Screening for Emotional Distress in Older Patients With Lung Cancer

Oncology Nurse EditionONCOLOGY Nurse Edition Vol 24 No 4
Volume 24
Issue 4

An estimated 219,440 new cases of lung cancer were expected in 2009, accounting for about 15% of cancer diagnoses.

An estimated 219,440 new cases of lung cancer were expected in 2009, accounting for about 15% of cancer diagnoses.[1] Most cancer-related deaths in both men and women are attributable to lung cancer, which represents about 28% of all cancer deaths. Lung cancer patients are often older, with approximately 60% of cancer diagnoses and 70% of cancer mortality occurring in those over the age of 65 years.[2]

The two major types of lung cancer are non–small-cell lung cancer (NSCLC), representing 80% to 85% of all lung cancers, and small-cell lung cancer (SCLC), which represents 15% to 20%. Surgery is the primary treatment modality for early stage I and II NSCLC. If NSCLC is diagnosed at a later stage, radiation is used for control and chemotherapy is used for advanced and metastatic disease. Limited SCLC disease is treated with chemotherapy and radiation, whereas more extensive disease is treated with chemotherapy alone.[3]

Older adults are more likely to have concurrent diseases (eg, diabetes, chronic obstructive pulmonary disease, heart disease, arthritis, hypertension) which can exacerbate complications from cancer[4] and reduce treatment tolerance and life expectancy.[5] Although the relative survival rate for older lung cancer survivors is increasing, largely as a result of improvements in surgical treatments and combined therapies (eg, surgery, radiation, chemotherapy, and targeted biological therapies), older lung cancer patients may suffer from severe psychological distress.

Psychological distress, particularly depression and anxiety, has been well documented in adults diagnosed with cancer[6] but prevalence rates for distress vary by type of cancer. Prevalence rates of up to 43.5% for lung cancer patients have been reported,[7] and rates of 41% have been found for older adults.[8] It is clear that older lung cancer patients are at risk for developing severe psychological distress-distress that is often unrecognized or untreated.

Psychological distress is an important problem in cancer survivorship because it significantly influences cancer recovery and quality of life (QOL).[9] Symptoms of depression, for example, are associated with decreased compliance with adjuvant therapy and a variety of cognitive and functional impairments.[6] Psychological distress has been linked to decreased immune function,[10] response to chemotherapy observed by tumor size,[10] and when severe and persistent, to long-term survival.[11] Psychological distress in older cancer survivors can increase treatment-related side effects and decrease abilities to manage their symptoms, adding to the burden of the illness.[12] Untreated psychological distress has been linked to suicide in older adults, with the rates of suicide in cancer patients twice that of the general population.[13]

People with lung cancer are acknowledged to have more unmet needs and greater distress than people with other cancers. In part, this is because there is no effective method for early detection and the majority of people with lung cancer are diagnosed with advanced disease. Patients report both physical and psychological symptoms across the disease course.

The most common symptoms reported by newly diagnosed lung cancer patients are fatigue, pain, insomnia, and depression. Many patients also experience breathing difficulty and coughing that affects their physical functioning.[14] Frequent communication is critical among the patient, family, and healthcare team to ensure better understanding of the side effects/symptoms of the disease and its treatment, and to decrease psychological distress.

The course of the patient's disease depends on the type of cancer and its biology. Some patients benefit from multiple chemotherapy regimens and experience long disease-free intervals before succumbing to the disease.[15] The experience of living with chronic disease and ongoing treatment can have physical, social, and emotional consequences that ultimately affect the patient's quality of life.

Characteristics of advanced cancer that require coordinated supportive care include multiple physical needs, intense psychological distress manifested by anxiety and depression, and complex patient and caregiver needs.

The goals of palliative care, a philosophy and approach to managing serious illness that focuses on optimizing quality of life and minimizing distress across the illness trajectory, are best achieved if palliative care is integrated with life-prolonging therapies from the point of diagnosis. One of the most efficient ways of monitoring patients' needs is to coordinate the overall plan of management with the oncology team during times of crisis; this approach decreases fragmentation of care and promotes continuity.[16]

Many review articles have documented the needs of oncology patients across the disease and treatment courses.[17] Although there can be important cultural differences in regard to the degree of desired information disclosure, patients and their families generally desire information about specific treatments, the expected course of care, traditional as well as alternative approaches to treatment, ways to manage symptoms, and which community resources are available.

Patients also need information about the emotional aspects of their illness, and their expected course of emotional recovery. Patient and family needs for information can change over the course of illness.[18] Evidence suggests that patients and families benefit from supportive services directed at their individual needs, including both physical and psychological needs.[19]

Distress Definition and Assessment With Nursing Management

With the publication in 2008 of the Institute of Medicine (IOM) report, Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs, there is a growing national recognition that many patients and their families report unmet psychosocial needs, and that psychosocial assessment and treatment should be a standard of quality cancer care.[20]

The National Comprehensive Cancer Network (NCCN) has published clinical practice guidelines for distress management (V.1.2010).[21] The term ‘distress' was selected because it was considered more acceptable and less stigmatizing than other terms such as ‘psychiatric,' ‘psychological,' or ‘emotional,' and it can be defined and measured by self-report.

