The psychological and social consequences of cancer treatment were largely neglected until the latter part of the 20th century, despite the awareness that cancer patients often struggled with anxiety, depression, and emotional upheaval so severe as to jeopardize adherence to treatment. These psychological and emotional states were attributed to patients’ subjective responses to their condition, which were deemed unmeasurable and therefore not easily assessed in routine cancer care. Nevertheless, a study in the early 1980s1 showed that if newly diagnosed patients were screened for distress, those identified as being distressed could be helped to cope better.
To improve the recognition and treatment of distress in cancer patients, the National Comprehensive Cancer Network (NCCN) created a panel of experts in 1997 to formulate clinical practice guidelines for distress management.2 The guidelines, which were based on the evidence and consensus of an expert panel, were the first in the United States designed for clinicians. The term “distress” was chosen because it suggests a normal response, which can vary from an expected level to a severe one (eg, anxiety, depression).3 The term also reduces the stigma attached to words such as “psychiatric.”
The NCCN Distress Management Guidelines, which are updated annually, recommend that each new patient be rapidly assessed for distress in the office or clinic waiting room using a brief screening tool.3,4 Based on the lessons learned from the success of pain management, the panel suggested using the Distress Thermometer (DT), a self-report measure with a 0–10 scale in which 0 indicates “no distress” and 10, “extreme distress.” Patients who score 4 or more are identified as having clinically significant distress, based on validity studies showing sensitivity and specificity.5 They are then asked to check off the domains they identify as causing the distress in a separate Problem List. Depending on the nature of the problem elicited by the nurse or oncologist, patients can be referred to a professional, such as a social worker, nurse, psychologist, chaplain, or psychiatrist.6,7 The screen should be repeated at points of transition during clinical treatment.7
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