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Where’s the evidence that screening for distress benefits cancer patients?
The Case Against
Patients for Distress
James C. Coyne, Ph.D.
Health Psychology Program
University Medical Center, Groningen, NL
Institute for Health Policy
Rutgers University, NJ, USA
Evaluating Practice Guidelines
guidelines from professional
organizations notoriously biased and not
Standards developed for evaluating process
by which guidelines are constructed and
Guidelines for Distress
review of the literature.
Composition of guidelines committee
including formal involvement of patients,
frontline clinicians, and other key
Articulation of guidelines in terms of strength
for medical problems is
commonplace in medical settings.
assumed clinicians should routinely
screen for problems that have significant
clinical and public health implications, if a
re-evaluation with the recognition
that consultations with clinicians cannot
accommodate screening for all problems.
than simply targeting an important
clinical problem, screening must lead to
improvement in patient outcomes.
Burden of Proof Falls on Those Who Would
Recommend Screening to Demonstrate
Improves Patient Outcomes.
Screening for Distress
Screening for distress is useful only to the extent
that it improves patient outcomes beyond any
detection and treatment that is already provided as
part of existing standard care.
Screening program must identify a significant
number of distressed patients who are not already
recognized, engage those patients in treatment,
and obtain sufficiently positive outcomes to justify
costs and potential harms from screening.
What Screening is Not
Definition excludes settings in which patients
complete screening and responses are then
used to structure discussions, regardless of
whether the patients meet pre-established
thresholds for distress.
Definition excludes situations in which a
questionnaire is used to facilitate a
conversation independent of patients’ level of
Great for the Dutch!
Current Dutch Guideline: Detection of Need for Care
does not comply with proposed international guidelines
for mandated screening.
All cancer patients, not only those who screen positive
for distress, are offered opportunity to talk to a
professional about their needs and concerns, unless they
explicitly indicate they do not want to do so.
Our Evaluation of Screening
Adopted the analytic framework of the U.S.
Preventive Services Task Force (USPSTF) in
searching for evidence of
the efficacy of interventions for reducing
the efficacy of routine screening in
reducing distress among cancer patients.
Conclusion: Treatment studies reported modest improvement in
distress symptoms, but only a single eligible study was found on the
effects of screening cancer patients for distress, and distress did not
improve in screened patients versus those receiving usual care.
Because of the lack of evidence of beneficial effects of screening
cancer patients for distress, it is premature to recommend or
mandate implementation of routine screening.
Four other systematic
Variously indicate that
may improve communication
between patients and clinicians.
discussions of psychosocial and
mental health issues increase referrals to
Provisional work suggests that screening for
psychological distress holds promise and is
often clinically valuable, but it is too early to
conclude definitively that psychological
screening itself affects the psychological wellbeing of cancer patients.
Four other systematic
High risk of bias in reporting of screening
multiple endpoints measured at multiple
timepoints cherry-picked with confirmatory bias.
retention, lack of intent to treat
Dodging the Basic Question?
Increasingly advocates of screening have the resources to
test whether it improves outcomes over routine care, but
dodge the question by excluding a routine care control.
“Previous work has already established the feasibility of
screening in cancer settings, and the superiority of
screening with triage to screening without triage (Carlson
et al, 2010), so it seemed somewhat unethical not to offer
some form of triage” (Carlson et al, BJC, 2012).
Evaluating Screening for
Preventive services interventions in PC provide
a model for evaluating screening for multiple
PCPs encouraged to screen for many different
conditions, some with psychosocial components
(e.g., depression, intimate partner violence,
alcohol abuse, smoking).
Impossible to determine which screening is
beneficial and cost-effective, unless each
Trajectories of Distress
Much of the heightened distress reported by
cancer patients is self-limiting or resolves within
routine cancer care without specialty
psychosocial or mental health services.
Rate of overall decline in distress in
routine care dwarfs any differences
among conditions in screening
Many of the minority of patients with
persistent distress have prior
problems or non-cancer related
Unmet Needs Do Not Equal
Interest in Services
A substantial proportion of the cancer patients
indicating unmet needs do not wish to receive
services within the context of cancer care.
