15th IPOS Debate on Screening for Distress by alex_j_mitchell in Rotterdam (Nov2013)

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15th IPOS debate on Screening for Distress by alex_j_mitchell in Rotterdam. Against the motion was Jim Coyne.

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  • Screening Cancer Patients for Distress: What Does the Evidence from 31 Studies Actually Show?
     
    Alex J Mitchell
    University of Leicester, UK
                                                                                                   
    Objectives
    There is still considerable uncertainty about the merits of screening for distress in cancer settings. Screening is not widely implemented nationally, but this is only problematic if screening actually has benefits and few harms. Several narrative reviews have addressed this area but none to date have been able to quantative summarize what screening can and cannot achieve.
    Method
    A systematic search and meta-analysis of the latest data was conducted. 17 observational screening studies were identified that revealed how many patients received psychosocial care or referral following screening. 19 implementation studies were identified that clarified how many patients benefited from distress screening (or feedback of screening results). An additional 5 implementation studies examined quality of life, making a total of 31 distress/QoL studies. Outcomes were effects on patient wellbeing, quality of care and communication.
    Results
    7  of 14 of the screening RCTs reported benefits on patient wellbeing. 2 of 10 non-randomized sequential cohort screening studies reported benefits on patient wellbeing. Nine implementation studies measured receipt of psychosocial referral. The chances of receiving a psychosocial referral increased by 3x in cancer patients who were screened vs not screened, an increase of 12% over usual care (p = 0.03). Six QoL implementation studies found that screening significantly increased clinician-patient communication of emotional issues after exclusion of studies which omitted feedback of results to clinicians.
    Barriers to screening were significant. The proportion of cancer patients who received  psychosocial care after a positive distress screen was only 31.3% but this was 20% greater than those given resources after a negative screen. Screening was more effective when screening was linked with mandatory intervention or referral.
    Conclusions
    Screening for distress potentially has added value but at a cost of clinician time. Barriers to screening must be addressed for screening to be fully effective.  
  • Mitchell AJ, Vaze A, Rao, S. Clinical diagnosis of depression in primary care: a meta-analysis. Lancet 2009; 374, Issue 9690: 609 – 619.
  • Maria Hewitt, Julia H. Rowland Mental Health Service Use Among Adult Cancer Survivors: Analyses of the National Health Interview Survey Journal of Clinical Oncology, Vol 20, Issue 23 (December), 2002: 4581-4590
    From the National Cancer Policy Board, Institute of Medicine, Washington,
    DC, and Office of Cancer Survivorship, National Cancer Institute,
    National Institutes of Health, Bethesda, MD.
  • 15th IPOS Debate on Screening for Distress by alex_j_mitchell in Rotterdam (Nov2013)

