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Use of psychosocial services increases after a social worker--mediated intervention in gynecology oncology patients.

A holistic approach to the evaluation and management of cancer patients has become well recognized in clinical oncology as an essential feature of patient-centered care (National Comprehensive Cancer Network, 2003). A comprehensive and multidisciplinary care plan, which supplements conventional cancer care with an added emphasis on the psychological, behavioral, and social aspects of illness, has been shown to positively affect a patient's overall wellness and quality of life (Institute of Medicine of the National Academies, 2010). This is especially important because of the prevalence of psychosocial distress in this population, affecting 30 percent to 43 percent of oncology patients in the ambulatory setting (Zabora, BrintzenhofeSzoc, Curbow, Hooker, & Piantadosi, 2001). Psychosocial distress is defined as "a multifactorial unpleasant emotional experience of a psychological (cognitive, behavioral, emotional), social, and/or spiritual nature" (National Comprehensive Cancer Network, 2009). Although psychosocial interventions, including those aimed at reducing distress, have been shown to improve quality of life in adult oncology patients (Rehse & Pukrop, 2003), cancer patients continue to underuse psychosocial services, with only a 14 percent acceptance rate (McDowell, Occhipinti, Ferguson, & Chambers, 2011). This underuse is attributable to a number of factors, including a lack of awareness that services are available, insufficient empowerment to seek out services, fear of associated stigmas, uncertainty regarding whether such resources would be helpful, and logistics such as time and transportation constraints (Eakin & Strycker, 2001; Holland, 2002).

In an analysis of sociodemographic, psychological, and illness-related factors in cancer patients, it has been demonstrated that female gender is an independent predictor of the need for psychosocial support (Ernstmann et al., 2009). In addition to the distress associated with cancer diagnosis and treatment, women with gynecologic malignancies face issues related to reduced reproductive ability and altered sexual function, which may threaten their sense of self and feelings of womanhood (Gilbert, Ussher, & Perz, 2011). This highlights the particular importance of developing methods to increase the awareness and use of psychosocial services by gynecologic oncology patients. Despite physicians' best efforts to provide supportive care, the assessment and management of psychosocial issues in gynecologic oncology patients remains inadequate (Chase, Monk, Wenzel, & Tewari, 2008).

In light of research indicating multiple patient--and provider-specific factors that may pose barriers to the evaluation and management of psychosocial well-being in cancer patients (Schofield, Carey, Bonevski, & Sanson-Fisher, 2006), various studies have explored methods to increase the rates of psychosocial service use. Approaches that have been studied include routine distress screening of all cancer patients, with referral for psychosocial services on detection of distress (Clark, Rochon, Brethwaite, & Edmiston, 2011; Lee, Katona, De Bono, & Lewis, 2010); education of health care staff in recognizing the signs and symptoms of distress, with subsequent implementation of formal distress screening and psychosocial service referral (Grassi et al., 2011); and offering a brief psychosocial intervention to all new oncology patients, independent of distress screening (Powell et al., 2008). It is notable that the majority of studies to date use some form of distress screening as a means of increasing psychosocial service usage. In addition, although several studies have evaluated the efficacy of interventions implemented by nurses and physicians, to our knowledge none have assessed a social worker-mediated approach (Preyde & Synnott, 2009). In this article, we report the results of a program featuring the introduction of psychosocial services to new gynecologic oncology outpatients by an oncology-trained licensed clinical social worker, independent of distress screening, and the effect of this program on the rate of referral for psychosocial services.



All new patients presenting to the gynecologic oncology outpatient service at a National Cancer Institute-designated Comprehensive Cancer Center from November 1, 2010, to May 18, 2011, excluding a 4.5-week period flanking the winter holidays, were identified. During the initial six-week period (phase I), we continued our standard practice in which patients were referred for psychosocial services as deemed necessary on the basis of the clinical judgment of oncology-trained nurses and physicians. During the following six-week period (phase II), an oncology nurse introduced the available services to each patient and provided her with a standardized, printed informational brochure. During the final 12-week period (phase III), we planned for an oncology-trained licensed clinical social worker to meet with each patient and directly introduce psychosocial services, in addition to providing the same informational brochure. Of note, only one social worker was assigned to the gynecologic oncology outpatient service and participated in this study.


We conducted a chart review to compare the rate of patient referral for psychosocial services during each study period. We also assessed whether these referrals were initiated by the patient herself or by clinic staff, including nurses and physicians. Demographic data collected included age, marital status, ethnicity, and presenting diagnosis. Marital status was divided into "married" and "unmarried" categories; the "married" category included married women as well as unmarried, partnered women; whereas the "unmarried" category included single, divorced, separated, and widowed women. The reason for social work referral was determined, as was the length of time between the first gynecologic oncology clinic visit and the referral request. We also performed an assessment of unmet needs, defined as needs that could not be adequately addressed, despite evaluation by the social worker, because of insufficient means or resources.


