ARTICLE IN PRESS

Seminars in Oncology Nursing, Vol 00, No 00 (), 2018: pp 1 11 1

TAGEDH1PSYCHOLOGICAL SYMPTOMS IN
ADVANCED CANCERTAGEDEN
TAGEDPD1X XJENNIFER R. BAILD2X X, D3X XLARA TRAEGERDX4 X, D5X XWILLIAM F. PIRLD6X X, AND D7X XMARIE A. BAKITASD8AGEDENX XT

OBJECTIVES: To discuss psychological symptoms among patients with

advanced cancer, assessment of psychological symptoms, and evidence-based
strategies to manage psychological symptoms.
DATA SOURCES: Current cancer-care guidelines and journal articles.
CONCLUSION: Psychological symptoms are prevalent among patients with
advanced cancer and may not be evident without appropriate screening. Dis-
tressed patients may not meet criteria for a full clinical psychiatric diagnosis,
but may still benefit from interventions to improve quality of life.
IMPLICATIONS FOR NURSING PRACTICE: Nurses can improve the lives of patients
by assessing for psychological symptoms; providing appropriate referrals,
treatment, and/or follow-up; and recommending integrative methods for psy-
chological symptom self-management.
TAGEDPKEYWORDS: psychological symptoms, advanced cancer, quality of life, nursing .

P
sychological symptoms are prevalent
among patients with advanced cancer
and may not be evident without appropri-
ate screening. Observational studies have
contributed to our knowledge of the prevalence and
Jennifer R. Bail, PhD, RN: Postdoctoral Fellow,
Department of Nutrition Sciences, University of Ala-
bama at Birmingham, Birmingham, AL. Lara Traeger,
PhD: Assistant Professor, Department of Psychiatry,
Harvard Medical School, Boston, MA. William F. Pirl,
MD, MPH: Associate Professor of Psychiatry, Miller
School of Medicine, University of Miami, Miami, FL.
Marie A. Bakitas, DNSc, NP-C, FAAN: Professor and
Marie O’Koren Endowed Chair, School of Nursing,
Associate Director of the Center for Palliative and Sup-
portive Care, School of Medicine, University of Ala-
bama at Birmingham, Birmingham, AL.
Address correspondence to Jennifer Bail, PhD, RN,
Department of Nutrition Sciences, University of Ala-
bama at Birmingham, WTI 102C, 1824 6th Ave. S., Bir-
mingham, AL, 35294-3300. e-mail: jbail@uab.edu
© 2018 Elsevier Inc. All rights reserved.
0749-2081
https://doi.org/10.1016/j.soncn.2018.06.005
nature of psychological distress in patients who are
facing end-of-life concerns. The importance of
addressing psychological distress aligns with key
goals of palliative care to reduce patient symp-
toms, enhance care decision-making, and optimize
quality of life. While patients at the end of life are
underrepresented in treatment trials of psychologi-
cal symptoms, the current evidence may be
adapted to the care of patients who are being
treated with palliative care in outpatient, inpatient,
and home care settings. Adaptation involves tailor-
ing assessment and treatment approaches to
patients facing a broad range of physical, psycholog-
ical, functional, and logistical burdens at the time of
receiving palliative care. This article addresses
common psychological symptoms and evidence-
guided recommendations for patients with
advanced cancer who are receiving palliative care.
TAGEDH1PSYCHOLOGICAL SYMPTOMSTAGEDEN
Patients living with advanced cancer experience
psychological symptoms (ie, anxiety, depressive
 ARTICLE IN PRESS
2 J.R. BAIL ET AL.

