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The patient needs assessment in cancer care: identifying barriers and facilitators to implementation in the UK and Canada. Support Care Cancer 2020; 29:805-812. [PMID: 32500207 PMCID: PMC7767902 DOI: 10.1007/s00520-020-05542-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 05/19/2020] [Indexed: 11/05/2022]
Abstract
Purpose Personalised information and support can be provided to cancer survivors using a structured approach. Needs assessment tools such as the Holistic Needs Assessment (HNA) in the UK and the Comprehensive Problem and Symptom Screening (COMPASS) questionnaire in Canada are recommended for use in practice; however, they are not widely embedded into practice. The study aimed to determine the extent to which nurses working in cancer care in the UK and Manitoba value NA and identify any barriers and facilitators they experience. Method Oncology nurses involved in the care of cancer patients in the UK (n = 110) and Manitoba (n = 221) were emailed a link to an online survey by lead cancer nurses in the participating institutions. A snowball technique was used to increase participation across the UK resulting in 306 oncology nurses completing the survey in the UK and 116 in Canada. Results Participants expressed concerns that these assessments were becoming bureaucratic “tick-box exercises” which did not meet patients’ needs. Barriers to completion were time, staff shortages, lack of confidence, privacy, and resources. Facilitators were privacy for confidential discussions, training, confidence in knowledge and skills, and referral to resources. Conclusion Many busy oncology nurses completed this survey demonstrating the importance they attach to HNAs and COMPASS. The challenges faced with implementing these assessments into everyday practice require training, time, support services, and an appropriate environment. It is vital that the HNA and COMPASS are conducted at optimum times for patients to fully utilise time and resources.
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Systematic screening as a tool for individualized rehabilitation following primary breast cancer treatment: study protocol for the ReScreen randomized controlled trial. BMC Cancer 2020; 20:484. [PMID: 32471390 PMCID: PMC7257149 DOI: 10.1186/s12885-020-06815-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 04/01/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND It is well known that women suffer from negative consequences following breast cancer (BC) treatment and that their largely varying needs for rehabilitation are often unmet. Up to 43% of these women are at risk of developing chronic distress requiring complex interventions; however, how to early identify and meet these women's needs is unknown, leaving them with suboptimal chances of rehabilitation. The aim of the ReScreen study is to develop a model for and evaluate the effect of screening-based, individualized rehabilitation following primary BC treatment. METHODS The ReScreen study is designed as a complex intervention. Women with newly diagnosed BC are consecutively included in a three-armed randomized controlled trial. At inclusion, patients score their distress level on the Distress Thermometer (scale of 0-10) aiming to identify patients with extended rehabilitation needs. Patients scoring ≥5 are randomized to the intervention or control group while patients scoring ≤4 are followed longitudinally as an observational group. Patients in the intervention group, in conjunction with a dedicated research nurse, create an individualized rehabilitation plan based on an evidence-based decision support tool that was developed to create a solid base for the intervention. The research nurse will act as a continuous health care contact and be responsible for proactively and systematically evaluating patients' needs to ensure that potential new problems or changed rehabilitation needs are identified throughout the 1-year follow-up period. The intervention will be evaluated through self-reported data focusing on physical and psychological outcomes as well as evaluation of satisfaction with care at baseline, 2 weeks and 3, 6, 9 and 12 months. Evaluation will also include health economic aspects based on register data and patients' and relatives' experiences of the rehabilitation process. In addition, optimal cut-off levels for distress as an indicator for extended rehabilitation needs will be investigated. DISCUSSION This study will provide important knowledge related to effectiveness of screening-based identification of rehabilitation needs and standardized evidence-based, individualized rehabilitation after primary BC treatment. With a complex intervention design, this study has the potential to form a comprehensive knowledge base which includes tools and guidelines for implementation into clinical practice. TRIAL REGISTRATION ClinicalTrials.gov NCT03434717. Registered February 15, 2018.