The data were analyzed in a manner analogous to the intention-to-treat method used in many randomized studies. Thus, regardless of whether a patient in phase II or III actually received an introduction to psychosocial services through the intended intervention, the referral rates in each phase were calculated as though the intervention had been delivered. We chose this method to avoid overestimating the impact of the planned intervention. All means were compared using the Student's t test. Categorical variables were compared using the chi-square test. The probability of referral for psychosocial services in each phase was compared by performing a calculation of relative risk, with a Yates continuity correction because of the modest sample sizes in this study. All figures were graphed using GraphPad Prism version 5.0c for Mac (GraphPad Software Inc., n.d.). This study was approved by the Institutional Review Board of the University of California, San Diego Medical Center.


One hundred ninety-six new patients presented during the study period. There were 52, 57, and 87 patients in phases I, II, and III, respectively. Demographic data are shown in Table 1. Mean age was 55 (range = 20-92). There was no demonstrable difference in mean age, marital status, ethnicity, or presenting diagnosis between the three phases.

During phase I, the rates of patient-initiated and staff-initiated psychosocial service referral were 3.8 percent and 5.8 percent, respectively. In phase II, the rate of patient-initiated referral was 3.5 percent, and no referrals were initiated by staff. It is notable that a survey of the clinic nursing staff revealed that the phase II intervention was implemented less than 50 percent of the time. Given the modest number of participants in phases I and II, and that there was no improvement in the referral rates as a result of the phase II intervention, we used the combined data from phases I and II as the baseline psychosocial service referral rates for comparison with phase III. The baseline rates of patient- and staff-initiated referral during phases I and II were 3.7 percent and 2.8 percent, respectively. During phase III, the rate of patient-initiated referral was 12.6 percent, and the rate of staff-initiated referral was 4.6 percent. Thus, the probability of a patient-initiated referral increased 3.4-fold (95 percent confidence interval [CI] [1.1, 10.4], p = .04) during phase III, as compared with baseline. The probability of any referral during phase III, including those initiated by the patient and by clinic staff, rose 2.7-fold (95 percent CI [1.1, 6.3], p =.03) (see Table 2).

The above results represent an intention-to-treat analysis, as though each patient in phase III received the intended intervention. However, although the program was intended for the introduction of psychosocial services by an oncology social worker to all patients during phase III, this was accomplished only in 34 patients (39 percent) because of scheduling conflicts and the limitations associated with having only one social worker available to participate in the study. Of these 34 patients, eight requested a referral for psychosocial services, resulting in a 24 percent patient-initiated referral rate among those who actually received the planned intervention of in-person introduction to psychosocial services by an oncology social worker.

The mean time from initial presentation to social work referral decreased significantly, from 79.4 days at baseline to 3.9 days during phase III (p < .001) (see Figure 1). There was no detectable difference in psychosocial service referral rates on the basis of patient age or race. However, a higher rate of referral in unmarried patients was noted in all phases; 73 percent of patients referred for psychosocial services were unmarried (see Table 3). Compared with the married patients, unmarried women were 2.6 times more likely to be referred (95 percent CI [1.05, 6.27], p = .05). The presenting diagnosis of the patients who were referred to social work included 27 percent with a pelvic mass, 23 percent with cervical cancer, 18 percent with ovarian cancer, 14 percent with uterine cancer, 9 percent with vulvar cancer, 4.5 percent with a precancerous condition, and 4.5 percent in the other/unknown category. In addition, although this finding did not reach clinical significance, it is notable that 24 percent of patients with human papillomavirus-related cancers were referred for psychosocial services, as compared with a 0 percent to 10 percent referral rate among patients with other cancers.

The specific indications for social work referral could be grouped into four broad categories: resources and benefits (51 percent), emotional support (37 percent), mental health (8 percent), and legal issues (4 percent). Although practical or financial issues were often the main reason for the patient's initial referral, upon evaluation by the social worker, other needs were also identified. Each patient presented with an average of four needs across multiple categories. Of the identified unmet needs, issues related to funding and health insurance were the most common. These included a lack of insurance coverage for oncology clinic visits or mental health services; limited affordable, temporary housing options for patients or family members who resided at a distance from the cancer center; insufficient availability of free or low-cost transportation; and the lack of accessible or affordable caregiver services for patients in need of in-home assistance for basic self-care.


The present cohort study evaluated the impact of a strategy of in-person introduction of psychosocial services to new gynecologic oncology outpatients by an oncology-trained licensed clinical social worker at a comprehensive cancer center. The patients in the intervention cohort (phase III) were found to have significantly higher rates of patient-initiated and overall referral for psychosocial services. We also found a substantial decrease in the length of time from initial visit to social work referral in the phase III cohort.

In contrast to many other studies evaluating methods to increase psychosocial service usage, we chose to deploy our intervention without prior distress screening. A review of the literature showed that the detection and diagnosis of distress does not consistently correlate with increased psychosocial service use. Although it has been demonstrated in hospitalized patients that distress screening leads to increased rates of referral to both psychology and social work (Lee et al., 2010), findings in the ambulatory setting have been variable. Grassi et al. (2011) observed a near-doubling in psychosocial service referral rates, from 6.7 percent to 12 percent, after the implementation of routine distress screening in new oncology outpatients, as well as improved accuracy of distress detection in patients who were referred after routine screening. However, a study by Thewes, Butow, and Stuart-Harris (2009) saw no significant increase in referral rates with routine distress screening among rural cancer patients. Thewes et al.'s study demonstrated a finding similar to ours with a significant diminution in the time to referral for psychosocial services, decreasing from 14 days at baseline to five days after the intervention.

