0.421 (95% ci: 0.339 to 0.502), and the specificity of the dt to the 4 hads criteria was, respectively, 0.860 (95% ci: 0.818 to 0.902), 0.860 (95% ci: 0.821 to 0.899), 0.854 (95% ci: 0.814 to 0.894), and 0.854 (95% ci: 0.814 to 0.894). At a cut-off score of 5, the corresponding sensitivities were lower than those at the cut-off score of 4. All potential cut-off scores showed poor sensitivity (<0.90).

CONCLUSIONS

The roc analysis showed poor discrimination. No potential dt cut-off score had an acceptable sensitivity. The dt showed poor sensitivity in npc survivors. Thus, the dt might not be a valid scale for psychological distress screening in long-term Chinese npc survivors.

A longitudinal study of anxiety, depression and distress as predictors of sexual and urinary quality of life in men with prostate cancer

OBJECTIVE

To evaluate the prevalence of depression, anxiety and distress among active surveillance (AS) and radical prostatectomy (RP) patients. To evaluate the impact of these symptoms at baseline on urinary and sexual quality of life at follow-up.

PATIENTS AND METHODS

Patients managed with AS or RP who completed validated questionnaires assessing levels of depression, anxiety, distress and urinary (UF) and sexual function (SF) and bother comprised the final analytic cohort. These measures were completed at baseline, within 1 year, and between 1 and 3 years from baseline. Mixed model repeated measures analysis was used to examine associations between mental health at baseline and sexual and urinary outcomes in a subset of RP patients with complete follow-up.

RESULTS

Among 679 men who comprised the study cohort, baseline prevalence of moderate or higher levels of depression or anxiety were low (<5%), while levels of mild depression or anxiety ranged from 3-16% over time. Baseline levels of elevated distress ranged from 8-20%. Among men who provided data at baseline and follow-up, there were no significant differences between AS and RP patients in the proportion of men with elevated levels of depression, anxiety, or distress. Among 177 men who underwent RP and had complete follow-up moderate or higher levels of depression or anxiety appeared to be associated with post-treatment SF and bother, while elevated levels of distress were associated with post-treatment UF.

CONCLUSION

Moderate or higher levels of depression or anxiety were low in men with localised prostate cancer but were associated with sexual outcomes, while elevated distress was associated with urinary outcomes. Greater attention should be paid to mental health symptoms among men with prostate cancer, as these symptoms may be associated with quality of life outcomes.

The incidence and causes of different subtypes of depression in prostate cancer patients: implications for cancer care

Although depression occurs in prostate cancer patients at a higher incidence than in age-matched non-cancer peers, little is known about the relative incidence of subtypes of depression among these patients. To examine this issue, 507 prostate cancer patients completed a survey questionnaire of background factors, depression symptoms, and common prostate cancer-related stressors. Five common subtypes of depression were defined from the wider literature, and patients' depressive symptomatology was used to determine their scores on each of the five depression subtypes. Nearly half of the patients had scores which could be classified as clinically significant for at least one of the five depression subtypes, with some patients showing clinically significant scores for multiple depression subtypes. Different depression subtypes were predicted by different prostate-cancer-related stressors. Because each of the five depressive subtypes examined here has different symptomatologies and treatment recommendations, these data suggest that treatment goals for prostate cancer patients might vary according to the type of depression a patient presents.

Implementing a distress screening instrument in a university breast cancer clinic: a quality improvement project

Distress remains a pervasive experience of patients with cancer. As a result, a quality improvement project was conducted in the breast cancer clinic of a university cancer center in the midwestern United States. Nurses identified a need to increase identification of distress over a six-month period when they made only eight referrals for distress support during 1,291 patient encounters. The eight referrals were the result of patient exhibitions of severe distress in the clinic. To increase identification of distress, as well as referrals for support before patients exhibited severe distress, the National Comprehensive Cancer Network's Distress Thermometer screening tool was implemented in the clinic from June 1 through July 6, 2010. The instrument was completed by each participant during a patient encounter, followed by a review of the responses with a nurse. Referrals for support were offered by nurses when responses indicated a significant level of distress. Nurses increased identification of distress by using the instrument. In addition, referrals for support increased before patients exhibited severe distress. Nurses are positioned to improve care by identifying distress and making referrals for support.

