Distress is a multifactorial and unpleasant emotional experience of a psychological (e.g., cognitive, behavioral, emotional), social, and/or spiritual nature that can interfere with the ability to effectively cope with a cancer diagnosis, physical symptoms and treatment, and long-term consequences of treatment. All patients are expected to experience some level of distress at some point in the cancer trajectory.
For distress, standards of care are based on established evidence-based practice.
• Distress is a multifactorial and unpleasant emotional experience of a psychological (e.g., cognitive, behavioral, emotional), social, and/or spiritual nature that can interfere with the ability to effectively cope with a cancer diagnosis, physical symptoms and treatment, and long-term consequences of treatment.
• All patients are expected to experience some level of distress at some point in the cancer trajectory.
Assessment Tools and Recommended Intervals
• NCCN Distress Thermometer and Problem List
• Assess distress at every visit. Use NCCN’s (2020) visual analog scale of 0 (no distress) to 10 (worst distress possible). A 39-item problem list helps to identify specific issues.
• Generalized Anxiety Disorder-7 scale
• Scores of 5, 10, and 15 may represent mild, moderate, and severe levels of anxiety, respectively (Spitzer et al., 2006). A score of 10 or more is a reasonable cut point for identifying cases of generalized anxiety disorder.
• Provide reputable resources for more information, from organizations such as the American Cancer Society, NCCN, or the National Cancer Institute.
Evidence-Based Interventions and Management
• Recommend cognitive behavioral, supportive (individual and group), couples, or psychoeducational therapies.
• Consider antidepressants to treat anxiety and depression.
• Consider benzodiazepines to treat acute (not long-term) anxiety.
• Consider antipsychotics for delirium, agitation, and psychosis.
• Encourage 30 minutes of intentional exercise daily.
• Recommend integrative therapies, such as yoga, relaxation therapy, guided imagery, music therapy, and art therapy.
• Refer patients scoring 4 or higher on the NCCN Distress Thermometer to a mental health professional for intensive assessment and intervention.
Agents and Interventions to Avoid
• Alcohol use can impair cognition and lead to depression.
• Discourage nonprescribed pharmacologic agents.
Evidence-Based Resources for Providers
• NCCN Clinical Practice Guidelines in Oncology: Distress (v.2.2021) (www.nccn.org/professionals/physician_gls/pdf/distress.pdf )
Evidence-Based Resources for Patients and Family
• NCCN Guidelines for Patients: Distress During Cancer Care (www.nccn.org/patients/guidelines/content/PDF/distress-patient.pdf)
About the Author(s)
Suzanne M. Mahon, DNS, RN, AOCN®, AGN-BC, FAAN, is a professor in the Department of Internal Medicine in the Division of Hematology/Oncology and in the Trudy Busch Valentine School of Nursing at Saint Louis University in Missouri and Ellen Carr, PhD, RN, AOCN®, is the editor of the Clinical Journal of Oncology Nursing at the Oncology Nursing Society in Pittsburgh, PA. The authors take full responsibility for this content. The article has been reviewed by independent peer reviewers to ensure that it is objective and free from bias. Mahon can be reached at firstname.lastname@example.org, with copy to CJONEditor@ons.org. (Submitted June 2021. Accepted August 26, 2021.)
National Comprehensive Cancer Network. (2020). NCCN Distress Thermometer and Problem List for Patients. https://www.nccn.org/docs/default-source/patient-resources/nccn_distress...
National Comprehensive Cancer Network. (2021). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®): Distress [v.2.2021]. https://www.nccn.org/professionals/physician_gls/pdf/distress.pdf
Spitzer, R.L., Kroenke, K., Williams, J.B.W., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092–1097.
Stout, N.L., Santa Mina, D., Lyons, K.D., Robb, K., & Silver, J.K. (2021). A systematic review of rehabilitation and exercise recommendations in oncology guidelines. CA: A Cancer Journal for Clinicians, 71(2), 149–175. https://doi.org/10.3322/caac.21639