The International Endorsement of US Distress Screening and Psychosocial Guidelines in Oncology: A Model for Dissemination

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Distress Management have, since 1997, called for routine screening of distress in patients with cancer. Following the example of pain as the fifth vital sign, the case for using the concept of distress as the sixth vital sign was made by leading psycho-oncologists in 2007. Cancer care organizations in Canada and the International Psycho-Oncology Society have adopted the NCCN Guidelines for Distress Management and have named distress screening as the sixth vital sign, thereby encouraging cancer care clinicians to think of screening for distress when they screen for pain and other vital signs. Using the evidence integration triangle, this article explores the dissemination of the notion of distress as the sixth vital sign in an international context. This exploration shows that NCCN and similar organizations can adopt the evidence integration triangle in its next phase of moving toward full implementation of the NCCN Guidelines for Distress Management.

Abstract

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Distress Management have, since 1997, called for routine screening of distress in patients with cancer. Following the example of pain as the fifth vital sign, the case for using the concept of distress as the sixth vital sign was made by leading psycho-oncologists in 2007. Cancer care organizations in Canada and the International Psycho-Oncology Society have adopted the NCCN Guidelines for Distress Management and have named distress screening as the sixth vital sign, thereby encouraging cancer care clinicians to think of screening for distress when they screen for pain and other vital signs. Using the evidence integration triangle, this article explores the dissemination of the notion of distress as the sixth vital sign in an international context. This exploration shows that NCCN and similar organizations can adopt the evidence integration triangle in its next phase of moving toward full implementation of the NCCN Guidelines for Distress Management.

Background

Moving new health care discoveries and innovations from evidence into everyday clinical practice remains a challenge, despite demonstrated benefits.1 The evidence-based NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Distress Management,2 which call for routine distress screening of patients with cancer, are no exception. Screening for distress attempts to identify in real time the concerns of patients, so that those concerns can be addressed in a timely manner. The NCCN standards state that “all patients should be screened for distress at their initial visit, and at appropriate intervals, as clinically indicated”2 (to view the most recent version of these guidelines, visit NCCN.org).

The Need for Distress Screening

Up to 43% of patients in treatment for cancer have been reported to have clinically significant levels of distress.3 In a 2005 study of 1281 patients screened for distress in a community-based oncology practice, 410 (32%) reported clinically significant distress.4 This distress may arise from the disease itself,5 but also from physical symptoms such as pain and fatigue,6 from emotional states such as depression and anxiety, and from spiritual concerns.7 Unaddressed, distress diminishes adherence to treatment, reduces quality of life and satisfaction with care, and negatively affects medical outcomes and survival.8-14

The Distress Thermometer

Integral to the NCCN Guidelines for Distress Management is the use of a standard instrument to screen for distress. The success of the 0 to 10 rating scale for pain assessment was seen as a possible model for screening for distress. Roth et al15 tested a single-item “Distress Thermometer” (DT) to assess distress rapidly in a user-friendly format. It asks people to rate how distressed they have felt in the past week on a scale from 0 (no distress) to 10 (extremely distressed). Jacobsen et al16 evaluated the single-item DT and found that it compared favorably with the 14-item Hospital Anxiety and Depression Scale and the 18-item version of the Brief Symptom Inventory as a method for screening distress among ambulatory patients with cancer. A cutoff distress score of 4 on the single-item DT was reported as sensitive, indicating moderate to severe distress.16

Benefits of Distress Screening

The benefits of distress screening have been identified as far back as 30 years ago, when Worden and Weisman17 found that more than two-thirds of patients at risk for cancer-related distress accepted screening. Patients at high risk for distress who were screened and offered psychological intervention reported a significant decrease in distress and a significant increase in the level of problem-solving.18 Since the 1980s, clinical trials have shown that assessing for distress improves both patient-reported outcomes19-21 and communication between patients and providers.19,21,22 For these reasons, the Institute of Medicine found that distress screening is an evidence-based way to integrate psychosocial cancer care with biomedical cancer care.23

Slow Uptake of Evidence-Based Distress Screening Practice Guidelines

However, even with the proven ability of the NCCN’s DT to detect distress, Pirl et al6 interviewed 1000 oncologists in the United States and found that fewer than 15% report having used a standardized method for distress screening. Convincing evidence suggests that, without the aid of a screening instrument such as the NCCN’s DT, cancer care providers do not often recognize distressed patients. In a study that evaluated the ability of 143 physicians to detect heightened distress among 2297 patients with cancer, only 29% of patients with scores exceeding the cutoff on an established screening measure were identified by their physicians as being distressed.7 Although one study found that a greater severity of distress is associated with better recognition by clinicians, it also found that without using a screening instrument to identify distress, clinicians detected only approximately half of all severely distressed patients.24

