PSYCHO-ONCOLOGY
Psycho-Oncology 15: 93–95 (2006)
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pon.1022
EDITORIAL
EMOTIONAL DISTRESS: THE SIXTH VITAL
SIGN}FUTURE DIRECTIONS IN CANCER CARE
BARRY D. BULTZa,b and LINDA E. CARLSONb
a
Department of Psychosocial Resources, Tom Baker Cancer Centre, Alberta Cancer Board } Holy Cross Site,
2202 2nd St. S.W. Calgary, Alta, Canada T2S-3C1
b
Department of Oncology, Faculty of Medicine, University of Calgary, Canada
Historically, those who work to treat and cure
illness have converged on five key indicators:
temperature, respiration, heart rate, blood pres-
sure and more recently, pain (National Pharma-
ceutical Council, 2001) to gauge whether a
patient’s physiological systems are functioning
sufficiently well to support survival and provide a
platform for achieving wellness. In cancer care
an area that is often, due the complexity and
ubiquity of the disease, a leader in progressive
approaches to managing disease}there is a grow-
ing recognition of the role a well-functioning mind
and spirit play in the path to health. In parallel,
there is recognition that interventions to support
this vitality need to be empirically supported.
Therein lies the need for the sixth vital sign to
highlight the importance of distress as a marker of
well-being and its reduction as a target outcome
measure.
For the most part, cancer care is still bio-
medically focused, despite numerous well-designed
studies demonstrating high prevalence of emo-
tional distress in cancer patients. As
well, rigorous intervention studies have clearly
demonstrated the benefits of psychosocial care to
patients, families, health-care systems, and society.
Given the advances in psychosocial screening and
care, we propose that psychosocial oncology be
considered a standard component of care of the
cancer patient. Further, given the advances in our
understanding of the psychosocial elements of the
disease, we suggest that it is timely to consider
cancer a biopsychosocial illness.
In Canada, the Canadian Strategy for Cancer
Control (CSCC) (Rebalance Focus-Action Group,
2005) elected to recognize emotional distress as a
core indicator of a patient’s health and well-being.
Copyright # 2006 John Wiley & Sons, Ltd.
Along with the other vital signs, it designated
emotional distress as the sixth vital sign.
Here was the argument used to accomplish this
goal:
Cancer is well known to be a difficult disease,
affecting cancer patients and their families both
emotionally and physically. Despite biomedical
progress, cancer is still often considered synon-
ymous with death, pain, and suffering (Powe and
Finnie, 2003). Research has demonstrated that
across the trajectory of the illness}from the time
of diagnosis to treatment, termination of treat-
ment, survivorship, or recurrence and pallia-
tion}the incidence of emotional distress in
North America ranges from 35 to 45% (Zabora
et al., 2001; Carlson et al., 2004; Carlson and
Bultz, 2003). Up to 58% of patients in palliative
care experience significant levels of emotional
distress (Potash and Breitbart, 2002), and in a
Jordanian sample of cancer inpatients the pre-
valence of distress was 70% (Khatib et al., 2004).
Similar overall rates to those in North America
were recently reported in several European coun-
tries (Gil et al., 2003; Dolbeault et al., 2003;
Mehnert et al., 2004), the Middle East (Isikhan
et al., 2001; Sadeh-Tassa et al., 2004; Montazeri
et al., 2004), South America (Santos, 2004), and
Asia (Fielding et al., 2004; Shimizu et al., 2004).
Large studies at Johns Hopkins Kimmel Cancer
Center in Baltimore (Zabora et al., 2001) and the
Tom Baker Cancer Centre in Alberta, Canada
(Carlson et al., 2004) found high levels of fatigue
(in 49% of all patients), pain (26%), anxiety
(24%), and depression (24%) along with signifi-
cant financial hardship and material challenges in
a representative cross-section of patients screened
for emotional distress.
