Psycho-Oncology

Psycho-Oncology 20: 463469 (2011)

Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/pon.1932

Commentary

Implementing screening for distress, the 6th vital

sign: a Canadian strategy for changing practicey
Barry D. Bultz, Shannon L. Groff, Margaret Fitch, Marie Claude Blais, Janice Howes, Karen Levy and Carole Mayer
Department of Psychosocial Resources, Tom Baker Cancer Centre, Holy Cross Site, Alberta Health Services, Cancer Care, Calgary, AB, Canada
* Correspondence to:
Department of Psychosocial
Resources, Tom Baker
Cancer Centre, Holy Cross
Site, Alberta Health Services,
Cancer Care, 2202 2nd St.
S.W., Calgary, AB, Canada
T2S 3C1. E-mail:
bdbultz@ucalgary.ca
y
The commentaries published
here on implementation of
distress screening preview a
special issue to appear in
June on empirical aspects of
screening for distress.
These commentaries highlight
issues for clinicians when
screening for distress is
implemented in to the patient
care setting. Successful
implementation is critical to
the development of distress
screening and the
commentaries described are
complementary to the
research findings which will be
published next month.

Abstract
Objective: Distress is prevalent among cancer patients at all stages of illness and has been
endorsed as the 6th Vital Sign in cancer care. Despite its prevalence, and calls to be monitored,
few cancer programs are Screening for Distress in a standardized manner. In this paper, the
implementation strategy employed in Canada to change practice by integrating Screening for
Distress in routine care is described.
Methods: The process from inception of the concept of distress to the implementation of
Screening for Distress is discussed. Pioneering work pertinent in laying the foundation for
Screening for Distress as a National initiative is highlighted. Additionally, the experience of
four jurisdictions currently Screening for Distress is utilized to demonstrate steps to successful
implementation and strategies for overcoming challenges.
Results: Integrating Screening for Distress into practice requires endorsements from key
stakeholders, developing and disseminating national recommendations and guidelines, and
utilizing a coordinated and standardized method focused on practice change. At a local level
successful implementations engage stakeholders, provide thorough and targeted education,
establish interprofesionnal teams, and utilize a phased approach to implementation. Common
challenges cited include time, buy-in and lack of resources.
Conclusions: Establishing a national approach to implementing Screening for Distress is
both feasible and benecial. A coordinated approach encourages collaboration beyond the walls
of any particular center and provides the opportunity for all patients to be provided with
improved person-centered care.
Copyright r 2011 John Wiley & Sons, Ltd.

Received: 5 January 2011

Accepted: 7 January 2011

Keywords: cancer; screening for distress; practice change; implementation; oncology; distress

Introduction
Distress has been dened by the National Comprehensive Cancer Network as an unpleasant experience of a psychological, social, and/or spiritual
nature which extends on a continuum from normal
feelings of vulnerability, sadness, and fears to
disabling problems such as depression, anxiety,
social isolation, and spiritual crisis [1]. Working
with this denition, research on the prevalence of
distress in cancer patients has consistently demonstrated that between 35 and 45% of patients
experience signicant levels of distress [2,3].
Branding distress as the 6th Vital Sign provided
a framework for care providers to conceptualize
distress in the medical model [4,5]. In routine
medical practice health professionals take vital
signs in order to assess the most basic bodily

Copyright r 2011 John Wiley & Sons, Ltd.

functions. The four vital signs that are standard

in medical settings are body temperature, pulse
s(or heart rate), blood pressure, and respiratory
rate. In 1999 the Joint Commission on Accreditation in the US acknowledged pain as the 5th vital
sign in cancer care. Given the prevalence of distress
and its recognition as the 6th Vital Sign, screening
for distress is now an accreditation standard in
Canada [6].
While the prevalence of distress in cancer
populations has resulted in an increase in screening,
few health-care providers screen using standardized
measures. In the US, a national study found that
65% of oncologists reported Screening for Distress,
but only 14.3% used a standardized measure [7]. A
similar nding emerged from a study conducted in
the UK. Physicians and nurses reported they often
inquired about distress, but only 10% reported

464

B. D. Bultz et al.

screening using a validated questionnaire [8]. Given

these ndings, it is clear that a gap exists in the
integration of Screening for Distress into practice.
This paper will highlight a national change management strategy being implemented in Canada focused
on integrating theory into practice. Additionally,
this paper seeks to better understand the barriers
and emphasize strategies for moving forward in the
Implementation of Screening for Distress.

