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Developing a clinical pathway for the identification and management of anxiety and depression in adult cancer patients: an online Delphi consensus process

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People with cancer and their families experience high levels of psychological morbidity. However, many cancer services do not routinely screen patients for anxiety and depression, and there are no standardized clinical referral pathways. This study aimed to establish consensus on elements of a draft clinical pathway tailored to the Australian context.


A two-round Delphi study was conducted to gain consensus among Australian oncology and psycho-oncology clinicians about the validity of 39 items that form the basis of a clinical pathway that includes screening, assessment, referral and stepped care management of anxiety and depression in the context of cancer. The expert panel comprised 87 multidisciplinary clinician members of the Australian Psycho-oncology Co-operative Research Group (PoCoG). Respondents rated their level of agreement with each statement on a 5-point Likert scale. Consensus was defined as >80 % of respondents scoring within 2 points on the Likert scale.


Consensus was reached for 21 of 39 items, and a further 15 items approached consensus except for specific contextual factors, after two Delphi rounds. Formal screening for anxiety and depression, a stepped care model of management and recommendations for inclusion of length of treatment and time to review were endorsed. Consensus was not reached on items related to roles and responsibilities, particularly those not applicable across cancer settings.


This study identified a core set of evidence- and consensus-based principles considered essential to a stepped care model of care incorporating identification, referral and management of anxiety and depression in adult cancer patients.

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  1. Mitchell AJ, Chan M, Bhatti H, Halton M, Grassi L, Johansen C, Meader N (2011) Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: a meta-analysis of 94 interview-based studies. Lancet Oncol 12:160–174

    Article  PubMed  Google Scholar 

  2. Howell D, Hack TF, Oliver TK, Chulak T, Mayo S, Aubin M et al (2011) Survivorship services for adult cancer populations: a pan-Canadian guideline. Curr Oncol 18:e265–e281

    PubMed Central  CAS  PubMed  Google Scholar 

  3. Walker J, Sawhney A, Hansen CH, Ahmed S, Martin P, Symeonides S et al (2014) Treatment of depression in adults with cancer: a systematic review of randomized controlled trials. Psychol Med 44:897–907

    Article  CAS  PubMed  Google Scholar 

  4. Barrera I, Spiegel D (2014) Review of psychotherapeutic interventions on depression in cancer patients and their impact on disease progression. Int Rev Psychiatr 26:31–43

    Article  Google Scholar 

  5. Subnis UB, Starkweather AR, McCain NL, Brown RF (2014) Psychosocial therapies for patients with cancer: A current review of interventions using psychoneuroimmunology-based outcome measures. Integr Cancer Ther 13:85–104

    Article  PubMed  Google Scholar 

  6. Newell S, Sanson-Fisher RW, Girgis A, Bonaventura A (1998) How well do medical oncologists' perceptions reflect their patients' reported physical and psychosocial problems? Data from a survey of five oncologists. Cancer 83:1640–1651

    Article  CAS  PubMed  Google Scholar 

  7. Jacobson PB (2007) Screening for psychological distress in cancer patients: challenges and opportunities. J Clin Oncol 25:4526–4527

    Article  Google Scholar 

  8. Carlson LE, Groff SL, Maciejewski O, Bultz BD (2010) Screening for distress in lung and breast cancer outpatients: a randomized controlled trial. J Clin Oncol 28:4884–4891

    Article  PubMed  Google Scholar 

  9. Bultz BD, Groff SL, Fitch M et al (2011) Implementing screening for distress, the 6th vital sign: a Canadian strategy for changing practice. Psycho-Oncology 20:463–469

    Article  PubMed  Google Scholar 

  10. Loscalzo M, Clark KL, Holland J (2011) Successful strategies for implementing biopsychosocial screening. Psycho-Oncology 20:455–462

    Article  PubMed  Google Scholar 

  11. Mitchell AJ, Kaar S, Coggan C, Herdman J (2008) Acceptability of common screening methods used to detect distress and related mood disorders—preferences of cancer specialists and non-specialists. Psycho-Oncology 17:226–236

    Article  PubMed  Google Scholar 

  12. Absolom K, Holch P, Pini S et al (2011) The detection and management of emotional distress in cancer patients: the views of health-care professionals. Psycho-Oncology 20:601–608

    Article  PubMed  Google Scholar 

  13. Meijer A et al (2013) Effects of screening for psychological distress on patient outcomes in cancer: a systematic review. J Psychosom Res 75(1):1–17

    Article  PubMed  Google Scholar 

  14. Mitchell AJ (2013) Screening for cancer-related distress: when is implementation successful and when is it unsuccessful? Acta Oncol 52(2):216–224

    Article  PubMed  Google Scholar 

  15. Carlson LE, Waller A, Mitchell AJ (2012) Screening for distress and unmet needs in patients with cancer: review and recommendations. J Clin Oncol 30:1160–1177

