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Use of the Distress Thermometer in Clinical Practice

Use of the Distress Thermometer in Clinical Practice Houston, Texas Distress is experienced by many cancer patients, adversely affecting Author’s disclosures of conflicts of interest are quality of life and cancer care. Although it is often manageable, it re- found at the end of this article. mains woefully underidentified and underreported. Distress can occur Correspondence to: Kristin K. Ownby, PhD, RN, anytime during the cancer experience and is associated with depres- ACHPN, AOCN®, ANP-BC, UT Health Cizik School of Nursing, 6901 Bertner Street, Houston, TX 77030. sion, anxiety, missed appointments, and adverse outcomes. In 1999, E-mail: kristin.k.ownby@uth.tmc.edu the National Comprehensive Cancer Network (NCCN), recommended https://doi.org/10.6004/jadpro.2019.10.2.7 routine screening for distress in all cancer patients. The Distress Ther- mometer (DT) was developed as a simple tool to effectively screen for © 2019 Harborside™ symptoms of distress. The instrument is a self-reported tool using a 0-to-10 rating scale. Additionally, the patient is prompted to identify sources of distress using a Problem List. The DT has demonstrated ad- equate reliability and has been translated into numerous languages. The tool is easy to administer and empowers the clinician to facilitate appropriate psychosocial support and referrals. or many patients, the can- may interfere with the ability to cope cer care journey is fraught effectively with cancer, its physi- with distress, beginning cal symptoms, and its treatment” with initial diagnosis, (NCCN, 2019). According to the through the treatment decision-mak- NCCN Guidelines (2019), “Distress ing process and cancer treatment, extends along a continuum, rang- and into survivorship. Uncertainty ing from common normal feelings of about the future is commonly pres- vulnerability, sadness, and fears, to ent throughout the cancer trajectory problems that can become disabling, (Bultz & Holland, 2006). The Na- such as depression, anxiety, panic, tional Comprehensive Cancer Net- social isolation, and existential and work Clinical Practice Guidelines spiritual crisis.” Guidelines) for in Oncology (NCCN Whereas 7% of the general popu- distress management define distress lation may experience distress at any as “multifactorial unpleasant experi- given time, 25% to 60% of cancer pa- ence of a psychological (i.e., cogni- tients report distress when they are tive, behavioral, emotional), social, assessed (Zabora, BrintzenhofeSzoc, J Adv Pract Oncol 2019;10(2):175–179 spiritual, and/or physical nature that Curbow, Hooker, & Piantadosi, 2001). AdvancedPractitioner.com Vol 10 No 2 Mar 2019 175   This article is distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. TOOLS & TECHNOLOGY OWNBY However, patient distress is an often overlooked 2015, the Commission on Cancer requires institu- but important constellation associated with physi- tions to screen for distress as part of their accredi- cal and/or psychological symptoms. Up to 80% of tation process. Institutions are required to develop patients with cancer attribute their distress to fi- a comprehensive plan that addresses six conditions: nancial stressors (Khera, Holland, & Griffin, 2017; (1) inclusion of a psychosocial representative on Yabroff et al., 2016); 58% have symptoms associ- the cancer committee; (2) determination of when ated with depression, and 34% report symptoms distress screening occurs; (3) a method of screen- of anxiety (Yabroff et al., 2016). ing; (4) selection of a well-validated screening tool; Research indicates patients who experience (5) protocols for further assessment and referrals; high levels of distress are less adherent to treat- and (6) documentation of the process and program ment plans, are more dissatisfied with overall evaluation (Buxton et al., 2014). One commonly used care, experience poorer quality of life, and have screening tool is the NCCN Distress Thermometer poorer survival rates (Faller, Bülzebruck, Drings, (DT) and Problem List for patients (Figure 1). & Lang, 1999; Hamer, Chida, & Molloy, 2009; Hol- NCCN DISTRESS THERMOMETER land & Alici, 2010; Von Essen, Larsson, Öberg, & AND PROBLEM LIST Sjödén, 2002). Untreated distress can result in The NCCN introduced the DT as a screening tool higher health-care costs and prolonged rehabili- tation (Abrahamson, 2010; Mitchell, Vahabzadeh, to identify sources of distress. The NCCN recom- & Magruder, 2011). Recognizing the impact of mends screening patients at the initial visit soon distress on the well-being of cancer patients, the after diagnosis and at each visit, although the NCCN Guidelines recommend routine screening screening schedule may be revised as clinically in- for distress and identifying its sources. dicated (NCCN, 2019). Important time points may All cancer patients are at risk for distress; how- include changes in disease activity such as remis- ever, research studies identified specific risk fac - sion, recurrence, or progression, or upon refer- tors that increase the prevalence of distress among ral to palliative care (Carlson, Waller, & Mitchell, certain cancer groups. Studies have shown gender 2012; Pirl et al., 2014). differences, with women experiencing higher lev - The NCCN DT is a single-item tool using a 0 els of distress (Jacobsen et al., 2005; Shim, Shin, (no distress) to 10 (extreme distress)–point Likert Jeon, & Hahm, 2008). Younger patients experi- scale resembling a thermometer. The