Cited by 541Cancer survivorship and careAnxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesChildhood Cancer Survivors' Quality of Life

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Screening for Emotional Distress in Cancer Patients: A Systematic Review of Assessment Instruments

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Vodermaier, A., Linden, W., Siu, C.·2009·JNCI Journal of the National Cancer Institute

DOI 10.1093/jnci/djp336PMC PMC3298956

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Abstract

Screening for emotional distress is becoming increasingly common in cancer care. This systematic review examines the psychometric properties of the existing tools used to screen patients for emotional distress, with the goal of encouraging screening programs to use standardized tools that have strong psychometrics. Systematic searches of MEDLINE and PsycINFO databases for English-language studies in cancer patients were performed using a uniform set of key words (eg, depression, anxiety, screening, validation, and scale), and the retrieved studies were independently evaluated by two reviewers. Evaluation criteria included the number of validation studies, the number of participants, generalizability, reliability, the quality of the criterion measure, sensitivity, and specificity. The literature search yielded 106 validation studies that described a total of 33 screening measures. Many generic and cancer-specific scales satisfied a fairly high threshold of quality in terms of their psychometric properties and generalizability. Among the ultrashort measures (ie, those containing one to four items), the Combined Depression Questions performed best in patients receiving palliative care. Among the short measures (ie, those containing five to 20 items), the Center for Epidemiologic Studies-Depression Scale and the Hospital Anxiety and Depression Scale demonstrated adequate psychometric properties. Among the long measures (ie, those containing 21-50 items), the Beck Depression Inventory and the General Health Questionaire-28 met all evaluation criteria. The PsychoSocial Screen for Cancer, the Questionnaire on Stress in Cancer Patients-Revised, and the Rotterdam Symptom Checklist are long measures that can also be recommended for routine screening. In addition, other measures may be considered for specific indications or disease types. Some measures, particularly newly developed cancer-specific scales, require further validation against structured clinical interviews (the criterion standard for validation measures) before they can be recommended.

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Figure 1 Flowchart of studies included in systematic review.CC BY-NC · PubMed Central

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Method
Prospective associations of depression with survival: a population-based cohort study in patients with newly diagnosed breast cancer
Vodermaier, A., Linden, W., Rnic, K., Young, S., Ng, A., Ditsch, N. C., & Olson, R. A. (2013) · Breast Cancer Research and Treatment · doi:10.1007/s10549-013-2795-4 · Cited by 73
Metabolic, nutritional and endocrine studies of the hereditary obesity-diabetes syndrome of mice and mechanism of its development.
Mayer, J., RUSSELL, R. E., Bates, M. W., & Dickie, M. M. (1953) · PubMed · Cited by 74
Physical Symptom Burden and Its Association With Distress, Anxiety, and Depression in Breast Cancer
McFarland, D. C., Shaffer, K. M., Tiersten, A., & Holland, J. C. (2018) · Psychosomatics · doi:10.1016/j.psym.2018.01.005 · Cited by 73
Global, regional, and national prevalence of depression among cancer patients
Mejareh, Z. N., Abdollahi, B., Hoseinipalangi, Z., Jeze, M. S., Hosseinifard, H., Rafiei, S., Aghajani, F., Dehnad, A., Ardakani, M. F., Ahmadi, S., et al. (2021) · Indian Journal of Psychiatry · doi:10.4103/indianjpsychiatry.indianjpsychiatry_77_21 · Cited by 77
“[24] Despite the multitude of studies carried out on this topic, there are still a number of gaps in the existing literature.”
Which symptoms are indicative of DSMIV depression in cancer settings? An analysis of the diagnostic significance of somatic and non-somatic symptoms
Mitchell, A. J., Lord, K., & Symonds, P. R. (2012) · Journal of Affective Disorders · doi:10.1016/j.jad.2011.11.009 · Cited by 72
Consolidation and prediction of long-term treatment effect of group and online mindfulness-based cognitive therapy for distressed cancer patients.