Even with the known need for psychosocial distress screening using a standardized instrument, little effort has been made to modify clinical practice. Between 2005 and 2012, only a 7% increase in NCCN Member Institutions conducting any routine screening occurred, and the number of these institutions screening all outpatients routinely increased only by 10%, which, in 2012, still only represented 35% of all NCCN Member Institutions.25,26

This slow uptake of the NCCN Guidelines for Distress Management is the conundrum of dissemination. This article explores the dissemination of these guidelines in an international context, and suggests that lessons learned can be applied to disseminating and implementing the guidelines in the United States.

Dissemination and Implementation in a Health Care Context

Unlike in other contexts, in which dissemination means something like spreading broadly and widely as if sowing seeds, some of which may germinate and others not, dissemination in a health care context means something narrower. Dissemination in the health care context is, as Glasgow et al1 define it, “the targeted distribution of information and intervention materials to a specific public health or clinical practice audience.” Of course, the intent is to spread knowledge and change clinical practice and influence health care policy, but it is exactly the targeted nature of the process that makes dissemination different in a health care context. Dissemination in a health care context, in other words, is active and targeted. Spreading the message without this active targeting is passive, and is what Glasgow et al1 call diffusion, not dissemination.

In another article, Glasgow et al27 argue that too often evidence is decontextualized and implementation is standardized, which in turn causes slow integration of evidence into clinical practice and policy. As with targeted dissemination, implementation likewise must be targeted. This targeting occurs through 3 components: 1) key stakeholders must be identified and engaged in the process of implementing evidence-based standards; 2) eschewing the tendency to force programmatic standardization, a program that can be adapted to the local practice or policy context must be used; and 3) specific and practical longitudinal measures must be used to provide rapid feedback on progress (Figure 1). Using these 3 components to target the practice environment will provide a framework for integrating evidence into practice and policy. Glasgow et al27 call this framework the evidence integration triangle.

The Targeted Dissemination and Implementation of the NCCN Guidelines for Distress Management in an International Context

Early adoption of routine distress screening has occurred in international settings. For example, in one state government in Australia, the cancer plan calls for routine distress screening.28 To sharpen the focus of discussion on dissemination and implementation, however, this article focuses on the Canadian example.

Figure 1.
Figure 1.

Evidence intergration triangle adapted to implementation of distress screening.

Based on Glasgow R, Green L, Taylor M, Stange K. An evidence integration triangle for aligning science with policy and practice. Am J Prev Med 2012;42:646-654.

Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 12, 2; 10.6004/jnccn.2014.0023

The Canadian Example

In June 2004, the Canadian Strategy for Cancer Control adopted the view that distress screening is “a core indicator of a patient’s health and well-being,” and made distress the sixth vital sign in cancer care.29 Just as with temperature, pulse, respiration, blood pressure, and pain, cancer care professionals in Canada now routinely screen for distress.30 The intent was to brand distress as a vital sign to enable cancer care providers “to conceptualize distress in the medical model.”31

In a 2011 paper, Bultz et al31 described how, in Canada, they moved from this early step of naming, or branding, distress as the sixth vital sign to a nationwide adoption of routine distress screening. First, they engaged high-level stakeholders at the national level for targeted, active dissemination. Second, they developed national recommendations, which provided an opportunity for a national discussion of local adaptation for programmatic implementation. Third, as of 2011, 4 jurisdictions within the Canadian cancer care system have implemented routine distress screening. The evidence from these 4 will be used to target other jurisdictions for complete nationwide adherence to the standard. The Canadian example exemplifies the targeted nature of dissemination and implementation as expressed in Glasgow’s evidence integration triangle (Table 1).

The International Psycho-Oncology Society’s Efforts

In 2010, in an effort to endorse the NCCN Guidelines for Distress Management standard of routine distress screening, the International Psycho-Oncology Society (IPOS) endorsed the concept that distress be viewed as the sixth vital sign. The official IPOS statement is 2-fold:

  1. Quality cancer care must integrate the psychosocial domain into routine care, and

  2. Distress should be measured as the sixth vital sign after temperature, blood pressure, pulse, respiratory rate, and pain.32

Since 2010, IPOS has targeted cancer care and advocacy organizations throughout the world with evidence of the need for, and benefits of, distress screening. So far, 66 organizations have endorsed the IPOS quality standard of cancer care (Table 2). Their endorsement represents IPOS’s targeted dissemination of the quality care standard.

