Key Takeaways:

• Among patients with breast, colorectal, and lung cancer, higher distress scores were associated with worse patient outcomes, indicating that the distress thermometer could be a prognostic tool used to predict clinical risk and guide intervention and supportive care.
• The effect of distress thermometer scores varied based on disease, illustrating the importance of tailoring treatments toward individual profiles and considering specific patient needs when developing treatment plans.
• Integrating the distress thermometer into clinical pathways and value-based care models could potentially improve survival outcomes by identifying patients with high disease burdens and referring them to supportive care.

In this interview, Jessica Paulus, ScD, vice president of real-world research at Ontada, discusses findings from the study “Distress Thermometer Scores and Outcomes in Metastatic Breast, Colorectal, and Lung Cancer: Real-World Evidence from a Large US Community Oncology Setting.” The study analyzed the real-world effect of psychosocial distress on survival outcomes. Paulus shares insights on the potential of the distress thermometer in assessing disease burden, predicting clinical risk, and informing supportive care.

Jessica Paulus, ScD: My name is Jess Paulus. I’m the vice president of real-world research at Ontada, and I lead a scientific team that’s focused on using real-world oncology data from electronic health records (EHR) to understand the experience of cancer patients in real-world clinical practice, particularly in the community setting. We look at patient outcomes and potential adverse events or safety issues. Today, we’ll talk about how clinical demographic and psychosocial factors can influence outcomes in routine care.

This study showed that higher distress scores were linked to worse survival outcomes. How should oncologists use distress screening results in everyday clinical decision-making?

Paulus: Some of these instruments are administered at baseline or at intake, and they might be treated as a screening checkbox or a baseline assessment. But our work suggests they merit further exploration as a potential prognostic clinical risk signal. Our work suggests that the utility of these scores in triggering further assessment and intervention and informing supportive care referrals should be explored. It could also be considered alongside clinical risk factors when managing patients.

In other words, we saw that the distress thermometer data had a statistically significant relationship with overall survival, even when accounting for things that are important for prognosis, like ECOG scores, metastatic disease treatment, and past treatment. We would love to see an integration of the score in decision-making rather than just documentation or screening.

Why do you think severe distress had a stronger impact on survival in lung cancer, while physical concerns were more predictive in breast and colorectal cancer patients?

Paulus: Some of the different patterns we observed across tumor types were not surprising when you think about the course of disease for these different conditions. It’s generally true that patients with lung cancer are more likely to be diagnosed at very advanced stages of disease. They have a shorter overall survival given that stage at diagnosis. Lung cancer patients have more acute disease burden, and the overall distress might reflect that broader instability in their health state. On the other hand, there are specific physical concerns for breast and colorectal cancer that are more tightly tied to treatment tolerance and outcomes. Taken together, this suggests that distress is indeed multidimensional and that different components of distress thermometer assessment matter in different contexts with different indications. Our work showed that the overall score matters and was significantly associated with overall survival along with disease-specific domains.

Many practices already collect distress thermometer scores, but not all use them consistently. What practical steps can oncology teams take to make distress screening more actionable within clinical pathways?

Paulus: Many practices already collect this data. A concern is that maybe it might stop there. What would work is clarity in thresholds for action, such as more automatic referral triggers or clarity on what certain scores mean. Another option would be to have defined workflows for follow-up and embedding the distress thermometer into the care pathways, not separate from the broader multidimensional team. Those are some offerings that would help the screening materially change patient outcomes.

The study found that patients with improving distress scores over time had better outcomes in metastatic colorectal cancer. What does this tell us about the importance of ongoing distress monitoring during treatment?

Paulus: The colorectal cancer finding is an interesting result. It suggests that distress is not static. This is not surprising, but the data corroborates the real-world experience that patients have ups and downs in relationship to changing symptoms and treatments. Our data also suggests that improvement over time in the distress score might reflect better symptom control or better support.

I acknowledge that this could also reflect a type of bias called regression to the mean. Patients might be motivated to complete the distress thermometer instrument when they’re at peak symptom burden. There are methodological issues that still bear more attention. But, all told, this generates some hypotheses that the distress thermometer score may not just be a prognostic marker. It could also be modifiable with the right care that’s put in place for the patient.

Based on these findings, do you think psychosocial distress measures should play a larger role in pathway development, supportive care referrals, or value-based oncology care models?

Paulus: The data that we presented at ISPOR on the distress thermometer, as well as other investigations completed over the last couple of years, suggest that psychosocial factors like the distress thermometer should play a larger role. The best way is to incorporate them in a practical and integrated way. They could be used to inform supportive care referrals. They could be embedded in pathways where appropriate, particularly with high symptom burden conditions. They could potentially be included in value-based care models. There’s more work that needs to be done to explore the prognostic significance of these scores and the meaning of score changes over time, but that could be a long-term goal.

Currently, the distress thermometer, at least in the US Oncology Network, is not mandatory. It would be great to have even more data coming from the distress thermometer because there can be selection issues in which patients are completing the distress thermometer with their care providers. There could be systematic differences among the patients that are producing this data. That’s another area that we need to better understand before thinking about policy changes.

Do you have any additional concluding thoughts for this study?

Paulus: One of the takeaways is that psychosocial factors carry meaningful prognostic significance, sometimes of the same magnitude as established clinical risk factors. Medical oncologists are the types of clinicians who are vested in caring for the whole patient. Having a tool like the distress thermometer that is highly embedded in the EHR makes it very accessible. It’s a useful and promising tool to support medical oncologists and their patients in understanding the best interventions for psychosocial factors and other measures of symptom burden.