Joint Statement Guides Implementation of Distress Screening Program

Distress screening programs will soon be a required component of care at cancer centers. Recommendations on the implementation of these programs were recently published.

Distress screening programs will soon be a required component of care at cancer centers. Recommendations on the implementation of these programs were recently published in Cancer through a joint report for the American Psychosocial Oncology Society, the Association of Oncology Social Work, and the Oncology Nursing Society.

The National Comprehensive Cancer Network defines distress as “an emotionally unpleasant psychological, social, and/or spiritual experience that might interfere with a patient’s ability to effectively cope with cancer, its physical symptoms, and its treatment.” Research has shown that patient distress can negatively affect outcomes.

“In 2015, the American College of Surgeons [ACS] Commission on Cancer’s standard requiring screening for psychosocial distress will go into effect,” said author William F. Pirl, MD, MPH, of the Center for Psychiatric Oncology and Behavioral Sciences at Massachusetts General Hospital. “Many of us have been getting asked by cancer practices for advice about how to implement this standard. Our professional societies came together to try to create recommendations that would be applicable for all cancer practices.”

Implementation of a successful screening program will require the development of a comprehensive system that involves physician, nurses, and social workers to screen for distress, review findings, conduct follow-up assessments, and refer appropriate patients for evaluation and support.

The joint report provides consensus-based recommendations to guide the implementation of each of the new ACS standard’s six required components.

Cancer Committee Meeting

Cancer centers will now be required to document discussions about distress screening during a leadership committee meeting with a psychosocial representative present to oversee the implementation of the program and report annually on its findings. If centers do not currently have a qualified psychosocial representative, one should be hired who will be familiar with the rate of distress at the center and the resources made available to patients for evaluation and treatment.

The joint report recommended that the cancer committee be familiar with certain items to help guide their discussion on screening, including the ACS standard 3.2; volume of patients at the center; the availability of mental health clinicians at the center and locally; and NCCN guidelines for distress management.

“Given critical roles for nursing and social work staff in the implementation of distress screening at many centers, nursing and social work leadership should be involved in a collaborative effort,” Pirl and colleagues wrote.

Timing of Screening

The new standards require that patients undergo at least one distress screening during a “pivotal medical visit.” Although no current consensus exists on the best timing of this screening, authors of the report recommended the initiation of screening within a specific time period after initial diagnosis.

“For example, screening for distress by the second oncology visit would be consistent with the ASCO Quality Oncology Practice Initiative measure,” they wrote. “Delaying screening until after the initial visit may limit the detection of temporary and transient anticipatory distress related to diagnosis and facilitate more efficient allocation of health care resources.”

Method of Screening

The two main methods for screening are clinician-administered or patient-administered, both of which have potential advantages. Clinician-administered screening allows the clinician to do immediate screening and interpretation of the results, allowing real-time intervention when signs of distress are present.

In contrast, patient-administered screening can be completed during the waiting period, chemotherapy infusions, or before visits. In addition, patients may be more forthcoming on self-administered questionnaires. However, patient-administered screening can be influenced by the patient’s literacy or language barriers, and may not allow for immediate response to signs of distress.

Screening Tools

Cancer centers must employ a distress screening tool that screens for multiple symptoms or quality-of-life issues that may help to elucidate the cause of a patient’s distress. Several tools have already been created and validated for distress screening, such as the Distress Thermometer and the Patient Health Quesionnaite-4.

The report recommended choosing a distress screening tool that has been validated in patients with cancer, is available in multiple languages, and that has performed well across different ethnicities and cultures. Cancer centers should also consider patient burden, completion time, and ease of scoring when deciding on a screening tool.

Evaluation and Referral

Evaluating patients for distress has little effect if cancer centers are not prepared to refer patients for further assessment and support.

“We recommend developing a standardized protocol for scoring and reviewing the results of screening: identifying patients who require a follow-up assessment, conducting follow-up assessments, and referring for further evaluation if indicated,” Pirl and colleagues wrote. It is also important that this protocol take place in a timely manner.


Finally, cancer centers will be required to document in the medical record which screening tool is used, what the patient’s results were, and the clinical interpretation of the screening. Acceptable methods for documentation include electronic importing of computerized screens, scanning of pen-and-paper screens, and recording a patient score within a clinical note.

In cases where distress is identified, clinicians must also note having reviewed the screening results, a plan for follow-up assessment, relevant history, suicidal ideation, and recommended interventions.

“Distress screening does not belong to any one discipline; clinicians need to work together to ensure that patients are being screened, evaluated, and treated appropriately,” Pirl said. “Implementing screening is feasible, but it will require some planning in order to create a useful, safe, and sustainable system.”