Screening for Distress Debate
Alex Mitchell
www.twitter.com/_alexjmitchell
University of Leicester
www.psycho-oncology.info
#ipos2013
…What are the sources of disagreement?
Areas of Disagreement:
1.
2.
3.
4.
5.
6.
How to screen (which tool)
When to screen
How often to screen
Which screening population
Who should screen
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)
100.0
5.9
11.1
90.0
21.4
25.9
Comment: Slide illustrates diagnostic
accuracy according to score on DT
38.7
80.0
43.5
14.3
11.8
38.1
22.2
46.7
14.3
59.6
70.0
21.4
72.4
Judgement = Non-distressed
60.0
33.3
19.4
50.0
Judgement = Unclear
Judgement = Distressed
19.0
26.1
82.4
24.4
40.0
71.4
66.7
30.0
57.1
25.0
20.0
15.8
30.4
28.9
Two
Three
41.9
42.9
40.7
Four
Five
Six
10.0
11.8
15.4
0.0
Zero
One
Seven
Eight
Nine
Ten
Lessons from primary care….
Results disappointing
Acceptability overlooked
Most are not depressed
Many do not want help
Some are already Rx
Screening in Cancer
Missed diagnosis
GP =
CNS =
Oncologists
Screening tools (validity)
Depression
Distress
Brief / ultra-short
Multi-domain
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 =>

6 studies
=>
Referral
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
+treatment
+10%
+10%
What is holding back screening success?
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
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
5.7 5
6.3
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
y ea
rs
4564
y ea
rs
1844
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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
Overall Effect of screening
Baseline CARE x =
35%
with screening
+10% (0-20%)
+ follow-up
+treatment
+10% (0-20%)
+10% (0-20%)
……..So is screening successful or not?
…….It depends
Analogy: How do we reduce speeding drivers?
US deaths 10,000
Analogy
Aim is to reduce speed (and hence deaths)
Not simply to detect speeding!
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