Experiences with a specific screening instrument to identify psychosocial support needs in breast cancer patients

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Abstract

Objective

In order to determine the need for professional psychosocial support in breast cancer patients, we used the physician-administered Basic Documentation for Psycho-Oncology (PO-Bado), which is an expert rating scale containing 12 items belonging to somatic and psychological problems. Furthermore, we investigated sociodemographic and medical predictors of somatic and psychological distress and need for psychosocial support.

Study design

From 2/2005 to 09/2007, n = 333 consecutive patients with breast cancer were included in the study. The majority of the patients suffered from early-stage breast cancer. The mean age of the participants was 59.9 years (SD = 12.6, range 24–92). Two physicians rated patients’ psychosocial distress and evaluated their need for psychosocial support according to the PO-Bado guidelines.

Results

Exhaustion/tiredness was the item rated highest in the physical distress dimension. In the psychological distress dimension, the items anxiety/worries/tension and grief/despondency/depression obtained the highest mean. Younger age and a history of psychiatric/psychotherapeutic treatment in the past were associated with higher current distress. Women who planned to undergo mastectomy were rated as showing more somatic distress than women for whom breast conserving therapy was planned, but the two groups did not differ with regard to psychological distress. Objective cancer-related variables (tumour size and grading) were not associated with distress. Need for professional psychosocial support was seen in 23% of the patients. Previous psychiatric/psychotherapeutic treatment was the only variable associated with current need for psychosocial support. Forty-six percent of the patients with need for psychosocial support accepted the counselling offered.

Conclusions

The structured assessment of breast cancer patients’ psychosocial distress with the interviewer-administered PO-Bado assists the physician to arrive at a detailed expert evaluation. This might help to improve the psychosocial care of breast cancer patients.

Introduction

Today, breast cancer is the malignancy with the highest incidence among women. In Western countries, 1 in 8–10 women will be diagnosed with breast cancer during her lifetime [1], [2]. A high percentage of cancer patients suffer from psychological distress during the course of illness and cancer treatment, impairing their quality of life. The intensity of the psychological reactions to the diagnosis of cancer varies widely and may range from normal feelings of vulnerability, anxiety, fear of disease progression and grief to major problems like depression, panic attacks, anxiety disorders and a substantial crisis [3], [4]. It is estimated that 20–40% of patients suffer from anxiety or depression [5], [6].

In breast cancer patients, it was found that younger women experience more psychological distress in terms of anxiety, depression, and post-traumatic stress symptoms [7]. Especially in the early treatment phase, many breast cancer patients report emotional distress. Söllner et al. [8] found that 31% of the patients reported moderate to severe anxiety and/or depression, and 42% expressed a subjective need for intensified psychosocial support. Of all the patients to whom support was offered, 69% accepted it.

Mehnert and Koch [9] found that more than half of the patients experienced the diagnosis of breast cancer as a traumatic event, reacting with fear and helplessness. Härtl et al. [10] reported that initial distress was the most potent predictive factor for long-term quality of life after 2 years.

Although numerous studies to date have contributed to our knowledge concerning psychosocial distress and treatment need in cancer patients, and especially in breast cancer patients, it has to be noted that the empirical evidence is mainly based on results obtained with self-report questionnaires. Undoubtedly, self-reports have many advantages, such as objectivity in administration and scoring, or economic brevity. Furthermore, self-report questionnaires focus on the patient's personal experience. However, these methods also have some disadvantages, including amenability to social desirability. Furthermore, patients may decline to fill in a questionnaire, or they may be too ill to be capable to undertake self-assessments. Therefore, the assessment of psychosocial distress by interviewers is a valuable and necessary complement. Interviewer-administered instruments allow for the examination and integration of nonverbal aspects of patients’ distress, and they can be used with patients who are unwilling or, due to physical or mental problems, unable to fill out a self-report questionnaire.

Studies with interviewer-administered instruments for the detection and screening of distress in cancer patients have shown that physicians and oncologists have difficulty detecting cancer patients’ distress. Furthermore, there is disagreement between the psychosocial treatment needs expressed by patients and the need perceived by oncologists [11], [12], [13], [14]. However, in most of these studies, physicians provided only gross evaluations of patients’ distress, using single-item assessments or visual analogue scales [11], [12]. Only few studies applied more sophisticated instruments for helping the professional to arrive at an expert evaluation. For instance, Newell et al. [13] provided detailed definitions of each response option concerning the professional assessment of a patient's anxiety, depression, and treatment need. However, they did not report whether different oncologists would arrive at the same evaluation using this structured assessment guide, i.e. they did not report interrater reliability. Jefford et al. [15] evaluated a short, four-item physician-administered instrument for the detection of depression in medical oncology and palliative care. This instrument showed reasonable psychometric properties. However, it is limited to the detection of depression and does not provide an explicit assessment of psychosocial treatment need.

Recently, the German PO-Bado Working Group provided an interviewer-administered instrument, the Basic Documentation for Psycho-Oncology (PO-Bado) [16]. This instrument was developed with the aim of providing a cancer-specific instrument applicable for all sites and stages of cancer. It allows health-care professionals to conduct a structured and standardized assessment of patients’ distress, which functions as a basis for determining psychosocial treatment needs. The PO-Bado was developed over several years and resulted in a 12-item version covering physical and psychological problems. To guide the expert, a manual and an interview guideline were developed, providing detailed item definitions, criteria for item ratings, and instructions for the structured assessment of patients’ distress. The assessment should be primarily based on the subjective experiences and feelings reported by the patients. The PO-Bado is an instrument with high interrater reliability, high validity and acceptable sensitivity to change [16], [17]. The PO-Bado has been used with different cancer populations, including a sample of more than 2100 breast cancer patients [18].

In the present study, we aimed at investigating the extent of psychosocial distress and treatment need in breast cancer patients, using the PO-Bado as an expert rating scale. Furthermore, we were interested in sociodemographic and medical correlates of distress and support need.

Section snippets

Materials and methods

From February 2005 to September 2007, we screened n = 333 consecutive patients with breast cancer, while taking their medical history on admission to hospital, using the PO-Bado interview. Included were all patients who were admitted to the ward for breast cancer surgery. Exclusion criteria were problems with the German language, poor mental health, and low overall health status. Because the study took place in a naturalistic setting which included the routine screening of consecutive patients, a

Results

Table 2 provides descriptive data for each item of the PO-Bado. In the physical distress dimension (somatic problems), the item with the highest mean is exhaustion/tiredness. In the psychological distress dimension (psychological problems), the items anxiety/worries/tension and grief/despondency/depression are rated highest. Regarding additional problems, 32.8% (n = 109) of the patients reported problems with family or friends, and 14.5% (n = 48) reported economic problems or problems at work.

In

Comment

Interviewer-administered instruments are an important complement to the self-report assessment of psychosocial distress and treatment need in cancer patients. Our study showed that oncologists can easily apply the PO-Bado to arrive at an expert rating of breast cancer patients’ distress and treatment need in routine clinical practice. The results showed that younger age was associated with higher somatic and psychological distress. Thus, these interviewer-derived results confirm previous

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