Distress in Oncology: Not Just a Psychosocial Phenomenon

Distress screening has been increasingly incorporated into oncology care since the American College of Surgeons Commission on Cancer made it an accreditation standard for cancer centers in the United States in 2015.1 The Commission on Cancer standard is written in such a manner as to allow a fair amount of leeway in how cancer centers implement distress screening. Thus, some cancer centers use a psychological measure to assess for distress, such as one of the versions of the Patient Health Questionnaire. In addition, many cancer centers use social workers or other psychosocial providers to triage patients who screen positive for distress.2 We believe these practices inappropriately restrict the focus and intent of distress screening. To most effectively screen and address distress in oncology, screening tools that consider multiple components of distress (including physical symptoms) should be used to broadly assess the patient’s experience of distress, with triage completed by the medical team. The National Comprehensive Cancer Network (NCCN) Guidelines for Distress Management define distress as “a multifactorial, unpleasant experience of a psychological (ie, cognitive, behavioral, emotional), social, spiritual, and/or physical nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment.”2(pDIS-2) This is an appropriately broad definition of distress, one that includes distress related to symptom burden associated with cancer and with cancer treatment. The NCCN developed the Distress Thermometer and Problem List (DT/PL) as a tool for distress screening.2 The DT/PL includes five problem areas (practical, family, emotional, physical, and spiritual) with a total of 38 specific problems listed (of which 22 are in the physical realm). Previous research has documented the prevalence of symptom burden in a cancer population and the association of symptom burden with distress.3,4 Distress is problematic in cancer care through its association with poorer health outcomes, increased morbidity and mortality, increased health care costs, treatment noncompliance (especially with oral medications), and longer hospital stays.5-7 Thus, recognizing and reducing distress is an important component of cancer care. In a study of the results of 16,537 distress screens at a large comprehensive cancer center, 1,236 screens (7.5%) were positive using the NCCN DT/PL and a cutoff score of six.8 The most common problem area endorsed by those patients with a positive screen was physical (49%), followed by emotional (42%), and