Screening of Distress and Referral Need in Dutch oncology practice
van Nuenen, Floor Maria
DOI:
10.33612/diss.97362459
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Publication date: 2019
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van Nuenen, F. M. (2019). Screening of Distress and Referral Need in Dutch oncology practice. Rijksuniversiteit Groningen. https://doi.org/10.33612/diss.97362459
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Summary and discussion
Learning that you have cancer and having to undergo cancer treatment is often associated with practical, social, emotional, spiritual and physical problems. In the scientific literature, these problems are referred to as ‘distress’1. The Groningen branch of the Netherlands Comprehensive Cancer Organisation (IKNL-G) initiated the development of the Screening for Distress and Referral Need (SDRN) process, because (severe) distress and unmet care needs may lead to a poorer quality of life (QoL) and could interfere with the treatment, recovery and coping process1-3. The SDRN process aims to 1) timely recognize distress and psychosocial problems in patients with cancer during and following the diagnosis and treatment process and to 2) refer patients to the right specialized psychosocial and/or allied healthcare professional to improve the patients’ quality of life and their satisfaction with the care provided. In 2005, IKNL-G began the development and implementation of SDRN in daily practice in hospitals in the north-eastern part of the Netherlands. This thesis examines various aspects of the SDRN process and its implementation and is aimed at optimizing the implementation of SDRN. The main results are summarized and discussed below. A few methodological considerations, the clinical implications of this study and recommendations for future research are also described.
Summary
Chapter 1 presents cancer incidence and prevalence rates and discusses various practical, social, emotional, and spiritual/existential problems (referred to as ‘distress’) that patients may perceive during and following the cancer diagnosis and treatment process4. The Stress and Coping Theory developed by Lazarus and Folkman5 is introduced as a theoretical basis for how patients tend to deal with a stressor, such as learning that they have cancer and having to undergo cancer treatment.
This theory is based on the principle that the patient first assesses the stressor in a certain way (primary appraisal). Internal resources (e.g. their personality, the ability to solve problems) and external resources (i.e. the people around the patient, such as their family members, friends, and care providers) help the patient to deal with the stressor (secondary appraisal) and the associated distress. The presence or absence of resources may also prove to be a risk factor for distress6.
The scientific literature indicates that 25-52% of patients perceive (severe) distress7-9, while only 10% of patients receive specialized psychosocial care10. An estimated 37-54%of patients are reported to have unmet psychosocial and paramedical care needs11,12. A considerable number of patients do not seem to receive adequate psychosocial and/or allied health care. It is necessary to improve the provision of psychosocial care, because (continuous) distress and unmet care needs are associated with a lower quality of life and increased care consumption and may interfere with the treatment, recovery, and coping processes1-3,13. Both the care providers and the patients may be responsible for the distress and psychosocial problems not being recognized (in a timely manner). For instance, care providers may have difficulty recognizing (severe) distress14,15 and patients may be reluctant to talk about these problems16.
In 1999, the US-based Comprehensive Cancer Network (NCCN) was the first organization to develop a guideline for distress screening in order to deal with this problem. In the early twenty-first century, the Netherlands acknowledged the importance of the systematic screening for distress as well. IKNL-G (taken over by the Netherlands Comprehensive Cancer Organisation IKNL in 2011) developed the Screening for Distress and Referral Need (SDRN) process to improve the quality of psychosocial care in the regional hospitals. This process was included in the guideline entitled ‘Screening for psychosocial distress’ (in Dutch: Detecteren behoefte psychosociale zorg), initiated and developed by the Dutch Society for Psychosocial Oncology (NVPO) and funded by the Dutch Cancer Society (KWF). The process was managed by IKNL. In 2011, the guideline was published on Oncoline17. In 2017, the revised version was published18. The SDRN process consists of the following elements:
1. Completion of the Dutch version of the Distress Thermometer in combination with the Problem List (DT&PL) by the patient to gain insight into the nature
and severity of the problems perceived by them;
2. Discussion of the responses by the patient and the care provider;
3. Referral to specialized psychosocial and/or allied healthcare professionals,
if necessary and/or desired by the patient, based on the discussion of the responses.