Cillessen, L., Schellekens, M. P. J., Van de Ven, M. O. M., Donders, A. R. T., Compen, F. R., Bisseling, E. M., Van der Lee, M. L., & Speckens, A. E. M. (2018) · Acta Oncologica · doi:10.1080/0284186x.2018.1479071 · Cited by 66
“The HADS has adequate psychometric properties to detect distress in cancer patients and is a suitable screening instrument for psychiatric disorders in this group [37,38].”
Method
Distress and Patient-Centered Communication among Veterans with Incidental (Not Screen-Detected) Pulmonary Nodules. A Cohort Study
Slatore, C. G., Golden, S. E., Ganzini, L. K., Wiener, R. S., & Au, D. H. (2014) · Annals of the American Thoracic Society · doi:10.1513/annalsats.201406-283oc · Cited by 71
Mediators of physical exercise for improvement in cancer survivors' quality of life
Buffart, L. M., Ros, W. J. G., Chinapaw, M. J. M., Brug, J., Knol, D. L., Korstjens, I., van Weert, E., Mesters, I., van den Borne, B. H. P., Hoekstra‐Weebers, J. E. H. M., et al. (2013) · Psycho-Oncology · doi:10.1002/pon.3428 · Cited by 70
“Emotional distress was assessed with the 14-item Hospital Anxiety and Depression Scale [28], validated for the Dutch population [29] and cancer patients [30].”
Method
Problems in Cross-Cultural Use of the Hospital Anxiety and Depression Scale: “No Butterflies in the Desert”
Maters, G. A., Sanderman, R., Kim, A. Y., & Coyne, J. C. (2013) · PLoS ONE · doi:10.1371/journal.pone.0070975 · Cited by 72
“Issues Raised in the Recent Literature Concerning the HADS Vodermaier et al’s [8] review noted a troublingly broad, inconsistent range of optimal cutoffs obtained across studies, ranging from 8–22 for total score and 5–11 for depression and anxiety subscales.”
BackgroundResultInfluential
Screening for major depressive disorder in adults with cerebral glioma: an initial validation of 3 self-report instruments
Rooney, A. G., McNamara, S., Mackinnon, M., Fraser, M., Rampling, R., Carson, A. J., & Grant, R. (2012) · Neuro-Oncology · doi:10.1093/neuonc/nos282 · Cited by 72
“It is known that the identification of depression can be improved by screening cancer patients with self-report questionnaires.(3,4) Indeed, the practice of screening for depression is supported by national and international health, cancer, and palliative care organizations.”
Background
Interventions to improve screening and appropriate referral of patients with cancer for psychosocial distress: systematic review
McCarter, K. L., Britton, B., Baker, A., Halpin, S. A., Beck, A. K., Carter, G. L., WRATTEN, C. R., Bauer, J. D., Forbes, E., Booth, D., et al. (2018) · BMJ Open · doi:10.1136/bmjopen-2017-017959 · Cited by 69
School students with chronic illness have unmet academic, social, and emotional school needs.
Lum, A., Wakefield, C. E., Donnan, B., Burns, M. A., Fardell, J. E., Jaffe, A., Kasparian, N. A., Kennedy, S. E., Leach, S. T., Lemberg, D. A., et al. (2019) · School Psychology · doi:10.1037/spq0000311 · Cited by 69
Referral patterns and psychosocial distress in cancer patients accessing a psycho‐oncology counseling service
Nekolaichuk, C., Cumming, C. E., Turner, J., Yushchyshyn, A., & Sela, R. A. (2010) · Psycho-Oncology · doi:10.1002/pon.1765 · Cited by 68
Patient-reported depression measures in cancer: a meta-review
Wakefield, C. E., Butow, P. N., Aaronson, N. K., Hack, T. F., Hulbert-Williams, N., & Jacobsen, P. B. (2015) · The Lancet Psychiatry · doi:10.1016/s2215-0366(15)00168-6 · Cited by 66
“Inventory (BDI), and/or its variations (the BDI-II and the BDI-short form, BDISF).(1,4,5,7,8,15,22,42,43) In each case, the BDI’s performance was considered in”
BackgroundMethodInfluential
Psychosocial predictors of health outcomes in colorectal cancer: A comprehensive review
Sales, P. M. G., Carvalho, A. F., McIntyre, R. S., Pavlidis, N. A., & Hyphantis, T. N. (2014) · Cancer Treatment Reviews · doi:10.1016/j.ctrv.2014.03.001 · Cited by 66
Measuring psychosocial functioning in the radiation oncology clinic: a systematic review: Radiation therapy psychosocial functioning
Hess, C. B., & Chen, A. M. (2014) · Psycho-Oncology · doi:10.1002/pon.3521 · Cited by 63
“Efforts to identify quick reliable surrogates to the psychiatric interview have resulted in lengthy questionnaires aimed at identifying single aspects of the psyche and in rapid questionnaires aimed at identifying a zoomed-out and broadened view of a patient’s global psychosocial function [63,64].”
