Clinical Practice Guidelines in Oncology - Distress Management
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Clinical Practice Guidelines in Oncology - Distress Management

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01/01/2010

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Published 01 January 2010
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NCCN Clinical Practice Guidelines in Oncology™
Distress
Management
V.1.2010
Continue
www.nccn.orgGuidelines Index
®
Distress Management TOC
Practice Guidelines
Discussion, References
Distress Management
NCCN
in Oncology – v.1.2010
NCCN Distress Management Panel Members
Matthew J. Loscalzo, MSW £
*
Jimmie C. Holland, MD/Chair Donna B. Greenberg, MD Þ
City of Hope
Memorial Sloan-Kettering Cancer Center Massachusetts General Hospital Cancer Center
Comprehensive Cancer Center
Barbara Andersen, PhD Carl B. Greiner, MD
Sharon Manne, PhD
The Ohio State University UNMC Eppley Cancer Center at
Fox Chase Cancer Center
Comprehensive Cancer Center - The Nebraska Medical Center
James Cancer Hospital and
Solove Research Institute Rev. George F. Handzo, MA, MDiv £ Randi McAllister-Black, PhD
Consultant City of Hope
Comprehensive Cancer Center
Þ
William S. Breitbart, MD
Laura Hoofring, MSN, APRN #
Memorial Sloan-Kettering Cancer Center
The Sidney Kimmel Comprehensive Cancer
Michelle B. Riba, MD, MS
Center at Johns Hopkins
University of Michigan
Bruce Compas, Phd
Vanderbilt-Ingram Cancer Center
* Paul B. Jacobsen, PhD
H. Lee Moffitt Cancer Center and Research Kristin Roper, RN #
Moreen M. Dudley, MSW
Institute at the University of South Florida Dana-Farber/Brigham and Women’s
Fred Hutchinson Cancer Research Center/
Cancer Center
Seattle Cancer Care Alliance
Sara J. Knight, PhD
UCSF Comprehensive Cancer Center Alan D. Valentine, MD
Stewart Fleishman, MD £
The University of Texas
Consultant
Kate Learson ¥ M. D. Anderson Cancer Center
Consultant
Caryl D. Fulcher, RN, MSN, CS
Lynne I. Wagner, PhD
*
Duke Comprehensive Cancer Center
Michael H. Levy, MD, PhD † £ Robert H. Lurie Comprehensive Cancer
Fox Chase Cancer Center
Center of Northwestern University
Psychiatry, psychology, including health behavior
Michael A. Zevon, PhD
Þ Internal medicine
Roswell Park Cancer Institute
‡ Hematology/Hematology oncology
£ Supportive Care including Palliative, Pain management,
Pastoral care and Oncology social work
Bone Marrow Transplantation
# Nursing
¥ Patient advocacy
Continue
† Medical oncology
Neurology/neuro-oncology
* Writing committee member
NCCN Guidelines Panel Disclosures
Version 1.2010, 01/22/10 © 2010 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.Guidelines Index
®
Distress Management TOC
Practice Guidelines
Discussion, References
Distress Management
NCCN
in Oncology – v.1.2010
Table of Contents
NCCN Distress Management Panel Members
Summary of Guidelines Updates
For help using these
documents, please click here
Key Terms:
Distress (DIS-1)
Definition of Distress in Cancer (DIS-2)
Discussion
Standards of Care for Distress Management (DIS-3)
References
Overview of Evaluation and Treatment Process (DIS-4)
Expected Distress Symptoms (DIS-5)
Clinical Trials: The NCCN
believes that the best management
Distress Management Assessment Tool (DIS-A)
for any cancer patient is in a clinical
trial. Participation in clinical trials is
Psychosocial Distress Patient Characteristics (DIS-B)
especially encouraged.
Psychological/Psychiatric Treatment Guidelines (DIS-6)
To find clinical trials online at NCCN
Social Work Services (DIS-18)
member institutions, click here:
nccn.org/clinical_trials/physician.html
Chaplaincy Services (DIS-19)
NCCN Categories of Evidence and
Recommendations for Implementation of Standards and Guidelines (DIS-26)
Consensus: All recommendations
are Category 2A unless otherwise
Institutional Evaluation of Standards of Care (DIS-27)
specified.
For End of Life Issues, See the NCCN Palliative Care Guidelines
See NCCN Categories of Evidence
and Consensus
For Cancer Pain, See the NCCN Cancer Pain Guidelines
Guidelines Index
Print the Distress Management Guideline
These 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 these guidelines is expected to use independent medical judgment in the context of individual clinical
circumstances to determine any patient's care or treatment. The National Comprehensive Cancer Network makes no representations nor warranties
of any kind whatsoever regarding their content, use, or application and disclaims any responsibility for their application or use in any way. These
guidelines are copyrighted by National Comprehensive Cancer Network. All rights reserved. These guidelines and the illustrations herein may not
be reproduced in any form without the express written permission of NCCN. ©2010.
Version 1.2010, 01/22/10 © 2010 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.Guidelines Index
®
Distress Management TOC
Practice Guidelines
Discussion, References
Distress Management
NCCN
in Oncology – v.1.2010
Summary of the Guidelines Updates
Summary of changes in the 1.2010 version of the Distress Management Guidelines from the 2.2009 version include:

