Distress Management: NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines)

NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines)
Distress
Management
Version 2.2014
NCCN.org
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NCCN Guidelines Version 2.2014 Panel Members NCCN Guidelines Index

Distress Management TOC
Distress Management Discussion
* Jimmie C. Holland, MD/Chair Stewart Fleishman, MD Randi McAllister-Black, PhD

Memorial Sloan-Kettering Cancer Center Consultant City of Hope
Comprehensive Cancer Center
Paul B. Jacobsen, PhD /Vice-Chair Jayme Flynn, NP #
H. Lee Moffitt Cancer Center and Research Vanderbilt-Ingrim Cancer Center Karen Y. Mechanic, MD
Institute at the University of South Florida Fox Chase Cancer Center
Caryl D. Fulcher, RN, MSN, CS William Mitchell, MD
Barbara Andersen, PhD Duke Cancer Institute UC San Diego Moores Cancer Center
The Ohio State University Comprehensive
Cancer Center - James Cancer Hospital and Donna B. Greenberg, MD Oxana Palesh, PhD, MPH
Solove Research Institute Massachusetts General Hospital Cancer Center Stanford Cancer Institute
William S. Breitbart, MD Carl B. Greiner, MD Janice P. Pazar, Rn, PhD

Memorial Sloan-Kettering Cancer Center Fred & Pamela Buffet Cancer Center St. Jude Childrens Research
at The Nebraska Medical Center Hospital/University of Tennessee Cancer
Benjamin Brewer, PsyD Institute
University of Colorado Rev. George F. Handzo, MA, MDiv
Michelle B. Riba, MD, MS
Consultant University of Michigan
Luke O. Buchmann, MD Comprehensive Cancer Center
Huntsman Cancer Institute Laura Hoofring, MSN, APRN #
at the University of Utah The Sidney Kimmel Comprehensive Kristin Roper, RN #
Cancer Center at Johns Hopkins Dana-Farber/Brigham and Womens
Teresa L. Deshields, PhD Cancer Center
Siteman Cancer Center at Barnes-Jewish Charles Hoover
Hospital and Washington University School of Patient Advocate Rosa Scrivani, LCSW
Medicine Roswell Park Cancer Institute
Elizabeth Kvale, MD
Moreen M. Dudley, MSW University of Alabama at Birmingham Alan D. Valentine, MD
The University of Texas
Fred Hutchinson Cancer Research Center/ Comprehensive Cancer Center M. D. Anderson Cancer Center
Seattle Cancer Care Alliance
Michael H. Levy, MD, PhD Lynne I. Wagner, PhD
Psychiatry, psychology, including health behavior Fox Chase Cancer Center Robert H. Lurie Comprehensive Cancer
Internal medicine Center of Northwestern University
Supportive Care including Palliative, Pain Matthew J. Loscalzo, MSW
management, Pastoral care and Oncology social work City of Hope
Bone Marrow Transplantation Comprehensive Cancer Center
# Nursing
Medical oncology
Surgery/Surgical oncology Continue NCCN
Patient Advocacy Nicole McMillian, MS
* Writing committee member
NCCN Guidelines Panel Disclosures Deborah Freedman-Cass, PhD
NCCN Guidelines Version 2.2014 Table of Contents NCCN Guidelines Index

NCCN Distress Management Panel Members

Summary of the Guidelines Updates Clinical Trials: NCCN believes that
Key Terms: the best management for any cancer
Distress (DIS-1) patient is in a clinical trial.
Participation in clinical trials is
Definition of Distress in Cancer (DIS-2) especially encouraged.
Standards of Care for Distress Management (DIS-3) To find clinical trials online at NCCN
Overview of Evaluation and Treatment Process (DIS-4) member institutions, click here:
nccn.org/clinical_trials/physician.html.
Expected Distress Symptoms (DIS-5)
NCCN Categories of Evidence and
NCCN Distress Thermometer and Problem List (DIS-A) Consensus: All recommendations
Psychosocial Distress Patient Characteristics (DIS-B) are Category 2A unless otherwise
specified.
Psychological/Psychiatric Treatment Guidelines (DIS-6) See NCCN Categories of Evidence
Social Work and Counseling Services: Practical Problems (DIS-20) and Consensus.
Social Work and Counseling Services: Psychosocial Problems (DIS-21)
Chaplaincy Services (DIS-22)
Recommendations for Implementation of Standards and Guidelines (DIS-29)
Recommended Readings for Implementation of Psychosocial Care Into the
Routine Care of Patients With Cancer (DIS-29)
Institutional Evaluation of Standards of Care (DIS-31)
For End of Life Issues, See the NCCN Guidelines for Palliative Care
For Cancer Pain, See the NCCN Guidelines for Adult Cancer Pain
The NCCN Guidelines are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment.
Any clinician seeking to apply or consult the NCCN Guidelines is expected to use independent medical judgment in the context of individual clinical
circumstances to determine any patients care or treatment. The National Comprehensive Cancer Network (NCCN) makes no representations or
warranties of any kind regarding their content, use or application and disclaims any responsibility for their application or use in any way. The NCCN
Guidelines are copyrighted by National Comprehensive Cancer Network. All rights reserved. The NCCN Guidelines and the illustrations herein may
not be reproduced in any form without the express written permission of NCCN. 2014.
NCCN Guidelines Version 2.2014 Updates NCCN Guidelines Index

Updates in version 2.2014 of the NCCN Guidelines for Distress Management from Version 1.2014 include:
The Discussion section has been updated to reflect the changes in the algorithm. (MS-1)
Updates in version 1.2014 of the NCCN Guidelines for Distress Management from Version 2.2013 include:
DIS-3 DIS-10 (Mood Disorder)
Third bullet revised: All patients should be screened for distress Evaluation: New bullet added, Evaluate family/home environment.
at their initial visit, at appropriate intervals, and as clinically (Also applies to Schizophrenia/Psychotic Disorder DIS-12; Anxiety
indicated especially with changes in disease status (ie, remission, Disorder DIS-16)
recurrence, progression, treatment-related complications). Treatment: The recommendation Antidepressant (category 1)
anxiolytic changed to Psychotropic medication (category 1).
DIS-4
Evaluation DIS-13 (Schizophrenia/Psychotic Disorder)
Recommendation revised, Clinical assessment (which may Under Evaluation, diagnostic studies and modification of factors
include clinical interviews and validated scales/screeners for related to: New sub-bullet added, Evaluate barriers to medication
anxiety and depression) by primary oncology team of oncologist, adherance.
nurse, social worker...
New bullet added: Emotional problems, including anxiety and DIS-17 (Substance-Related Disorder/Abuse)
depression. History of abuse pathway;Treatment:
New footnote a added: The Problem List of the NCCN Distress Second bullet revised, Consider referral to risk reduction program or
Thermometer Screening Tool may be modified to fit the needs of substance management program.
the local population. New bullet added, Discuss risk reduction strategies.
DIS-A DIS-18 (Substance-Related Disorder/Abuse)

The NCCN Distress Thermometer and Problem List were Response pathway, Fourth column revised: Referral to specialized
reformatted for usability and clarity. treatment maintenance programs or Discuss strategies for abuse
prevention.
DIS-B (Psychosocial Distress Patient Characteristics)
Periods of Increased Vulnerability: New bullet added, Significant
treatment-related complication(s).
DIS-9 (Delirium)
Far right; Augment medication...: After No response the
pathway was revised for clarity.
UPDATES
1 OF 2
NCCN Guidelines Version 2.2014 Updates NCCN Guidelines Index

DIS-21 (Social Work and Counseling Services)

Psychosocial problems; Social Work and Counseling Interventions: First bullet revised, Patient and family counseling/psychotherapy, sex
counseling, and or grief counesling.
DIS-29 (Recommended Readings For Implementation of Psychosocial Care Into The Routine Care of Patients With Cancer)
Section title revised, Recommended Readings For Implementation of Programs That Integrate Psychosocial Care Into The Routine Care of
Patients With Cancer.
The following readings were added:
Donovan KA, Jacobsen PB. Progress in the implementation of NCCN guidelines for distress management by members institutions. J Natl
Compr Canc Netw 2013;11:223-236. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23411388.
Hammelef KJ, Friese CR, Breslin TM, et al. Implementing distress management guidelines in ambulatory oncology: a quality improvement
project. Clin J Oncol Nurs 2014;18 (Suppl):31-36. Available at: http://www.ncbi.nlm.nih.gov/pubmed/24480661.
Hammonds LS. Implementing a distress screening instrument in a university breast cancer clinic: a quality improvement project. Clin J
Oncol Nurs 2012;16:491-494. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23022932.
Lazenby M. The international endorsement of US distress screening and psychosocial guidelines in oncology: A model for dissemination.
J Natl Compr Canc Netw 2014;12:221-227. Available at: http://www.ncbi.nlm.nih.gov/pubmed/24586084.
Wagner LI, Spiegel D, Pearman T. Using the science of psychosocial care to implement the new american college of surgeons commission
on cancer distress screening standard. J Natl Compr Canc Netw 2013;11:214-221.
Available at: http://www.ncbi.nlm.nih.gov/pubmed/23411387.
UPDATES
Version 2.2014, 07/08/14 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. 2 OF 2
NCCN Guidelines Version 2.2014 NCCN Guidelines Index

DISTRESS
Term distress was chosen because it:
Is more acceptable and less stigmatizing than psychiatric,

psychosocial, or emotional
Sounds normal and less embarrassing
Can be defined and measured by self-report.
Definition of Distress in Cancer (DIS-2)
Note: All recommendations are category 2A unless otherwise indicated.

Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
Version 2.2014, 07/08/14 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. DIS-1

DEFINITION OF DISTRESS IN CANCER
Distress is 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 a continuum, ranging from common
normal feelings of vulnerability, sadness, and fears to problems that can become disabling, such as
depression, anxiety, panic, social isolation, and existential and spiritual crisis.
Standard of Care for Distress Management (DIS-3)


STANDARDS OF CARE FOR DISTRESS MANAGEMENT
Distress should be recognized, monitored, documented, and treated promptly at all stages of disease and in all settings.
Screening should identify the level and nature of the distress.
All patients should be screened for distress at their initial visit, at appropriate intervals, and as clinically indicated especially with
changes in disease status (ie, remission, recurrence, progression, treatment-related complications).
Distress should be assessed and managed according to clinical practice guidelines.
Interdisciplinary institutional committees should be formed to implement standards for distress management.
Educational and training programs should be developed to ensure that health care professionals and certified chaplains have
knowledge and skills in the assessment and management of distress.
Licensed mental health professionals and certified chaplains experienced in psychosocial aspects of cancer should be readily
available as staff members or by referral.
Medical care contracts should include reimbursement for services provided by mental health professionals.
Clinical health outcomes measurement should include assessment of the psychosocial domain (eg, quality of life and patient and
family satisfaction).
Patients, families, and treatment teams should be informed that management of distress is an integral part of total medical care and
provided with appropriate information about psychosocial services in the treatment center and the community.
Quality of distress management programs/services should be included in institutional continuous quality improvement (CQI) projects.


OVERVIEW OF EVALUATION AND TREATMENT PROCESS

EVALUATION TREATMENT
Clinical assessment
(which may include See Psychological/
clinical interviews, Mental healthc Psychiatric
and validated scales/ services treatment
screeners for anxiety Guidelines (DIS-6)
Clinical evidence Follow-up and
and depression) by
of moderate to communication
primary oncology
severe distress Social work See Social Work with primary
team of oncologist,
or score of 4 or Referral and counseling and Counseling oncology team
nurse, social worker
more on services Services (DIS-20) and family/
for:
screening tool caregivers
High risk patientsb
(DIS-A)a Periods of
vulnerability Chaplaincy See Chaplaincy
Unrelieved physical Risk factors for services Services (DIS-22)
Brief screening symptoms, treat as distress
for distress per disease specific Practical problems
or supportive care Family problems If
(DIS-A):a
guidelines (See Spiritual/religious necessary
Screening tool
Problem list NCCN Guidelines for concerns
Supportive Care) Physical problems
Social problems
Emotional problems,
Clinical evidence including anxiety
of mild distress and depression
or score of Primary
oncology team See Expected Distress
less than 4 on Symptoms (DIS-5)
screening tool + resources available
(DIS-A) Refer to NCCN Guidelines
aThe Problem List of the NCCN Distress Thermometer Screening Tool may be modified to fit the needs of the local population. Table of Contents for
bSee Psychosocial Distress Patient Characteristics (DIS-B). Supportive Care Guidelines.
cPsychiatrist, psychologist, advanced practice clinicians, and/or social worker.


