Journal of Psychosocial Oncology

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/wjpo20

Detection of psychosocial distress in cancer

patients: A survey of Mexican oncologists

Oscar Galindo Vázquez, Samuel Rivera, Abel Lerma, Germán Calderillo Ruiz,
Marcos Espinoza Bello, Abelardo Meneses & Claudia Lerma

To cite this article: Oscar Galindo Vázquez, Samuel Rivera, Abel Lerma, Germán Calderillo Ruiz,
Marcos Espinoza Bello, Abelardo Meneses & Claudia Lerma (2021): Detection of psychosocial
distress in cancer patients: A survey of Mexican oncologists, Journal of Psychosocial Oncology,
DOI: 10.1080/07347332.2021.1986765

To link to this article: https://doi.org/10.1080/07347332.2021.1986765

Published online: 30 Nov 2021.

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Journal of Psychosocial Oncology
https://doi.org/10.1080/07347332.2021.1986765

ARTICLE

Detection of psychosocial distress in cancer patients:

A survey of Mexican oncologists
Oscar Galindo Vázquez, PhDa , Samuel Rivera, MDb , Abel Lerma,
PhDc , Germán Calderillo Ruiz, MDd, Marcos Espinoza Bello, MScd ,
Abelardo Meneses, MDd and Claudia Lerma, PhDe
a
Service of Psycho‐Oncology, Research and Development Unit of Psycho-Oncology, National Cancer
Institute of Mexico, INCan, Mexico, Mexico; bMexican Social Security Institute, Mexico, Mexico;
c
Institute of Health Sciences (ICSa), Autonomous University of the Hidalgo State, Pachuca, Mexico;
d
Psicooncología, National Cancer Institute of Mexico, INCan, Mexico, Mexico; eNational Cardiology
Institute of Mexico, INCar, Mexico, Mexico

ABSTRACT KEYWORDS
Purpose: Identification of patients’ distress is relevant for an cancer; distress;
on-time referral to psychosocial treatment. The objective was to Mexico; oncology;
assess the implementation of the guidelines for distress managing patients
in Mexican oncologists based on the NCCN guidelines.
Design: The study was non-experimental and cross-sectional.
Sample: Two hundred thirty-one oncologists participated with
an average age of 38 ± 11 years.
Methods: The likelihood of distress assessment was quantita-
tively evaluated.
Findings: A high percentage of oncologists knew and used
procedures to assess psychosocial discomfort. However, a
smaller percentage used a valid and reliable instrument. Factors
associated with performing distress identification procedures
were knowing the distress guidelines and lack of time. Factors
for questionnaire usage are the availability of brief instruments
and the percentage of patients suffering from stress.
Implications for Psychosocial Providers: Psychosocial providers
should develop strategies to educate and ensure that oncologists
are familiar with guidelines on distress in oncology. More dis-
semination of screening procedures and referral to psychosocial
programs in oncology is required. Integrating a distress screening
program involving psychosocial providers and oncologists should
be approached as a routine in high-quality cancer care, to reduce
the stigma associated with mental health services.

Introduction
Cancer diagnosis accompanies severe psychosocial problems for the patient,
their relatives, and society.1 In this context, oncologists play an essential
role in identifying psychological distress and its prevention by providing

CONTACT Abel Lerma, PhD abel_lerma@uaeh.edu.mx psic.abel.lerma@gmail.com Service of Psycho‐

Oncology, Research and Development Unit of Psycho-Oncology, National Cancer Institute of Mexico, INCan,
Mexico 14080, Mexico.
© 2021 Taylor & Francis Group, LLC
2 O. GALINDO VÁZQUEZ ET AL.