Throughout the Distress Management Guidelines, the terminology “Pastoral” was changed to “Chaplaincy”.
()DIS-3
First bullet: Changed to, “...documented, and treated promptly at all stages of disease and in all settings.”
Fifth bullet: “Multidisciplinary institutional committees...” changed to “Interdisciplinary institutional committees...”
(Also for DIS-26 and DIS-27)
Sixth/Seventh bullet: “Pastoral caregivers” changed to “Certified chaplains”.
Last bullet: Changed to “Quality of distress management programs/services should be...”
()DIS-4
Footnote “a”: “Nurse and clinical nurse specialist” changed to “Advanced practice clinicians”.
()DIS-A
Family Problems: The panel added “Ability to have children”.
()DIS-8
First column; Last bullet: After “Pain”, the panel added “Fatigue, sleep disorders, cognitive impairment.”
()DIS-19
“Pastoral evaluation” changed to “Chaplaincy assessment”.
()DIS-20
“Spiritual evaluation” changed to “Spiritual assessment” throughout the Chaplaincy Service algorithms.
()DIS-22
Top pathway after “Severe depressive symptoms...” recommendation changed to “Refer to mental health professional for further
assessment, intervention, and follow-up.”
()DIS-24
Second column: Recommendation changed to “Physician consultation to clarify treatment options and goals of care.”
Top pathway; After “Conflict not resolved”: Recommendation changed to “Ethics/Palliative care consultation”.
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 1.2010, 01/22/10 © 2010 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
UPDATESGuidelines Index
®
Distress Management TOC
Practice Guidelines
Discussion, References
Distress Management
NCCN
in Oncology – v.1.2010
“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 1.2010, 01/22/10 © 2010 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
DIS-1Guidelines Index
®
Distress Management TOC
Practice Guidelines
Discussion, References
Distress Management
NCCN
in Oncology – v.1.2010
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)
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 1.2010, 01/22/10 © 2010 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
DIS-2Guidelines Index
®
Distress Management TOC
Practice Guidelines
Discussion, References
Distress Management
NCCN
in Oncology – v.1.2010
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).
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.
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 1.2010, 01/22/10 © 2010 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. DIS-3Guidelines Index
®
Distress Management TOC
Practice Guidelines
Discussion, References
Distress Management
NCCN
in Oncology – v.1.2010
OVERVIEW OF EVALUATION AND TREATMENT PROCESS
EVALUATION TREATMENT
Clinical assessment
See Psychological/
by primary oncology
b
Mental health Psychiatric
team of oncologist,
services treatment
nurse, social worker
Follow-up
Guidelines (DIS-6)
for:
and
Clinical evidence of
a
High risk patients
commun-
moderate to severe
Periods of ication
See Social Work
distress or score of Social work
with
vulnerability
Referral
Services (DIS-18)
services
4 or more on
primary
Risk factors for
screening tool oncology
distress
()DIS-A team
Practical problems
Family problems
Chaplaincy See Chaplaincy
Spiritual/religous
services Services (DIS-19)
concerns
Unrelieved physical
Brief screening
Physical problems
for distress symptoms, treat as
(DIS-A):
per disease specific If
Screening tool necessary
or supportive care
Problem list
guidelines
Clinical evidence
of mild distress
Primary
See Management of Expected
or score of less
oncology team
than 4 on Distress Symptoms (DIS-5)
+ resources available
screening tool
()DIS-A
Refer to NCCN Guidelines Table
a
See Psychosocial Distress Patient Characteristics (DIS-B). of Contents for Supportive Care
b
Guidelines.
Psychiatrist, psychologist, advanced practice clinicians, social worker and certified chaplain.
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 1.2010, 01/22/10 © 2010 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
DIS-4Guidelines Index
®
Distress Management TOC
Practice Guidelines
Discussion, References
Distress Management
NCCN
in Oncology – v.1.2010
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
education materials (eg, NCCN
Patients at increased risk of
a Treatment Summaries for Patients)
vulnerability to distress
Educate patient that points of
Signs and symptoms of Stable or Continue
transition may bring increased
diminished monitoring
normal fear and worry of
vulnerability to distress
the future and uncertainty distress and support
Acknowledge distress
Concerns about illness
Build trust
Sadness about loss of Monitor
Ensure continuity of care
usual health
functional level
Anger, feeling out of Mobilize resources
and reevaluate
control Consider medication to manage
at each visit
See Distress
Poor sleep
symptoms:
Poor appetite
Analgesics Score 4 or
Increased or
Poor concentration
(See NCCN Adult Cancer Pain
moderate to
persistent
Preoccupation with
Guidelines) severe distress
distress
thoughts of illness and
Anxiolytics
(DIS-4)
death
Hypnotics
Disease or treatment side
Antidepressants
effects
Support groups and/or individual
counseling
Family support and counseling
Relaxation, meditation, creative
therapies (eg, art, dance, music)
Exercise
a
See Psychosocial Distress Patient Characteristics (DIS-B).
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 1.2010, 01/22/10 © 2010 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
DIS-5Guidelines Index
®
Distress Management TOC
Practice Guidelines
Discussion, References
Distress Management
NCCN
in Oncology – v.1.2010
SCREENING TOOLS FOR MEASURING DISTRESS Second, 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: First 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
Diarrhea
10
10
Extreme distress
Family Problems Eating
9 Dealing with children Fatigue
9
with partner Feeling Swollen
8
8
Ability to have children Fevers
7 Getting around
7
Emotional Problems
Indigestion
6
6
Depression
Memory/concentration
Fears

5 Mouth sores
5

Nervousness
Nausea
4
4
Sadness
Nose dry/congested
Worry
Pain
3
3
Loss of interest in
Sexual
2 usual activities
2
Skin dry/itchy
Sleep
1
1
Spiritual/religious
Tingling in hands/feet
concerns
0
0
No distress
Other Problems: _________________________________________
________________________________________________________
Version 1.2010, 01/22/10 © 2010 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
DIS-A