Chapter 2 reports the results of an explorative, descriptive study among 25 healthcare professionals responsible for the implementation of the SDRN process in daily clinical practice19. This study shows the successfulness of SDRN implementation based on a structured roadmap including available supporting materials and centralized project management by IKNL-G. It was shown that 21 of 23 hospitals had achieved SDRN implementation in daily practice when the study was being conducted. It was also shown that the majority of these hospitals had implemented SDRN in the care process of more than one patient group; breast cancer patients was the patient group in whose care process SDRN was most often implemented. Care providers were pleased that they could give attention to the patient’s psychosocial and physical functioning in a systematic way and that the interdisciplinary communication had improved as a result of the implementation of SDRN. In general, they were also pleased with the use of the DT&PL to gain insight into and to communicate about the psychosocial and physical problems perceived by the patients and their desire, if any, to be referred for these. According to the care providers, the SDRN process did not necessarily lead to more referrals. However, the care providers felt that the SDRN process did lead to more substantiated and appropriate referrals. Although the respondents felt largely positive about the implementation of SDRN, this study also shows that they think that the implementation of SDRN could be even better. The respondents were less satisfied with adherence to logistical agreements, the systematic completion of the DT&PL, and the discussion of the instrument responses. The care providers reported a lack of time as the greatest barrier. They also felt that there was room for improvement in terms of the frequency and timing of the SDRN process. Care providers in hospitals where SDRN occurred at least three times during the treatment and follow-up process reported more positive experiences than care providers in hospitals that did not have it occur so frequently. In the hospitals, nurses were the professionals that were always involved in the SDRN implementation process.
Chapter 3 reports the patients’ experiences with and their opinions of SDRN based on a quantitative observational study20. The study shows that 81% of the 498 respondents (response rate = 54%) indicated that they had completed a DT&PL and that 61% of these patients had followed all the steps involved (completing the DT&PL, receiving information about the aim of SDRN and the DT&PL (86%), discussing the results (76%), receiving information about the
possibilities for referral, and the expertise of the care providers to whom they could be referred (87%)). After the implementation of SDRN, only three patients with a desire for referral had not been referred. Seventy-eight percent of patients would recommend SDRN to others. In general, patients were pleased with the DT&PL. The more frequently they had completed a DT&PL and the more steps of the process they had followed, the more positive they felt about SDRN. However, the patients’ experiences and opinions also indicate that the implementation of SDRN could and should be improved. The study shows that patients should be offered the opportunity to complete a DT&PL on a regular basis and that the instrument responses should be discussed with them.
Chapter 4 focuses on the effect of SDRN implementation on the functioning of the individual patient21. Two cohorts of patients were compared with each other to examine this. The first cohort of patients (n = 518) was recruited prior to the implementation of SDRN, whereas the second cohort of patients (n = 442) was recruited after the implementation of SDRN. The second cohort of patients reported significantly fewer and less severe problems in the practical, social, and emotional domains as defined by the DT&PL. The two cohorts showed no differences in the level of distress, spiritual and physical problems, desire for referral, QoL, anxiety, depression, and patient satisfaction with the provided care. These results are consistent with the current scientific evidence of a modest yet positive effect of distress screening on such outcome measures.
Patients may complete a DT&PL on www.lastmeter.nl (the instrument is currently available on www.kanker.nl) to prepare themselves for a consultation with their doctor or nurse or just to gain insight into their situation. They can complete this tool whenever and wherever they like. Chapter 5 shows that there were significant differences between the responses of patients in a clinical care setting completing the online version of the DT&PL (n = 4756) and those of patients in a research setting completing the DT&PL on paper (n = 1340)22. The patients in a clinical care setting showed a higher average DT-score (p<0.001), reported more problems in all domains listed (p<0.001) and had a desire for referral more frequently (p<0.001). Researchers should realize that the context of data collection may affect the responses and, therefore, the representativeness and generalizability of the findings.
