Assessment of emotional distress in palliative care: Edmonton Symptom Assessment System-revised (ESAS-r) vs Distress Thermometer

OBJECTIVES

To evaluate the sensitivity and specificity of the Distress Thermometer (DT) as a screening tool for emotional distress in oncological palliative care patients and to compare the DT with the Edmonton Symptom Assessment System-revised (ESAS-r) and the gold standard to determine the most appropriate assessment method in palliative psychological care.

METHODS

Data were collected from psychological screening tests (ESAS-r and DT), and clinical interviews (gold standard) were conducted by a clinical psychologist specialist in palliative oncology from January 2021 to January 2022 in an oncology palliative care service.

RESULTS

The sample consisted of 356 first-time patients with a diagnosis of advanced cancer in palliative care. The most frequently reported oncological diagnoses were gastrointestinal tract (49.3%) and breast (18.3%). Most patients were female (n = 206; 57.9%), 60.4% were married/with a partner, 55.4% had between 6 and 9 years of schooling, and a median age of 57 (range, 46-65) years. The cutoff of the DT was 5, with a sensitivity of 75.88% and specificity of 54.3%. Emotional problems (sadness and nervousness) had a greater area under the curve (AUC) when measured using the DT than the ESAS-r; however, only in the case of the comparative sadness and discouragement was the difference between the AUC marginally significant.

SIGNIFICANCE OF RESULTS

The use of the DT as a screening tool in oncological palliative care is more effective in the evaluation of psychological needs than the ESAS-r. The DT, in addition to evaluation by an expert psychologist, allows for a more comprehensive identification of signs and symptoms to yield an accurate mental health diagnosis based on the International Classification of Diseases-11th Revision and/or Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition.

Distress, problems, referral wish, and supportive health care use in breast cancer survivors beyond the first year after chemotherapy completion

PURPOSE

We examined distress levels, problems, referral wish, and supportive health care use in a cross-sectional group of breast cancer survivors at two-time points with a 1-year time interval. Also, factors related to continuing elevated distress were explored.

METHODS

Breast cancer survivors, 1-5 years after chemotherapy completion, filled in the Dutch Distress Thermometer/Problem List (DT/PL) and questions on background characteristics at study inclusion (T1). DT/PL responses and health care use were discussed during semi-structured interviews. One year later, re-assessment took place (T2). The data were analyzed by descriptive and univariate analyses. Continuing elevated distress was defined as a DT score ≥ 5 at T1 and T2.

RESULTS

Seventy-three survivors completed all questionnaires (response = 84.6%). Eighteen (25%) experienced continuing elevated distress. Fatigue (T1 N = 48 (66%); T2 N = 41 (56%)) and lack of physical fitness (T1 N = 44 (60%); T2 N = 36 (49%)) were most often reported. Time since diagnosis, health care use, and practical, social, emotional and physical problems were significantly associated with continuing elevated distress. Between diagnosis and T1, N = 49(67%) used supportive healthcare services, mostly a psychologist and/or a physical/lymphedema therapist, and between T1 and T2, 39 (53%) did. At T1, 8 (11%) expressed a referral wish and at T2, 11 (16%) did.

CONCLUSIONS

Screening and management of distress, problems, and referral wish are important, even years after chemotherapy completion as a substantial proportion of breast cancer survivors continue to report elevated distress and problems. Special attention should be paid to survivors reporting physical problems, especially fatigue and lack of physical fitness, since these problems are most strongly related to continuing elevated distress.

Use of the Distress Thermometer in Cancer Survivors: Convergent Validity and Diagnostic Accuracy in a Spanish Sample

OBJECTIVES

To explore the performance of the National Comprehensive Cancer Network Distress Thermometer (DT) as a distress screening tool in cancer survivors.

SAMPLE & SETTING

236 Spanish adult-onset cancer survivors who visited the Fundación Instituto Valenciano de Oncología in Valencia, Spain, for follow-up appointments.

METHODS & VARIABLES

Survivors completed the DT and the Brief Symptom Inventory 18 (BSI-18), which has established a cutoff score for identifying clinically significant distress.