adequate information and the referral to necessary emotional support ser-

vices for the patients and their families.2 However, studies such as Jacobsen
and Ransom report that only 53% of institutions treating cancer performed
distress detection tests, and only 20% implemented procedures according
to the National Comprehensive Cancer Network (NCCN) recommendations.3
In consequence, distress is often not recognized in cancer care and system-
atic methods are required for timely distress identification and treatment.4,5
According to a study with oncologists by Pirl et  al.,6 32.3% reported
being somewhat familiar with the NCCN distress guidelines, 65.0% per-
formed screening routinely, but only 14.3% used a screening instrument.
The independent positive predictors for detecting distress included the
availability of mental health services, knowledge of the NCCN guidelines,
experience, and the professional’s female gender. In contrast, lack of time
and uncertainty about identifying distress were negative predictors for
detecting distress.6
Another study reported that the main barriers (i.e., negative predictors)
to successful distress detection are lack of time, insufficient training, and
low trust between the patient and the oncologist.7 Once distress was
detected, only 40% of the physicians were prepared to give the necessary
time to patients with symptoms. Positive predictors for using more
advanced screening methods were the length of follow-up appointments
and the time spent detecting distress. Physicians who used a formal ques-
tionnaire were only 2.3%, and the proportion who used one, two, or three
simple questions was 20.5%.7
Söllner et  al.8 reported that oncologists poorly recognized the presence
of distress with severe symptoms. The correct perception of distress was
lower in patients with head and neck cancer, lung cancer, and in patients
of low socioeconomic groups. Finally, the recommendations from oncol-
ogists for supportive counseling do not correlate with the patient’s level
of distress or the amount of perceived support, but rather with advanced
disease and less denial behavior.8 Another study has identified that detec-
tion by physicians was negatively associated with the educational level of
patients (p = 0.042) and with reported distress (p < 0.000).9 On the other
hand, detection by physicians was positively associated with giving bad
news (p = 0.022), the use of assessment skills (p = 0.015), and support skills
(p = 0.045).9
The ability to detect distress varies among different oncologists. They
may underestimate distress in their patients, which may reflect the level
of training in assessment skills that clinicians generally receive.10 Oncologists
do not recognize distress because their interview techniques are charac-
terized by closed questions and less attention to psychosocial problems,
which can discourage patients from disclosing their emotional and
 Journal of Psychosocial Oncology 3

psychosocial state.8 Therefore, crucial objectives are as follows: (1) to

promote knowledge of clinical guidelines of the NCCN, (2) to provide
brief training in communication strategies on mental health problems, and
(3) to generate knowledge of local diagnostic criteria in Mexico as well
as criteria for psycho-oncology consultation in each oncology center or
general hospital where the oncologist works.
These aspects are essential considering that oncologists are the most
relevant element for the patient within the health team: 47% of patients
reported that they would approach them to obtain information and 52%
to receive support.11 However, the detection of distress by oncologists in
cancer patients from Mexico has been little studied. The aims of this study
were: (1) to know the implementation of management guidelines for dis-
tress assessment based on the NCCN, (2) to identify the predictive factors
for routine distress assessment, and (3) to identify the factors associated
with the probability of using a brief instrument for distress assessment.

Design
The study design was nonexperimental and cross-sectional.

Sample

The study included 231 professionals who care for cancer patients. They
had a median age of 38 (32–46) years, 98 women (42%) and 133 men
(58%), the highest percentage with subspecialty and specialty. The most
prevalent disciplines were oncological surgery, radiation oncology, and
medical oncology.

Participants

The inclusion criteria were: (1) members of the Mexican Society of

Oncology; (2) from any of the following specialties: medical oncology,
oncological surgery, or radiation oncology; and (3) agreement to participate
in the study through informed consent. The exclusion criterion was a
report that they currently do not carry out professional activity in oncol-
ogy. The elimination criterion was incorrect filling of the
questionnaires.

Procedure

An online survey was conducted through the affiliate registry of the

Mexican Society of Oncology (SMEO). The participants were sent an
4 O. GALINDO VÁZQUEZ ET AL.

invitation via email followed by two reminders within two months of

difference.

Instruments

Identification Card
A participant identification card was designed that included sociodemo-
graphic data such as age, sex, level of studies, specialty, and health insti-
tution where they work.

 Survey of psychosocial distress in cancer patients

Developed by Pirl et  al., the survey of psychosocial distress in cancer
patients consists of 21 questions on observed rates of emotional distress,
availability of mental health services, detection of distress, barriers to
detection, management of the condition, and knowledge of the NCCN
guidelines.6 This survey contains multiple-choice items or numerical esti-
mates. Free text responses were added for items on barriers to screening,
helpful screening resources, and questions used to identify distress. For
the questionnaire adaptation, the survey was translated into Spanish by
two professional health psychologists. Subsequently, this version was judged
by experts on psycho-oncology or psychometrics to make the appropriate
modifications in terms of clarity, understanding, and relevance of the
questions and the response options.

