To compare the five-day administration of aprepitant with a single administration of fosaprepitant meglumine to prevent chemotherapy-induced nausea and vomiting (CINV) associated with highly emetogenic chemotherapy regimens containing cisplatin

Participants were randomly assigned to receive a five-day course of aprepitant or a single administration of fosaprepitant meglumine. CINV was monitored for seven days after the first administration of chemotherapy.

• N = 93
• MEAN AGE = 63.6 years (range not specified)
• MALES: 80%, FEMALES: 20%
• KEY DISEASE CHARACTERISTICS: Gastric cancer, esophageal cancer, lung cancer, or head and neck cancer
• OTHER KEY SAMPLE CHARACTERISTICS: Highly emetogenic chemotherapy regimens containing cisplatin

• SITE: Single site    
• SETTING TYPE: Not specified    
• LOCATION: University hospital in Japan

• PHASE OF CARE: Active antitumor treatment

Randomized, controlled trial

• The Multinational Association of Supportive Care in Cancer (MASCC) Antiemesis Tool (MAT) was used to measure the occurrence of nausea and vomiting. It consisted of a daily review of nausea and vomiting symptoms over seven days.
• Nausea was measured on a 0–10 scale.
• Vomiting was measured by the number of vomiting episodes per day.

When CINV was compared, five days of aprepitant versus a single administration of fosaprepitant meglumine did not yield statistically significant results.

Five days of aprepitant for five days and a single administration of fosaprepitant meglumine had similar outcomes in regard to the prevention of CINV.

• Small sample (< 100)

In this study, one dose of fosaprepitant meglumine had similar effects on CINV as five-day aprepitant. One dose of a medication is more cost effective and reduces patient medication burden, so this may be a preferable treatment alternative.

To assess the efficacy of a Short-Term Life Review process on spiritual well- being, anxiety, depression, suffering, and happiness in terminally ill patients with cancer

The intervention was Short-Term Life Review completed with a psychologist, who then created an album based on the participant’s interview. In the first part, participants reviewed their life, and in the second, they reevaluated, reconstructed, and appreciated their life. In the second session, the album was reviewed with the participant.

• The study reported on a sample of 30 patients with cancer.
• Mean patient age was 74 years (SD = 9.1).
• The sample was 73.3% female and 26.7% male.
• Multiple tumor sites were represented.
• Of the sample, 90% had no specific religious affiliation, and 96.7% were married.
• Mean time from interview to death was 67 days.

• Single site
• Inpatient setting
• Japan

• Patients were undergoing the end-of-life phase of care.
• The study has clinical applicability for end-of-life and palliative care.

A prospective pre/post-test design was used.

• Functional Assessment of Chronic Illness Therapy–Spiritual Well-Being (FACIT-Sp) – Japanese version
• Hospital Anxiety and Depression Scale (HADS) – Japanese version
• Numeric rating scales for suffering (0–6) and happiness (1–7)

Anxiety and depression scores significantly decreased (p = 0.001).

The Short-Term Life Review process is feasible for terminally ill patients and appears to be beneficial to reduce anxiety and depression, reduce suffering, and improve happiness.

• Statistical significance may not impart sufficient clinical significance for such an intensive intervention.
• The study did not have a control group.

• Cultural differences may affect efficacy; further study is required.
• The intervention was completed by a trained psychologist and required a large time investment to create the album.

To determine the effects of a mindfulness intervention on anxiety, depression, and spirituality

The intervention involved 30–60-minute cyclic meditation and yoga training with practice at home. In pretherapy sessions, patients learned the cyclic meditation program and were recommended to perform the therapy at home once daily. After two weeks, patients met therapists in a second session to talk about their impressions.

• The study reported on a sample of 28 patients.
• Mean patient age was 60 years (SD = 9.2).
• The sample was 85.7% female and 14.3% male.
• Most patients were diagnosed with breast cancer, with other sites including colon, stomach, and bladder.
• All patients were actively receiving either chemotherapy, radiation, or medication at a general hospital.

• Single site
• Outpatient clinic
• Western Japan

Patients were undergoing the active treatment phase of care.

A pre/post-intervention study design was used.