Chapter 6 presents a study into the effect of life phases and marital status on the level of distress, the number of problems and the desire for referral in a cross-sectional group of patients (n = 1340)23. The results show that single patients and patients in LAT relationships (Living-Alone-Together, couples who live at separate addresses) aged younger than 65 years are twice as likely to develop clinically relevant distress (a DT-score of ≥ 5) and/or a desire for referral than patients who are married. The findings suggest that cohabitation, or the daily presence of a partner, could be a stronger buffer for distress than simply having a partner. The presence of a partner seems less relevant in patients aged older than 65 years. Care providers involved in the implementation and/or performance of SDRN in daily practice are more likely to encounter problems in younger patients in LAT relationships and those who are single.
Methodological considerations
The studies presented in this thesis are based on data collected from both care providers and various patient groups. The paragraphs below discuss the strengths and weaknesses of the studies.
One of the strengths of the research is that data was collected from care providers as well as various patients groups, i.e., the people directly involved in the performance of SDRN. Another strength is that all 23 hospitals in the north-eastern part of the Netherlands, i.e., approximately 25% of Dutch hospitals, varying from small regional and top-clinical hospitals to university medical centres, implemented the SDRN process and a majority of these hospitals were additionally willing to participate in the research. Another three hospitals in the middle and southern part of the Netherlands participated in the study in which patients completed questionnaires prior to the implementation of SDRN. Patients from across the Netherlands completed the online version of the DT&PL. Another strength of the research was the participation of patients with various sociodemographic and illness-related characteristics, such as tumour type, stage of the disease, time since diagnosis, and types of treatment. Finally, the number of respondents and, therefore, the number of data to be analysed were considerable. All of these strengths may increase the reliability of the study results.
However, the research also has some weaknesses. The response rate among patients who were asked to complete questionnaires including the DT&PL prior to and after the implementation of SDRN was 51-54%20,21,23. Although this is a fairly reasonable response rate compared to the response rates of questionnaire surveys described in the scientific literature24, it also means that more than 45% of the patients who were approached did not participate in the study. This may be attributed to the study design. During a period of two to four weeks, all patients who received cancer treatment or follow-up care in a hospital were approached to participate and informed of the aim of the study by their care provider. The patients then anonymously decided whether or not to participate. Care providers did not share any information about whom they had approached with the researchers. Consequently, patients who did or did not participate in the study could not be compared with each other. Therefore, we do not know whether and to what extent the participating patients are representative of the entire patient group that had been approached to participate. This may affect the representativeness and, therefore, the generalizability of the findings.
A weakness of the data collection on the website www.lastmeter.nl may be that the DT&PL and the other questions were likely only completed by patients who were familiar with this website because they had been informed by their care provider or had read about it. On the other hand, this method of data collection allowed us to collect data from people receiving clinical care who might otherwise not have participated in a questionnaire survey.
The SDRN process was implemented in the daily clinical practice of many different hospitals with their own methods and culture. Although the IKNL-G employees implemented SDRN in a systematic way, i.e., based on centralized project management, an implementation plan including supporting materials, and regional meetings allowing healthcare professionals from different regional hospitals to exchange their knowledge of and experiences with SDRN, there were also some unverifiable hospital-specific characteristics. For instance, the decisions made by an individual hospital as to which patients to include in the SDRN implementation process, the motivation of care providers to implement and perform SDRN, and the amount of time available to do so. Consequently, the hospitals and departments may show differences in the extent of SDRN
influenced the effect of SDRN on the patients’ functioning (chapter 5). The best way to demonstrate the effectiveness of an intervention such as SDRN is to set up a randomized controlled trial. However, the aim of IKNL-G was to implement the SDRN process. Therefore, a time sequential design was used to compare two cross-sectional groups (i.e., prior to and after SDRN implementation). As a result, the effects that we found may not be fully attributed to SDRN.
