Should patients with cancer be screened for distress during their first appointment with an oncologist?
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Yes.
Although most cancer centers may not screen every patient at every visit, I believe in it whole-heartedly, and this is what we do at Rush University. If we believe in the value of asking patients how they are doing, it’s hard to justify excluding certain visits from this practice, particularly considering we aren’t very good about predicting when any individual patient might be struggling.
Data indicate distress scores are higher at the first office visit, but not every patient will be distressed enough to trigger a positive screen or to need additional support. For those who are suffering, it seems important that we acknowledge this and address it in a timely manner. Ultimately, we want to catch patients who are struggling, whether it’s the first visit or the last visit, so that we can help them through this experience.
All of this makes a good case for distress screening that is efficient and integrated into routine practices. If a program has a process that is very resource-intensive, that may encourage them to limit screening to selected time points. If the response to a positive screen is a telephone call the next day or later, it may feel like wasted effort if the distress was resolved during the clinic visit. Ideally, the response to a positive screen would happen while the patient is onsite and come from a member of the patient’s clinical team to ensure continuity of care.
Teresa L. Deshields, PhD, ABPP, is director of supportive oncology at Rush University. She can be reached at teresa_deshields@rush.edu.
No.
The news of a cancer diagnosis is usually accompanied by a variety of emotions — some negative (fear, anger, anxiety) and others positive (hope, optimism, determination). It is essential for oncology clinicians to maintain curiosity about these emotions and to provide patients the opportunity to express how they feel about their diagnosis and treatment throughout the cancer care cycle, not just during the first office visit.
We should incorporate psychological well-being conversations throughout the care cycle of patients with cancer. These conversations should be pursued during the early phases of the cycle, including at the time of diagnosis, because patients can have intense emotions in the early phases of their diagnosis and treatment. As we explore the range of emotions that patients experience with their cancer diagnosis and treatment, oncology clinicians should also familiarize themselves with institutional resources that can help support patients psychologically if they need it.
NCCN has advocated for cancer centers to pursue distress screening, but it is important to note that distress screening may not always identify people who are at risk for severe psychiatric disorders, including patients at risk for suicide. There are also a lot of people who have positive emotional experiences during their cancer journey. Many patients maintain hope, are optimistic and have gratitude toward their caregivers and clinicians. Hence, assessing psychological health in a holistic way may be more insightful.
Patients’ emotions and mechanisms of coping during the cancer care cycle evolve over time. The nature of the disease or prognosis, stage of treatment and recovery or challenges that may accompany treatment, such as adverse events, may all impact patients’ emotions at different points in the care cycle. There is some risk to screening for distress at the first office visit, as patients may be inappropriately diagnosed with psychiatric symptoms during an acute phase of their illness experience. For many patients with cancer, strong emotions could wane over time as they develop more acceptance, have a plan for treatment, etc. Hence, we run the risk for false-positive results with distress screening during the first office visit, especially if it is not accompanied by follow-up assessments or conversations about psychological well-being throughout the illness experience and in recovery.
Hermioni L. Amonoo, MD, MPP, is an assistant professor of psychiatry at Harvard Medical School, Dana-Farber Cancer Institute and Brigham and Women’s Hospital. She can be reached at hermioni_amonoo@dfci.harvard.edu.
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