symptoms, and hopelessness).1-9 Psychological poor adjustment to illness,16,17 poor quality of life,18
symptoms tend to co-occur, having a synergistic and a desire for hastened death.1,19,20
effect and influencing functional activities (eg,
physical, social, role performance, and daily liv- TAGEDH1IMPLICATIONS OF PSYCHOLOGICAL SYMPTOMS IN
ing).10 While the severity, duration, and experi-
ence of psychological symptoms may vary per THE CARE OF PATIENTS WITH ADVANCED CANCERTAGEDEN
individual, it is estimated that one or more psy-
Despite their clinical significance, psychological
chological symptoms occur in 20% to 65% of
symptoms often go unrecognized and untreated.21,22
patients with advanced cancer.1-9
Left unaddressed, psychological symptoms can
Anxiety Symptoms lead to distress.23 The National Comprehensive
Cancer Network (NCCN) defines distress as “. . . a
Anxiety is an emotional and/or physiologic
multifactorial unpleasant psychological (cognitive,
response that is a common experience among
patients coping with any cancer diagnosis. Symp- behavioral, emotional), social, spiritual and/or
physical nature that might interfere with the ability
toms of anxiety are reported to occur in 20% to
to cope effectively with cancer, its physical symp-
60% of cancer patients.2 5,7,9 Anxiety responses
toms, and its treatment. Distress extends along a
can range from normal reactions to extreme dys-
continuum, ranging from common normal feelings
function that can affect decision making, adher-
of vulnerability, sadness, and fears, to problems
ence to treatment, and numerous aspects of quality
that can become disabling, such as depression,
of life and function. While anxiety can occur at dif-
anxiety, panic, social isolation, and spiritual
ferent times throughout different phases of cancer
care, generally it tends to peak at the time of diag- crisis.”24 Investigators report that 32% to 52% of
cancer patients experience a clinically significant
nosis and again at disease progression.4
level of distress (4 on the NCCN Distress
Depressive Symptoms Thermometer screening tool24), with the highest
levels of distress seen among patients who were
Symptoms such as depressed mood, diminished
female, older (>60 years), unemployed, or had
interest or pleasure in activities that were previ-
advanced cancer.15,25,26 Psychological distress may
ously enjoyed, loss of energy, feeling of worthless-
influence patients’ treatment adherence, health
ness or guilt, diminished ability to think or
behaviors, decision-making, relationship with
concentrate, and recurrent thoughts of death or
health care provider, and quality of life. Patients
suicide are indicative of depression. Depressive
experiencing psychological distress are more likely
symptoms are reported to occur in 20% to 35% of
to misunderstand provider recommendations, fear
cancer patients.2,5-7,9 Some depressive symptoms
cancer treatment complications, and perceive
(eg, changes in sleep, energy, or appetite) can over-
barriers to treatment, leading to low engagement in
lap with cancer treatment side effects and may be
medical care and non-acceptance or completion of
attributed to treatment. Thus making depression
cancer treatment.27-30 In addition, psychological
difficult to identify and complicating a differential
distress may limit critical communication with
diagnosis. Depressive symptoms most commonly
oncology providers, interfere with acceptance
occur with disease progression and proximity to
of prognosis, influence decision-making about
death.6
end-of-life care, and increase the risk for hospital-
Hopelessness izations.31-33 Among hospitalized patients with
advanced cancer, psychological distress is associ-
Hope is vital to life and is essential for effectively
ated with extended hospitalizations and inadver-
coping with illness.11 Hopelessness is a feeling or
tent hospital readmissions.34 In time, psychological
state of despair and is associated with anxiety and
distress may lead to diminished quality of life and
depressive symptoms.8,12-14 Feelings of hopelessness
worse cancer outcomes among patients with
are a common reaction to the diagnosis of advanced
advanced cancer.35-41
cancer and have been reported to occur among 45%
to 65% of patients with advanced cancer.1,8 Patients
with feelings of hopelessness may perceive their TAGEDH1ASSESSMENT OF PSYCHOLOGICAL SYMPTOMSTAGEDEN
medical provider as disengaged and less support-
ive.15 Hopelessness can threaten a patient’s psycho- Current cancer care guidelines recommend
logical well-being and has been associated with screening for psychological symptoms as part of
 ARTICLE IN PRESS
standard of care.42-46 Evidence suggests that
screening for and addressing psychological symp-
toms enhances quality of life and may be associ-
ated with improved cancer outcomes.39-41
Screening tools may be rapid, unidimensional, or
multidimensional. Rapid screens can aid in symp-
tom tracking over time. For example, the NCCN
Distress Thermometer provides a rapid distress
screening via a single item (ie, “Please circle the
number [0 10] that best describes how much dis-
tress you have been experiencing in the last week
including today”). While single items provide a
rapid screening, unidimensional instruments may
provide a more substantial evaluation. Unidimen-
sional instruments evaluate symptom severity and
impact on functioning. In addition, lengthier multi-
dimensional instruments evaluate symptoms across
multiple dimensions (eg, physical, emotional,
social, and functional). Table 1 provides a brief list
of example self-report instruments.24, 47-53 The
NCCN Guidelines for Distress Management advise
screening patients at their initial visit and at appro-
priate intervals thereafter as clinically indicated,
including periods of increased vulnerability for dis-
tress (see Table 2).24
Patients who are experiencing psychological
symptoms may have difficulty with recalling events
over a period of weeks; therefore, screenings may
need to be modified. Health care providers may
choose to query patients about a typical day. Sub-
sequently, corroborative information about symp-
tom patterns over time may be obtained from
family members or caregivers. When assessing the
onset of new psychological symptoms, cancer-
related complications need to be considered. For
example, anxiety symptoms can also be because of
an abrupt withdrawal from opioids, adverse medi-
cation effect, cardiac symptoms, or metabolic dis-
order. Patients may not always appear to be
experiencing psychological symptoms and should
be encouraged to inform their health care provider
when they are feeling increased distress, anxiety,
or depression. Providers need to be aware of any
previous history of anxiety and/or depression and
other pertinent risk factors for psychological symp-
toms (see Table 3).54 Individuals who screen posi-
tive for psychological symptoms should be referred
to a mental health professional for a more in-depth
assessment.55 However, many communities lack
mental health providers and few cancer care cen-
ters have the resources for conducting such assess-
ments. In these cases, other approaches, such as
telehealth, may need to be considered.56-58
PSYCHOLOGICAL SYMPTOMS IN ADVANCED CANCER 3
TH1IAGED NTERVENTIONS AIMED AT ADDRESSING
PSYCHOLOGICAL SYMPTOMS IN ADVANCED
CANCERAGEDNTE
While patients experiencing psychological
symptoms may not meet criteria for a clinical
psychiatric diagnosis, they may still benefit from
interventions to improve quality of life. Address-
ing psychological symptoms in advanced cancer
requires collaboration among oncologists,
nurses, pharmacists, and allied health professio-
nals. The following discussion focuses on phar-
macologic, non-pharmacologic, and integrated
approaches.
TAGEDH1PHARMACOLOGIC INTERVENTIONSTAGEDEN
In general, pharmacologic interventions for psy-
chological symptoms follow the same strategies in
individuals with advanced cancer as those without
cancer. This is at least partly because of the evi-
dence base for the effectiveness of pharmacologic
interventions not being as developed as that for
non-pharmacologic interventions. There have
been no randomized, controlled trials in individu-
als with cancer investigating the superiority of one
psychotropic medication over another for psycho-
logical symptoms, and the American Society of
Clinical Oncology’s guidelines for the treatment of
depression and anxiety in cancer survivors do not
include recommendations for specific medica-
tions.54 It should be noted, though, that the exist-
ing evidence for the benefits of psychotropic
medications in individuals without major medical
comorbidities is based on trials with stringent cri-
teria for psychiatric disorders and not merely the
presence of some symptoms. Therefore, it is
unclear if these medications would be beneficial
for psychological symptoms that do not meet crite-
ria for psychiatric disorders.
When psychotropic medications are pre-
scribed for individuals with advanced cancer,
special attention needs to be given to their side-
effect profiles, tolerability, and potential for
interactions. Diarrhea, constipation, nausea,
orthostatic hypotension, QTc prolongation, and
lowered seizure thresholds can be side effects of
some antidepressant medications, and sedation
and confusion can be side effects of benzodiaze-
pines for anxiety.59 However, some side effects
that may be bothersome in non-medically ill
 ARTICLE IN PRESS
4 J.R. BAIL ET AL.

