Easier Said Than Done: Keys to Successful Implementation of the Distress Assessment and Response Tool (DART) Program

Li, Madeline; Macedo, Alyssa; Crawford, Sean A.; Bagha, Sabira; Leung, Yvonne; Zimmermann, Camilla; Fitzgerald, Barbara; Wyatt, Martha; Stuart-McEwan, Terri; Rodin, Gary

doi:10.1200/jop.2015.010066

Cited by 69 publications

(80 citation statements)

References 51 publications

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“…18 The mechanism of pain in DT is complex and multifactorial, but clinical experience suggests it is often considered out of proportion to the physical effects of the DT, raising the possibility of emotional distress contributing to a presentation of total pain. 22 As benign DT and malignant sarcoma are both connective tissue diseases, they are seen at our institution within the same clinic and are treated by the same physicians and multidisciplinary approach. Thus, we formally investigated symptom distress in our patients with DT.…”

Section: Introductionmentioning

confidence: 99%

“…We evaluate DART scores in patient cohorts over time to identify predictors of distress for patients living with DT, and compare cross sectional DART scores between DT and sarcoma patients. 22 DART also includes the Informational Problems (understanding the illness, communication with the health care team, making treatment decisions, knowing about available resources) and Spiritual Problems (meaning/purpose in life, faith), domains from the Canadian Problem Checklist (CPC). 26 If a patient in either DT or sarcoma cohorts had completed more than one DART survey within the study time points, their most symptomatic DART score (highest distress) was used as our objective was to measure the highest distress levels patients experience during the management and surveillance of DT.…”

Section: Introductionmentioning

confidence: 99%

“…20,21 The Distress Assessment and Response Tool (DART) is a patient reported outcome (PRO) distress screening program established as a standard of care in all clinics at our institution. 22 As benign DT and malignant sarcoma are both connective tissue diseases, they are seen at our institution within the same clinic and are treated by the same physicians and multidisciplinary approach. We evaluate DART scores in patient cohorts over time to identify predictors of distress for patients living with DT, and compare cross sectional DART scores between DT and sarcoma patients.…”

Section: Introductionmentioning

confidence: 99%

“…25 The SDI-21 is a 21-item self-report for social problems and needs with three validated subscales: Everyday Living (e.g., independence, personal care), Money Matters (e.g., finances, future plans), and Self and Others (e.g., communication, support, body image, isolation) 26 Prescreening questions are administered in DART to trigger each of the three subscales of the SDI-21. 22 DART also includes the Informational Problems (understanding the illness, communication with the health care team, making treatment decisions, knowing about available resources) and Spiritual Problems (meaning/purpose in life, faith), domains from the Canadian Problem Checklist (CPC). 28 Other patient-reported variables include: current living situation (alone/with spouse or family/with friends or others), personal and family history of depression or anxiety, supportive care services received, and desire for referral for supportive care services (answered using a yes/no format).…”

Section: Introductionmentioning

confidence: 99%

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High prevalence of persistent emotional distress in desmoid tumor