EXPECTED DISTRESS INTERVENTIONS RE-EVALUATION

SYMPTOMS
Clarify diagnosis, treatment options

and side effects
Be sure patient understands
disease and treatment options
Refer to appropriate patient
Patients at increased risk of
education materials (eg, NCCN
vulnerability to distressb
Treatment Summaries for Patients)
Signs and symptoms of fear
Educate patient that points of
and worry about the future
transition may bring increased Stable or Continue
and uncertainty
vulnerability to distress diminished monitoring
Concerns about illness
Acknowledge distress distress and support
Sadness about loss of
Build trust
usual health
Ensure continuity of care
Anger, feeling out of Monitor
Mobilize resources
control functional level
Consider medication to manage
Poor sleep and reevaluate
symptoms:
Poor appetite at each visit
Analgesics
Poor concentration See Distress
(See NCCN Adult Cancer Pain
Preoccupation with Increased or Score 4 or
Guidelines)
thoughts of illness and persistent moderate to
Anxiolytics
death distress severe distress
Hypnotics
Disease or treatment side (DIS-4)
Antidepressants
effects
Support groups and/or individual
Concerns about social role
counseling
(ie, as father, mother)
Family support and counseling
Relaxation, meditation, creative
therapies (eg, art, dance, music)
Spiritual support
Exercise
bSee Psychosocial Distress Patient Characteristics (DIS-B).


NCCN DISTRESS THERMOMETER PROBLEM LIST

Please indicate if any of the following has been a problem for you in
the past week including today.
Be sure to check YES or NO for each.
YES NO Practical Problems YES NO Physical Problems
Instructions: Please circle the number (0-10) that best Child care Appearance
describes how much distress you have been experiencing in Housing Bathing/dressing
the past week including today. Insurance/financial Breathing
Transportation Changes in urination
Work/school Constipation
Extreme distress 10 Treatment decisions Diarrhea
Eating
9
Family Problems Fatigue
8 Dealing with children Feeling Swollen
Dealing with partner Fevers
7 Ability to have children Getting around
6 Family health issues Indigestion
Memory/concentration
5 Emotional Problems Mouth sores
Depression Nausea
4
Fears Nose dry/congested
3 Nervousness Pain
Sadness Sexual
2 Worry Skin dry/itchy
1 Loss of interest in Sleep
usual activities Substance abuse
No distress 0 Tingling in hands/feet
Spiritual/religious
concerns
Other Problems:__________________________________________
________________________________________________________
Version 2.2014, 07/08/14 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. DIS-A

PSYCHOSOCIAL DISTRESS PATIENT CHARACTERISTICSd
PATIENTS AT INCREASED RISK FOR DISTRESSe PERIODS OF INCREASED VULNERABILITY
History of psychiatric disorder/substance abuse Finding a suspicious symptom

History of depression/suicide attempt During diagnostic workup
Cognitive impairment Finding out the diagnosis
Communication barriersf Awaiting treatment
Severe comorbid illnesses Change in treatment modality
Social issues Significant treatment-related complication(s)
Family/caregiver conflicts End of treatment
Inadequate social support Discharge from hospital following treatment
Living alone Transition to survivorship
Financial problems Medical follow-up and surveillance
Limited access to medical care Treatment failure
Young or dependent children Recurrence/progression
Younger age; woman Advanced cancer
History of abuse (physical, sexual) End of life
Other stressors
Spiritual/religious concerns
Uncontrolled symptoms
dForsite-specific symptoms with major psychosocial consequences, see Holland, JC, Greenberg, DB, Hughes, MD, et al. Quick Reference for Oncology Clinicians:
The Psychiatric and Psychological Dimensions of Cancer Symptom Management. (Based on the NCCN Distress Management Guidelines). IPOS Press, 2006.
Available at www.apos-society.org.
eFrom the NCCN Palliative Care Clinical Practice Guidelines in Oncology. Available at www.nccn.org.
fCommunication barriers include language, literacy, and physical barriers.

Version 2.2014, 07/08/14 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. DIS-B

PSYCHOLOGICAL/PSYCHIATRIC
TREATMENT GUIDELINES
Dementia (DIS-7)
Delirium (encephalopathy) (DIS-9)
Evaluation for:
Mood Disorder (DIS-10)
Distress
Behavior symptoms
Psychiatric history/medications Follow-up and
Schizophrenia/psychotic disorder (DIS-12)
Referral by Pain and symptom control communication
oncology team (See NCCN Adult Cancer Pain Guidelines) with primary
to mental Body image/sexuality oncology team
health teamc Impaired capacity Adjustment Disorder (DIS-14) and family/
Safety caregivers
Psychological/psychiatric disorder
Medical causes
(refer to primary oncology team) Anxiety Disorder (DIS-16)
Substance-Related Disorder/Abuse (DIS-17)
Personality Disorder (DIS-19)
For End of Life Issues, See NCCN

cPsychiatrist, psychologist, advanced practice clinicians, and/or social worker. Palliative Care Guidelines

DEMENTIA EVALUATION
(ICD-10 codes: F00-F03)
Negative Observe
No
Evaluate for depression
impairment
See Mood Disorder

Positive
Signs and Neurologic and mental (DIS-10)
symptoms of status examination
dementia in neuropsychological See Delirium
cancer testing Delirium
(DIS-9)
Evaluate for See Dementia

Dementia
Delirium/dementia (DIS-8)
Impairment
Assess safety
present
Assess capacity Decision-making Document and refer to
to make decisions capacity and safety institutional policies
impaired and procedures
Arrange for ongoing

Thought
primary psychiatric
disorder/psychosis
management
Return to Psychological/Psychiatric Guidelines (DIS-6)


DEMENTIA (continued) TREATMENT FOLLOW-UP

Evaluation, diagnostic studies, Reevaluate

and modification of factors Attend to patient safety
related to: Consider capacity to
No Follow-up and
Cancer make decisions
response communication
Treatment Refer to social services
Medications Consider alternate level with primary
Medical causes Cognitive rehabilitation of care oncology team
Withdrawal states medications and family/
Pain, fatigue, sleep disorders, caregivers
cognitive impairment, and
other symptoms Response
Assess safety
Assess family/caregiver
resources


DELIRIUM EVALUATION TREATMENT FOLLOW-UP

(Encephalopathy)
(ICD-10 code: F05)
Evaluation,
diagnostic studies,
and modification
of factors related Response
to: Follow-up and
Cancer communication
Treatment with primary
Signs and
Medications Neuroleptics + family oncology team
symptoms Augment
Medical causes support/education and family/
of delirium medication
Withdrawal environment caregivers
in cancer Continue:
states
Pain and other Support Response
symptoms Education
Assess safety Safety
No Consider See
Assess decision- Assess
response dementia (DIS-7)
making capacity decision-
making
capacity No Reevaluate
Re-evaluate response
cause of
delirium
Consider other
diagnoses


MOOD DISORDER EVALUATION TREATMENT FOLLOW-UP

(ICD-10 codes: F34, F38, F39)
Evaluation, diagnostic studies,
and modification of factors
related to: See Mood
No/partial
Cancer Disorder
Psychotherapy response
Treatment (DIS-11)
Psychotropic
Medications
medication Follow-up and
Medical causes communication
(category 1)
Withdrawal states with primary
Response
Pain
Psychiatric follow- oncology team
Fatigue
up for hospitalized and family/
No danger to
Insomnia
patients and caregivers
Anorexia
self or others outpatients
Anhedonia
Consider referral
Decreased interest in activities
to social work
Signs and symptoms Wish to die
services or
of mood disorders in Suicidal thoughts
chaplaincy services
cancer: Mood swings
See Social work
Mood disorder Consider psychosocial and
and Counseling
related to medical spiritual concerns
services (DIS-20) or
illness Assess decision-making
Chaplaincy services
Major depression capacity
(DIS-22)
Dysthymia Assess safety
Bipolar disorder Evaluate family/home
environment
Assure patient safety:

Consider psychiatric
consultation Psychiatric treatment and
Danger to self Increase monitoring follow-up for hospitalized
or others Consider removing dangerous and outpatients
objects
Consider hospitalization

MOOD DISORDER (continued) EVALUATION TREATMENT FOLLOW-UP

(ICD-10 codes: F34, F38, F39)
Consider augmenting or
changing medications
No/partial Consider electroconvulsive
Follow-up and
response therapy
Reevaluate diagnosis communication
No or partial response Consider consult/second
and response/adjust with primary
to treatment for signs opinion
medications as oncology team
and symptoms of mood indicated and family/
disorder in cancer psychotherapy caregivers
Response


SCHIZOPHRENIA/PSYCHOTIC DISORDER EVALUATION

(ICD-10 codes: 295.0, 296.0, 298.8, 298.9,
295.7, 298.0 298.4)
Follow-up and
communication with
No signs or history
primary oncology
of psychosis
team and family/
caregivers
Obtain history
of psychosis/
Signs and schizophrenia/
symptoms affective psychosis
of psychotic Obtain history of Evaluate for:
episode in corticosteriod use Delirium
cancer Neurologic and Steroid-induced Dementia See DIS-7
mental status psychosis
examination Substance-related
disorder/Abuse or Delirium See DIS-9
withdrawal
History of psychosis or Mood disorder See DIS-10
New diagnosis or
psychotic signs on mental
relapse of
status examination Schizophrenia/
psychotic disorder See DIS-13
(especially hallucination/ Psychotic disorder
Mood disorder
delusion/thought disorder)
Dementia
Akathisia from Substance-related
See-DIS-17
antipsychotics or disorder/Abuse
antiemetics
Assess safety Decision-making Document and refer to
Assess capacity to capacity and safety institutional policies
make decisions impaired and procedures
Evaluate family/home
environment


SCHIZOPHRENIA/PSYCHOTIC DISORDER TREATMENT FOLLOW-UP

(ICD-10 codes: 295.0, 296.0, 298.8, 298.9,
295.7, 298.0 298.4)
Evaluation, diagnostic studies, and

modification of factors related to:
Cancer
Secure safety
Treatment
Consider anti- Reevaluate
Medications (particularly steroids)
psychotic Attend to patient safety
Delirium
medications Consider capacity to make
Withdrawal states or substance
(Urgently administer No decisions Follow-up and
abuse
if necessary.) response Maintain communication with communication
New diagnosis of psychotic
Consider team for chronic psychotic with primary
disorder
medications for disorder/psychiatric service oncology team
Relapse of psychotic disorder
mood Consider alternate level of care and family/
(eg, not taking maintenance anti-
Consider transfer caregivers
psychotic medications)
to psychiatric unit/
Evaluate barriers to medication
hospital
adherance Response
Consider role of
Dementia
electroconvulsive
Assess safety
therapy in psychotic
Assess capacity to make decisions
depression/mania,
Assess family/caregiver resources
catatonia
including inpatient psychiatry
hospitalization and community
mental health team