patient rates ence higher levels of distress (Hegel et al., 2008). his/her level of distress over the past week. The Married patients are less likely to experience dis- established cutoff score for further screening is a tress than single patients, and patients diagnosed 4 (Donovan, Grassi, McGinty, & Jacobsen, 2014; with specific cancers of the breast, head and neck, Jacobsen et al., 2005; NCCN, 2019). A recent study colon, lung, brain, or pancreas experience greater suggests a lower cutoff score of 3 when screening distress (Carlson et al., 2004; Hurria et al., 2009; during the first month of a new cancer diagnosis Zabora et al., 2001). A decline in physical, emo- (Cutillo at al., 2017). Studies have found that cutoff tional, and/or cognitive functioning has been as- scores for specific patient populations vary from sociated with patient-reported distress as well the established cutoff, including childhood can- (Keir, Calhoun-Eagan, Swartz, Saleh, & Friedman, cer survivors (cutoff score of 3; van der Geest, van 2008). Stressors may include family relationship Dorp, Pluijm, & van den Heuvel-Eibrink, 2018), problems and feeling that the information provid- cancer patients receiving palliative home-care ed about their cancer diagnosis and treatment was services (cutoff score of 6; Ohnhäuser, Wüller, inadequate (Graves et al., 2007). Foldenauer, & Pastrana, 2018), and women recent- All patients with cancer must be viewed as be- ly diagnosed with breast cancer (cutoff score of 7; ing at risk for distress. Numerous cancer-related Ploos van Amstel et al., 2017). organizations, including the NCCN and the Ameri- The DT has been translated into 26 languages, can College of Surgeons Commission on Cancer, including Spanish, and 18 of the translated ver- advocate for screening for distress (American Col- sions have demonstrated adequate validity in vali- lege of Surgeons, 2012; NCCN, 2019). Beginning in dation studies (Donovan et al., 2014). One advan- J Adv Pract Oncol AdvancedPractitioner.com 176 DISTRESS THERMOMETER TOOLS & TECHNOLOGY DISTRESS THERMOMETER PROBLEM LIST Instructions: Please circle the Please indicate if any of the following has been a problem for you in the past number (0–10) that best describes week including today. Be sure to check YES or NO for each. how much distress you have been YES NO Physical Problems YES NO Practical Problems experiencing in the past week ❏ ❏ Child care ❏ ❏ Appearance including today. ❏ ❏ Housing ❏ ❏ Bathing/dressing ❏ ❏ Breathing ❏ ❏ Insurance/financial ❏ ❏ Transportation ❏ ❏ Changes in urination ❏ ❏ Work/school ❏ ❏ Constipation Extreme distress ❏ ❏ Treatment decisions ❏ ❏ Diarrhea ❏ ❏ Eating Family Problems ❏ ❏ Fatigue ❏ ❏ Dealing with children ❏ ❏ Feeling swollen ❏ ❏ Dealing with partner ❏ ❏ Fevers ❏ ❏ Ability to have children ❏ ❏ Getting around 6 ❏ ❏ Family health issues ❏ ❏ Indigestion Emotional Problems ❏ ❏ Memory/concentration ❏ ❏ Depression 4 ❏ ❏ Mouth sores ❏ ❏ Fears ❏ ❏ Nausea ❏ ❏ Nervousness ❏ ❏ Nose dry/congested ❏ ❏ Sadness ❏ ❏ Pain ❏ ❏ Worry ❏ ❏ Sexual ❏ ❏ Loss of interest in usual activities 0 ❏ ❏ Skin dry/itchy No distress ❏ ❏ Sleep ❏ ❏ Spiritual/Religious Concerns ❏ ❏ Substance use ❏ ❏ Tingling in hands/feet Other Problems: Figure 1. NCCN screening tools for measuring distress. Adapted with permission from the 2019 NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Distress Management V.2.2019. © 2019 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and illustra- tions herein may not be reproduced in any form for any purpose without the express written permission of NCCN. To view the most recent and complete version of the NCCN Guidelines, go online to NCCN. org. The NCCN Guidelines are a work in progress that may be refined as often as new significant data becomes available. tage of the DT is its brevity: studies have shown on the DT select more items from the NCCN Prob- that nurses need an average of only 2 minutes and lem List (VanHoose et al., 2015). Patients who re- 20 seconds to help a patient complete the tool port distress frequently select problems from the (Musiello et al., 2017). Overall, it is easy to admin- emotional domain, and worry is the item most ister, and patients find the tool easy to use. Admin- frequently selected. Other items associated with istration and interpretation of the DT are provid- risk for distress include problems from the physi- ed by a cancer provider. cal domain, such as sleep and getting around, and The NCCN Problem List for patients is a 39- problems from the emotional domain, such as ner- item supplemental list of potential sources of dis- vousness (Clover et al., 2016). A common source tress (NCCN, 2019). The NCCN recommends in- of distress later on in the cancer care trajectory is corporating the Problem List for patients as part of financial strain (VanHoose et al., 2015). the assessment to assist the provider in identifying Once screening has been completed and the sources of patient distress. The NCCN Problem results have been interpreted, the provider deter- List provides a comprehensive list of categories, mines whether the patient needs to be referred including practical, family, physical, and emotional for psychosocial support. Referrals can include problems, as well as spiritual/religious concerns. psychologists, chaplains, and social workers. The Not surprisingly, patients who score a 4 or higher cancer care provider may use community-based AdvancedPractitioner.com Vol 10 No 2 Mar 2019 177   TOOLS & TECHNOLOGY OWNBY resources as well as resources provided by the in- claims