RESULTS

Receiver operating characteristic curve analysis of the DT scores relative to the BSI-18 cutoff score showed good overall accuracy. For a score of 5 or greater, sensitivity, specificity, positive predictive value, negative predictive value, and clinical utility indexes indicated that the DT appeared to be satisfactory for screening but had restricted use for case finding.

IMPLICATIONS FOR NURSING

Screening for and responding to distress is considered an important part of nursing practice. The DT is suitable for use as a first-stage, quick-detection instrument in a two-step screening process to rule out noncases among Spanish post-treatment cancer survivors.

A Distress Thermometer Intervention for Patients With Head and Neck Cancer

OBJECTIVES

To investigate the feasibility of an intervention using the National Comprehensive Cancer Network Distress Thermometer and Problem List with nurse-guided follow-up and the effect on depressive symptoms, health-related quality of life, and worry of cancer in patients with head and neck cancer.
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SAMPLE & SETTING

110 patients with head and neck cancer in a two-arm randomized, controlled trial in an outpatient clinic of a university hospital. 
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METHODS & VARIABLES

Patients were randomized to usual care (n = 57) or the intervention group (n = 53), which consisted of screening with the Distress Thermometer and Problem List plus nurse-guided follow-up lasting about 20 minutes three to four times during 12 months. Intention-to-treat analysis was performed using linear mixed models with outcomes at 6 and 12 months and baseline adjustment.
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RESULTS

The intervention showed moderate compliance and acceptable session duration. Intervention participants were satisfied with nurses' care. Depressive symptoms, health-related quality of life, and worry of cancer were not significantly different in the two treatment groups. The intervention seemed feasible in clinical practice, but no effects on patient outcomes were seen.
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IMPLICATIONS FOR NURSING

Patients with head and neck cancer appreciated the opportunity to discuss their problems and challenges with a nurse. Nurses supported patients with basic psychosocial care, minor interventions, and referral possibilities.

Patient-reported distress is prevalent in systemic light chain (AL) amyloidosis but not determined by severity of disease

We conducted this retrospective study to assess patient-reported distress in light chain (AL) amyloidosis, using the Distress Thermometer (DT) survey at first evaluation at our center. Of 78 patients who completed the survey, 75 scored their distress (distress: <4 - low, 4-6 - moderate, >6 - high). Moderate and high distress were self-reported by 30% and 17% patients, respectively. More patients with distress lived alone and had lower haemoglobin than patients without. AL stage did not correlate with distress (Stage I/II median DT 4 compared to 3 in Stage III/IV, p = .09), while cardiac AL was associated with lower distress at 3 compared to 5 in those without (p = .02). Karnofsky performance score (KPS) was concordant with stage (KPS ≥90 in 60% stage I/II versus 19% stage III/IV, p = .005) and cardiac involvement (26% with versus 63% without cardiac involvement had KPS ≥90, p = .01). Significant correlates of high distress included dealing with children, family health, depression, fears, nervousness, sadness, appearance, nausea, dry nose/congestion, memory/concentration, pain, sleep, neuropathy symptoms, and bathing/dressing. In conclusion, we demonstrate moderate to high distress in 47% of AL population at initial evaluation. Distress in amyloidosis is not influenced by amyloid stage or type of organ involvement.

Focusing on cancer patients' intentions to use psychooncological support: A longitudinal, mixed-methods study

OBJECTIVE

Distress screening programs aim to ensure appropriate psychooncological support for cancer patients, but many eligible patients do not use these services. To improve distress management, we need to better understand patients' supportive care needs. In this paper, we report the first key finding from a longitudinal study that focused on patients' intentions to use psychooncological support and its association with distress and uptake of the psychooncology service.

METHODS

We conducted a prospective, observational study in an Oncology Outpatient Clinic and assessed distress, intention to use psychooncological support, and uptake of the psychooncology service by using the Distress Thermometer, a semistructured interview, and hospital records. We analyzed data with a mixed-methods approach.

RESULTS

Of 333 patients (mean age 61 years; 55% male; 54% Distress Thermometer ≥ 5), 25% intended to use the psychooncology service (yes), 33% were ambivalent (maybe), and 42% reported no intention (no). Overall, 23% had attended the psychooncology service 4 months later. Ambivalent patients reported higher distress than patients with no intention (odds ratio = 1.18, 95% confidence interval [1.06-1.32]) but showed significantly lower uptake behavior than patients with an intention (odds ratio = 14.04, 95% confidence interval [6.74-29.24]). Qualitative analyses revealed that ambivalent patients (maybe) emphasized fears and uncertainties, while patients with clear intentions (yes/no) emphasized knowledge, attitudes, and coping concepts.