 Statistical analysis

The quantitative variables were examined to verify normal distribution

using the Kolmogorov-Smirnov test. All the variables of interest for the
study were compared for two outcomes (observed variables). The first was
whether health professionals routinely assess emotional distress (Yes or
No). The second was the probability that health professionals would use
a brief and straightforward instrument to assess emotional distress (Yes
or No). Values are shown in frequencies and percentages or as medians
(25th percentile–75th percentile). The groups were compared by the Mann-
Whitney U test, the chi-square test, or Fisher’s exact test.
For each outcome, the variables that obtained significant differences in
the comparisons between groups were included in a logistic regression
analysis with each of the variable separately. Then, variables were simul-
taneously added in two separate multivariate logistic regression models to
determine which factors had an independent and explanatory association
with their respective outcome or observed variable. For each model, the
 Journal of Psychosocial Oncology 5

odds ratios (OR) with their confidence intervals, beta estimator, and the
separate constant were estimated. Also, the explained variance (Nagelkerke
index), the goodness of fit index of the model (Hosmer-Lemeshow test),
the sensitivity, the specificity, and the total variance percentage explained
by each model were calculated. The level of statistical significance was
established at p < 0.05.

Results
The total sample includes 231 oncologists: 98 women (42%) and 133 men
(58%), median age = 38 years (32–46), most of them (59%) with subspe-
cialty studies. On average, they dedicated 40 hours per week to attend
patients and they identified distress in 80% of the patients (Table 1).
Tables 2 and 3 show the comparison of the two outcomes (observed
variables) of this study: the first compares whether the professionals assess
distress and the second compares whether they will use a brief and
straightforward instrument to assess distress. Table 2 shows that the factors
associated with not evaluating distress are: not having time (p = 0.013),
perceiving that patients are unwilling to talk about distress (p = 0.022),
being unlikely to use a short questionnaire, and not being familiar with
the NCCN distress guidelines (p = 0.021). Table 3 shows that factors asso-
ciated with using a short and simple questionnaire to assess distress were:
(1) having more patients with indisposition to talk about distress
(p = 0.036), (2) being able to use short-term instruments in the waiting
room (p ≤ 0.001), (2) having the training to identify treatments for distress
(p = 0.013), and (4) having a higher percentage of patients with distress
(p = 0.035).
Tables 4 and 5 show the logistic regression analyses (both univariate
and multivariate) for each of the two outcomes observed in this study. In
both tables, the significant association described in the previous compar-
ative analysis can be monitored and confirmed by estimating the magnitude
of said association (i.e., the OR) for both models.
Table 4 shows the factors that independently explain why health pro-
fessionals do not evaluate distress: lack of time (OR = 1.99, 95% CI,
1.07–3.70, p = 0.029) and unfamiliarity with the guidelines of the NCCN
(OR = 1.83, 95% CI, 1.02–3.29, p = 0.043). The decision not to assess
distress in cancer patients is explained by the percentage (≥ 71%) of pro-
fessionals who do not assess distress. Variance explained for this model
is represented in the Nagelkerke R2 value = 0.107, sensitivity = 97%, and
specificity = 17% are shown at the bottom of the model. The goodness
of fit test is the Hosmer-Lemeshow, which indicates low or no error (the
chi squared was not significant, p-value = 0.885).
6 O. GALINDO VÁZQUEZ ET AL.

Table 1. General description of the oncologist’s sample (n = 231).