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3
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Olsson Möller U, Olsson IM, Sjövall K, Beck I, Rydén L, Malmström M. Barriers and facilitators for individualized rehabilitation during breast cancer treatment - a focus group study exploring health care professionals' experiences. BMC Health Serv Res 2020; 20:252. [PMID: 32216786 PMCID: PMC7098158 DOI: 10.1186/s12913-020-05107-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 03/12/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Breast cancer (BC) and related treatment are associated with the risk of developing a wide range of persistent disabling impairments. Despite extensive research in the field and an enhanced focus on BC rehabilitation, up to 34-43% of these patients are at risk of developing chronic distress. In addition, it is known that these patients repeatedly report unmet needs, which are strongly associated with reduced quality of life. However, despite knowledge that patients' needs for support during BC rehabilitation varies greatly, individualized rehabilitation is often lacking. Therefore, this study aimed to explore health care professionals' (HCPs) experiences of current rehabilitation practice and describe current barriers and facilitators for individualized rehabilitation for patients following BC treatment. METHODS A total of 19 HCPs were included, representing various professions in BC care/rehabilitation within surgical, oncological and specialized cancer rehabilitation units at a university hospital in Sweden. Five semi structured focus group interviews were conducted and inductively analysed using conventional qualitative content analysis. RESULTS Three categories were captured: (1) varying attitudes towards rehabilitation; (2) incongruence in how to identify and meet rehabilitation needs and (3) suboptimal collaboration during cancer treatment. The results showed a lack of consensus in how to optimize individualized rehabilitation. It also illuminated facilitators for individualized rehabilitation in terms of extensive competence related to long-term experience of working with patients with BC care/rehabilitation. Further, the analysis exposed barriers such as a great complexity in promoting individualized rehabilitation in a medically and treatment-driven health care system, which lacked structure and knowledge, and overarching collaboration for rehabilitation. CONCLUSION This study suggests that the cancer trajectory is medically and treatment-driven and that rehabilitation plays a marginal role in today's BC trajectory. It also reveals that structures for systematic screening for needs, evidence-based guidelines for individualized rehabilitation interventions and structures for referring patients for advanced rehabilitation are lacking. To enable optimal and individualized recovery for BC patients', rehabilitation needs to be an integrated part of the cancer trajectory and run in parallel with diagnostics and treatment.
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Affiliation(s)
- Ulrika Olsson Möller
- Department of Nursing and Integrated Health Sciences, Faculty of Health Sciences, Kristianstad University, Kristianstad, Sweden
| | - Ing-Marie Olsson
- Department of Health Sciences, Lund University, Box 157, 221 00, Lund, Sweden.,Skåne University Hospital, Lund, Sweden
| | - Katarina Sjövall
- Department of Clinical Sciences in Lund, Oncology and Pathology, Lund University, Lund, Sweden
| | - Ingela Beck
- Department of Nursing and Integrated Health Sciences, Faculty of Health Sciences, Kristianstad University, Kristianstad, Sweden.,Department of Clinical Sciences in Lund, Oncology and Pathology, Lund University, Lund, Sweden.,The Institute for Palliative Care, Lund University and Region Skåne, Lund, Sweden
| | - Lisa Rydén
- Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Surgery, Lund, Sweden
| | - Marlene Malmström
- Department of Health Sciences, Lund University, Box 157, 221 00, Lund, Sweden. .,Skåne University Hospital, Lund, Sweden. .,The Institute for Palliative Care, Lund University and Region Skåne, Lund, Sweden.