CONCLUSIONS

We identified a vulnerable group of ambivalent patients with high distress levels and low uptake behavior. To optimize distress screening programs, we suggest addressing and discussing patients' supportive care needs in routine clinical practice.

Use of a self-reported psychosocial distress screening tool as a predictor of need for psychosocial intervention in a general medical setting

This study describes the development of a self-reported psychosocial distress screening tool for a general medical population and criteria to predict the need for psychosocial intervention. The objectives were to develop criteria to determine which patients need in-person screening and establish criteria identifying patients who are more likely to require psychosocial interventions. The outcomes have bearing on reducing initial psychosocial screening workload for medical social workers in high volume medical settings. Furthermore, a criterion for scoring the self-reported tool can predict which patients will need further social work intervention. The results suggest criteria are a score on the adapted Distress Thermometer of five or greater, at least two negative emotions, and a lack of health insurance. The optimal criterion identified 36% (446/1228) of patients in need of in-person screening with the remaining 64% (782/1228) screened low risk through the tool, representing a significant workload reduction.

Metastatic Lung Cancer and Distress: Use of the Distress Thermometer for Patient Assessment

BACKGROUND

Patients with metastatic lung cancer experience high levels of distress related to their disease trajectory and treatment. Oncology nurses are experts in patient care and symptom management, giving them an opportunity to screen and treat patients' distress.
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OBJECTIVES

The objectives of this study were to screen patients for distress and manage their symptoms to positively affect their quality of life, treatment adherence, and clinical outcomes, and to reduce healthcare costs. 
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METHODS

This quality improvement project was conducted to pilot the Distress Thermometer (DT) into the care of patients with thoracic cancer and to evaluate the effect of a multifaceted intervention, consisting of a patient education pamphlet and a nurse coaching call, on distress levels. 
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FINDINGS

Severe distress was reported in more than half the patients. A paired-sample t test revealed a significant decrease in distress scores following the intervention.

The Distress Thermometer: Cutoff Points and Clinical Use

Purpose/Objectives

To establish an optimal cutoff point for the National Comprehensive Cancer Network’s Distress Thermometer (DT) as a screening measure to identify and address psychological distress in individuals with cancer, and to examine whether distress as measured by the DT significantly changes across the treatment trajectory.

Design

Secondary analyses of baseline data from a longitudinal parent study examining a computerized psychosocial assessment.

Setting

Three diverse comprehensive cancer centers across the United States.

Sample

836 patients with a current or past diagnosis of cancer.

Methods

Study participants were selected from a randomized clinical trial. Patients during any stage of the cancer treatment trajectory were recruited during a chemotherapy infusion or routine oncology appointment.

Main Research Variables

The Behavioral Health Status Index and the DT were administered and compared using receiver operating characteristic analyses.

Findings

Results support a cutoff score of 3 on the DT to indicate patients with clinically elevated levels of distress. In addition, patients who received a diagnosis within the 1–4 weeks prior to the assessment indicated the highest levels of distress.

Conclusions

Providers may wish to use a cutoff point of 3 to most efficiently identify distress in a large, diverse population of patients with cancer. In addition, results indicate that patients may experience a heightened state of distress within 1–4 weeks postdiagnosis compared to other stages of coping with cancer.

Implications for Nursing

Using a brief measure of distress can help streamline the process of screening for psychosocial distress.

Psychosocial burden and desire for support in outpatients with skin cancer

BACKGROUND

An important basis for adequate psycho-oncological and psychosocial care of cancer patients is the regular assessment of their psychosocial distress and thus their need for care. For this purpose, there are numerous questionnaires available. The objective of the present study was to assess whether distressed patients require professional support and which screening instrument outpatients with skin cancer prefer.