ADJUSTMENT EVALUATION TREATMENT FOLLOW-UP

DISORDER
(ICD-10 code: F43.2)
See Reevaluate
No Adjust medications/ moderate/severe
response dosages adjustment
Moderate/severe
(DIS-15)
adjustment disorder
Medications prescribed
+ psychotherapy Follow-up and
Response
communication
with primary
oncology team
No danger to and family/
self or others caregivers
Response
Initiate
Mild adjustment disorder
psychotherapy/
Signs and symptoms No medications prescribed
counseling
of adjustment
disorder in cancer See Reevaluate
No
(mixed anxiety and mild adjustment
response
depressive symptoms) (DIS-15)
Assure patient safety:
Consider psychiatric
consultation
Danger to self Increase monitoring Follow-up for hospitalized
or others Consider removing patients and outpatients
dangerous objects
Consider
hospitalization


ADJUSTMENT DISORDER (continued) FOLLOW-UP

(ICD-10 code: F43.2)
Follow-up and communication

Response with primary oncology team
and family/caregivers
Reevaluate patients with
moderate/severe adjustment
disorder after adjusting Another disorder without See appropriate psychological/psychiatric pathway
medications/dosages personality disorder (DIS-6)
No See Personality Disorder

Personality disorder
response (DIS-19)
Continue therapy
Reevaluate
See pathway for Moderate/severe adjustment disorder

Adjustment disorder
Medications prescribed + psychotherapy (DIS-14)
Reevaluate patients with mild Another disorder without See appropriate psychological/psychiatric pathway
adjustment disorder after personality disorder (DIS-6)
psychotherapy/counseling
See Personality disorder

Personality disorder
(DIS-19)


ANXIETY DISORDER EVALUATION TREATMENT FOLLOW-UP

(ICD-10 codes: F40, F41)
Evaluate for
depression
Evaluation, No
and other
diagnostic studies, response
psychiatric
and modification of comorbidity
factors related to: Reevaluate
Signs and symptoms of Cancer medication
anxiety disorder in cancer: Treatment No (consider
Anxiety due to general Nausea/vomiting response neuroleptics),
medical condition Medications psychotherapy,
Generalized anxiety Medical causes support, education
disorder Withdrawal states
Panic disorder Pain Psychotherapy Response
Post-traumatic stress Poor anxiolytic Follow-up and
disorder concentration antidepressant communication
Phobic disorder Insomnia (category 1) with primary
Conditioned Anxiety or panic oncology team
nausea/vomiting attacks and family/
(See NCCN Guidelines Hypervigilance caregivers
for Antiemesis) Fears Response
Obsessive-compulsive Irritability
disorder Assess safety
Assess decision-
making capacity
Evaluate family and
home environment


SUBSTANCE-RELATED EVALUATION TREATMENT

DISORDER/ABUSE
See Appropriate
Treat symptoms
Current substance Detoxification
Substance abuse
abuse dependence Follow-up Treatment
management program
(DIS-18)
Signs, symptoms,
and history of Substance abuse history
dependence, active Toxicology screen
abuse or Labs, as clinically indicated
addictiong Assess impact on patient
(See NCCN with respect to cancer Discuss risk
Guidelines for treatment reduction strategies
Adult Cancer Pain) Consider referral
to risk reduction
program or See Prophylactic
substance Detoxification
History of abuse
management Follow-up Treatment
program (DIS-18)
Monitor for signs
and symptoms of
relapse
gOpioids, alcohol, tobacco, or other. Return to Psychological/Psychiatric Guidelines (DIS-6)


SUBSTANCE-RELATED DISORDER/ABUSE (continued) FOLLOW-UP

See appropriate
Treatment team meeting
No Evaluate for continued psychological/
Reevaluate for other
response drug abuse psychiatric pathway
psychiatric comorbidity
(DIS-6)
Following appropriate
detoxification regimen Referral to specialized Follow-up and
Psychoeducation maintenance program communication with
Response cognitive/behavioral psychotherapy or primary oncology
medications Discuss strategies for team and family/
abuse prevention caregivers
See appropriate
Treatment team meeting
No psychological/
Reevaluate for other
response psychiatric pathway
psychiatric comorbidity
(DIS-6)
Following prophylactic
detoxification regimen Referral to specialized
Follow-up and
maintenance program
Psychoeducation communication with
or
Response cognitive/behavioral psychotherapy primary oncology
Discuss strategies for
medications team and family/
abuse prevention
caregivers


PERSONALITY EVALUATION TREATMENT FOLLOW-UP

DISORDER
(ICD-10 code: F60)
Evaluation, diagnostic studies,

and modification of factors
related to:
Signs and symptoms Cancer Follow-up and
of personality Treatment communication
disorder in cancer: Medications with primary
Response
Personality change Medical causes oncology team
Withdrawal states Develop coordinated behavioral, and family/
related to medical
psychological, and medical treatment caregivers
or treatment factors Pain
Manipulative behavior plan with health care team
Borderline
(behavioral management medications) Reevaluate for
Dramatic/histrionic Anger
Threatening behavior Staff education for management other
Schizoid
Obsessive Dramatic/histrionic behavior No psychiatric
Paranoid Demanding behavior response comorbidity or
Anti-social Fearful substance
Assess safety abuse
Assess decision-making
capacity


SOCIAL WORK CATEGORY TYPE OF PROBLEM SOCIAL WORK AND COUNSELINGh

AND COUNSELING INTERVENTIONS
SERVICESh
Patient and family

counseling/psychotherapy
Illness-related problems Community resource
Concrete needs, including Severe/
mobilization/linkage
housing, food, financial moderate
Problem-solving teaching Follow-up and
assistance programs, Advocacy and patient/family communication
assistance with activities education with primary
Practical of daily living, oncology team
problems transportation and family/
Employment/school/career caregivers
concerns Patient/family education
Referral by
Cultural/language issues Education/support group
oncology
Family and caregiver Mild sessions
team
availability Resource lists
to social Patient/family
work assessment
and
counseling
servicesh
Psychosocial See (DIS-21)

problems
hSocial work and counseling services include mental health services using psychological/psychiatric treatment guidelines.
Note: All recommendations are category 2A unless otherwise indicated. See NCCN Guidelines
for Palliative Care

CATEGORY TYPE OF PROBLEM SOCIAL WORK AND COUNSELINGh

INTERVENTIONS
Patient and family counseling/

psychotherapy, sex counseling, or
grief counseling
Community resource mobilization
Problem-solving teaching
Adjustment to illness Advocacy and family/patient
Severe/ Follow-up and
Family and social conflict/isolation education
moderate communication
Treatment decisions, quality-of-life Education/support group sessions
issues, and transitions in care Protective services with primary
Advance directive Consider referral for psychosocial/ oncology team
Psychosocial Abuse and neglect psychiatric treatment and family/
problems Coping/communication Consider referral for chaplaincy caregivers
Functional changes including body counseling
image and sexuality
End of life/bereavement Patient/family education
Cultural concerns Education/support group sessions
Caregiver issues Mild Resource lists
(mobilizing caregiver support) Sex counseling
Grief counseling
hSocial work and counseling services include mental health services using psychological/psychiatric treatment guidelines.
Note: All recommendations are category 2A unless otherwise indicated. See NCCN Guidelines
for Palliative Care

CHAPLAINCY SERVICES
Grief (DIS-23)
Concerns about death and afterlife (DIS-23)
Conflicted or challenged belief systems (DIS-23)
Loss of faith (DIS-23)
Concerns with meaning/purpose of life (DIS-23) Follow-up and

communication
Referral by oncology
Chaplaincy Concerns about relationship with deity (DIS-23) with primary
team to chaplaincy
assessment oncology team
services
Isolation from religious community (DIS-24) and family/
caregivers
Guilt (DIS-25)
Hopelessness (DIS-26)
Conflict between religious beliefs and

recommended treatments (DIS-27)
Ritual needs (DIS-28)


CHAPLAINCY SERVICES
Continued
Yes
support
Spiritual counseling See appropriate

Reading materials psychological/
Concerns
Evidence of: (spiritual, philosophical) psychiatric
relieved Yes
Grief Prayer pathways (DIS-6)
Concerns about death Rituals and continued
and afterlife Refer to spiritual counseling
Conflicted or challenged mental
Spiritual No
belief systems health
assessment
Loss of faith professional
Concerns with
meaning/purpose of life
Continued
Concerns about Refer to social work or No
spiritual counseling
relationship with deity mental health services
(DIS-4)
Return to Chaplaincy Services (DIS-22) See NCCN Palliative Care Guidelines


CHAPLAINCY SERVICES: ISOLATION FROM RELIGIOUS COMMUNITY
Participation in religious
community resumed
Spiritual assessment/
Current member counselingi
of religious Serve as liaison between
community patient and religious
communityj
Refer to local
congregation
Evidence
Continuing support
of isolation
Refer to local
congregation
or certified chaplain
Not current Assist patient
member of Spiritual to access
religious assessment spiritual
community resources
Refer to social work

or mental health
professional
iConsider referral to community religious resource

jPuchalski C; Ferrell B; Birani Ret al. Special Report:
Improving the Quality of Spiritual Care as a dimension of
Palliative Care: The Report of the Consensus Conference. Journal of Palliative Medicine 2009; 12:885-905. Return to Chaplaincy Services (DIS-22)

CHAPLAINCY SERVICES: GUILT
Severe Refer to mental health

depressive professional for further
symptoms assessment, intervention,
and/or suicidal and follow-up
ideation present Spiritual counselingi Guilt
Reconciliation Reconciliation
ritual desired ritual performed relieved
Guilt
expressed Spiritual
counselingi Continuing
Reconciliation Guilt not support
ritual not desired relieved
No severe Refer to
depressive mental
symptoms Spiritual counselingi
health
and/or suicidal professional
ideation present
iConsider referral to community religious resource. Return to Chaplaincy Services (DIS-22)


CHAPLAINCY SERVICES: HOPELESSNESS
Refer to mental health

Severe professional for further
depressive assessment, intervention,
Symptoms Continuing
symptoms and/or and follow-up
relieved support
suicidal ideation Spiritual counselingi
present Palliative/supportive care
consultation
Hopelessness
expressed
No severe Spiritual counselingi

Symptoms Continuing
depressive Spiritual counselingi and/or
not relieved support
symptoms and/or Palliative/supportive mental health referral
suicidal ideation care consultation
not present


CHAPLAINCY SERVICES: CONFLICT BETWEEN RELIGIOUS BELIEFS

AND RECOMMENDED TREATMENTS
Conflict
resolved
Decision- Continuing
making Spiritual support
capacity counselingi Conflict
present resolved
Assess Ethics/palliative
Physician Conflict not
Evidence of decision- care
consultation resolved
conflict between making consultation
to clarify
religious beliefs capacity Conflict
treatment
and recommended Mental health not resolved
options and
treatment consult if
goals of care Spiritual
indicated
Decision- counselingi
making Refer to mental
capacity health professional
absent


CHAPLAINCY SERVICES: RITUAL NEEDS
Refer to clergy of
persons faith
Evidence of Ritual Continuing
or
ritual needs needs met support
Chaplain provides
ritual if appropriate


RECOMMENDATIONS FOR IMPLEMENTATION OF STANDARDS AND GUIDELINES
Encourage establishment of institutional interdisciplinary committees for implementation of standards and guidelines
Conduct multicenter trials that explore brief screening instruments and pilot treatment guidelines
Encourage institutional CQI (continuous quality improvement) projects in quality of distress management
Develop educational approaches to distress management for staff, patients, and family
RECOMMENDED READINGS FOR IMPLEMENTATION OF