f (%), Median
Variables IC95 25–75
Age (years) 38 (32–46)
Sex (female) 98 (42)
(male) 133(58)
Maximum level of studies
Specialty 36 (16)
Subspecialty 137 (59)
Master´s degree 34 (15)
Doctorate 15 (7)
Hours seen patients (hours/week) 40 (25–50)
Percentage of patients with distress 80 (60–90)
Percentage of patients with distress and requiring additional treatment 50 (30–90)
Percentage of patients who follow referrals 50 (30–80)
How often do patients express concerns about the following to you?
Never Rarely Sometimes Almost always Always
Work-related issues 5 (2) 25 (11) 107 (46) 77 (33) 17 (7)
Relationship problems 17 (7) 70 (30) 104 (45) 31 (13) 9 (4)
Emotional problems not related to the 5 (2) 40 (17) 108 (47) 64 (28) 13 (6)
illness (depression, anxiety, anger)
Problems with children 28 (12) 58 (25) 112 (49) 26 (11)++ 7 (3)
Practical problems (housing, insurance, 9 (4) 47 (20) 86 (37) 64 (28) 25 (11)
transportation, finances)
Spiritual concerns 32 (14) 107 (46) 59 (26) 24 (10) 9 (4)
Psychological adaptation to illness and 13 (6) 39 (17) 84 (36) 67 (29) 28 (12)
treatment
Which of the following can affect your patients’ emotional distress?
Mortality 108 (47)
Treatment adherence 120 (52)
Quality of life 166 (72)
Ability to actively participate in treatment decisions 90 (39)
Disease progression 86 (37)
Response to treatment 80 (35)
The severity of side effects 126 (55)
How do you assess emotional distress in your patients?
I do not evaluate emotional distress in my patients 61 (26)
Through the history of the patient 61 (26)
Directly asking the patient 127 (55)
Using evaluation tools or questionnaires 18 (8)
Talking to the family 85 (37)
Noting the moods of the patient 103 (45)
Having all patients see a mental health professional 53 (23)
If you identify distress in a patient, what do you do?
Refer to social work 21 (9)
Refer to psycho-oncology/psychiatry 205 (89)
Treat directly with the patient 52 (23)
Start psychiatric drugs 16 (7)
Observe the patient in their practice 24 (10)
Refer to a support group 74 (32)
In your practice, what do you think are barriers to any type of distress assessment?
Lack of time 144 (62)
Uncertainty about how to identify emotional distress 52 (23)
Uncertainty about treatment options 43 (19)
Not believing that psychosocial interventions are effective 41 (18)
Limited resources for referrals 68 (29)
Discomfort to discuss emotional distress with patients 38 (17)
Patients who are unwell or resistant to discussing their emotional distress 113 (49)
It is the responsibility of other health professionals 16 (7)
What resources would be useful for assessing emotional distress among their patients?
Psycho-oncology staff 170 (74)
Psychiatry staff 98 (42)
Brief assessment tools to be completed in the waiting room 125 (54)
Staff to help carry out the evaluation 87 (38)
More training on how to identify and treat emotional distress 109 (47)
Time in years after graduating from a specialty
≥ 20 years 38 (17)
10–19 years 35 (15)
5–9 years 38 (17)
1–5 years 93 (40)
Still in training 27 (12)
Note. The figures represent frequencies and percentages or medians and quartiles 25 and 75.
 Journal of Psychosocial Oncology 7

Table 2. Comparison of socio-demographic variables by routine evaluation of emotional

distress (n = 231).
Do you routinely assess distress?
No n = 76 Yes n = 155 p-value
Age (years) 36 (32–42) 38 (33–49) 0.109
Young vs. mature professionals 0.285
  37 years or younger 110 (48) 40 (53) 70 (45)
  38 years or older 121 (52) 36 (47) 85 (55)
Gender 0.725
 Female 98 (42) 31 (41) 124 (43)
  Male 133 (58) 45 (59) 88 (57)
Education Level 0.377
  Bachelors, masters, specialty 79 (34) 23 (30) 56 (36)
 Subspecialty, PhD 152 (66) 53 (70) 99 (64)
  Barriers to assessing distress
Lack of time 0.013
 No 87 (38) 20 (26) 67 (43)
 Yes 144 (62) 56 (74) 88 (57)
Uncertainty to identify distress 0.480
 No 179 (78) 61 (80) 118 (76)
 Yes 52 (22) 15 (20) 37 (24)
Uncertainty regarding distress treatment options 0.440
 No 188 (82) 64 (84) 124 (80)
 Yes 3 (19) 12 (16) 31 (20)
Does not believe in psychosocial interventions for distress 0.585
 No 190 (82) 64 (84) 126 (81)
 Yes 1 (18) 12 (16) 29 (19)
Has limited resources to refer for distress 0.099
 No 163 (71) 59 (17) 104 (67)
 Yes 68 (29) 17 (22) 51 (33)
Feels uncomfortable discussing distress with patients 0.854
 No 193 (84) 64 (84) 129 (83)
 Yes 38 (16) 12 (16) 26 (17)
Perceive patients unwilling to discuss distress 0.022
 No 118 (51) 47 (62) 71 (46)
 Yes 113 (49) 29 (38) 84 (54)
It is up to other professionals 0.486
 No 215 (93) 72 (95) 143 (92)
 Yes 6 (7) 4 (5) 12 (8)
What resources would you use to refer to distress treatment?
  Psych oncology 0.540
 I would not use it 61 (26) 22 (29) 39 (25)
 Yes, I would use it 170 (74) 54 (71) 116 (75)
Psychiatry 0.942
 I wouldn’t use it 133 (58) 44 (58) 89 (57)
 Yes, I would use it 98 (42) 32 (42) 66 (43)
What resources would you use to assess distress?
  Brief instruments in waiting room 0.419
 I wouldn’t use it 106 (46) 32 (42) 74 (48)
 Yes, I would use it 125 (54) 44 (58) 81 (52)
Evaluating staff 0.639
 I wouldn’t use it 144 (62) 49 (64) 95 (61)
 Yes, I would use it 87 (38) 27 (36) 60 (39)
Training in how to identify and treat distress 0.279
 I wouldn’t use it 122 (53) 44 (58) 78 (50)
 Yes, I would use it 109 (47) 32 (42) 77 (50)
Probability would use a distress questionnaire 0.022
 Unlikely 48 (21) 22 (29) 26 (17)
  Probable or very probable 183 (79) 54 (71) 129 (83)
Familiarization with NCCN distress guides 0.021
 No 127 (55) 50 (66) 77 (50)
 Yes 104 (45) 26 (34) 78 (50)
It belongs to a medical discipline 0.851
 Yes 190 (82) 62 (82) 128 (83)
 Other discipline 41 (18) 14 (18) 27 (17)
Years of professional experience 0.122
 No experience or up to 4 years 120 (52) 45 (59) 75 (48)
  5 or more years of experience 111 (48) 31 (41) 80 (52)
Percentage of patients suffering from distress 80 (55–90) 80 (70–90) 0.105
Percentage of patients suffering from distress and requiring additional 50 (25–80) 60 (30–90) 0.078
treatment
Percentage of patients who follow referrals 50 (30 − 70) 50 (40 − 80) 0.078
Hours per week he cares for patients 40 (30–50) 40 (25–45) 0.391
Note. Values represent frequencies and percentages or medians and quartiles (p25–p75). The comparison was made with
Fisher’s exact test, chi-squared test, or Mann-Whitney U test.
8 O. GALINDO VÁZQUEZ ET AL.