National workshop
In March 2008, the Cancer Journey Action Group
(CJAG) of the Canadian Partnership Against
Cancer partnered with the Public Health Agency
of Canada and the Canadian Association of
Provincial Cancer Agencies to hold a workshop
that brought together decision-makers and experts
in the eld of cancer care. The workshop sought to
review existing practices in Screening for Distress
and to determine whether there was an opportunity
to move forward with the concept of Canada-wide
screening.
Six key concepts emerged from this workshop [9]:
(1)
(2)

(3)
(4)
(5)
(6)

Distress needs to be monitored and addressed

In addition to anxiety and depression, distress
also arises from diculties in domains such as
pain, fatigue, and other common problems
Screening should be implemented at point of
entry
Short, standardized measures possessing good
psychometric properties should be used
Screening should be electronic
The implementation of screening should be
properly resourced, follow project management
models, and include quality improvement
strategies.

stimulate both access to a range of services as well

as a movement toward the type of cancer care
system that has the capacity to respond to the
range of needs patient and families experience
during the cancer journey.

Screening for distress national

recommendations
Building on the recommendations from the
Screening for Distress workshop, CJAG established national recommendations for Screening for
Distress. A denition for Screening for Distress
was developed and recommendations were made
for whom to screen, when to screen, how to screen,
which domains to screen, and which tools should
be used (Table 1) [11].
A clear distinction between screening and assessment also emerged from this work. Screening for
Distress was dened as the pro-active rapid
identication of key indicators that allow for
further assessment and appropriate referral [11].
Consistent with clinical guidelines around the
care of the adult cancer patient this denition
conceptualizes screening as a ag for concerns
leading to assessment, a more comprehensive and
focused examination of the patients situation that
leads to targeted and evidence-based intervention
(Figure 1) [12].
It was determined that all patients should be
screened routinely, at point of entry into the cancer
care system and at critical time points (diagnosis,
start and end of treatment, post-treatment, transition to survivorship, recurrence or progression,
advanced disease, and during times of personal
transition) [12]. Additionally, the group members
Table 1. Summary of recommendations and/or conclusions

Additionally, three key recommendations to

move Screening for Distress forward emerged:
(1)
(2)
(3)

Establish national standards and guidelines

for Screening for Distress
Raise the prole of Screening for Distress, the
6th Vital Sign
Secure proper resources for national Screening
for Distress implementation

Following this workshop, CJAG selected Screening for Distress as a key driver at a national level
for moving toward a vision of person-centered
cancer care (the provision of care that is respectful of, and responsive to, individual preferences,
needs, and values). Achieving this vision necessitates a shift in practice culture, enhanced interprofessional teamwork, and the formation of
partnerships between formal cancer programs and
community-based settings [10]. Implementing
Screening for Distress was recognized as a way to
Copyright r 2011 John Wiley & Sons, Ltd.

Area
Rationale for screening
Who to screen
When to screen
How to screen

Screening domains

Minimum data set

Recommendations/Conclusions
Pro-active identification of key indicators that allow
for further assessment and appropriate referral
All cancer patients should be screened for distress
Standardized routine screeningincluding at
point of entry and at critical time points
No formal recommendation was put forward. It was
noted that when possible electronic screening
offers advantages over paper and pencil screening
(e.g. less paper work, automatic data entry, etc).
Screening tools should include three domains:
1. Psychosocial
2. Practical
3. Physical
Screening for Distress programs should use the
recommended tools to screen for the minimum
data set, but can also incorporate additional items
based on specific needs of each jurisdiction
The recommended minimum data set includes
the following tools:
1. Edmonton Symptom Assessment System
2. Canadian Problem Checklist

Psycho-Oncology 20: 463469 (2011)

DOI: 10.1002/pon

A Canadian strategy for changing practice

465

instrument was found to screen for psychological,

practical, and physical concerns, the Edmonton
Symptom Assessment System (ESAS) and a
Canadian Problem Checklist (CPC) were selected
as the minimum data set (Figure 2). The ESAS is
a commonly used screening tool [14] where nine
symptoms are rated on a numerical scale from 0 to
10. The ESAS is a psychometrically sound instrument [15] that has been validated in both advanced
cancer populations and patients earlier in the
cancer trajectory [16,17]. The CPC, generated by
the Screening for Distress Toolkit Working Group,
complements the ESAS by including an evidencebased list of common concerns that patients
experience [10,18]. Both the ESAS and CPC are
used to facilitate a conversation between the
patient and clinician around distressing concerns.
The minimum data set, national recommendations,
and the addition of screening to national cancer
agency accreditation standards laid a solid foundation for Screening for Distress in Canada.