TABLE 1.
Psychological Symptom Self-Report Instruments

Assessment Psychological Instrument Items Recall Screening Scoring and Implications

Type Symptom Period Time

Rapid
Psychological National 1 1 week <1 minute A score of 4 requires further evaluation by
distress Comprehensive the oncologist or nurse and referral to an
Cancer Network appropriate resource
(NCCN) Distress
Thermometer
(DT)24
Anxiety and Patient Health 4 2 weeks <1 minute Each item is scored 0 to 3.
depression Questionnaire-4 Scores range from 0 to 12. Higher scores
(PHQ-4)47 indicate higher depressive and/or anxiety
symptoms
Unidimensional
Anxiety General Anxiety 7 2 weeks 2 3 minutes Each item is rated on a 4-point Likert scale
Disorder that ranges from “not at all (0)” to “nearly
Questionnaire-7 every day (3).” Scores range from 0 to 21.
(GAD-7)48 Clinical cutoffs are: 5 = mild anxiety,
10 = moderate anxiety, and 15 = severe
anxiety. A score of 10 warrants further
evaluation
Depression Patient Health 9 2 weeks 2 3 minutes Each item is rated on a 4-point Likert scale
Questionnaire that ranges from “not at all (0)” to “nearly
Depression Module every day (3).” Scores range from 0 to 27.
(PHQ-9)49 Clinical cutoffs are: 5 = mild depression,
10 = moderate depression, 15 = moderately
severe depression, and 20 = severe
depression. A score of 5 warrants
monitoring re-evaluation and 10 warrants
further evaluation and treatment plan
Anxiety and Hospital Anxiety 14 1 week 3 5 minutes Consists of two subscales, one for anxiety
depression and Depression and one for depression. Each item is rated
Scale (HADS)50 on a 4-point Likert scale that ranges from
“no problems (0)” to “maximum distress
(3).” Subscale cutoff are: 7 = non-case;
8 10 = doubtful case; and 11 = case
Hopelessness Hearth Hope Index 12 2 weeks 3 5 minutes Each item is rated on a 4-point Likert scale
(HHI)51 that ranges from “strongly disagree (1)” to
“strongly agree (4).” Scores range from 12
to 48. Higher scores indicate higher levels
of hope
Beck 20 5 8 minutes Each item response is either “true (0)” or
Hopelessness “false (1).” Scores range from 0 to 20.
Scale (BHS)52 Higher scores indicate higher levels of
hopelessness. Clinical cutoffs are: 3 = no
hopelessness at all; 4 8 = mild
hopelessness, 9 14 = moderate
hopelessness; 15 = severe hopelessness
Multi-dimensional
Quality of life Functional 27 1 week 5 8 minutes Contains the four subscales of: physical (seven
Assessment of items), functional (seven items), social/family
Cancer Therapy (seven items), and emotional well-being (six
(FACT-G)53 items). Each item is rated on a 5-point Likert
scale that ranges from “not at all (0)” to “very
much (4).” Scores range from 0 to 108, with
higher scores reflecting better quality of life

