Alex Mitchell www.twitter.com/_alexjmitchellUniversity of Leicester

www.psycho-oncology.info #ipos2013www.psycho-oncology.info #ipos2013

Screening for Distress Debate

…What are the sources of disagreement?

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

……in short

Should we screen at all?

But what are the alternatives to screening?

1. Diagnosis as usual (do nothing)

2. Enhanced diagnosis (clinician = screen)

3. Screen everyone

4. Screen high risk (targeted screening)

Comment: Slide illustrates diagnostic accuracy according to score on DT

11.815.4

30.4 28.9

41.9 42.9 40.7

57.1

82.4

66.771.4

15.8

25.0

26.124.4

19.4 19.0

33.3

21.4

11.8

22.2 14.3

72.4

59.6

43.546.7

38.7 38.1

25.921.4

5.911.1

14.3

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Zero One Two Three Four Five Six Seven Eight Nine Ten

Judgement = Non-distressed

Judgement = Unclear

Judgement = Distressed

Lessons from primary care…. Lessons from primary care….

Results disappointing

Acceptability overlooked

Most are not depressed

Many do not want help

Some are already Rx

Screening in Cancer Screening in Cancer

Missed diagnosis

GP = CNS = Oncologists

Screening tools (validity) Screening tools (validity)

Depression

Distress

Brief / ultra-short

Multi-domain

Implementation evidence Implementation evidence

Randomized

Non-Randomized

Q. What type of studies?

Q. How many +ve studies?

Q. What are the beneficial outcomes?

Q. What is the size of the effect?

Implementation Reviews

Implementation Studies

9 studies Distress => Referral

6 studies => Communication

….this is getting complex…….

………………..what is the overall effect?

Overall Effect of screening

Baseline CARE x%

with screening +10% (0-20%)

Overall Effect of screening

Baseline CARE x%

with screening +10%

+ follow-up +10%

+treatment +10%

What is holding back screening success?

BOTH. How Many Receive Ps Help? (n=2557)

Proportion meta-analysis plot [random effects]

0.0 0.2 0.4 0.6 0.8 1.0

combined 0.35 (0.25, 0.46)

McDowell et al (2010) 0.14 (0.11, 0.18)

Sharpe et al (2004) 0.15 (0.10, 0.22)

Morasso et al (2010) 0.16 (0.05, 0.33)

Merckaert et al (2009) 0.21 (0.17, 0.25)

Shimizu et al (2009) 0.25 (0.18, 0.33)

Shimizu et al (2005) 0.28 (0.18, 0.41)

Söllner et al (2004) 0.35 (0.26, 0.45)

Bogaarts et al (2011) 0.38 (0.27, 0.49)

Fritsche et al (2004) 0.43 (0.28, 0.59)

Siedentopf et al (2009) 0.46 (0.35, 0.58)

Plass and Koch (2001) 0.60 (0.46, 0.72)

Kadan-Lottick et al (2005) 0.89 (0.77, 0.96)

proportion (95% confidence interval)

% Receiving Any treatment for Mental Health% Receiving Any treatment for Mental Health

7.2

34.6

5.7 6.3 6.4

11.7

19.1

14

8.9

3.9 3.2

5.7

32.7

5 5

7.7

11

16.1

6.5 6.2

2.3 1.8

0

5

10

15

20

25

30

35

40

Cancer n=4878

No Cancer n=90,737

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

12mo Service Use 12mo Service Use (NIH, 2002)(NIH, 2002)

Overall Effect of screening

Baseline CARE x = 35%

with screening +10% (0-20%)

+ follow-up +10% (0-20%)

+treatment +10% (0-20%)

……..So is screening successful or not?……..So is screening successful or not?

…….It depends

Analogy: How do we reduce speeding drivers?

US deaths 10,000

Aim is to reduce speed (and hence deaths)

Not simply to detect speeding!

Analogy

Aim is to reduce distress (improving QoL)

Not simply to detect distress!

1

2

3

0. Summary

Screening can be ineffective or effective

Screening may be optional or mandated