Background
A comprehensive examination of mental health in patients with head and neck cancer: systematic review and meta-analysis
Jiménez-Labaig, P., Aymerich, C., Braña, I., Rullan, A., Cacicedo, J., Torres, M. Á. G., Harrington, K. J., & Catalán, A. (2024) · JNCI Cancer Spectrum · doi:10.1093/jncics/pkae031 · Cited by 72
“…screening for emotional distress in patients with some cancer types, in addition to present evidence in the early detection of mental disorders (100), promotes equal access to psychological services, in contrast with a referral system solely reliant on the initiative of doctors or patients (101).”
Background
Sensitivity and specificity of the Distress Thermometer and a two‐item depression screen (Patient Health Questionnaire‐2) with a ‘help’ question for psychological distress and psychiatric morbidity in patients with advanced cancer
Ryan, D. A., Gallagher, P., Wright, S., & Cassidy, E. M. (2012) · Psycho-Oncology · doi:10.1002/pon.2042 · Cited by 62
“This finding is consistent with the literature among early-stage and mixed-stage cancer patients [12,23].”
BackgroundResult
Psychological Adjustment in Breast Cancer Survivors
Stanton, A. L., & Bower, J. E. (2015) · Advances in experimental medicine and biology · doi:10.1007/978-3-319-16366-6_15 · Cited by 63
Anxiety and depression among haematological cancer patients attending treatment centres: Prevalence and predictors
Clinton‐McHarg, T., Carey, M. L., Sanson‐Fisher, R., Tzelepis, F., Bryant, J., & Williamson, A. (2014) · Journal of Affective Disorders · doi:10.1016/j.jad.2014.04.072 · Cited by 62
“The HADS meets psychometric criteria for high internal consistency and discriminant validity (Vodermaier et al., 2009), and has been validated for use with many cancer patient groups including those diagnosed with haematological cancers (Smith et al.”
Background
Nutritional status, acute phase response and depression in metastatic lung cancer patients: correlations and association prognosis
Giannousi, Z., Gioulbasanis, I., Pallis, A. G., Xyrafas, A., Daliani, D., Kalbakis, K., Papadopoulos, V. G., Mavroudis, D., Georgoulias, V., & Papandreou, C. N. (2011) · Supportive Care in Cancer · doi:10.1007/s00520-011-1282-x · Cited by 62
Do cancer and treatment type affect distress?
Admiraal, J. M., Reyners, A. K. L., & Hoekstra‐Weebers, J. E. H. M. (2012) · Psycho-Oncology · doi:10.1002/pon.3211 · Cited by 63
Factors associated with anxiety and depression in cancer patients prior to initiating adjuvant therapy
Jiménez‐Fonseca, P., Calderón, C., Hernández, R., y Cajal, T. R., Mut, M., Ramchandani, A., Donnay, O., & Carmona‐Bayonas, A. (2018) · Clinical & Translational Oncology · doi:10.1007/s12094-018-1873-9 · Cited by 69
“Brief Symptom Inventory (BSI) is one of the most widely used instruments to assess anxiety and depression in clinical cases and was used in this study [13].”