NOTE: All measures included in Table 1 are available in the public domain.
 ARTICLE IN PRESS
TABLE 2.
Periods of Increased Vulnerability for Psychological
Distress in Patients with Cancer
 Finding a suspicious symptom
 During diagnostic workup
 Finding out the diagnosis
 Awaiting treatment
 Change in treatment modality
 End of treatment
 Discharge from hospital following treatment
 Transition to survivorship
 Medical follow-up and surveillance
 Treatment failure
 Recurrence/progression
 Advanced cancer
 End of life
Data from the National Comprehensive Cancer Network.24
individuals may actually be exploited to help
with comorbid cancer-related symptoms. For
example, mirtazapine, an antidepressant medica-
tion, can increase appetite and cause weight
gain, which might be beneficial for patients with
poor appetite.60
Because patients with advanced cancer are
often on multiple medications, prescribers should
check for potential interactions with a new psy-
chotropic medication. Some antidepressant medi-
cations can increase the risk of serotonin
syndrome by interacting with medications that
inhibit monoamine oxidase, such as procarbazine
and linezolid, and medications that inhibit seroto-
nin-norepinephrine reuptake like tramadol.61
Additionally, some psychotropic medications can
inhibit or induce the metabolism of other
TABLE 3.
Risk Factors for Psychological Symptoms
 Prior depressive or anxiety disorder
 Familial history of depression or anxiety
 Persons with other comorbid psychiatric disorders
 History of or current alcohol or substance use or abuse
 Recurrent, advanced, or progressive disease
 Presence of chronic illness(es)
 Single (unmarried or widowed)
 Unemployed or lower socioeconomic status
 Female gender
Data from the American Society of Clinical Oncology.54
PSYCHOLOGICAL SYMPTOMS IN ADVANCED CANCER 5
medications through the hepatic p450 cyto-
chrome system.62 Although its clinical significance
is controversial, one example of this is the poten-
tial inhibition of tamoxifen being metabolized into
its active metabolites.63 An example that may be
more relevant to patients with advanced cancer is
the potential inhibition of codeine being converted
to morphine by paroxetine and fluoxetine.
TAGEDH1NON-PHARMACOLOGIC INTERVENTIONSTAGEDEN
A broad range of non-pharmacologic interven-
tions have been tested to manage, reduce, or pre-
vent psychological symptoms in patients affected
by cancer, although the number of studies in
patients with advanced disease is more limited.
Depending on patient needs, clinicians may con-
sider intervention intensity, frequency, and dura-
tion, as well as the extent to which interventions
may be delivered alone or in combination with
pharmacologic treatments.
With respect to ‘low-dose’ interventions, infor-
mal conversations with oncology nurses provide
opportunities for patients to discuss personal
concerns that they may be harboring because of
not wanting to bother or burden clinic staff.
More formal orientations (eg, a chemotherapy
education session) can further help patients to
normalize and address their concerns and
reduce anticipatory distress before initiating a
new treatment regimen.64 Communication and
education will help to assist patients in managing
normative fluctuations in psychological symp-
toms at specific times, such as treatment initia-
tion, follow-up tests and scans, or changes in
treatment response.65,66
In comparison, moderate to severe psychologi-
cal symptoms that are interfering with quality of
life warrant ‘higher dose’ approaches, such as
psychotherapy, supportive counseling, or stress
management. For patients who do not have prior
exposure to mental health care services and/or
who attribute a negative connotation to a mental
health referral, nurses may help to normalize the
referral by discussing it as a common strategy to
assist patients in managing physical and emo-
tional challenges of cancer care. Nurses also
should inquire about current sources of support
because some patients might already receive
mental health care services or prefer other sup-
port (such as pastoral counseling) within their
community.67
 ARTICLE IN PRESS
6 J.R. BAIL ET AL.
Evidence-based non-pharmacologic interventions
for patients with advanced cancer commonly draw
from cognitive behavioral therapy (CBT), support-
ive-expressive psychotherapy, and/or mind-body
strategies. While the underlying treatment princi-
ples and philosophies may vary, strategies are often
integrated in practice to provide a patient-centered
treatment approach. CBT reflects a problem-ori-
ented approach that patients can apply to enhance
their interpretations and responses to cancer-
related concerns and reduce physical and psycho-
logical symptoms.68-70 In comparison, supportive
expressive psychotherapy reflects a more open-
ended approach that patients can use to process
their cancer-related experiences, including more
existential end-of-life concerns,71 and reduce psy-
chological distress.72 Finally, patients may learn
mind-body strategies such as relaxation to help bol-
ster resilience to stressors and a range of symptoms.
Such strategies can be integrated into clinic settings
as patients undergo chemotherapy or radiation or
await specific procedures.73-76
Given the co-occurrence of symptoms in
advanced cancer,77 as well as limitations in phar-
macologic treatments for physical symptoms
such as chronic cancer pain and fatigue, inter-
ventions for patients may co-address symptom
clusters. However, in the case of severe or
uncontrolled disorders, clinicians should con-
sider referral for treatment protocols that have
been established in the general population.78,79
Notably, several treatment trials in cancer have
focused on specific problems such as insomnia,
anxiety, or post-traumatic stress, while also
showing some benefit on comorbid psychological
symptoms.68,80,81
The use of non-pharmacologic interventions
for patients with advanced cancer depends in
part on treatment accessibility. Recently,
research has increasingly focused on strategies
for increasing accessibility to care, such as inter-
vention delivery via phone or mHealth and/or by
trained nurses and clinicians in palliative and
hospice care.82,83
TAGEDH1INTEGRATED INTERVENTIONSTAGEDEN
One integrated approach aimed at addressing
psychological symptoms in advanced cancer is
the collaborative care model. Researchers have
demonstrated collaborative care models, which
involve sharing care between mental health and
medical care providers, to be effective for treat-
ing depression in samples of patients with can-
cer.84-89 One such collaborative care model, the
Symptom Management Research Trials (SMaRT),
is comprised of a team of oncology nurses and
psychiatrists in collaboration with primary care
physicians. Under the supervision of a psychia-
trist, the SMaRT intervention is delivered by a
specially trained oncology nurse who serves as a
care manager. Oncology nurses were selected
because of their ability to integrate the patient's
depression management with their oncology care
and to prevent the stigma associated with “psy-
chiatric” treatment. The oncology nurses estab-
lish a therapeutic relationship with the patients,
provide information about depression and its
treatment, deliver brief evidence-based psycho-
logical interventions (problem-solving therapy90
and behavioral activation91), and monitor
patients’ progress via routine depression screen-
ing (ie, Patient Health Questionnaire [PHQ]-949).
In addition, the nurses coordinate the patient's
depression management by collaborating with
both the primary care provider and the oncology
team. The psychiatrists supervise the delivery of
the intervention, advise primary care providers
about anti-depressants, and provide direct con-
sultations to participants who are not improving.
Collectively, the SMaRT Oncology Trials have
demonstrated the ability to reduce depression,
anxiety, pain, and fatigue, and to improve quality
of life among cancer patients,85-89 providing a
model for an integrated approach in addressing
psychological symptoms among patients with
advanced cancer.
TAGEDH1ADAPTING INTERVENTIONS FOR PATIENTS WITH
ADVANCED CANCERAGEDNTE
Implementing interventions among patients
with advanced cancer is challenging because of
physical limitations and compromised health sta-
tus.92-94 Alternative approaches (eg, telemedicine)
for patients who are too ill to travel may be consid-
ered.95 Greater accommodation in appointment
scheduling, based on patient availability, and
timely recruitment before progressive physical
decline may be beneficial.96 Furthermore, inter-
ventions can be made brief and portable; such
approaches may include integration into the che-
motherapy infusion visit or delivery via a mobile
app.97,98
 ARTICLE IN PRESS
TAGEDH1ACCESS TO PSYCHOLOGICAL CARE IN INPATIENT
AND OUTPATIENT SETTINGSAGEDNTE
Access to psychological care varies considerably
across geographical locations and cancer care cen-
ters. Many cancer care centers face the obstacles
of lack of mental health providers and limited
community resources. Patients may not have the
means or may be too ill to travel long distances
when local resources are not available. In addition,
the stigma of mental health may prevent patients
from seeking care. Novel strategies to increase
access to care include phone-based, mobile
(mHealth), and nurse-led approaches.
Phone-based
Given that the majority of Americans have access
to a phone, providing an opportunity to talk to
someone about their psychological symptoms via
phone may be one approach for addressing barriers
to psychological care among those with advance
cancer. Kornblith and colleagues99 randomized 192
older patients undergoing treatment for advanced
cancer to receive either a 6-month telephone moni-
toring (TM) + educational materials (EM) (interven-
tion) or EM alone (control). Patients in the EM
group received written materials regarding cancer-
related psychosocial issues and available resources.
Patients in the TM + EM group received monthly
telephone calls to monitor their distress, in addition
to EM. Trained telephone monitors conducted the
monthly monitoring sessions, which screened for
psychologic distress using the Hospital Anxiety and
Depression Scale (HADS50). Distressed patients
(HADS total score 15; or Anxiety and Depression
subscale scores 8) were reported to an oncology
nurse within 24 hours. The oncology nurse then fol-
lowed up with the patient for further assessment,
discussion, and recommendations as needed. At
post-intervention (6-month), patients in the
TM + EM group reported significantly less anxiety
(P <.0001), depression (P = .0004), and overall dis-
tress (P <.0001) compared with patients in the EM
group.
Mobile (mHealth)
Innovations in mobile technology have created a
valuable platform for health education and manage-
ment that may be applied to psychological care
among patients with advanced cancer. Greer and
colleagues98 examined the effectiveness of a CBT
mobile app in remediating anxiety symptoms
PSYCHOLOGICAL SYMPTOMS IN ADVANCED CANCER 7
among 145 patients with advanced cancer. Partici-
pants were randomized to receive either the CBT
mobile app for anxiety or a mobile health educa-
tion program (control). Both programs were deliv-
ered via an electronic tablet over the period of 12
weeks. The CBT app included seven modules
teaching skills to relax the body, reduce worry,
stay present-focused, improve communication, and
plan/pace activities. Overall, both groups reported
improvements in anxiety. However, among partici-
pants with higher baseline anxiety, those in the
intervention reported greater improvements in
anxiety compared with the controls (P = .04).
Nurse-led
Given the extended time that oncology nurses
spend with patients with advanced cancer via che-
motherapy infusions and follow-up visits, they tend
to develop unique long-term relationships and
awareness of patient and family psychological func-
tioning. Thus, nurses can use their existing skills,
or develop specific skills, for addressing psychologi-
cal symptoms. The ongoing Care Management by
Oncology Nurses to Address Supportive Care Needs
(CONNECT) intervention100 is an oncology nurse-
led care management approach to providing sup-
portive care for patients with advanced cancer and
their family caregivers. Oncology nurses are
trained to provide symptom management and emo-
tional support and to use evidence-based strategies
in coordinating care. The trial will assess the
impact of CONNECT among patients (ie, quality of
life, symptom burden, mood, and resource utiliza-
tion) and caregivers (ie, caregiver burden, mood,
and resource utilization).
TAGEDH1NURSING IMPLICATIONSTAGEDEN
As care providers who incorporate assessment
and referral into their clinical practice, oncology
nurses play a pivotal role in psychological symp-
tom management. Oncology nurses are encour-
aged to use assessment skills to evaluate patients
for signs of psychological symptoms, with the
understanding that severity, duration, and experi-
ence of these symptoms may vary per individual.
Nurses may refer patients to an appropriate men-
tal health professional or may perform evaluation
and treatment as their expertise and resources
allow. Assessment of follow-through, compliance,
and satisfaction with referrals and/or pharmaco-
logic treatment is essential.54 Effective
 ARTICLE IN PRESS
8 J.R. BAIL ET AL.

