The NCCN Guideline for Distress Management: A Case for Making Distress the Sixth Vital Sign

Psychosocial care of patients has traditionally been seen as separate from routine medical care and has been criticized as being “soft” and lacking evidence. This traditional perspective continues in many settings, despite the fact that patients and families, when asked, state that emotional care is highly valued. The question of how to integrate psychosocial care into routine cancer care has also been an issue, partly because of the stigma associated with cancer.In 1997, the National Comprehensive Cancer Network (NCCN) established a multidisciplinary panel to examine this problem.1 Because patient and physician attitudes toward pain can pose similar barriers to care as can distress, the panel used as a model the rating system for assessing pain that resulted in successful improvement of pain management in the United States. The rating system's success seemed partly based on routinely using a single question to assess a patient's pain: “How is your pain on a scale of 0 to 10?” The system uses a score of 5 or higher as the indication to reassess pain medications or refer the patient for more expert management. This system is widely used, and patient self-report of subjective symptoms is now accepted as appropriate and reliable. Pain has become the fifth vital sign, after pulse, respiration, blood pressure, and temperature, ensuring that it is evaluated as part of routine care.Drawing on this experience, the NCCN panel recommended a simple question to ask patients about psychosocial concerns. They found that distress was the best umbrella word to...

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Jimmie C. Holland, MD, is the Wayne Chapman Chair in Psychiatric Oncology and Attending Psychiatrist in the Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, NY.

Barry D. Bultz, PhD, is the Director of the Department of Psychosocial Resources, Tom Baker Cancer Centre/Alberta Cancer Boards, and Chief and Adjunct Professor, Division of Psychosocial Oncology in the Department of Oncology, University of Calgary, Alberta, Canada.

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