Ana L. Thomat, PhD, and Roger P. Greenberg, PhD

Continuing Education Information

Author Note

Ana Laura Thomat, Department of Psychiatry and Behavioral Sciences, State University of New York, 750 East Adams St., Syracuse, NY 13210

Roger P. Greenberg, Department of Psychiatry and Behavioral Sciences, State University of New York, 750 East Adams St., Syracuse, NY 13210, 315-464-3120, greenber@upstate.edu

Correspondence concerning this article should be addressed to Roger P. Greenberg, PhD Department of Psychiatry and Behavioral Sciences, SUNY, Upstate Medical University, 750 East Adams St., Syracuse, NY 13210. E-mail: greenber@upstate.edu.

Disclosure: The authors of this publication did not have any financial interest or benefit arising from the direct applications of their research.

Abstract

Emotional aspects of cancer care impact the treatment experience and potentially the illness’s morbidity (Pinquart & Duberstein, 2010). Since the establishment of psycho-oncology in the 1970s the role for psychologists in cancer hospitals has increased. Psychologists on cancer units work on the emotional aspects and the psychological, social, and behavioral components that influence the cancer’s course (Die-Trill & Holland, 1995). If you are a psychologist working with cancer patients or a medical professional, you probably have had ample encounters with the emotional dimensions of the illness. This article provides an overview of psychological aspects of cancer, describes the stress cancer care puts on practitioners, and delineates how cognitive behavioral and insight-oriented interventions can address psychological reactions to the illness.

Keywords: cancer, emotion, cancer psychotherapy, psycho-oncology

Introduction

There is little doubt that receiving a cancer diagnosis is an emotional event.  For most people the diagnosis is disturbing. Even the word “cancer” evokes images of suffering, pain, and death. Cancer is an illness that is likely to arouse stress in the patients as well as their families. It challenges belief systems, trust, hope, and the probability of future existence. Cancer also forces people to focus on the present moment. The illness confronts people on an individual and very personal level. While support from family and friends is crucial, the fight with the illness is in many ways carried out alone.

This review provides a summary of research on how personality and cancer intersect, how cancer affects emotional resources and interpersonal relationships, and makes concrete suggestions for addressing the psychological aspects throughout the illness from diagnosis to remission or palliative care. Psychological theories of personality and change serve to delineate the diversity of emotional reactions to cancer based on individual characteristics as well as between-patient differences in their level of readiness to engage in medical treatment of the illness.

Emotional Tolls of Cancer

While the roles emotions play in cancer are not fully known, there is strong evidence for their importance in recovery (Choi, Chung, & Park, 2013). Individuals have different emotional profiles that are based on sensitivity to emotional stimuli, overall reactivity, and the time it takes to calm down (Miller, Rathus, & Linehan, 2007). Emotional reactions are provoked by several aspects of a cancer diagnosis. For example, cancer patients experience role shifts when family members take over responsibilities during times of acute illness or hospitalization, children become caregivers, and job duties can no longer be fulfilled. The illness does not represent a time-out but a time-on-hold so that planning for life or family goals becomes nearly impossible. Cancer treatment can last anywhere from months to years. Adler and Page (2008) state that treatment protocols by themselves for breast, prostate, and colon cancer can last months, while certain oral chemotherapeutic regimens for breast cancer or chemotherapy for some forms of leukemia can last for  years. Even after the acute illness is over, the patient is faced with years of follow-ups at specialists’ offices.

Cancer is a life changer, and yet, contemporary medical care is unmatched by psychological services for this population. This is surprising given that physical, psychological, and social stressors are intertwined. Stressors with income, housing, and poor health augment the risk for a medical illness. When psychological needs remain unaddressed they are likely to negatively interfere with cancer treatment (Stringer, 2014). Adler and Page (2008) argue that the prevalence of psychological distress varies by the type of cancer, the time that passed since diagnosis, the degree of physical and role impairment, the amount of pain, prognosis, and other variables. This points to the usefulness of a thorough needs assessment on cancer patients prior to implementing psychological services in order to determine service allocation.