Table 3. Sociodemographic, clinical, and psychological characteristics (n = 231) are compared

regarding the probability of using an emotional distress questionnaire (EM).
Would you use a short and simple questionnaire to assess distress?
Unlikely Likely
(N = 48) (N = 183) p-value
Age (years) 38 (32–46) 39 (32–46) 38 (33–46) 0.909
Young vs. mature professionals 0.781
  = <37 Years 22 (46) 88 (48)
  = > 38 Years 26 (54) 95 (52)
Gender 0.835
  Female 21 (44) 77 (42)
  Male 27 (56) 106 (58)
Barriers to assessing distress in patients
  Lack of time 0.979
  No 18 (38) 69 (39)
  Yes 30 (62) 114 (61)
Uncertainty to identify distress 0.276
  No 40 (83) 139 (76)
  Yes 8 (17) 44 (24)
Treatment options uncertainty 0.697
  No 40 (83) 148 (81)
  Yes 8 (17) 35 (19)
Does not believe in psychosocial interventions 0.825
  No 40 (83) 150 (82)
  Yes 8 (17) 33 (18)
Resources for referring patients with distress are limited 0.142
  No 38 (79) 125 (68)
  Yes 10 (21) 58 (32)
Discomfort talking about distress with patients 0.407
  No 42 (88) 151 (83)
  Yes 6 (13) 32 (17)
Patients unwilling to talk about distress 0.036
  No 31 (65) 87 (48)
  Yes 17 (35) 96 (52)
Corresponds to other professionals 0.666
  No 44 (92) 171 (93)
  Yes 4 (8) 12 (7)
What resources would you use to assess distress in your patients?
Psycho-oncology 0.538
  I would not use it 11 (23) 50 (27)
  Yes, I would use it 37 (77) 133 (73)
Psychiatry 0.905
  I would not use it 28 (58) 105 (57)
  Yes, I would use it 20 (42) 78 (43)
Brief instruments in the waiting room ≤ 0.001
  I would not use it 36 (75) 70 (38)
  Yes, I would use it 12 (25) 113 (62)
Personnel assessing distress 0.172
  I would not use it 34 (71) 110 (60)
  Yes, I would use it 14 (29) 73 (40)
Training to identify distress 0.013
  I would not use it 33 (69) 89 (49)
  Yes, I would use it 15 (31) 94 (51)
Are you familiar with the NCCN distress guides? 0.842
  No 27 (56) 100 (55)
  Yes 21 (44) 83 (45)
Percentage of patients suffering from distress 70 (50–90) 80 (70–90) 0.035
Percentage of patients suffering from distress and 50 (20–75) 50 (30–90) 0.124
requiring additional treatment from the doctor
Percentage of patients follow referrals 50 (30 − 80) 50 (30 − 80) 0.606
Hours per week you see patients 40 (30–50) 36 (25–45) 0.052
Note. Values are shown in frequencies and percentages or as medians (25th percentile–75th percentile). The
comparison was made using Mann-Whitney U, chi-squared, or Fisher’s exact test.
 Journal of Psychosocial Oncology 9