The next step beyond endorsement for these 66 organizations, however, is dissemination and implementation within their spheres of influence. This will involve taking the 3 steps of the evidence integration triangle. These steps, from endorsement to implementation, may be illustrated through considering the current state of affairs in the United States.

Apply the Evidence Integration Triangle to United States

In 2011, the American College of Surgeons Commission on Cancer (CoC) published Cancer Program Standards 2012,33 stipulating that CoC-accredited cancer centers will have to conduct psychosocial distress screening a minimum of one time at a pivotal medical visit. If a patient is clinically significantly distressed, the standards also stipulate further assessment, referral to appropriate psychosocial health care resources, and follow-up after referral, all of which must be documented in the patient’s medical record. Furthermore, the entire distress screening program must be overseen by the psychosocial health care professional on the cancer center’s cancer committee.

Table 1

Matching the Canadian Strategy With the Evidence Integration Triangle

Table 1

The CoC standards follow the evidence integration triangle. The committees target key stakeholders through the cancer center’s cancer committee, which according to the CoC, leads the cancer center’s program and sets goals, monitors program activities, and evaluates patient outcomes.33 The committees make it possible for cancer centers to determine the methods and tools then use to screen for distress, thus adapting to the practice environment, and they will judge the progress made on implementing the psychosocial distress screening standard on a 1 (compliance) to 5 (noncompliance) rating scale.

Although the CoC standards do not go all the way to adopting the IPOS quality care standard of distress as the sixth vital sign, they will ensure that every patient with cancer is screened for distress at least once. Distress as the sixth vital sign is a conceptual mnemonic, as it were, placing before the minds of cancer care clinicians the need to screen their patients.20 However, if the CoC mandated that this screening occur at specific times, the adaptability of the quality care standard might be lost, in the same way as if the CoC dictated which instrument to use and at which cutoff score distress is considered clinically significant. Although the NCCN’s DT is a standardized tool that may be used in most cancer care settings, even on it the cutoff score may differ depending on the stage and place within the trajectory of disease.

More important, perhaps, is that the very notion of distress as a vital sign does not itself dictate the frequency of measurement. The frequency of vital sign monitoring depends on the clinical practice’s scope of care, the patient’s condition, the treatment the patient is receiving, and the need for information for clinicians to make clinical judgments about care. It is obvious to state that, for example, vital signs are monitored more frequently in an acute care setting than in a step-down unit or a general medical-surgical floor, or even a primary care setting. This variability of frequency notwithstanding, the purpose of monitoring vital signs is to provide clinicians with information about the types of clinical judgments they need to make. The IPOS quality care standard of distress as the sixth vital sign, therefore, should not itself dictate the frequency of vital sign monitoring.

A limitation of the CoC standard, however, is that it requires distress screening at only one pivotal visit. This visit may be the initiation of medical treatment, such as at the first cycle of chemotherapy. However, other pivotal visits occur on the cancer care trajectory, such as at the end of treatment and the move to survivorship or when disease recurs. An important facet of the concept of distress as the sixth vital sign is that the place on the disease trajectory and the patient’s status determine the frequency of the screening, rather than a standard that may allow cancer centers to aim merely to comply. The focus of distress screening is, of course, on improving the quality of care through integrating psychosocial with biomedical cancer care.

However, IPOS and other psychosocial cancer care organizations, including NCCN, need to educate cancer centers’ cancer committees on applying the evidence integration triangle to their rollout of the CoC standard, including the frequency of distress screening. Education of the cancer committees is not all that is needed. Teams of clinicians must be coached through the process of distress screening as described in the NCCN Guidelines for Distress Management. They need support not only from outside experts but also from each other, sharing their unique expertise as they implement evidence-based distress screening. This education and support target key stakeholders and engage them in adapting the quality care standard to their practice settings, including their patient population—the first 2 steps in the evidence integration triangle’s integration of evidence into practice.

