SIDEBAR: Key Issues in Joint Commission Statement by American Psychosocial Oncology Society,  Association of Oncology Social Work, and Oncology Nursing Society 

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  • It is imperative that [Commission on Cancer]-accredited programs adopt a universal definition of distress. We concur with the National Comprehensive Cancer Network definition of distress as an “unpleasant emotional experience of a psychological (cognitive, behavioral, emotional), social, and/or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment.”1
  • A variety of tools exist for distress screening,2  and programs should select and use validated instruments, following published threshold values and ranges to identify distressed patients.
  • Given that distress has multiple dimensions, instruments should screen broadly and not focus solely on one particular symptom.
  • Distress can occur at multiple time points from a cancer diagnosis onward and may go unrecognized if screening is conducted at only one time.
  • Processes need to be established for the results of every screen to be communicated to and reviewed by the patient’s treatment team in a timely manner. Similar to measuring vital signs, a medical assistant could administer a screening instrument, but clinicians trained in distress screening must interpret the results.
  • If the score exceeds the distress threshold, a trained clinician should differentiate the cause of distress (i.e., depression, lack of transportation, shortness of breath, etc.) and ensure that an assessment by or referral to an appropriate qualified clinician is completed. Programs should follow the NCCN guidelines for the management of distress. 1
  • Referrals for the assessment and management of distress should be considered part of a patient’s routine medical care, and presented to the patient as such. Because the risk of suicide is elevated in individuals with cancer, patients whose screens suggest suicide risk should be asked about suicidal ideation as part of their clinical evaluation.3-5
  • The required psychosocial representative on the cancer committee who oversees the screening program should have training in the identification and management of distress in patients with cancer. Programs without such a person should consider educating a current staff member. Information about training opportunities can be found through APOS (, AOSW ( and ONS ( and
  • In the event that a cancer program does not have licensed mental health professionals on staff, we strongly encourage contracting with a professional psychosocial oncology expert or qualified community organization for referral and follow-up. ■


1. National Comprehensive Cancer Network. Distress Management Clinical Practice Guidelines in Oncology. Version 3.2012. Available at Accessed August 1, 2012.

2. Carlson LE, Waller A, Mitchell AJ: Screening for distress and unmet needs in patients with cancer: Review and recommendations. J Clin Oncol 30(11):1160-1177, 2012.

3. Misono S, Weiss NS, Fann JR, Redman M, Yueh B. (2008) Incidence of suicide in persons with cancer. J Clin Oncol 26: 4731-4738, 2008.

4. Anguaino L, Mayer DK, Piven ML, Rosenstein  D. (2011) A literature review of suicide in cancer patients. Cancer Nurs 35: E14-E26.

5. Cooke L, Gotto J, Mayorga L, Grant M, Lynn R. (2013) What do I say? Suicide assessment and management. Clin J Oncol Nurs 17: E1-E7.

Used with permission from APOS. © 2013 American Psychosocial Oncology Society

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