Transcript Deidre Pereira - Markey Cancer Center

Distress Screening &
Management in Cancer
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
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
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 onsite 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
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
Distress as the 6th 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
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
Distress Screening & Management:
A Stepped Care Model
Mental Health
Assessment
& Intervention
Health & Behavior
Assessment &
Intervention
Distress Screening
Distress Screening Participants
Oncology
Nurse
Navigators
Psychiatry
PsychoOncology
Service
PatientCentered
Oncology
Care
Palliative
Care &
Symptom
Management
Oncology
Social Work
Integrative
Medicine
Health & Behavior Assessment/Intervention
Participants
Oncology
Nurse
Navigators
PsychoOncology
Service
PatientCentered
Oncology
Care
Palliative
Care &
Symptom
Management
Oncology
Social Work
Integrative
Medicine
Mental Health Assessment/Intervention
Participants
Oncology
Social
Work
Psychiatry
PatientCentered
Oncology
Care
PsychoOncology
Service
Integrative
Medicine
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.
Health & Behavior Assessment
Components
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Cancer
History
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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
Mood
Screening
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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
Behavioral
Screening
Cognitive
Screening
• Current/past
psychopharmacologic
medications
• Current/recent/past alcohol use
• Current/recent/past tobacco use
• Current/recent/past illicit
substance use
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Getting lost in familiar places
Misplacing belongings
Inability to concentrate
Short- or long-term memory
impairments
• Confusion or disorientation
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Hallucinations
Delusions
Dissociation
Depersonalization
Unusual beliefs
• Other current stressors
• History of trauma
• Main problem- and/or emotionfocused coping mechanisms
used, including their efficacy
Psychosis
Screening
Stress
and
Coping
Screening
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Brief
Psychosocial
History
• Patient Health Questionnaire - 9 (PHQ9)
Self-Report
Testing
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
Mental Health
Assessment
• 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)
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)
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 patient desires,
referrals to Oncology
Social Work and/or
Psycho-Oncology
Service provided
HCP discusses
results with
patient and
offers
appropriate
referrals
If Distress
Thermometer >
4 or PHQ-2 >
3, MA alerts
HCP
Oncology Social Work
and Psycho-Oncology
Service document receipt
of referral and any followup care in EHR
Offered at every clinic visit but no more
than once a week. Patient may decline to
participate.
…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
Range of Mental Health Issues
Treated at UFHCC
Delirium
Personality D/O
Adjustment D/O
Health Behaviors
Nonadherence
Relational Issues
Anxiety D/O
Psychosis
Depressive D/O
Substance D/O
Posttraumatic
Suicidality
Stress D/O
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.”
“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.”
Thank you!