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September 2013, Volume 40, Number 5


Oncology Nursing Society Position


Implementing Screening for Distress: The Joint Position Statement

From the American Psychosocial Oncology Society, Association of

Oncology Social Work, and Oncology Nursing Society


In 2015, the American College of Surgeons (ACoS) Commission on Cancer (CoC) will require cancer centers to implement screening programs for psychosocial distress as a new criterion for accreditation.1 Distress, an indicator of suffering and predictor of poor health and quality of life outcomes throughout the disease trajectory, is common and treatable.2–10 Emerging research suggests that screening for and addressing distress not only enhances quality of life but may also be associated with improved cancer outcomes.11-13 Unfortunately, distress often goes unrecognized in oncology care, necessitating the development of systematic methods for its identification and management.14,15 Our organizations wholly endorse the new CoC standard 3.2 on psychosocial distress screening and recognize that it will help address unmet psychosocial needs and improve “cancer care for the whole patient.”16 While the CoC standard articulates basic components and processes that must be included in the implementation of screening, there remain some key issues that we believe are critical to quality patient care. This statement summarizes our position on these issues.


·         It is imperative that CoC-accredited programs adopt a universal definition of distress. We concur with the National Comprehensive Cancer Network (NCCN) definition of distress as an “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.”17


·         A variety of tools exist for distress screening,18 and programs should select and use validated instruments, following published threshold values and ranges to identify distressed patients.


·         Given that distress has multiple dimensions, instruments should screen broadly and not focus solely on one particular symptom.


·         Distress can occur at multiple time points from a cancer diagnosis onward and may go unrecognized if screening is conducted at only one time.


·         Processes need to be established for the results of every screen to be communicated to and reviewed by the patient’s treatment team in a timely manner. Similar to measuring vital signs, a medical assistant could administer a screening instrument, but clinicians trained in distress screening must interpret the results.


·         If the score exceeds the distress threshold, a trained clinician should differentiate the cause of distress (i.e., depression, lack of transportation, shortness of breath, etc.) and ensure that an assessment by or referral to an appropriate qualified clinician is completed. Programs should follow the NCCN guidelines for the management of distress.17


·         Referrals for the assessment and management of distress should be considered part of a patient’s routine medical care, and presented to the patient as such.  Because the risk of suicide is elevated in individuals with cancer, patients whose screens suggest suicide risk should be asked about suicidal ideation as part of their clinical evaluation.19–21


·         The required psychosocial representative on the cancer committee who oversees the screening program should have training in the identification and management of distress in patients with cancer. Programs without such a person should consider educating a current staff member. On-line training opportunities are available through APOS (www.apos-society.org) and ONS (www.ons.org/CourseDetail.aspx?course_id=87 and www.ons.org/Research/PEP/). In the event that a cancer program does not have licensed mental health professionals on staff, we strongly encourage contracting with a professional psychosocial oncology expert or qualified community organization for referral and follow-up.


Approved by the ONS Board of Directors, 6/2013.

Approved by the AOSW Board of Directors, 6/2013.

Approved by the APOS Board of Directors, 6/2013.




1.        American College of Surgeons. Cancer Program Standards (CPS) 2011 Project. [Online] [Cited: July 10, 2012.] http://www.facs.org/cancer/coc/cps2011.html


2.        Hoffman BM, Zevon MA, D’Arrigo MC, et al. (2004) Screening for distress in cancer patients: the NCCN rapid-screening measure. Psychooncology 13: 792-799.


3.        Jacobsen PB, Donovan KA, Trask PC, et al. (2005) Screening for psychologic distress in ambulatory cancer patients. Cancer 103: 1494-1502.


4.        Trask PC, Paterson A, Riba M, et al. (2002) Assessment of psychological distress in prospective bone marrow transplant patients. Bone Marrow Transplant 29: 917-925.


5.        Kennard BD, Smith SM, Olvera R, et al. (2004) Nonadherence in adolescent oncology patients: preliminary data on psychological risk factors and relationships to outcome. J Clin Psych Med Settings 11: 30-39.


6.        Von Essen L, Larsson G, Oberg K, et al. (2002) Satisfaction with care: associations with health-related quality of life and psychosocial function among Swedish patients with endocrine gastrointestinal tumours. Eyr J Cancer Care 11: 91-99.


7.        Skarstein J, Aass N, Fossa SD, et al. (2000) Anxiety and depression in cancer patients: relation between the Hospital Anxiety and Depression Scale and the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire. J Psychosom Res 49: 27-34.


8.        Greer JA, Pirl WF, Park E, Lynch TJ, Temel JS. Behavioral and psychological predictors of chemotherapy adherence in patients with advanced non-small-cell lung cancer. J Psychosom Res, 2008; 65: 549-552.


9.        Pirl WF, Traeger L, Greer J, Jackson V, Gallagher E, Lennes I, Sequist L, Temel J. (2012). Depression and survival in stage IV NSCLC: impact of early palliative care. J Clin Oncol 30: 1310-1315.


10.    Zabora J, BrintzenhofeSzoc K, Curbow B, Hooker C, Piantadosi S. (2001) The prevalence of psychosocial distress by cancer site. Psycho-oncology 10: 19-28.


11.    Andersen BL, Thornton LM, Shapiro CL, Farrar WB, Mundy BL, Yang HC, and William E. Carson WE. (2010) Biobehavioral, Immune, and Health Benefits following Recurrence for Psychological Intervention Participants. Clin Cancer Res 16: 3270-3278.


12.    Giese-Davis J, Collie K, Rancourt KM, Neri E, Kraemer HC, Spiegel D. (2011) Decrease in depressive symptoms is associated with longer survival in patients with metastatic breast cancer: a secondary analysis. J Clin Oncol 29: 413-20.


13.    Pirl WF, Greer JA, Gallagher ER, Temel JS, Traeger L, Lennes IT. (2012) Association of screening for psychosocial distress in patients with newly diagnosed stage IV NSCLC and survival. J Clin Oncol 30, 2012 (suppl; abstr 9030).


14.    Carlson LE, Angen M, Cullum J, et al: High levels of untreated distress and fatigue in cancer patients. Br J Cancer 90(12):2297-2304, 2004.


15.    Passik SD, Dugan W, McDonald MV, et al: Oncologists’ recognition of depression in their patients with cancer. J Clin Oncol 16(4):1594-1600, 1998.


16.    Institute of Medicine (IOM). Cancer care for the whole patient: Meeting psychosocial health needs. Washington, DC: The National Academies Press; 2008.


17.    National Comprehensive Cancer Network. Distress Management Clinical Practice Guidelines in Oncology. Version 3.2012. Accessed on August 1, 2012, from http://www.nccn.org/professionals/physician_gls/pdf/distress.pdf


18.    Carlson LE, Waller A, Mitchell AJ: Screening for distress and unmet needs in patients with cancer: Review and recommendations. J Clin Oncol 30(11):1160-1177, 2012.


19.    Misono S, Weiss NS, Fann JR, Redman M, Yueh B. (2008) Incidence of suicide in persons with cancer. J Clin Oncol 26: 4731-4738.


20.    Anguaino L, Mayer DK, Piven ML, Rosenstein D. (2011) A literature review of suicide in cancer patients. Cancer Nurs 35: E14-E26.


21.    Cooke L, Gotto J, Mayorga L, Grant M, Lynn R. (2013) What do I say? Suicide assessment and management. Clin J Oncol Nurs 17: E1-E7.