any responsibility for their application or stitution based on the patient’s preference. use in any way. BARRIERS TO SCREENING References Abrahamson, K. (2010). Dealing with cancer-related distress. Barriers to screening for distress do exist. For ex- American Journal of Nursing, 110(4), 67–69. https://doi. ample, patients may have trouble understanding org/10.1097/01.NAJ.0000370162.07674.f6 what the word “distress” means (Mitchell, 2013). American College of Surgeons. (2012). Cancer Program Stan- Patient barriers to screening include language and dards 2012. Version 1.1: Ensuring patient-centered care. Chicago, IL: American College of Surgeons. Retrieved cultural differences as well as literacy (Lo, Ian- from https://www.facs.org/quality-programs/cancer/ niello, Sharma, Sarnacki, & Finn, 2016). Another coc/standards barrier occurs when referring distressed patients Bultz, B. D., & Holland, J. C. (2006). Emotional distress in patients with cancer: The sixth vital sign. Community for psychosocial services. Studies have also shown Oncology, 3(5), 311–314. http://dx.doi.org/10.1016%2 that patients who score high on the DT may not FS1548-5315(11)70702-1 necessarily want help. Conversely, studies have Buxton, D., Lazenby, M., Daugherty, A., Kennedy, V., Wagner, L., Fann, J. R., & Pirl, W. F. (2014). Distress screening for shown that when patients were screened and did oncology patients: Practical steps for developing and not receive any referrals or assistance, their lev- implementing a comprehensive distress screening pro- els of distress increased (Mitchell, 2013). Institu- gram. Retrieved from www.accc-cancer.org. tional barriers identified include insufficient time Carlson, L. E., Angen, M., Cullum, J., Goodey, E., Koopmans, J., Lamont, L.,…Bultz, B. D. (2004). High levels of un- and training, lack of privacy for screening, poor treated distress and fatigue in cancer patients. Brit- documentation of results, discomfort discussing ish Journal of Cancer, 90(12), 2297–2304. https://doi. results, and a lack of resources for patient referrals org/10.1038/sj.bjc.6601887 Carlson, L. E., Waller, A., & Mitchell, A. J. (2012). Screen- (Chiang, Amport, Corjulo, Harvey, & McCorkle, ing for distress and unmet needs in patients with can- 2015; Girgis, Smith, & Durcinoska, 2018). cer: Review and recommendations. Journal of Clinical Oncology, 30(11), 1160–1177. https://doi.org/10.1200/ CONCLUSION JCO.2011.39.5509 Chiang, A. C., Amport, S. B., Corjulo, D., Harvey, K. L., & Distress is considered the sixth vital sign in oncol- McCorkle, R. (2015). Incorporating patient-reported ogy care. Numerous research studies have demon- outcomes to improve emotional distress screening and strated the prevalence of distress and the signifi- assessment in an ambulatory oncology clinic. Jour- nal of Oncology Practice, 11(3), 219–222. https://doi. cant impact it has on the patient’s quality of life org/10.1200/JOP.2015.003954 and treatment success. Research continues to de- Clover, K., Oldmeadow, C., Nelson, L., Rogers, K., Mitchell, termine the validity of the DT and Problem List A. J., & Carter, G. (2016). Which items on the distress in various cancer populations based on ethnicity, thermometer problem list are the most distressing? Sup- portive Care in Cancer, 24(11), 4549–4557. https://doi. cancer type, language, and age. Research is need- org/10.1007/s00520-016-3294-z ed to validate interventions used to manage dis- Cutillo, A., O’Hea, E., Person, S. D., Lessard, D., Harralson, T. tress. Because the NCCN DT is a tool with well- L., & Boudreaux, E. (2017). The distress thermometer: Cutoff points and clinical utility. Oncology Nursing Fo - established validity and brevity that is available rum, 44(3), A1–A9. https://doi.org/10.1188/17.ONF.329- in multiple languages and easy for the provider to interpret, the use of the instrument is being stud- Donovan, K. A., Grassi, L., McGinty, H. L., & Jacobsen, P. B. (2014). Validation of the distress thermometer world- ied in other patient populations, including those wide: State of the science. Psycho-Oncology, 23(3), 241– with chronic obstructive pulmonary disease and 250. https://doi.org/10.1002/pon.3430 acquired immune deficiency syndrome. Faller, H., Bülzebruck, H., Drings, P., & Lang, H. (1999). Coping, distress, and survival among patients with lung cancer. Archives of General Psychiatry, 56(8), 756–762. Retrieved Disclosure from https://www.ncbi.nlm.nih.gov/pubmed/10435611 The author has no conflicts of interest to disclose. Girgis, A., Smith, A. B., & Durcinoska, I. (2018). Screening for distress in survivorship. Current Opinion in Supportive and Palliative Care, 12(1), 86–91. https://doi.org/10.1097/ Disclaimer SPC.0000000000000328 The National Comprehensive Cancer Network Graves, K. D., Arnold, S. M., Love, C. L., Kirsh, K. L., Moore, makes no warranties of any kind whatsoever re- P. G., & Passik, S. D. (2007). Distress screening in a mul- garding their content, use or application and dis- tidisciplinary lung cancer clinic: Prevalence and predic- J Adv Pract Oncol AdvancedPractitioner.com 178 DISTRESS THERMOMETER TOOLS & TECHNOLOGY tors of clinically significant distress. Lung Cancer, 55(2), tional Comprehensive Cancer Network, Inc. 2019. All 215–224. https://doi.org/10.1016/j.lungcan.2006.10.001 rights reserved. To view the most recent and complete Hamer, M., Chida, Y., & Molloy, G. J. (2009). Psychological version of the guideline, go online to NCCN.org. Re- distress and cancer mortality. Journal of Psychosomatic trieved from http://www.nccn.org/professionals/physi- Research, 