• Functional Assessment of Chronic Illness Therapy–Spirituality (FACIT-Sp)
• Hospital Anxiety and Depression Scale (HADS)
• Caregiving Consequence Inventory: Selected two items to measure appreciation
• Benefit Finding Scale: Three items to measure growth
• Pain and physical symptoms measured on a 10-point numeric scale

Anxiety (p = 0.01) and depression (p = 0.009) decreased significantly. There was no significant change related to spirituality. Spirituality is correlated with anxiety and depression.

Mindfulness-based cyclic meditation affects anxiety and depression for Japanese patients with cancer and may be effective as an individual short-term therapy.

• The study had a small sample.
• The study did not have a control or comparison group.
• No information was given regarding patients’ adherence to home practice.

This type of intervention may be helpful to some patients to affect anxiety and depression during cancer treatment. The amount of training required for administration of the therapy, as well as therapist time with the patient, suggests that this approach may be feasible.

To evaluate the effect of three brief cognitive behavioral interventions as adjunct treatment for chronic cancer-related pain

Patients were randomly assigned to one of four groups: relaxation, distraction, positive mood, or wait-list control. Patients in the relaxation, distraction, and positive-mood groups received audiotapes and instructions to practice a specific psychoeducational technique at least five times weekly.The relaxation group received a 20-minute audiotape providing standard progressive muscle relaxation instructions. Patients in the distraction group selected an audiotape on a topic such as history, foreign language, or geography. Patients in the positive-mood group received audiotapes of positive-mood statements and positive-imagery suggestions. The research nurse telephoned all patients periodically to answer questions and encourage use of the assigned tapes. Patients completed assessments at baseline and in weeks 2–3, weeks 4–5, and weeks 8–9. For the first seven weeks, patients rated pain, according to a visual analog scale (VAS), before and after using the audiotapes. 

• The sample was composed of 59 randomized patients, of whom 30 completed the study.
• Mean patient age was 52 years. Age range was 30–80 years.
• Of all patients, 79% were female and 21% were male.
• Of all patients, 67% had breast cancer. Other diagnoses in the sample were prostate and lung cancer and multiple myeloma.
• Of all patients, 72% were Caucasian; 23%, African American; and 5%, Hispanic. Of all patients, 54% were married, 21% were working, and 56% had an annual income greater than $40,000.

• Single site
• Outpatient
• MD Anderson Cancer Center, Houston, Texas

Randomized controlled trial

• Brief Pain Inventory (BPI)
• MD Anderson Symptoms Inventory
• Numeric Rating Scale (0–10)
• Functional Assessment of Cancer Therapy-General (FACT-G)
• Profile of Mood States questionnaire
• Outcome Expectancy and Self-Efficacy questionnaire

Subjects in the distraction and control groups reported a significant decrease (p < 0.05) in worst pain severity from baseline to follow-up at 2–3 weeks. Subjects in the positive-mood and control groups reported a significant decrease (p < 0.05) in BPI average pain score from baseline to the follow-up at 2–3 weeks. Analysis of mailed data showed that patients in the distraction group reported a mean reduction in pain severity of 1.16 (p = 0.004) and that, after listening to the tapes, patients in the relaxation group reported a mean reduction in pain severity of 0.9 (p = 0.023). Patients in the positive-mood group reported a nonsignificant increase in pain severity after audiotape use. Authors noted no differences between groups after 2–3 weeks. Authors noted no intervention effects on quality of life, mood, or perceived self-efficacy. There were no differences between groups in pain interference scores from the BPI. More than one-half the patients reported using the audiotapes at least five times per week. More than one-half the patients dropped out of the study or were lost to follow-up; 25% of these withdrew prior to the first follow-up assessment, at 2–3 weeks. The most common reasons for withdrawal were ineffectiveness of intervention and disease progression.

Distraction and relaxation audiotapes appeared to produce immediate short-term decreases in pain intensity. However, authors observed no long-term effects and no overall differences between intervention groups and the control group.

• The study had a small sample size, with fewer than 100 patients.
• The study had risks of bias due to no attentional control and no blinding.
• A large proportion of subjects dropped out of the study, resulting in an underpowered sample.
• Authors did not state the frequency of follow-up telephone calls. Whether the timing or frequency of calls was different, group to group, is unknown. Such differences could have affected results.
• Authors did not describe use of analgesics or changes in pain medications.
• Whether the types of audiotapes selected for distraction were indeed distracting is unclear.
• The intervention did not include education or cognitive restructuring, which are usually included in cognitive behavioral techniques.