Cancer can overwhelm a person’s coping mechanisms and lead to psychological illness. For example, research has found that common psychiatric diagnoses among cancer patients are depression, adjustment disorders, and anxiety (Carlsen, Jensen, Jacobsen, Krasnik, & Johansen, 2005; Hegel et al., 2006; Spiegel & Giese-Davis, 2003). Meta-analytic findings estimate that 14.9% of cancer patients meet diagnostic criteria for depression and 10.3% display symptoms of anxiety (Jacobson & Andrykowski, 2015; Mitchell et al., 2011). Yet, it is estimated that approximately 73% of cancer patients with depression do not receive treatment for their mood disorder (Walker et al., 2014). It is clear that cancer has an emotional aspect that thus far has been largely ignored in the medical care structure.

The American College of Surgeons’ Commission on cancer has decided that psychosocial services need to be more organically integrated into cancer care by mandating that a psychosocial distress screening be a fully integrated psycho-oncological service by 2015 (Zebrack et al., 2015). The National Comprehensive Cancer Network (2013) has published the Distress Thermometer as a brief instrument to assess for levels of distress and problems in health-related areas. Patients are asked to rate their distress on a 10-point scale in order to provide feedback on their psychological wellbeing to medical staff onsite. The rationale for such a tool is that patients are unlikely to initiate conversations about emotional distress with their physician, and physicians tend to avoid such conversations with their patients (Miller, 2014). By formally assessing for distress at different time points, the treatment team can make referrals to psychosocial services if indicated. Screening tools like the Distress Thermometer can enhance treatment adherence and patient satisfaction by reducing barriers caused by untreated mental distress (Miller, 2014).

Emotional aspects of cancer are multifold; they can arise as reaction to the diagnosis, response to the course of treatment, or they can be pre-morbid, that is, some cancer patients may already be struggling with anxiety or depression before receiving a medical diagnosis. In the medical context, patients may present with specific phobias about needles or blood also referred to as blood-injection-injury phobia (Harris, Jones, & Carey, 2006). On the other hand, anxiety may develop over the course of treatment when the smell of the infusion room becomes a feared stimulus generating fight or flight responses of an elevated heart rate, sweaty palms, release of stress hormones, and shallow breathing. Just like anxiety, depressive symptoms can be pre-morbid or develop throughout the stress of cancer treatment. A meta-analysis by Krebber et al. (2014) found that up to 24% of cancer patients who are not in palliative care develop depression during or after treatment. This prevalence rate surpasses that of the general population and supports the interconnection between cancer and emotions. Moreover, the authors found that most patients reported depressive symptoms in the acute phase of treatment.

Cancer patients may also experience their illness as a trauma and develop posttraumatic stress disorder symptoms of intrusive thoughts, flashbacks, distressing dreams, avoidance of cancer-related cues, negative belief about oneself, guilt or shame, estrangement from others, irritability, hypervigilance, and difficulty concentrating (Connerty & Knott, 2013). Other psychological consequences of cancer are emotional difficulties with adjusting to bodily changes and self-concept, feelings of guilt about becoming a burden on family and others, relationship problems, and anger (Middleton, 2014). A cancer diagnosis sets in motion an emotional response that, if not addressed and treated, can interfere with receiving appropriate cancer care and recovery (Stringer, 2014).

A new cancer patient with a pre-existing psychiatric disorder like borderline personality disorder (BPD) requires a unique treatment approach (Hay & Passik, 2000). This patient may struggle with relating to the medical staff and engage in problematic behaviors such as devaluation of the staff’s helping attempts and missing appointments in an attempt to regain control and return to an emotional equilibrium. A patient with a character disorder like BPD is therefore more likely to be emotionally sensitive and display behaviors that can interfere with cancer treatment.

When treating patients with cancer it is important to view the complexity of the individual person. Cancer patients arrive at the doctor’s office with personality traits that may make them prone to high levels of anxiety or angry outbursts. Emotions and personal histories interlace with the medical aspects of cancer. Effective cancer treatment assesses for mental health and wellbeing as part of treatment planning. Psychologists can play a critical role in helping the medical team understand their patient better in order to improve interpersonal communication and ultimately, treatment outcomes.

Psychological Treatments and Outcomes

The systematic study of effective psychological interventions for cancer patients is at a relatively early stage. Psycho-oncology is a growing field that addresses the psychosocial effects of cancer.

Psycho-oncologists address two major areas: the emotional responses to the illness and related psychological, behavioral, and social factors that impact prognosis and morbidity.