PSYCHOSOCIAL CARE INTO THE ROUTINE CARE OF PATIENTS WITH CANCER
Bultz BD, Groff SL, Fitch M, et al. Implementing screening for Fulcher CD, Gosselin-Acomb TK. Distress assessment: practice
distress, the 6th vital sign: a Canadian strategy for changing change through guideline implementation. Clin J Oncol Nurs
practice. Psychooncology 2011;20:463-469. Available at: 2007;11:817-821. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/21456060. http://www.ncbi.nlm.nih.gov/pubmed/18063540.
Carlson LE, Waller A, Mitchell AJ. Screening for distress and unmet Grassi L, Rossi E, Caruso R, et al. Educational intervention in cancer
needs in patients with cancer: review and recommendations. J Clin outpatient clinics on routine screening for emotional distress: an
Oncol 2012;30:1160-1177. Available at: observational study. Psychooncology 2011;20:669-674. Available at:
Dolbeault S, Boistard B, Meuric J, et al. Screening for distress and Hammelef KJ, Friese CR, Breslin TM, et al. Implementing distress
supportive care needs during the initial phase of the care process: management guidelines in ambulatory oncology: a quality
a qualitative description of a clinical pilot experiment in a French improvement project. Clin J Oncol Nurs 2014;18 (Suppl):31-36
cancer center. Psychooncology 2011;20:585-593. Available at: Available at:
http://www.ncbi.nlm.nih.gov/pubmed/21425386. http://www.ncbi.nlm.nih.gov/pubmed/24480661
Donovan KA, Jacobsen PB. Progress in the implementation Hammonds LS. Implementing a distress screening instrument in a
of NCCN guidelines for distress management by members university breast cancer clinic: a quality improvement project. Clin J
institutions. J Natl Compr Canc Netw 2013;11:223-236. Available at: Oncol Nurs 2012;16:491-494. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/23411388. http://www.ncbi.nlm.nih.gov/pubmed/23022932
Fann JR, Ell K, Sharpe M. Integrating psychosocial care into cancer Hendrick SS, Cobos E. Practical model for psychosocial care. J Oncol
services. J Clin Oncol 2012;30:1178-1186. Available at: Pract 2010;6:34-36. Available at:
Frost GW, Zevon MA, Gruber M, Scrivani RA. Use of distress Lazenby M. The international endorsement of US distress screening
thermometers in an outpatient oncology setting. Health Soc Work and psychosocial guidelines in oncology: A model for dissemination.
2011;36:293-297. Available at: J Natl Compr Canc Netw 2014;12:221-227. Available at:
Note: All recommendations are category 2A unless otherwise indicated. Continue


RECOMMENDED READINGS FOR IMPLEMENTATION OF

PSYCHOSOCIAL CARE INTO THE ROUTINE CARE OF PATIENTS WITH CANCER (continued)
Loscalzo M, Clark KL, Holland J. Successful strategies for implementing biopsychosocial screening. Psychooncology 2011;20:455-462.
Available at:
http://www.ncbi.nlm.nih.gov/pubmed/21456059.
Lowery AE, Holland JC. Screening cancer patients for distress:guidelines for routine implementation. Community Oncology 2011;8:502-
505. Available at:
http://www.oncologypractice.com/fileadmin/content_images/co/articles/0811502.pdf.
Mehta A, Hamel M. The development and impact of a new Psychosocial Oncology Program. Support Care Cancer 2011;19:1873-1877.
Available at:
Rodriguez MA, Tortorella F, St John C. Improving psychosocial care for improved health outcomes. J Healthc Qual 2010;32:3-12. Available at:
Wagner LI, Spiegel D, Pearman T. Using the science of psychosocial care to implement the new american college of surgeons commission
on cancer distress screening standard. J Natl Compr Canc Netw 2013;11:214-221. Available at:


INSTITUTIONAL EVALUATION OF STANDARDS OF CAREk
INTERVENTIONS OUTCOMES
Interdisciplinary committee tailors

standards to institutional setting
Screening tool (0-10) in clinics

and inpatient setting
Professional Patient
Problem list
Surveys Attitudes Satisfaction
Education of primary oncology
Knowledge (CQI survey
teams via rounds and liaison with
Assessment of impact)
nurses and social workers
Clarification of resources access

(psychological, social, religious)
CQI studies
kBased on implementation/evaluation of pain management guidelines.


Distress Management Table of Contents
Discussion Fertility ................................................................................. MS-10

Substance Abuse ................................................................. MS-10
NCCN Categories of Evidence and Consensus Initial Evaluation and Treatment by Oncology Team ................... MS-10
Psychological/Psychiatric Treatment by Mental Health Professionals
Category 1: Based upon high-level evidence, there is uniform NCCN
................................................................................................... MS-11
consensus that the intervention is appropriate.
Psychosocial Interventions ...................................................... MS-11
Category 2A: Based upon lower-level evidence, there is uniform Cognitive Behavioral Therapy .............................................. MS-12
NCCN consensus that the intervention is appropriate.
Supportive Psychotherapy ................................................... MS-12
Category 2B: Based upon lower-level evidence, there is NCCN Family and Couples Therapy ............................................... MS-12
consensus that the intervention is appropriate.
Pharmacologic Interventions ................................................... MS-13
Category 3: Based upon any level of evidence, there is major NCCN Psychological/Psychiatric Treatment Guidelines ......................... MS-13
disagreement that the intervention is appropriate. Dementia and Delirium ............................................................ MS-13
All recommendations are category 2A unless otherwise noted. Mood and Adjustment Disorders ............................................. MS-14
Anxiety Disorder ...................................................................... MS-14
Substance-Related Disorder/Abuse ........................................ MS-15
Table of Contents Personality Disorder ................................................................ MS-15
Psychotic Disorder and Schizophrenia .................................... MS-15
Overview....................................................................................... MS-2
Social Work and Counseling Services ........................................ MS-16
Psychosocial Problems in Patients with Cancer ............................ MS-2
Spiritual Care and Chaplaincy Services ...................................... MS-16
Barriers to Distress Management in Cancer .............................. MS-3
Oncologist Burnout ..................................................................... MS-17
NCCN Guidelines for Distress Management ............................... MS-3
The Journal of Clinical Oncology Special Series on Psychosocial Care
The New Standard of Care for Distress Management in Cancer ... MS-4 in Cancer .................................................................................... MS-18
Recommendations for Implementation of Standards and Guidelines Summary .................................................................................... MS-18
..................................................................................................... MS-5
References ................................................................................. MS-20
Screening Tools for Distress and Meeting Psychosocial Needs .... MS-7
The Distress Thermometer (DT) ................................................ MS-8
The Problem List ....................................................................... MS-9
Cognitive Impairment ............................................................. MS-9
Version 2.2014, 07/08/14 National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. MS-1

Overview may have pre-existing psychological or psychiatric conditions that

In the United States, it is estimated that a total of 1,665,540 new cancer impact their ability to cope with cancer.
cases and 585,720 deaths from cancer will occur in 2014.1 All patients
The prevalence of psychological distress in individuals varies by the
experience some level of distress associated with the cancer diagnosis
type and stage of cancer as well as by patient age, gender, and race.7
and the effects of the disease and its treatment regardless of the stage
In a study of 4496 patients with cancer, Zabora and colleagues reported
of disease. Distress can result from the reaction to the cancer diagnosis
that the overall prevalence of distress was 35.1%, which varied from
and to the various transitions throughout the trajectory of the disease
29.6% for patients with gynecologic cancers to 43.4% for patients with
including during survivorship. Clinically significant levels of distress
lung cancer.8 The prevalence of distress, depression, and psychiatric
occur in a subset of patients, and identification and treatment of distress
disorders has been studied in many sites and stages of cancer.9-15
are of the utmost importance.
Overall, surveys have found that 20% to 47% of patients who are newly
These NCCN Guidelines for Distress Management discuss the diagnosed and those with recurrent cancer show a significant level of
identification and treatment of psychosocial problems in patients with distress. A recent metaanalysis reported that 30% to 40% of patients
cancer. They are intended to assist oncology teams to identify patients with various types of cancer have some combination of mood
who require referral to psychosocial resources and to give oncology disorders.16
teams guidance on interventions for patients with mild distress. These
Patients at increased risk for moderate or severe distress are those with
guidelines also provide guidance for social workers, certified chaplains,
a history of psychiatric disorder, depression, or substance abuse and
and mental health professionals by describing treatments and
those with cognitive impairment, severe comorbid illnesses,
interventions for various psychosocial problems as they relate to
uncontrolled symptoms, communication barriers, or social issues. Social
patients with cancer.
issues/risk factors include younger age, being female, living alone,
Psychosocial Problems in Patients with Cancer having young children, and prior physical or sexual abuse.
In the past two decades, dramatic advances in early detection and Distress is a risk factor for non-adherence to treatment, especially with
treatment options have increased the overall survival rates in patients of oral medications. In women with primary breast cancer, Partridge and
all ages with cancer. At the same time, these improved treatment colleagues observed that the overall adherence to tamoxifen decreased
options are also associated with substantial long-term side effects: to 50% in the fourth year of therapy and nearly one fourth of patients
fatigue, pain, anxiety, and depression are the most frequently reported may be at risk of inadequate clinical response due to poor adherence.17
cancer-related symptoms that interfere with the patients ability to In a meta-analysis, DiMatteo and colleagues found that noncompliance
perform daily activities.2 In addition, the physiologic effects of cancer was 3 times greater in depressed patients compared to non-depressed
itself and certain anti-cancer drugs can also be non-psychological patients.18 In addition to decreased adherence to treatment, failure to
contributors to distress symptoms.3-6 Furthermore, patients with cancer recognize and treat distress may lead to several problems: patients may

have trouble making decisions about treatment and may make extra practices where there are few to no psychosocial resources and cancer
visits to the physician's office and emergency room, which takes more care is often provided by short visits.
time and causes greater stress to the oncology team.19,20 Distress in
patients with cancer also leads to poorer quality of life and can even An additional barrier to patients receiving the psychosocial care they
negatively impact survival.15,21-23 Furthermore, survivors with untreated require is the stigma associated with psychological problems. For many
distress have poorer compliance with surveillance screenings and are centuries, patients were not told their diagnosis of cancer due to the
less likely to exercise and quit smoking.24 stigma attached to the disease. Since the 1970s, this situation has
changed and patients are well aware of their diagnosis and treatment
Early evaluation and screening for distress leads to early and timely options.34 However, patients are reluctant to reveal emotional problems
management of psychological distress, which in turn improves medical to the oncologist. The words psychological, psychiatric, and
management.25,26 A recent randomized study showed that routine emotional are as stigmatizing as the word cancer. The word
screening for distress, with referral to psychosocial resources as distress is less stigmatizing and more acceptable to patients and
needed, led to lower levels of distress at 3 months than did screening oncologists than these terms, but psychological issues remain
without personalized triage for referrals.27 Those with the highest level stigmatized even in the context of coping with cancer. Consequently,
of initial distress benefitted the most. In addition, there is evidence from patients often do not tell their physicians about their distress and
randomized trials that psychologically effective interventions may lead physicians do not inquire about the psychological concerns of their
to a survival advantage in patients with cancer.28-30 Overall, early patients. The recognition of patients distress has become more difficult
detection and treatment of distress leads to as cancer care has shifted to the ambulatory setting, where visits are
better adherence to treatment, often short and rushed. These barriers prevent distress from receiving
better communication, the attention it deserves, despite the fact that distress management is a
fewer calls and visits to the oncologists office, and critical component of the total care of the person with cancer.
avoidance of patients anger and development of severe anxiety or
depression.
NCCN Guidelines for Distress Management
A major milestone in the improvement of psychosocial care in oncology
Barriers to Distress Management in Cancer was made by NCCN when it established a panel to develop clinical
Less than half of distressed patients with cancer are actually identified practice guidelines, using the NCCN format. The panel began to meet in
and referred for psychosocial help.31,32 Many patients with cancer who 1997 as an interdisciplinary group. The clinical disciplines involved
are in need of psychosocial care are not able to get the help they need were: oncology, nursing, social work and counseling, psychiatry,
because of the under-recognition of patients psychological needs by psychology, and clergy. A patient advocate was also on the panel.
the primary oncology team and lack of knowledge of community Traditionally, clergy have not been included on NCCN Guideline panels,
resources.33 The need is particularly acute in community oncologists

