HAMBURG, GermanySignificant numbers of women with
breast cancer have psychological distress that goes
unidentified, said David Payne, PhD, of the Department of
Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center.
In a presentation at the Fourth International Congress of
Psychooncology, Dr. Payne reported results of a screening study for
distress in 279 breast cancer patients at either Memorial
Sloan-Ketterings Breast Cancer Center or North Shore Hematology
and Oncology Associates on Long Island.
The researchers used three different screening methods: the Hospital
Anxiety and Depression Scale (HADS), a visual analog scale, and the
Brief Symptom Inventory. All three instruments are designed to
detect psychological distress in medically ill patients, Dr.
Payne said, but differ in length and complexity.
Although psychiatric distress exists in women with breast cancer, he
said, this distress may not be identified. Patients may be reluctant
to spontaneously disclose their distress to oncologists, and with the
constraints of a busy clinic schedule, oncology staff members may not
have time to ask about distress. Paper and pencil screening methods
may be an inexpensive and convenient method to identify distress.
Dr. Payne and his colleagues found that, with the use of these
instruments, approximately 33% of the women in this study had
psychiatric symptomatology significant enough to warrant further
psychiatric evaluation. If we had used a more stringent
cut-off, 27% of the patients would have qualified for further
evaluation, still a significant number. We can adjust the cut-off to
match our ability to evaluate and treat patients, he said.
Although all of the instruments used were effective in identifying
distress, they differed in their complexity and acceptance to
patients. We found that some people had a difficult time
understanding the visual analog scale. Although they were asked to
indicate their psychological distress, patients told us that it was
hard to separate psychological and physical distress. If they were
nauseous, patients would say that they were distressed.
The Brief Symptom Inventory was the longest screening instrument.
Although it probably gave the most comprehensive view of a
patients psychiatric functioning, patients had difficulty with
this instrument. This instrument had questions that asked about
a variety of psychiatric problems. Our patients felt uncomfortable
answering it because they didnt want to be labeled as having
psychiatric problems, Dr. Payne said.
HADS Easiest to Use
The easiest and most acceptable screening instrument was the Hospital
Anxiety and Depression Scale. The HADS also correlated well with more
complex measures of psychiatric symptomatology such as the Brief
We found that all the instruments we used showed about the same
thing, that our patients were distressed, Dr. Payne said.
Although many patients whose scores indicated distress were already
being followed by the psychiatry service, 64% were not being
followed. This represented a significant number of women who
were suffering in silence, Dr. Payne said. Our project
has helped us to quantify the level of psychiatric distress in our
population and to further our exploration of the means by which we
can identify those women with breast cancer who most need to receive
Dr. Payne noted that the results of the screening project also served
as a vehicle to further communication with oncologists. Our
project raised the oncologists awareness and provided a means
for us to educate them about underdiagnosed psychiatric distress in
their populations as well as to give them an acceptable tool to
evaluate distress in their patients, Dr. Payne said.
One of the reasons for conducting this research was to stay
competitive in the health care market by documenting the need for our
services, Dr. Payne said. In the era of managed care, the
necessity and feasibility of psychiatric interventions are under
scrutiny, and we needed to find methods for evaluating the distress
that patients experience as well as the effectiveness of our programs
in treating this distress.
He said that the project allowed the psychiatry service to take
a fresh look at what we were doing in providing services. The good
news was that we were focusing our attention on many of the right
patients, but, unfortunately, there remained a significant number of
women who were unserved.
By using the HADS on a regular basis, Dr. Payne said, we can
identify those women before they are sitting in their
oncologists offices crying. We want to identify distress before
it overwhelms the patient.