Psycho-oncologists are mental health professionals who complement the medical treatment team in significant ways because they are trained in recognizing, assessing, and treating emotional needs and psychiatric disorders. They can aid with communicating diagnoses, increasing treatment participation, assessing for pathological responses to the cancer, enhancing patients’ existing coping skills and addressing staff burnout.

While there does not appear to be just one validated psychological approach for treating cancer patients, there is a common element of providing the space for patients to tell their story. The psycho-oncologist’s most critical skill is flexibility in approach. When doing psychotherapy with cancer patients the clinician should be sensitive to timing, level of distress, and rapid changes in the patient’s presentation due to having received new information about the illness. Other factors to be considered in the psychological treatment are sociodemographic, medical, and psychosocial. These include age, cultural background, whether the patient has children to take care of at home, severity of the cancer, pre-existing trauma history or psychological illness, life stressors, coping style, and social support. Such factors put patients at different levels of risk and need for intervention (Esplen & Hunter, 2011).

Given the current status of research, there is no one psychological treatment model that serves all cancer patients. Yet, even distinct successful treatment approaches tend to have several similar ingredients (Greenberg, 2012). A common factor found to relate to positive psychotherapy outcomes across different treatment approaches is a strong therapeutic alliance built on unconditional positive regard, empathic understanding, and warmth (Greenberg, 2012; Rogers, 1957). Moreover, fostering the expression of emotional reactions to the cancer diagnosis and the impact the illness has on the patient’s life are essential to psychological cancer care (Spiegel & Classen, 2000). For patients at a low level of distress, psychoeducation about coping with cancer may suffice, whereas individual psychotherapy is indicated for those in high distress. Cognitive behavioral interventions are helpful for restructuring catastrophic thoughts and to teach coping strategies (Esplen & Hunter, 2011). Supportive-expressive group therapy (SEGT) is a psychodynamic approach that has been widely studied and proven to be effective for expression of emotions such as grief, adjustment to the illness, and learning how to cope (Esplen & Hunter, 2011).

It should be noted that some research studies in the 1980s and 1990s on patients with metastatic breast cancer and malignant melanoma proclaimed that psychotherapy could not only improve quality of life but also extend longevity (e.g., Fawzy et al., 1993; Spiegel, Bloom, Kraemer, & Gottheil, 1989). While this idea continues to have appeal, systematic reviews of past studies found reason to question this conclusion because of problems with studies’ design, power, sampling methods, and analyses (Coyne, Stefanek, & Palmer, 2007). However, in contrast to the debatable issue of whether psychotherapy extends life for cancer patients, quality of life enhancement has emerged as an undeniably beneficial outcome of psychotherapy treatments (American Psychological Association, 2014).

Assessment of personality traits can provide helpful clues to how treatment might be most effectively delivered. This is so because the way a person diagnosed with cancer will respond to and process this significant stressor will largely depend on their personality characteristics (Choi et al., 2013; Hay & Passik, 2000; Husson, Denollet, Oerlemans, & Mols, 2013). Personality traits are revealed by interpersonal patterns of behaviors, commonly used defense mechanisms, and cognitive schemas for thinking about self and others. Therefore, a patient’s personality style will influence not only thoughts and emotional reactions about the self but also shape interactions with the family and treatment staff.

Clearly, the medical staff of a cancer unit is confronted with a diversity of patient reactions and behaviors to their illness. In order to improve compliance with treatment regimens and effective communication, medical staff needs to respond sensitively to those individual differences. For example, a highly anxious patient is likely to ask more questions about treatment side effects, may delay treatment decisions, and complain more often about pain and discomfort. A provider being knowledgeable about personality effects can plan ahead and schedule more time for this patient, or, use targeted psycho-oncological interventions to address the patient’s unique reaction. Active listening—reflecting the concerns and fears of the patient as well as countering those with empathic support and education on the effectiveness and appropriateness for the scheduled medical intervention—decreases the emotional intensity of the fear allowing the patient to feel more comfortable and at ease. Accordingly, medical providers who address their patient’s emotions, thoughts and behaviors about cancer, are likely to benefit by having more cooperative patients.

An essential ingredient of all psychological services rendered to cancer patients is providing the space for the patient to express feelings in relation to the illness. When fostering expression of emotions and helping cancer patients understand their emotional reactions, a patient is supported in the coping process. Talking about one’s own story with cancer may not cure the cancer itself, but it can promote healing the emotional havoc the illness wreaked. With a strengthened sense of self, the illness will lose its dominance over the patient’s life and allow for life to be experienced once more.