noted that whenever possible, screening should be

electronic. Psychosocial, practical, and physical
concerns were endorsed as key domains that need
to be incorporated into screening. The psychosocial domain includes the social, psychological,
emotional, spiritual, quality-of-life, and functional aspects of cancer, from prevention through
bereavement [13]. These domains represent a
person-centered approach to cancer care that
incorporates a range of needs that, when addressed
in a comprehensive, interdisciplinary way, may
improve quality of life for people aected by cancer.
A minimum data set was developed to standardize screening. While no single gold standard

Screening

Assessment

Intervention

Figure 1. Screening, assessment, and intervention

Date of Completion: _____________________ Time: _______________

Completed by:
Patient
Family
Health Professional
Assisted by family or health
professional

Please circle the number that best describes:

No pain

10

Worst possible pain

Not tired

10

Worst possible tiredness

Not nauseated

10

Worst possible nausea

Not depressed

10

Worst possible depression

Not anxious

10

Worst possible anxiety

Not drowsy

10

Worst possible drowsiness

Best appetite

10

Worst possible appetite

Best feeling of
wellbeing

10

Worst possible feeling of

wellbeing

No shortness of
breath

10

Worst possible shortness

of breath

Other problem

10

Please check all of the following items that have been a concern or problem for you in the past week
including today:
Emotional:

Practical:

Fears/Worries

Work/School

Sadness

Finances

Informational:
Understanding my illness and/or
treatment
Talking with the health care team

Frustration/Anger

Getting to and from appointments

Making treatment decisions

Changes in appearance

Accommodation

Knowing about available resources

Intimacy/Sexuality
Spiritual:

Social/Family:

Physical:

Meaning/Purpose of life

Feeling a burden to others

Faith

Worry about family/friends

Concentration/Memory
Sleep

Feeling alone

Weight

*Questionnaire from the Cancer Journey Advisory Group, Canadian Partnership Against Cancers Minimum Data Set

Figure 2. Canadian minimum data set

Copyright r 2011 John Wiley & Sons, Ltd.

Psycho-Oncology 20: 463469 (2011)

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466

B. D. Bultz et al.

From theory to practice

Bringing together professionals to determine
national recommendations provided an opportunity
for national collaboration focused on implementation. It also highlighted that although many of the
programs diered in their methodology, they often
resulted in similar challenges and obstacles. These
observations emphasized the potential benets of
creating a community of practice for the implementation of a programmatic approach to Screening
for Distress. Formalization of this collaboration
occurred when CJAG endorsed start-up funds to
support jurisdictions striving to implement Screening for Distress. These jurisdictions vary in scope
and could be province wide, cancer center or program based. Jurisdictions participate in a national
group that supports the planning, development, and
implementation of national Screening for Distress.
The group also provides the opportunity for jurisdictions to develop and share materials, resources,
and implementation strategies, as well as, work to
overcome challenges.
Presently, there are four jurisdictions collaborating with CJAG: (1) British Columbia Cancer
Agency; (2) Regional Cancer Program of the
Hopital regional de Sudbury Regional Hospital;
(3) Cancer Care Nova Scotia; and (4) the Centre
Hospitalier Universitaire de Quebec (CHUQ) in
Quebec City. Taken together, these jurisdictions
involve the screening of patients from rural and
urban areas, those who speak English, French, or
other languages, and those of majority and
minority populations. All of the jurisdictions
working with CJAG are inclusive of the national
recommendations and committed to providing
person-centered care. All are engaged in implementing a programmatic approach to screening for
distress.
A programmatic approach to Screening for
Distress means that there is a coordinated and
intentional eort on the part of a cancer agency to
introduce all the structural and process elements
that will achieve the outcomes of embedding
Screening for Distress within routine daily clinical
practice and improving the delivery of personcentered care.
Introducing a program of Screening for Distress
includes organizing procedures and policies for:




Completion of the screening tool by all

patients
Communication of the screening results to
the clinical team
Interaction between the patient and clinical team
based on the screening scores (conversation for
validation, triage, and brief assessment)
Conducting deeper and focused assessments
based on the patient identied concerns and
clinical judgment

Copyright r 2011 John Wiley & Sons, Ltd.

