Psychosocial Distress Among Cancer Patients: A single Institution Experience at the State of Qatar

Introduction The prevalence of psychosocial distress is up to 45% among cancer patients. It is crucial to identify and treat distress. The aim of the study is to report on the prevalence of distress among cancer patients, analyze the variable causes of distress and to study the effect of the disease stage using the Distress Thermometer. Methods We studied distress among 3 groups, each consisting of 100 patients: those initially diagnosed, patients undergoing treatment, and patients who were referred to the palliative team. Different variables such as time of screening, sex, age, nationality, and tumor type were analyzed. Results There was an overall distress incidence of 62% (level ≥ 4) and out of that 17% of the patients had severe distress (level >7). Similarly, there was 75% of distress among patients who were referred to palliative care, compared to 56% of patients at initial diagnosis and 54% for those undergoing cancer treatments. In addition, women (69%) had more distress (53%). Expatriates had high distress, compared to Qataris (64.3% versus 51%). Breast (69%) and lung (70%) cancer patients had the highest level of distress. Physical causes of distress were the most common followed by emotional causes. Conclusion There is a substantially higher overall incidence of distress among cancer patients in Qatar. Distress should be assessed in patients at cancer diagnosis and at the time of disease progression. Screening alone isn’t enough, the different causes of distress should be identi�ed and addressed by the appropriate interventions.


Introduction
Psychological Distress is de ned as an unpleasant emotional, psychological, social or spiritual experience that interferes with the ability to cope with cancer and/or its treatment.It extends along a continuum from the normal feeling of vulnerability, sadness to real disabling problems such as true depression, anxiety, panic and spiritual crisis [1,2].This distress can be present in form of physical symptoms such as fatigue, pain, nausea and vomiting, sleep disorder, loss of weight, all of which don't respond to traditional treatment [3[.According to international studies, psychosocial distress was found to be a common health problem among cancer patients ranging from 15% at early cancer diagnosis to around 60% upon referral to palliative care [4].Failure to identify and treat anxiety and depression increases the risk of distress.The following factors have been identi ed as the causes for the increased incidence of distress such as recurrent, advanced, or progressive disease, younger age, female gender, lack of social support and history of previous psychiatric illness [5,6].The National Comprehensive Cancer Network (NCCN) states that "Distress extends along a continuum, ranging from common normal feelings of vulnerability, sadness, and fears to problems that can become disabling, such as depression, anxiety, panic, social isolation, and existential and spiritual crisis" [7].Being distressed isn't a pleasant experience; It may affect how well the patient or even the caregiver's function.Distress may also interfere with health decisions or actions.Distress can occur at any point in time during the patient's cancer journey.Identifying and treating distress is crucial and it helps the cancer patients to stay more compliant with the treatment.Like all the cancer centers in the world the National Center for Cancer Care and Research (NCCCR), Hamad Medical Corporation (HMC), Qatar also has distress as a major challenge among cancer patients.NCCCR currently does not have the practice of screening distress among cancer patients despite the international recommendations for screening and to consider distress screening as a sixth vital signs [8,9,10].We believe that identifying and implementing a system for screening distress shall relieve suffering, improve patient's outcome, encourage the delivery of support services on an individual basis and enrich the quality of life.
Several tools have been identi ed and used in the screening of psychological distress among cancer patients, the most used tools are Depression-Anxiety Hospital Scale (DAHS), The Distress Thermometer (DT), and the Distress Assessment and Response Tool (DART).
DT is by far the most used, simplest, and mostly validated tool adopted in many centers.It is composed of two parts, a scale from zero to 10 to determine the severity of distress and a second part related to patients life in more details (Family, practical, emotional, physical problems as well as spiritual and religious concerns) [7,8].This tool has proved to be effective both in hospital and in community settings.

Aim:
The goal of the study is to assess the prevalence of psychosocial distress among cancer patients at National Center for Cancer Care and Research (NCCCR), Qatar at different stages of their disease as well as to identify the most common causes for this distress using the DT as a tool.We also aim to compare the intensities of distress using demographic and clinical variables.