‘Distress' in the context of cancer is defined as, “a multifactorial unpleasant emotional experience of a psychological (cognitive, behavioral, emotional), social, and/or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms and its treatment.” Distress extends along the continuum, ranging from normal feelings of sadness or fears to problems that can become disabling, such as depression, anxiety, panic, social isolation, and existential and spiritual crises.[21]

In keeping with this definition, NCCN has developed the Distress Thermometer and Problem List (Figure 1), a one-item questionnaire that can be used to rapidly screen for distress. Patients are asked to first circle the number from 0–10 that best describes how much distress they have been experiencing in the past week, including today, and then to check if any of the problems listed has been a problem for them in the past week, including today. The efficacy of the Distress Thermometer has been established in prior studies reporting it to be a good screening tool.[22] Scores of > 4 indicate moderate to severe distress requiring a more in-depth evaluation.

The next step for patients who score > 4 on the Distress Thermometer is for the nurse or other healthcare team member to conduct an in-depth follow-up interview to determine potential diagnoses, referrals, or treatments (see Figure 2). Distress at all stages of disease should be recognized, monitored, documented, and treated promptly.

Case Study

Without any warning, Mr. Davenport, a 67-year-old married Caucasian, developed flu-like symptoms and a nagging cough. His wife encouraged him to go to his physician, who sent him for a chest X ray. Mr. Davenport was told that he had a mass on the upper lobe of his lung that was pushing on the vessel of his heart, and that the mass was presumed to be cancerous. The doctors conveyed that surgery was critical to remove the mass and relieve the pressure. Within 2 weeks, Mr. Davenport was scheduled for a pneumonectomy. His surgery was uneventful. He was discharged with instructions to return to his surgeon in 1 week and was given a referral to a medical oncologist.

Once home, Mr. Davenport tried to quickly assume all his former roles, including helping his wife, who suffered from multiple chronic illnesses. He found that any exertion aggravated his pain to the point that it was intolerable. The surgeon had sent him home on Percocet (oxycodone and acetaminophen), but the drug did not provide adequate relief. He refused to contact his doctor about the pain stating, “it just isn't worth it.”

His wife called the surgeon's office and was told to increase the dose to two pills as needed. Within two days, Mr. Davenport had a fever, his incision looked irritated, and he was having difficulty catching his breath. As Mr. Davenport's pain persisted, he stayed in bed, ate little, and did not want to be disturbed. He was irritable and angry, refusing to contact his physician, and he told his wife, to “leave me alone and let me die in peace.”

She tearfully called her children, who lived out of state, for support and was told to contact the doctor again. She reported to Mr. Davenport's doctor that her husband had a fever; was coughing; refused to talk, except in anger; and at times seemed to “simply fade away.” She was told to give him Tylenol (acetaminophen) for the fever and to bring him to the clinic in 2 days, but to take her husband to the nearest hospital emergency department if the symptoms persisted or got worse.

Mr. Davenport woke with a high fever and in severe pain early the next morning, and his wife called an ambulance. He was admitted to the hospital with a pulmonary embolus and remained on anticoagulants, intravenous antibiotics, and pain medications for 5 days. During this time, the staff nurse evaluated him for emotional distress using the Distress Thermometer, and also administered the Problem List.

Mr. Davenport reported his distress at a level 6. He related his problems to his inability to provide for his wife; worry about what would happen during the next phase of treatment, and if he should die; anger that the lung cancer was not cured; and his own physical problems of inability to sleep because of his increased pain, fatigue, depression, and stress.

The staff nurse referred Mr. Davenport to the palliative care nurse practitioner for further evaluation. He was diagnosed with unmanaged pain and with comorbid depression with some anxiety (often manifested by irritability in elderly men). He was started on oxycodone for pain and an SSRI (selective serotonin reuptake inhibitor), Celexa (citalopram), for depression. Arrangements were made for a home health aide to assist his wife with her daily care during Mr. Davenport's postsurgical recovery and his subsequent cancer treatment. A follow-up appointment was scheduled for him in the palliative care outpatient clinic.


In summary, the nurse was able to accurately assess Mr. Davenport's psychological distress and current problems using a standardized screening tool, and appropriately refer him for a more in-depth evaluation. The palliative care nurse practitioner was able to develop a discharge plan for Mr. Davenport's complex medical needs to relieve his pain, treat his psychological distress, and obtain home health assistance for his wife during his recovery. Without nursing intervention and management, Mr. Davenport would have continued to experience unrelieved pain and psychological distress and would have been at risk for suicide.

