The Evolution of Distress Screening in Oncology
In oncology, the focus has traditionally been on the physical manifestations of disease and the rigors of treatment. however, the psychological burden of a cancer diagnosis is often just as meaningful, influencing everything from treatment adherence to overall survival. Recognizing this, the field has undergone a transformative shift over the last 3 decades to elevate psychosocial health to a clinical priority.
In this discussion, Daniel C. McFarland, DO, and Michelle Riba, MD, explored the fundamentals of distress screening. Riba, a key contributor to the development of the NCCN distress guidelines, details the transition from fragmented psychiatric research to a standardized mandate that treats distress as the “fifth vital sign”.
They also touched on integrated care models that include moving beyond parallel screening toward a collaborative care model that utilizes integrated medical records and multidisciplinary teams to treat the patient in their totality.
As cancer centers shift toward a population-based public health approach, this conversation highlights the necessity of destigmatizing mental health and ensuring that psychosocial care is an integral, measured component of every oncology appointment.
McFarland: What are the fundamentals of distress screening, and how did it come to be?
Riba: Jimmie Holland, MD, was the chair of psychiatry at Memorial Sloan Kettering [Cancer Center], and recognized that, first of all, the literature and the research that had been done prior to, let’s say, 1998 was not adequate to address some of the issues that we needed to know about, like, what was the impact of not addressing distress screening in the cancer clinic? What was the prevalence of various psychiatric conditions and patients coming to oncology care, and the differences between coming to a pancreatic cancer clinic vs a breast cancer clinic vs a leukemia clinic? The research was not robust in the 1980s and 1990s regarding this.as we began to understand the importance of recognizing mental health issues in the cancer clinic, cancer centers were growing, and the NCCN was being funded by the National Cancer Institute to look at cancers differently, using large data sets. Dr. Holland was working with a large committee, I was lucky
Integrating Mental Health Screening into Oncology Care
McFarland: The transition of care for oncology patients frequently enough involves moving information-and the associated emotional burden-between systems, including emergency departments. primary care clinics increasingly utilize depression screenings and the Columbia Suicide Severity Rating Scale. These tools provide valuable data points for oncology teams. patients are generally accustomed to completing these screens a day or two before their oncology appointments.It is indeed crucial for all members of the care team-those administering X-rays or chemotherapy, such as-to review these screening results in the patient’s record.Standardizing these scales ensures consistent data collection and comparison.
Riba: Ideally, oncologists should be aware of their patients’ levels of distress. While we monitor for distress, anxiety, and other factors, research consistently demonstrates that depression is most strongly linked to negative outcomes, including medication non-adherence and reduced survival rates. this raises the question of whether we should adopt a routine depression screening approach in oncology,similar to primary care.
Many clinics are already implementing this approach. At our cancer center,individual clinics have the versatility to choose the screening tools they prefer. This is due to the varied nature of patient visits across different clinics-bone marrow transplant, survivorship, breast cancer, and others. Some clinics have adopted the PHQ-9 for depression screening, while others focus on distress assessment. Emerging research highlights the high prevalence of depression, anxiety, and substance use in high-risk groups, such as those with head and neck cancer, and explores the potential benefits of early antidepressant intervention.
Anxiety might potentially be as significant a concern as, or even more so than, depression. It frequently leads patients to discontinue medications like aromatase inhibitors or maintenance therapies. Thus,assessing and addressing anxiety and substance use are also essential components of comprehensive oncology care. Many patients hesitate to disclose substance use, highlighting the need for a supportive and non-judgmental approach.