HAMBURG, GermanyThe next goal for psychooncology is to
stamp out distress, said Jimmie Holland, MD, chair of the
Department of Psychiatry and Behavioral Sciences, Memorial
Sloan-Kettering Cancer Center.
In a presentation at the Fourth International Congress of
Psychooncology, Dr. Holland said that the National Comprehensive
Cancer Network (NCCN), representing 17 major US cancer centers, has
developed a distress management guideline that will be used for the
treatment of psychological distress in patients. She presented the
updated guideline at the NCCNs recent fourth annual conference
in Fort Lauderdale, Florida.
We used the word distress because we think that it
provides the patient with a sense of dignity that using words like
psychiatric or psychological does not,
Dr. Holland said. Anybody could say Im
distressed without feeling embarrassed. We dont want to
stigmatize people who may already feel stigmatized because they have
the diagnosis of cancer.
Dr. Holland said that distress can be conceptualized as
psychological, social, or spiritual, or as any problem that
interferes with the patients ability to cope with cancer.
Each institution should have an interdisciplinary team focused
on stress management, she said.
Distress management guidelines can also assist the busy oncologist
who may not have the time or training to assess psychological,
financial, or spiritual distress in his or her patients.
Patients may also be reluctant to share their level of distress with
their oncologist for fear that this may distract the oncologist from
focusing on the treatment of their cancer.
Oncologists are busy and patients dont want to be seen as
crazy. There are barriers to the dialog between patients
and physicians, Dr. Holland said.
There are several areas of concern in the management of stress, Dr.
Holland said. Health care professionals and clergy need to be trained
in the identification and management of distress. Dr.
Holland also feels that medical contracts must include, for the
purposes of insurance coverage, reimbursements for the management of
Finally, she said that clinical health outcome research needs to
include the assessment of distress (see report on page 1) and its
impact on cost effectiveness.
More and more patient health outcome research is looking not
only at how much a treatment costs and how well it works but also at
how satisfied patients are with the treatment they are receiving.
Patient satisfaction is an integral part of medical care, she said.
Dr. Holland pointed out that there has been a major shift of care to
ambulatory settings. No longer are patients hospitalized for
long periods; instead, they are in their homes, coming in for care,
and attempting to cope with more and more cancer-related stress with
less and less support from the hospital, she said.
Consequently, the identification and management of distress is
something that must be accomplished while patients are in for their
brief outpatient visits. Having efficient methods and
guidelines for this will streamline the process of treating a
patients distress, she said.
The first goal of the distress guideline, Dr. Holland said, is to
establish standards for the identification and treatment of distress
in cancer patients. In developing the guideline, Dr. Hollands
group followed the footsteps of the palliative care movement, which
has established guidelines to treat people in pain.
Every cancer patient should be screened for distress on his or
her initial visit and every subsequent visit, she said. This
screening provides the nature of the problem and then the appropriate
referral can be made. Dr. Holland indicated that her group at
Memorial Sloan-Kettering Cancer Center has used a stress
thermometer in which people rate their level of distress.
Weve found that when people score 5 or greater (on a
scale of 10), they are experiencing significant anxiety, she
Other sections of a screening instrument might ask patients if they
are experiencing problems in financial, social, or spiritual areas.
Although mild distress may be handled by the primary oncologic team,
the new guideline will help the primary team know when they should
refer a patient and to whom, thus providing a streamlined continuum
of care. The guideline also offers clinicians the freedom to refer
back and forth between disciplines when it turns out that the problem
is more complicated than it first appeared.
Describing the psychiatric guideline in more detail, Dr. Holland
indicated that there would be an established pathway for the
treatment of each psychiatric disorder. Some patients will have
distress that is identified by a screening instrument while others
may be identified because they have a psychiatric history or are on a
psychotropic medication like lithium, she said.
In any event, an established treatment pathway will be available to
guide the clinician in the management of the patients symptoms.
Similar guidelines will also be written for other professionals such
as social workers and chaplains.
In conclusion, Dr. Holland stated, the goal for psychooncology
today should be to ensure that no patient in distress goes
unrecognized and untreated. It is clear that many patients are never
questioned about how they feel. She said that by systematic use
of treatment guidelines and research on screening, more patients
needs will be addressed.
The pain people have a little badge or insignia they use that
says Stop Pain, she said. I think we need exactly the
same for distress, Stop Distress. No patients distress should