Psychologist Provider Stress

It is obvious that receiving a serious diagnosis, like cancer, and undergoing a medical treatment that may have an uncertain outcome is stressful for patients. Often overlooked is the fact that providing psychotherapeutic treatments in these situations is stressful for the clinician as well. Typically, psychologists have a primary aim of providing hope to those they work with in psychotherapy. Here, however, one of the goals may be to help patients face something they (and their therapists) do not want to accept, the notion that life could be coming to an end. The American Hospice Foundation underlines the distress involved in helping people come to terms with their condition and accepting the possibility of saying goodbye. For those whose practice focuses on work with cancer patients, loss becomes a frequent and emotionally upsetting event. It is therefore critical that clinicians learn to acknowledge and deal with their own grief and feelings about death. On their website, the American Hospice Foundation emphasizes the importance of practitioners who work with cancer attending to their own needs by giving priority to the inclusion of rest, proper nutrition and exercise in their schedules. Relatedly, it is helpful to dilute stress by making sure there are opportunities for relaxation and spending time with family and friends who are unrelated to thinking about and dealing with cancer.

One significant concept related to providing therapy for cancer patients is death anxiety. It is common to have fears about death and clinicians are not immune to this concern. Many scales have been created to assess for this concern and this type of fear is positively related to the inability of health care providers to be emotionally available to their patients (Peters et al. 2013).  In general, the evidence shows that those who are more anxious about death have a less positive attitude about caring for those who are dying. Moreover provider death anxiety is higher in those who are younger, less experienced, and less educated about death. Finally, studies do indicate that providing even relatively brief teaching about death and dying does lower clinician fears and can translate into better quality care.

Another potential obstacle to psychologists providing good care for cancer patients is described in the notion of compassion fatigue. Compassion fatigue in health care professionals has been described as resulting from being repetitively exposed to the trauma and suffering of others (Melvin, 2015). It is related to the term “burnout” which Figley (1995) defined as the physical, emotional, and mental exhaustion brought on by lengthy involvement with emotionally demanding situations.

In sum, psychologists providing care for cancer patients are likely to be exposed to substantial stress that needs to be recognized and dealt with through a variety of good self-help practices as well as death education, peer support systems, boundary setting and periodic distancing from the work environment          

Conclusion: The State of Knowledge Regarding Emotions and Cancer

Cancer evokes emotional reactions involving distress, fear of dying, and sadness about losses. Losses abound in a serious medical illness like cancer. They pertain to losing previously mastered abilities and, possibly, body functions or parts, as well as relationships as the patient becomes disconnected from a former life in health. Emotional difficulties are to be expected with a diagnosis of cancer.

Working with patients who have a serious medical illness requires sensitivity and attunement as well as psychological know-how. Psychotherapies that focus on the present moment and support patients in processing their experiences can help them cope and use emotions in constructive ways (Lederberg & Holland, 2011). Offering such interventions reflects the understanding of the medical patient as a complex human being, and it communicates the idea that cancer sets us on a journey that has the power to transform us in the moment.

Psychologists also need to pay attention to the amount of stress that they will be exposed to as the result of treating cancer patients. The debilitating demands of this work cry out for keeping vigilant about preserving balance between work and one’s own personal lifestyle.

In contrast to the medical goal of prolonging life, psychological services for cancer patients focus on enhancing one’s participation in and experience of life with the illness in the moment. The present-focused psychology of cancer treatment can be contrasted with the future-oriented medical model that works on helping patients attain a future free of disease. Both approaches are valuable in patient care. They complement each other because even though patients are motivated by the prospect of recovery, they often find themselves caught in a present moment of distress that can feel overwhelming.

Authors

Ana Thomat, PhD, completed two Bachelor's degrees in International Business and Psychology at the University of New South Wales, Sydney, Australia. She earned a Master's degree in Global Studies while spending time in Vienna, Leipzig, and Wroclaw. She graduated with a PhD in Clinical Psychology from the University of California, Santa Barbara, and completed her pre-doctoral internship at the State University of New York (SUNY) Upstate Medical University in Syracuse. She has conducted clinical research on the relations between traumatic experiences and introverted personality traits as well as self-conscious emotions.