TABLE 4.
Resources for Addressing Psychological Symptoms in Advanced Cancer

Organization Resources Web site Telephone

American Cancer Treatment and Support section discusses managing www.cancer.org 1-800-227-2345
Society (ACS) psychological symptoms
American APOS’s Helpline is a national referral program to help people with www.apos-society.org 1-866-276-7443
Psychosocial cancer and their caregivers find resources, in their own
Oncology Society communities, for the management of psychological symptoms
(APOS)
National Guidelines section includes the NCCN Supportive Care www.nccn.org 1-215-690-0300
Comprehensive Guidelines, which provide evidence-based management of
Cancer Network psychological symptoms
(NCCN) Patient Resources section includes translations of the NCCN
clinical guidelines to help patients talk with their physicians and
empower them to make informed decisions
National Institute of Health and Education section includes information on signs, www.nimh.nih.gov 1-866-615-6464
Mental Health symptoms, risk factors, and treatment for mental health
(NIMH) disorders, as well as downloadable brochures and fact sheets
(English and Spanish)
Oncology Nursing Practice Resources section includes: 1) Putting Evidence into www.ons.org 1-866-257-4667
Society (ONS) Practice (PEP), which categorizes evidence-based
interventions for psychological symptoms by level of
effectiveness, and 2) assessment tools that may be used in
clinical practice
The Patient Health Web site provides Patient Health Questionnaire (PHQ) and the www.phqscreeners.com
Questionnaire General Anxiety Disorder Questionnaire-7 (GAD-7) screeners,
(PHQ) Screeners translations, and instruction manuals for free download. No
permission is required to reproduce, translate, display, or
distribute

