Although the diagnosis and treatment of cancer is associated with psychosocial distress, routine distress screening is difficult in hospitalized oncology settings. We developed a consecutive screening program for psychosocial distress to promote psychiatric treatment of cancer patients and evaluated the feasibility of our program by Distress Thermometer (DT) and Hospital Anxiety and Depression Scale (HADS).
Among 777 cancer inpatients recruited from the Catholic Comprehensive Institute of Seoul St. Mary's Hospital, 499 agreed to complete primary distress screening through DT. We conducted secondary distress screening through HADS in 229 patients who had high scores of DT.
Of the 499 participants, 270 patients with low scores of DT were included in the distress education program. 229 patients with high scores of DT received secondary distress screening through HADS. Among 115 patients with low scores of HADS, 111 patients received distress management. Among 114 patients with high scores in the secondary distress screening, 38 patients received psychiatric consultation service whereas 76 patients refused psychiatric consultation.
Using consecutive screening for psychosocial distress appeared to be feasible in an inpatient oncology setting. Nevertheless, the low participation rate of psychiatric consultation service in cancer patients with high distress level should be improved.
Clinicians have been attentive to psychological aspects of cancer patients because cancer is a life-threatening disease. Since Derogatis et al.
Several investigators have suggested that a high distress level in cancer patients might be correlated with several negative consequences such as decreased medical adherence, increased lengths of hospital stays, reduced quality of life, more psychological distress of family members, and possible increased mortality.
For detecting prevalent psychiatric diseases in cancer patients that could be beneath the surface, psychological distress screening can be an optimal strategy. Several studies showed that psychological distress screening successfully detected psychiatric disorders of cancer patients.
Nevertheless, psychological distress of patients with cancer tends to be underrated. Only 14.3% of oncologists used instruments for screening psychosocial distress
The primary objective of this study was to assess the effectiveness of a distress screening and management system in oncology practice. The secondary objective was to assess the feasibility of the stepwise applications of Distress Thermometer (DT) and Hospital Anxiety and Depression Scale (HADS) and recommendations for referral to psycho-oncologist.
A total of 777 subjects were inpatients (aged 18 or over) with confirmed histological diagnosis of cancer from the Seoul St. Mary's Hospital, Seoul, Republic of Korea. Inclusion criteria were: 1) cancer patients who were firstly admitted in the Catholic Comprehensive Cancer Institute in July 2007; 2) patients who were stratified according to the site of cancer diagnosis (colorectal, stomach, hepatobiliary, gynecological, lung, breast, thyroid, head and neck, and other cancer diagnosis); and 3) those who were able to read and understand Korean. This study was conducted in accordance with the ethical and safety guidelines set forth by the local Institutional Review Board of the Catholic University of Korea. Of the 999 subjects, 129 were excluded to participate because their first admissions were not for hospitalized interventions of oncology. The confinement of participants to first admission for oncologic interventions could clarify our feasibility study by eliminating overlapped data of a patient who hospitalized several times during the study period. Furthermore, we could focus on psychological distress of patients who experienced first-ever admission for oncologic intervention. A total of 149 patients were also excluded in this study, including 87 who had severe medical conditions, 8 who were discharged early (<24 hours), 8 who had cognitive impairments, and 2 who had severe psychiatric disorders.
Included patients were contacted by a clinical research associate who introduced them to the objectives and procedures of the study. Oncology nurses or oncologists helped participants complete a primary distress screening through DT. Then the oncology nurses or oncologists helped participants with DT score over 4 complete a secondary distress screening using HADS. Patients with high score of HADS (over score of 13) were referred to psychiatric consultation service. Singer and colleagues reported that the best trade between sensitivity and specificity for the total scale was a ≥13 score for cancer patients.
Patients with cancer was educated about psychological distress and coping method by oncologic nurses.
Patients with cancer was received supportive psychotherapy three times by trained psychiatric nurses.
Psychiatrist conducted psychiatric interviewing, diagnosed psychiatric disease, assessed disease severity, and decided appropriate interventions.
For all participants, medical data (type of cancer site, metastasis, medical comorbidity, time since diagnosis, reason to admission, and performance status), demographic data (age, sex, education, marital status, socioeconomic status, occupational status, residence, religion, smoking, and alcohol drinking), and psychosocial information were collected from a package that included questionnaires and interviews by oncology nurses, oncologists, and psychiatrists.
In recent years, considering patients with cancer have difficulty in finishing long time interview or surveys, National Comprehensive Cancer Center Network (NCCN) suggested to use DT, a visual measurement scale with one sentence.
HADS, a self-assessment scale, was developed to detect states of depression, anxiety and psychological distress amongst patients who were being treated for a variety of clinical problems.