66(3), 255–258. https://doi.org/10.106/j.jpsy- cian_gls/distress.pdf. chores.2008.11.002 Ohnhäuser, S., Wüller, J., Foldenauer, A. C., & Pastrana, T. Hegel, M. T., Collins, E. D., Kearing, S., Gillock, K. L., Moore, (2018). Changes in distress measured by the distress C. P., & Ahles, T. A. (2008). Sensitivity and specificity of thermometer as reported by patients in home palliative the Distress Thermometer for depression in newly di- care in Germany. Journal of Palliative Care, 33(1), 39–46. agnosed breast cancer patients. Psychooncology, 17(6), https://doi.org/10.1017/S1478951516000699 556–560. https://doi.org/10.1002/pon.1289 Pirl, W. F., Fann, J. R., Greer, J. A., Braun, I., Deshields, T., & Holland, J. C., & Alici, Y. (2010). Management of distress in Fulcher, C.,…Bardwell, W. A. (2014). Recommendations cancer patients. Journal of Supportive Oncology, 8(1), 4–12. for the implementation of distress screening programs in Hurria, A., Li, D., Hansen, K., Patil, S., Gupta, R., Nelson, C.,… cancer centers: Report from the American Psychosocial Kelly, E. (2009). Distress in older patients with cancer. Oncology Society (APOS), Association of Oncology So- Journal of Clinical Oncology, 27(26), 4346–4351. https:// cial Work (AOSW), and Oncology Nursing Society (ONS) doi.org/10.1200/JCO.2008.19.9463 joint task force. Cancer, 120(19), 2946–2954. https://doi. Jacobsen, P. B., Donovan, K. A., Trask, P. C., Fleishman, S. B., org/10.1002/cncr.28750 Zabora, J., Baker, F., & Holland, J. C. (2005). Screening Ploos van Amstel, F., Tol, J., Sessink, K., van der Graaf, W. for psychologic distress in ambulatory cancer patients. T., Prins, J., & Ottevanger, P. (2017). A specific distress Cancer, 103(7), 1494–1502. https://doi.org/10.1002/ cutoff score shortly after breast cancer diagnosis. Can - cncr.20940 cer Nursing, 40(3), E35–E40. https://doi.org/10.1097/ Keir, S. T., Calhoun-Eagan, R. D., Swartz, J. J., Saleh, O. A., & NCC.0000000000000380 Friedman, H. S. (2008). Screening for distress in patients Shim, E.-J., Shin, Y.-W., Jeon, H. J., & Hahm, B.-J. (2008). with brain cancer using the NCCN’s rapid screening Distress and its correlates in Korean cancer patients: measure. Psycho-Oncology, 17(6), 621–625. https://doi. Pilot use of the distress thermometer and the prob- org/10.1002/pon.1271 lem list. Psycho-Oncology, 17(6), 548–555. https://doi. Khera, N., Holland, J. C., & Griffin, J. M. (2017). Setting the org/10.1002/pon.1275 stage for universal financial distress screening in rou- van der Geest, I. M. M., van Dorp, W., Pluijm, S. M. F., & van tine cancer care. Cancer, 123(21), 4092–4096. https://doi. den Heuvel-Eibrink, M. M. (2018). The distress ther- org/10.1002/cncr.30940 mometer provides a simple screening tool for selecting Lo, S. B., Ianniello, L., Sharma, M., Sarnacki, D., & Finn, K. distressed childhood cancer survivors. Acta Paediatrica, T. (2016). Experience implementing distress screening 107(5), 871–874. https://doi.org/10.1111/apa.14251 using the National Comprehensive Cancer Network dis- VanHoose, L., Black, L. L., Doty, K., Sabata, D., Twumasi-An- tress thermometer at an urban safety-net hospital. Psy- krah, P., Taylor, S., & Johnson, R. (2015). An analysis of cho-Oncology, 25(9), 1113–1115. https://doi.org/10.1002/ the distress thermometer problem list and distress in pa- pon.4214 tients with cancer. Supportive Care Cancer, 23(5), 1225– Mitchell, A. (2013). Screening for cancer-related distress: 1232. https://doi.org/10.1007/s00520-014-2471-1 When is implementation successful and when is it un- Von Essen, L., Larsson, G., Öberg, K., & Sjödén, P. O. (2002). successful? Acta Oncologia, 52(2), 216–224. https://doi.or ‘Satisfaction with care’: Associations with health-related g/10.3109/0284186X.2012.745949 quality of life and psychosocial function among Swed- Mitchell, A. J., Vahabzadeh, A., & Magruder, K. (2011). Screen- ish patients with endocrine gastrointestinal tumors. Eu- ing for distress and depression in cancer settings: 10 les- ropean Journal of Cancer Care, 11(2), 91–99. https://doi. sons from 40 years of primary-care research. Psycho-On- org/10.1046/j.1365-2354.2002.00293.x cology, 20(6), 160–174. https://doi.org/10.1002/pon.1943 Yabroff, K. R., Dowling, E. C., Guy, G. P., Jr., Banegas, M. P., Musiello, T., Dixon, G., O’Connor, M., Cook, D., Miller, L., Pet- Davidoff, A., Han, X.,…Ekwueme, D. (2016). Financial terson, A.,…& Johnson, C. (2017). A pilot study of rou- hardship associated with cancer in the United States: tine screening for distress by a nurse and psychologist Findings from a population-based sample of adult cancer in an outpatient haematological oncology clinic. Applied survivors. Journal of Clinical Oncology, 34(3), 259–267. Nursing Research, 33, 15–18. https://doi.org/10.1016/j. https://doi.org/10.1200/JCO.2015.62.0468 apnr.2016.09.005 Zabora, J., Brintzenhofe Szoc, K., Curbow, B., Hooker, C., & Pi- National Comprehensive Cancer Network. (2019). NCCN antadosi, S. (2001). The prevalence of psychological dis- Clinical Practice Guidelines in Oncology: Distress man- agement. v2.2019. Referenced with permission from the tress by cancer site. Psycho-Oncology, 10(1), 19–28. https:// NCCN Clinical Practice Guidelines in Oncology (NCCN doi.org/ 10.1002/ 1099-1611(200101/02)10:<19::AID - Guidelines®) for Distress Management V.2.2019. © Na- PON501>3.0.CO;2-6 AdvancedPractitioner.com Vol 10 No 2 Mar 2019 179   http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of the Advanced Practitioner in Oncology Pubmed Central