Method
Measuring Preoperative Anxiety in Patients With Intracranial Tumors
Goebel, S., Kaup, L., & Mehdorn, H. M. (2011) · Journal of Neurosurgical Anesthesiology · doi:10.1097/ana.0b013e318222b787 · Cited by 61
“The HADS is a widely used questionnaire to assess symptoms of anxiety and depression in patients with somatic complaints with good reliability and validity.(22,23) It consists of 14 items, with 7 per subscale.”
Method
Circadian disruption and cancer- and treatment-related symptoms
Amidi, A., & Wu, L. M. (2022) · Frontiers in Oncology · doi:10.3389/fonc.2022.1009064 · Cited by 66
“Examples of these include the Hospital Anxiety and Depression Scale (HADS) (87) and the Center for Epidemiologic Studies Depression Scale (CES-D) (88), but many more exist (89).”
Multiple Group Confirmatory Factor Analysis of the DASS-21 Depression and Anxiety Scales: How Do They Perform in a Cancer Sample?
Fox, R. S., Lillis, T. A., Gerhart, J. I., Hoerger, M. P., & Duberstein, P. R. (2017) · Psychological Reports · doi:10.1177/0033294117727747 · Cited by 63
“Accordingly, accurately and appropriately assessing distress in cancer patients has garnered a great deal of research attention (Vodermaier, Linden, & Siu, 2009).”
Background
Assessment of the Hospital Anxiety and Depression Scale for cancer patients
Villoria, E., & Lara, L. (2018) · Revista médica de Chile · doi:10.4067/s0034-98872018000300300 · Cited by 61
Heath-related quality of life in Spanish breast cancer patients: a systematic review
Delgado‐Sanz, C., García-Mendizábal, M. J., Pollán, M., Forjaz, M. J., López‐Abente, G., Aragonés, N., & Pérez‐Gómez, B. (2011) · Health and Quality of Life Outcomes · doi:10.1186/1477-7525-9-3 · Cited by 59
“These three ratings were condensed into a five-level overall judgment (excellent, good, moderate, fair, or poor) using the same decision rules as Vodermaier et al.[16].”
Method
Distress, quality of life, neuroticism and psychological coping are related in head and neck cancer patients during follow-up
Aarstad, A. K. H., Beisland, E., Osthus, A. A., & Aarstad, H. J. (2011) · Acta Oncologica · doi:10.3109/0284186x.2010.504227 · Cited by 58
The next generation of the supportive care needs survey: a brief screening tool for administration in the clinical oncology setting
Girgis, A., Stojanovski, E., Boyes, A., King, M. T., & Lecathelinais, C. (2011) · Psycho-Oncology · doi:10.1002/pon.1973 · Cited by 58
“A recent review [10] concluded that short screening tools consisting of 5–20 items had a moderate chance of adoption in busy clinics, high sensitivity and specificity, were able to assess multiple domains, and could minimise scoring costs by automation.”
Background
Routine screening for suicidal intention in patients with cancer
Leung, Y. W., Li, M., Devins, G. M., Zimmermann, C., Rydall, A. C., Lo, C., & Rodin, G. (2013) · Psycho-Oncology · doi:10.1002/pon.3319 · Cited by 58
Factors associated with emotional distress in newly diagnosed prostate cancer patients
Orom, H., Nelson, C. J., Underwood, W., Homish, D. L., & Kapoor, D. A. (2015) · Psycho-Oncology · doi:10.1002/pon.3751 · Cited by 57
“However, even though effective screening tools for emotional distress, anxiety, or depression are available to identify those who could benefit from additional support [6,7], less is known about the kinds of intervention components that are needed [8].”
Background
Use of the Distress Thermometer to discern clinically relevant quality of life differences in women with breast cancer
Head, B. A., Schapmire, T. J., Keeney, C. E., Deck, S. M., Studts, J. L., Hermann, C. P., Scharfenberger, J. A., & Pfeifer, M. (2011) · Quality of Life Research · doi:10.1007/s11136-011-9934-3 · Cited by 57
“Specifically, ultra-short measures lack specificity in identifying particular problems such as depression; problems with determining the face-validity of single-item measures and patient’s difficulty scaling themselves on single-item measures further complicate their use [40].”
