During the past several years, numerous studies have shown that among patients with cancer who suffer from emotional distress, the right help from a psychosocial health professional can improve psychological health and quality of life, and lead to lower medical costs. In response to these findings, the American College of Surgeons’ (ACS) Commission on Cancer announced in 2012 that, starting in 2015, cancer centers would now have to screen patients for emotional distress in order to receive accreditation. The new ACS standard also stated that in instances when screening uncovers emotional distress, a referral must be made to a trained social worker, psychologist, or other psychosocial health provider. (In 2014, ASCO issued the guidelines, “Screening, Assessment, and Care of Anxiety and Depressive Symptoms in Adults with Cancer”).

Now, A study in the Journal of Clinical Oncology (JCO), “Psychosocial Distress Screening Implementation in Cancer Care: An Analysis of Adherence, Responsiveness, and Acceptability,” published online, ahead of print, February 23, set out to answer two questions: What are the rates of adherence to these new distress-screening and referral requirements at two tertiary cancer care centers and, do clinicians find the screening useful?

To answer the study’s questions, first author Brad Zebrack, PhD, MSW, MPH, and his coauthors reviewed 583 medical records recorded over a 12-week period at the two centers—a National Cancer Institute-designated Comprehensive Cancer Program (NCIP), which included pancreatic and colorectal clinics; and an Academic Comprehensive Cancer Program (ACAD), which included a lung, head-neck, gastro-intestinal, genito-urinary, and hematology clinic.

The study found that at the ACAD, 63.8-73.3% of patient-records across the five clinics showed documentation of screening. At NCIP, rates of documentation differed by clinic type—at the pancreatic clinic, 67.1% of records showed evidence of distress screening, while at the colorectal clinic, 47.7% of records showed the same evidence. Interestingly, 64.7%.of female patients’ records showed evidence of screening, while among male patients, the rate was 57.2%.

As evidence that screening was carried out, the reviewers looked for a scanned copy of the National Comprehensive Cancer Network Distress Thermometer (DT) and Problem/Symptom Checklist. As evidence that a referral was made when a DT score indicated clinically significant emotional distress, reviewers looked for any kind of referral-documentation in the medical records. In addition, the study sent all providers questionnaires asking them to assess the usefulness of the distress-screening and referral protocol.

Emotional distress as a “vital sign”

In describing the goals of the study, Dr. Zebrack said, “Distress can be conceptualized as a vital sign, signifying psychological, social, or practical challenges that cancer patients are struggling with. We wanted to see how cancer centers are doing in terms of the implementation of distress screening, and also, we wanted to use the paper as a model for the way that clinicians can actually measure compliance with the standard.”

When emotional distress is found, are referrals made?

In terms of referrals, the study found that among patients who scored a 4 or above on the DT (the clinical cut-point indicating clinically significant emotional distress), the rate of referral was 50.1% at NCIP and 63.5% at ACAD. At NCIP, patients with “high” scores (8-10) were significantly more likely than patients with moderate scores (4-7) to receive a referral.

In explaining why the NCIP colorectal clinic had lower rates of screening and referrals, the authors of the JCO article cite research indicating that the more experience a practice has with a mental health protocol, the more likely they are to consistently implement it—and the protocol was relatively new at the colorectal clinic. This factor might also explain another one of the study’s findings:  While 89.5% and 87.5% of health professionals at ACAD and NCIP pancreatic clinic, respectively, agreed that “distress screening protocol helps elicit patient concerns,” 44% of providers in the NCIP colorectal clinic agreed with the statement.

Clinicians may overestimate psychosocial services

The study found that while nearly 70% of the clinicians found the screening useful in terms of patients receiving needed support, 40-60% of distressed patients, depending on the clinic, did not receive referrals to a psychosocial care provider. Commenting on these findings Dr. Zebrack said, “This data points to a possible disconnect in that clinicians may be overestimating the extent to which their patients are actually getting their needs met. Addressing this disconnect may require more patient communication and integration of oncology social workers across spheres of care.”

Brad Zebrack, PhD, MSW, MPH, is an Associate Professor at the University of Michigan School of Social Work.

Abstract of the original JCO article.

PDF of the original JCO article.

Zebrack B, Kayser K, Sundstrom L, et al. Psychosocial distress screening implementation in cancer care: an analysis of adherence, responsiveness, and acceptability. J Clin Oncol. Epub 2015 Feb 23.

The Exclusive Coverage series on ASCO.org highlights selected research from JCO and JOP with additional perspective provided by the lead or corresponding author.

@ 2014 American Society of Clinical Oncology