Statistical analyses for demographic and clinical data were performed with the Statistical Package for Social Sciences software (SPSS version 12.0, SPSS Inc., Chicago, IL, USA). For assessing potential differences between groups (non-distressed group vs. distressed group on primary distress screening, low-scored group vs. high-scored group on secondary distress screening, and refused group vs. accepted group of a psychiatric consultation service, respectively), independent t test for continuous variables and χ2 test for categorical variables were used. Fisher's exact test was applied if there are more than 20% of cells having expected number less than 5. All statistical analyses had a two-tailed α level of <0.05 for statistical significance.
Data from 499 participants were analyzed. Demographic and clinical characteristics of participants are summarized in
Among eligible participants (n=561) who had some form of DT, 62 (11.05%, 62/561) refused to be screened. A total of 499 patients (88.95%, 499/561) finished the primary distress screening using DT. The distribution of DT response of participants at the primary distress screening is shown in
Patients who were residing in urban area showed higher DT score than patients who were residing in rural area (
The comparison between cancer patients who refused psychiatric consultation service and those who accepted the service is shown in
In this study, we developed a novel program of psychosocial distress-screening and intervention for hospitalized cancer patients and evaluated the feasibility of our program. Our study is not the first research to evaluate the feasibility of a novel intervention program to unburden psychosocial distress of cancer patients. However, we used a novel phased-approach to evaluate and treat inpatients with various types of cancer through cooperation between oncology and psychiatry teams. Since researchers could change the course of the trials while processing feasibility studies, we finished this study with the same procedure from the beginning to the end in a short period of time (1 month). All participants were hospitalized patients. Due to the nature of cancer diagnosis and treatment, almost all patients initially experienced admission for diagnosis and treatment. Therefore, oncology and psychiatric team could have enough time to conduct phased-approach distress screenings. Moreover, the medical team could be emphatic about the necessity of psychosocial distress assessment. Distress screening program through admission can facilitate psychiatric intensive care for patients who need the distress intervention. We tried to conduct primary distress screening on the admission day for all patients and to evaluate whether the distress at the time of psychiatric illness was aggravated. Based on the primary distress screening, psychiatrists, oncologists, nurses, psychologists, and social workers were involved in the assessment and treatment using various psychiatric interventions.
We found that DT and HADS could classify psychosocial interventions for cancer patients into the following three groups: distress education group, distress management group, and psychiatric consultation service group. The refusal rates to primary and secondary distress screening were 11.05% and 0%, respectively. The refusal rates to distress education, management, and psychiatric consultation service were 0%, 3.48%, and 66.67%, respectively. While patients with relatively lower distress tended to participant in psychosocial interventions for relieving patients' distress, patients with higher distress were inclined to refuse psychosocial intervention (psychiatric consultation service). Regarding the lower participation rate of the psychiatric consultation service, we agree to the explanations of Fukui et al.
This feasibility study provided a lot of information about psychosocial evaluations and interventions of distress in patients with cancer.
Several researchers showed that distress was significantly associated with poor performance status.
The current study has some limitations. First, it might be difficult to generalize about all patients with cancer from our study because it was a cross-sectional study with small sample size. More research including longitudinal studies with larger sample size is needed to confirm our findings. Second, the current study was conducted at one institution which might lead to institutional bias. Therefore, our findings could be more generalizable after multi-institutional studies. Third, the refusal rate to psychiatric intervention (a psychiatric consultation service) was rather high. Although our findings showed that the distress level was not associated with the refusal rate, the cut-off score of HADS could be controversial.
In this study, we demonstrated a novel feasible phased-approach of distress screening and management program for hospitalized cancer patients. This strategy of using mutual cooperation between oncologist and psychiatrist could increase the awareness to psychosocial distress experienced by cancer patients amongst medical team, cancer patients, and their caregivers. Follow-up studies on the clinical effectiveness of this strategy through realistic and optimal modifications are warranted.
This work was supported by the Basic Science Research Program through the National Research Foundation of Korea funded by the Ministry of Education, Science and Technology (2010-0003505) and by the Catholic Medical Center Research Foundation made in the program year of 2014.
Performance status as defined by Eastern Cooperative Oncology Group (ECOG). The cutoff score of DT was 4 (not distressed: <4, distressed: ≥4). DT: Distress Thermometer, SD: standard deviation
Performance status as defined by Eastern Cooperative Oncology Group (ECOG). HADS: Hospital Anxiety and Depression Scale, SD: standard deviation
Performance status as defined by Eastern Cooperative Oncology Group (ECOG). DT: Distress Thermometer, SD: standard deviation, HADS: Hospital Anxiety and Depression Scale