Clinical implications
The aim of IKNL-G was to implement SDRN in the hospitals in the north-eastern part of the Netherlands to improve the quality of psychosocial care for and the quality of life of cancer patients.
In retrospect, we can state that the implementation project set up by IKNL-G has certainly helped to emphasize the importance of psychosocial care as an integrated part of oncology care. When the measurements were being conducted, the SDRN process had been implemented – although not for all tumour types – in 21 hospitals. The SDRN implementation process had started in the other 2 hospitals as well. The IKNL employees explained the importance of the systematic screening for distress to hospitals in other regions, too. The integration of psychosocial care into regular oncology care was also stimulated by the report published by the National Cancer Control Programme (NPK). The section of this report drawn up by the working group ‘Integration of Psychosocial Care’ described the importance of the systematic screening for distress and the importance of the development of a guideline25. The report also addressed subjects such as evidence of the effectiveness of psycho-oncological interventions, psychosocial aspects of tumour-specific guidelines, funding of psychosocial care, and education on psychosocial problems and care in oncology for medical specialists, nurses, and psychosocial healthcare providers. Subsequent national and regional initiatives based on this report also focused on the integration of psychosocial care in the quality standards for oncology care26.
Although progress has been made, the studies presented in this thesis and the experiences in practice suggest that the systematic screening for distress and psychosocial care needs in all cancer patients has not yet been realized. The development of an oncology care system addressing medical-technical aspects as well as psychosocial problems in a systematic way requires continued efforts and
dedication. Therefore, the importance of the guideline ‘Screening for psychosocial distress’ and its (extended) implementation in practice in all hospitals and for all tumour types should be continuously emphasized.
The implementation, and optimization of the implementation, of the entire SDRN process requires continued effort and dedication as well. The studies among patients and care providers show the importance of addressing all aspects of the process, i.e., completion of the DT&PL, discussion of the responses, and referral if necessary or desired by the patient. Patients indicate that they benefit more from SDRN if they have followed all the steps of the process. Although completion of the DT&PL in itself may have a therapeutic effect, we strongly recommend that the responses always be discussed with a patient. Asking a patient to complete a DT&PL as part of the care that they receive makes them believe this will be discussed somehow at some point. If not, the patient may feel that it is useless to complete the DT&PL or, even worse, may become dissatisfied with the care that they receive. In addition, discussion of the responses in the completed DT&PL allows the care provider to gain insight into and pay attention to the problems perceived by patients and to provide tailored information and information about support and self-management. In other words, it enables them to offer basic psychosocial care. If the discussion indicates that more specialized care is necessary or desired, the care provider is better informed about to which specialized psychosocial and/or allied care provider(s) the patient should be referred.
Based on our research, we make a few recommendations on how to optimize the implementation of SDRN. It is important to make time to frequently perform SDRN during the diagnosis, treatment, and follow-up processes. However, time often means money. Currently, the screening for distress and psychosocial care needs in hospital as well as non-hospital settings are not covered by any basic or specific financial arrangements27. The official reason for this is that the costs of psychosocial care come from the amount that a patient’s insurance company pays the hospital for all medical expenses related to their diagnosis and treatment. However, organizations should and could explicitly allocate budget for these costs. Unfortunately, they often make other choices. The provision of a specific budget may help to integrate the screening for distress and care needs and the provision
It is also important to provide nurses and doctors with additional training in adequate psychosocial care as an integral part of oncology care. The training programme should focus on the following elements: knowledge of risk factors for distress, the aim of the DT&PL and the provision of information about this to the patient, (communicative) skills to discuss the problems and concerns reported by the patient in a professional manner, the expertise of specialized psychosocial and allied health care providers, and the provision of information about this to the patient. Since early 2019, the e-learning module ‘Psychosocial care for cancer patients’ (https://zorgpadpro.noordhoff.nl/psychosocialezorg) has become available for nurses and nurse specialists. This e-learning module was developed by IKNL and the Dutch Oncology Nursing Society (V&VN Oncologie) on behalf of the Landelijk Overleg Psychosociale Oncologie (LOPSOZa
1
). A specific learning module for doctors has not yet become available. The project ‘Transparency of psychosocial effects and care in cancer’, also initiated by LOPSOZ, may raise awareness in this target group.
