Screening Identifies Distress in Women With Breast Cancer

HAMBURG, Germany—“Significant numbers of women with breast cancer have psychological distress that goes unidentified,” said David Payne, PhD, of the Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center.

In a presentation at the Fourth International Congress of Psychooncology, Dr. Payne reported results of a screening study for distress in 279 breast cancer patients at either Memorial Sloan-Kettering’s Breast Cancer Center or North Shore Hematology and Oncology Associates on Long Island.

The researchers used three different screening methods: the Hospital Anxiety and Depression Scale (HADS), a visual analog scale, and the Brief Symptom Inventory. “All three instruments are designed to detect psychological distress in medically ill patients,” Dr. Payne said, “but differ in length and complexity.”

Although psychiatric distress exists in women with breast cancer, he said, this distress may not be identified. Patients may be reluctant to spontaneously disclose their distress to oncologists, and with the constraints of a busy clinic schedule, oncology staff members may not have time to ask about distress. Paper and pencil screening methods may be an inexpensive and convenient method to identify distress.

Dr. Payne and his colleagues found that, with the use of these instruments, approximately 33% of the women in this study had psychiatric symptomatology significant enough to warrant further psychiatric evaluation. “If we had used a more stringent cut-off, 27% of the patients would have qualified for further evaluation, still a significant number. We can adjust the cut-off to match our ability to evaluate and treat patients,” he said.

Although all of the instruments used were effective in identifying distress, they differed in their complexity and acceptance to patients. “We found that some people had a difficult time understanding the visual analog scale. Although they were asked to indicate their psychological distress, patients told us that it was hard to separate psychological and physical distress. If they were nauseous, patients would say that they were distressed.”

The Brief Symptom Inventory was the longest screening instrument. Although it probably gave the most comprehensive view of a patient’s psychiatric functioning, patients had difficulty with this instrument. “This instrument had questions that asked about a variety of psychiatric problems. Our patients felt uncomfortable answering it because they didn’t want to be labeled as having psychiatric problems,” Dr. Payne said.

HADS Easiest to Use

The easiest and most acceptable screening instrument was the Hospital Anxiety and Depression Scale. The HADS also correlated well with more complex measures of psychiatric symptomatology such as the Brief Symptom Inventory.

“We found that all the instruments we used showed about the same thing, that our patients were distressed,” Dr. Payne said.

Although many patients whose scores indicated distress were already being followed by the psychiatry service, 64% were not being followed. “This represented a significant number of women who were suffering in silence,” Dr. Payne said. “Our project has helped us to quantify the level of psychiatric distress in our population and to further our exploration of the means by which we can identify those women with breast cancer who most need to receive psychiatric services.”

Dr. Payne noted that the results of the screening project also served as a vehicle to further communication with oncologists. “Our project raised the oncologists’ awareness and provided a means for us to educate them about underdiagnosed psychiatric distress in their populations as well as to give them an acceptable tool to evaluate distress in their patients,” Dr. Payne said.

One of the reasons for conducting this research was to “stay competitive in the health care market by documenting the need for our services,” Dr. Payne said. “In the era of managed care, the necessity and feasibility of psychiatric interventions are under scrutiny, and we needed to find methods for evaluating the distress that patients experience as well as the effectiveness of our programs in treating this distress.”

He said that the project allowed the psychiatry service “to take a fresh look at what we were doing in providing services. The good news was that we were focusing our attention on many of the right patients, but, unfortunately, there remained a significant number of women who were unserved.”

By using the HADS on a regular basis, Dr. Payne said, “we can identify those women before they are sitting in their oncologists’ offices crying. We want to identify distress before it overwhelms the patient.”