Screening for Distress Now a Routine Part of Quality Cancer Care-At Last

Jimmie C. Holland, MD

At the 2014 ASCO meeting, OncologyLive sat down with Jimmie C. Holland, MD, the Wayne E. Chapman Chair in Psychiatric Oncology at Memorial Sloan Kettering Cancer Center and the recipient of the 2014 Giants of Cancer Care™ Award for her pioneering contributions in the field of supportive care.

Her groundbreaking work has raised critical awareness among oncology practitioners of the importance of meeting the psychosocial needs of patients and of the evidence-based interventions now available to address those needs. This is important, she said, not only so that patients will adhere to their therapies, but also so that they will have an improved quality of life during treatment and be better equipped for survivorship—a phase she noted presents its own set of challenges that she and other researchers are continuing to study.

Why has the role of supportive care grown in importance?

You would think that since cancer is such a frightening disease, the focus would have been there from the start, but it wasn’t. I often heard “we’re just too busy to study that. We’re trying to cure cancer.” I and others kept pointing out that how patients cope with it all is a key part of how well they do with their treatments. Supportive care improves quality of life, as well as the patient’s ability to handle a cancer diagnosis, and this support needs to be extended to the whole family, because we know that cancer is not just a disease of one person. There is a whole panoply of problems that are associated with cancer that fall under supportive care—pain management, symptom control, psychological problems, spiritual problems. We’re finding that we now have an evidence base for interventions that will help people cope. The field has come a long way over the last 30 years.

A Vintage Readers Book Club

In her practice today, Jimmie Holland works mostly with older people, the fastest-growing group of cancer survivors. She noted that this group typically prefers the telephone to digital engagement, and she and her colleagues at Memorial Sloan Kettering Cancer Center have developed a psychotherapy telephone intervention for these patients to deal with the loneliness, isolation, and associated feelings of depression that may accompany the “double whammy” of aging and a cancer diagnosis.

As part of her Aging and Cancer Group, Holland facilitates a “Vintage Readers Book Club,” involving about 10-12 patients each month who read and discuss the classics. Holland said the initiative has proven very motivating for these patients who range in age from the mid-60s to the mid-90s. She sends out a reading every month—in big font—and members who can’t come in may call in and be part of the group. Readings have included writings by Benjamin Franklin and Cicero’s essay, “On Old Age.”

“The idea came from my granddaughter. I started reading the Great Books with her during her gap year, and when she went to college, she suggested I begin a group for my older patients,” Holland explained. She added that such a group helps to give older adults, who may not be comfortable talking about themselves, a focus and a goal and inspires them to discuss their ideas and experiences in the context of a shared reading. Nurses and navigators who would like to learn more about the program may email hollandj@mskcc.org.

What are some examples of interventions that are being used successfully in practice today?

The whole idea of counseling patients has really emerged, with some models now being very carefully tested, for example, a cognitive— behavioral approach that addresses the patient’s “here and now” experiences and aims to work through their present-day concerns: “What are your issues? What are you having trouble with right now?” Another approach developed here at Memorial Sloan Kettering is called Meaning-Based Therapy—helping those patients who do have a limited lifespan to find the meaning that is most important and live as much as they can during whatever time they have left. There are also various medications that can help and are continuing to be studied.

How are notions of palliative care being redefined? How is that affecting practice? Oncologists have typically associated palliative care with end of life and hospice. Now palliative care is being talked about for emphasis early on and in the context of symptom control.

People survive longer when their symptoms are well controlled. Psychosocial issues are embedded in that, which we also refer to as the “management of distress,” to avoid any stigma that’s sometimes attached to mental health issues. We developed the NCCN distress thermometer which uses a 0 to 10 scale, much like we do to measure pain: It is one question, it’s not stigmatizing, and oncologists are willing to ask that. If a patient ranks distress as 4 or higher, that’s a trigger for the nurse to step in and begin a discussion of what the problems are and then triage the patient to the right resources.

What are some of your recommendations for providers to integrate psychosocial services at their own practices? We’re working now to help institutions gear up to meet the 2015 Commission on Cancer standard that to be accredited, cancer centers must demonstrate that they are developing a process for distress screening at their institutions. It’s important to note that these services do not always need to be provided face-to-face.

There are virtual, online support groups, for example, as well as telephone interventions, and these methods are being studied now for how effective they are and who is using them. You can’t ignore the psychosocial aspects of care anymore. This was a big focus of the meeting of the American Psychosocial Oncology Society meeting earlier this year. Our members could see that suddenly, healthcare policy supports routine, psychosocial care! We thought it would never happen.