PATIENTS AND METHODS

In a cross-sectional survey, we asked outpatients with skin cancer to fill out three questionnaires assessing psychosocial stress, and to indicate which one they considered most adequate. Patients were offered the following three instruments: Hornheide Questionnaire (27 items), Hornheide Screening Instrument (7 items), and the Distress Thermometer. In addition, we inquired about the patients' desire for support.

RESULTS

(1) Comparing subjective distress and patients' declared desire for support revealed a marked divergence. While one-third of the 137 patients were identified as being in need of care, only 11.5% of the sample requested such support. (2) 63.7% of patients chose the long version of the Hornheide Questionnaire.

CONCLUSIONS

In addition to their psychosocial burden, patients' desire for support should be assessed. Moreover, apart from screening tools, other ways to provide access to psychosocial care should be considered.

Distress prior to undergoing hematopoietic stem cell transplantation: demographic and symptom correlations and establishing a baseline

BACKGROUND

Distress can arise from physical and/or psychosocial impairments and has been documented in patients after hematopoietic stem cell transplantation in the outpatient setting. It has not been evaluated in inpatients admitted to undergo the transplant, nor has potential correlations with length of hospital stay, physical function, and pain after receiving the transplant.

OBJECTIVES

To measure distress in patients admitted to the hospital to undergo hematopoietic stem cell transplantation, and to evaluate potential correlations with length of hospital stay, physical function, pain, and depression/anxiety.

METHODS

Eighty patients were given a questionnaire to report levels of distress and physical and psychosocial functioning. Hierarchical multiple regression analysis was used to test the relationship of demographic and transplant factors with length of stay (LOS), distress, presence of pain, and depression/anxiety.

RESULTS

Patients reported pretransplant distress with an average score of 2.2 out of 10, and 16 out of 80 patients reported clinically relevant distress. Pain was reported by 42.5% of patients, and 28.8% reported depression/anxiety. Physical functioning was generally high. Distress was correlated with depression/anxiety (P-value <0.01) and pain (0.04) but not with LOS, physical function, patient age, or transplant type.

CONCLUSION

LOS after receiving stem cell transplant was not related to pretransplant distress. Distress exists pretransplant but is generally low. Pain and the presence of depression/anxiety may be risk factors for distress. Measuring distress prior to transplant gives a baseline from which to measure changes, potentially leading to earlier intervention.

Significance of Nonphysical Predictors of Distress in Cancer Survivors

BACKGROUND

The Distress Thermometer (DT) is a well-validated tool that is frequently used in patients with cancer to screen for general distress and to generate referrals. However, a majority of the DT problem list items relate to physical concerns; this may lead to psychosocial issues being overshadowed.

OBJECTIVES

The purpose of the current study is to examine the endorsement rates for nonphysical items, as well as the relationship between these items and overall DT scores.

METHODS

A multiple logistic regression analysis of the first-time distress rating scale of 1,209 patients from 2005-2009 was conducted to determine whether nonphysical items on the DT significantly contributed to a patient falling into one of two categories.

FINDINGS

This study provides evidence that emotional variables are particularly significant for patients who are at risk for distress and, consequently, should be prioritized for intervention when endorsed on the DT problem list.

Significance of Nonphysical Predictors of Distress in Cancer Survivors

BACKGROUND

The Distress Thermometer (DT) is a well-validated tool that is frequently used in patients with cancer to screen for general distress and to generate referrals. However, a majority of the DT problem list items relate to physical concerns; this may lead to psychosocial issues being overshadowed.

OBJECTIVES

The purpose of the current study is to examine the endorsement rates for nonphysical items, as well as the relationship between these items and overall DT scores.

METHODS

A multiple logistic regression analysis of the first-time distress rating scale of 1,209 patients from 2005-2009 was conducted to determine whether nonphysical items on the DT significantly contributed to a patient falling into one of two categories.

FINDINGS

This study provides evidence that emotional variables are particularly significant for patients who are at risk for distress and, consequently, should be prioritized for intervention when endorsed on the DT problem list.

The suitability of the Hospital Anxiety and Depression Scale, Distress Thermometer and other instruments to screen for psychiatric disorders in both lung cancer patients and their partners

BACKGROUND

Lung cancer patients and their partners report high rates of distress. Although distress is of importance, psychiatric disorders might be more important in terms of prognostic value and additional psychological treatment. This study examined the suitability of the Hospital Anxiety and Depression Scale (HADS), Distress Thermometer (DT), Beck Depression Inventory (BDI-II) and State subscale of State Trait Anxiety Inventory (STAI-S) to screen for psychiatric disorders in lung cancer patients and partners.

