Standards & Best Practices
Introduction:
Distress screening has been advocated as a routine practice in cancer care since the 2007 Institute of Medicine publication “Cancer Care for the Whole Patient.” With time, there has been a transition to the label “distress management,” with the acknowledgement that identifying distress without addressing it is not effective. Incorporation of and adherence to distress management protocols has been associated with better patient quality of life, reduced patient depression and anxiety, fewer emergency room visits, and fewer hospitalizations.1,2
Key Standards for Distress Management:
The National Comprehensive Cancer Network® (NCCN®) first called for distress screening over 20 years ago. The NCCN Distress Management Panel publishes annual NCCN Clinical Guidelines in Oncology (NCCN Guidelines®) for distress management based on existing evidence and expert consensus. The American Society of Clinical Oncology (ASCO) implemented the first Quality Oncology Practice Initiative (QOPI) in 2009, and distress assessment is a QOPI practice standard. The American College of Surgeons Commission on Cancer (CoC) first advocated for distress screening in 2012, and this became an accreditation standard in 2015. Given that most cancer treatment settings in the U.S. are CoC accredited, this change resulted in almost universal rollout of distress screening for cancer patients in the U.S. See the key elements of distress management for each organization in Table 1 below.
Table 1. Key Requirements for Distress Management
| Organization | Screening construct | Requirement | Timing | Follow up |
| NCCN Guidelines® (2024 version)3 | Broad conceptualization of distress (physical, psychological, social, spiritual) | Assessment, documentation, and treatment – at all stages of disease and in all settings | Regular screening, at minimum at “pivotal visits” | Clinical assessment to determine nature of distress and appropriate follow-up |
| ASCO (2020 version)4 | Mental health, social status, functional capacity | Assessment and documentation of psychosocial concerns and need for support | Each chemotherapy cycle | Information about and/or referral to psychosocial services provided |
| CoC (2020 version)5 | Broad conceptualization of distress (physical, psychological, social, spiritual, financial) | Assessment, documentation, and triage to needed services (in house or by referral) | At least once and before the first course of any treatment | Clinical assessment for moderate or severe distress; Resources and/or referral for psychosocial needs |
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Best Practices:
In 2014, the American Psychosocial Oncology Society (APOS), the Association of Oncology Social Workers (AOSW), and the Oncology Nursing Society published a joint position statement on distress screening, recommending these practices:6
- Selection and use of validated screening instruments, following published threshold values and ranges;
- Use of screening instruments based on a broad conceptualization of distress;
- Screening at multiple time points;
- Review of screening results by the patient’s treatment team in a timely manner;
- Follow-up of positive screens by a trained clinician to identify causes of distress and make appropriate referral; and
- Inclusion of referrals for the assessment and management of distress as part of a patient’s routine medical care.
The most recent version of the NCCN Guidelines for Distress Management includes these recommendations:3
- Recognize, monitor, document, and treat distress promptly at all stages of disease;
- Identify the level and nature of distress;
- Screen for distress at every medical visit or regular intervals; and
- Assess and manage distress according to clinical practice guidelines.
In 2021, APOS and AOSW published a joint position paper on recommendations for addressing challenges in distress management. The main recommendations were:7
- Screen broadly for distress;
- Integrate screening results into clinic procedures to reduce patient and staff burden;
- Reduce patient burden associated with screening by incorporating screening into existing clinic procedures, accommodating disabilities and access issues, and completing screening at no charge to the patient;
- Make screening results available to clinicians in advance of clinical contact;
- Follow a positive screen with further assessment in the identified problem areas to delineate the patient’s areas of need;
- Use targeted, evidence-based interventions to address individual distress; and
- Identify online, community, and self-help resources to extend the array of options for referral to address distress.
Conclusions:
There is general consensus for using a broad conceptualization of distress (including psychological, physical, and social aspects) and for institutionalizing the response to a positive distress screen. There is also consensus for using validated tools for screening (see section 2) and evidence-based interventions for responding to positive screens. The more completely that distress screening and response to screening can be incorporated into existing clinic procedures, the easier they are to implement. Finally, there is growing awareness of the need to reduce barriers to all aspects of cancer care, including distress management.