Background
Coping Strategies of Southern Italian Women Predict Distress Following Breast Cancer Surgery
Feudis, R. L. D., Lanciano, T., & Rinaldi, S. (2015) · Europe’s Journal of Psychology · doi:10.5964/ejop.v11i2.908 · Cited by 56
S3-Leitlinie – Diagnostik und Therapie der Plattenepithelkarzinome und Adenokarzinome des Ösophagus
Porschen, R., Fischbach, W., Gockel, I., Hollerbach, S. H., Hölscher, A. H., Jansen, P., Miehlke, S., Pech, O., Stahl, M., Thuss-Patience, P. C., et al. (2019) · Zeitschrift für Gastroenterologie · doi:10.1055/a-0833-5712 · Cited by 57
Psychosocial Distress in Patients with Thyroid Cancer
Buchmann, L. O., Ashby, S., Cannon, R. B., & Hunt, J. P. (2015) · Otolaryngology · doi:10.1177/0194599814565761 · Cited by 56
“The DT has been validated and accepted as a psychometric instrument and subjected to the most validation studies on the largest patient samples of any assessment tool.(6-8)”
Method
Unmet needs and distress in people with inoperable lung cancer at the commencement of treatment
Ugalde, A., Aranda, S. K., Krishnasamy, M., Ball, D., & Schofield, P. E. (2011) · Supportive Care in Cancer · doi:10.1007/s00520-011-1296-4 · Cited by 56
Health-related quality of life in well-differentiated metastatic gastroenteropancreatic neuroendocrine tumors
On behalf of the Spanish Neuroendocrine Tumor Group (GETNE), Jiménez‐Fonseca, P., Carmona‐Bayonas, A., Martín‐Pérez, E., Crespo, G., Serrano, R., Llanos, M., Villabona, C., García‐Carbonero, R., Aller, J., et al. (2015) · Cancer and Metastasis Reviews · doi:10.1007/s10555-015-9573-1 · Cited by 56
“Despite their validation for use in the cancer population [95], none of them are cancer specific and, hence, may not be able to provide comprehensive information.”
Background
The utility of the Edmonton Symptom Assessment System in screening for anxiety and depression
Bagha, S., MACEDO, A., Jacks, L. M., Lo, C., Zimmermann, C., Rodin, G., & Li, M. (2012) · European Journal of Cancer Care · doi:10.1111/j.1365-2354.2012.01369.x · Cited by 57
“Ultra-brief screening tools have the potential to minimise patient and clinic burden, but may lack specificity (Vodermaier et al. 2009).”
Background
Identifying psychological morbidity among people with cancer using the Hospital Anxiety and Depression Scale: time to revisit first principles?
Carey, M. L., Noble, N., Sanson‐Fisher, R., & Mackenzie, L. (2011) · Psycho-Oncology · doi:10.1002/pon.2057 · Cited by 52
Stepped care targeting psychological distress in head and neck and lung cancer patients: a randomized clinical trial
Krebber, A.-M. H., Leemans, C. R., de Bree, R., van Straten, A., Smit, F., Smit, E. F., Becker‐Commissaris, A., Eeckhout, G. M., Beekman, A. T. F., Cuijpers, P. J., et al. (2012) · BMC Cancer · doi:10.1186/1471-2407-12-173 · Cited by 53
“This scale has been proven to have adequate psychometrical properties and the total HADS score has been recommended for routine monitoring of psychological distress in cancer patients [29-32].”
Screening for emotional disorders in patients with cancer using the Brief Symptom Inventory (BSI) and the BSI‐18 versus a standardized psychiatric interview (the World Health Organization Composite International Diagnostic Interview)
Grassi, L. G., Caruso, R., Mitchell, A. J., Sabato, S., & Nanni, M. G. (2018) · Cancer · doi:10.1002/cncr.31340 · Cited by 53
“6 [22-70] Education: Mean 6 SD [range], y 9.”