Care providers should be aware of and pay attention to risk factors for distress and specific risk groups, such as young single patients and patients in LAT relationships (chapter 6). It has also been shown that young women, patients with tumour types other than prostate cancer, patients who receive high-intensity treatment and patients who receive treatment with palliative intent perceive more distress (chapter 5). However, it has been shown that sociodemographic and illness-related risk factors for distress, such as age, sex, treatment intensity, and intention of treatment, only have a modest predictive value for distress22,28.
Patients without these characteristics may also perceive high levels of distress. Therefore, it is important to always discuss the responses to the DT&PL to allow the patient and the care provider to gain insight into the nature and severity of
a The following organizations participate in LOPSOZ: the Dutch Cancer Society (KWF), the
Netherlands Comprehensive Cancer Organisation (IKNL), the Dutch Society for Psychosocial Oncology (NVPO), Walk-in Centres and Psycho-Oncology Centres Collaboration and Support (IPSO), the Dutch Oncology Nursing Society (V&VN), the Dutch Association of Medical Psychologists (PAZ/LVMP), the Royal Dutch Society for Physiotherapy (KNGF) and the National Working Group of Oncology Dietitians (LWDO). This initiative is supported by the Dutch Federation of Cancer Patients’ Organisations (NFK).
the problems, the actions that the patient can take themselves to deal with the problems, and possible referral to the type of care provider that the patient could benefit from.
Finally, in accordance with the guideline recommendations, it is advisable to share information about the patient’s functioning, as obtained by the screening process and information about the psychosocial care that the patient may have received with the patient’s general practitioner at the end of hospital follow-up18. Long-term symptoms resulting from the illness and treatment, such as anxiety, depression, prolonged fatigue and a need for help to return to work or school may also occur after completion of treatment and follow-up. Therefore, the hospital and general practitioner should work together to provide the patient with the best possible care18,27.
Although our study shows only a modest effect of SDRN on the patients’ functioning21, this should not be a barrier to implement SDRN. The aim of SDRN is to recognize in a timely manner and discuss distress and psychosocial care needs and to refer a patient, if necessary. The opinions and experiences of patients and psychosocial care providers indicate a positive contribution of the SDRN process19,20. Therefore, SDRN is a useful intervention to integrate (basic) psychosocial care into regular cancer care. It is recommended that the implementation of SDRN is extended and optimized.
Future research
Distress screening has been suggested to improve the patients’ quality of life. Therefore, studies examining the effectiveness of distress screening implementation generally use QoL, anxiety and depression as outcome measures. We also used these outcome measures in our research. However, the results described in the scientific literature vary between a positive effect and no effect on QoL, anxiety, depression, and perceived problems18. Our study showed similar results. Is it, therefore, realistic to expect that the distress screening process itself (i.e., completion of a screening instrument and, potentially and preferably, a discussion of the responses and referral of the patient) will improve the patients’ quality of life and reduce symptoms of anxiety and depression? Previous studies did not examine whether, to whom, and for which problems a
advice (a meta-analysis showed that the use of psychological support in a clinical setting was 50%29); why a patient did or did not decide to follow this advice; whether a patient completed the care that they received from a care provider (the same meta-analysis showed that the compliance among patients receiving care was 90%29); or the effect of the provided specialized care on the patient’s functioning and quality of life. High levels of distress and unmet care needs are associated with increased care consumption and costs. Therefore, the extent to which medical care is used and the accompanying costs should be studied both in patients participating and patients not participating in a screening process. It is also useful to perform more longitudinal studies, because the level of distress perceived by patients may vary over time and problems may occur during or after completion of treatment4,18. When conducting longitudinal research, patients who do and do not desire or receive specialized psychosocial and/or paramedical care must be differentiated from each other. In current analyses, these patients are considered as one group, whereas only one-third of patients (may) desire care21 and less than one-quarter of patients actually receive additional psychosocial care30.
