Ductal carcinoma in situ (DCIS) of the breast represents a heterogeneous group of neoplastic lesions in the breast ducts. The goal for management of DCIS is to prevent the development of invasive breast cancer. This manuscript focuses on the NCCN Guidelines Panel recommendations for the workup, primary treatment, risk reduction strategies, and surveillance specific to DCIS.

https://www.unitypoint.org/desmoines/filesimages/Cancer%20Education/Oncology%20Nursing%20Conference/2015/2014%20NCCN%20Clin%20Pract%20Guidelines%20Male%20Sex%20Dysf.pdf

Clinical practice guidelines in oncology

Screening for emotional distress is becoming increasingly common in cancer care. This systematic review examines the psychometric properties of the existing tools used to screen patients for emotional distress, with the goal of encouraging screening programs to use standardized tools that have strong psychometrics. Systematic searches of MEDLINE and PsycINFO databases for English-language studies in cancer patients were performed using a uniform set of key words (eg, depression, anxiety, screening, validation, and scale), and the retrieved studies were independently evaluated by two reviewers. Evaluation criteria included the number of validation studies, the number of participants, generalizability, reliability, the quality of the criterion measure, sensitivity, and specificity. The literature search yielded 106 validation studies that described a total of 33 screening measures. Many generic and cancer-specific scales satisfied a fairly high threshold of quality in terms of their psychometric properties and generalizability. Among the ultrashort measures (ie, those containing one to four items), the Combined Depression Questions performed best in patients receiving palliative care. Among the short measures (ie, those containing five to 20 items), the Center for Epidemiologic Studies-Depression Scale and the Hospital Anxiety and Depression Scale demonstrated adequate psychometric properties. Among the long measures (ie, those containing 21-50 items), the Beck Depression Inventory and the General Health Questionaire-28 met all evaluation criteria. The PsychoSocial Screen for Cancer, the Questionnaire on Stress in Cancer Patients-Revised, and the Rotterdam Symptom Checklist are long measures that can also be recommended for routine screening. In addition, other measures may be considered for specific indications or disease types. Some measures, particularly newly developed cancer-specific scales, require further validation against structured clinical interviews (the criterion standard for validation measures) before they can be recommended.

/pdf/screening-for-emotional-distress-in-cancer-patients-a-oh93y5n4sh.pdf

Screening for Emotional Distress in Cancer Patients: A Systematic Review of Assessment Instruments

Ultra-short screening tools involving fewer than five questions have been recommended as a simple method of detecting distress, anxiety, or depression in cancer settings. Such methods have practical appeal, but their diagnostic accuracy is unclear. A literature search limited to diagnostic validity studies of ultra-short screening in cancer settings identified 38 analyses, including 19 assessing the Distress Thermometer alone, involving a total of 6,414 unique patients. The pooled ability of ultra-short methods to detect depression was given by a sensitivity of 78.4%, a specificity of 66.8%, a positive predictive value (PPV) of 34.2%, and a negative predictive value (NPV) of 93.4%. Thus these tools were very good at excluding possible cases of depression but poor at confirming a suspected diagnosis. The pooled ability of ultra-short methods to detect anxiety was given by a sensitivity of 77.3% and a specificity of 56.6% (PPV, 55.2%; NPV, 80.25%) and for distress a sensitivity of 78.3% and a specificity of 66.5% (PPV, 59.7%; NPV, of 82.8%). Results using the Distress Thermometer alone were similar. Scores of integrated accuracy, using the Youden index and diagnostic odds ratio, suggested modest overall accuracy with least success in diagnosing anxiety disorders. Ultra-short methods were modestly effective in screening for mood disorders. Their rule-in ability was poorer than their rule-out ability. Ultra-short methods cannot be used alone to diagnose depression, anxiety, or distress in cancer patients but they may be considered as a first-stage screen to rule out cases of depression.

https://ascopubs.org/doi/pdf/10.1200/JCO.2006.10.0438

Pooled Results From 38 Analyses of the Accuracy of Distress Thermometer and Other Ultra-Short Methods of Detecting Cancer-Related Mood Disorders

Background
Incurable cancer, which often constitutes an enormous challenge for patients, their families, and medical professionals, profoundly affects the patient's physical and psychosocial well-being. In standard cancer care, palliative measures generally are initiated when it is evident that disease-modifying treatments have been unsuccessful, no treatments can be offered, or death is anticipated. In contrast, early palliative care is initiated much earlier in the disease trajectory and closer to the diagnosis of incurable cancer.

