Alex Mitchell twitter/_alexjmitchell University of Leicester
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Transcript of Alex Mitchell twitter/_alexjmitchell University of Leicester
Alex Mitchell www.twitter.com/_alexjmitchellUniversity of Leicester
www.psycho-oncology.info #ipos2013www.psycho-oncology.info #ipos2013
Screening for Distress Debate
…What are the sources of disagreement?
Areas of Disagreement:
1.How to screen (which tool)
2.When to screen
3.How often to screen
4.Which screening population
5.Who should screen
6.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)
Comment: Slide illustrates diagnostic accuracy according to score on DT
11.815.4
30.4 28.9
41.9 42.9 40.7
57.1
82.4
66.771.4
15.8
25.0
26.124.4
19.4 19.0
33.3
21.4
11.8
22.2 14.3
72.4
59.6
43.546.7
38.7 38.1
25.921.4
5.911.1
14.3
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
Zero One Two Three Four Five Six Seven Eight Nine Ten
Judgement = Non-distressed
Judgement = Unclear
Judgement = Distressed
Lessons from primary care…. Lessons from primary care….
Results disappointing
Acceptability overlooked
Most are not depressed
Many do not want help
Some are already Rx
Screening in Cancer Screening in Cancer
Missed diagnosis
GP = CNS = Oncologists
Screening tools (validity) Screening tools (validity)
Depression
Distress
Brief / ultra-short
Multi-domain
Implementation evidence 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 => Referral
6 studies => 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 +10%
+treatment +10%
What is holding back screening success?
BOTH. How Many Receive Ps Help? (n=2557)
Proportion meta-analysis plot [random effects]
0.0 0.2 0.4 0.6 0.8 1.0
combined 0.35 (0.25, 0.46)
McDowell et al (2010) 0.14 (0.11, 0.18)
Sharpe et al (2004) 0.15 (0.10, 0.22)
Morasso et al (2010) 0.16 (0.05, 0.33)
Merckaert et al (2009) 0.21 (0.17, 0.25)
Shimizu et al (2009) 0.25 (0.18, 0.33)
Shimizu et al (2005) 0.28 (0.18, 0.41)
Söllner et al (2004) 0.35 (0.26, 0.45)
Bogaarts et al (2011) 0.38 (0.27, 0.49)
Fritsche et al (2004) 0.43 (0.28, 0.59)
Siedentopf et al (2009) 0.46 (0.35, 0.58)
Plass and Koch (2001) 0.60 (0.46, 0.72)
Kadan-Lottick et al (2005) 0.89 (0.77, 0.96)
proportion (95% confidence interval)
% Receiving Any treatment for Mental Health% Receiving Any treatment for Mental Health
7.2
34.6
5.7 6.3 6.4
11.7
19.1
14
8.9
3.9 3.2
5.7
32.7
5 5
7.7
11
16.1
6.5 6.2
2.3 1.8
0
5
10
15
20
25
30
35
40
Cancer n=4878
No Cancer n=90,737
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
12mo Service Use 12mo Service Use (NIH, 2002)(NIH, 2002)
Overall Effect of screening
Baseline CARE x = 35%
with screening +10% (0-20%)
+ follow-up +10% (0-20%)
+treatment +10% (0-20%)
……..So is screening successful or not?……..So is screening successful or not?
…….It depends
Analogy: How do we reduce speeding drivers?
US deaths 10,000
Aim is to reduce speed (and hence deaths)
Not simply to detect speeding!
Analogy
Aim is to reduce distress (improving QoL)
Not simply to detect distress!
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0. Summary
Screening can be ineffective or effective
Screening may be optional or mandated