    Article  PubMed  Google Scholar 

  16. Panella M, Marchisio S, Di Stanislao F (2003) Reducing clinical variations with clinical pathways: do pathways work? Int J Qual Health Care 15:509–521

    Article  CAS  PubMed  Google Scholar 

  17. Luckett T, Butow PN, King MT (2009) Improving patient outcomes through the routine use of patient-reported data in cancer clinics: future directions. Psycho-Oncology 18:1129–1138

    Article  CAS  PubMed  Google Scholar 

  18. Howell D, Keller-Olaman S, Oliver T, et al (2010) A Pan-Canadian Practice Guideline: Screening, Assessment and Care of Psychosocial Distress (Depression, Anxiety) in Adults with Cancer. Canadian Partnership Against Cancer (Cancer Journey Action Group) and the Canadian Association of Psychosocial Oncology: Toronto. Date Accessed: 31/7/2014

  19. NCCN, Clinical Practice Guidelines in Oncology. Distress Management Version 2.(2013) National Comprehensive Cancer Network. Date Accessed: 31/7/2014

  20. Andersen BL, DeRubeis RJ, Berman BS et al (2014) Screening, assessment, and care of anxiety and depressive symptoms in adults with cancer: an american society of clinical oncology guideline adaptation. J Clin Oncol 31:1605–1619

    Article  Google Scholar 

  21. National Breast Cancer Centre and National Cancer Control Initiative (2003) Clinical practice guidelines for the psychosocial care of adults with cancer. National Breast Cancer Centre, Camperdown, NSW. Date Accessed: 31/7/2014

  22. Zafar SY, Currow DC, Daugherty CK, Abernethy AP (2010) Standards for palliative care delivery in oncology settings. Cancer 16:436–443

    Article  Google Scholar 

  23. Rankin N, Butow P, Thein T et al. Everybody wants it done but nobody wants to do it:’ an exploration of the barrier and enablers of critical components towards creating a clinical pathway for anxiety and depression in cancer. BMC Health Services Research. 15:28 DOI 10.1186/s12913-015-0691-9

  24. Green B, Jones M, Hughes D, Williams A (1999) Applying the Delphi technique in a study of GPs’ information requirements. Health Soc Care Comm 7:198–205

    Article  Google Scholar 

  25. Bruera E, Kuehn N, Miller MJ et al (1991) The Edmonton symptom assessment system (ESAS): a simple method for the assessment of palliative care patients. J Palliat Care 7:6–9

    CAS  PubMed  Google Scholar 

  26. Akizuki N, Akechi T, Nakanishi T et al (2003) Development of a brief screening interview for adjustment disorders and major depression in patients with cancer. Cancer 97:2605–2613

    Article  PubMed  Google Scholar 

  27. Vanhaecht K, De Witte K, Panella M, Sermeus W (2009) Do pathways lead to better organized care processes? J Eval Clin Pract 15:782–788

    Article  PubMed  Google Scholar 

  28. Kadan-Lottick NS, Vanderwerker LC, Block SD et al (2005) Psychiatric disorders and mental health service use in patients with advanced cancer. Cancer 104:2872–2881

    Article  PubMed Central  PubMed  Google Scholar 

  29. Vanhaecht K, Panella M, van Zelm R, Sermeus W (2010) An overview on the history and concept of care pathways as complex interventions. Int J Care Pathw 14:117–123

    Article  Google Scholar 

  30. Cook C, Heath F, Thompson RL (2000) A meta-analysis of response rates in Web- or internet-based surveys. Educ Psychol Meas 60:821–836

    Article  Google Scholar 

  31. Akins RA, Tolson H, Cole BR (2005) Stability of response characteristics of a Delphi panel: application of bootstrap data expansion. BMC Med Res Methodol 5:37. doi:10.1186/1471-2288-5-37

    Article  PubMed Central  PubMed  Google Scholar 

  32. Dudgeon D, King S, Howell D et al (2012) Cancer care Ontario's experience with implementation of routine physical and psychological symptom distress screening. Psycho-Oncology 21:357–364

    Article  PubMed  Google Scholar 

  33. Rotter T, Kinsman L, James E et al (2010) Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database Syst Rev. doi:10.1002/14651858.CD006632

    PubMed  Google Scholar 

  34. Grol R, Grimshaw J (2003) From best evidence to best practice: effective implementation of change in patients' care. Lancet 362:1225–1230

    Article  PubMed  Google Scholar 

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The authors would like to thank the contribution of all participants and Sydney Catalyst, who provided funding for the study.

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Correspondence to Joanne M Shaw.

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Shaw, J.M., Price, M.A., Clayton, J.M. et al. Developing a clinical pathway for the identification and management of anxiety and depression in adult cancer patients: an online Delphi consensus process. Support Care Cancer 24, 33–41 (2016).

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