Use of the Distress Thermometer in Clinical Practice

Journal of the Advanced Practitioner in Oncology , Volume 10 (2) – Mar 1, 2019

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Abstract

Houston, Texas Distress is experienced by many cancer patients, adversely affecting Author’s disclosures of conflicts of interest are quality of life and cancer care. Although it is often manageable, it re- found at the end of this article. mains woefully underidentified and underreported. Distress can occur Correspondence to: Kristin K. Ownby, PhD, RN, anytime during the cancer experience and is associated with depres- ACHPN, AOCN®, ANP-BC, UT Health Cizik School of Nursing, 6901 Bertner Street, Houston, TX 77030. sion, anxiety, missed appointments, and adverse outcomes. In 1999, E-mail: kristin.k.ownby@uth.tmc.edu the National Comprehensive Cancer Network (NCCN), recommended https://doi.org/10.6004/jadpro.2019.10.2.7 routine screening for distress in all cancer patients. The Distress Ther- mometer (DT) was developed as a simple tool to effectively screen for © 2019 Harborside™ symptoms of distress. The instrument is a self-reported tool using a 0-to-10 rating scale. Additionally, the patient is prompted to identify sources of distress using a Problem List. The DT has demonstrated ad- equate reliability and has been translated into numerous languages. The tool is easy to administer and empowers the clinician to facilitate appropriate psychosocial support and referrals. or many patients, the can- may interfere with the ability to cope cer care journey is fraught effectively with cancer, its physi- with distress, beginning cal symptoms, and its treatment” with initial diagnosis, (NCCN, 2019). According to the through the treatment decision-mak- NCCN Guidelines (2019), “Distress ing process and cancer treatment, extends along a continuum, rang- and into survivorship. Uncertainty ing from common normal feelings of about the future is commonly pres- vulnerability, sadness, and fears, to ent throughout the cancer trajectory problems that can become disabling, (Bultz & Holland, 2006). The Na- such as depression, anxiety, panic, tional Comprehensive Cancer Net- social isolation, and existential and work Clinical Practice Guidelines spiritual crisis.” Guidelines) for in Oncology (NCCN Whereas 7% of the general popu- distress management define distress lation may experience distress at any as “multifactorial unpleasant experi- given time, 25% to 60% of cancer pa- ence of a psychological (i.e., cogni- tients report distress when they are tive, behavioral, emotional), social, assessed (Zabora, BrintzenhofeSzoc, J Adv Pract Oncol 2019;10(2):175–179 spiritual, and/or physical nature that Curbow, Hooker, & Piantadosi, 2001). AdvancedPractitioner.com Vol 10 No 2 Mar 2019 175   This article is distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. TOOLS & TECHNOLOGY OWNBY However, patient distress is an often overlooked 2015, the Commission on Cancer requires institu- but important constellation associated with physi- tions to screen for distress as part of their accredi- cal and/or psychological symptoms. Up to 80% of tation process. Institutions are required to develop patients with cancer attribute their distress to fi- a comprehensive plan that addresses six conditions: nancial stressors (Khera, Holland, & Griffin, 2017; (1) inclusion of a psychosocial representative on Yabroff et al., 2016); 58% have symptoms associ- the cancer committee; (2) determination of when ated with depression, and 34% report symptoms distress screening occurs; (3) a method of screen- of anxiety (Yabroff et al., 2016). ing; (4) selection of a well-validated screening tool; Research indicates patients who experience (5) protocols for further assessment and referrals; high levels of distress are less adherent to treat- and (6) documentation of the process and program ment plans, are more dissatisfied with overall evaluation (Buxton et al., 2014). One commonly used care, experience poorer quality of life, and have screening tool is the NCCN Distress Thermometer poorer survival rates (Faller, Bülzebruck, Drings, (DT) and Problem List for patients (Figure 1). & Lang, 1999; Hamer, Chida, & Molloy, 2009; Hol- NCCN DISTRESS THERMOMETER land & Alici, 2010; Von Essen, Larsson, Öberg, & AND PROBLEM LIST Sjödén, 2002). Untreated distress can result in The NCCN introduced the DT as a screening tool higher health-care costs and prolonged rehabili- tation (Abrahamson, 2010; Mitchell, Vahabzadeh, to identify sources of distress. The NCCN recom- & Magruder, 2011). Recognizing the impact of mends screening patients at the initial visit soon distress on the well-being of cancer patients, the after diagnosis and at each visit, although the NCCN Guidelines recommend routine screening screening schedule may be revised as clinically in- for distress and identifying its sources. dicated (NCCN, 2019). Important time points may All cancer patients are at risk for distress; how- include changes in disease activity such as remis- ever, research studies identified specific risk fac - sion, recurrence, or progression, or upon refer- tors that increase the prevalence of distress among ral to palliative care (Carlson, Waller, & Mitchell, certain cancer groups. Studies have shown gender 2012; Pirl et al., 2014). differences, with women experiencing higher lev - The NCCN DT is a single-item tool using a 0 els of distress (Jacobsen et al., 2005; Shim, Shin, (no distress) to 10 (extreme distress)–point Likert Jeon, & Hahm, 2008). Younger patients experi- scale resembling a