During Cancer Treatment, Distress Is Associated With Missed Appointments & Hospital Admission

By Sondra Forsyth

Psychological distress has long been associated with negative health outcomes for cancer patients, though specific reasons remain unclear. A 2017study finds that roughly half of all patients who reported having severe distress, which the National Comprehensive Cancer Network® (NCCN) describes as “a mix of anxiety and depressive symptoms,” subsequently missed one or more radiation therapy appointments and/or were admitted to the hospital during their treatment, compared with fewer than 20 percent of patients who reported lower levels of distress. The study wAS be presented September 24th at the 59th Annual Meeting of the American Society for Radiation Oncology (ASTRO) in San Diego, California.

A release from the society notes that the emotional side effects of cancer, compared with physical side effects, often are more difficult to diagnose and manage. The NCCN estimates that significant distress afflicts roughly a third of cancer patients, leading to further symptoms–such as loss of appetite, difficulty concentrating and sleeplessness–that undermine patients’ ability to fight their diseases.

The release quotes lead authors Justin Anderson, a medical student at the Virginia Commonwealth University School of Medicine in Richmond, Virginia, as saying, “Focusing on the ‘whole patient’ allows oncologists to deliver the best possible treatment. We know that having cancer is stressful, which means that we have a responsibility to consider a patient’s mental well-being when planning a course of action with them While distress does not directly impact a patient’s disease, it impacts how she or he copes with treatment, such as the ability to follow a doctor’s recommendations and adhere to a treatment plan. Findings from this study also link higher levels of distress to outcomes specific to radiation oncology, including missed radiation therapy appointments and hospital admission during a course of radiation.”

Study findings are based on 54 patients who received external beam radiation therapy with curative intent in the authors’ radiation oncology department during a one-year period between 2015 and 2016. The average patient age was 59 (range 32-85), and 58 percent of the patients were male.

Researchers evaluated patients’ levels of distress with the NCCN Distress Thermometer, a brief instrument that asks patients to rate “how much distress [they] have been experiencing in the past week including today,” on a scale from 0 (No distress) to 10 (Extreme distress), similar to common pain scales. Distress scores were grouped into four categories: severe (scores of 7-10), moderate (4-6), low (1-3) and none (0). Fifteen percent of the patients in this study reported severe distress, 29 percent reported moderate stress, 29 percent reported low distress and 25 percent reported no distress.

Patients with higher distress scores were more likely to miss appointments during their course of radiation therapy. More than half (57%) of the patients with severe distress scores missed one or more appointments, compared to 18 percent of patients with moderate, low or no distress (p < 0.01).

Distressed patients also were more likely to be admitted to the hospital during treatment. Half of the patients with severe distress scores were admitted during treatment, compared with 11 percent of patients with moderate, low or no distress (p < 0.01).

Researchers also examined the influence of clinical and demographic factors on levels of patient distress. Neither weight loss during treatment nor duration of time between initial consultation and start of treatment correlated significantly with distress scores. The stage of a patient’s cancer, however, was positively associated with distress, such that each increase in stage predicted an average increase of 0.8 points on a patient’s distress score (p < 0.05).

The study demonstrates that the NCCN Distress Thermometer or similar instruments can be useful prognostic tools for radiation oncologists to determine which patients may need additional support during treatment, explained Mr. Anderson.

“Our field has made great advancements in treatments for patients with cancer, but psychosocial factors influence a patient’s ability to receive the appropriate treatment without delay or interruption. Our study demonstrates an association between distress and radiation therapy-specific outcomes, adding to the growing body of evidence emphasizing a need for an interdisciplinary approach to cancer care,” said Mr. Anderson.

“These findings underscore the importance of devising treatment plans that address mental well-being and are unique to each patient’s individual needs. For example, if a patient is experiencing severe distress–and therefore is at higher risk of missing appointments or being admitted to the hospital–we can offer transportation or housing support.”