but NCCN recognized that many distressed patients prefer a certified The New Standard of Care for Distress Management in
chaplain.35 Cancer
Psychosocial care had not been considered as an aspect of quality
The first step was to understand why this area has been so difficult to
cancer care until the publication of a 2007 Institute of Medicine (IOM)
develop. The panel members decided that words like psychiatric or
report, Cancer Care for the Whole Patient.37 The IOM report is based on
psychological are stigmatizing; patients and oncologists were reluctant
the pioneering work of the NCCN Panel, which recommends screening
to label any symptoms or patients as such. The way around this barrier
for distress and the development of a treatment plan with referrals as
was developed by using a term that would feel normal and
needed to psychosocial resources. Psychosocial care is now a part of
non-stigmatizing. This led to the first published guidelines in 1999 for
the new standard for quality cancer care and should be integrated into
the management of distress in patients with cancer. This
routine care.37,38 The IOM report supported the work of the NCCN
accomplishment provided a benchmark, which has been used as a
Guidelines for Distress Management by proposing a model for the
framework in the handbook for oncology clinicians published by the
effective delivery of psychosocial health services that could be
IPOS press (International Psycho-Oncology Society).36
implemented in any community oncology practice:
The panel defines distress as a multifactorial, unpleasant, emotional Screening for distress and psychosocial needs,
experience of a psychological (ie, cognitive, behavioral, emotional), Making and implementing a treatment plan to address these needs,
social, and/or spiritual nature that may interfere with the ability to cope Referring to services as needed for psychosocial care, and
effectively with cancer, its physical symptoms, and its treatment. Reevaluating, with plan adjustment as appropriate.
Distress extends along a continuum, ranging from common, normal
In Canada, routine psychosocial care is part of the standard of care for
feelings of vulnerability, sadness, and fears to problems that can
patients with cancer; emotional distress is considered the sixth vital sign
become disabling, such as depression, anxiety, panic, social isolation,
that is checked routinely along with pulse, respiration, blood pressure,
and existential and spiritual crisis.
temperature, and pain.19,39
Recommendations in the guidelines are based on evidence and on
In August 2012, the Commission on Cancer (CoC) of the American
consensus among panel members. In addition to the guidelines for
College of Surgeons (ACS) released new accreditation standards for
oncologists, the panel established guidelines for social workers, certified
hospital cancer programs
chaplains, and mental health professionals (psychologists, psychiatrists,
(http://www.facs.org/cancer/coc/programstandards2012.html). Their
psychiatric social workers, and psychiatric nurses).
patient-centered focus now includes screening all patients with cancer
for psychosocial distress. The American Psychosocial Oncology Society
(APOS), the Association of Oncology Social Work (AOSW), and the
Oncology Nursing Society (ONS) published a report and a joint

statement endorsing the new CoC accreditation standards and Clinical health outcomes measurements should include assessment
discussing several issues critical to quality patient care.40,41 of the psychosocial domain (eg, quality of life; patient and family
satisfaction).
The standards of care for managing distress proposed by the NCCN
Patients, families, and treatment teams should be informed that
Distress Management Panel are broad in nature and should be tailored
distress management is an integral part of total medical care and is
to the particular needs of each institution and group of patients. The
provided with appropriate information about psychosocial services in
overriding goal of these standards is to ensure that no patient with
the treatment center and in the community.
distress goes unrecognized and untreated. The panel based these
Finally, the quality of distress management programs/services should
standards of care on quality improvement guidelines for the treatment of
be included in institutional continuous quality improvement (CQI)
pain.42 The standards of care developed by the NCCN Distress
projects.
Management Panel, which can also be found in the guidelines, are:
Distress should be recognized, monitored, documented, and treated Patients and families should be made aware that this new standard
promptly at all stages of disease and in all settings. exists and that they should expect it in their oncologists practice. The
Screening should identify the level and nature of the distress. Alliance is a coalition of professional and advocacy organizations whose
All patients should be screened to ascertain their level of distress at goal is to advance the recommendations from the IOM report. In
the initial visit, at appropriate intervals, and as clinically indicated, addition, the Alliance advocates for policies promoting access to quality
especially with changes in disease status (eg, remission, recurrence, psychosocial care for all patients with cancer and helps to advance
or progression; treatment-related complications). research in psychosocial oncology.43 Its website
Distress should be assessed and managed according to clinical (http://www.wholecancerpatient.org/) has hundreds of psychosocial
practice guidelines. resources for health care professionals, patients, and caregivers,
Interdisciplinary institutional committees should be formed to searchable by state.
implement standards for distress management.
Educational and training programs should be developed to ensure Recommendations for Implementation of Standards
and Guidelines
that health care professionals and certified chaplains have knowledge
and skills in the assessment and management of distress. Implementation of the IOM standards for integration of psychosocial
Licensed mental health professionals and certified chaplains care into the routine care of patients with cancer can be improved by
experienced in the psychosocial aspects of cancer should be readily providing feedback to oncology practices on the quality of their
available as staff members or by referral. psychosocial care. Quality indicators were thus developed by Jacobsen
Medical care contracts should include reimbursement for services and colleagues. They developed a patient chart audit that permits an
provided by mental health professionals. oncologists office or clinic to evaluate the quality of their psychosocial
care.44 The survey queries whether there is documentation that the

patients current emotional well-being has been assessed and if there is Jacobsen and colleagues conducted a study in 2005 evaluating the
documentation that any action has been taken if the patient has been implementation of NCCN Guidelines for Distress Management by 15
identified as having a problem. These quality indicators can be widely NCCN Member Institutions.49 Eight institutions (53%) conducted routine
used to determine the quality of psychosocial care given by a clinic or distress screening of some patient populations, and an additional 4
office. institutions (27%) also performed pilot testing of screening strategies.
However, concordance to NCCN Guidelines (defined as screening all
The Quality Oncology Practice Initiative (QOPI) was started in 2002 by outpatients) was observed in only 20% of the member institutions at that
ASCO as a pilot project (http://qopi.asco.org/program.html).45 This time. A follow-up survey was conducted 7 years later that found
program became available to all ASCO member medical oncologists in increased levels of screening.50 As of 2012, 14 of 20 responding NCCN
2006. Jacobsons psychosocial quality indicators were added as part of Member Institutions (70%) performed routine screening for distress in at
the core measures in the QOPI quality measures in 2008.46 In a recent least some patient populations. Half of responding centers reported
analysis, Jacobson and colleagues reported that practices participating screening all outpatients for distress. Another survey of 233 APOS
in QOPI demonstrated improved performance, with initially members and attendees at the APOS 2008 and 2009 annual meetings,
low-performing practices showing the greatest improvement.46 Blayney representing 146 U.S. institutions, found that routine distress screening
and colleagues from the University of Michigan Comprehensive Cancer was not performed at a majority of cancer centers.51 In this survey, 51%
Center recently reported that QOPI can be adapted for use in practice of cancer care organizations performed routine screening for distress in
improvement at an academic medical center.47 APOS has also adopted newly diagnosed patients with cancer.
these quality indicators.48
A recently published survey of oncology nurses identified barriers to
The panel also encourages the establishment of institutional adoption of distress screening and found that time, staff uncertainties,
interdisciplinary committees to implement and monitor distress and ambiguous accountability were the biggest barriers.52 The survey
management. The interdisciplinary committee should be responsible for also found that nurses who were familiar with these NCCN Guidelines
evaluation of standard care in distress management with CQI studies. for Distress Management were more comfortable discussing distress.
The panel encourages interdisciplinary CQI studies to assess the
quality of distress management programs as well as the efficacy of The MD Anderson Cancer Center published a report on its efforts to
standards of care, implementation of these NCCN Guidelines for implement the integration of psychosocial care into clinical cancer
Distress Management, and the quality standard established by the IOM care.53 The authors outline strategies they used to accomplish the
report.37 The panel also emphasizes that multicenter randomized trials required cultural shift and describe the results of their efforts. Other
and pilot testing are needed to compare the efficacy of brief screening groups have also described their efforts toward implementing
instruments. Educational approaches should be developed for medical psychosocial screening in various outpatient settings.54-61 Additional
staff, patients, and caregivers to increase their awareness of the guidance for the implementation of the new IOM standards has been
prevalence of distress and of psychological interventions. published.62-65 In Canada, a national approach has been used to

implement screening for distress. Their strategies have been A recent metaanalysis compared 8 tools designed to screen for
described.66 Groups in Italy and France have also described results of depression in the cancer setting that had been validated by at least 2
their preliminary efforts toward the implementation of psychosocial separate studies.78 This analysis included the Hospital Anxiety and
distress screening.67,68 A reading list for implementation of programs Depression Scale (HADS), the Beck Depression Inventory version 2
that integrate psychosocial care into the routine care of patients with (BDI-II), and the DT (discussed below). Other tools have also been
cancer is provided in these guidelines above. described.79
To implement the new standard of integrating psychosocial care into the Some recent results have caused doubts in the minds of some
routine care of all patients with cancer, it is critical to have a fast and regarding the efficacy of distress screening for improving patient
simple screening method that can be used to identify patients who outcomes. For instance, a recent systematic review failed to find
require psychosocial care and/or referral to psychosocial resources.65 evidence that screening improved distress levels over usual care in
The NCCN Distress Management Panel developed such a rapid patients with cancer.80 Criticisms of this review include the
screening tool, as discussed below. inappropriately narrow inclusion criteria and the focus on only distress
as an outcome.81 A recent, unblinded, two-arm, parallel, randomized
Screening Tools for Distress and Meeting Psychosocial controlled trial that used the DT and Problem List (see below) as a
Needs screening tool versus usual care found no differences in psychological
Identification of a patients psychological needs is essential to develop a distress at 12 months between the arms.82 However, no specific triage
plan to manage those needs. Ideally, patients tell their oncologists algorithms were followed, and inadequate staff training may have
about their problems or they respond to the oncologists query about prevented effective referral and treatment.83 Indeed, another
them. In routine clinical practice, time constraints and the stigma related randomized trial found that distress screening followed by personalized
to psychiatric and psychological needs often leads to no discussion of triage in patients with lung cancer led to improvements in pain,
these issues. Screening tools have been found to be effective and breathlessness, coping, and family relationships compared to patients
feasible in reliably identifying distress and the psychosocial needs of who were merely screened.84 Furthermore, a recent systematic review
patients.69-71 Mitchell and colleagues recently reported that ultra-short found that trials reporting a lack of benefit to distress screening in
methods (PHQ2 or the Distress Thermometer [DT]) were acceptable to patients with cancer lacked appropriate follow-up care of distressed
about three quarters of clinicians.72,73 Automated touch-screen patients, while trials that linked screening with mandatory referral or
technologies and web-based assessments have also been used for intervention showed improvements in patient outcomes.85 Overall,
psychosocial and symptom screening of patients with cancer.74-76 results of these studies show that screening, while a critical component
Recently, an internet-based program that includes distress screening, of psychosocial care, is not sufficient to impact patient outcomes without
reporting, referrals, and follow-up components has been developed. adequate follow-up referrals and treatment. As proposed by Lazenby,
The screening component was validated in a trial of 319 community-
based cancer survivors and showed good psychometric properties.77