Roger Greenberg, PhD, is a Distinguished Professor at State University of New York (SUNY) Upstate Medical University. Dr. Greenberg received his PhD from Syracuse University and completed his internship at the Veteran Affairs Medical Center in Syracuse, NY. In addition to publishing more than 250 highly influential articles, books, and presentations, he co-authored "The Scientific Credibility of Freud's Theories and Therapies," which was selected as one of the ten best books in behavioral sciences by the National Library Association and Psychology Today. He has also been selected to receive the 2016 American Psychological Association Career Award for Distinguished Contributions to Education and Training. Dr. Greenberg has been credentialed as a health service psychologist since 1975.

References

Adler, N. E., & Page, A. E. K. (2008). Cancer care for the whole patient: meeting psychosocial health needs. Washington, D.C.: Institute of Medicine of the National Academies. Retrieved from http://www.nap.edu/catalog/11993/cancer-care-for-the-whole-patient-meeting-psychosocial-health-needs

American Psychological Association, APA Center for Psychology and Health. (2014). Briefing Series on the role of psychology in health care: adult cancer. Retrieved from http://www.apa.org/health/briefs/adult-cancer.pdf

Carlsen, K., Jensen, A. B., Jacobsen, E., Krasnik, M., & Johansen, C. (2005). Psychosocial aspects of lung cancer. Lung Cancer, 47(3), 293-300. Retrieved from http://www.lungcancerjournal.info/

Choi, J. H., Chung, K.-M., & Park, K. (2013). Psychosocial predictors of four health-promoting behaviors for cancer prevention using the stage of change model of Transtheoretical Model. Psycho-Oncology 22, 2253-2261. doi: 10.1002/pon.3278

Connerty, T. J., & Knott, V. (2013). Promoting positive change in the face of adversity: experiences of cancer and post-traumatic growth. European Journal of Cancer Care, 22, 334-344. doi: 10.1111/ecc.12036

Coyne, J. C., Stefanek, M., & Palmer, S. C. (2007). Psychotherapy and survival in cancer: the conflict between hope and evidence. Psychological Bulletin, 133(3), 367-394. doi: 10.1037/0033-2909.133.3.

Die-Trill, M, & Holland, J. (1995). A model curriculum for training in psycho-oncology. Psycho-Oncology, 4, 169-182. Retrieved from http://onlinelibrary.wiley.com/journal/10.1002/%28ISSN%291099-1611

Esplen, M. J., & Hunter, J. (2011). Therapy in the setting of genetic predisposition to cancer. In

  1. Watson & D. Kissane (Eds.), Handbook of psychotherapy in cancer care (pp. 201-213). Hoboken, NJ: John Wiley & Sons, Ltd.

Fawzy, F. I., Fawzy, N. W., Hyun, C. S., Elashoff, R., Guthrie, D., Fahey, J. L., Morton, D. L. (1993). Malignant melanoma: effects of an early structured psychiatric intervention, coping, and affective state on recurrence and survival 6 years later. Archives of General Psychiatry, 50(9), 681-689. Retrieved from http://archpsyc.jamanetwork.com/journal.aspx

Figley, C.R. (1995). Compassion Fatigue.  New York: Brunner/Mazel.

Greenberg, R.P. (2012). Essential ingredients for successful psychotherapy: Effect of common factors. In M. J. Dewan, B. N. Steenbarger, & R. P. Greenberg (Eds.), The art and science of brief psychotherapies: An illustrated guide (2nd ed.) (pp. 15-27). Washington, DC: American Psychiatric Publishing.

Harris, L. M., Jones, M. K., & Carey, C. L. (2009). Characteristics of blood-injection-injury fears in people receiving intravenous chemotherapy. Current Psychology, 28, 124-132. doi: 10.1007/s12144-009-9048-z

Hay, J. L., & Passik, S. D. (2000). The cancer patient with borderline personality disorder: suggestions for symptom-focused management in the medical setting. Psycho-Oncology, 9, 91-100. Retrieved from http://onlinelibrary.wiley.com/journal/10.1002/%28ISSN
%291099-1611

Hegel, M. T., Moore, C. P., Collins, E. D., Kearing, S., Gillock, K. L., Riggs, R. L., Clay, K. F., & Ahles, T. A. (2006). Distress, psychiatric syndromes, and impairment of function in women with newly diagnosed breast cancer. Cancer, 107(12), 2924-2931. doi: 10.1002
/cncr.22335