communication is vital and should include review-
ing and reinforcing patient and family education
materials and resources, which may include:
stress reduction strategies, sources of informa-
tional support/resources, availability of supportive
care services, availability of financial support, and
signs and symptoms of psychological symptoms.54
Nurses may recommend integrative methods (eg,
relaxation, music therapy, mindfulness) as a form
of psychological symptom self-management.24
When recommending integrative methods, it is
important to keep in mind that patients may vary
in what they prefer, institutions may vary in what
is available, and methods may vary as to the
extent to which they are evidence-based. To effec-
tively aid psychological symptom management of
patients, nurses need to identify and familiarize
themselves with institutional, community, and
online resources for addressing psychological
symptoms (see Table 4). Given that patients living
with advanced cancer experience concurrent psy-
chological symptoms, nurses need to shift focus
from one symptom to the entire experience. It is
important to note that the symptom experience
may vary among patients and may be related to
who they are rather than just their disease.101
TAGEDH1CONCLUSIONTAGEDEN
The diagnosis and treatment of cancer can have
a substantial impact on a patient’s psychological
well-being. Oncology nurses must be aware that
psychological symptoms are prevalent among
patients with advanced cancer and may not be evi-
dent without appropriate screening. Distressed
patients may not meet criteria for a full clinical
psychiatric diagnosis, but may still benefit from
interventions to improve quality of life. Psycholog-
ical symptom management is a critical component
of quality oncology nursing care. Nurses can
improve the lives of patients by assessing for psy-
chological symptoms; providing appropriate refer-
rals, treatment, and/or follow-up; and
recommending integrative methods for psycholog-
ical symptom self-management.
 ARTICLE IN PRESS
TAGEDH1REFERENCESTAGEDEN
1. Breitbart W, Rosenfeld B, Pessin H, et al. Depression,
hopelessness, and desire for hastened death in terminally ill
patients with cancer. JAMA. 2000;284:2907–2911.
2. Brintzenhofe-Szoc KM, Levin TT, Li Y, Kissane DW,
Zabora JR. Mixed anxiety/depression symptoms in a large can-
cer cohort: Prevalence by cancer type. Psychosomatics.
2009;50:383–391.
3. Brocken P, Prins JB, Dekhuijzen P, van der Heijden HF.
The faster the better? A systematic review on distress in the
diagnostic phase of suspected cancer, and the influence of rapid
diagnostic pathways. Psychooncology. 2012;21:1–10.
4. Bronner MB, Nguyen MH, Smets EMA, van de Ven AWH,
van Weert JCM. Anxiety during cancer diagnosis: Examining
the influence of monitoring coping style and treatment plan.
Psychooncology. 2018;27:661–667.
5. Linden W, Vodermaier A, MacKenzie R, Greig D. Anxi-
ety and depression after cancer diagnosis: prevalence rates
by cancer type, gender, and age. J Affect Disord.
2012;141:343–351.
6. Lo C, Zimmermann C, Rydall A, et al. Longitudinal study
of depressive symptoms in patients with metastatic gastrointes-
tinal and lung cancer. J Clin Oncol. 2010;28:3084–3089.
7. Mitchell AJ, Chan M, Bhatti H, et al. Prevalence of depres-
sion, anxiety, and adjustment disorder in oncological, haemato-
logical, and palliative-care settings: a meta-analysis of 94
interview-based studies. Lancet Oncol. 2011;12:160–174.
8. Mystakidou K, Tsilika E, Parpa E, et al. Illness-related hope-
lessness in advanced cancer: influence of anxiety, depression,
and preparatory grief. Arch Psychiatr Nurs. 2009;23:138–147.
9. Wilson KG, Chochinov HM, Skirko MG, et al. Depression
and anxiety disorders in palliative cancer care. J Pain Symp-
tom Manage. 2007;33:118–129.
10. Lenz ER, Pugh LC, Milligan RA, Gift A, Suppe F. The
middle-range theory of unpleasant symptoms: an update. ANS
Adv Nurs Sci. 1997;19:14–27.
11. Fitzgerald Miller J. Hope: a construct central to nursing.
Nurs Forum. 2007;42:12–19.
12. Grassi L, Travado L, Gil F, et al. Hopelessness and
related variables among cancer patients in the Southern Euro-
pean Psycho-Oncology Study (SEPOS). Psychosomatics.
2010;51:201–207.
13. Mansano-Schlosser TC, Ceolim MF, Valerio TD. Poor
sleep quality, depression and hope before breast cancer sur-
gery. Appl Nurs Res. 2017;34(Suppl C):7–11.
14. Yildirim Y, Sertoz OO, Uyar M, Fadiloglu C, Uslu R.
Hopelessness in Turkish cancer inpatients: the relation of hope-
lessness with psychological and disease-related outcomes. Eur
J Oncol Nurs. 2009;13:81–86.
15. Meggiolaro E, Berardi MA, Andritsch E, et al. Cancer
patients' emotional distress, coping styles and perception of
doctor-patient interaction in European cancer settings. Palliat
Support Care. 2016;14:204–211.
16. Grassi L, Rosti G, Lasalvia A, Marangolo M. Psychosocial
variables associated with mental adjustment to cancer. Psy-
chooncology. 1993;2:11–20.
17. Classen C, Koopman C, Angell K, Spiegel D. Coping
styles associated with psychological adjustment to advanced
breast cancer. Health Psychol. 1996;15:434–437.
18. Ferrero J, Barreto MP, Toledo M. Mental adjustment to
cancer and quality of life in breast cancer patients: an explor-
atory study. Psychooncology. 1994;3:223–232.
PSYCHOLOGICAL SYMPTOMS IN ADVANCED CANCER 9
19. Jones JM, Huggins MA, Rydall AC, Rodin GM. Symptom-
atic distress, hopelessness, and the desire for hastened death in
hospitalized cancer patients. J Psychosom Res. 2003;55:411–
418.
20. Mystakidou K, Parpa E, Tsilika E, Pathiaki M, Galanos A,
Vlahos L. Depression, hopelessness, and sleep in cancer patients'
desire for death. Int J Psychiatry Med. 2007;37:201–211.
21. Kissane DW. Unrecognised and untreated depression in
cancer care. Lancet Psychiatry. 2014;1:320–321.
22. Walker J, Hansen CH, Martin P, et al. Prevalence, associ-
ations, and adequacy of treatment of major depression in
patients with cancer: a cross-sectional analysis of routinely col-
lected clinical data. Lancet Psychiatry. 2014;1:343–350.
23. Vitek L, Rosenzweig MQ, Stollings S. Distress in patients
with cancer: definition, assessment, and suggested interven-
tions. Clin J Oncol Nurs. 2007;11:413–418.
24. National Comprehensive Cancer Network (NCCN).
NCCN clinical practice guidelines in oncology: distress man-
agement; Fort Washington, PA: National Comprehensive Can-
cer Network; 2017. Version 2.20172017. Available at: https://
www.nccn.org/. Accessed December 26, 2017.
25. Mehnert A, Hartung TJ, Friedrich M, et al. One in two
cancer patients is significantly distressed: prevalence and indi-
cators of distress. Psychooncology. 2018;27:75–82.
26. Kendall J, Glaze K, Oakland S, Hansen J, Parry C.
What do 1281 distress screeners tell us about cancer
patients in a community cancer center? Psychooncology
2011;20:594-600.