Enhancing the experience of carers in the chemotherapy outpatient setting: an exploratory randomised controlled trial to test impact, acceptability and feasibility of a complex intervention co-designed by carers and staff
Tsianakas, V., Robert, G., Richardson, A., Verity, R., Oakley, C. M., Murrells, T., Flynn, M., & Ream, E. (2015) · Supportive Care in Cancer · doi:10.1007/s00520-015-2677-x · Cited by 50
“Although well validated, the GHQ-12 performs less well than other short tools including the Hospital Anxiety and Depression Scale [39] and was developed to detect psychiatric disorders rather than emotional distress.”
Method
Changes in caseness of anxiety and depression in breast cancer patients during the first year following surgery: Patterns of transiency and severity of the distress response
Saboonchi, F., Petersson, L., Wennman‐Larsen, A., Alexanderson, K. A. E., Bränström, R., & Vaez, M. (2014) · European Journal of Oncology Nursing · doi:10.1016/j.ejon.2014.06.007 · Cited by 58
How does the Distress Thermometer compare to the Hospital Anxiety and Depression Scale for detecting possible cases of psychological morbidity among cancer survivors?
Boyes, A., D’Este, C. A., Carey, M. L., Lecathelinais, C., & Girgis, A. (2012) · Supportive Care in Cancer · doi:10.1007/s00520-012-1499-3 · Cited by 51
“Although one of the most commonly used short screening measures, recent reviews [21, 30, 33] have revealed a lack of consistency in HADS cut-off scores compared with clinical assessments to identify cases.”
Quality of life in cancer rehabilitation: the role of life goal adjustment
von Blanckenburg, P., Seifart, U., Conrad, N., Exner, C., Rief, W., & Nestoriuc, Y. (2014) · Psycho-Oncology · doi:10.1002/pon.3538 · Cited by 51
“The questionnaire is reliable, well validated, and recommended for the use in cancer populations [34].”
Background
Longitudinal Assessment of Distress among Veterans with Incidental Pulmonary Nodules
Slatore, C. G., Wiener, R. S., Golden, S. E., Au, D. H., & Ganzini, L. K. (2016) · Annals of the American Thoracic Society · doi:10.1513/annalsats.201607-555oc · Cited by 49

Authors: Vodermaier, A., Linden, W., & Siu, C.
Affiliations: BC Cancer Agency (CA)
Corresponding author: Vodermaier, A.
ORCID: Vodermaier, A.
Linden, W.
Venue: JNCI Journal of the National Cancer Institute
Publisher: Oxford University Press (OUP)
Published: 2009-10-13
Volume: 101
Issue: 21
Pages: 1464-1488
ISSN: 0027-8874 (ISSN-L)
1460-2105
DOI: 10.1093/jnci/djp336
PMC: PMC3298956
OpenAlex: W1996766132
Cited by: 541
References: 160
Citations by year: 2026: 12 · 2025: 16 · 2024: 30 · 2023: 20 · 2022: 27 · 2021: 34 · 2020: 24 · 2019: 32 · 2018: 49 · 2017: 28 · 2016: 32 · 2015: 42 · 2014: 38 · 2013: 52 · 2012: 48
FWCI: 2.98
Type: journal article
Language: en
Open access: bronze
doi.org
Locations: JNCI Journal of the National Cancer Institute (publishedVersion)
PubMed Central (publishedVersion, cc-by-nc)
PubMed (publishedVersion)
HighWire Press Open Archive (submittedVersion)
Funders: Canadian Institutes of Health Research (#AQC83559)
Topics: Health Sciences › Medicine › Oncology › Cancer survivorship and care
Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Childhood Cancer Survivors' Quality of Life
Keywords: emotional distress screening, cancer patients, psychometric properties, depression screening, anxiety screening, screening tool, scale validation, CES-D, Hospital Anxiety and Depression Scale, Beck Depression Inventory, Rotterdam Symptom Checklist, palliative care, sensitivity and specificity
MeSH terms: Adjustment Disorders, Anxiety Disorders, Depression, Depressive Disorder, Major, Major Depressive Disorder, Humans, Mass Screening, Neoplasms, Psychometrics, Surveys and Questionnaires, Stress, Psychological, Reproducibility of Results, Dysthymic Disorder

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Screening for Emotional Distress in Cancer Patients: A Systematic Review of Assessment Instruments

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