the concept of comprehensive distress screening includes screening work and counseling, or chaplaincy services) the patient should be
plus triage of patients to appropriate referral sources.64 referred.
The Distress Thermometer (DT) The DT has been validated by many studies in patients with different
The NCCN Distress Management Panel developed the DT, a now well- types of cancer, in different settings, and in different languages,
known tool for initial screening, which is similar to the successful rating cultures, and countries and has revealed concordance with the
scale used to measure pain: 0 (no distress) to 10 (extreme distress). HADS.69,86-100 The DT has shown good sensitivity and specificity. The
The DT serves as a rough initial single-item question screen, which needs assessment surveys performed in ambulatory clinics using these
identifies distress coming from any source, even if unrelated to cancer. screens show 20% to 40% of patients have significant levels of distress.
The receptionist can give it to the patient in the waiting room. Two studies validated a version of the DT with an expanded problems
list.101,102 Tuinman and colleagues validated the DT with the 46-item
The word distress was chosen as described above, because it is less problem list in a cross-sectional group of 227 patients with cancer.102
stigmatizing and more acceptable to patients and oncologists than other Graves and colleagues validated the DT with an adapted problems list
terms such as psychiatric, psychosocial, or emotional. Using this with two new problem categories (information concerns and cognitive
non-stigmatizing word diminishes clinicians' concerns that the patient problems) in patients with lung cancer.101 The DT is also a useful tool
will be embarrassed or offended by these questions. Asking an for screening distress among bone marrow transplant recipients.103,104
objective question such as, How is your pain today on a scale of 0 to The DT had acceptable overall accuracy and greater sensitivity and
10? makes it easier and more comfortable for caregivers to learn about specificity when compared to the Center for Epidemiologic
patients' pain. Similarly, asking patients, How is your distress today on Studies-Depression Scale (CES-D) in the assessment of depression in
a scale of 0 to10? opens a dialogue with the oncologist or nurse for a patients undergoing bone marrow transplants.103 A meta-analysis of 42
discussion of emotions that is more acceptable. studies with >14,000 patients with cancer found the pooled sensitivity of
the DT to be 81% (95% CI, 0.790.82) and the pooled specificity to be
The patient in the waiting room places a mark on the DT scale 72% (95% CI, 0.710.72) at a cut-off score of 4.105
answering: How distressed have you been during the past week on a
scale of 0 to 10? Scores of 4 or higher suggest a level of distress that The NCCN DT and Problem List (discussed below) are freely available
has clinical significance. If the patients distress level is mild (score is <4 for non-commercial use. In addition, the NCCN patient website includes
on the DT), the primary oncology team may choose to manage the a patient-friendly description of distress with a copy of the tool
concerns by usual clinical supportive care management. If the patients (http://www.nccn.org/patients/resources/life_with_cancer/distress.aspx).
distress level is 4 or higher, a member of the oncology team looks at Finally, NCCN has verified translations of the DT and Problem List in
the problem list (see below) to identify key issues of concern and asks various languages that are freely available online
further questions to determine to which resources (mental health, social (http://www.nccn.org/international/international_adaptations.aspx).

The Problem List cause cancer-related cognitive impairment is essential for the
The screening tool developed by the NCCN Distress Management development of treatments to improve cognitive function and quality of
Panel includes a 39-item Problem List, which is on the same page with life in patients with cancer.106,107,121
the DT. The Problem List asks patients to identify their problems in five
There is no standard treatment for the management of cognitive
different categories: practical, family, emotional, spiritual/religious, and
changes in patients with cancer. Cognitive behavioral therapy (CBT),
physical. The panel notes that the Problem List may be modified to fit
cognitive rehabilitation programs, and exercise may be effective
the needs of the local population.
interventions to improve cognitive function in patients with cancer.122-124
Cognitive Impairment In addition, some studies have shown that the use of psychostimulants
Memory/concentration problems is one item on the Problem List. such as methylphenidate and modafinil improved cognitive function in
Cognitive impairment is common in patients with primary central patients with cancer.123,125-130 Donepezil, a reversible
nervous system (CNS) cancers, due to the effects of brain tumors acetylcholinesterase inhibitor (approved to treat mild to moderate
themselves and the effects of treatment targeted to the brain.106,107 dementia in patients with Alzheimers disease) also improved cognitive
Recent evidence has shown that chemotherapy-related cognitive function, mood, and health-related quality of life in patients with primary
dysfunction is also prevalent in patients with non-CNS cancers and low-grade glioma.131 Further placebo-controlled trials are needed to
without brain metastases.108-113 Chemotherapy can cause subtle confirm these preliminary findings.126
cognitive changes, studied primarily in patients with breast cancer or
In October 2006 the International Cognition and Cancer Task Force
lymphoma. It can continue over years and at times, when more severe,
(ICCTF), comprised of a multidisciplinary group of health professionals
can impact quality of life and function. The underlying mechanisms for
and health advocates, was formed. The mission of ICCTF is to advance
chemotherapy-induced cognitive changes are not known. Recent
understanding of the impact of treatment-related cognitive and
studies have reported elevated levels of cytokines or DNA damage as
behavioral functioning in patients with non-CNS cancers.132 ICCTF also
some of the possible mechanisms.114 Furthermore, changes in brain
has a website (www.icctf.com) to provide up-to-date information to both
activity have been observed in patients following chemotherapy,
physicians and patients seeking assistance in the management of
suggesting that direct damage to the brain may contribute to
cognitive symptoms associated with cancer treatment.
chemotherapy-induced cognitive decline.115
The NCCN Guidelines for Survivorship (available at www.NCCN.org)
Evidence suggests that cancer itself and therapies other than
contain more information on this topic, with recommendations for the
chemotherapy, such as hormone therapy, can cause cognitive
management of cognitive dysfunction in survivors.
impairments in patients with cancer.116-119 A recent national cross-
sectional study found that a history of cancer is independently
associated with a 40% increase in the likelihood of self-reported
memory problems.120 A better understanding of the mechanisms that

Fertility List. Common symptoms that require further evaluation are: excessive
Another item on the Problem List is the ability to have children. worries and fears, excessive sadness, unclear thinking, despair and
Chemotherapy and radiation therapy also have an impact on the fertility hopelessness, severe family problems, social problems, and spiritual or
of patients, especially in those who are of child-bearing age.133 religious concerns.
Therefore, the panel has included ability to have children as one of the
items under the family problems category. The Oncofertility Consortium Mild distress (DT score of less than 4) is routinely managed by the
is a useful patient education resource for those who are concerned primary oncology team and represents what the panel terms "expected
about the possible effect of cancer treatment on their fertility distress" symptoms. The symptoms that the team manages are fear,
(www.MyOncofertility.org). Additionally, the NCCN Guidelines for worry, and uncertainty about the future; concerns about the illness;
Adolescent and Young Adult (AYA) Oncology (available at sadness about loss of good health; anger and the feeling that life is out
www.NCCN.org) have information on fertility preservation. of control; poor sleep, poor appetite, and poor concentration;
preoccupation with thoughts of illness, death, treatment, and side
Substance Abuse effects; and concerns about social roles (eg, mother, father). Most
For the 2013 version of these guidelines, the panel added substance patients experience these symptoms at the time of diagnosis and during
abuse to the list of possible physical problems. Substance abuse in arduous treatment cycles. They might persist long after the completion
patients with cancer who do not have a history of abuse or addiction is of treatment. For instance, minor symptoms are often misinterpreted by
rare and is usually caused by insufficient symptom control. Improving survivors as a sign of recurrence, which causes fear and anxiety until
symptom control often alleviates the substance dependence. This they are reassured.
problem is discussed in more detail below in Substance-Related
Disorder/Abuse. The primary oncology team is the first to deal with these painful
problems. The oncologist, nurse, and social worker each have a critical
Initial Evaluation and Treatment by Oncology Team role. First and foremost is the quality of the physicians communication
The panel recommends that all patients be assessed in the waiting with the patient, which should occur in the context of a mutually
room using a simple screening tool. While there are several types of respectful relationship so that the patient can learn the diagnosis and
screening tools, the DT and the accompanying Problem List are understand the treatment options and side effects.134,135 Adequate time
recommended to assess the level of distress and to identify causes of should be provided for the patient to ask questions and for the physician
distress. If the patient's distress is moderate or severe (thermometer to put the patient at ease. When communication is done well at
score of 4 or more), the oncology team must recognize that score as a diagnosis, the stage is set for future positive trusting encounters. It is
trigger to a second level of questions, including clinical interviews and/or important to ensure that the patient mentally grasps what has been
validated scales/screeners for anxiety and depression, and should said. Information may be reinforced with drawings or by taping the
prompt referral to a mental health professional, social worker, or session and giving the tape to the patient. Communication skills training
spiritual counselor, depending on the problems identified in the Problem programs that teach oncology professionals, for example, how to

discuss prognosis and unanticipated adverse events and how to reach

a shared treatment decision may be very helpful. In fact, a recent Clinicians should be aware of the evidence-supported interventions
randomized controlled trial found that patients of oncologists who had available for the management of distress. In addition to these NCCN
communication skills training were less depressed at follow-up than Guidelines for Distress Management, the following clinical practice
patients of oncologists from the control group (P = .027).136 guidelines will be useful to clinicians, including the oncology team:
Communication skills training was recently reviewed by Kissane et al.137 National Cancer Institute and several partners have developed a web
site that provides information about research-tested intervention
It is important for the oncology team to acknowledge that this is a programs (http://rtips.cancer.gov/rtips/index.do).
difficult experience for the patient and that distress is normal and
ASCO Guideline Adaptation: Screening, Assessment, and Care of
expected. Being able to express distress to the staff helps provide relief
Anxiety and Depressive Symptoms in Adults With Cancer
to the patient and builds trust. The team needs to ensure that social
(http://www.asco.org/)
supports are in place for the patient and that he or she knows about
community resources such as support groups, teleconferences, and Follow-up at regular intervals or at transition points in illness is an
help lines. The IOM report contains a list of national organizations and essential part of the NCCN Guidelines for Distress Management and
their toll-free numbers.37 Some selected organizations that provide free the IOM model for care of the whole patient. This reassessment is
information services to patients with cancer are: particularly important in elderly patients with cancer.139
American Cancer Society www.cancer.org
Psychological/Psychiatric Treatment by Mental Health
American Institute for Cancer Research www.aicr.org Professionals
American Psychosocial Oncology Society www.apos-society.org Psychosocial Interventions
(APOS provides a toll-free Help Line [866.276.7443] to which patients Psychosocial interventions have been effective in reducing distress and
and their caregivers can be referred to help them find psychological improving overall quality of life among patients with cancer.37,38 The
resources in their community. This help line is now available through 2007 IOM report noted that a strong evidence base supports the value
the Cancer Support Community [see below])138 of psychosocial interventions in cancer care.37 The review examined the
range of interventions (psychological, social, and pharmacologic) and
Cancer Support Community http://www.cancersupportcommunity.org
their impact on any aspect of quality of life, symptoms, or survival. The
(Cancer Support Community provides the Cancer Support Helpline at extensive review found randomized clinical trials, systematic reviews,
888.793.9355) and meta-analyses supporting the conclusion that psychosocial aspects
CancerCare www.cancercare.org must be integrated into routine cancer care in order to give quality
National Cancer Institute www.cancer.gov cancer care. More recent meta-analyses have come to similar
conclusions, although more research is clearly needed.140-142 CBT,
Cancer.net, sponsored by ASCO www.cancer.net.