The findings of this study do not support the use of the specified techniques with audiotapes and minimal direct patient contact via telephone. This study does not add to knowledge regarding full cognitive behavioral techniques, because this study did not include many aspects typical of these techniques.

To determine the effectiveness of early exercise intervention programs on the quality of life, physical function, and arm volume for breast cancer survivors immediately following breast cancer surgery

Participants were randomized into a control group and an intervention group. The control group received patient education only (tips about lymphedema awareness and prevention exercises from a general newsletter). The intervention group underwent a tailored comprehensive program (the RESTORE program), which consisted of a structured exercise regimen, a lymphedema prevention module, patient and diet education, and counseling sessions. The intervention occurred every 3 months, beginning from 4–12 weeks after breast cancer treatment. The final session occurred at 18 months.

• The sample (N = 82) was comprised of female patients.
• Mean age was 53.6 years with a range of 32–82 years.
• Patients were within 4–12 weeks of surgery and had stage I–III breast cancer.
• Of the sample, 46% had breast-conserving surgery, 79% had axillary node dissection, 59% received chemotherapy, 64% received radiation, and 71% had a mass body index of equal or greater than 25 kg/m².

The study took place across multiple in-patient and home settings in association with Wake Forest University Health Center.

Patients were undergoing transition from breast cancer treatment to active treatment for lymphedema.

The study used a single, blinded, randomized controlled design.

The effectiveness of the RESTORE program was measured using the Functional Assessment of Cancer Therapy for Breast Cancer (FACT-B), distance traveled during a six-minute walk (measured by a pedometer), and arm volumes measured at three-month intervals using the water displacement method. The FACT-B was a survey that assessed physical, social, and functional well-being of the participants.

Those in the exercise intervention had a significantly higher distances walked in the six-minute walk test than in the control group by the end of all the study (p = 0.00098). However, there was no statistical difference between the average FACT-B scores from the control and intervention groups. (p = 0.57). There also was no statistical significance between groups in terms of arm volume when compared with measurements at baseline and 18 months (p = 0.54).

There appears to be a positive correlation between the RESTORE program and physical function in individuals immediately after breast cancer treatment. Unexpectedly, this did not translate into a decrease in lymphedema-related symptoms (like edema) or social perceptions of the disease.

• The sample was small (N < 100).
• The intervention was expensive, impractical, or required extensive training for a long period of time.
• Subject withdrawals were greater than or equal to 10%.

Nurses should be aware of the symptoms that patients can present with after breast cancer remission. Nurses should encourage their patients to seek regular visits to their healthcare providers because this study showed that physical function can improve with more vigorous self-maintenance and early intervention. Further research should be conducted to determine the effectiveness of the RESTORE program as a standalone therapy.

To systematically review the literature on the prevention and palliation of multikinase inhibitor (MKI)-associated hand-foot syndrome (HFS) to identify areas for further clinical study and to provide a foundation for evidence-based guidelines for HFS management

DATABASES USED: PubMed, Cochrane Database of Systematic Reviews, BIOSIS, and CANCERLIT

KEYWORDS: Hand foot syndrome, hand foot skin reaction, acral erythema, palmar-plantar erythrodysesthesia, acral erythrodysesthesia, Burgdorf reaction, toxic erythema of the palms and soles. Medical subject headings (MeSH) included skin disease, hand injuries, chemically induced, antineoplastic agents, and protein kinase inhibitors. Names of specific agents also were entered into the MeSH search.

INCLUSION CRITERIA: English language clinical studies; meta-analysis, reviews, or practice guidelines; literature through August 31, 2008. Literature was categorized (C) according to the type of agent and cutaneous reaction.

• C1—Articles pertaining to MKI-associated HFS containing histology, pathogenesis, incidence, quality of life, impact, treatment, or prevention
• C2—Articles focused on MKI-associated skin reactions other than HFS
• C3—Articles focused on antineoplastic agents other than MKIs and HFS
• C4—Articles that did not focus on clinical details of pathophysiology or treatment of HFS (e.g., health policy, study design issues)

EXCLUSION CRITERIA: Conditions other than HFS, topics unrelated to antineoplastic therapy

TOTAL REFERENCES RETRIEVED = 2,069 abstracts 

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: After screening for inclusion, 350 abstracts (17%) met criteria for inclusion in C1–C4 categories.