 Action taken by the clinical team based on

clearly articulated roles and responsibilities
for each team member (within respective
scopes of practice) and evidence-based guidelines for intervention in response to the
assessment results for the patient identied
concerns and clinical judgment
 Referral to other disciplines and/or services
as required based on specied referral criteria
and pathways
 Monitoring of the program eciency and
eectiveness.

Steps to successful implementation

Implementation strategies often vary as they are
based on the unique circumstances of each
jurisdiction; however, successful implementations
often share the following common steps:
(1) Engage high-level stakeholders and establish
steering groups: Aligning with organizational
strategic plans and/or other high priority
initiatives, partnering with community organizations, and highlighting the role of screening
in addressing gaps in patient care can all
facilitate stakeholder engagement. The inclusion of Screening for Distress as part of
Accreditation Standards also serves as a
motivator for many institutions.
(2) Educate sta about Screening for Distress:
Widely distributing information about
Screening for Distress to various groups
through activities such as workshops, sta
meetings, and internal websites is pivotal to
educating sta. Workshops focused on the
current situation in the jurisdiction (e.g.
results of satisfaction surveys), the theoretical background of Screening for Distress,
national recommendations, and utilizing
small group discussions to brainstorm around
challenges, benets, and strategies for moving
things forward can play a key role in engaging
sta and building champions within the
organization.
(3) Establish inter-professional implementation
teams: Inter-professional teams comprising
management and front-line sta provide an
opportunity to further engage sta and
develop champions within each local context.
This group also plays an important role in
determining details of screening, including
logistics for screening, clinical workow, and
referral pathways.
(4) Provide targeted training on Screening for
Distress: Everyone from administrators to
front-line care providers require targeted
education about screening. This training
focuses on the roles of each provider and on
building skills and condence in areas where
Psycho-Oncology 20: 463469 (2011)
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A Canadian strategy for changing practice

gaps exist. Strategies for training front-line

sta include peer mentorship and role play to
demonstrate how a conversation related to
screening can be initiated with patients.
(5)

Roll out screening in a phased approach:

Implementation of screening can start with
one location or one tumor group. Starting
small is seen as a way to minimize fears
related to screening (e.g. lack of resources)
and build positive support.

Complimentary to the steps above is the

integration of guidelines and algorithms. National
evidence-based guidelines support the view of
screening as an initial ag that should be followed
by appropriate assessment and intervention [12].
These guidelines also support the stance that
screening should encompass a range of concerns
and take place at critical time points. Additionally,
evidence-based algorithms, which outline how to
respond to patient concerns, have been developed
within the context of this national work for
adaptation at local jurisdictions.
Another pivotal component to the implementation of Screening for Distress is evaluation. Four
objectives on which to base an evaluation framework are: (1) to organize and plan implementation
of Screening for Distress; (2) to develop the
skills, knowledge, and core competencies to screen
for distress; (3) to establish inter-professional
collaboration in care planning; and (4) to improve
the experience of the patient and the family [19].
In addition to the evaluation framework, a
quality improvement model including rapid cycle
approaches [20] can be utilized to accelerate
the implementation of Screening for Distress
(Figure 3). These approaches encourage implementation teams to identify challenges, test out strategies, measure the response, and take action based
on the ndings.

Figure 3. Quality improvement model. The QI model for

improvement was developed by Associates in Process Improvement; http://www.apiweb.org/API_home_page.htm
Copyright r 2011 John Wiley & Sons, Ltd.