Methods
A total of 300 patients were studied from January 2015 up to December 2015.We categorized the patients into three groups, each consisting of 100 patients.The three groups were categorized based on (a) those initially diagnosed with cancer (group 1), b) patients undergoing cancer treatment (group2), and (c) patients with progressive disease who were referred to palliative care (group3).Different variables such as time of screening, sex, age, nationality, and tumor type were analyzed.Cancer patients aged 16 years and above were enrolled in the study.Participants were identi ed through existing records held at HMC and NCCCR.Participants were asked to take part in the study by the clinicians.In-patients, outpatients, daycare unit patients and radiotherapy patients were included in the study.Data was collected at HMC and NCCCR by using the DT tool over a period enough to collect samples of 300 cases.For the inpatients, the data was collected in the ward at their convenience.Similarly, for patients receiving chemotherapy or radiotherapy, they were given the DT tool to be completed at the daycare unit or in the radiotherapy department either before or after treatment session according to their preferences while outpatient participants were asked to take part following their regular visits at the clinic.The physicians were present during the lling of the survey and assisted with the queries the participant had.The lling of the DT took 5-10 minutes on average.The DT tool records the number (0-10) that best describe how much distress the patient has been experiencing in the past week including the day of assessment (e.g.0 has no distress and 10 have extreme distress).Responses are made on a 10-point scale.Low scores ranging from 0-3 meant mild distress not requiring any intervention, scores from 4-7 meant moderate degree of distress that can affect patient's life; while those who scored from 8-10 had a high level of distress that can signi cantly affect their life and compliance with cancer treatment.The primary outcome measure was to assess the severity of distress according to the score of DT at different stages of the disease trajectory.Secondary measures included the description of the detected problems from the lists of the various factors contributing to distress.

Analysis:
The data were analyzed using SPSS 22.0 software.Descriptive statistics were used to summarize the collected data on the severity of distress at different stages of the patient's diseases.Chi-square test was applied to examine an association between severity of distress with demographic and different factors related to problems like practical, emotional, and physical.
All P values presented were two-tailed, and P values were considered as statistically signi cant if ≤ 0.05.All Statistical analyses were done using statistical packages SPSS 22.0 (SPSS Inc.Chicago, IL) and Epiinfo (Center for Disease Control and Prevention, Atlanta, GA) software.

Results
We screened 300 adult cancer patients.The patients were categorized into three groups, 100 patients at the time of initial diagnosis with cancer (group 1), 100 patients undergoing cancer treatment (group 2), and the last group included patients with progressive disease who were referred to palliative care (group3).Fifty ve percent of patients were females compared to forty ve percent males.The majority (52%) of the patients were in the middle age group between (45-65) years of age followed by 30% < 45year-old and lastly 17% aged >65 years.Out of 300 patients, only 7.3 % were Qatari Nationals while 48.3% from other Arab countries and remaining 44.3% belong to Non-Arab Asian countries and the West.The most common type of cancer among the studied patients were breast cancer (31%) followed by G.I cancer (24 %) and hematological malignancies (11.7%) (Table :1).
There was an overall distress incidence of 62% (95% Con dence interval 56.4,67.3) (distress score level ≥ 4), out of that 17% of patients had severe distress (distress score level > 7) (Graph 1).The mean distress score was 4.5 ± 2.78 (range 0-10).There was a signi cantly higher level of distress observed among patients who were referred to palliative care (75%) compared to (54%) those who were at their initial diagnosis and (57%) of patients undergoing treatment; (P=0.004)(Graph 2).The incidence of distress was signi cantly higher among women (69.3%) compared to men which were (53%), (P=0.004)(Graph 3).Age had no impact on the level of distress (Table 2).Expatriates had higher levels of distress, compared to Qatari nationals (64.3% versus 59%), however, their difference was statistically insigni cant (P=0.28).Breast (69%) and lung (70%) cancer patients had a higher incidence of distress.In our study we found that the level of distress is more signi cant among patients with practical, emotional, physical, and family problems.Level of distress was statistically higher among patients who have practical problems compared to those who didn't have practical problems (69.5% s 46.4%, P=0.001).However, when we look at the components of the practical, emotional, physical and family problems individually the difference in level of distress noted was statistically insigni cant (refer Table :2).Our study also showed that the spiritual problems had no effect on the level of distress among our patients.(p=0.55)