• FINAL NUMBER STUDIED INCLUDED = 56 articles categorized as C1 were reviewed and evaluated. Only those that fell into this category were discussed in this review. None of the citations on prevention or palliation approaches to HFS were randomized, controlled trials.

Prevention approaches for MKI-associated HFS included

• Screening for preexisting plantar hyperkeratosis (e.g., podiatry care)
• Prophylactic removal of hyperkeratotic areas (e.g., manicure or pedicure before and during treatment to remove hyperkeratosis)
• Use of prophylactic skin care (e.g., emollients, topical exfoliating products applied to calluses, pedicures, manicures)
• Protection of pressure-sensitive areas of the hands and feet (e.g., wearing well-fitting, soft shoes; cushioning of callused areas by soft or padded shoes)
• Use of prophylactic systemic treatments (e.g., administration of prophylactic pyridoxine [vitamin B₆], glucocorticoids, cyclooxygenase-2 inhibitors).

The following are recommendations on patient education prior to MKI therapy.

• Providers are encouraged to listen to patient concerns, offer options to enhance patient comfort, and identify treatment issues early.
• No studies were found that tested efficacy of patient education approaches for preventing hand-foot skin reactions (HFSRs) (e.g., written materials, videos).

Treatment and palliation for management of HFS symptoms:

• Grade 1 HFS
  • Dermatology referral and management, as appropriate
  • Use of keratolytics (e.g., 40% urea and/or salicylic acid) to aid in exfoliation of callused areas
  • Cushioning of affected regions with gel inserts in shoes or use of loose-fitting shoes or slippers
  • Frequent application of emollients and creams, especially to palms and soles, to maintain moisture and prevent breaks in skin integrity
  • Analgesics
  • Local/regional cooling (e.g., cool compresses)
  • Foot soaks in magnesium sulfate to soften calluses and reduce pain upon pressure
• Grade 2 HFS
  • All interventions as outlined for grade 1
  • Dosage or regimen adjustments of MKIs
  • Continue to control symptoms and relieve patient discomfort
• Grade 3 HFS
  • Topical therapy to reduce symptoms and prevent further progression (e.g., frequent use of creams and lotions, especially to palms and soles of feet; wet disinfectant to treat blisters and erosions; cortisone creams and topical antibiotics for severe forms of HFSRs)
  • Systemic strategies to reduce symptoms and prevent further progression (e.g., pyridoxine may be beneficial in doses of 50–150 mg/day)
  • Dosage or regimen adjustments of MKIs (e.g., interruption of MKI therapy for a minimum of seven days until toxicity is resolved to grade 0 or 1)

Authors stated that no evidenced-based treatment algorithms exist for cutaneous toxicities of the MKIs in the dermatologic or oncologic literature. It was noted that none of these recommendations were based upon strong evidence-based data and that none of the C1 articles were randomized, controlled trials designed to test HFS reactions management. It was revealed that clinical approaches to HFS are largely anecdotal, from case reports, based on practices during clinical trials of antineoplastic treatment, obtained from post-marketing practices, or extrapolated from approaches often used with chemotherapeutic treatments.

No actual convincing evidence was found in this review for any recommendation identified.

• Among all the C1 articles reviewed, none were randomized, controlled trials designed to test HFS management approaches.
• None of the ancillary, observational, or case control studies described in the literature reviewed were designed to test the effectiveness of HFS management interventions.
• Most information being used is anecdotal or based upon individual provider experience and preference.

This review points to the need for research to test and compare various recommendations for prevention and management of HFS on clinical and patient-centered outcomes.

Research is needed in the following.

• Appropriate and effective patient education for prevention
• How often the patient should be seen and assessed for HFS
• How to accurately diagnose mild HFS and recognize subsequent skin complications
• How to effectively treat without leading to increased HFS damage and symptoms
• Providing guidance on the best types of gel inserts, cushions, and soft footwear
• Identifying treatment strategies that are most effective at all grades of HFS
• Testing specific emollients or creams for preventive or reactive treatment of MKI-associated HFS

To determine if a mindfulness-based stress reduction (MBSR) intervention improves sleep quality in postoperative patients with breast cancer.

