Patient-Reported Physical Symptoms More Likely to Be Addressed by Oncologists Than Depression or Anxiety

February 2019, Vol 9, No 2

Providers are more likely to respond to and act on patient-reported physical symptoms than they are to psychosocial symptoms, according to data presented at the 2018 ASCO Quality Care Symposium by Lisa Catherine Barbera, MD, MPA, Senior Scientist, Odette Cancer Centre, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada.

Patients undergoing cancer treatment often experience physical and psychosocial symptoms that go undetected by their providers, underscoring the need for clinicians to incorporate measures of patient-reported outcomes into routine clinical practice.

Measuring Provider Response

According to Dr Barbera, the province of Ontario already has a fairly robust symptom-screening program in place for patients with cancer. Measures are routinely collected using systems such as the Patient Reported Functional Status and the Edmonton Symptom Assessment Scale (ESAS), but ensuring adequate provider response to those symptoms is crucial to addressing patient symptom burden and providing high-quality care.

To measure provider response to patient-reported outcomes, she and her team developed a chart audit process to evaluate whether cancer care teams were acknowledging, assessing, and/or addressing symptoms measured by ESAS.

All 14 regional cancer centers in Ontario received a chart audit package with instructions, a data dictionary, and a chart audit tool with preset drop-down menu options. Between September and December 2016, regional cancer centers audited 2380 charts from patients whose ESAS symptom scores were moderate to severe (scores between 4 and 10). A total of 7 ESAS symptoms were audited—depression, anxiety, dyspnea, fatigue, nausea, appetite, and pain—and at least 20 patients’ charts were audited per symptom.

Physical versus Psychological Symptoms

Overall, 56% of patients reported having their symptom acknowledged by at least one of their providers at the time of completing their ESAS screening, and symptoms were most often—70% of the time—acknowledged by providers when the symptom intensity was severe, regardless of the type.

Approximately 60% of patients received some form of assessment in response to this screening, and 42% received an intervention, such as referral to a specialist, further tests, or a prescription for a medication.

“When we look for signs of interventions, we see that about half the time there is an intervention put in place for the patients with pain, but depression and anxiety have lower rates of intervention, at about one-third,” Dr Barbera said.

Providers offered acknowledgment (71.5%), assessment (67.7%), and intervention (55.8%) most often to patients who reported pain. Psychosocial symptoms, such as ­depression and anxiety, were the least likely to be acknowledged (44.5% and 45%, respectively), to be offered assessments (45.8% and 50.1%), or to receive an intervention (35.7% and 36.6%). Also of note, patients who reported moderate-to-severe depression and anxiety were more likely to decline ­interventions (7.8% and 7.7%, ­respectively).

Based on these data, the investigators found that providers in the study disproportionately respond to physical symptoms, such as pain, and are much less likely to respond to psychosocial complaints.

“We speculate that this is because clinical teams are more accustomed to and more comfortable dealing with physical symptoms, like pain or shortness of breath, and are less comfortable—or maybe less willing—to take the time to handle psychosocial symptoms, like anxiety and depression,” Dr Barbera said.

Consider the Patient’s Emotional Burden

She and her colleagues have given these results to the psychosocial oncology team at Cancer Care Ontario so that they can conduct further quality work around managing these particular symptoms within the cancer program. Continuous chart audits will also continue to elucidate opportunities for improving patient care and managing cancer symptoms.

To offer true patient-centered care, the patient’s emotional burden related to cancer must also be addressed, and providers should be trained to respond to psychosocial symptoms properly, according to Dr Barbera and colleagues.

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