Table 2

List of Organizations Endorsing the IPOS Quality Care Standard

Table 2

Furthermore, cancer committees and teams of clinicians must agree on the frequency of screening for distress in their cancer centers, and more specifically in the population of patients their particular clinics serve. A patient in the first 100 days after diagnosis may experience distress more acutely than a patient who is in survivorship care, and therefore the frequency of screening may need to differ for each patient. At the heart of the question of frequency of distress screening is the notion of staying current with the evidence, and understanding the critical times when patients may be at greater risk for distress and therefore may need more frequent screening.

IPOS and NCCN, likewise, can educate cancer centers’ cancer committees on the importance of measuring progress toward integrating evidence into their clinical care. Jacobsen and Kadlubeck34 have shown that if practices measure their progress on 2 psychosocial quality indicators—that patients were screened for distress within 1 month of their initial visit and, if found to have clinically significant distress, evidence in the medical record shows that action was taken—practices increased their rates of screening patients and of taking action to address any concerns.

Conclusions

NCCN and similar organizations can adopt the 3 steps of the evidence integration triangle in its next phase of moving toward full adoption of the quality care standard of distress screening as a way of integrating psychosocial cancer care with biomedical cancer care. Cancer care professionals must be educated that, to disseminate the evidence of the benefits of routine distress screening and to work toward its full implementation, key stakeholders must be targeted. When targeting these key stakeholders for their support of distress screening, forcing programmatic standardization on them will slow implementation; the methods, tools, and frequency of distress screening must be adaptable to the practice environment, taking into account the place on the disease trajectory and the condition of the patients served by the practice. Finally, practices must be educated on how to use quality indicators to measure their progress toward the ultimate goal of integrating psychosocial cancer care with biomedical cancer care: practices can audit their patients’ medical records to determine whether patients were screened and whether action was taken when necessary. Preparing cancer care practices, including and especially NCCN Member Institutions, to take these 3 practical steps may help them integrate the evidence of distress screening into their practices, thus moving evidence from the pages of the researchers’ scientific papers to the everyday reality of quality, patient-centered cancer care.

The author has disclosed that he has no financial interests, arrangements, affiliations, or commercial interests with the manufacturers of any products discussed in this article or their competitors.

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    • Search Google Scholar
    • Export Citation
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    HollandJAndersenBBreitbartW. Distress management. J Natl Compr Canc Netw2013;11:190209.

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    ZaboraJBrintzenhofeSzocKCurbowB. The prevalence of psychological distress by cancer site. Psychooncology2001;10:1928.

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    RothAJKornblithABBatel-CopelL. Rapid screening for psychologic distress in men with prostate carcinoma: a pilot study. Cancer1998;82:19041908.

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    JacobsenPBDonovanKATraskPC. Screening for psychologic distress in ambulatory cancer patients. Cancer2005;103:14941502.

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    Von EssenLLarssonGObergKSjodenPO. ‘Satisfaction with care’: associations with health-related quality of life and psychosocial function among Swedish patients with endocrine gastrointestinal tumours. Eur J Cancer Care2002;11:9199.

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    VelikovaG. Patient benefits from psychosocial care: screening for distress and models of care. J Clin Oncol2010;28:48714873.

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    FallowfieldLRatcliffeDJenkinsVSaulJ. Psychiatric morbidity and its recognition by doctors in patients with cancer. Br J Cancer2001;84:10111015.

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    DonovanKJacobsenP. Progress in the implementation of NCCN guidelines for distress management by member institutions. J Natl Compr Canc Netw2013;11:223226.

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    • Export Citation
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    JacobsenPBRansomS. Implementation of NCCN distress management guidelines by member institutions. J Natl Compr Canc Netw2007;5:99103.

    • Search Google Scholar
    • Export Citation
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    GlasgowRGreenLTaylorMStangeK. An evidence integration triangle for aligning science with policy and practice. Am J Prev Med2012;42:646654.

    • Search Google Scholar
    • Export Citation
  • 28.

    Victoria (Australia) Department of Health. Victoria’s Cancer Action Plan 2008-2011. Available at: http://docs.health.vic.gov.au/docs/doc/Victorias-Cancer-Action-Plan-2008-2011-complete-document---Dec-2008. Accessed July 8 2013.

    • Search Google Scholar
    • Export Citation
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    Accreditation Canada. Cancer care and oncology services standards 2008 2009. Available at: www.accreditation.ca/cancer-care-and-oncology-services.

    • Search Google Scholar
    • Export Citation
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    Rebalance Focus Action Group. A position paper: screening key indicators in cancer patients—pain as a 5th vital sign and emotional distress as a 6th vital sign. Canadian Strategy for Cancer Control Bulletin2005;7(Suppl):4.