thermometer. The patient rates ence higher levels of distress (Hegel et al., 2008). his/her level of distress over the past week. The Married patients are less likely to experience dis- established cutoff score for further screening is a tress than single patients, and patients diagnosed 4 (Donovan, Grassi, McGinty, & Jacobsen, 2014; with specific cancers of the breast, head and neck, Jacobsen et al., 2005; NCCN, 2019). A recent study colon, lung, brain, or pancreas experience greater suggests a lower cutoff score of 3 when screening distress (Carlson et al., 2004; Hurria et al., 2009; during the first month of a new cancer diagnosis Zabora et al., 2001). A decline in physical, emo- (Cutillo at al., 2017). Studies have found that cutoff tional, and/or cognitive functioning has been as- scores for specific patient populations vary from sociated with patient-reported distress as well the established cutoff, including childhood can- (Keir, Calhoun-Eagan, Swartz, Saleh, & Friedman, cer survivors (cutoff score of 3; van der Geest, van 2008). Stressors may include family relationship Dorp, Pluijm, & van den Heuvel-Eibrink, 2018), problems and feeling that the information provid- cancer patients receiving palliative home-care ed about their cancer diagnosis and treatment was services (cutoff score of 6; Ohnhäuser, Wüller, inadequate (Graves et al., 2007). Foldenauer, & Pastrana, 2018), and women recent- All patients with cancer must be viewed as be- ly diagnosed with breast cancer (cutoff score of 7; ing at risk for distress. Numerous cancer-related Ploos van Amstel et al., 2017). organizations, including the NCCN and the Ameri- The DT has been translated into 26 languages, can College of Surgeons Commission on Cancer, including Spanish, and 18 of the translated ver- advocate for screening for distress (American Col- sions have demonstrated adequate validity in vali- lege of Surgeons, 2012; NCCN, 2019). Beginning in dation studies (Donovan et al., 2014). One advan- J Adv Pract Oncol AdvancedPractitioner.com 176 DISTRESS THERMOMETER TOOLS & TECHNOLOGY DISTRESS THERMOMETER PROBLEM LIST Instructions: Please circle the Please indicate if any of the following has been a problem for you in the past number (0–10) that best describes week including today. Be sure to check YES or NO for each. how much distress you have been YES NO Physical Problems YES NO Practical Problems experiencing in the past week ❏ ❏ Child care ❏ ❏ Appearance including today. ❏ ❏ Housing ❏ ❏ Bathing/dressing ❏ ❏ Breathing ❏ ❏ Insurance/financial ❏ ❏ Transportation ❏ ❏ Changes in urination ❏ ❏ Work/school ❏ ❏ Constipation Extreme distress ❏ ❏ Treatment decisions ❏ ❏ Diarrhea ❏ ❏ Eating Family Problems ❏ ❏ Fatigue ❏ ❏ Dealing with children ❏ ❏ Feeling swollen ❏ ❏ Dealing with partner ❏ ❏ Fevers ❏ ❏ Ability to have children ❏ ❏ Getting around 6 ❏ ❏ Family health issues ❏ ❏ Indigestion Emotional Problems ❏ ❏ Memory/concentration ❏ ❏ Depression 4 ❏ ❏ Mouth sores ❏ ❏ Fears ❏ ❏ Nausea ❏ ❏ Nervousness ❏ ❏ Nose dry/congested ❏ ❏ Sadness ❏ ❏ Pain ❏ ❏ Worry ❏ ❏ Sexual ❏ ❏ Loss of interest in usual activities 0 ❏ ❏ Skin dry/itchy No distress ❏ ❏ Sleep ❏ ❏ Spiritual/Religious Concerns ❏ ❏ Substance use ❏ ❏ Tingling in hands/feet Other Problems: Figure 1. NCCN screening tools for measuring distress. Adapted with permission from the 2019 NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Distress Management V.2.2019. © 2019 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and illustra- tions herein may not be reproduced in any form for any purpose without the express written permission of NCCN. To view the most recent and complete version of the NCCN Guidelines, go online to NCCN. org. The NCCN Guidelines are a work in progress that may be refined as often as new significant data becomes available. tage of the DT is its brevity: studies have shown on the DT select more items from the NCCN Prob- that nurses need an average of only 2 minutes and lem List (VanHoose et al., 2015). Patients who re- 20 seconds to help a patient complete the tool port distress frequently select problems from the (Musiello et al., 2017). Overall, it is easy to admin- emotional domain, and worry is the item most ister, and patients find the tool easy to use. Admin- frequently selected. Other items associated with istration and interpretation of the DT are provid- risk for distress include problems from the physi- ed by a cancer provider. cal domain, such as sleep and getting around, and The NCCN Problem List for patients is a 39- problems from the emotional domain, such as ner- item supplemental list of potential sources of dis- vousness (Clover et al., 2016). A common source tress (NCCN, 2019). The NCCN recommends in- of distress later on in the cancer care trajectory is corporating the Problem List for patients as part of financial strain (VanHoose et al., 2015). the assessment to assist the provider in identifying Once screening has been completed and the sources of patient distress. The NCCN Problem results have been interpreted, the provider deter- List provides a comprehensive list of categories, mines whether the patient needs to be referred including practical, family, physical, and emotional for psychosocial support. Referrals can include problems, as well as spiritual/religious concerns. psychologists, chaplains, and social workers. The Not surprisingly, patients who score a 4 or higher cancer care provider may use community-based AdvancedPractitioner.com Vol 10 No 2 Mar 2019 177   TOOLS & TECHNOLOGY OWNBY resources as well as resources provided by the