Psychosocial decline occurs in an estimated one-third of patients undergoing radiotherapy for cancer, according to a recently published evidence review. These declines are associated with poor patient quality of life but may sometimes be ameliorated by vigilant recognition of the need to refer patients for psychosocial support interventions. There are myriad psychometric instruments available for assessing and monitoring patients’ psychosocial function status before and during treatment, including a recently promulgated, very simple self-report tool, the NCCN Distress Thermometer for Patients.

Psychosocial functioning is a complex construct, referring to social, emotional, and cognitive performance and well-being; psychosocial declines can involve fear, anxiety, depression, panic, social isolation, fatigue, and existential and spiritual crisis.1 These declines can be accompanied and exacerbated by declines in cognitive function such as chemo-brain or advanced age.2

Concomitant cognitive disorders such as Alzheimer’s disease profoundly impair patients’ working memory and decision-making abilities, and can complicate the frequently already-ambiguous legal landscapes surrounding medical care.2 But radiation therapy (RT) team members should be alert for the more subtle signs of psychosocial decline as well. Declines in psychosocial function correlate with impaired resilience and lower quality of life, and can increase patients’ psychological, and possibly physical, suffering during their remaining lifetime.2,3

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The National Comprehensive Cancer Network (NCCN) therefore includes patient distress management in its standards of care.1 The NCCN uses the term distress rather than psychosocial, psychiatric, or emotional because the term is less potentially stigmatizing, has been deemed less embarrassing to patients, and is readily measured with self-report instruments. The timely recognition, monitoring, documentation, and treatment of distress starts with initial screening at diagnosis and is repeated at appropriate intervals and as clinically indicated, particularly when disease status changes (eg, at remission, recurrence, or tumor progression).1

The guideline also recommends developing educational/training programs for all appropriate staff on assessment and management of distress in patients.1 Licensed mental health professionals experienced in the psychosocial aspects of cancer should be available for patient referrals by staff.1


Psychological screening for patients undergoing cancer radiotherapy has been relatively little studied, and research efforts have been poorly coordinated, resulting in myriad different screening and psychosocial function assessment tools used at different centers.4 “These uncoordinated efforts have amassed inconsistent data, leaving many unanswered questions regarding psychosocial function maintenance in radiation oncology,” report Hess and Chen, authors of a systematic literature review of 93 published English-language studies of psychosocial function measurement in radiotherapy clinics.4

These authors conducted their review to assess what is known about the prevalence of psychosocial decline in patients undergoing radiotherapy, the risk factors for decline, and intervention strategies.4 Their review identified more than a dozen risk factors associated with psychosocial decline in radiotherapy in two or more reviewed studies; five of the risk factors were particularly robust: female sex, younger age, point in treatment course, severity of physical symptoms, and treatment includes chemotherapy4 (Table 1). The association with point in treatment course requires further study, but several of the reviewed studies suggest that decline accelerates during or after radiotherapy, whereas anxiety is higher before treatment begins.4

“Psychosocial function declines in approximately one-third of RT patients,” Hess and Chen report.4 “Anxiety can dissipate after initiation of RT, whereas depression can persist throughout and after RT.” Severe physical symptoms and time-related factors are the greatest predictors of psychosocial function decline. Psychotherapy and interventions by the radiotherapy team aimed to improve patient education are effective mitigating strategies. For example, two studies in the review reported that psychosocial decline was alleviated by patient education sessions; however, one reported only stress reaction improved, not overall quality of life.4

But before referrals for psychology services or other interventions can be made, declines must be reliably detected. “The gold standard psychiatric interview is optimal to assess the multifaceted components of human psychosocial response,” note Hess and Chen; “but is reportedly too time-consuming for practically widespread implementation in busy clinics.”4 Many clinics and researchers therefore use quicker instruments such as questionnaires patients complete on their own or with help from a nurse, such as the Beck Depression Index (BDI).4 Perhaps the simplest instrument is the NCCN Patient Distress Thermometer, a self-report questionnaire.6 However, the evidence base for its use is immature; only five (5.4%) of the studies reviewed by Hess and Chen utilized it.4

Oncology nurses should be familiar with the risk factors of psychosocial decline, their institution’s preferred instrument for measuring psychosocial function and its administration, as well as education or referral procedures when psychosocial decline is detected.

Bryant Furlow is a medical journalist based in Albuquerque, New Mexico.  


1. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Distress Management, Version 2.2013. Accessed November 13, 2013.

2. Kuśnierkiewicz M, Kędziora J, Jaroszyk-Pawlukiewicz J, Nowak-Jaroszyk M. Psychosocial and legal aspects of oncological treatment in patients with cognitive impairment. Rep Pract Oncol Radiother. 2014;19(3):157-164.

3. Brix C, Schleussner C, Füller J, et al. The need for psychosocial support and its determinants in a sample of patients undergoing radiooncological treatment of cancer. J Psychosomatic Res. 2008;65(6):541-548.

4. Hess CB, Chen AM. Measuring psychosocial functioning in the radiation oncology clinic: a systematic review. Psychooncology. 2014;23(8):841-854.

5. Lowery AE, Holland JC. Screening cancer patients for distress: guidelines for routine implementation. Community Oncol. 2001;8(11):502-504. Accessed November 13, 2014.

6. National Comprehensive Cancer Network (NCCN). NCCN distress thermometer for patients. Accessed November 13, 2014.