To the best of our knowledge, this is the first study that evaluates the problem of emotional distress among a large number of newly diagnosed patients with different types of cancer, attending 3 University cancer centers in Egypt.
Using the Arabic version of DT  had identified that 46% of our cancer patients had significant distress, which was significantly related to the tumor site, advanced stage of the disease, and to many items of the problem list. This is the second study that utilizes the Arabic version of the DT, after that of Alosaimi, et al , in screening a large number of patients with different types of cancer for emotional distress. DT is a single-item, self-report measure of distress that provides a brief, visual analogue, non-invasive, valid and acceptable alternative to longer and more burdensome psychometric instruments. In addition, its associated PL can be used to provide words for psychological problems with non-stigmatizing connotations to identify possible contributing factors [3, 18]. We think that, despite the apparent simplicity of that tool, it covers most-if not all- problems might be faced by any study population (i.e. populations with different racial, religious, social and financial aspects), and world-wide. So, it is not surprising that DT has been successfully translated from English into several languages [14–18].
Almost half of our cohorts had a significant distress. This is in agreement with the world-wide reported prevalence rates of 20–52% of cancer patients [2, 9, 19] for distress among cancer patients. Particularly, our figures are very similar to that (45.89%) reported by Hahn, et al .
Our study revealed that there were significant differences between patients with significant distress and those without; with regards to the presence of chronic disease, tumor site, and stage of the disease. We enrolled a large number of patients and with different types and sites of cancers, which may explain these significant associations. Our results contradict those of previous reports that were incapable to find significant links between the DT and socio-demographic and clinical characteristics [3, 13, 15, 18]. Differences in the study populations, numbers, and types of cancer might explain these different findings. The most frequent problems reported on the practical domain of the PL were, treatment decision (64.4%), worry (47%), fears (44.5%), and pain (42.2%).
These encountered problems are similar to those found by Alosaimai and coworkers  and could be explained by the similatrities between the cultural, emotional, spiritual, and physical demographics in the two study Arabian populations. The relationship between experienced distress and dissatisfaction with the treatment decision is probably bidirectional . To alleviate treatment decision-related distress, it might be helpful to provide with patients with prognostic information, elicit decision-making preferences, and appreciate their fears and goals .
The results of this study had highlighted the importance of early screening cancer patients (at their initial diagnosis with cancer) for distress. Univariate analysis had revealed that our participants who scored 4 or more on the DT described extra problems in the practical, family, emotional, spiritual/religious and physical areas (26 out of 36 problems) than patients who scored below this cut off score. Although degrees vary, this finding suggests that a wide range of problems contributes to distress in cancer patients , which is also consistent with many similar studies performed worldwide, and among various cancer populations [11–14, 18, 23].
Despite that multivariate analysis had identified the presence of only 16 out of 36 problems, as independent factors associated with significant distress in cancer patients, still this is considered a large number of problems for a cancer patient to challenge. These findings are very similar to those observed by Alosaimi, et al , while they are quite different from those reported by McFarland, et al  who stated that only three factors were significantly associated with distress (breathing problem, eating, and nausea). This agreement with Alosaimi, et al [18 ] is attributed to the fact that the 2 studies recruited Arabian population with nearly similar cultural, spiritual and emotional factors. While, the contrary with McFarland et al  could be explained by the differences in patients’ numbers and cancer type between the two studies. We include a wide range of malignancies, while they included only patients with breast cancer.
Practically speaking, barriers to screening for distress do exist and they should be put into consideration upon implementing a screening programm for distress . For instance, patients may have trouble understanding what the word “distress” means . Patient barriers to screening include cultural differences as well as literacy . Unfortunately, 49% of our study cohorts had low education levels (illiteracy and primary school education). Another barrier occurs when referring distressed patients for psychosocial services. Studies have also shown that patients who score high on the DT may not necessarily want help. Conversely, studies have shown that when patients were screened and did not receive any referrals or assistance, their levels of distress increased .
Overall, findings of the current study confirm the importance of “routine” screening of cancer patients for emotional distress. Also, they support the importance of recognition of distress among cancer patients that comes from the possibility of overcoming its hazardous sequalae. These sequalae are noncompliance with cancer treatment, difficulty in taking a decision of treatment, frequent unneeded medical visits to caregivers, more stress on medical team [4, 9] and more hospitalization . Moreover, it has a bad impact on survival in some studies [27, 28]. It is well known that screening programs improve patient outcomes only when linked to an effective system of assessment and treatment. Therefore, cancer centers should implement DT screening only after developing a plan for the timely evaluation of distress, reviewing its results and managing patients whose scores suggest clinically significant distress, including making appropriate referrals based on the problem areas specified on the PL .
Being the first multicenter study with large number of patients of different types of cancer does not guarantee that it has no limitations. Possible limitations include possible bias from including many types of cancers and possible convenience sampling which may affect generalizability of the study findings to all cancer patients in Egypt.