Discussion
In the present study, the overall incidence of distress (≥ score of 4) was 62% which is much higher than that reported internationally (ranging from 25% to 45%) [13] This higher incidence has also been noted in a study from Saudi Arabia [12] where the incidence of moderate to severe distress was 57.3%.This can be attributed to the fact that most of the population in both countries are expatriates who live alone and lack of psychological support.
Results from this study showed signi cantly higher incidence of distress among women compared to men (69% versus 53%, p=0.004).This nding could be due to the fact of a higher incidence of distress in breast cancer cases (69%) which is more common among females.It is also known that female cancer patients are more emotionally labile and depressed compared to male cancer patients.This nding was also seen in a study performed at the Edinburgh Cancer Center which showed a higher incidence of distress among females compared to males (25% versus 17% respectively) [14].The level of distress is affected by cancer type Carlson et al reported in 2019 a higher level of distress among pancreatic and lung cancer cases is more than 4500 cases treated in 55 North American Cancer Centers [11].This nding was also con rmed by another study which reported higher incidence of distress in patients with lung, pancreatic and head and neck cancers [15].In a large cohort of patients with cancer diagnosis, Linden et al reported a higher level of anxiety and distress in patients with Lung, gynecological or hematological cancer [16].
In our present study, higher level of distress (≥ 4) were found in lung cancer (71%), Breast cancer (69%), gynecological (65%) and hematological (60%) malignancies.This is in accordance with the previously reported literature, except that we had a higher incidence of signi cant distress in breast cancer cases.This nding could be attributed to the higher prevalence of breast cancer in our cohort of patients (31% of cases).
In this study, the incidence of distress was signi cantly higher (75%) among the group of patients with progressive advanced disease who were referred to Palliative care compared to those at initial diagnosis or during cancer therapy (54% and 57% respectively).This nding is in complete agreement with the reported incidence in the literature.A Korean study in 2017 reported a signi cantly higher level of psychological distress in advanced stages of gastric cancer compared to earlier stages [17].The same nding was also reported among patients the diagnosis of Sarcoma in a Canadian trial in 2019 [18] where patients with unresectable or metastatic disease had signi cantly higher psychological distress compared to patients with early operable disease.
An earlier study in 2008 [19] reported a signi cantly higher level of distress for patients treated in in Palliative care compared to patients recruited from hospitals and outpatient clinics (p <0.001).Also, a German study on bladder cancer revealed a signi cantly higher distress level and expressed need for psychosocial support in patients with progressive disease compared to those at rst diagnosis [20].
To the best of our knowledge, this is the rst study in the Middle East to compare the incidence of distress at 3 different stages of the disease (at initial presentation, during therapy and upon referral to palliative care).This means that assessment of psychosocial distress should be performed at regular intervals during the patient trajectory with cancer.
We also found that the incidence of distress was slightly higher among expatriates (64%) compared to Qatari nationals (59%).This difference could be attributed to the lack of adequate psychosocial and family support among expatriates, who are usually alone.
In our study we found that the level of distress was more signi cant among patients who had practical, emotional, physical and family problems.The level of distress was statistically more signi cant among patients who had practical problems compared to those who didn't have practical problems ( 69.5% vs 46.4%, P=0.001).However, when we look at the components of the practical, emotional, physical and family problems individually the difference in level of distress noted disappears.Our study also showed that the spiritual problems had no effect on the level of distress among our patients.(p=0.55).A similar result from Saudi Arabia [12] showed that the level of distress is signi cantly higher among the patients with practical, emotional, physical, and family problems except the spiritual problem which is in accordance with our study.The individual components analyzed in our study provides vital information to identify the possible causes of distress in the State of Qatar and help us in adapting new effective interventions to minimize distress among our cancer patients. Limitations: The study did not intend to assess the role of different strategies to minimize the level of distress.However, we shall address this issue with our upcoming research.Few potential predictors related to distress example: employment, marital status, educational status, psychiatric evaluation have not been captured in the current study.

Conclusion
The present study clearly demonstrates a higher percentage of distress in Qatar compared to that reported internationally.Patients referred to palliative care, female patients, those with breast and lung cancers had the highest level of distress.The early identi cation of distress and its severity among cancer patients serves as a guide to us to address this problem.Patients scoring more than 4 can be identi ed earlier and referred to appropriate professionals according to their problems for further assistance.This emphasizes the fact that distress screening helps in early identi cation of distress and its severity among cancer patients.The availability of the multi-disciplinary team such as psychotherapy, psychiatry, social services, spiritual services, and counseling services along with the palliative care can identify, treat, and follow up distress among the patients throughout their cancer journey.This is the rst study at NCCCR to assess cancer patients from the psychosocial aspect and manage them accordingly.Also, the results from the study may have positive consequences on screening to manage them accordingly in the future studies.The easy practical adaptability of this simple distress tool also helps in implementing this tool in our daily practice.We hope that the results of this study will re ect on the initial assessment of our cancer patients and consider distress screening as the 6th vital sign.It also helps us to integrate psychosocial care into our routine cancer treatment pathway to enhance patient care.

Declarations Acknowledgement
The project was approved by Medical Research Center of Hamad Medical Corporation, Doha, Qatar and no funding was received for the same.

Funding
interest/Competing interests THERE IS NO CONFLICT OF INTEREST

Table 1 .
Demographic characteristics of the patients

Table 2 :
Comparison of Demographic and clinical characteristics between patients with and without psychological distress

Table 3 :
Comparison of Demographic and clinical characteristics between patients with and without psychological distress

Table 3 :
Comparison of Demographic and clinical characteristics between patients with and without psychological distress * Signi es that there is a problem in any one of the component under the main problems namely Practical, emotional, physical or family problems