supportive psychotherapy, and family and couples therapy are the three women with early-stage breast cancer receiving adjuvant
key types of psychotherapies discussed in the IOM report.37 chemotherapy.150 Meaning-centered group psychotherapy, designed to
help patients with advanced cancer sustain or enhance a sense of
Cognitive Behavioral Therapy meaning, peace, and purpose in their lives (even as they approach the
CBT involves relaxing, enhancing problem-solving skills, and identifying end of life), has also been shown to reduce psychological distress
and correcting inaccurate thoughts associated with feelings. In among patients with advanced cancer.151,152 Dignity therapy has been
randomized clinical trials, CBT has been shown to effectively reduce assessed in a randomized controlled trial of patients with a terminal
psychological symptoms (anxiety and depression) as well as physical diagnosis (not limited to cancer).153 Although there was no significant
symptoms (pain and fatigue) in patients with cancer.143-145 A 2012 improvement in levels of distress in patients receiving dignity therapy as
systematic review, however, concluded that data on the efficacy of CBT measured by several scales, significant improvements, specifically for
in patients with advanced cancer are lacking.146 depression and self-reported aspects of quality-of-life, were seen.
Ferguson and colleagues have developed a brief CBT intervention Family and Couples Therapy
(Memory and Attention Adaptation Training [MAAT]) aimed at helping A cancer diagnosis causes distress in partners and family as well as the
breast cancer survivors manage cognitive dysfunction associated with patient. Psychosocial interventions aimed at patients and their families
adjuvant chemotherapy.147 In this single-arm pilot study, improvements together might lessen distress more effectively than individual
in self reporting of cognitive function, quality of life, and standard interventions. In a longitudinal study of couples coping with early-stage
neuropsychological test performance were observed in all patients (29 breast cancer, mutual constructive communication was associated with
women at an average of 8 years after adjuvant chemotherapy for stage less distress and more relationship satisfaction for both the patients and
III breast cancer). The authors have since performed a randomized partners compared to demand/withdraw communication or mutual
study to evaluate the efficacy of MAAT.122 They found that patients in avoidance, suggesting that training in constructive communication
the intervention arm had improved verbal memory performance and would be an effective intervention.154
spiritual well-being.
Family and couples therapy has not been widely studied in controlled
Supportive Psychotherapy trials. A small randomized trial was reported in 2011 in which patients
Supportive psychotherapy, aimed at flexibly meeting patients changing and their caregivers received 8 emotionally focused therapy sessions or
needs, is most widely used. Different types of group psychotherapy standard care.155 Significant improvements in marital functioning and
have been evaluated in clinical trials among patients with cancer. patient experience of empathetic care by the caregiver were seen.
Supportive-expressive group therapy has been shown to improve These effects were maintained 3 months after the intervention. In
quality of life and psychological symptoms, especially improvements in addition, a randomized controlled trial showed that family-focused grief
mood and pain control in patients with metastatic breast cancer.148,149 therapy can reduce the morbid effects of grief in families with terminally
Cognitive-existential group therapy has been found to be useful in ill patients with cancer.156 A recent systematic review of 23 studies that

assessed the efficacy of psychosocial interventions for couples affected perform the evaluation. All of these professionals are skilled in mental
by cancer found evidence that couples therapy might be at least as health assessment and treatment.
effective as individual therapy.157
The panel has developed evaluation and treatment guidelines for the
Pharmacologic Interventions most commonly encountered psychiatric disorders: dementia, delirium
Research suggests that antidepressants and antianxiety drugs are (encephalopathy), mood disorder, adjustment disorder, anxiety disorder,
beneficial in the treatment of depression and anxiety in adult patients substance abuse-related disorder, psychotic disorder, schizophrenia,
with cancer.158-164 In randomized controlled trials, alprazolam165,166 (a and personality disorder. Psychotropic drugs are recommended
benzodiazepine) and fluoxetine167,168 (a selective serotonin reuptake throughout the guidelines to treat psychiatric disorders. It is important to
inhibitor [SSRI]) are effective in improving depressive symptoms in note that these drugs can sometimes interact with anticancer therapies
patients with cancer. SSRIs are widely used for depression and anxiety and cause adverse effects. Howard et al172 reviewed some of these
symptoms. interactions and discusses other challenges in treating cancer in
patients with severe mental illness.
Psychostimulant drugs help in the management of fatigue.169-171
Methylphenidate is likely effective for the treatment of cancer-related Dementia and Delirium
fatigue, but additional trials are needed. Wakefulness-promoting agents Dementia and delirium are cognitive impairments that can severely
such as modafinil are also commonly used to treat fatigue in patients impair the patients decision-making capacity. Dementia is a permanent
with cancer, but their efficacy remains to be shown conclusively.169 cognitive impairment. It is not a common complication of cancer
treatment, but is often present in elderly patients as a comorbid
Psychological/Psychiatric Treatment Guidelines condition.173,174 Dementia can be treated with cognitive rehabilitation,
Patients scoring 4 or higher on the DT during any visit to the oncologist with or without medications, though treatment is largely behavior
are referred to the appropriate supportive service (mental health, social management.
work and counseling, or chaplaincy services) based on the identified
problem. Delirium is a short-term cognitive impairment and has been reported to
occur in as many as 43% of patients with advanced cancer.175 It is
Mental health professionals are expected to conduct a psychological or usually reversible and occurs in cancer treatment related to any toxic
psychiatric evaluation that includes an assessment of the nature of the state, and it is often related to medication, particularly opioids.176
distress, behavior and psychological symptoms, psychiatric history, use Delirium is managed by attention to safety, modification of opioids or
of medications, pain, fatigue, sleep disturbances, other physical other medications, neuroleptics, and family support and education.177
symptoms, cognitive impairment, body image and sexuality, and The United Kingdoms National Institute for Health and Clinical
capacity for decision making and physical safety. A psychiatrist, Excellence (NICE) issued detailed guidelines for the diagnosis,
psychologist, nurse, advanced practice clinician, or social worker may prevention, and management of delirium.178 In addition, a

comprehensive review in The Journal of Clinical Oncology Special Anxiety Disorder

Series on Psychosocial Care in Cancer by Breitbart and Alici179 Anxiety occurs at times in most patients with cancer.180,196 The
describes the evidence base for recommended pharmacologic and non- diagnosis of cancer and the effects of the disease and its treatment are
pharmacologic treatments for delirium in patients with cancer. obvious sources of unease; however, anxiety may also be related to
physiological aspects of the medical condition (eg, hormone-secreting
Mood and Adjustment Disorders
tumors; effects of certain types of medications [bronchodilators];
Mood disorders such as depression and adjustment disorder (mixed withdrawal from alcohol or narcotics; pain or some other distressing
anxiety and depressive symptoms) are common in patients with cancer physical symptom). Anxiety may not be severe or problematic, but
and can be debilitating.180-182 Patients with uncontrolled mood and needs to be addressed when it becomes disruptive. After ruling out
adjustment disorders can develop suicidal tendencies. A study of over medical causes, the clinician should assess symptoms to determine the
5000 patients at one center found that 6% of patients with cancer particular nature of the anxiety disorder(s). Generalized anxiety disorder
experienced suicidal ideation.183 The incidence of suicide among is usually pre-existing and may be exacerbated by illness. Panic
patients with cancer in the United States is twice that of the general disorder may recur during illness in a person with previous panic
population.184-186 Older patients and men with head and neck cancer or symptoms. Post-traumatic stress disorder (PTSD) may develop after
myeloma seem to have a higher risk of suicide.187 arduous cancer treatments, during a cancer treatment that triggers a
traumatic memory of a past frightening event, or just from the stress of a
Mood disorder is usually managed with psychotherapy or psychotropic
cancer diagnosis. In fact, as many as 12% of patients with stage IIII
medication (category 1). The evidence for these treatments has been
breast cancer were found to have persistent PTSD.197 Obsessive-
described.38,188-193 In particular, a review by Li et al194 in The Journal of
compulsive disorder is a pre-existing disorder that results in difficulty in
Clinical Oncology Special Series on Psychosocial Care in Cancer
making decisions, ruminative thoughts about illness, and fearfulness to
comprehensively describes the evidence for recommended
take medication. Some patients develop phobias of needles, hospitals,
pharmacologic and psychosocial interventions for treating depression in
and blood or conditioned nausea/vomiting related to chemotherapy.
patients with cancer. Referral to social work and counseling and
Chemotherapy-induced nausea and vomiting should be managed
chaplaincy services may also be considered. Patients considered to be
according to the NCCN Guidelines for Antiemesis (www.NCCN.org).
a danger to themselves or others should be considered for psychiatric
consultation. Increased monitoring is also warranted, and the removal of The NCCN Distress Management Panel recommends psychotherapy
dangerous objects should be considered. Psychiatric treatment and with or without an anxiolytic and/or an antidepressant for the treatment
hospitalization may sometimes be necessary. of anxiety (category 1), after eliminating medical causes. If the anxiety
responds to initial treatment, follow-up should occur with the primary
ASCO recently released a clinical oncology guideline adaptation of a
oncology team and family/caregivers. If no response is noted, the
pan-Canadian practice guideline for the screening, assessment, and
patient should be re-evaluated and treated with different medications (a
treatment of anxiety and depression in patients with cancer.195

neuroleptic should be considered) with continued psychotherapy, Personality Disorder

support, and education. If there is still no response, then the patient Patients with cancer may have a pre-existing personality disorder,
should be evaluated for depression and other psychiatric comorbidity. which can be exacerbated by the stress of cancer and its treatment.199
When a personality disorder is suspected, the patient should be
The evidence for the effectiveness of these treatments has been
evaluated by a mental health professional, and safety and decision-
reviewed.37,38 In a review in The Journal of Clinical Oncology Special
making capacity should be assessed. If possible, any medication or
Series on Psychosocial Care in Cancer, Traeger et al198 give a
other factors that could be aggravating the condition should be
comprehensive description of the evidence for recommended
modified. A coordinated behavioral, psychological, and medical
pharmacologic and non-pharmacologic treatments for anxiety in
treatment plan, with or without medication, should be developed with
patients with cancer.
the health care team.
Substance-Related Disorder/Abuse
Psychotic Disorder and Schizophrenia
Substance abuse is rare among patients with cancer who do not have a
Psychotic disorder includes hallucinations, delusions, and/or thought
history of active abuse or addiction to opioids, alcohol, or tobacco.
disorders; patients with recurrent psychotic episodes have
Substance abuse or dependence developing during the course of the
schizophrenia. Psychotic disorder and schizophrenia can exist as
treatment may be due to insufficient symptom control and can be
comorbidities in patients with cancer and can also be caused or
treated by improving symptom control.
exacerbated by cancer and its associated stress and treatment. In
In patients with a history of substance abuse, its impact on cancer particular, steroids or steroid withdrawal can induce psychosis, which
treatment should be assessed and risk-reduction strategies should be may be relieved by modifying dose or changing steroid choice.200,201
discussed. Patients with a history of substance abuse should also be When a patient in a long-term psychiatric facility develops cancer, there
monitored for signs and symptoms of relapse. Referral should be made is a need for coordination of care between the psychiatric facility and
to risk reduction, substance abuse management, or specialized the inpatient cancer facility. Special attention should be paid to the
treatment programs as needed. Patients with current substance transition of a psychiatric patient who needs inpatient oncology care.
dependence issues should enter a substance abuse management The issues around continuation of psychotropic medications, when they
program. must be stopped for surgery or chemotherapy and when they should be
restarted, are important issues in total care.
Following appropriate detoxification regimens, patients should be
provided psychoeducation with or without cognitive behavioral When a psychotic episode occurs in a patient with cancer, differential
psychotherapy and with or without medication. Referral can also be diagnoses must be ruled out. Delirium is often confused with psychotic
made to specialized maintenance programs, and strategies to prevent disorder and is much more common; dementia, mood disorder, and
future abuse can be discussed. substance abuse/withdrawal should also be considered. When