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4
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Coats V, Moffet H, Vincent C, Simard S, Tremblay L, Maltais F, Saey D. Feasibility of an eight-week telerehabilitation intervention for patients with unresectable thoracic neoplasia receiving chemotherapy: A pilot study. CANADIAN JOURNAL OF RESPIRATORY, CRITICAL CARE, AND SLEEP MEDICINE 2020. [DOI: 10.1080/24745332.2019.1575703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Valérie Coats
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Canada
| | - Hélène Moffet
- Department of Rehabilitation, Faculty of Medicine, Université Laval, Québec, Canada
- Centre for Interdisciplinary Research in Rehabilitation and Social Integration in Quebec City, Université Laval, Québec, Canada
| | - Claude Vincent
- Department of Rehabilitation, Faculty of Medicine, Université Laval, Québec, Canada
- Centre for Interdisciplinary Research in Rehabilitation and Social Integration in Quebec City, Université Laval, Québec, Canada
| | - Sébastien Simard
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Canada
| | - Lise Tremblay
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Canada
| | - François Maltais
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Canada
| | - Didier Saey
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Canada
- Department of Rehabilitation, Faculty of Medicine, Université Laval, Québec, Canada
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5
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Johnston L, Young J, Campbell K. The implementation and impact of Holistic Needs Assessments for people affected by cancer: A systematic review and thematic synthesis of the literature. Eur J Cancer Care (Engl) 2019; 28:e13087. [DOI: 10.1111/ecc.13087] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 04/14/2019] [Accepted: 04/17/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Lucy Johnston
- School of Health and Social Care Edinburgh Napier University Edinburgh UK
| | - Jenny Young
- School of Health and Social Care Edinburgh Napier University Edinburgh UK
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6
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Aubin M, Vézina L, Verreault R, Simard S, Desbiens JF, Tremblay L, Dumont S, Fillion L, Dogba MJ, Gagnon P. Effectiveness of an intervention to improve supportive care for family caregivers of patients with lung cancer: study protocol for a randomized controlled trial. Trials 2017; 18:304. [PMID: 28676071 PMCID: PMC5496252 DOI: 10.1186/s13063-017-2044-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 06/05/2017] [Indexed: 11/25/2022] Open
Abstract
Background Family caregivers (FC) often experience higher distress levels than their relative with cancer. Many cancer centers have implemented distress screening programs, but most of them concentrate their efforts on patients, with little attention to their FC. To fill this gap, a pragmatic intervention has been designed to improve supportive care for FC of patients with lung cancer. This article describes the study protocol of a single-center randomized controlled trial to assess its effectiveness. Methods/design A total of 120 lung cancer patients and their FC are randomly assigned to the experimental group (exposed to intervention, N = 60) or to the control group (usual care, N = 60). The intervention includes: (1) systematic FC distress screening and problem assessment near their relative’s cancer diagnosis, and every 2 months, (2) privileged contact with an oncology nurse (ON) away from the patient to address FC problems and (3) liaison by the ON with the family physician of FC reporting high distress (thermometer score ≥5/10), or problems relying on FP expertise. In both groups, FC, patient and process-of-care outcomes are measured at baseline and every 3 months, up to 9 months. The primary endpoint is FC distress measured by the Hospital Anxiety and Depression Scale (HADS) and the Psychological Distress Index used in the Quebec Health Survey (PDQHS). Individual interviews with 10 FC and a focus group with the oncology team will be conducted at the study end to further document the effectiveness of the intervention and its impact on quality of life (for FC) and practice organization (for the oncology team). Discussion This trial will assess the effectiveness of an innovative intervention based on interprofessional collaboration between primary care and oncology care. It targets a population in great need, yet often neglected, and has the potential to clearly improve patient and caregiver experience of cancer care, and reduce the burden of disease. Trial registration ClinicalTrials.gov, ID: NCT02531464. Registered on 15 July 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2044-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michèle Aubin
- Research Centre of the Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, QC, Canada. .,Research Centre of Primary Care and Services-Université Laval (CERSSPL-UL), Quebec, QC, Canada. .,Research Centre of the CHU de Quebec, Quebec, QC, Canada. .,Department of Family Medicine and Emergency Medicine, Université Laval, Quebec, QC, Canada. .,Maison Michel-Sarrazin Research Team in Palliative Care and Psychosocial Oncology (ERMOS), Quebec, QC, Canada. .,Laval Family Medicine Unit, Université Laval, Quebec, QC, Canada. .,CIUSSS Capitale-Nationale , 2690, Chemin des Quatre-Bourgeois, Quebec, QC, G1V 0B7, Canada.