METHODS

A consecutive sample of lung cancer patients and partners completed the screening instruments. The Structured Clinical Interview DSM-IV (SCID-I) was used to diagnose psychiatric axis I disorders.

RESULTS

In 144 patients, overall ability of HADS total score (HADS-T) screening for patients with psychiatric disorders was good, whereas DT appeared less suitable. In 98 partners, the performance of HADS-T was good. Although no instrument was successful in identifying psychiatric disorders, HADS-T came closest with a fair performance in patients and partners.

LIMITATIONS

Several patients and partners declined participation because they perceived participation as too distressing. As decliners possibly have the highest rates of disorders, our findings might underestimate the prevalence of psychiatric disorders. A low prevalence negatively affects the positive predictive value and complicates efficient screening for psychiatric disorders.

CONCLUSION

The HADS-T appears to be a suitable screening instrument for ruling out those lung cancer patients and partners without a psychiatric disorder. Regarding identifying those with a psychiatric disorder, HADS-T should be used to refer both patients and partners for further diagnostics and treatment to a psychiatrist/psychologist.

Accuracy of the Distress Thermometer for home care patients with palliative care needs in Germany

OBJECTIVE

Our aim was to examine the accuracy of the German version of the Distress Thermometer (DT) compared with the Hospital Anxiety and Depression Scale (HADS) in patients with palliative care needs living at home.

METHOD

Ours was a 15-month cross-sectional study beginning in September of 2013 in Germany with consecutive patients cared for by a palliative home care service. The survey was implemented during the initial visit by a home care team. Patients were excluded if they were under 18 years of age, mentally or physically unable to complete the assessment questionnaires as judged by their healthcare worker, or unable to understand the German language. During the first encounter, the DT and HADS were applied, and sociodemographic and medical data were collected.

RESULTS

A total of 89 persons completed both the HADS and DT questionnaires (response rate = 59.7%; mean age = 67 years; female = 55.1%; married = 65.2%; living home with relatives = 73.0%; oncological condition = 92.1%; Karnofsky Performance Scale [KPS] score: 0-40 = 30.3%, 50-70 = 57.3%, >80 = 6.7%). The mean DT score was 6.3 (±2.3), with 84.3% of participants scoring above the DT cutoff (≥4). The mean HADStotal score was 17.9 (±7.8), where 64% of participants had a total HADS score (HADStotal) ≥15, 51.7% reported anxiety (HADSanxiety ≥ 8), and 73% reported depression (HADSdepression ≥ 8). Using the HADS as a gold standard, a DT cutoff score ≥5 was optimal for identifying severe distress in patients with palliative care needs, with a sensitivity of 93.0%, a specificity of 34.4%, a positive predictive value (PPV) of 73.3%, and likelihood ratios LR+ = 1.42 (<3) and -LR = 0.203 (<0.3).

SIGNIFICANCE OF RESULTS

The DT performed satisfactorily compared to the HADS in screening for distress in our study and can be employed as an instrument for identification of patients with distress. Consequent to the high prevalence of distress, we recommend its routine use for screening distressed persons at home with palliative care needs in order to offer adequate support.

The Distress Thermometer for screening for severe fatigue in newly diagnosed breast and colorectal cancer patients

OBJECTIVE

Internationally, the Distress Thermometer and associated Problem List are increasingly used in oncology as screening tools for psychological distress. Cancer-related fatigue is common but often overlooked in clinical practice. We examined if severe fatigue in cancer patients can be identified with the fatigue item of the Problem List.

METHODS

Newly diagnosed breast (N = 334) and colorectal (N = 179) cancer patients were screened for severe fatigue, which was defined as having a positive score on the fatigue item of the Problem List. The Fatigue Severity subscale of the Checklist Individual Strength was used as gold standard measure for severe fatigue.