et al. 2019

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Objective: Clinical experience suggests a high prevalence of emotional distress in patients with desmoid tumor (DT). We examine longitudinal Distress Assessment and Response Tool (DART) scores to estimate prevalence and persistence of distress, and compare cross-sectional data between DT and malignant sarcoma cohorts, to identify predictors of distress. Methods: Patients with DT completed DART at: T1-diagnosis, T2-during, T3-<6 months, and T4-≥6 months, post-treatment. DART includes patient-reported outcome measures of physical symptoms (ESAS-r), depression (PHQ-9), anxiety (GAD-7), and social difficulties (SDI-21). Descriptive prevalence and persistence of anxiety, depression, and wellbeing are reported, and mixed model regression analyses determine predictors of distress. Results: Between 2012 and 2018, a total of 152 DART screens from 94 patients with DT were completed (T1: n = 44, T2: n = 31, T3: n = 22, T4: n = 55). Patients had a mean age 40 years, 78% were female and DT locations were abdominal wall (48%), extremity (30%), and mesentery (22%). Moderate to severe ESAS-r scores (≥4) persisted at T4 for anxiety (20%), depression (13%), and poor wellbeing (31%). Compared to 402 patients with malignant sarcoma, patients with abdominal wall sited DT reported severe PHQ-9 and GAD-7 scores twice as frequently. Abdominal wall location, female sex, history of mood problems, and psychosocial concerns were significant predictors of anxiety, depression, and poor wellbeing in DT. Conclusions: Adults with DT experience persistently high emotional distress compared to patients with malignant sarcoma. Women with abdominal wall DT, prior mood, and current psychosocial concerns need early attention within multidisciplinary treatment settings to reduce persistent distress. K E Y W O R D S aggressive fibromatosis, cancer, desmoid tumor, Edmonton Symptom Assessment Scalerevised (ESAS-r), emotional distress, oncology, psychological distress, quality of life (QOL), sarcoma supportive careThe last two authors contributed equally to this article and share last authorship.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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High prevalence of persistent emotional distress in desmoid tumor

et al. 2019

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“…Although high intensity scores on distress screening tools may indicate a need for a specialized referral, other specialized areas, such as psychosocial oncology, have shown that many of the trigger criteria can be managed with more frequent assessment in the primary clinic first, and that patients can be referred out only when necessary. 9 Feldstain et al found that low-intensity symptom scores increased at the next follow-up appointment. This finding has been previously published, and various reasons have been hypothesized, including the volatility of symptoms and the relation to underlying disease progression.…”

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confidence: 99%

Palliative Care: Who is Responsible?

Rosenblum¹,

Chasen²

2018

J Natl Compr Canc Netw

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In a time when medicine has been fairly criticized as producing too many subspecialists, a positive movement toward multidisciplinary care teams has begun. Oncology programs are no exception. Although many cancer centers have dedicated teams based on the primary cancer, individual members within these teams represent multiple disciplines. For example, at minimum, a head and neck cancer team should include a medical oncologist, radiation oncologist, surgical oncologist, nurse, dietitian, speech language pathologist, and social worker. For patients with advanced cancer, multiple randomized studies have shown that early palliative care improves patient quality of life, and in some instances quantity of life. 1 Therefore, an oncology program is not complete without palliative care.In "Outcomes From a Patient-Centered, Interprofessional, Palliative Consult Team in Oncology" published in this issue, Feldstain et al skillfully demonstrate not only the statistical but also the clinical benefits of interdisciplinary specialist palliative care in reducing symptom burden and detecting distress in patients with high intensity scores. Their team consistently used 2 validated tools at patient encounters: the Edmonton Symptom Assessment System (ESAS) and the Canadian Problem Checklist (CPC). The ESAS is a questionnaire that asks patients to rate the severity of 9 common symptoms-pain, fatigue, tiredness, nausea, appetite, shortness of breath, depression, anxiety, and wellbeing-on a visual analogue scale ranging from 0 to 10. 2 The CPC is a checklist of the most commonly reported problems, divided into the following domains of functioning: physical, emotional, social/family, spiritual, informational, and practical, although the version used by Feldstain and colleagues also included mobility. 3 Similarly, the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Distress Management recommend use of the NCCN Distress Thermometer (on which patients rate their distress from 0-10) and Problem List as brief initial screening tools at all clinical visits. 4 Similar to the CPC, the Problem List includes the following domains: physical problems, practical problems, family problems, emotional problems, and spiritual or religious concerns. A Distress Thermometer score ≥4 is considered a positive result, and should prompt further questioning and potentially a referral to the appropriate provider based on the source or sources of distress identified. Screening for distress beyond physical sources improves recognition of the impact that social determinants of health have on cancer care. Although these tools are not new to most palliative care programs, their uptake into standard oncology practice has not been universal. 5 Yet, palliative care also finds itself at a critical juncture in ensuring equitable and accessible delivery. Feldstain et al note that their team has tried to expand beyond the ambulatory oncology setting, using phone calls to improve patient follow-up. However, they also mention that several different palliati...