Received 1 November 2005
Accepted 22 November 2005
94 EDITORIAL
Despite medicine’s acknowledgement of the
emotional side of cancer there has been little
movement to expand relevant hospital budgets,
implement third-party coverage or provide appro-
priate professional support for this core compo-
nent of patient care. In Canada, where health care
is publicly funded and delivered, a 1999 survey of
provincial cancer agencies found that less than 2%
of cancer center direct operating dollars were
allocated to psychosocial care, compared to no less
than 5% directed to cleaning of cancer facilities
(Bultz, 2002).
Insurance companies in private healthcare
systems, healthcare administrators in public sys-
tems, and health agencies worldwide may argue
‘the system’ cannot afford more health-care. The
evidence suggests the contrary: neglecting this
problem exacerbates illness and increases costs.
The literature is clear: high prevalence of emo-
tional distress is commonplace in cancer popula-
tions globally; when the emotional needs of cancer
patients remain unresolved, patients are more
likely to use community health services and to
visit emergency facilities (Carlson and Bultz,
2004). Such patients place higher demands on
scarce care-provider resources and are more likely
to be offered expensive third- and fourth-line
chemotherapy (Ashbury et al., 1998), inappropri-
ately applying limited resources in an attempt to
relieve anxiety}usually, without extending life
and often with detrimental quality of life effects.
Clinical studies have repeatedly demonstrated
that patients benefit from psychosocial care
(Newell et al., 2002). If the current discussion
around distress prevalence and benefit of psycho-
social care does not provide a compelling enough
argument for attending to the emotional and
psychosocial needs of cancer patients, the econom-
ic argument around medical cost offset might.
Studies have demonstrated benefit of psychosocial
care with no increased cost (Koocher et al., 2001),
while Simpson et al. (2001) showed a 25% decrease
in billings to the medical system over a 2-year
period as a result of a 6-week psychosocial
intervention in breast cancer patients, compared
to a randomized control group. A meta-analysis of
90 studies (Chiles et al., 1999) showed that medical
cost offset of psychosocial care averages 20% of
overall healthcare expenditures}significant bene-
fit to the system.
Given the high prevalence rates of psychosocial
and emotional distress in a rapidly expanding
cancer population}cancer prevalence is expected
Copyright # 2006 John Wiley & Sons, Ltd.
to double within the next 15 years in developed
countries (Canadian Strategy for Cancer Control,
2001)}and the demonstrated benefit to patients
and families, it is indeed no wonder that the CSCC
supported emotional distress as the sixth vital
sign}implying that monitoring of emotional
distress is as vital an indicator of a patient’s state
of being, needs and progress through the disease,
as are the other vital signs (Rebalance Focus
Action Group, 2005).
Reducing the emotional burden of cancer care
will reduce the economic burden, but putting
patient needs squarely at the center of the
healthcare model involves a fundamental shift in
not only spending allocations, but also in the
overall approach to patient care. Full recognition
that the ‘people part’ of cancer care is vital to a
well-managed and compassionate cancer system
makes ethical, emotional and economic sense
(Bultz, 2002). Is it not time for all providers to
consider emotional distress as an essential compo-
nent in the care of their patients}and therefore
screen, routinely monitor and treat its symptoms?
As Psychosocial professionals, we have an obliga-
tion to effectively communicate the evidence and
attempt to influence practice. Promoting emo-
tional distress as the sixth vital sign in cancer care
might be one key way to do just that.
ACKNOWLEDGEMENTS
The content of this editorial is based on
‘Correspondence to the Editor’. Originally published in
the Journal of Clinical Oncology, vol. 23(26); 2005:
6440–6441. This paper has been modified and Reprinted
with permission from the American Society of Clinical
Oncology.
Dr Linda Carlson is supported by a Canadian
Institutes of Health Research New Investigator Award.
The Authors wish to acknowledge the support of Dr
Neil Berman, past director, of the Canadian Strategy for
Cancer Control.
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Psycho-Oncology 15: 93–95 (2006)