467

Challenges and strategies

Although health-care providers exhibit dedication
to the vision of improving person-centered care
through Screening for Distress, several concerns
exist. Research indicates that the most commonly
reported barriers to Screening for Distress are time
constraints, inconsistent usage, lack of buy-in, and
lack of resources for follow-up [14]. These barriers
were consistently reported by the four jurisdictions
implementing Screening for Distress.
In busy clinics time is always a factor. Education
and mentorship play a key role in teaching how to
have short eective conversations and how to
manage patients indicating multiple concerns.
When considering time spent with patients early
in the cancer journey, we also need to consider the
impact of not addressing concerns. Research has
demonstrated that health-care providers are not
doing a good job of addressing the symptoms of
patients and that unaddressed symptom may
increase the number of patient visits, therefore
creating further burden to the system [18].
Furthermore, despite some indications that screening takes more time, those who report this also
state that screening is benecial and should take
place.
Another frequently reported challenge is lack of
buy-in, which is often manifested through dismissive comments. Strategies for increasing buy-in
include: (1) ensuring the support of the administration; (2) acknowledging the resistance of front
line sta and actively listening to their concerns;
(3) showing interest and understanding toward
culture/work organization; (4) having open communication with implementation teams and working together to overcome situations perceived as
barriers; (5) taking extra time for eld consultation
and preparation (meet individually with sta
members to ensure they feel free to express their
actual concerns); and (6) tailoring training materials according to the scope of practice of each
professional group and adapt language to cultural
specicities. All of these strategies help to overcome resistance and keep the implementation
moving forward.
Concerns about limited resources are also
frequently heard when implementing screening.
Two strategies that may be helpful to alleviate
stress on resources are to ensure that the scope of
practice is understood and work with professionals
to determine how to handle various concerns.
Remind people that screening is not creating any
new concerns; it is helping to standardize the
identication of concerns. Person-centered care is
about working with the patient to identify what is
most concerning to him/her at the time and to
develop a plan for the future to address other less
salient concerns. When examining what resources
are available it is important to look beyond the
Psycho-Oncology 20: 463469 (2011)
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468

walls of the cancer center into the community, and

establish connections that might not otherwise be
utilized.
Pre-existing systemic issues may be highlighted
through screening creating another challenge.
For example, determining how the screening will
be charted may reveal gaps in charting that have not
been addressed. It is important that stakeholders
are aware that systemic issues may arise and that
they oer an opportunity to improve the care for
patients. However, they are not always within the
scope of the implementation team to solve.

Conclusions
Screening for Distress oers a rapid initial step that
aids health-care providers in identifying what is
considered a point of distress to patients. It is a
starting point for a person-centered conversation
about the type of assistance or intervention that
could be benecial. Throughout this important
change of practice, we observed a strong commitment from many professionals toward Screening
for Distress. Front line sta are dedicated to
quality improvement, while being in need of
support and feedback. Health-care providers
report that Screening for Distress has a positive
impact on their communication with patients and
with their colleagues.
As with any change, there are challenges related to
implementing Screening for Distress. It is important
to identify these challenges early and develop strategies to overcome them, in order to minimize their
impact throughout the implementation. Despite
these challenges, all CJAG jurisdictions continue to
move forward with implementation. Feedback from
health-care providers suggests that Screening for
Distress is helpful and that the screening process is a
systematic way to identify and discuss several patient
concerns.
Future work will include further resource development, including the development of evidence-based
algorithms, education materials, and sustainability
tools. More jurisdictions will be able to partner with
CJAG and benet from the work that has taken
place. The commitment around sharing information,
resources, and materials will continue.
Overall, national endorsements, guidelines, and
recommendations have laid a solid foundation in
Canada, which has allowed for the rapid uptake
and implementation of Screening for Distress.
Creating a community willing and committed to
sharing resources has allowed the jurisdictions to
progress more quickly than they would have been
able to individually. Ultimately, the vision is one
where the knowledge gained by working with the
jurisdictions who have embraced Screening for
Distress will be passed on to other jurisdictions so
Copyright r 2011 John Wiley & Sons, Ltd.

B. D. Bultz et al.

we can continue to enhance person-centered care

through Screening for Distress.

Acknowledgements
We acknowledge the following groups for their support:
Canadian Partnership Against Cancer, Cancer Journey
Portfolio, Screening for Distress Toolkit Working
Group, the Centre hospitalier universitaire de Quebec
(CHUQ), Cancer Care Nova Scotia, British Columbia
Cancer Agency, Regional Cancer Program of the Hopital
regional de Sudbury Regional Hospital. We would also like
to acknowledge the following contributors: Marianne Arab,
Mike Colon, Sheila Damore-Petingola, Kelly Fenn, Lise
Fillion, Joshua Lounsberry, Josiane Mathieu, Marie De
Serres, Ann Syme, Annie Tremblay, and Kathleen Yue.
Finally, we would like to thank all sta and patients
participating in this important initiative.
Funding: Production of this paper has been made possible
through a nancial contribution from Health Canada,
through the Canadian Partnership Against Cancer. The
views expressed herein represent the views of the authors.

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