Finally, it would be interesting to re-examine the extent to which SDRN is currently implemented and performed in daily clinical practice. Follow-up research should focus on the extent to which SDRN is implemented for each tumour type. Our studies showed that implementation has been achieved in patients with breast cancer in particular. Although the project ‘Transparency of psychosocial effects and care of cancer patients’ mainly focuses on patients with breast and colon cancer, it is a good way to find out more about this subject.
References
1. National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: distress management V.2.2019. Retrieved on April 22, 2019 from www.nccn.org.
2. Mehnert A, Brahler E, Faller H, Harter M, Keller M, Schulz H, Koch U. Fourweek prevalence of mental disorders in patients with cancer across major tumor entities. Journal of Clinical
Oncology. 2014;32(31):3540–3546.
3. Chen AM, Hsu S, Felix C, Garst J, Yoshizaki T. Effect of psychosocial distress on outcome for head and neck cancer patiënts undergoing radiation. Laryngoscope. 2018;128(3):641-645. 4. de Haes H, Gualthérie van Weezel L, Sanderman R. Psychologische patiëntenzorg in de
oncologie, handboek voor professionals. Uitgever Koninklijke van Gorcum B.V.; 2017.
5. Lazarus RS, Folkman S. Stress, appraisal and coping. New York: Springer; 1984.
6. Weisman AD. Early diagnosis of vulnerability in cancer patients. American Journal of Medical
Science. 1976;271(2),187–196.
7. Zabora J, BrintzenhofeSzoc K, Curbow B, Hooker C, Piantadosi S. The prevalence of psychological distress by cancer site. Psycho-Oncology. 2001;10(1):19-28.
8. Carlson LE, Zelinski EL, Toivonen KI, Sundstrom L, Jobin CT, Damaskos P, Zebrack B. Prevalence of psychosocial distress in cancer patients across 55 North American cancer centers. J Psychosoc
Oncol. 2018;28:1-17.
9. Mehnert A, Hartung TJ, Friedrich M, Vehling S, Brähler E, Härter M, Keller M, Schulz H, Wegscheider K, Weis J, Koch U, Faller H. One in two cancer patiënts is significantly distressed: Prevalence and indicators of distress. Psycho-Oncology. 2018;27(1):75-82.
10. Carlson LE, Angen M, Cullum J, Goodey E, Koopmans J, Lamont L, MacRae JH, Martin M, Pelletier G, Robinson J, Simpson JS, Speca M, Tillotson L, Bultz BD. High levels of untreated distress and fatigue in cancer patiënts. Br J Cancer. 2004;90:2297–2304.
11. Beesley VL, Janda M, Goldstein D, Gooden H, Merrett ND, O’Connell DL, Rowlands IJ, Wyld D, Neale RE. A tsunami of unmet needs: Pancreatic and ampullary cancer patients’ supportive care needs and use of community and allied health services. Psycho-Oncology. 2016;25:150–157. 12. Faller H, Koch U, Brähler E, Härter M, Keller M, Schulz H, Wegscheider K, Weis J, Boehncke A,
Hund B, Reuter K, Richard M, Sehner S, Szalai C, Wittchen HU, Mehnert A. (2016). Satisfaction with information and unmet information needs in men and women with cancer. Journal of
Cancer Survivorship. 2016;10(1):62–70.
13. Rim SH, Yabroff KR, Dasari S, Han X, Litzelman K, Ekwueme DU. Preventive care service use among cancer survivors with serious psychological distress: An analysis of the medical expenditure panel survey data. Prev Med. 2019;123:152-159.
