Review
Effects of screening for psychological distress on patient outcomes in cancer: A systematic review

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Abstract

Objective

Several practice guidelines recommend routine screening for psychological distress in cancer care. The objective was to evaluate the effect of screening cancer patients for psychological distress by assessing the (1) effectiveness of interventions to reduce distress among patients identified as distressed; and (2) effects of screening for distress on distress outcomes.

Methods

CINAHL, Cochrane, EMBASE, ISI, MEDLINE, PsycINFO, and SCOPUS databases were searched through April 6, 2011 with manual searches of 45 relevant journals, reference list review, citation tracking of included articles, and trial registry reviews through June 30, 2012. Articles in any language on cancer patients were included if they (1) compared treatment for patients with psychological distress to placebo or usual care in a randomized controlled trial (RCT); or (2) assessed the effect of screening on psychological distress in a RCT.

Results

There were 14 eligible RCTs for treatment of distress, and 1 RCT on the effects of screening on patient distress. Pharmacological, psychotherapy and collaborative care interventions generally reduced distress with small to moderate effects. One study investigated effects of screening for distress on psychological outcomes, and it found no improvement.

Conclusion

Treatment studies reported modest improvement in distress symptoms, but only a single eligible study was found on the effects of screening cancer patients for distress, and distress did not improve in screened patients versus those receiving usual care. Because of the lack of evidence of beneficial effects of screening cancer patients for distress, it is premature to recommend or mandate implementation of routine screening.

Introduction

Emotional distress is common among cancer patients as a result of the diagnosis of a life-threatening disease, aggressive medical treatments, changes in lifestyle that occur, and the direct effects of the tumor [1], [2], [3]. Increasingly, attention is being paid to the psychological consequences of cancer, with recognition of not only psychiatric disorders such as major depressive disorder (MDD) or anxiety disorders, but also of subsyndromal symptoms of depression and anxiety. In addition, attention is being paid to the broader and more inclusive concept of emotional or psychological distress, as indicated by an elevated score on a one-item distress thermometer or another psychological symptom questionnaire. A number of major cancer organizations have recommended routine screening for distress, broadly defined, and several accrediting agencies mandate routine distress screening on the assumption that identification of distress will result in increased uptake of services and reductions in distress [4], [5], [6].

Well-accepted, standard definitions of medical screening define it as an intervention that involves the application of a screening tool to individuals who are not otherwise aware they are at risk, in order to detect a medical condition that can be alleviated through intervention [7], [8]. Screening for MDD, for instance, involves the use of depression symptom questionnaires or small sets of questions about depression to identify patients who may have depression, but who have not sought treatment and whose depression has not already been recognized by healthcare providers. Patients identified as possible cases based on a positive screen need to be further assessed to determine if they have depression and, if appropriate, offered treatment [9].

Screening for “distress” is less well-defined since it does not seek to identify patients with a medical condition, and the meaning of a positive screen is less clear. If screening for “distress” is to be done, nonetheless, consistent with well-established definitions of screening [7], [8], it would involve using scores above a pre-defined cutoff on a distress screening tool to identify patients to be offered an intervention to reduce psychological distress. Distress screening would be potentially useful if it could improve patient outcomes beyond existing standard care in which patients had access to the same services without being screened.

Three previous reviews [10], [11], [12] have sought to evaluate whether there is evidence that routine screening for psychological distress improves psychosocial outcomes among patients with cancer. The reviews have concluded that screening may improve communication between patients and health care providers and may stimulate discussions of psychosocial and mental health issues. The reviews agreed, however, that there is not conclusive evidence that screening for distress improves patient outcomes. One concern about these reviews is that they included studies that would not be considered “screening” based on any standard definition of screening. For example, some included studies used psychosocial questionnaires to inform psycho-oncology consultations that were provided to all patients. This is not screening, however, which, by definition, would involve using the questionnaires to actually determine which patients would receive the psychosocial consultations and potentially be offered psychosocial services [7], [8], [9].