Table 4. Logistic regression analysis of the variables associated with not evaluating distress
in a sample of oncologists (n = 231).
Simple regression Multivariate regression
Variables OR (CI95%) p-value OR (CI.95%) p-value
Barrier: lack of time (Yes) 2.13 (1.17–3.89) 0.014 1.99 (1.07–3.70) 0.029
Barrier: patients unwilling to 1.92 (1.10–3.36) 0.023 1.63 (0.91–2.92) 0.101
discuss distress (No)
Probability of using a 2.02 (1.06–3.87) 0.034 1.92 (0.98–3.79) 0.059
questionnaire on distress (No)
Familiarization with the NCCN 1.95 (1.10–3.44) 0.022 1.83 (1.02–3.29) 0.043
guidelines (No)
Note. For the multivariate model: constant = −1.922, Nagelkerke R2= 0.107, chi-squared = 3.68, 8 df., p = 0.885,
sensitivity = 97%, specificity = 17%, total percentage = 71%.

Table 5. Logistic regression analysis of the variables associated with the probability of using
a questionnaire assessing distress in a sample of oncologists (n = 231).
Simple regression Multivariate regression
Variables OR (CI95%) p-value OR (CI95%) p-value
Barrier: unwilling patients to talk 2.01 (1.04–3.89) 0.038 1.49 (0.74–3.01) 0.268
about distress (No)
Resources: brief instruments to 4.84 (2.36–9.93) ≤ 0.001 4.44 (2.05–9.61) ≤ 0.001
assess distress in the waiting
room (Yes)
Resources: training to identify 2.32 (1.18–4.57) 0.014 1.50 (0.72–3.12) 0.282
treatments for distress (Yes)
Percentage of patients suffering 1.02 (1.01–1.03) 0.023 1.02 (1.01–1. 04) 0.013
from distress
Note. For the multivariate model: constant = −1.143, Nagelkerke R2= 0.192, chi-squared = 13.57, 8 df, p = 0.094,
sensitivity = 98%, specificity = 13%, total percentage = 80%.

Table 5 shows the factors that independently explain the likelihood for
health professionals to use a short and simple questionnaire to assess
distress: the availability of short-term instruments (OR = 4.44, 95% CI,
2.05–9.61, p ≤ 0.001) and the higher percentage of patients presenting
distress (OR = 1.02, 95% CI, 1.01–1.04, p = 0.023). The use of the short
and simple instrument to assess emotional distress is explained by the
percentage (≥ 80%) of professionals who would use it. Variance explained
for this model is observed in the Nagelkerke R2 value = 0.192, with sen-
sitivity = 98% and specificity = 13%, as shown at the model’s bottom. The
goodness of fit test was the Hosmer-Lemeshow, which indicated low or
no error since the chi squared was nonsignificant (p = 0.094).

Discussion
This study is the first one that reports the knowledge, attitudes, and
behaviors of medical oncologists in Mexico with a national sample regard-
ing the NCCN guidelines for managing distress. Although most oncologists
report knowing about the policies on distress, performing some screening
procedures, and considering that this was beneficial for their practice,
10 O. GALINDO VÁZQUEZ ET AL.

few use valid and reliable instruments. These findings are similar to a
study by Pirl et  al.,6 in which 32.3% reported knowing the NCCN distress
guidelines and 65.0% performed screening routinely but only 14.3% used
a screening instrument. Similarly, the study by Brintzenhofe Szoc 12
reported that only half of the oncologists used a standardized tool (54%).
The current study identified that the lack of time and not perceiving the
patients’ unwillingness to discuss distress are factors associated with lack
of distress screenings (Table 2). The probability of using a questionnaire
on distress and familiarization with the NCCN guidelines was positively
associated with carrying out distress screening. This implies limitations
in the health-system conditions that have been reported in several studies
in oncology and the need for integration of mental health professionals
in oncology. Institutional barriers, such as lack of ownership of the dis-
tress screening, no input into the protocol development, and lack of
support from the administration emerged in the current study but not
in the previous studies. A difference in the samples could explain these
discrepancies with previous studies.
While most health professionals working in cancer care are interested
in detecting mood problems, there is considerable uncertainty about which
instrument to use (if any), reflecting the lack of guidance on this theme.7
On the other hand, in an experimental study, doctors were trained in
communication skills and identifying distress using the HADS scale.13 The
study determined that the detection by doctors of the patient’s distress
was positively associated with doctors who communicated bad news, used
assessment skills, and applied support skills. According to our results in
Table 2, most oncologists who do not assess distress routinely deny per-
ceiving unwillingness of the patient to discuss distress (62%), with fewer
oncologists (38%) perceiving unwillingness of the patient to discuss distress.
This is likely related to communication barriers between the oncologist
and the patient. Some patients are reluctant to disclose problems and to
share emotional difficulties, particularly those with higher distress.14,15
Finally, our instrument covers interest in a health system from the following
questions:

How often do patients express concerns about the following?