    1. 1. Screening for Distress Debate Alex Mitchell University of Leicester www.twitter.com/_alexjmitchell www.psycho-oncology.info #ipos2013
    2. 2. …What are the sources of disagreement?
    3. 3. Areas of Disagreement: 1.How to screen (which tool) 2.When to screen 3.How often to screen 4.Which screening population 5.Who should screen 6.Does screening work
    4. 4. ……in short Should we screen at all?
    5. 5. But what are the alternatives to screening?
    6. 6. 1. Diagnosis as usual (do nothing) 2. Enhanced diagnosis (clinician = screen) 3. Screen everyone 4. Screen high risk (targeted screening)
    7. 7. 100.0 5.9 11.1 90.0 Comment: Slide illustrates diagnostic accuracy according to score on DT 80.0 43.5 25.9 38.7 11.8 38.1 22.2 46.7 59.6 70.0 21.4 14.3 14.3 21.4 72.4 Judgement = Non-distressed 60.0 33.3 19.4 50.0 26.1 40.0 Judgement = Unclear Judgement = Distressed 19.0 82.4 24.4 66.7 30.0 20.0 57.1 25.0 41.9 15.8 30.4 10.0 11.8 71.4 Three 40.7 Four Five Six 28.9 Two 42.9 15.4 0.0 Zero One Seven Eight Nine Ten
    8. 8. Lessons from primary care….
    9. 9. Results disappointing Acceptability overlooked Most are not depressed Many do not want help Some are already Rx
    10. 10. Screening in Cancer
    11. 11. Missed diagnosis GP = CNS = Oncologists
    12. 12. Screening tools (validity)
    13. 13. Depression Distress Brief / ultra-short Multi-domain
    14. 14. Implementation evidence Randomized Non-Randomized
    15. 15. Q. What type of studies? Q. How many +ve studies? Q. What are the beneficial outcomes? Q. What is the size of the effect?
    16. 16. Implementation Reviews
    17. 17. Implementation Studies  9 studies Distress =>  6 studies => Referral Communication
    18. 18. ….this is getting complex……. ………………..what is the overall effect?
    19. 19. Overall Effect of screening Baseline CARE x% with screening +10% (0-20%)
    20. 20. Overall Effect of screening Baseline CARE x% with screening +10% + follow-up +treatment +10% +10%
    21. 21. What is holding back screening success?
    22. 22. BOTH. How Many Receive Ps Help? (n=2557) Proportion meta-analysis plot [random effects] Kadan-Lottick et al (2005) 0.89 (0.77, 0.96) Plass and Koch (2001) 0.60 (0.46, 0.72) Siedentopf et al (2009) 0.46 (0.35, 0.58) Fritsche et al (2004) 0.43 (0.28, 0.59) Bogaarts et al (2011) 0.38 (0.27, 0.49) Söllner et al (2004) 0.35 (0.26, 0.45) Shimizu et al (2005) 0.28 (0.18, 0.41) Shimizu et al (2009) 0.25 (0.18, 0.33) Merckaert et al (2009) 0.21 (0.17, 0.25) Morasso et al (2010) 0.16 (0.05, 0.33) Sharpe et al (2004) 0.15 (0.10, 0.22) McDowell et al (2010) 0.14 (0.11, 0.18) combined 0.35 (0.25, 0.46) 0.0 0.2 0.4 0.6 proportion (95% confidence interval) 0.8 1.0
    23. 23. 12mo Service Use (NIH, 2002) 40 34.6 32.7 35 Cancer n=4878 No Cancer n=90,737 30 25 19.1 20 16.1 % Receiving Any treatment for Mental Health 14 15 10 11.7 11 7.2 5.7 6.3 5.7 5 6.4 5 8.9 7.7 6.5 6.2 3.9 5 2.3 3.2 1.8 75+ y ea rs 6574 ear s 4564 y y ea rs 1844 con diti o ns hro nic me di ca l 3c 2c hro nic me di ca l con diti o ns con diti o n hro nic me di ca l 1c con d iti No c hr o ni cm edi cal Me n ta l Ill No ons Hea l th th eal Il l H Me nt a l Al l P atie nt s 0 Maria Hewitt, Julia H. Rowland Mental Health Service Use Among Adult Cancer Survivors: Analyses of the National Health Interview Survey Journal of Clinical Oncology, Vol 20, Issue 23 (December), 2002: 4581-4590
    24. 24. Overall Effect of screening Baseline CARE x = 35% with screening +10% (0-20%) + follow-up +treatment +10% (0-20%) +10% (0-20%)
    25. 25. ……..So is screening successful or not? …….It depends
    26. 26. Analogy: How do we reduce speeding drivers? US deaths 10,000
    27. 27. Analogy Aim is to reduce speed (and hence deaths) Not simply to detect speeding!
    28. 28. Aim is to reduce distress (improving QoL) Not simply to detect distress!
    29. 29. 1
    30. 30. 2
    31. 31. 3
    32. 32. 0. Summary Screening can be ineffective or effective Screening may be optional or mandated

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