Who should be screened
All individuals referred to prehabilitation should be screened for psychological concerns at intake using a brief screening tool.
Most available screening tools focus primarily on symptoms of depression, anxiety, or distress and may not adequately identify other factors associated with a more complex cancer surgery recovery. Therefore, screening should be complemented by a clinical discussion to better understand the individual’s circumstances, needs, and preferences.
In addition to psychological symptoms, a range of clinical and sociodemographic factors may increase the risk of poor physical and psychological recovery following surgery.1 These factors should also be considered when determining prehabilitation needs.
This broader assessment helps ensure people are connected with the most appropriate supports, promotes engagement with prehabilitation services, and may reduce stigma associated with accessing psychological care.
Why screening for psychological concerns is important
Psychological concerns such as depression are related to increased risk of post-surgical complications and poorer psychological outcomes.
The aim of psychological screening is to identify the individuals with cancer who are at higher risk of poorer psychological or physical recovery to determine appropriate psychological intervention referrals.
Routine screening also helps to normalise and de-stigmatise psychological concerns.
If the person with cancer has minimal distress (e.g., PHQ-4 ≤ 2 on both subscales; ESAS-A ≤2 and ESAS-D ≤ 1; or Distress Thermometer ≤3*) AND no clinical/demographic risk factors = offer universal intervention
If the person with cancer is distress positive (e.g., PHQ-4 ≥3 on either subscale (PHQ-2 or GAD-2), or Distress Thermometer ≥ 4, or ESAS-A ≥3 or ESAS-D ≥2*) OR has clinical/demographic risk factor(s) = refer to psychology service (or equivalent discipline) for triage and risk assessments.
*For further information about the screening measures outlined above refer to Which screening tool(s) to use below.
Psychology intake assessment
Upon identification of distress or other psychological concerns, the individual with cancer is referred to a clinician with training in mental health who completes the further psychology intake assessment:
- Assess risks (suicidal and self-harm ideation; thoughts of not proceeding with treatment; lack of social supports; lack of effective coping mechanisms);
- Significant risks to self or others endorsed: immediate consultation with mental health service, provide patient with lifeline and suicide call back service numbers and local area mental health service, call emergency services if risks are immediate.
- Assess clinical and demographic risk factors as above including current concerns about surgical procedure/recovery and current mental health concerns such as depression, anxiety, and trauma symptoms among others.
- To support assessment of mental health symptoms, a secondary line of assessment tool could be used such as the Hospital Anxiety and Depression Scale (HADS) or PHQ-9 and Generalised Anxiety Disorder 7 item (GAD-7). These assessment tools can also be used to monitor progress throughout the patient’s treatment. Note: An intake assessment is still required as these tools will capture only depression/anxiety and not other concerns that may impact prehabilitation or surgical recovery.
^Correct at time of publication
Second-line screening tools
The following measures could be considered as part of the second stage psychological triage. However, these measures assess only anxiety and depression, as there is currently no measure to assess all aspects of prehabilitation psychological concerns. A clinical triage assessment may therefore be preferable. Further screening and assessment measures that can be considered at psychological assessment in the first intervention session and are available in Psychological assessment measures.
^Correct at time of publication