in- claims any responsibility for their application or stitution based on the patient’s preference. use in any way. BARRIERS TO SCREENING References Abrahamson, K. (2010). Dealing with cancer-related distress. Barriers to screening for distress do exist. For ex- American Journal of Nursing, 110(4), 67–69. https://doi. ample, patients may have trouble understanding org/10.1097/01.NAJ.0000370162.07674.f6 what the word “distress” means (Mitchell, 2013). American College of Surgeons. (2012). Cancer Program Stan- Patient barriers to screening include language and dards 2012. Version 1.1: Ensuring patient-centered care. Chicago, IL: American College of Surgeons. Retrieved cultural differences as well as literacy (Lo, Ian- from https://www.facs.org/quality-programs/cancer/ niello, Sharma, Sarnacki, & Finn, 2016). Another coc/standards barrier occurs when referring distressed patients Bultz, B. D., & Holland, J. C. (2006). Emotional distress in patients with cancer: The sixth vital sign. Community for psychosocial services. Studies have also shown Oncology, 3(5), 311–314. http://dx.doi.org/10.1016%2 that patients who score high on the DT may not FS1548-5315(11)70702-1 necessarily want help. Conversely, studies have Buxton, D., Lazenby, M., Daugherty, A., Kennedy, V., Wagner, L., Fann, J. R., & Pirl, W. F. (2014). Distress screening for shown that when patients were screened and did oncology patients: Practical steps for developing and not receive any referrals or assistance, their lev- implementing a comprehensive distress screening pro- els of distress increased (Mitchell, 2013). Institu- gram. Retrieved from www.accc-cancer.org. tional barriers identified include insufficient time Carlson, L. E., Angen, M., Cullum, J., Goodey, E., Koopmans, J., Lamont, L.,…Bultz, B. D. (2004). High levels of un- and training, lack of privacy for screening, poor treated distress and fatigue in cancer patients. Brit- documentation of results, discomfort discussing ish Journal of Cancer, 90(12), 2297–2304. https://doi. results, and a lack of resources for patient referrals org/10.1038/sj.bjc.6601887 Carlson, L. E., Waller, A., & Mitchell, A. J. (2012). Screen- (Chiang, Amport, Corjulo, Harvey, & McCorkle, ing for distress and unmet needs in patients with can- 2015; Girgis, Smith, & Durcinoska, 2018). cer: Review and recommendations. Journal of Clinical Oncology, 30(11), 1160–1177. https://doi.org/10.1200/ CONCLUSION JCO.2011.39.5509 Chiang, A. C., Amport, S. B., Corjulo, D., Harvey, K. L., & Distress is considered the sixth vital sign in oncol- McCorkle, R. (2015). Incorporating patient-reported ogy care. Numerous research studies have demon- outcomes to improve emotional distress screening and strated the prevalence of distress and the signifi- assessment in an ambulatory oncology clinic. Jour- nal of Oncology Practice, 11(3), 219–222. https://doi. cant impact it has on the patient’s quality of life org/10.1200/JOP.2015.003954 and treatment success. Research continues to de- Clover, K., Oldmeadow, C., Nelson, L., Rogers, K., Mitchell, termine the validity of the DT and Problem List A. J., & Carter, G. (2016). Which items on the distress in various cancer populations based on ethnicity, thermometer problem list are the most distressing? Sup- portive Care in Cancer, 24(11), 4549–4557. https://doi. cancer type, language, and age. Research is need- org/10.1007/s00520-016-3294-z ed to validate interventions used to manage dis- Cutillo, A., O’Hea, E., Person, S. D., Lessard, D., Harralson, T. tress. Because the NCCN DT is a tool with well- L., & Boudreaux, E. (2017). The distress thermometer: Cutoff points and clinical utility. Oncology Nursing Fo - established validity and brevity that is available rum, 44(3), A1–A9. https://doi.org/10.1188/17.ONF.329- in multiple languages and easy for the provider to interpret, the use of the instrument is being stud- Donovan, K. A., Grassi, L., McGinty, H. L., & Jacobsen, P. B. (2014). Validation of the distress thermometer world- ied in other patient populations, including those wide: State of the science. Psycho-Oncology, 23(3), 241– with chronic obstructive pulmonary disease and 250. https://doi.org/10.1002/pon.3430 acquired immune deficiency syndrome. Faller, H., Bülzebruck, H., Drings, P., & Lang, H. (1999). Coping, distress, and survival among patients with lung cancer. Archives of General Psychiatry, 56(8), 756–762. Retrieved Disclosure from https://www.ncbi.nlm.nih.gov/pubmed/10435611 The author has no conflicts of interest to disclose. Girgis, A., Smith, A. B., & Durcinoska, I. (2018). Screening for distress in survivorship. Current Opinion in Supportive and Palliative Care, 12(1), 86–91. https://doi.org/10.1097/ Disclaimer SPC.0000000000000328 The National Comprehensive Cancer Network Graves, K. D., Arnold, S. M., Love, C. L., Kirsh, K. L., Moore, makes no warranties of any kind whatsoever re- P. G., & Passik, S. D. (2007). Distress screening in a mul- garding their content, use or application and dis- tidisciplinary lung cancer clinic: Prevalence and predic- J Adv Pract Oncol AdvancedPractitioner.com 178 DISTRESS THERMOMETER TOOLS & TECHNOLOGY tors of clinically significant distress. Lung Cancer, 55(2), tional Comprehensive Cancer Network, Inc. 2019. All 215–224. https://doi.org/10.1016/j.lungcan.2006.10.001 rights reserved. To view the most recent and complete Hamer, M., Chida, Y., & Molloy, G. J. (2009). Psychological version of the guideline, go online to NCCN.org. Re- distress and cancer mortality. Journal of Psychosomatic trieved from