Which of the following can affect patients’ emotional distress?

How do you assess emotional distress in patients?

If you identify distress in a patient, what do you do?

In practice, what do you think are barriers to any distress assessment?

What resources would help assess emotional distress among their patients?
 Journal of Psychosocial Oncology 11

The findings in the present study are relevant, considering that up to

80% of oncologists identify distress in patients, and 50% of those with
distress require psychosocial care according to the oncologist’s criteria in
Mexico. The screening competencies perceived by patients have been
reported by Sapir et  al.,11 showing that patients expect their oncologists
to show patience and to have expertise in diagnostic procedures (98%),
tactfulness, consideration, and therapeutic ability (90–95%). Also, the
patients expect the oncologist to have experience in the management of
pain and the psychosocial consequences of cancer (75–85%).11
Our findings agree with research indicating a low number of hours that
oncologists dedicate to clinical care, which in Mexico is not an exception.
Even well-trained and empathetic oncologists face numerous clinical tasks,
a large caseload, and a lack of time for the individual patient in daily
practice.8 In this sense, patients may perceive doctors as busy people who
should not be burdened with their concerns.
In summary, our research detected barriers to identifying distress by
Mexican oncologists similar to those reported in previous studies, which
suggests that participation of the oncologists may be useful in recognizing
and meeting their information need from their patients. Still, they do not
acknowledge or deal with the patient’s emotional needs. If clinicians do
not recognize the signs of emotional support from patients, those patients
will be discouraged from seeking support during the doctor’s appointment.16
In this context, cancer care provision requires an effective therapeutic
alliance between patients and their health-care providers. The transfer of
information and providing emotional support are critical elements in this
caring relationship.17 Effective care requires a match between the health-
care provider’s skills, the delivery of services, and the patient’s needs and
expectations.11 Given the importance of the physician’s role to encourage
the expression of emotional needs in their patients, training should include
the development of communication skills between the physician and the
patient.16
Although Mexican oncologists reported a high rate of implementing
some type of distress detection, they identified significant institutional and
individual barriers to their detection efforts. Moreover, having a high
percentage of mental health teams, specifically psycho-oncology, is relevant
for health institutions in Latin America. The results underscore the need
to educate oncologists to improve their ability to identify patient distress,
along with the need for incorporating more psycho-oncologists.8
One aspect to highlight is identifying the main concerns (children,
emotional, spiritual, and labor problems) and the effect of distress on
patients’ quality of life and the severity of secondary symptoms of cancer
and its treatment in Mexico. In this context, Pirl et  al.18 established that
12 O. GALINDO VÁZQUEZ ET AL.

the effective detection and treatment of distress in cancer settings requires

a comprehensive program of timely detection. Such an approach involves
using an appropriate screening instrument and a system for administering
screening, reviewing screening results, conducting follow-up evaluations
for identified patients, and referring to further assessment, support, and
treatment as required. Additionally, integrating a distress screening program
should be approached as a routine in high-quality cancer care, reducing
the stigma often associated with mental health services.
Our results indicate that the role of the oncologist extends beyond the
prescription of drugs. The oncologist should recognize the patients’ per-
ception of social support, his/her psychological well-being, and the attitudes
and behaviors concerning compliance to treatment.19 We emphasize the
need to develop more psycho-oncology awareness in the oncologists, incor-
porate more knowledge of the NCCN distress guidelines promptly, and
integrate the psycho-oncologists into the health team. This approach would
achieve both systematic screening and timely psychological care.
A necessary aspect is a referral of patients from the oncologist to the
mental health professional on time. Also, brief interventions from the
psycho-oncologists aimed primarily at the evaluation and follow up of
psychosocial and behavioral health are needed.
These actions can be seen as priorities of care in psycho-oncology in
the Latino population, as mentioned below:
Psycho-oncologists reported the themes they address when counseling
Latino patients: (1) emotional responses, (2) coping strategies, (3) patient’s
autonomy and decision making, (4) cancer experiences after diagnosis,
during treatment and survivorship, (5) end-of-life concerns, (6) education
about cancer and treatment processes, (7) communication with the psy-
cho-oncologist and health-care team, (8) access to health and psychosocial
services, (9) physical issues, (10) family-related issues, (11) socioeconomic
issues, and (12) religious and spiritual beliefs and concerns.
Psycho-oncologists also reported using various therapeutic approaches,
types of service, and therapeutic methods and techniques. The therapy
goals included building distress tolerance and empowerment, improving
resilience and self-care, and managing physical symptoms. It is essential
to study the practice of psycho-oncology with underserved populations
and in low-resource settings to address disparities in access to psychosocial
oncology services and support the use of evidence-based practice.20,21
Besides the efforts mentioned above needed to screen and refer for
psychosocial distress effectively, resources (i.e., trained professionals and
systems) are insufficient to address the proper care of patients, even with
the current level of detection. This situation will become a more significant
problem as more patients needing psychosocial support and services are
 Journal of Psychosocial Oncology 13