An MBSR intervention was implemented using a standardized MBSR manual and was led by trained instructors. The intervention included eight weekly MBSR group sessions lasting two hours each. Sessions included psychoeducation on stress response, gentle yoga, and mindfulness meditation. No additional content was added in regard to sleep problems. All participants were encouraged to practice MBSR at home for 45 minutes daily and were given CDs and meditation guides for home practice. All participated in a five-hour retreat after week 7. Assessments were performed postintervention and at 6 and 12 months.

• The study included 336 women in the intention-to-treat (ITT) analysis. The final sample was comprised of 264 women.
• Mean (standard deviation [SD]) age was 53.9 years (SD = 10.1 years) in the MBSR group and 54.4 years (SD = 10.5 years) in the control group.
• Participants had breast cancer and were 3 to 18 months postoperative.

• Multisite 
• Denmark

Participants were undergoing the transition phase of care after active treatment.

The study was a randomized, controlled trial with repeated measures.

• Medical Outcome Study (MOS) Sleep Scale (not validated in patients with breast cancer)
• Symptom Checklist-90-revised (SCL-90-R)
• Hot Flush Score (stated as validated, but no further information was provided on validity or reliability)

Sleep quality improved from baseline to postintervention for both groups, with statistically significant differences in mean scores for sleep quality for the MBSR group in two indices of the sleep problem index (p = 0.03). There were no significant differences between groups at the 6- and 12-month follow-ups. Change in overall sleep quality was also significantly better in the MBSR group from baseline to postintervention (p = 0.05) but with a small effect size (<0.3). Further quantile regression analysis revealed that those who participated in MBSR had a significantly smaller increase in sleep disturbances from baseline than the control group in the twenty-fifth percentile, although this effect was not significant across quartiles. The effects of MBSR on sleep quality were not modified by hot flushes or psychological distress.

MBSR has limited short-term but no long-term effects on sleep quality in postoperative patients with breast cancer. Effects on sleep quality are small and are not modified by hot flushes or psychological distress. Further study is needed to determine if MBSR is effective for patients with significant sleep problems immediately after surgery and if booster MBSR sessions have longer-term effects.

• The study had risks of bias due to no blinding and no appropriate attentional control condition.
• Measurement validity/reliability was questionable.
• Subject withdrawals were 10% or greater.
• Of the patients, 7% in the intervention group were either lost to follow-up or discontinued the intervention and about 15% in the control group were lost to follow-up. No analysis of differences was performed on those lost to follow-up and those who continued. Although not statistically significant, baseline sleep disturbance data showed lower results for disturbance in the intervention group, and ITT analysis was the last value carried forward. ITT analysis may have overstated the effects of MSRB in this case.

Further study is needed to determine if MBSR is effective for improving sleep quality in patients with breast cancer. Nurses should assess for sleep problems in patients with breast cancer across treatment and especially after treatment.

To evaluate whether a six-week supervised multimodal exercise intervention can reduce cancer-related fatigue levels.

The intervention involved having patients exercise for 2.25 hours for four days per week for a total of six weeks in a group session of dynamic exercises using heavy resistance, cardiovascular training, relaxation techniques, body awareness (i.e., stretching, breathing, yoga, and Pilates), and massage.  The study was wait-list controlled.

• The sample was comprised of 213 patients.
• Mean age was 47.5 years (range 20–65).
• In the control, 28% of patients were male and 72% were female. In the intervention, 20.8% of patients were male and 79.2% were female. 
• Mean days since diagnosis was 82/86.5, and 52% to 58% of patients had no evidence of disease at baseline.
• Of the patients, 103 had breast cancer and 29 had bowel cancer.
• Of the patients, 83.7% of the control and 82.7% of the intervention reported some kind of exercise at baseline.

• Single site 
• Outpatient 
• Copenhagen

Patients were undergoing the active antitumor treatment phase of care. 

This was a randomized, controlled trial.

Functional Assessment of Cancer Therapy-Anaemia Questionnaire (FACT-An) 

Improvement occurred in fatigue score in the intervention compared to the control (p = 0.002; effect size = 0.44).  FACT-An subscale score (13 items were related to fatigue, and seven were indirectly related) was also improved in the intervention compared to the control (p = 0.015). FACT-An improved (p = 0.009), and Anemia-ANS improved (p = 0.002). Well-being scores of Quality of Life (QOL) scores showed no difference.

Supervised exercise can have an effect on fatigue levels for patients during chemotherapy. Specific diagnoses and fatigue after treatment were not evaluated.