| | - Lucie Vézina
- Research Centre of the Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, QC, Canada.,Laval Family Medicine Unit, Université Laval, Quebec, QC, Canada
| | - René Verreault
- Research Centre of Primary Care and Services-Université Laval (CERSSPL-UL), Quebec, QC, Canada.,Department of Social and Preventive Medicine, Université Laval, Quebec, QC, Canada
| | - Sébastien Simard
- Research Centre of the Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, QC, Canada.,Maison Michel-Sarrazin Research Team in Palliative Care and Psychosocial Oncology (ERMOS), Quebec, QC, Canada.,Pulmonary Oncology Centre, IUCPQ, Quebec, QC, Canada
| | - Jean-François Desbiens
- Research Centre of the CHU de Quebec, Quebec, QC, Canada.,Maison Michel-Sarrazin Research Team in Palliative Care and Psychosocial Oncology (ERMOS), Quebec, QC, Canada.,Faculty of Nursing, Université Laval, Quebec, QC, Canada
| | - Lise Tremblay
- Research Centre of the Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, QC, Canada.,Pulmonary Oncology Centre, IUCPQ, Quebec, QC, Canada.,Department of Medicine, Université Laval, Quebec, QC, Canada
| | - Serge Dumont
- Research Centre of Primary Care and Services-Université Laval (CERSSPL-UL), Quebec, QC, Canada.,Research Centre of the CHU de Quebec, Quebec, QC, Canada.,Maison Michel-Sarrazin Research Team in Palliative Care and Psychosocial Oncology (ERMOS), Quebec, QC, Canada.,Faculty of Social Sciences, Université Laval, Quebec, QC, Canada
| | - Lise Fillion
- Research Centre of the CHU de Quebec, Quebec, QC, Canada.,Maison Michel-Sarrazin Research Team in Palliative Care and Psychosocial Oncology (ERMOS), Quebec, QC, Canada.,Faculty of Nursing, Université Laval, Quebec, QC, Canada
| | - Maman Joyce Dogba
- Research Centre of Primary Care and Services-Université Laval (CERSSPL-UL), Quebec, QC, Canada.,Research Centre of the CHU de Quebec, Quebec, QC, Canada.,Department of Family Medicine and Emergency Medicine, Université Laval, Quebec, QC, Canada
| | - Pierre Gagnon
- Research Centre of Primary Care and Services-Université Laval (CERSSPL-UL), Quebec, QC, Canada.,Research Centre of the CHU de Quebec, Quebec, QC, Canada.,Maison Michel-Sarrazin Research Team in Palliative Care and Psychosocial Oncology (ERMOS), Quebec, QC, Canada.,Department of Psychiatry, Université Laval, Quebec, QC, Canada
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Groff S, Holroyd-Leduc J, White D, Bultz BD. Examining the sustainability of Screening for Distress, the sixth vital sign, in two outpatient oncology clinics: A mixed-methods study. Psychooncology 2017; 27:141-147. [DOI: 10.1002/pon.4388] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 01/05/2017] [Accepted: 01/23/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Shannon Groff
- Department of Community Health Sciences; University of Calgary; Alberta Canada
- Department of Psychosocial Oncology; Tom Baker Cancer Centre; Alberta Canada
| | - Jayna Holroyd-Leduc
- Department of Community Health Sciences; University of Calgary; Alberta Canada
- Department of Medicine; University of Calgary; Alberta Canada
| | - Deborah White
- Faculty of Nursing; University of Calgary; Alberta Canada
| | - Barry D. Bultz
- Department of Psychosocial Oncology; Tom Baker Cancer Centre; Alberta Canada
- Department of Oncology, Cumming School of Medicine; University of Calgary; Alberta Canada
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Formation au dépistage des difficultés psychosociales en cancérologie : apport d’un guide d’entretien (PO-Bado) sur la pratique des soignants du dispositif d’annonce. PSYCHO-ONCOLOGIE 2014. [DOI: 10.1007/s11839-014-0451-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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9
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Fillion L, de Serres M, Tremblay A, Blais MC, Robitaille MA, Boucher S. Sensibiliser les équipes soignantes à la prise en compte de la souffrance psychique : l’expérience du dépistage de la détresse au CHU de Québec. PSYCHO-ONCOLOGIE 2014. [DOI: 10.1007/s11839-014-0456-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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10
