Screening Alone Is Not Enough: The Importance of Appropriate Triage, Referral, and Evidence-Based Treatment of Distress and Common Problems
Authors: Linda E. Carlson
Journal: Journal of Clinical Oncology (2013)

Hollingworth et al are to be commended on their careful execution of this study, including an adequately powered sample size, long follow-up period, and the addition of a thorough economic analysis, which is rarely undertaken in the context of psychosocial interventions. This is particularly important in countries with nationalized health care systems such as the United Kingdom, where changes to practice may often be widely implemented without knowledge of the economic implications. In general, psychosocial interventions tend to pay for themselves many times over in subsequent cost-offsets, but this needs to be examined carefully on a case-by-case basis before widespread implementation. In this study, implementation of the screening-for-distress program did not result in lower subsequent health care costs. However, despite several strengths, major study design limitations may explain this result, temper interpretations, and inform further clinical implementation of screening for distress programs. Though the authors have called their program a needs assessment in their report, the background literature, tools chosen, and the analysis and outcome measures seem to have been designed to test a distress-screening intervention, and my editorial considers the shortcomings of the study in such light. For distress screening programs to be efficacious, three things have to happen: broad identification of patients potentially in need (using the screening tool), further assessment and triage to appropriate services (by adequately trained staff), and evidence-based treatment of symptoms and problems (also by adequately trained professionals across a variety of disciplines). Specific evidence-based treatments would depend on the problems identified but could include cognitive-behavioral therapy, stress reduction, fatigue management, exercise, resource counseling, or family counseling. While step one was followed in this trial, step two did not happen, and therefore step three didn’t even have a chance. The major design limitations around these omissions include confounding of treatment and control arms; lack of training of implementation staff; and, most seriously, not following evidence-based triage and referral algorithms (ie, screening and assessment applied as if it were treatment). The staff who delivered the intervention was the same in both the treatment arm, which implemented the screening tool, and the control arm, which did not. Hence, there is concern of a contamination or spill-over effect into the usual care control arm from the distress-screening training for the intervention, which would theoretically increase sensitivity toward psychosocial issues. This would be more of an issue in a trial that showed benefit in both arms. In this case, the result was no benefit in either arm, which mitigates concerns about contamination but raises questions of the adequacy of staff training. Indeed, the training received by the nurses and radiographers was one four-hour seminar “including an audiovisual example of Distress Thermometer and Problem List administration, role playing, and advice on dealing with strong emotions.” Hollingworth et al developed a directory of resources providing information on selfmanagement techniques, guidance for staff on when to refer patients, and lists of information resources and patient support groups. However, “referrals were at the discretion of the clinician,” so no specific triage algorithms were followed. Subsequent to this, staff members were expected to manage all arising patient concerns. Given this scenario and its departure from best practices in staff training, it is not at all surprising that no treatment effects were found. Regarding training, there has been a consistent call for staff education as a critical component in promoting effective and sustainable screening programs. It is widely acknowledged that successful implementation of screening programs depends on health professionals’ knowledge and skills; however, health professionals themselves have reported a perceived lack of skills in identifying distress and a lack of guidance around referral pathways. It is recommended that in addition to initial training, conducting ongoing training sessions may help to maintain the fidelity of the intended behavior change. In a recent implementation study of routine screenings for distress in the clinical environment using existing staff, we used a quality improvement methodology to address challenges in following screening protocols, which involved continually identifying and addressing areas in which process change was required. The work utilized continuing cycles of “plan-do-study-act,” in which clinical processes were reviewed and modified as required over a 6-month implementation period. In terms of how well standardized evidence-based triage and referral was implemented in this trial, although 37% of patients had high levels of distress and 84% and 56% reported physical or JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 31 NUMBER 29 OCTOBER 1