RESULTS

In total, 78% of breast cancer patients and 81% of colorectal cancer patients were correctly identified with the fatigue item. The sensitivity was 89% in breast cancer patients and 91% in colorectal cancer patients. The specificity was 75% in breast cancer patients and 77% in colorectal cancer patients. The positive predictive value was 53% in breast cancer patients and 64% in colorectal cancer patients, whereas the negative predictive value was 95% in both tumor types.

CONCLUSIONS

The fatigue item of the Problem List performs satisfactorily as a quick screening tool for severe fatigue. However, a positive screen should be followed up with a more thorough assessment of fatigue, ie, a questionnaire with a validated cutoff point. Given time pressure of clinicians, this already implemented and brief screening tool may prevent severe fatigue from going undetected in clinical practice.

Prevalence and related factors of psychological distress among cancer inpatients using routine Distress Thermometer and Chinese Health Questionnaire screening

BACKGROUND

Clinical practice guidelines suggest routine screening for distress among cancer patients for immediate early psychiatric care. However, previous studies focusing on routine screening for psychological distress among cancer inpatients in Taiwan are scant. Thus, the aim of this study was to evaluate the prevalence and related factors of psychological distress and mental illness among cancer inpatients in Taiwan.

PATIENTS AND METHODS

This study was conducted as a retrospective chart review in a general hospital in southern Taiwan. Cancer inpatients were regularly screened by nursing staff using the Distress Thermometer and the 12-item Chinese Health Questionnaire. Positive screening results on either instrument were followed by a non-commanded referral to psychiatrists for clinical psychiatric diagnosis and treatment.

RESULTS

Of the 810 participants in this study, 179 (22.1%) were recognized as having psychological distress. Younger age (odds ratio [OR] =1.82), having head and neck cancer (OR =2.43), and having not received chemotherapy (OR =1.58) were significantly related to psychological distress. Among the 56 patients (31.3%) with psychological distress who were referred to psychiatrists, the most common mental illness was adjustment disorder (n=22, 39.2%), followed by major depressive disorder (n=13, 23.2%), depressive disorder not otherwise specified (n=6, 10.7%), and anxiety disorder not otherwise specified (n=4, 7.1%).

CONCLUSION

Our study indicated that cancer inpatients with psychological distress were more likely to be younger in age, have head and neck cancer, and have not received chemotherapy. The most common psychiatric disorder was adjustment disorder. Early detection of psychological distress and prompt psychiatric consultation and management are very important for cancer inpatients.

Screening young adult cancer survivors for distress with the Distress Thermometer: Comparisons with a structured clinical diagnostic interview

BACKGROUND

The validity of the Distress Thermometer (DT) as a screen for psychological distress in young adult cancer survivors was assessed by comparing it with the results of a psychiatric diagnostic interview, the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) (SCID), to evaluate the accuracy of the DT and identify optimal cutoff scores for this population.

METHODS

A total of 247 survivors aged 18 to 40 years completed the DT and SCID. Based on the SCID, participants were classified as having: 1) ≥ 1 SCID diagnoses; 2) significant symptoms, but no SCID diagnosis; or 3) no significant SCID symptoms. Receiver operating characteristic analyses determined the sensitivity and specificity of all possible DT cutoff scores for detecting survivors with a SCID diagnosis, and subsequently for survivors with significant SCID symptoms or a SCID diagnosis.

RESULTS

The recommended DT cutoff score of ≥5 failed to identify 31.81% of survivors with a SCID diagnosis (sensitivity of 68.18% and specificity of 78.33%), and 32.81% of survivors with either significant SCID symptoms or a SCID diagnosis. No alternative DT cutoff score met the criteria for acceptable sensitivity (≥85%) and specificity (≥75%).

CONCLUSIONS

The DT does not reliably identify young adult cancer survivors with psychiatric problems identified by a "gold standard" structured psychiatric interview. Therefore, the DT should not be used as a stand-alone psychological screen in this population. Cancer 2016;122:296-303. © 2015 American Cancer Society.

Improving the Diagnostic Accuracy of the Distress Thermometer: A Potential Role for the Impact Thermometer

CONTEXT

Screening for and management of distress in clinical practice is an important issue in the field of psycho-oncology. The Distress Thermometer (DT) is a common screening tool, but other methods recently have been proposed, with the aim of improving its diagnostic accuracy.