27. Akechi T, Ietsugu T, Sukigara M, et al. Symptom indica-
tor of severity of depression in cancer patients: a comparison of
the DSM-IV criteria with alternative diagnostic criteria. Gen
Hosp Psychiatry. 2009;31:225–232.
28. Ell K, Sanchez K, Vourlekis B, et al. Depression, corre-
lates of depression, and receipt of depression care among low-
income women with breast or gynecologic cancer. J Clin
Oncol. 2005;23:3052–3060.
29. Colleoni M, Mandala M, Peruzzotti G, Robertson C,
Bredart A, Goldhirsch A. Depression and degree of accep-
tance of adjuvant cytotoxic drugs. Lancet. 2000;356:1326–
1327.
30. Berry DL, Blonquist TM, Hong F, Halpenny B, Partridge
AH. Self-reported adherence to oral cancer therapy: Relation-
ships with symptom distress, depression, and personal charac-
teristics. Patient Prefer Adherence. 2015;9:1587–1592.
31. Thompson GN, Chochinov HM, Wilson KG, et al. Prog-
nostic acceptance and the well-being of patients receiving palli-
ative care for cancer. J Clin Oncol. 2009;27:5757–5762.
32. Brink P, Smith TF, Kitson M. Determinants of do-not-
resuscitate orders in palliative home care. J Palliat Med.
2008;11:226–232.
33. DiMatteo MR, Lepper HS, Croghan TW. Depression is a
risk factor for noncompliance with medical treatment: meta-
analysis of the effects of anxiety and depression on patient
adherence. Arch Intern Med. 2000;160:2101–2107.
34. Nipp RD, El-Jawahri A, Moran SM, et al. The relationship
between physical and psychological symptoms and health care
utilization in hospitalized patients with advanced cancer. Can-
cer. 2017;123:4720–4727.
35. Jacobsen PB, Donovan KA, Trask PC, et al. Screening for
psychologic distress in ambulatory cancer patients. Cancer.
2005;103:1494–1502.
 ARTICLE IN PRESS
10 J.R. BAIL ET AL.
36. Trask P, Paterson A, Riba M, et al. Assessment of psycho-
logical distress in prospective bone marrow transplant patients.
Bone Marrow Transplant. 2002;29:917–925.
37. Kennard BD, Stewart SM, Olvera R, Bawdon RE, Lewis
CP, Winick NJ. Nonadherence in adolescent oncology patients:
preliminary data on psychological risk factors and relationships
to outcome. J Clin Psychol Med Settings. 2004;11:31–39.
38. Pirl WF, Greer JA, Traeger L, et al. Depression and sur-
vival in metastatic non small-cell lung cancer: effects of early
palliative care. J Clin Oncol. 2012;30:1310–1315.
39. Andersen BL, Thornton LM, Shapiro CL, et al. Biobehav-
ioral, immune, and health benefits following recurrence for psy-
chological intervention participants. Clin Cancer Res.
2010;16:3270–3278.
40. Giese-Davis J, Collie K, Rancourt KM, Neri E, Kraemer
HC, Spiegel D. Decrease in depression symptoms is associated
with longer survival in patients with metastatic breast cancer: a
secondary analysis. J Clin Oncol. 2011;29:413–420.
41. Pirl WF, Greer JA, Gallagher ER, Temel JS, Traeger L,
Lennes IT. Association of screening for psychosocial distress in
patients with newly diagnosed stage IV NSCLC and survival
[abstr 9030]. J Clin Oncol. 2012;30(15S).
42. Skolarus TA, Wolf AM, Erb NL, et al. American Cancer
Society prostate cancer survivorship care guidelines. CA Can-
cer J Clin. 2014;64:225–249.
43. Runowicz CD, Leach CR, Henry NL, et al. American
Cancer Society/American Society of Clinical Oncology Breast
Cancer Survivorship Care Guideline. CA Cancer J Clin.
2016;66:43–73.
44. El-Shami K, Oeffinger KC, Erb NL, et al. American Can-
cer Society Colorectal Cancer Survivorship Care Guidelines.
CA Cancer J Clin. 2015;65:428–455.
45. Denlinger CS, Ligibel JA, Are M, et al. NCCN Guidelines
insights: survivorship. Version 1.2016. J Natl Compr Canc
Netw. 2016;14:715–724.
46. Cohen EE, LaMonte SJ, Erb NL, et al. American Cancer
Society Head and Neck Cancer Survivorship Care Guideline.
CA Cancer J Clin. 2016;66:203–239.
47. Kroenke K, Spitzer RL, Williams JB, L€ owe B. An ultra-
brief screening scale for anxiety and depression: the PHQ 4.
Psychosomatics. 2009;50:613–621.
48. Spitzer RL, Kroenke K, Williams JB, L€ owe B. A brief mea-
sure for assessing generalized anxiety disorder: the GAD-7.
Arch Intern Med. 2006;166:1092–1097.
49. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity
of a brief depression severity measure. J Gen Intern Med.
2001;16:606–613.
50. Zigmond AS, Snaith RP. The hospital anxiety and
depression scale. Acta Psychiatr Scand. 1983;67:361–370.
51. Herth K. Abbreviated instrument to measure hope:
development and psychometric evaluation. J Adv Nurs.
1992;17:1251–1259.
52. Beck AT, Weissman A, Lester D, Trexler L. The mea-
surement of pessimism: the hopelessness scale. J Consult Clin
Psychol. 1974;42:861–865.
53. Cella DF, Tulsky DS, Gray G, et al. The Functional
Assessment of Cancer Therapy scale: development and vali-
dation of the general measure. J Clin Oncol. 1993;11:570–
579.
54. Andersen BL, DeRubeis RJ, Berman BS, et al. Screening,
assessment, and care of anxiety and depressive symptoms in
adults with cancer: an American Society of Clinical Oncology
guideline adaptation. J Clin Oncol. 2014;32:1605–1619.
55. Pirl WF, Fann JR, Greer JA, et al. Recommendations for
the implementation of distress screening programs in cancer
centers: report from the American Psychosocial Oncology Soci-
ety (APOS), Association of Oncology Social Work (AOSW), and
Oncology Nursing Society (ONS) joint task force. Cancer.
2014;120:2946–2954.
56. Hearn RT, Rooney DL, Grecco EC. Integrating mental
health specialty services via telehealth. Arch Psychiatr Nurs.
2015;29:364.
57. Lal S, Adair CE. E-mental health: a rapid review of the
literature. Psychiatr Serv. 2014;65:24–32.
58. Fortney JC, Pyne JM, Edlund MJ, et al. A randomized
trial of telemedicine-based collaborative care for depression. J
Gen Intern Med. 2007;22:1086–1093.
59. Grassi L, Caruso R, Hammelef K, Nanni MG, Riba M. Effi-
cacy and safety of pharmacotherapy in cancer-related psychiat-
ric disorders across the trajectory of cancer care: a review. Int
Rev Psychiatry. 2014;26:44–62.
60. Muriel AC. Psycho-oncology: a quick reference on the
psychosocial dimensions of cancer symptom management.
New York, NY: Oxford University Press; 2017.
61. Wang RZ, Vashistha V, Kaur S, Houchens NW. Serotonin
syndrome: preventing, recognizing, and treating it. Cleve Clin J
Med. 2016;83:810–817.
62. Davis MP, Homsi J. The importance of cytochrome P450
monooxygenase CYP2D6 in palliative medicine. Support Care
Cancer. 2001;9:442–451.
63. Kelly CM, Juurlink DN, Gomes T, et al. Selective seroto-
nin reuptake inhibitors and breast cancer mortality in women
receiving tamoxifen: a population based cohort study. BMJ.
2010;340(Suppl C):693.
64. McQuellon RP, Wells M, Hoffman S, et al. Reducing dis-
tress in cancer patients with an orientation program. Psychoon-
cology. 1998;7:207–217.
65. Gabriel GS, Lah M, Barton M, Au G, Delaney G, Jalaludin
B. Do cancer follow-up consultations create anxiety? J Psycho-
soc Oncol. 2008;26:17–30.
