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Deidre B. Pereira, PhD Associate Professor Licensed Psychologist Psychosocial Rep., UFHCC Joint Oncology Program Department of Clinical & Health Psychology.

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Presentation on theme: "Deidre B. Pereira, PhD Associate Professor Licensed Psychologist Psychosocial Rep., UFHCC Joint Oncology Program Department of Clinical & Health Psychology."— Presentation transcript:

1 Deidre B. Pereira, PhD Associate Professor Licensed Psychologist Psychosocial Rep., UFHCC Joint Oncology Program Department of Clinical & Health Psychology College of Public Health & Health Professions Distress Screening & Management in Cancer

2 Definition of Distress in Cancer: NCCN Distress Management Guidelines Version 2.2014 An unpleasant emotional experience of a psychological (cognitive, behavioral, emotional), social, and/or spiritual nature Multifactorial Interferes with the ability to manage cancer Exists on a continuum: – –Common feelings of sadness and fear – –Disabling panic, depression, anger

3 Distress Screening Requirement American College of Surgeons (ACoS) Commission on Cancer (CoC) 2012 Cancer Program Standards Hospital Cancer Committee must develop and implement a process to integrate and monitor on- site psychosocial distress screening and referral for treatment as standard of care Overseen by psychosocial representative on cancer committee Method of assessment can be determined by the program

4 CoC Requirements Assessed at least once during a pivotal medical visit Preference for assessment methods that are standardized, validated, and have clinical cut-offs Individuals with moderate/severe distress must be referred to appropriate resources for management Assessment, referral, follow-up must be documented in the medical record

5 Distress as the 6 th Vital Sign (Howell & Olsen, 2011) Assessment of distress via Distress Thermometer or Visual Analog Scale (0 [No distress] – 10 [Worst distress imaginable] ) parallel to assessment of other vitals, such as temperature and pain

6 Cancer-Related Distress & Disability Years Lost due to Disability in cancer: –270 years per 100,000 population Clinically-significant distress: Epi research –5.7% of cancer survivors –4.3% of patients with other health conditions –0.7% of healthy individuals Clinically-significant distress: Acute care –31.3% of cancer patients, self-reported –56.3% of cancer patients, expert-rated

7 Distress Screening & Management: A Stepped Care Model Health & Behavior Assessment & Intervention Distress Screening Mental Health Assessment & Intervention

8 Patient- Centered Oncology Care Oncology Nurse Navigators Oncology Social Work Integrative Medicine Palliative Care & Symptom Management Psycho- Oncology Service Psychiatry Distress Screening Participants

9 Patient- Centered Oncology Care Oncology Nurse Navigators Oncology Social Work Integrative Medicine Palliative Care & Symptom Management Psycho- Oncology Service Health & Behavior Assessment/Intervention Participants

10 Patient- Centered Oncology Care Oncology Social Work Integrative Medicine Psycho- Oncology Service Psychiatry Mental Health Assessment/Intervention Participants


12 Distress is an unpleasant emotional state that may affect how you feel, think, and act. It can include feelings of unease, sadness, worry, anger, helplessness, guilt, and so forth. It is common to feel sad, fearful, and helpless. Feeling distressed may be a minor problem or it may be more serious. You may be so distressed that you can't do the things you used to do. Serious or not, it is important that your treatment team knows how you feel. The Distress Thermometer is a tool that you can use to talk to your health care providers about your distress. It has a scale on which you circle your level of distress. It also asks about the parts of life in which you are having problems. The Distress Thermometer has been tested in many studies and found to work well. The Distress Thermometer and the other questions below will help your treatment team know if you need supportive services. You may be referred to supportive services at UF or in your community. Supportive services can include help from support groups, chaplains, social workers, mental health counselors, psychologists, or psychiatrists.