Do patient-reported androgen-deprivation therapy side effects predict anxiety and depression among prostate cancer patients undergoing radiotherapy? Implications for psychosocial therapy interventions

Antiandrogen therapy (AAT) is a common adjunct treatment for prostate cancer (PCa) patients and has shown significant benefits to long-term outcomes from radiation or surgery. Although AAT has some adverse side effects and data from breast cancer patients indicate that such side effects from hormonal therapies may contribute to anxiety and depression and may also hinder AAT treatment compliance, this issue has not been investigated within a sample of PCa patients. This study explores the incidence of AAT side effects in a sample of PCa patients, the links between those side effects and anxiety and depression, the possible ways in which these factors may contribute to AAT treatment noncompliance in PCa patients, and how psychosocial treatments might be developed to attend to this issue. 147 PCa patients completed questionnaires on demographic factors, treatment compliance, AAT side effects, anxiety and depression. About 18% of the sample reported AAT side effects, and there was a significant association between the presence of side effects and elevated anxiety and depression scores. Increased frequency of side effects was significantly associated with elevated anxiety, but not depression. The most powerful relationship between AAT side effects and anxiety-depression was for the subfactors of (1) Fatigue, Pain and Discomfort, and (2) Psychological Agitation and Pessimism. Although fatigue, pain, and discomfort may be outcomes of the hormonal treatment itself, psychological agitation and pessimism represent a discrete psychological pathway between AAT side effects and anxiety and depression and (potentially) treatment noncompliance. Methods of addressing patients' loss of optimism in their treatment outcomes are discussed.

Screening for Distress and Unmet Needs in Patients With Cancer: Review and Recommendations

Purpose

This review summarizes the need for and process of screening for distress and assessing unmet needs of patients with cancer as well as the possible benefits of implementing screening.

Methods

Three areas of the relevant literature were reviewed and summarized using structured literature searches: psychometric properties of commonly used distress screening tools, psychometric properties of relevant unmet needs assessment tools, and implementation of distress screening programs that assessed patient-reported outcomes (PROs).

Results

Distress and unmet needs are common problems in cancer settings, and programs that routinely screen for and treat distress are feasible, particularly when staff are supported and links with specialist psychosocial services exist. Many distress screening and unmet need tools have been subject to preliminary validation, but few have been compared head to head in independent centers and in different stages of cancer. Research investigating the overall effectiveness of screening for distress in terms of improved recognition and treatment of distress and associated problems is not yet conclusive, but screening seems to improve communication between patients and clinicians and may enhance psychosocial referrals. Direct effects on quality of life are uncertain, but screening may help improve discussion of quality-of-life issues.

Conclusion

Involving all stakeholders and frontline clinicians when planning screening for distress programs is recommended. Training frontline staff to deliver screening programs is crucial, and continuing to rigorously evaluate outcomes, including PROs, process of care, referrals, and economic costs and benefits is essential.

Pretreatment depressive symptoms and treatment modality predict post-treatment disease-specific quality of life among patients with localized prostate cancer

PURPOSE

This study examines the prevalence of depressive symptoms before prostate cancer treatment and explores associations among pre-treatment depressive symptoms and post-treatment disease-specific QOL, controlling for treatment modality, and demographic and clinical covariates.

MATERIALS AND METHODS

A case series of patients diagnosed with localized prostate cancer (T1-2N0M0) at a comprehensive cancer center was assessed. Of the 1,370 eligible patients, 869 (63.34%) completed questionnaires at diagnosis (baseline) and 6 months following treatment. Patients were treated with surgery (16.8%), brachytherapy (27.6%), or external beam radiation (EBRT; 55.6%). Depressive symptoms and disease-specific QOL were assessed with established measures (i.e., Center for Epidemiologic Studies Depression Scale (CES-D); sexual adjustment questionnaire (SAQ); and the American Urological Association symptom index).

RESULTS

A fifth of the sample (19.7%) reported clinically elevated levels of depressive symptoms at baseline. The proportion of clinically elevated levels of baseline depressive symptoms was higher among surgery patients compared with patients treated with brachytherapy or external beam radiation. Depressive symptoms at baseline and treatment modality significantly predicted sexual and urinary dysfunction, related bother, activity limitation due to urinary dysfunction at 6 months, controlling for, age, PSA level, Gleason score, relevant baseline indicators of sexual and urinary dysfunction, related bother, and activity limitation (P < 0.05).

CONCLUSIONS

Pretreatment depressive symptoms and treatment modality predict QOL after PrCa treatment. Health care providers should be sensitive to the display of depressive symptoms before PrCa treatment and consider preventative interventions, including preparing patients for the changes in disease-specific QOL and related bother following prostate cancer treatment.

The psychometric properties of the Icelandic version of the distress thermometer and problem list

OBJECTIVE

While a significant number of cancer patients experience distress only a minority are offered appropriate psychosocial interventions. Untreated distress can interfere with compliance to treatment and quality of life. The purpose of this study was to evaluate the psychometric properties and feasibility of the Icelandic translation of the distress thermometer (DT) and problem list, a tool developed to screen for distress in cancer patients.  

METHODS

Participants were 149 cancer patients receiving treatment at outpatient oncology clinics at Landspítali-The National University Hospital of Iceland, mean±SD age 59.06 years ±12.92. Participants answered the DT, HADS and GHQ-30, demographic questions and questions regarding the DT.  