In a previous systematic review, we considered the evidence on screening for MDD in cancer patients [13], but did not find evidence to support recommendations of systematic screening for depression. Compared to depression, the target of recommendations for screening for psychological distress is broader in scope, but less clearly defined in terms of targeting a specific medical condition. The objective of the present systematic review was to evaluate the evidence on screening for psychological distress in cancer. Review questions were developed based on the U.S. Preventive Services Task Force (USPSTF) [14], [15] analytic framework for evaluating screening programs. The USPSTF framework recognizes the need for RCTs to directly assess links between screening programs and patient outcomes. When direct evidence from screening RCTs is not available or is of low quality, the USPSTF framework assesses key links that are necessary for screening to benefit patients, such as the availability of effective treatments [14], [15].

Screening for distress per se differs from other medical screening programs in that there is not a clear, defined medical condition, such as MDD, that screening tools seek to detect. Thus, although reviews of screening usually assess screening tool accuracy compared to a gold standard [14], [15], we were not able to do this. Nonetheless, an important prerequisite if screening of psychological distress is to improve patient outcomes is that distress can be reduced through intervention for patients identified as distressed. Thus, consistent with USPSTF methods, Review Question #1 was, “What are the effects of interventions to reduce distress among cancer patients who have been selected for treatment based on a minimum threshold of psychological distress, as would be done in a screening program?” If screening is to be actually recommended as policy, there should be consistent evidence from well-conducted randomized controlled trials (RCTs) [16], [17] that screening benefits patients in excess of any possible harms. Thus, Review Question #2 was, “Is routine screening for psychological distress of cancer patients more effective than usual care in reducing symptoms of distress?”

Section snippets

Search strategy

The CINAHL, Cochrane, EMBASE, ISI, MEDLINE, PsycINFO, and SCOPUS databases were searched through April 6, 2011. A search was conducted for studies of interventions designed to reduce psychological distress among cancer patients identified as having distress (Review Question #1) and for studies that assessed outcomes of psychological distress screening interventions (Review Question #2). Search terms are reported in Appendix A. Manual searches were done on relevant systematic reviews (Appendix

Review question #1: effect of treatment of psychological distress

The combined database search for Review Questions #1 (treatment) and #2 (screening) generated 4167 unique citations. As shown in Fig. 1, for Review Question #1 (treatment), 3754 were excluded after title/abstract review and 399 after full-text review, leaving 14 eligible studies for review. No additional studies were identified through alternative sources, such as hand searching of journals, forward citation of included articles, and review of trial registries.

As shown in Table 1, the 14

Discussion

Several clinical recommendations [4], [5], [6] have been made for screening for psychological distress to be part of standard cancer care. Guidelines and recommendations, however, vary in the degree to which they are evidence-based [53] and none of these recommendation statements have been based on a systematic review that found benefits from screening, defined according to standard definitions.

There are well-established procedures for evaluating screening programs [8], [16], [17]. The

Funding/support

This research was supported by a grant from the Canadian Institutes for Health Research (KRS 108456; PI Thombs). Ms. Meijer was supported by a VIDI grant from the Dutch Medical Research Council (grant 016.086.397). Ms. Roseman was supported by a Master's Training Award from the Fonds de la recherche en santé Québec, a McGill University Provost's Graduate Fellowship and a McGill University Principal's Graduate Fellowship. Ms. Delisle was supported by a Master's Training Award from the Fonds de

Financial disclosures

All authors have completed the Unified Competing Interest form at http://www.icmje.org/coi_disclosure.pdf and declare that Dr. Stewart is on the Depression Global Advisory Board and Cymbalta Pregnancy Registry Scientific Advisory Committee for Eli Lilly and received support from Ranbaxy Labs in 2012 to travel to Thailand to teach on women's mental health. No other authors have any conflict of interest disclosures for the past 3-year reporting period.

Conflict of interest

All authors have completed the Unified Competing Interest form at http://www.icmje.org/coi_disclosure.pdf and declare that Dr. Stewart is on the Depression Global Advisory Board and Cymbalta Pregnancy Registry Scientific Advisory Committee for Eli Lilly and received support from Ranbaxy Labs in 2012 to travel to Thailand to teach on women's mental health. No other authors have any conflict of interest disclosures for the past 3-year reporting period.

Acknowledgments

The authors thank Dr. Roy C. Ziegelstein of the Johns Hopkins University School of Medicine, Baltimore, Maryland, USA for his helpful comments on an earlier version of this article. He was not compensated for his contribution.

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