http://www.nccn.org/professionals/physi- Research, 66(3), 255–258. https://doi.org/10.106/j.jpsy- cian_gls/distress.pdf. chores.2008.11.002 Ohnhäuser, S., Wüller, J., Foldenauer, A. C., & Pastrana, T. Hegel, M. T., Collins, E. D., Kearing, S., Gillock, K. L., Moore, (2018). Changes in distress measured by the distress C. P., & Ahles, T. A. (2008). Sensitivity and specificity of thermometer as reported by patients in home palliative the Distress Thermometer for depression in newly di- care in Germany. Journal of Palliative Care, 33(1), 39–46. agnosed breast cancer patients. Psychooncology, 17(6), https://doi.org/10.1017/S1478951516000699 556–560. https://doi.org/10.1002/pon.1289 Pirl, W. F., Fann, J. R., Greer, J. A., Braun, I., Deshields, T., & Holland, J. C., & Alici, Y. (2010). Management of distress in Fulcher, C.,…Bardwell, W. A. (2014). Recommendations cancer patients. Journal of Supportive Oncology, 8(1), 4–12. for the implementation of distress screening programs in Hurria, A., Li, D., Hansen, K., Patil, S., Gupta, R., Nelson, C.,… cancer centers: Report from the American Psychosocial Kelly, E. (2009). Distress in older patients with cancer. Oncology Society (APOS), Association of Oncology So- Journal of Clinical Oncology, 27(26), 4346–4351. https:// cial Work (AOSW), and Oncology Nursing Society (ONS) doi.org/10.1200/JCO.2008.19.9463 joint task force. Cancer, 120(19), 2946–2954. https://doi. Jacobsen, P. B., Donovan, K. A., Trask, P. C., Fleishman, S. B., org/10.1002/cncr.28750 Zabora, J., Baker, F., & Holland, J. C. (2005). Screening Ploos van Amstel, F., Tol, J., Sessink, K., van der Graaf, W. for psychologic distress in ambulatory cancer patients. T., Prins, J., & Ottevanger, P. (2017). A specific distress Cancer, 103(7), 1494–1502. https://doi.org/10.1002/ cutoff score shortly after breast cancer diagnosis. Can - cncr.20940 cer Nursing, 40(3), E35–E40. https://doi.org/10.1097/ Keir, S. T., Calhoun-Eagan, R. D., Swartz, J. J., Saleh, O. A., & NCC.0000000000000380 Friedman, H. S. (2008). Screening for distress in patients Shim, E.-J., Shin, Y.-W., Jeon, H. J., & Hahm, B.-J. (2008). with brain cancer using the NCCN’s rapid screening Distress and its correlates in Korean cancer patients: measure. Psycho-Oncology, 17(6), 621–625. https://doi. Pilot use of the distress thermometer and the prob- org/10.1002/pon.1271 lem list. Psycho-Oncology, 17(6), 548–555. https://doi. Khera, N., Holland, J. C., & Griffin, J. M. (2017). Setting the org/10.1002/pon.1275 stage for universal financial distress screening in rou- van der Geest, I. M. M., van Dorp, W., Pluijm, S. M. F., & van tine cancer care. Cancer, 123(21), 4092–4096. https://doi. den Heuvel-Eibrink, M. M. (2018). The distress ther- org/10.1002/cncr.30940 mometer provides a simple screening tool for selecting Lo, S. B., Ianniello, L., Sharma, M., Sarnacki, D., & Finn, K. distressed childhood cancer survivors. Acta Paediatrica, T. (2016). Experience implementing distress screening 107(5), 871–874. https://doi.org/10.1111/apa.14251 using the National Comprehensive Cancer Network dis- VanHoose, L., Black, L. L., Doty, K., Sabata, D., Twumasi-An- tress thermometer at an urban safety-net hospital. Psy- krah, P., Taylor, S., & Johnson, R. (2015). An analysis of cho-Oncology, 25(9), 1113–1115. https://doi.org/10.1002/ the distress thermometer problem list and distress in pa- pon.4214 tients with cancer. Supportive Care Cancer, 23(5), 1225– Mitchell, A. (2013). Screening for cancer-related distress: 1232. https://doi.org/10.1007/s00520-014-2471-1 When is implementation successful and when is it un- Von Essen, L., Larsson, G., Öberg, K., & Sjödén, P. O. (2002). successful? Acta Oncologia, 52(2), 216–224. https://doi.or ‘Satisfaction with care’: Associations with health-related g/10.3109/0284186X.2012.745949 quality of life and psychosocial function among Swed- Mitchell, A. J., Vahabzadeh, A., & Magruder, K. (2011). Screen- ish patients with endocrine gastrointestinal tumors. Eu- ing for distress and depression in cancer settings: 10 les- ropean Journal of Cancer Care, 11(2), 91–99. https://doi. sons from 40 years of primary-care research. Psycho-On- org/10.1046/j.1365-2354.2002.00293.x cology, 20(6), 160–174. https://doi.org/10.1002/pon.1943 Yabroff, K. R., Dowling, E. C., Guy, G. P., Jr., Banegas, M. P., Musiello, T., Dixon, G., O’Connor, M., Cook, D., Miller, L., Pet- Davidoff, A., Han, X.,…Ekwueme, D. (2016). Financial terson, A.,…& Johnson, C. (2017). A pilot study of rou- hardship associated with cancer in the United States: tine screening for distress by a nurse and psychologist Findings from a population-based sample of adult cancer in an outpatient haematological oncology clinic. Applied survivors. Journal of Clinical Oncology, 34(3), 259–267. Nursing Research, 33, 15–18. https://doi.org/10.1016/j. https://doi.org/10.1200/JCO.2015.62.0468 apnr.2016.09.005 Zabora, J., Brintzenhofe Szoc, K., Curbow, B., Hooker, C., & Pi- National Comprehensive Cancer Network. (2019). NCCN antadosi, S. (2001). The prevalence of psychological dis- Clinical Practice Guidelines in Oncology: Distress man- agement. v2.2019. Referenced with permission from the tress by cancer site. Psycho-Oncology, 10(1), 19–28. https:// NCCN Clinical Practice Guidelines in Oncology (NCCN doi.org/ 10.1002/ 1099-1611(200101/02)10:<19::AID - Guidelines®) for Distress Management V.2.2019. © Na- PON501>3.0.CO;2-6 AdvancedPractitioner.com Vol 10 No 2 Mar 2019 179  

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Published: Mar 1, 2019

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