    • Search Google Scholar
    • Export Citation
  • 31.

    BultzBDGroffSLFitchM. Implementing screening for distress, the 6th vital sign: a canadian strategy for changing practice. Psychooncology2011;20:463469.

    • Search Google Scholar
    • Export Citation
  • 32.

    International Psycho-Oncology Society. IPOS international standard of quality cancer care. Standards of Care News. http://ipos-society.org/about/news/standards_news.aspx. Updated 2013. Accessed May 21 2013.

    • Search Google Scholar
    • Export Citation
  • 33.

    American College of Surgeons. Cancer program standards (CPS) 2011 project. Available at: http://www.facs.org/cancer/coc/cps2011.html. Accessed September 1 2011.

    • Search Google Scholar
    • Export Citation
  • 34.

    JacobsenPKadlubekP. Changes over time in quality of psychosocial care: results from the Quality Oncology Practice Initiative (QOPI). J Clin Oncol2010;28(Suppl):15s.

    • Search Google Scholar
    • Export Citation

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Correspondence: Mark Lazenby, PhD, RN, Yale University, 100 Church Street South, New Haven, CT 06536-0740. E-mail: mark.lazenby@yale.edu

Article Sections

Figures

  • View in gallery

    Evidence intergration triangle adapted to implementation of distress screening.

    Based on Glasgow R, Green L, Taylor M, Stange K. An evidence integration triangle for aligning science with policy and practice. Am J Prev Med 2012;42:646-654.

References

  • 1.

    GlasgowRVinsonCChambersD. National institutes of health approaches to dissemination and implementation science: current and future directions. Am J Public Health2012;102:12741281.

    • Search Google Scholar
    • Export Citation
  • 2.

    HollandJAndersenBBreitbartW. Distress management. J Natl Compr Canc Netw2013;11:190209.

  • 3.

    ZaboraJBrintzenhofeSzocKCurbowB. The prevalence of psychological distress by cancer site. Psychooncology2001;10:1928.

  • 4.

    BultzBCarlsonL. Emotional distress: the sixth vital sign in cancer care. J Clin Oncol2005;23:64406441.

  • 5.

    AzizNMRowlandJH. Trends and advances in cancer survivorship research: challenge and opportunity. Semin Radiat Oncol2003;13:248266.

  • 6.

    PirlWFMurielAHwangV. Screening for psychosocial distress: a national survey of oncologists. J Support Oncol2007;5:499504.

  • 7.

    SollnerWDeVriesASteixnerE. How successful are oncologists in identifying patient distress, perceived social support, and need for psychosocial counselling?Br J Cancer2001;84:179185.

    • Search Google Scholar
    • Export Citation
  • 8.

    Institute of Medicine. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press; 2008.

    • Search Google Scholar
    • Export Citation
  • 9.

    JacobsenPBDonovanKAVadaparampilSTSmallBJ. Systematic review and meta-analysis of psychological and activity-based interventions for cancer-related fatigue. Health Psychol2007;26:660667.

    • Search Google Scholar
    • Export Citation
  • 10.

    ValdimarsdottirUHelgasonARFurstCJ. The unrecognised cost of cancer patients’ unrelieved symptoms: a nationwide follow-up of their surviving partners. Br J Cancer2002;86:15401545.

    • Search Google Scholar
    • Export Citation
  • 11.

    DiMatteoMRLepperHSCroghanTW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med2000;160:21012107.

    • Search Google Scholar
    • Export Citation
  • 12.

    PrietoJMBlanchJAtalaJ. Psychiatric morbidity and impact on hospital length of stay among hematologic cancer patients receiving stem-cell transplantation. J Clin Oncol2002;20:19071917.

    • Search Google Scholar
    • Export Citation
  • 13.

    HjerlKAndersenEWKeidingN. Depression as a prognostic factor for breast cancer mortality. Psychosomatics2003;44:2430.

  • 14.

    SteelJLGellerDAGamblinTC. Depression, immunity, and survival in patients with hepatobiliary carcinoma. J Clin Oncol2007;25:23972405.

    • Search Google Scholar
    • Export Citation
  • 15.

    RothAJKornblithABBatel-CopelL. Rapid screening for psychologic distress in men with prostate carcinoma: a pilot study. Cancer1998;82:19041908.