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Cognitive Symptoms Across Diverse Cancers

Mayo,

Edelstein,

Atenafu

et al. 2024

JAMA Netw Open

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ImportancePsychosocial health services for adults with cancer should include support for cognitive symptoms and symptom clusters.ObjectiveTo characterize the frequency and severity of cognitive symptoms and to identify demographic and clinical risk factors associated with moderate to severe cognitive symptoms among outpatient adults with cancer seeking psychosocial support.Design, Setting, and ParticipantsThis cross-sectional study analyzed data from routine patient-reported symptom screening during clinic appointments at the Princess Margaret Cancer Centre in Toronto, Canada, between January 1, 2013, and December 31, 2019. Participants were outpatient adults (aged ≥18 years) with diverse cancer diagnoses who endorsed interest in receiving psychosocial support from a health care team member. Data analysis was performed from April 2020 to June 2024.Main Outcomes and MeasuresThe presence and severity of cognitive symptoms as self-rated by participants were characterized across 12 cancer types: brain or central nervous system (CNS), breast, gastrointestinal, head and neck, gynecological, thyroid, lung and bronchus, sarcoma, genitourinary, melanoma, hematological, and all other cancers. Multivariable logistic regression was used to explore the associations between demographic, clinical, and symptom factors and moderate to severe cognitive symptoms.ResultsAcross the sample of 5078 respondents (2820 females [55.5%]; mean [SD] age at time of survey, 56.0 [14.1] years) requesting psychosocial support, 3480 (68.5%) reported cognitive symptoms of any severity, ranging from 59.5% in sarcoma to 86.5% in brain or CNS cancer. Moderate to severe cognitive symptoms were reported by 1544 patients (30.4%), with the proportions being 51.3% for patients with brain or CNS, 37.0% for breast, 36.2% for thyroid, 30.9% for melanoma, 29.6% for head and neck, 28.3% for gastrointestinal, 28.2% for hematological, 28.1% for gynecological, 24.9% for lung and bronchus, 24.9% for sarcoma, 21.0% for genitourinary, and 26.8% for all other cancers. Across the entire sample, moderate to severe cognitive symptoms were associated with recurrence or progression involving the CNS (odds ratio [OR], 2.62; 95% CI, 1.80-3.81), depression (OR, 1.92; 95% CI, 1.59-2.31), tiredness (OR, 1.82; 95% CI, 1.52-2.19), drowsiness (OR, 1.64; 95% CI, 1.39-1.93), anxiety (OR, 1.57; 95% CI, 1.30-1.89), shortness of breath (OR, 1.38; 95% CI, 1.16-1.61), female sex (OR, 1.33; 95% CI, 1.14-1.56), first-line chemotherapy received (OR, 1.22; 95% CI, 1.05-1.41), and metastatic disease at diagnosis (OR, 0.74; 95% CI, 0.61-0.89). Within individual cancer types, tiredness and depression were consistently associated with moderate to severe cognitive symptoms.Conclusions and RelevanceThis cross-sectional study found that cognitive symptoms were frequently reported by patients across a wide range of cancer types; higher severity of cognitive symptoms was consistently associated with higher symptom burden. The findings could be used to inform decision-making regarding access to cognitive screening, assessment, and supportive care in outpatient oncology clinics.

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Easier Said Than Done: Keys to Successful Implementation of the Distress Assessment and Response Tool (DART) Program

Cited by 69 publications

References 51 publications

High prevalence of persistent emotional distress in desmoid tumor

High prevalence of persistent emotional distress in desmoid tumor

Palliative Care: Who is Responsible?

Cognitive Symptoms Across Diverse Cancers

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