Best Practices in Oncology Distress Management: Beyond the Screen

The field of psychosocial oncology is a young discipline with a rapidly expanding evidence base. Over the past few decades, several lines of research have established that psychosocial problems, such as anxiety, depression, post-traumatic stress, fatigue, sexual dysfunction, and cognitive complaints, are both common and consequential in patients with cancer. During this same time, dozens of studies have shown the effectiveness of various interventions to alleviate the psychosocial suffering of patients with cancer.1 Beginning in the late 1990s, efforts by several professional and accrediting organizations (e.g., the National Comprehensive Cancer Network, the International Psychosocial Oncology Society, the Institute of Medicine, and the ASCO) to establish standards for psychosocial care of patients with cancer led to the promotion of systematic screening for “psychosocial distress.”1-3 The National Comprehensive Cancer Network defines distress as “a multifactorial unpleasant experience of a psychological (i.e., 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. It extends along a continuum, ranging from common, normal feelings of vulnerability, sadness, and fears to problems that can be disabling, such as depression, anxiety, panic, social isolation, and existential and spiritual crisis.”4 The ultimate goal of systematic distress screening in oncology settings is to identify and address otherwise unmet biopsychosocial needs. In contrast to more narrowly defined constructs, like depression, the word distress was chosen deliberately to capture a broader concept. Consequently, distress screening is meant to function as an initial step in the more targeted evaluation of the source or sources of the patient’s distress. Consider two patients who each score above a trigger threshold for distress screening. The first patient is a 29-year-old woman with breast cancer who had been doing well until she developed severe panic attacks during radiation therapy. The second patient is a 55-year-old man with colon cancer who is moderately troubled by peripheral neuropathy that interferes with his piano playing, financial concerns since taking a leave from work, and the fact that he has to pay for parking at the cancer hospital. Both patients may have similar scores on a distress screening instrument but clearly require quite different clinical and programmatic responses to their distress. In 2015, the American College of Surgeons’