15 Cancer History Primary diagnosis Date of diagnosis Type(s) of treatment completed to date Type(s) of treatment under consideration Dates and brief descriptions of any cancer-related inpatient hospitalizations to date Previous cancer diagnosis Medications and any side effects experienced Changes in quality of life due to cancer/cancer treatment (including pain) Other significant medical problems Health & Behavior Assessment Components

16 Mood Screening Sadness/Depressed mood Anhedonia Crying spells Fatigue/loss of energy Appetite disturbance Sleep disturbance Psychomotor agitation or retardation Irritability Feelings of guilt/worthlessness/hopelessness/helple ssness Changes in libido Suicidal ideation Homicidal ideation Anxiety Mania/hypomania

17 Behavioral Screening Current/past psychopharmacologic medications Current/recent/past alcohol use Current/recent/past tobacco use Current/recent/past illicit substance use Cognitive Screening Getting lost in familiar places Misplacing belongings Inability to concentrate Short- or long-term memory impairments Confusion or disorientation

18 Psychosis Screening Hallucinations Delusions Dissociation Depersonalization Unusual beliefs Stress and Coping Screening Other current stressors History of trauma Main problem- and/or emotion- focused coping mechanisms used, including their efficacy

19 Brief Psychosocial History Age Date and location of birth Location of current residence Education Marital status Number of children Brief description of quality of family (including spouse/partner) relationships Employment status, including job satisfaction if employed Hobbies, activities that bring enjoyment Plans for the future Self-Report Testing Patient Health Questionnaire - 9 (PHQ- 9)

20 Past/current depressive symptoms Current hopelessness Past/recent/current suicidal ideation, intent, plan, gestures, or behavior Significant current, exacerbating stressors (including relational) Past/current anxious symptoms Trauma history Significant previous stressors and effectiveness of skills used to cope with these Past/current alcohol, tobacco, and illicit substance use Patient's strengths Nature of social support network Cancer-related quality of life (e.g., pain, fatigue, nausea/vomiting, anorexia/cachexia, sleep, sexual functioning) Cancer-related concerns (e.g., end of life concerns, body image concerns, fears of recurrence, thoughts about death, spiritual/religious crisis, sexuality/intimacy concerns, reproductive health/fertility concerns) Mental Health Assessment

21 Current Distress Screening & Management at UFHCC Routine Distress Screening –Multidisciplinary GI Oncology Clinic (2009 – Present) –Inpatient Medical Oncology (January 2015 - Present) –Outpatient Medical Oncology (June 2015) –Outpatient Radiation Oncology (August 2015)

22 Registration staff provides distress screening form to patient Patient completes form in waiting room Medical Assistant (MA) gathers form and enters data into “Vitals” in EHR If Distress Thermometer > 4 or PHQ-2 > 3, MA alerts HCP HCP discusses results with patient and offers appropriate referrals If patient desires, referrals to Oncology Social Work and/or Psycho-Oncology Service provided Oncology Social Work and Psycho-Oncology Service document receipt of referral and any follow- up care in EHR Offered at every clinic visit but no more than once a week. Patient may decline to participate.

23 …Current Distress Screening & Management at UFHCC Routine Psychological Evaluation –Hematopoietic Stem Cell Transplant patients –Prophylactic Mastectomy patients Referral-Based Psychological Evaluation (2003 – Present) –Evaluation and treatment of mental and behavioral health issues in the context of cancer survivorship

24 Range of Mental Health Issues Treated at UFHCC Adjustment D/O Health Behaviors Nonadherence Relational Issues Anxiety D/O Depressive D/O Posttraumatic Stress D/O Delirium Personality D/O Psychosis Substance D/O Suicidality

25 Integration of Distress Screening Practice and Research “Treatment studies reported modest improvement in distress symptoms, but only a single eligible study was found on the effects of screening cancer patients for distress, and distress did not improve in screened patients versus those receiving usual care. Because of the lack of evidence of beneficial effects of screening cancer patients for distress, it is premature to recommend or mandate implementation of routine screening.”

26 “Screening is resource intensive, and questions can be raised as to what alternative purposes the resources consumed by screening could be put…apply the resources that would otherwise go to screening instead to facilitating completion of referrals for the minority of patients who want services, particularly those who are having low income or otherwise disadvanged…screening for distress should not be implemented without demonstration that it actually improves patient outcomes over routine care and that benefits exceed costs at patient and system levels.”

27 Thank you!

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