    • Search Google Scholar
    • Export Citation
  • 16.

    JacobsenPBDonovanKATraskPC. Screening for psychologic distress in ambulatory cancer patients. Cancer2005;103:14941502.

  • 17.

    WordenJWWeismanAD. Do cancer patients really want counseling?Gen Hosp Psychiatry1980;2:100103.

  • 18.

    WordenJWWeismanAD. Preventive psychosocial intervention with newly diagnosed cancer patients. Gen Hosp Psychiatry1984;6:243249.

  • 19.

    VelikovaGBoothLSmithAB. Measuring quality of life in routine oncology practice improves communication and patient well-being: a randomized controlled trial. J Clin Oncol2004;22:714724.

    • Search Google Scholar
    • Export Citation
  • 20.

    Von EssenLLarssonGObergKSjodenPO. ‘Satisfaction with care’: associations with health-related quality of life and psychosocial function among Swedish patients with endocrine gastrointestinal tumours. Eur J Cancer Care2002;11:9199.

    • Search Google Scholar
    • Export Citation
  • 21.

    VelikovaG. Patient benefits from psychosocial care: screening for distress and models of care. J Clin Oncol2010;28:48714873.

  • 22.

    DetmarSBMullerMJSchornagelJH. Health-related quality-of-life assessments and patient-physician communication: a randomized controlled trial. JAMA2002;288:30273034.

    • Search Google Scholar
    • Export Citation
  • 23.

    AdlerNEPageA eds. Cancer care for the whole patient [electronic resource]: meeting psychosocial health needs/Committee on Psychosocial Services to Cancer Patients/Families in a Community Setting Board on Health Care Services. Washington, DC: National Academies Press; 2008.

    • Search Google Scholar
    • Export Citation
  • 24.

    FallowfieldLRatcliffeDJenkinsVSaulJ. Psychiatric morbidity and its recognition by doctors in patients with cancer. Br J Cancer2001;84:10111015.

    • Search Google Scholar
    • Export Citation
  • 25.

    DonovanKJacobsenP. Progress in the implementation of NCCN guidelines for distress management by member institutions. J Natl Compr Canc Netw2013;11:223226.

    • Search Google Scholar
    • Export Citation
  • 26.

    JacobsenPBRansomS. Implementation of NCCN distress management guidelines by member institutions. J Natl Compr Canc Netw2007;5:99103.

    • Search Google Scholar
    • Export Citation
  • 27.

    GlasgowRGreenLTaylorMStangeK. An evidence integration triangle for aligning science with policy and practice. Am J Prev Med2012;42:646654.

    • Search Google Scholar
    • Export Citation
  • 28.

    Victoria (Australia) Department of Health. Victoria’s Cancer Action Plan 2008-2011. Available at: http://docs.health.vic.gov.au/docs/doc/Victorias-Cancer-Action-Plan-2008-2011-complete-document---Dec-2008. Accessed July 8 2013.

    • Search Google Scholar
    • Export Citation
  • 29.

    Accreditation Canada. Cancer care and oncology services standards 2008 2009. Available at: www.accreditation.ca/cancer-care-and-oncology-services.

    • Search Google Scholar
    • Export Citation
  • 30.

    Rebalance Focus Action Group. A position paper: screening key indicators in cancer patients—pain as a 5th vital sign and emotional distress as a 6th vital sign. Canadian Strategy for Cancer Control Bulletin2005;7(Suppl):4.

    • Search Google Scholar
    • Export Citation
  • 31.

    BultzBDGroffSLFitchM. Implementing screening for distress, the 6th vital sign: a canadian strategy for changing practice. Psychooncology2011;20:463469.

    • Search Google Scholar
    • Export Citation
  • 32.

    International Psycho-Oncology Society. IPOS international standard of quality cancer care. Standards of Care News. http://ipos-society.org/about/news/standards_news.aspx. Updated 2013. Accessed May 21 2013.

    • Search Google Scholar
    • Export Citation
  • 33.

    American College of Surgeons. Cancer program standards (CPS) 2011 project. Available at: http://www.facs.org/cancer/coc/cps2011.html. Accessed September 1 2011.

    • Search Google Scholar
    • Export Citation
  • 34.

    JacobsenPKadlubekP. Changes over time in quality of psychosocial care: results from the Quality Oncology Practice Initiative (QOPI). J Clin Oncol2010;28(Suppl):15s.

    • Search Google Scholar
    • Export Citation

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