• There were risks of bias due to no blinding, lack of an appropriate attentional control condition, and sample characteristics [patients were self-referred to the program, suggesting a highly motivated group]).
• Participant withdrawals were 10% or greater.

 Patients experiencing fatigue during active treatment may benefit from supervised multimodal exercise.

To evaluate the effect of a multidimensional exercise program on managing symptoms in patients with cancer undergoing chemotherapy

Patients receiving chemotherapy participated in a structured, supervised exercise program, consisting of resistance-fitness training, massage, relaxation, and body-awareness training held in a workout room within the hospital, two to three times per week for a six-week period. Participants trained in mixed groups of seven to nine. Physiotherapists and a specially trained nurse, who participated in the physical training, supervised the program. Participants selected a total package of high or low intensity physical activity. They were not able select one activity over another.

• The study consisted of 54 patients with cancer.
• Participant ages ranged from 18-65 years.
• All patients had been diagnosed at least one month prior receiving chemotherapy for adjuvant or advanced disease and had World Health Organization (WHO) performance statuses of 0-1 (0-5 scale).
• Patients were excluded from the study if they had documented brain metastases, had received anticoagulation treatment or treatment for arrhythmia or myocardial infarction within the past three months, had dementia and psychotic conditions, or were unable to read and write in Danish.

The study was conducted at university outpatient and inpatient settings in Denmark.

This was a prospective, exploratory study.

Using semi-structured diaries, patients rated 12 symptoms, including lack of appetite, nausea and vomiting, diarrhea, paraesthesia, constipation, physical fatigue, treatment-related fatigue, muscle pain, arthralgia, and other pain, defined by Common Toxicity Criteria (CTC) daily using a 0-4 scale.

• During the intervention, patients reported decreases in 10 of 12 symptoms.
• Patients with evidence of disease scored symptoms higher than those without evidence of disease.
• Both groups responded positively to the intervention based on sum of symptom scores.

A six-week, multidimensional exercise intervention administered while patients were simultaneously receiving chemotherapy led to reductions in symptoms.

• The use of daily diaries is time consuming for patients.
• Some data was missing.
• Because this continued over time, participants may have recorded the previous score just to fill it in.
• An exercise program takes commitment. The length of time for classes varied between high- and low-intensity groups.
• Providing space for workout rooms accessible to inpatients and outpatients may be an issue for some centers.
• Each symptom was given equal weight whereas some symptoms may be perceived as more problematic for patients.
• This intervention requires a high level of knowledge and specific skills on the part of the individual who trains and supervises patients.

The guideline provides an algorithm for the screening and assessment of anxiety, a care map for anxiety in adults with cancer, an algorithm for the screening and assessment of depression, a care map for depression in adults with cancer, the Patient Health Questionnaire (PHQ 9) symptom depression scale and generalized anxiety disorder (GAD) items, and selected measures for depression and anxiety (modified).

• Before the implementation of guidelines, referral systems and resources should be identified and available in each institution.
• The guidelines are designed for healthcare providers, patients, family members, and caregivers to guide in the screening, assessment, and treatment approaches of adult patients with cancer who have anxiety and depression at any stage of the cancer continuum, regardless of cancer type, disease stage, or treatment modality. 
• All patients with cancer and cancer survivors should be evaluated for the symptoms of anxiety and depression with validated instruments at periodic times during the cancer care. Treatment recommendations are based on the levels of symptoms. Follow-up care and reassessment are important in this setting to monitor for follow-through, compliance with referrals, and pharmacologic management. If compliance is poor, develop a plan. After eight weeks of treatment, if symptoms are not improved or poor compliance is noted, alter the treatment course and add a psychological or pharmacologic intervention. The guidelines recommend that individual psychological interventions be delivered by a licensed mental health professional, which may include cognitive and behavioral strategies, education and relaxation strategies, group psychosocial interventions, and physician-prescribed antidepressants. 

• A guideline that has been adapted from another country often can't lend itself to different policies or cultural influences.
• Some of the recommendations were removed from the original guideline because of references to the Edmonton Symptom Assessment Scale screening measure, which is not widely used in the United States.

Nurses play a vital role in the early screening, assessment, and treatment of patients who may have significant symptoms of anxiety and depression. By screening and making appropriate referrals, we can impact the emotional, interpersonal, and financial costs for patients and reduce the economic impact for providers and the healthcare system.