14. Fagerlind H, Kettis A, Glimelius B, Ring L. Barriers against psychosocial communication: oncologists’ perceptions. Journal of Clinical Oncology. 2013;31(30):3815–3822.
15. Kruijver I, Garssen B, Kuiper AJ, Visser A, Kuiper A. Signalising psychosocial problems in cancer care. The structural use of a short psychosocial checklist during medical or nursing visits.
Patiënt Education and Counseling. 2006; 62:163-77.
16. Tondorf, Theresa. Comprehensive cancer care: cancer patients’ and oncologists’ perspectives on psycho-oncological support. 2019, Doctoral Thesis, University of Basel, Faculty of Psychology.
17. Netherlands Comprehensive Cancer Organisation. Dutch guideline: ‘Detecteren behoefte psychosociale zorg’, versie: 1.0. 2010. Retrieved on May 3, 2015 from http://oncoline.nl/ detecterenbehoefte-psychosociale-zorg.
18. Netherlands Comprehensive Cancer Organisation. Dutch guideline: ‘Detecteren behoefte psychosociale zorg’, versie 2.0:2017. Retrieved on January 17, 2019 from https://www. oncoline.nl/detecteren-behoefte-psychosociale-zorg.
19. van Nuenen FM, Donofrio SM, Tuinman MA, van de Wiel HB, Hoekstra-Weebers JE. Feasibility of implementing the ‘Screening for Distress and Referral Need’ process in 23 Dutch hospitals.
Supportive care in cancer. 2017;25(1):103-110.
20. van Nuenen FM, Donofrio SM, van de Wiel HBM, Hoekstra-Weebers JEHM. Cancer patiënts’ experiences with and opinions on the process ‘Screening of Distress and Referral Need’ (SDRN) in clinical practice: A quantitative observational clinical study. PLoS One. 2018;13(6):e0198722. doi: 10.1371/journal.pone.0198722.
21. van Nuenen FM, Donofrio SM, Tuinman MA, van de Wiel HB, Hoekstra-Weebers JE. (2019) Effects on patient reported outcomes of ‘Screening of Distress and Referral Need’ implemented in Dutch oncology practice. (submitted).
22. van Nuenen FM, Donofrio SM, van de Wiel HBM, Hoekstra-Weebers JEHM. (2019) Cancer patients’ responses to Distress Thermometers and Problem Lists completed for clinical care or for research purpose differ. (submitted).
23. Tuinman MA, Van Nuenen FM, Hagedoorn M, Hoekstra-Weebers JE. Distress, problems and referral wish of cancer patients: differences according to relationship status and life phase.
Psycho-Oncology. 2015;24(6):699-704.
24. Gazendam-Donofrio S, Hoekstra H, van der Graaf W, van de Wiel H, Visser A, Huizinga G, Hoekstra-Weebers JE. Parent-child communication patterns during the first year after a parent’s cancer diagnosis. Cancer 2009;115:4227-4237.
25. Nationaal Programma Kankerbestrijding 2005-2010. Rapport Nationaal Programma Kankerbestrijding, werkgroep 5: Integratie van psychosociale zorg in de oncologie, 2010. 26. VISIE PSYCHOSOCIALE ONCOLOGISCHE ZORG OP MAAT Kansen en knelpunten. Retrieved on
April 12, 2019 from: https://nvpo.nl/wp-content/uploads/2014/04/140414-Visie-PSOZ-final. pdf.
27. Admiraal JM, Reyners AK, Hoekstra-Weebers JE. Do cancer and treatment type affect distress?
Psycho-Oncology. 2013;22:1766–1773.
28. Brebach R, Sharpe L, Costa DSJ, Rhodes P, Butow P. Psychological intervention targeting distress for cancer patients: a meta-analytic study investigating uptake and adherence.
Psycho-Oncology. 2016;25(8):882–890.
29. Carlson LE, Waller A, Mitchell AJ. Screening for distress and unmet needs in patients with cancer: review and recommendations. J Clin Oncol. 2012;30:1160–1177.