OBJECTIVES

To investigate the diagnostic accuracy of the DT alone and combined with the Impact Thermometer (IT), via the use of two possible combination methods.

METHODS

A heterogeneous sample of 385 adult patients with cancer completed the DT, the IT, and the Brief Symptom Inventory-18.

RESULTS

The results of the DT were comparable with those found in previous studies, indicating that the DT was adequate for "screening" but had limited value for "case finding." The DT and the IT combined (summed or paired scores) showed minor differences in accuracy indexes compared with the DT alone.

CONCLUSION

The results of this study suggest that the addition of the IT to the DT failed to improve its accuracy for identifying distress.

Brief Distress Screening in Clinical Practice: Does it Help to Effectively Allocate Psycho-Oncological Support to Female Cancer Inpatients?

BACKGROUND

The usefulness of distress screening in cancer inpatient settings has rarely been investigated. This study evaluated a brief distress screening of inpatients in a breast cancer centre and a gynaecological cancer centre.

PATIENTS AND METHODS

Hospitalised patients with breast or gynaecological cancers were screened with the Distress Thermometer. Patients who scored above the cut-off, were referred by the medical staff, or self-referred were offered bedside psycho-oncological counselling.

RESULTS

Of 125 patients, 68 (54.4%) received an offer of counselling, and 62 patients (49.6%) accepted. Most of the counselling was induced by distress screening. Only 4 (3.2%) patients self-referred to the counselling service. Of the counselled patients, 65.8% stated that they had substantially benefited from psycho-oncological support; only 5.6% of the non-counselled patients indicated that they might have benefited from psycho-oncological support.

CONCLUSION

Almost all patients who will accept and benefit from psycho-oncological counselling can be identified if distress screening is used in conjunction with referrals by physicians and nurses. Distress screening is a worthwhile component in a framework of psycho-oncological support in a cancer inpatient setting. It paves the way to counselling for cancer inpatients who need it and are willing to accept it but hesitate to self-refer to psycho-oncological services.

Screening for distress in patients with cancer: methodologic considerations

Distress has been declared the 6th vital sign in Canadian cancer care. Accordingly, health care professionals in Canada are expected to screen for distress in patients with cancer, for which a toolkit has been developed. Identifying patients who may be in need of further resources has the potential to improve quality of care because those patients are more likely to have their existing distress identified and to be referred for appropriate follow-up services. The present article briefly reviews the background literature and the validation of the measures in the toolkit, and highlights future directions for methodologic validation of the toolkit for use according to the protocol.

Evaluation of Distress and Stress in Cancer Patients in AMIR Oncology Hospital in Shiraz

BACKGROUND

Routine screening for distress is internationally recommended as a necessary standard for good cancer care given its high prevalence and negative consequences on quality of life. This study attempts to support validation of Distress Thermometer (DT) in Shiraz, Iran and in the second step to investigate privilege/priority of DT over other referent criterion measures.

MATERIAL AND METHODS

In total, 58 outpatients with cancer were recruited from AMIR Oncology hospital in Shiraz, Iran. Each participant completed the DT and a list of 34 possible cancer-related problems (the Problem List), the Hospital Anxiety and Depression Scale (HADS), the 18-item Brief Symptom Inventory (BSI-18), and a short visual analog scale to determine the understandability of the tools.

RESULTS

Characteristic analysis revealed that DT cutoff scores ≥4 and ≥5 had optimal sensitivity and specificity relative to both HADS and BSI-18 cutoff scores for general caseness and more severe psychological distress, respectively. Patients with DT scores ≥4 (cases) were more likely to be women suffering from psychological problems in the past experience stressful events in the 3 years ago and encounter more family, emotional, and physical issue related to cancer or cancer treatment (p=0.02).

CONCLUSION

Patients indicated that the DT was easier to fill out and to understand than the HADS, but not the BSI-18. The DT was identified as a simple and effective screening instrument for detecting distress in Iranian cancer patients as a first step toward more properly referring those in need to psychosocial intervention.

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.

Development and validation of the distress thermometer for parents of a chronically ill child

OBJECTIVE

To develop and validate a Distress Thermometer for Parents (DT-P) for chronically ill children and to determine a cutoff score for clinical distress.

