NCCN Guidelines® Insights: Distress Management, Version 2.2023.

These NCCN Guidelines for Distress Management discuss the identification and treatment of psychosocial problems in patients with cancer. All patients experience some level of distress associated with a cancer diagnosis and the effects of the disease and its treatment regardless of the stage of disease. Clinically significant levels of distress occur in a subset of patients, and identification and treatment of distress are of utmost importance. The NCCN Distress Management Panel meets at least annually to review comments from reviewers within their institutions, examine relevant new data from publications and abstracts, and reevaluate and update their recommendations. These NCCN Guidelines Insights describe updates to the NCCN Distress Thermometer (DT) and Problem List, and to the treatment algorithms for patients with trauma- and stressor-related disorders.

Distress Management, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology.

Distress is defined in the NCCN Guidelines for Distress Management as a multifactorial, unpleasant experience of a psychologic (ie, cognitive, behavioral, emotional), social, spiritual, and/or physical nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment. Early evaluation and screening for distress leads to early and timely management of psychologic distress, which in turn improves medical management. The panel for the Distress Management Guidelines recently added a new principles section including guidance on implementation of standards of psychosocial care for patients with cancer.

Delirium frequency among advanced cancer patients presenting to an emergency department: A prospective, randomized, observational study.

BACKGROUND: The frequency of delirium among patients with cancer presenting to the emergency department (ED) is unknown. The purpose of this study was to determine delirium frequency and recognition by ED physicians among patients with advanced cancer presenting to the ED of The University of Texas MD Anderson Cancer Center. METHODS: The study population was a random sample of English-speaking patients with advanced cancer who presented to the ED and met the study criteria. All patients were assessed with the Confusion Assessment Method (CAM) to screen for delirium and with the Memorial Delirium Assessment Scale (MDAS) to measure delirium severity (mild, ≤15; moderate, 16-22; and severe, ≥23). ED physicians were also asked whether their patients were delirious. RESULTS: Twenty-two of the 243 enrolled patients (9%) had CAM-positive delirium, and their median MDAS score was 14 (range, 9-21 [30-point scale]). The median age of the enrolled patients was 62 years (range, 19-89 years). Patients with delirium had a poorer performance status than patients without delirium (P < .001); however, the 2 groups did not differ in other characteristics. Ten of the 99 patients who were 65 years old or older (10%) had CAM-positive delirium, whereas 12 of the 144 patients younger than 65 years (8%) did (P = .6). According to the MDAS scores, delirium was mild in 18 patients (82%) and moderate in 4 patients (18%). Physicians correctly identified delirium in 13 of the CAM-positive delirious patients (59%). CONCLUSIONS: Delirium is relatively frequent and is underdiagnosed by physicians in patients with advanced cancer who are visiting the ED. Further research is needed to identify the optimal screening tool for delirium in ED. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2918-2924. © 2016 American Cancer Society.

Distress management.

The integration of psychosocial care into the routine care of all patients with cancer is increasingly being recognized as the new standard of care. These NCCN Clinical Practice Guidelines in Oncology for Distress Management discuss the identification and treatment of psychosocial problems in patients with cancer. They are intended to assist oncology teams identify patients who require referral to psychosocial resources and to give oncology teams guidance on interventions for patients with mild distress to ensure that all patients with distress are recognized and treated.

Fear of cancer recurrence after curative pancreatectomy: a cross-sectional study in survivors of pancreatic and periampullary tumors.

BACKGROUND: Fear of disease recurrence is well documented among cancer survivors, but its significance among patients treated for solid pancreatic and periampullary neoplasms is unknown despite the known risk of recurrence associated with these tumors. We hypothesized that fear of cancer recurrence (FCR) represents a common source of psychosocial distress in this population and sought to characterize subgroups for whom FCR might represent a target for intervention to improve quality of life. METHODS: We conducted a cross-sectional study of FCR in patients who were disease-free after potentially curative pancreatectomy for ductal or periampullary adenocarcinoma or pancreatic neuroendocrine tumor. We assessed seven discrete dimensions of FCR using the Fear of Recurrence Inventory and evaluated quality of life and psychosocial distress using the Functional Assessment of Cancer Therapy-Hepatobiliary Questionnaire and the Hospital Anxiety and Depression Scale. RESULTS: Of 354 eligible patients, 240 (68 %) participated in the study a median of 48 months after potentially curative pancreatectomy. An FCR severity score indicative of frequent fearful thoughts, emotional disturbance and functional impairment was identified in 37, 28, and 35 % of patients with pancreatic adenocarcinoma, nonpancreatic periampullary adenocarcinoma, and pancreatic neuroendocrine tumor, respectively. Anxiety (P < 0.001) and low quality of life (P = 0.028) were independently associated with a clinically significant level of FCR, but histopathologic diagnosis and clinicopathologic markers of prognosis were not. CONCLUSIONS: FCR represents a significant concern for one-third of patients after curative surgery for a pancreatic or periampullary tumor, regardless of their actual likelihood of recurrence or disease-related death.

Neurobehavioral effects of interferon therapy.

Interferon (IFN) therapy is associated with neuropsychiatric side effects including cognitive dysfunction and mood syndromes of varying severity. These problems are the most common causes of treatment discontinuation. Dose and duration of treatment influence risk of IFN-induced side effects. Rates of IFN-induced depression vary, but approach 50% in recent studies. Presence and severity of depressive symptoms at or before treatment predicts development of mood disorders during IFN therapy. Several possible endocrine and neurotransmitter perturbations may be responsible for IFN neurotoxicity, with recent research suggesting different symptoms clusters are related to different underlying mechanisms. The interpretation of these clusters has been influenced by subjective versus objective evaluation of cognitive function. Effective management of IFN-induced neuropsychiatric side effects should involve pretreatment screening and interval assessment during therapy. Antipsychotic and psychostimulant drugs may be used against cognitive dysfunction. Antidepressants have been shown to be effective against IFN-induced depression and can be very valuable in support of adequate or completed therapy.

Cancer pain and depression: management of the dual-diagnosed patient.

Depressive disorders and pain syndromes are very common in the experience of cancer patients and may be experienced simultaneously. There is an intuitive association between cancer pain and cancer depression, both of which are multidimensional entities. Research has suggested, but not conclusively proven a cause-effect relationship. Suicidal ideation is a common concern in cancer patients with severe depression or pain. Antidepressant therapy is a mainstay of management of depression. That some antidepressants have use in the management of cancer pain may influence choice of drug selection in depressed patients. Antidepressant side effects and the patient's drug history are relevant variables. Because antidepressants that are effective as coanalgesics may not be tolerated at doses effective for depression, the clinician must be familiar with newer classes of antidepressants and psychostimulants. Combination drug therapy may be required. Psychotherapy also is common to the treatment of cancer pain and depression. With or without the intervention of pain and mental health specialists, ongoing supportive therapy from the primary clinician is essential.

Cognitive dysfunction and depression during treatment with interferon-alpha and chemotherapy.

Trials with interferon-alpha (IFN-alpha) have provided contradictory findings regarding the presence of cognitive side effects. The development of depression in some patients also raises questions about whether cognitive dysfunction might be secondary to an organic, interferon-induced mood disorder. Thirty patients with chronic myelogenous leukemia were examined before and during treatment with IFN-alpha alone or IFN-alpha and chemotherapy. Increased depressive symptoms and declines in information processing and executive functions were observed, but depression alone could not account for cognitive dysfunction. There was some evidence suggesting that exposure to chemotherapy and higher cumulative IFN-alpha dose may contribute to cognitive impairment.