psychotic disorder or schizophrenia is diagnosed, several interventions mobilized; problem solving is taught; and advocacy, education, and
can be considered: 1) anti-psychotic medication; 2) medication for protective services are made available.
mood; 3) transfer to a psychiatric unit/hospital; or 4) electroconvulsive
therapy (ECT) for psychotic depression/mania or catatonia. In ECT, Spiritual Care and Chaplaincy Services
electrical currents are passed through the brain in a controlled fashion, Many patients use their religious and spiritual resources to cope with
inducing a brief seizure. ECT appears to be an effective treatment of illness212; many cite prayer as a major help. In addition, the diagnosis of
psychotic depression, mania, catatonia, and other psychiatric cancer can cause an existential crisis, making spiritual support of critical
disorders.202-206 Although the use of ECT in cancer has not been well importance. Balboni et al213 surveyed 230 patients with advanced
studied, several case studies suggest that it can be safe and cancer treated at multiple institutions who had failed to respond to
effective.207-211 first-line chemotherapy. The majority of patients (88%) considered
religion as somewhat or very important. Nearly half of the patients
Social Work and Counseling Services (47%) reported receiving very minimal or no support at all from their
Social work and counseling services are recommended when a patient religious community, and 72% reported receiving little or no support
has a psychosocial or practical problem. Practical problems are from their medical system.213 Importantly, patients receiving spiritual
illness-related concerns; concrete needs (eg, housing, food, financial support reported a higher quality of life. Religiousness and spiritual
assistance, help with activities of daily living, transportation); support have also been associated with improved satisfaction with
employment, school, or career concerns; cultural or language issues; medical care. Astrow et al214 found that 73% of patients with cancer had
and caregiver availability. The guidelines outline interventions that vary spiritual needs, and that patients whose spiritual needs were not met
according to the severity of the problem. reported lower quality of care and lower satisfaction with their care. A
recent multi-institution study of 75 patients with cancer and 339
Psychosocial problems are adjustment to illness; family conflicts and oncologists and nurses (the Religion and Spirituality in Cancer Care
social isolation; difficulties in decision making; quality-of-life issues; Study) found that spiritual care had a positive effect on patient-provider
concerns about advance directives; domestic abuse and neglect; poor relationships and the emotional well-being of patients.215 However, a
coping or communication skills; concerns about functional changes (eg, survey conducted in 2006 through 2009 found that most patients with
body image, sexuality); and issues pertaining to end of life and advanced cancer never receive spiritual care from their oncology
bereavement (including cultural and caregiver concerns). team.216
Social workers intervene in mild psychosocial problems by using patient The panel has included chaplaincy services as part of psychosocial
and family education, support groups, and/or sex or grief counseling services. All patients should be referred for chaplaincy services when
and by suggesting available local resources. For moderate to severe their problems are spiritual or religious in nature or when they request it.
psychosocial problems, counseling and psychotherapy are used The panel identified 11 issues related to illness for which people often
(including sex and grief counseling); community resources are

seek chaplaincy services. A treatment guideline is available for each of The following guidelines on religion and spirituality in cancer care may
these issues: grief, concerns about death and the afterlife, conflicted or be useful for clinicians and patients:
challenged belief systems, loss of faith, concerns with meaning and National Consensus Project Clinical Practice Guidelines for Quality
purpose of life, concerns about relationship with deity, isolation from the Palliative Care, Third Edition, 2013. These guidelines provide a
religious community, guilt, hopelessness, conflict between beliefs and framework to acknowledge the patients religious and spiritual needs
recommended treatments, and ritual needs. in a clinical setting. Spiritual, Religious, and Existential Aspects of
Care are included as 1 of the 8 clinical practice domains in these
The certified chaplain evaluates the problem and may offer spiritual or
guidelines:
philosophical reading materials, spiritual advice and guidance, prayer,
http://www.nationalconsensusproject.org/NCP_Clinical_Practice_Guid
and/or rituals. For patients who are members of a religious community,
elines_3rd_Edition.pdf.
the certified chaplain could also serve as a liaison between the patient
The National Cancer Institutes comprehensive cancer information
and the religious community or assist the patient to access spiritual
database (PDQ) has information on Spirituality in Cancer Care for
resources. Some patients may be referred for social work and
patients:
counseling or mental health services if the problems indicate a need for
http://www.cancer.gov/cancertopics/pdq/supportivecare/spirituality/Pat
more than spiritual counseling. In addition, patients whose concerns are
ient and for health care professionals:
not allayed may be referred for mental health evaluation while
http://www.cancer.gov/cancertopics/pdq/supportivecare/spirituality/He
continuing to receive spiritual counseling if they wish. In particular,
althProfessional.
patients who experience guilt or hopelessness should also be evaluated
by mental health professionals for further assessment since they may Oncologist Burnout
also have severe depressive symptoms or suicidal ideations. A
The stress and demands of treating patients with cancer and making life
palliative/supportive care consultation can also be important for patients
and death decisions daily often cause psychologic distress for
who express hopelessness.
oncologists. This distress can in turn cause depression, anxiety, and
A consensus conference on improving the quality of spiritual care as a fatigue. It can also cause moral distress, compassion fatigue, and/or
dimension of palliative care was held in February 2009. The report from burnout. Burnout, characterized by a lack of enthusiasm for work,
this conference provides recommendations for health care professionals feelings of cynicism, and a low sense of personal accomplishment with
on the integration of spiritual care into the patients overall treatment work, occurs in as many as 28% to 45% of oncologists.218,219 Burnout
plan.217 The inclusion of a certified chaplain in the interdisciplinary team can affect patient care, physician-patient relationships, and personal
is critical for the implementation of spiritual care into routine clinical relationships and can lead to substance abuse and even suicide.
practice. Strategies for avoiding and reducing burnout include training in self-
care, personal wellness, mindful meditation, and behavioral change by
medical schools, residency programs, hospitals, and private

practices.218,220 Organizational strategies can also create a culture that In addition, an article was included on oncologist burnout, a problem
is less stressful and less conducive to oncologist burnout. with an estimated prevalence of 28% to 38%, depending on medical
specialty.218 The Special Series concludes with a review and meta-
The Journal of Clinical Oncology Special Series on analysis of studies that provide evidence for the development of an
Psychosocial Care in Cancer appropriate curriculum for communication skills training of
In April 2012, the Journal of Clinical Oncology published a Special oncologists.137 Patient benefit from such training (ex, better adherence
Series on psychosocial care (http://jco.ascopubs.org/content/30/11.toc), to treatment) has yet to be demonstrated.
demonstrating that this topic is now getting the attention is has so long
deserved. The Special Series includes a review by Jacobsen and Summary
Wagner that describes how the new standard of psychosocial care, the Psychosocial care is increasingly being recognized as an integral
development of clinical practice guidelines for psychosocial care such component of the clinical management of patients with cancer. Treating
as these NCCN Guidelines, and the establishment of indicators to distress in cancer benefits the patients, their families/caregivers, and
measure the quality of psychosocial care can help increase the number the treating staff and helps improve the efficiency of clinic operations.
of patients with cancer receiving psychosocial care.221 Integral to the For patients with cancer, integration of mental health and medical
successful integration of psychosocial care into routine cancer care is a services is critically important. Spirituality and religion also play an
distress screening program. In the Special Series, Carlson et al62 important role for many patients with cancer in coping with the diagnosis
present their recommendations for implementing such a program, and and the illness.
Fann et al63 discuss the organizational challenges of this new integrated
care model, with a focus on the collaborative care service model. The NCCN Guidelines for Distress Management recommend that each
new patient be rapidly assessed in the office or clinic waiting room for
Research on psychosocial care in cancer treatment has expanded evidence of distress using the DT and Problem List as an initial rough
greatly in recent years. This fact attests to the growing awareness of the screen.226 A score of 4 or greater on the DT should trigger further
importance of the topic, both by health care professionals and by the evaluation by the oncologist or nurse and referral to a psychosocial
public.222 The Special Series includes reviews of evidence-based service, if needed. The choice of which psychological service is needed
interventions for 3 common psychosocial problems in patients with is dependent on the problem areas specified on the Problem List.
cancer: depression, anxiety, and delirium.179,194,198 Patients with practical and psychosocial problems should be referred to
social workers; those with emotional or psychological problems should
Worries and concerns about cancer do not necessarily end with the end
be referred to mental health professionals including social workers; and
of acute care. The Special Series thus also includes articles addressing
spiritual concerns should be referred to certified chaplains.
the psychosocial needs of AYA and adult cancer survivors.223,224 An
article on the psychosocial needs of care givers is also included.225 Health care contracts often allow these services to fall through the
cracks by failing to reimburse for them through either behavioral health

or medical insurance. Reimbursement for services to treat psychosocial

distress must be included in medical health care contracts to prevent
fragmentation of mental health services for the medically ill. Outcomes
research studies that include quality-of-life assessment and analysis of
cost-effectiveness are needed to help make this a reality.
The primary oncology team members (oncologist, nurse, and social

worker) are central to making this model work. It is critical for at least
one team member to be familiar with the mental health, psychosocial,
and chaplaincy services available in the institution and the community.
A list of the names and phone numbers for these resources should be
kept in all oncology clinics and should be updated frequently.
Education of patients and families is equally important to encourage

them to recognize that control of distress is an integral part of their total
cancer care.

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Distress Management: NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines)

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NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines)

NCCN Guidelines Version 2.2014 Panel Members NCCN Guidelines Index

* Jimmie C. Holland, MD/Chair Stewart Fleishman, MD Randi McAllister-Black, PhD

William S. Breitbart, MD Carl B. Greiner, MD Janice P. Pazar, Rn, PhD

NCCN Guidelines Version 2.2014 Table of Contents NCCN Guidelines Index

NCCN Distress Management Panel Members

NCCN Guidelines Version 2.2014 Updates NCCN Guidelines Index

DIS-A DIS-18 (Substance-Related Disorder/Abuse)

NCCN Guidelines Version 2.2014 Updates NCCN Guidelines Index

DIS-21 (Social Work and Counseling Services)

NCCN Guidelines Version 2.2014 NCCN Guidelines Index

Term distress was chosen because it:

Is more acceptable and less stigmatizing than psychiatric,

Sounds normal and less embarrassing

Can be defined and measured by self-report.

Definition of Distress in Cancer (DIS-2)

Note: All recommendations are category 2A unless otherwise indicated.

NCCN Guidelines Version 2.2014 NCCN Guidelines Index

DEFINITION OF DISTRESS IN CANCER

Distress is a multifactorial unpleasant emotional experience of a psychological (cognitive, behavioral,

Standard of Care for Distress Management (DIS-3)

NCCN Guidelines Version 2.2014 NCCN Guidelines Index

STANDARDS OF CARE FOR DISTRESS MANAGEMENT

Screening should identify the level and nature of the distress.

Distress should be assessed and managed according to clinical practice guidelines.

Note: All recommendations are category 2A unless otherwise indicated.

NCCN Guidelines Version 2.2014 NCCN Guidelines Index

OVERVIEW OF EVALUATION AND TREATMENT PROCESS

Note: All recommendations are category 2A unless otherwise indicated.

NCCN Guidelines Version 2.2014 NCCN Guidelines Index

EXPECTED DISTRESS INTERVENTIONS RE-EVALUATION

Clarify diagnosis, treatment options

bSee Psychosocial Distress Patient Characteristics (DIS-B).

Note: All recommendations are category 2A unless otherwise indicated.

NCCN Guidelines Version 2.2014 NCCN Guidelines Index

NCCN DISTRESS THERMOMETER PROBLEM LIST

NCCN Guidelines Version 2.2014 NCCN Guidelines Index

PSYCHOSOCIAL DISTRESS PATIENT CHARACTERISTICSd

PATIENTS AT INCREASED RISK FOR DISTRESSe PERIODS OF INCREASED VULNERABILITY

History of psychiatric disorder/substance abuse Finding a suspicious symptom

Note: All recommendations are category 2A unless otherwise indicated.

NCCN Guidelines Version 2.2014 NCCN Guidelines Index

Delirium (encephalopathy) (DIS-9)

Substance-Related Disorder/Abuse (DIS-17)

Personality Disorder (DIS-19)

For End of Life Issues, See NCCN

NCCN Guidelines Version 2.2014 NCCN Guidelines Index

See Mood Disorder

Evaluate for See Dementia

Arrange for ongoing

Return to Psychological/Psychiatric Guidelines (DIS-6)

NCCN Guidelines Version 2.2014 NCCN Guidelines Index

DEMENTIA (continued) TREATMENT FOLLOW-UP

Evaluation, diagnostic studies, Reevaluate

Return to Psychological/Psychiatric Guidelines (DIS-6)

NCCN Guidelines Version 2.2014 NCCN Guidelines Index

DELIRIUM EVALUATION TREATMENT FOLLOW-UP

Return to Psychological/Psychiatric Guidelines (DIS-6)

NCCN Guidelines Version 2.2014 NCCN Guidelines Index

MOOD DISORDER EVALUATION TREATMENT FOLLOW-UP

Assure patient safety:

NCCN Guidelines Version 2.2014 NCCN Guidelines Index

MOOD DISORDER (continued) EVALUATION TREATMENT FOLLOW-UP