Rates of receipt of services not much higher after
diagnosis than what was received before
detection and diagnosis.
More interest in physical therapy and nutrition than
specialty psychosocial and mental health
Screening Does Not
Uptake of Services.
a minority of cancer patients who screen
positive for distress subsequently receive
available data suggest that screening
is not a cost-effective way of getting cancer
patients into services.
The Pseudoscience of
Validation of Screening
guidelines indicate that screening for
distress should make use of validated
instruments with published cutpoints to
identify distressed patients.
instruments are most often
validated in terms of their performance as
measures of emotional distress
Distress is not a vital sign.
Optimal cutpoint on distress
thermometer varies between
cancer sites, clinical settings,
and health systems, and
Validation of Screening
variations in cutpoints from study
floating cutpoints, capitalizing on chance
inclusion of patients already receiving treatment
of assuming that for screening
purposes, it is instruments that are being
validated, not cutpoints
Hospital Anxiety and
of different factor analytic
techniques fail to identify separate anxiety
and depression subscales,
At best, the items of the HADS converge on a
single general distress factor.
Problems with HADS in translation.
Patients unable to follow changes in
response keys, direction of items.
The HADS Should Not Be
Coyne JC, van Sonderen
E: The Hospital Anxiety
and Depression Scale
(HADS) is dead, but like
Elvis, there will still be
citings. Journal of
Validation of Screening
Instruments Against Unmet
Measures of unmet need insufficiently
developed psychometrically to serve as
comparison for calculating opitmal cutpoints.
Individual need items vary widely in correlation
with DT: a few strongly, few more moderately,
rest null to weak correlations.
What we can learn from
screening for depression
in medical settings
Conclusions of Review
No trials have found that patients who undergo
screening have better outcomes than patients who do
not when the same treatments are available to both
Existing rates of treatment, high rates of false-positive
results, small treatment effects and the poor quality of
routine care may explain the lack of effect seen with
Developers of future guidelines should require
evidence of benefit from randomized controlled trials
of screening, in excess of harms and costs, before
Monitoring screening for distress with
Pfizer gives $10 million
grant to American
psychologist to develop
quality indicators to monitor
oncologists’ screening for
Oncologists cannot close their medical records
without indicating whether they have asked a
patient about distress.
Oncologists can comply with quality indicators by
asking simply “you feeling depressed?” and
prescribing antidepressants to patients who
answer “yes” without formal diagnosis, patient
education, or follow-up.
Depending on the Context,
Mandated Screening for
Increase inappropriate prescription of
psychotropic medication in absence of
adequate diagnosis and follow up.
Disrupt patients readily accessing services
on their own by consuming scarce resources
and requiring patient psychiatric evaluation for
patients who screen positive.
Increase health disparities.
Screening for distress
should be limited to well
where it may not be
Be prepared for
Consider alternative uses
of same resources.
Raffle, A and Gray, M. (2007).
Screening: Evidence and
Practice . Oxford Press.
Screening must be delivered in a well functioning
total system if it is to achieve the best chance of
maximum benefit and minimum harm. The system
needs to include everything from the identification of
those to be invited right through to follow-up after
intervention for those found to have a problem.
Alternatives to Screening
• Enhanced support, access to services, and
follow up for patients already known to be
distressed or socially disadvantaged.
• Provide ready access for patients to discuss
unmet needs with professional and peer
counselors regardless of level of distress.
• Increase resources for addressing health
disparities in access to psychosocial services.
Give patients time to talk and listen to them,
don't let screening for distress get in the way.
Don't require cancer patients to interact
through computer touchscreen assessments.
Do give them the opportunity to talk about
their experiences, their needs, their concerns,
and their preferences regardless of their level
Should we disconnect talking to
patients and determining
meetable unmet needs from
routine screening for distress?
Where is the Evidence?
Advocates for screening need to demonstrate
that implementation will not be associated with
in the opportunity for cancer
patients to discuss concerns with oncology
Routine screening for
distress is currently not an