Objectives
To compare effects of early palliative care interventions versus treatment as usual/standard cancer care on health-related quality of life, depression, symptom intensity, and survival among adults with a diagnosis of advanced cancer.

Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, OpenGrey (a database for grey literature), and three clinical trial registers to October 2016. We checked reference lists, searched citations, and contacted study authors to identify additional studies.

Selection criteria
Randomised controlled trials (RCTs) and cluster-randomised controlled trials (cRCTs) on professional palliative care services that provided or co-ordinated comprehensive care for adults at early advanced stages of cancer.

Data collection and analysis
We used standard methodological procedures as expected by Cochrane. We assessed risk of bias, extracted data, and collected information on adverse events. For quantitative synthesis, we combined respective results on our primary outcomes of health-related quality of life, survival (death hazard ratio), depression, and symptom intensity across studies in meta-analyses using an inverse variance random-effects model. We expressed pooled effects as standardised mean differences (SMDs, or Hedges' adjusted g). We assessed certainty of evidence at the outcome level using GRADE (Grading of Recommendations Assessment, Development, and Evaluation) and created a 'Summary of findings' table.

Main results
We included seven randomised and cluster-randomised controlled trials that together recruited 1614 participants. Four studies evaluated interventions delivered by specialised palliative care teams, and the remaining studies assessed models of co-ordinated care. Overall, risk of bias at the study level was mostly low, apart from possible selection bias in three studies and attrition bias in one study, along with insufficient information on blinding of participants and outcome assessment in six studies.

Compared with usual/standard cancer care alone, early palliative care significantly improved health-related quality of life at a small effect size (SMD 0.27, 95% confidence interval (CI) 0.15 to 0.38; participants analysed at post treatment = 1028; evidence of low certainty). As re-expressed in natural units (absolute change in Functional Assessment of Cancer Therapy-General (FACT-G) score), health-related quality of life scores increased on average by 4.59 (95% CI 2.55 to 6.46) points more among participants given early palliative care than among control participants. Data on survival, available from four studies enrolling a total of 800 participants, did not indicate differences in efficacy (death hazard ratio 0.85, 95% CI 0.56 to 1.28; evidence of very low certainty). Levels of depressive symptoms among those receiving early palliative care did not differ significantly from levels among those receiving usual/standard cancer care (five studies; SMD -0.11, 95% CI -0.26 to 0.03; participants analysed at post treatment = 762; evidence of very low certainty). Results from seven studies that analysed 1054 participants post treatment suggest a small effect for significantly lower symptom intensity in early palliative care compared with the control condition (SMD -0.23, 95% CI -0.35 to -0.10; evidence of low certainty). The type of model used to provide early palliative care did not affect study results. One RCT reported potential adverse events of early palliative care, such as a higher percentage of participants with severe scores for pain and poor appetite; the remaining six studies did not report adverse events in study publications. For these six studies, principal investigators stated upon request that they had not observed any adverse events.

Authors' conclusions
This systematic review of a small number of trials indicates that early palliative care interventions may have more beneficial effects on quality of life and symptom intensity among patients with advanced cancer than among those given usual/standard cancer care alone. Although we found only small effect sizes, these may be clinically relevant at an advanced disease stage with limited prognosis, at which time further decline in quality of life is very common. At this point, effects on mortality and depression are uncertain. We have to interpret current results with caution owing to very low to low certainty of current evidence and between-study differences regarding participant populations, interventions, and methods. Additional research now under way will present a clearer picture of the effect and specific indication of early palliative care. Upcoming results from several ongoing studies (N = 20) and studies awaiting assessment (N = 10) may increase the certainty of study results and may lead to improved decision making. In perspective, early palliative care is a newly emerging field, and well-conducted studies are needed to explicitly describe the components of early palliative care and control treatments, after blinding of participants and outcome assessors, and to report on possible adverse events.