STUDY DESIGN

Parents of a chronically ill child (0-18 years) were recruited via announcements or were actively approached at the outpatient clinics of the Emma Children's Hospital/Academic Medical Center and Vrije Universiteit Medical Center. We modeled the development of the DT-P on the Distress Thermometer used in oncology medical care. The DT-P consists of a thermometer score from 0 (no distress) to 10 (extreme distress) and a problem list (practical, social, emotional, physical, cognitive, and parenting domains). The DT-P was validated with the Hospital Anxiety and Depression Scale (HADS) and the Parenting Stress Index.

RESULTS

The mean thermometer score of the 706 participating parents was 3.7 (SD 3.0). The thermometer score and the scores in the practical, emotional, physical, and cognitive problem domains were strongly related to anxiety, depression, and the total score of the HADS (0.55 ≤ r ≤ 0.72). The thermometer score and all problem domain scores were moderately-to-strongly related to the Parenting Stress Index (0.38 ≤ r ≤ 0.63). A cutoff-score of 4 correctly identified 86% of "clinical HADS cases" (sensitivity) and 67% of "nonclinical HADS cases" (specificity).

CONCLUSIONS

We developed the DT-P and examined its diagnostic utility in a large sample. The DT-P appeared to be a valid and useful short screening-tool for identifying parental distress.

Validation of the Distress Thermometer in a Swedish population of oncology patients; accuracy of changes during six months

PURPOSE

To validate the Swedish version of the Distress Thermometer (DT) against the Hospital Anxiety and Depression Scale (HADS) for screening of distress and to explore how well DT measures changes of distress during six months in a population of heterogeneous oncology patients.

METHODS

The DT was translated into Swedish according to the forward- and back-translation procedure. HADS total score ≥15 was used as gold standard. Consecutive patients were invited to participate at their first visit to the Oncology department. The HADS and the DT were completed at baseline and after 1, 3 and 6 months.

RESULTS

462 baseline and 321 six-month assessments were completed. The patients had a variety of cancer diagnoses (n = 42). Most patients (95%) received active treatment. The DT compared favourably with the HADS. The area under the curve was 0.86 (95% CI, 0.82-0.90). DT ≥ 4 showed a sensitivity of 87%, a specificity of 73%, a positive predictive value (PPV) of 52% and a negative predictive value (NPV) of 95% at baseline. The results from the 1, 3 and 6 months assessments were equivalent baseline results. The DT means changed in the same direction as HADS at all points of assessment. Patients with distress reported statistically significantly more problems in all categories on the associated 'Problem List' compared to non-distressed patients.

CONCLUSION

The Swedish version of the DT with a score ≥4 is valid for screening of distress in heterogeneous oncology patients. Its ability to measure changes in distress over time is comparable to HADS.

Measurement of distress in Chinese inpatients with lymphoma

PURPOSE

The aim of this study was to assess the levels and sources of distress in patients with lymphoma. This study also focused on the influence of factors of the level of distress and the cutoff score using the Distress Thermometer (DT) relative to the Hospital Anxiety and Depression Scale (HADS).

METHOD

DT and HADS were used to estimate the psychological status of 323 eligible lymphoma patients. The DT was evaluated against the HADS for its sensitivity and specificity.

RESULTS

One hundred and ninety-three (59.7%) lymphoma patients experienced overall distress on the HADS, with 137 (42.4%) experiencing anxiety and 114 (35.3%) suffering from depression. There were 199 (61.6%) and 163 (50.5%) patients with distress score ≥ 4 and ≥ 5, respectively. DT was significantly correlated with the HADS-total (T) (r=0.820, p<0.001), HADS-depression (D) (r=0.763, p<0.001), and HADS-anxiety (A) (r=0.738, p<0.001). The consistency of the DT and HADS was favorable (coherence index=0.6030, p<0.01) when the cutoff score was 5 for the DT. Referring to the cutoff of 15 on HADS, 5 on DT yielded optimal specificity (0.869, p<0.001) and sensitivity (0.756, p<0.001). In multiple logistic regression analysis, patients with 'B symptoms' were more likely to have a distress score ≥ 5 [OR=4.512, p<0.05, 95% CI 1.953-10.467].

CONCLUSION

DT is efficacious for screening for anxiety and depression in lymphoma patients.