66. Lofters A, Juffs HG, Pond GR, Tannock IF. "PSA-itis":
knowledge of serum prostate specific antigen and other causes
of anxiety in men with metaststic prostate cancer. J Urol.
2002;168:2516–2520.
67. Lengacher CA, Bennett M, Kip KE, et al. Frequency of
use of complementary and alternative medicine in women with
breast cancer. Oncol Nurs Forum. 2002;29:1445–1452.
68. Greer JA, Traeger L, Bemis H, et al. A pilot randomized
controlled trial of brief cognitive-behavioral therapy for anxiety in
patients with terminal cancer. Oncologist. 2012;17:1337–1345.
69. Kangas M, Bovbjerg DH, Montgomery GH. Cancer-
related fatigue: a systematic and meta-analytic review of non-
pharmacological therapies for cancer patients. Psychol Bull.
2008;134:700–741.
70. Lee YH, Chiou PY, Chang PH, Hayter M. A systematic
review of the effectiveness of problem-solving approaches
towards symptom management in cancer care. J Clin Nurs.
2011;20:73–85.
71. Breitbart W. Spirituality and meaning in supportive care:
spirituality- and meaning-centered group psychotherapy inter-
ventions in advanced cancer. Support Care Cancer.
2002;10:272–280.
72. Miovic M, Block S. Psychiatric disorders in advanced
cancer. Cancer. 2007;110:1665–1676.
73. Jacobsen PB, Meade CD, Stein KD, Chirikos TN, Small
BJ, Ruckdeschel JC. Efficacy and costs of two forms of stress
 ARTICLE IN PRESS
management training for cancer patients undergoing chemo-
therapy. J Clin Oncol. 2002;20:2851–2862.
74. Krischer MM, Xu P, Meade CD, Jacobsen PB. Self-admin-
istered stress management training in patients undergoing
radiotherapy. J Clin Oncol. 2007;25:4657–4662.
75. Luebbert K, Dahme B, Hasenbring M. The effectiveness
of relaxation training in reducing treatment-related symptoms
and improving emotional adjustment in acute non-surgical can-
cer treatment: a meta-analytical review. Psychooncology.
2001;10:490–502.
76. Sheinfeld Gorin S, Krebs P, Badr H, et al. Meta-analysis
of psychosocial interventions to reduce pain in patients with
cancer. J Clin Oncol. 2012;30:539–547.
77. Thornton LM, Andersen BL, Blakely WP. The pain,
depression, and fatigue symptom cluster in advanced breast
cancer: covariation with the hypothalamic-pituitary-adrenal
axis and the sympathetic nervous system. Health Psychol.
2010;29:333–337.
78. Craske MG, Barlow DH. Mastery of your anxiety and
panic: therapist guide. New York, NY: Oxford University Press;
2006.
79. Foa E, Hembree E, Rothbaum B. Prolonged exposure ther-
apy for PTSD: emotional processing of traumatic experiences.
Therapist guide. New York, NY: Oxford University Press; 2007.
80. DuHamel KN, Mosher CE, Winkel G, et al. Randomized
clinical trial of telephone-administered cognitive-behavioral
therapy to reduce post-traumatic stress disorder and distress
symptoms after hematopoietic stem-cell transplantation. J Clin
Oncol. 2010;28:3754–3761.
81. Savard J, Simard S, Ivers H, Morin CM. Randomized
study on the efficacy of cognitive-behavioral therapy for insom-
nia secondary to breast cancer, part I: sleep and psychological
effects. J Clin Oncol. 2005;23:6083–6096.
82. Mannix KA, Blackburn IM, Garland A, et al. Effectiveness
of brief training in cognitive behaviour therapy techniques for
palliative care practitioners. Palliat Med. 2006;20:579–584.
83. McCorkle R, Dowd M, Ercolano E, et al. Effects of a nursing
intervention on quality of life outcomes in post-surgical women
with gynecological cancers. Psychooncology. 2009;18:62–70.
84. Ell K, Xie B, Quon B, Quinn DI, Dwight-Johnson M, Lee
P-J. Randomized controlled trial of collaborative care manage-
ment of depression among low-income patients with cancer. J
Clin Oncol. 2008;26:4488–4496.
85. Rodin G. Effective treatment for depression in patients
with cancer. Lancet. 2014;384:1076–1078.
86. Sharpe M, Walker J, Hansen CH, et al. Integrated collab-
orative care for comorbid major depression in patients with
cancer (SMaRT Oncology-2): a multicentre randomised con-
trolled effectiveness trial. Lancet. 2014;384:1099–1108.
87. Strong V, Waters R, Hibberd C, et al. Management of
depression for people with cancer (SMaRT oncology 1): a rand-
omised trial. Lancet. 2008;372:40–48.
PSYCHOLOGICAL SYMPTOMS IN ADVANCED CANCER 11
88. Walker J, Hansen CH, Martin P, et al. Integrated collabo-
rative care for major depression comorbid with a poor progno-
sis cancer (SMaRT Oncology-3): a multicentre randomised
controlled trial in patients with lung cancer. Lancet Oncol.
2014;15:1168–1176.
89. Walker J, Sharpe M. Depression care for people with can-
cer: a collaborative care intervention. Gen Hosp Psychiatry.
2009;31:436–441.
90. Mynors-Wallis L. Problem-solving treatment for anxiety
and depression: a practical guide. New York, NY: Oxford Uni-
versity Press; 2005.
91. Hopko DR, Lejuez C, Ruggiero KJ, Eifert GH. Contempo-
rary behavioral activation treatments for depression: proce-
dures, principles, and progress. Clin Psychol Rev. 2003;23:
699–717.
92. Ewing G, Rogers M, Barclay S, McCabe J, Martin A, Todd
C. Recruiting patients into a primary care based study of pallia-
tive care: why is it so difficult? Palliat Med. 2004;18:452–459.
93. Sherman DW, McSherry CB, Parkas V, Xiang YY, Calabr-
ese M, Gatto M. Recruitment and retention in a longitudinal
palliative care study. Appl Nurs Res. 2005;18:167–177.
94. Steinhauser KE, Clipp EC, Hays JC, et al. Identifying,
recruiting, and retaining seriously-ill patients and their care-
givers in longitudinal research. Palliat Med. 2006;20:745–754.
95. Hennemann-Krause L, Lopes AJ, Araujo JA, Petersen
EM, Nunes RA. The assessment of telemedicine to support out-
patient palliative care in advanced cancer. Palliat Support
Care. 2015;13:1025–1030.
96. Lo C, Hales S, Chiu A, et al. Managing Cancer And Living
Meaningfully (CALM): randomised feasibility trial in patients
with advanced cancer. BMJ Support Palliat Care 2016. http://
dx.doi.org/10.1136/bmjspcare-2015-000866. [Epub ahead of
print].
97. Song QH, Xu RM, Zhang QH, Ma M, Zhao XP. Relaxation
training during chemotherapy for breast cancer improves men-
tal health and lessens adverse events. Int J Clin Exp Med.
2013;6:979–984.
98. Greer J, Jacobs JM, Pensak N, et al. Randomized trial of a
cognitive-behavioral therapy mobile app for anxiety in patients
with incurable cancer. J Clin Oncol. 2017;35(Suppl 15).
10022-10022.
99. Kornblith AB, Dowell JM, Herndon JE, et al. Tele-
phone monitoring of distress in patients aged 65 years or
older with advanced stage cancer. Cancer. 2006;107:2706–
2714.
100. Becker CL, Arnold RM, Park SY, et al. A cluster ran-
domized trial of a primary palliative care intervention (CON-
NECT) for patients with advanced cancer: protocol and key
design considerations. Contemp Clin Trials. 2017;54:98–104.
101. Matthews EE, Schmiege SJ, Cook PF, Sousa KH. Breast
cancer and symptom clusters during radiotherapy. Cancer
Nurs. 2012;35:E1–E11.