Emotional distress: the sixth vital sign—future directions in cancer care

Historically, those who work to treat and cure illness have converged on five key indicators: temperature, respiration, heart rate, blood pressure and more recently, pain (National Pharmaceutical Council, 2001) to gauge whether a patient’s physiological systems are functioning sufficiently well to support survival and provide a platform for achieving wellness. In cancer care an area that is often, due the complexity and ubiquity of the disease, a leader in progressive approaches to managing disease}there is a growing recognition of the role a well-functioning mind and spirit play in the path to health. In parallel, there is recognition that interventions to support this vitality need to be empirically supported. Therein lies the need for the sixth vital sign to highlight the importance of distress as a marker of well-being and its reduction as a target outcome measure. For the most part, cancer care is still biomedically focused, despite numerous well-designed studies demonstrating high prevalence of emotional distress in cancer patients. As well, rigorous intervention studies have clearly demonstrated the benefits of psychosocial care to patients, families, health-care systems, and society. Given the advances in psychosocial screening and care, we propose that psychosocial oncology be considered a standard component of care of the cancer patient. Further, given the advances in our understanding of the psychosocial elements of the disease, we suggest that it is timely to consider cancer a biopsychosocial illness. In Canada, the Canadian Strategy for Cancer Control (CSCC) (Rebalance Focus-Action Group, 2005) elected to recognize emotional distress as a core indicator of a patient’s health and well-being. Along with the other vital signs, it designated emotional distress as the sixth vital sign. Here was the argument used to accomplish this goal: Cancer is well known to be a difficult disease, affecting cancer patients and their families both emotionally and physically. Despite biomedical progress, cancer is still often considered synonymous with death, pain, and suffering (Powe and Finnie, 2003). Research has demonstrated that across the trajectory of the illness}from the time of diagnosis to treatment, termination of treatment, survivorship, or recurrence and palliation}the incidence of emotional distress in North America ranges from 35 to 45% (Zabora et al., 2001; Carlson et al., 2004; Carlson and Bultz, 2003). Up to 58% of patients in palliative care experience significant levels of emotional distress (Potash and Breitbart, 2002), and in a Jordanian sample of cancer inpatients the prevalence of distress was 70% (Khatib et al., 2004). Similar overall rates to those in North America were recently reported in several European countries (Gil et al., 2003; Dolbeault et al., 2003; Mehnert et al., 2004), the Middle East (Isikhan et al., 2001; Sadeh-Tassa et al., 2004; Montazeri et al., 2004), South America (Santos, 2004), and Asia (Fielding et al., 2004; Shimizu et al., 2004). Large studies at Johns Hopkins Kimmel Cancer Center in Baltimore (Zabora et al., 2001) and the Tom Baker Cancer Centre in Alberta, Canada (Carlson et al., 2004) found high levels of fatigue (in 49% of all patients), pain (26%), anxiety (24%), and depression (24%) along with significant financial hardship and material challenges in a representative cross-section of patients screened for emotional distress.