The position statement approved by the Oncology Nursing Society Board of Directors in March 2008 recognizes that psychosocial assessment is a standard component of cancer care and that each patient's psychosocial needs must be documented with a plan for needed services.[23] Nurses can be leaders in quality cancer care by documenting a psychosocial assessment, the plan of action, and health outcomes following treatment. As members of the largest health profession and as front-line care providers, nurses are ideally situated in our health care systems to meet the newest standard in quality cancer care, addressing the psychosocial needs of cancer patients and integrating psychosocial care into routine
cancer treatment.



1. American Cancer Society: Cancer Facts & Figures 2009. Atlanta, GA, American Cancer Society. Available at: Accessed on December 23, 2009.

2. Reis L, Harkins D, Krapcho M, et al: SEER Cancer Statistics Review, 1975–2003. Bethesda, MD, National Cancer Institute. Available at: Accessed on December 28, 2009.

3. DeVita VT Jr, Hellman S, Rosenberg SA (eds): Cancer: Principles & Practice of Oncology, 8th ed. Philadelphia, PA, Lippincott, Williams & Wilkins, 2008.

4. Yancik R, Ganz P, Varricchio C, et al: Perspectives on comorbidity and cancer in older patients: Approaches to expand the knowledge base. J Clin Oncol 19(4):1147–1151, 2001.

5. Carreca I, Balducci L, Extermann M: Cancer in the older person. Cancer Treat Rev 31(5):380–402, 2005.

6. Jacobsen P, Jim HS: Psychosocial interventions for anxiety and depression for adult cancer patients. CA Cancer J Clin 58(4):214–230, 2008.

7. Zabora J, Brintzenhofe-Szoc K, Jacobsen P, et al: A new psychosocial screening instrument for use with cancer patients. Psychosomatics 42(3):241–246, 2001.

8. Hurria A, Li D, Hansen K, et al: Distress in older patients with cancer. J Clin Oncol 27(26):4361–4351, 2009.

9. Badger T, Segrin C, Dorros SM, et al: Depression and anxiety in women with breast cancer and their partners. Nurs Res 56(1):44–53, 2007.

10. Carlson LE, Speca M, Patel KD, et al: Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and prostate cancer outpatients. Psychosom Med 65(4): 571–581, 2003.

11. Denollet J, Maas K, Knottnerus A, et al: Anxiety predicted premature all-cause and cardiovascular death in a 10-year follow-up of middle-aged women. J Clin Epidemiol 62(4):452–456, 2009.

12. Stommel M, Kurtz M, Kurtz J, et al: A longitudinal analysis of the course of depressive symptomatology in geriatric patients with cancer of the breast, colon, lung, or prostate. Health Psychol 23(6):564–573, 2004.

13. Misono S, Weiss NS, Fann JR, et al: Incidence of suicide in persons with cancer. J Clin Oncol 26(29):4731–4738.

14. Cooley ME, Short T, Moriarty H: Symptom prevalence, distress, and change over time in adults receiving treatment for lung cancer. Psychooncology 12(7):694–708, 2003.

15. Murray S, Kendall M, Boyd K, et al: Illness trajectories and palliative care. BMJ 330(7498):1007–1011, 2005.

16. Borneman T, Koczywas M, Cristea M, et al: An interdisciplinary care approach for integration of palliative4 care in lung cancer. Clin Lung Cancer 9(6):352–360, 2008.

17. Whitmer K, Pruemer J, Nahleh Z, et al. Symptom management needs of oncology outpatients. J Pall Med 9(3):628–630, 2006.

18. Northouse LL, Peters-Golden H: Cancer and the family: Strategies to assist spouses. Semin Oncol Nurs 9(2):74–82, 1993.

19. Ferrell B, Paice J, Koczywas M: New standards and implications for improving the quality of supportive oncology practice. J Clin Oncol 26 (23):3824–3831.

20. Institute of Medicine (IOM): Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Adler NE, Page AE (eds). Washington, DC, The National Academies Press, 2008.

21. Adapted with permission from The NCCN 1.2010 Distress Management Clinical Practice Guidelines in Oncology. National Comprehensive Cancer Network, 2010. Available at: Accessed on January 25, 2010. To view the most recent and complete version of the guideline, go online to

22. Jacobsen PB, Donovan KA, Trask PC, et al: Screening for psychologic distress in ambulatory cancer patients: A multicenter evaluation of the distress thermometer. Cancer 103(7):1494–1502, 2005. Available at: Accessed on December 22, 2009.

23. Oncology Nursing Society: Oncology Nursing Society Position: Psychosocial Care and Services for Patients With Cancer and Their Families. Approved by the Oncology Nursing Society Board of Directors in March 2009 and October 2009. Available at: Accessed on December 23, 2009.

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