identified. Addressing this problem requires three measures: (1) a sub-

stantial increase of the existing resources, (2) including the psychosocial
services into oncology care, and (3) implementing better models of inte-
grated supportive care in oncology.22 These improved models of care
require interdisciplinary teams organized differently. For instance, Hui D.
et  al. proposed a model where all the supportive-care team members work
in the same department administratively and clinically. This approach
would facilitate critical features for integrated care such as universal refer-
ral, systematic screening, tailored specialist involvement, collaborative team-
work, streamlined care, consolidated leadership, and improved outcomes.22
Enhancing the coordination and integration of a multidisciplinary team
is essential to increase the efficiency of the provided care,23 where other
health professionals (e.g., social workers)24 and other aides (e.g., navigators)
are actively involved.23

Study limitations

The results in the present study depend on self-reports and are not actual
observations of the scope and effectiveness of psycho-oncology measures.
An alternative for future studies is to apply valid and reliable instruments
of distress, anxiety symptoms, or depression to the patients concurrently
with the physicians’ evaluations. There are currently various screening
instruments for cancer patients adapted for the Mexican population, which
could identify a correlation between the physician’s point of view and the
findings in the measurement instruments.
On the other hand, various psycho-oncology studies in Latin America20,21
recommend the following priorities based on the best available evidence
to standardize national care for cancer patients in the third level of care:
(1) identifying patients with clinical criteria of distress, (2) suggesting the
most effective psycho-oncological treatments for patient care, and (3)
establishing the criteria for referral in patients with a history of cancer
and psychological disorders. There are several advantages to treating the
psychosocial needs of this group of patients and their informal primary
caregivers. By reducing the emotional burden of cancer care, we can also
reduce its financial burden. Placing the needs of patients directly at the
center of the health-care model implies a fundamental change in the focus
of patient care.23
These priorities should lead to more rigorous work on clinical practice
and research from psychologists and psychiatrists to cancer patients and
informal primary caregivers, even more so in the Latin American popu-
lation where the mental health needs of the oncological patient remain a
priority yet to be addressed.
14 O. GALINDO VÁZQUEZ ET AL.

The present study is considered representative of oncology in Mexico.

The Mexican Association of Oncology (SMEO) represents the largest
association in Mexico, a regulatory body for this discipline similar to the
American Society for Clinical Oncology (ASCO) for the United States.
The response rate of our study was similar to the one reported by Pirl
et  al.,6 which is why it is considered representative of Mexico.
Developing psycho-oncology programs is a priority in Mexico. This
notion can increase the detection of psychological needs in patients and
their families, a task oncologists may not have enough time to do through-
out the health system.
Finally, the results of the present study have the following implications
for psychosocial providers: (1) psychosocial providers should develop strat-
egies to educate and ensure that oncologists are familiar with guidelines
on distress in oncology, (2) more dissemination of screening procedures
and referral to psychosocial programs in oncology is required, and (3)
integrating a distress screening program that involves both psychosocial
providers and oncologists should be approached as a routine in high-quality
cancer care, reducing the stigma associated with mental health services.

Disclosure statement
No potential conflict of interest was reported by the author.

Funding
The author(s) reported there is no funding associated with the work featured in this article.

ORCID
Oscar Galindo Vázquez http://orcid.org/0000-0001-7929-0125
Samuel Rivera http://orcid.org/0000-0002-4921-4195
Abel Lerma http://orcid.org/0000-0001-7212-641X
Marcos Espinoza Bello http://orcid.org/0000-0003-3090-8098
Abelardo Meneses http://orcid.org/0000-0003-4032-4598
Claudia Lerma http://orcid.org/0000-0002-4679-7751

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