Early palliative care for adults with advanced cancer

Objective
Psychological distress is common in cancer patients and awareness of its indicators is essential We aimed to assess the prevalence of psychological distress and to identify problems indicative of high distress

Methods
We used the Distress Thermometer (DT) and its 34-item Problem List to measure psychological distress in 3,724 cancer patients (mean age 58 years; 57% women) across major tumor entities, enrolled in an epidemiological multicenter study To identify distress-related problems, we conducted monothetic analyses (MONA)

Results
We found high levels of psychological distress (DT≥5) in 52% of patients The most prevalent problems were fatigue (56%), sleep problems (51%), and problems getting around (47%) Sadness, fatigue and sleep problems were most strongly associated with the presence of other problems High distress was present in 814% of patients reporting all three of these problems (DT M=64) When analyzing only the subset of physical problems, fatigue, problems getting around and indigestion showed the strongest association with the remaining problems and 763% of patients with all three problems were highly distressed (DT M=61)

Conclusions
Our results show a high prevalence of psychological distress in cancer patients, as well as a set of problems that indicate the likely presence of other problems and high distress and can help clinicians identify distressed patients even if no routine distress screening is available

One in two cancer patients is significantly distressed: Prevalence and indicators of distress.

Purpose To provide the 4-week prevalence estimates of mental disorders in cancer populations. Patients and Methods We enrolled adult patients with cancer from in- and outpatient care facilities, using a proportional stratified random sample based on the nationwide cancer incidence in Germany. Patients who scored 9 or above on the Patient Health Questionnaire (PHQ-9) were administered to the standardized computer-assisted Composite International Diagnostic Interview for mental disorders adapted for cancer patients (CIDI-O). A random sample of those with a PHQ-9 score that was less than 9 were selected for a CIDI-O. Results A total of 5,889 patients were identified, which led to 4,020 participants (a 68.3% response rate); of those, 2,141 patients were interviewed. The 4-week total prevalence for any mental disorder was 31.8% (95% CI, 29.8% to 33.8%); this included any anxiety disorder (11.5%; 95% CI, 10.2% to 12.9%), any adjustment disorder (11.1%; 95% CI, 9.7% to 12.4%), any mood disorder (6.5%; 95% CI, 5....

Four-Week Prevalence of Mental Disorders in Patients With Cancer Across Major Tumor Entities

Recognition of distress and psychiatric morbidity in cancer patients: a multi-method approach

Unter veranderten Rahmenbedingungen onkologischer Behandlung ist die fruhzeitige, zutreffende Identifizierung hoch belasteter Tumorpatienten erforderlich, um eine adaquate psychoonkologische Behandlung zu gewahrleisten. Fur die klinische Routine sind valide und praktikable Screening-Instrumente verfugbar. Mit diesen konnen hoch belastete Patienten zuverlassig ermittelt werden, ‘uberschwellige’, potenziell behandlungsbedurftige Patienten bedurfen erganzend einer diagnostischen Abklarung. Die Autoren diskutieren Eigenschaften kurzer Screening-Instrumente, berichten uber Erfahrungen und Ergebnisse bei der Umsetzung von Screening in der Routineversorgung und leiten daraus Empfehlungen fur die Praxis ab. Der Einsatz systematischer Screening-Verfahren verspricht eine verbesserte psychoonkologische Betreuung von Krebspatienten.

Sabine Sommerfeldt

Papers

Four-Week Prevalence of Mental Disorders in Patients With Cancer Across Major Tumor Entities

Recognition of distress and psychiatric morbidity in cancer patients: a multi-method approach

Psychoonkologisches Screening in der Routineversorgung