Husson, O., Denollet, J., Oerlemans, S., & Mols, F. (2013). Satisfaction with information provision in cancer patients and the moderating effect of type D personality. Psycho-Oncology, 22, 2124-2132. doi: 10.1002/pon.3267

Jacobsen, P. B., & Andrykowski, M. A. (2015). Tertiary prevention in cancer care: understanding and addressing the psychological dimensions of cancer during the active treatment period. American Psychologist, 70(2), 134-146. doi: 10.1037/a0036513

Krebber, A. M. H., Buffart, L.M., Kleijn, G., Riepma, I. C., de Bree, R., Leemans, C. R., Becker, A., Brug, J., van Straten, A., Cuijpers, P., & Verdonck-de Leeuw, I. M. (2014). Prevalence of depression in cancer patients: a meta-analysis of diagnostic interviews and self-report instruments. Psycho-Oncology, 23, 121-130. doi: 10.1002/pon.3409

Lederberg, M. S., & Holland, J. C. (2011). Supportive psychotherapy in cancer care: an essential ingredient to all therapy. In M. Watson & D. Kissane (Eds.), Handbook of psychotherapy in cancer care (pp. 1-15). Hoboken, NJ: John Wiley & Sons, Ltd.

Melvin, C.S. (2015). Historical review in understanding burnout, professional compassion fatigue, and secondary traumatic stress disorder from a hospice and palliative nursing perspective.  Journal of Hospice and Palliative Nursing, 17, 66-72.

Middleton, R. J. (2014). Meeting the psychological care needs of patients with cancer. Nursing Standard, 28(21), 39-45. doi: 10.7748/ns2014.01.28.21.39.e8149

Miller, A. L., Rathus, J. H., & Linehan, M. M. (2007). Dialectical behavior therapy with suicidal adolescents. New York, NY: Guilford Press.

Mitchell, A. J., Chan, M., Bhatti, H., Halton, M., Grassi, L., Johansen, C., & Meader, N. (2011). Prevalence of depression, anxiety, and adjustment disorder in oncological, haemetological, and palliative care settings; a meta-analysis of 94 interview-based studies. Lancet Oncology, 12, 160-174. doi: 10.1016/S1470-2045(11)700

Peters, L., Cant, R., Payne, S., O’Connor, M., McDermott, F., Hood, K., Morphet, J., & Shimoinaba, K. (2013).  How death anxiety impacts nurses’ caring for patients at the end of life: A review of literature.  Open Nursing Journal, 7, 14-21. doi: 10.2174/1874434601307010014

Pinquart, M., & Duberstein, P. R. (2010). Depression and cancer mortality: a meta-analysis. Psychological Medicine, 40, 1797-1810. doi: 10.1017/S0033291709992285

Rogers, C.R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95-103.

Spiegel, D., Bloom, J. R., Kraemer, H. C., & Gottheil, E. (1989). Effect of treatment on the survival of patients with metastatic breast cancer. Lancet, 2, 888-891. Retrieved from http://www.thelancet.com/

Spiegel, D., & Classen, C. (2000). Group therapy for cancer patients. New York, NY: Basic.

Spiegel, D., & Giese-Davis, J. (2003). Depression and cancer: mechanism and disease progression. Biological Psychiatry, 54(3), 269-282. Retrieved from http://www.biologicalpsychiatryjournal.com/

Stringer, H. (2014, November). Unlocking the emotions of cancer. Monitor on Psychology, 45(10), 36-37.

Walker, J., Hansen, C. Holm, Martin, P., Symeonides, S., Ramessur, R., Murray, G., & Sharpe, M. (2014). Prevalence, associations, and adequacy of treatment of major depression in patients with cancer: a cross-sectional analysis of routinely collected clinical data. The Lancet Psychiatry, 1(5), 343-350. doi: 10.1016/S2215-0366(14)70313-X

Zebrack, B., Kayser, K., Sundstrom, L., Savas, S. A., Henrickson, C., Acquati, C., & Tamas, R. L. (2015). Psychosocial distress screening implementation in cancer care: an analysis of adherence, responsiveness, and acceptability. Journal of Clinical Oncology, 33, 1-8.
doi: 10.1200/JCO.2014.57.4020