A slide show and annotated commentary….
Professional organizations have gone from recommending routine screening of cancer patients for distress to mandating that screening be implemented in US cancer care settings as a condition for accreditation. Yet screening has not yet been shown to be an evidence-based practice.
As with any other medical procedure or re-organization of services, the burden of proof lies with those who recommend screening, not those who remain skeptical.
As I argue in this slide presentation, there is a lack of evidence that screening improves patient outcomes or is cost effective, relative to other uses of the same resources. Moreover, screening threatens to
- Impose rationing of services and even the opportunity for patients to discuss problems.
- Denial access to services to the many patients who currently seek them but who are not distressed.
- Aggravate the social inequalities that already existed in which patients get services.
- Increase inappropriate prescription of antidepressants to cancer patients who have not been formally diagnosed as depressed and who will not receive follow up.
Screening for distress should only be mandated if there is solid evidence that patients will benefit with reduced distress. Such evidence would come from randomized trials in which patients receiving screening would be compared to patients having access to the same resources without being screened.
Thus, the comparison group would involve patients simply to have ready opportunities to talk with professionals or peer counselors and to be able to refer themselves or ask to be referred to the services that interest them—without first having to be screened.
My colleagues and I conducted a systematic review and failed to find sufficient evidence to recommend screening.
Screening for distress is always a two stage process.
Cancer patients first complete a paper questionnaire or interact with a touch screen. If they indicate enough distress as defined by some cutpoint, they go then receive a follow up interview for their responses to be interpreted.
In practice, this two stage screening process can prove to be just another barrier to patients getting their concerns heard, their needs addressed. In the typical screening procedure, patients may have to explain themselves at least twice, once to the interviewer and then to whomever they are referred to get their problem addressed. And if patients have a particular problem they want to discuss but do not meet the threshold for being considered distressed, they may not to get to discuss it.
As it is increasingly becoming apparent, the necessary second step of screening takes the dedicated time of personnel who have been trained to interpret screening scores and discuss options with patients. These staff might more usefully be put to serving other purposes.
The slide show
This slide show is my presentation in a debate with UK psychiatrist Alex Mitchell UK at the International Psycho Oncology Conference, Rotterdam, November 7, 2013.
The debate is a rematch.
On September 18, 2012 at the European Cancer Rehabilitation & Survivorship Symposium (ECRS) in Copenhagen, Dr. Mitchell and I had a very lively, but cordial debate over whether screening improves patient outcomes. The conference room was packed despite the 8 AM start.
We were selected for the debate in Copenhagen to represent opposing viewpoints. Yet, we found surprising agreement that there was no strong evidence yet that screening would reduce patient distress. I would agree with, but amplify Dr. Mitchell’s conclusion from Copenhagen:
… Screening for psychological distress holds promise and is often clinically valuable, but it is too early to conclude definitively that psychological screening itself affects the psychological well-being of cancer patients.
Dr. Mitchell nonetheless argued that implementing of screening would improve patient-clinician communication and increase referrals. I argued that these were not suitable surrogate outcomes if the real question is whether having screening implemented lowers cancer patients’ distress.
Better communication doesn’t guarantee that patients will be less distressed, unless barriers can be overcome to their getting timely and affordable services consistent with their preferences. We know too well that patients often do not complete referrals and services are either expensive or have long waiting lists or not responsive to their needs. Even when services are free or low-cost, there are substantial social inequalities in accessing them, with the rich and well educated getting more access than the poor or on educated.
After the debate, Dr. Mitchell and I were invited to submit papers based on our presentations to Acta Oncologica. Dr. Mitchell’s published paper is available here.
However, my invited paper was savaged by a reviewer who at the outset of his review announced his bias against anyone arguing that screening had not been shown to patient outcomes. The reviewer essentially demanded that I express allegiance to the prevailing dogma.
I informed the journal that I was withholding my invited paper until the reviewer was chastised (I could identify who he was, despite the anonymous review). I requested additional reviews, but again the reviewers objected to my not expressing support for recommendations for screening about which there was such consensus. They did not really dispute the evidence that I presented, but only objected that I was criticizing the accepted view in ways that might damage efforts to implement routine screening.
I would’ve hoped that it would be evidence that matters most, not some consensus among professional groups with obvious conflicts of interest in advocating procedures that increased demands for their services.
I appreciate the international and local Dutch organizing committees’ invitation to Dr. Mitchell and me to hold a rematch in Rotterdam. I know there was some opposition to this occurring. And it has become all too unusual for journals or professional gatherings to have open debate over whether screening cancer patients for distress is a good idea.
The powerful lobbies for screening, now with support from the pharmaceutical industry, get ready access to journals without the usual peer review. They are able to enforce recommendations for screening appearing in the discussion sections of published papers, even when what is presented in the results section provides a striking contradiction.
Recently, authors got an article accepted at the prestigious Journal of Clinical Oncology showing that screening produced few referrals for psychosocial services and was not cost effective. When the article was published, it was accompanied by an editorial from a leading proponent of screening that trashed it. The authors were neither informed nor offered an opportunity to respond.
Despite the enforcement of a strict pro-screening bias on what gets published and how the evidence is interpreted, I think ultimately the evidence will get out that implementing screening for distress does not improve patient outcomes. However, in the meantime I have serious concerns about the distortion and even corruption of the editorial processes of the journals of the field.
When the battle over screening is finally resolved, there will be a lot of work to do in rebuilding the credibility and integrity of the editorial and peer review processes of psycho-oncology.
If I have sparked your interest, please click on the embedded slide presentation above and you can view the actual slides that I present in a rematch with Alex Mitchell in Rotterdam on November 7, 2013.
At my secondary blog, there is a new posting that provides rich citations and annotation for points made in the slide presentation. Once there, you will be able to click to retrieve the abstracts of the papers that are being cited or the actual papers. In some instances the hyperlinks take you to blog posts where there is more material available.