RESULTS

Scores on the DT ranged from 0 to 10 with a mean ±SD score of 3.09 ± 2.40, 7.30 ± 4.86 on HADS and 5.28 ± 5.60 on GHQ-30. Significant correlations were between the DT and all categories on the Problem List as well as between the DT and HADS (r = 0.45), and between DT and GHQ-30 (r = 0.57). ROC-analysis supported that a cut-off point of 3 gives the best sensitivity and specificity for the DT predicting depression or anxiety according to the HADS and GHQ. Sixty-nine (48.3%) patients scored < or =2 on DT and 74 (51.7%) scored ≥3.  

CONCLUSION

The Icelandic version of the DT is a valid instrument to screen for distress in clinical practice. The study adds to a growing literature suggesting that this brief instrument may aid in identifying cancer patients suffering from distress and consequently providing appropriate treatment.

Cancer treatment adherence among low-income women with breast or gynecologic cancer: a randomized controlled trial of patient navigation

BACKGROUND

The authors implemented a controlled, randomized trial that compared 2 interventions: the provision of written resource navigation information (enhanced usual care [EUC]) versus written information plus patient navigation (TPN) aimed at improving adjuvant treatment adherence and follow-up among 487 low-income, predominantly Hispanic women with breast cancer or gynecologic cancer.

METHODS

Women were randomized to receive either TPN or EUC; and chemotherapy, radiation therapy, hormone therapy, and follow-up were assessed over 12 months. Patients with breast cancer were analyzed separately from patients with gynecologic cancer.

RESULTS

Overall adherence rates ranged from 87% to 94%, and there were no significant differences between the TPN group and the EUC group. Among women with breast cancer, 90% of the EUC group and 88% of the TPN group completed chemotherapy (14% of the EUC group and 26% of the TPN group delayed the completion of chemotherapy), 2% of the EUC group and 4% of the TPN group failed to complete chemotherapy, and 8% of the EUC group and 7% of the TPN group refused chemotherapy. Radiation treatment adherence was similar between the groups: Ninety percent of patients completed radiation (40% of the EUC group and 42% of the TPN group delayed the completion of radiation); in both groups, 2% failed to complete radiation, and 8% refused radiation. Among gynecologic patients, 87% of the EUC group and 94% of the TPN group completed chemotherapy (41% of the EUC group and 31% of the TPN group completed it with delays), 7% of the EUC group and 6% of the TPN group failed to complete chemotherapy, 6% of the EUC refused chemotherapy, 87% of the EUC group and 84% of the TPN group completed radiation (51% of the EUC group and 42% of the TPN with delays), 5% of the EUC group and 8% of the TPN group failed to complete radiation, and 8% of the EUC group and 5% of the TPN group refused radiation.

CONCLUSIONS

Treatment adherence across randomized groups was notably higher than reported in previous studies, suggesting that active telephone patient navigation or written resource informational materials may facilitate adherence among low-income, predominantly Hispanic women. Adherence also may have be facilitated by federal-state breast and cervical cancer treatment funding.

Screening for distress (the sixth vital sign) in a global recession: sustainable approach to maintain patient-centered care

A substantial volume of research on the psychosocial impact of cancer clearly indicates that patients are likely to experience emotional distress. There is also evidence that psychosocial interventions aimed at decreasing distress provide tangible cost offsets to cancer patients, caregivers and treating institutions. One seemingly major drawback in the setup and delivery of a fully fledged screening program for distress is the extensive pecuniary requirements. Given that the categorical need for distress screening may be confounded by financial limitations, especially in a time of global recession, a cost-effective alternative seems appropriate. The model proposed herein is not a substitute screening program, nor does it eliminate the need to allocate resources to address the identified risks. It does, however, offer a cost-effective alternative to implement a high-risk distress patient identifying process, quite similar to algorithms used in screening for prostate cancer.

Cancer patient ethnicity and associations with emotional distress--the 6th vital sign: a new look at defining patient ethnicity in a multicultural context

Variations in access to care, utilization of available resources and treatment outcomes in the context of ethnicity have been recognized, but very little research of this nature exists in the oncology context. The present paper is an in-depth analysis of data on a large representative sample of Canadian cancer patients with a focus on the role of 'ethnicity', its association to psychological distress, and its impact on the cancer experience. Because of a heterogeneous representation of ethnic self-identifications which were not easily grouped or classified, English as a second language was considered as a surrogate marker to ethnicity. People who self-reported to be from an English-speaking country were grouped together and compared to those hailing from countries which do not have English as a primary language. In a hierarchical logistic regression model (n = 2,402) the demographic and cancer-related variables associated with significant clinical distress in the first block were gender (male, except those with prostate cancer), age less that 68 years, less than a year since diagnosis, diagnosis of lung cancer, and recurrent disease. In the second block, after controlling for the influence of these factors, patient-reported ethnicity (being originally from a non-English speaking country) added significantly to the prediction of patient distress. Though compelling, there is a need to understand the relationship between the ethnic features and language (English versus non-English language). A hypothesis is presented as an attempt to understand an individual's 'ethnicity' within the framework of a multicultural society.