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Dauchy S, Bacqué MF, Consoli SM, Durdux C, Ellien F, Espérou H, Fillion L, Pucheu S, Reich M, Bendrihen N. L’intégration de la psycho-oncologie dans les formations en cancérologie. Les recommandations de la Société Française de Psycho-Oncologie (SFPO). PSYCHO-ONCOLOGIE 2014. [DOI: 10.1007/s11839-014-0458-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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A pan-Canadian web-based education program to support screening for distress: Evaluation of outcomes. Palliat Support Care 2013; 12:15-23. [DOI: 10.1017/s1478951513000072] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjective:Cancer-related distress has been endorsed as the sixth vital sign by many international cancer organizations, and some countries such as Canada have implemented national screening for distress programs. The completion of a screening tool is an important first step in improving responsiveness to cancer-related distress, but screening must be followed with skilled supportive care to make a difference in patient-reported outcomes. Our objective was to create a web-based education program to support nurses and other frontline staff in providing an initial response to screening results.Method:To address screening and supportive care learning needs, the Canadian Association of Psychosocial Oncology (CAPO), with support from the Canadian Partnership Against Cancer, created a web-based education program as one component of the national screening for distress agenda. The program provides clinically grounded and interactive learning through the use of PowerPoint presentations, video clips of clinical interactions with patients and family members, and test questions. Presentation topics include, for example, strategies for dealing with screening results, managing referrals, and supportive counseling. We employed a matched pairs, pre-post survey design to assess the effect of the education program on confidence in screening and in providing initial supportive care.Results:Our analysis of the first 147 matched pairs to complete the course suggests that satisfaction with the course was high. Statistically significant increases in confidence in relation to screening for distress and assessing distress, and in providing initial supportive care, were evident.Significance of results:Our ongoing experience with CAPO's Interprofessional Psychosocial Oncology Distance Education (IPODE) project (www.ipode.ca) project suggests that healthcare professionals value web-based learning for its accessibility and convenience. Such programs appear to offer excellent opportunities for cost-effective education that supports practice change.
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12
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What to do with screening for distress scores? Integrating descriptive data into clinical practice. Palliat Support Care 2013; 12:25-38. [DOI: 10.1017/s1478951513000059] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjective:Implementation of routine Screening for Distress constitutes a major change in cancer care, with the aim of achieving person-centered care.Method:Using a cross-sectional descriptive design within a University Tertiary Care Hospital setting, 911 patients from all cancer sites were screened at the time of their first meeting with a nurse navigator who administered a paper questionnaire that included: the Distress Thermometer (DT), the Canadian Problem Checklist (CPC), and the Edmonton Symptom Assessment System (ESAS).Results:Results showed a mean score of 3.9 on the DT. Fears/worries, coping with the disease, and sleep were the most common problems reported on the CPC. Tiredness was the most prevalent symptom on the ESAS. A final regression model that included anxiety, the total number of problems on the CPC, well-being, and tiredness accounted for almost 50% of the variance of distress. A cutoff score of 5 on the DT together with a cutoff of 5 on the ESAS items represents the best combination of specificity and sensitivity to orient patients on the basis of their reported distress.Significance of results:These descriptive data will provide valuable feedback to answer practical questions for the purpose of effectively implementing and managing routine screening in cancer care.
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Carlson LE, Waller A, Mitchell AJ. Screening for Distress and Unmet Needs in Patients With Cancer: Review and Recommendations. J Clin Oncol 2012; 30:1160-77. [PMID: 22412146 DOI: 10.1200/jco.2011.39.5509] [Citation(s) in RCA: 373] [Impact Index Per Article: 31.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Linda E. Carlson
- Linda E. Carlson, Tom Baker Cancer Centre; Linda E. Carlson and Amy Waller, University of Calgary, Calgary, Alberta, Canada; and Alex J. Mitchell, Leicestershire Partnership Trust and University of Leicester, Leicester, United Kingdom
| | - Amy Waller
- Linda E. Carlson, Tom Baker Cancer Centre; Linda E. Carlson and Amy Waller, University of Calgary, Calgary, Alberta, Canada; and Alex J. Mitchell, Leicestershire Partnership Trust and University of Leicester, Leicester, United Kingdom
| | - Alex J. Mitchell
- Linda E. Carlson, Tom Baker Cancer Centre; Linda E. Carlson and Amy Waller, University of Calgary, Calgary, Alberta, Canada; and Alex J. Mitchell, Leicestershire Partnership Trust and University of Leicester, Leicester, United Kingdom
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