A distress screening tool that has been used in the past at our institution, the Patient Health Questionnaire--9, is useful in the evaluation of depression but does not elicit other etiologies of distress, including anxiety, social needs, and practical issues. This is especially relevant in our study as we found that over 50 percent of the reasons for social work referral were unrelated to mental and emotional health. Numerous other distress screening tools, including those that detect psychosocial issues other than depression, have been validated in the literature (Vodermaier, Linden, & Siu, 2009) and could be considered for use in future studies. Care should be taken when implementing distress screening to avoid labeling a patient with a diagnosis or risk category on the basis of the results, as negative illness perception has been associated with poorer functional status and emotional health, as seen in a study of breast cancer patients (Rozema, Vollink, & Lechner, 2009). This may lead to lower acceptance of available support services, as noted in a study by Shimizu et al. (2010), where only 25 percent of breast and medical oncology patients who were referred to the psychooncology service after positive distress screening actually accepted the referral.

Finally, as a successful outcome with any intervention relies on a patient's readiness and acceptance, we chose an approach that would educate patients about available resources and empower them to seek assistance on their own. The importance of this is illustrated in a study by Powell and colleagues (2008), in which new gynecologic oncology outpatients were randomized to either a one-time, one-hour meeting with a psychologist or to no intervention. Women in the intervention group were found to have improved affect regulation and functional well-being. This result is similar to the findings in a systematic review by Hersch, Juraskova, Price, and Mullan (2009) that included 1,926 gynecologic oncology patients and found that, upon evaluation of a variety of psychosocial interventions, counseling was found to have the greatest impact on improving depression, anxiety, and overall emotional well-being. However, scheduling conflicts and noncompliance in Powell et al.'s (2008) study resulted in less than 50 percent of women randomized to the intervention group actually meeting with a psychologist. In fact, of the patients in the intervention group with an actual diagnosis of cancer, precancer, or a prior gynecologic cancer, the majority did not meet with the psychologist. This may indicate poor patient acceptance of psychosocial interventions that were not requested by the patient, as compared with independently sought support services. It is also notable that use of the cancer resource center for additional informational and supportive services by patients in Powell et al.'s study was low, at 12 percent. This could reflect a lower than expected patient awareness of available services and suggests that a general introduction to the spectrum of existing support services would provide patients with the information necessary to seek out these helpful resources. The increased rate of patient-initiated referral for psychosocial services seen in our study may indicate enhanced patient empowerment.

A review of the literature showed that younger cancer patients tend to have a higher prevalence of distress (Carlson et al., 2004) and are more likely to use psychosocial services (Steginga et al., 2008). Although our study did not find a difference in psychosocial service referral rates by age, the relatively modest sample size may have resulted in insufficient power to reliably assess the influence of age in our population. We did find that a higher proportion of unmarried patients were referred to social work, with a trend toward clinical significance. In a study of breast cancer patients by Wittenberg et al. (2010), newly diagnosed single women had increasing levels of depression, as compared with newly diagnosed partnered women. Unmarried breast cancer survivors also had a higher incidence of reexperiencing trauma symptoms than did their married counterparts. In gynecologic oncology patients, de Groot and colleagues (2007) demonstrated that although both single and partnered women reported psychosocial distress, the etiology of distress varied between the two groups; single patients reported greater concern regarding treatment side effects and communication with the health care team, whereas partnered patients reported worries surrounding changes in sexual function and relationship issues. These findings may help to guide clinicians in determining which patients to offer supportive services to and what type of services are most likely to benefit each individual patient.

In our assessment of psychosocial needs that were unmet despite use of supportive services, issues related to finances and health insurance coverage predominated. It is difficult to compare this finding with the distribution of unmet needs in other settings, as health insurance options and patient populations vary considerably between communities. For example, an assessment of unmet needs in cancer patients in Pennsylvania found the greatest number of unmet needs in the emotional domain and the fewest in transportation (Barg et al., 2007). This is quite different from the findings of our study and may be related to differences in societal infrastructure, such as the location of health care facilities and the availability of public transportation options. In addition, studies have shown that the types of distress and psychosocial needs vary with the phase of care, from initial diagnosis through treatment (Annunziata, Muzzatti, & Bidoli, 2010). Unmet needs are not only an issue in patients undergoing active treatment, but also significantly prevalent in long-term cancer survivors because of fears of recurrence, concerns about the future, and loss of a sense of self (Beesley et al., 2008; Hodgkinson et al., 2007). It is therefore important to periodically assess psychosocial needs throughout the entirety of a patient's treatment and follow-up. As it is often difficult to accurately determine a patient's supportive care needs by clinical impression alone, the use of a validated survey is recommended (Okuyuma et al., 2011; Snyder et al, 2007). Although we did not use such a survey in our study, given that the assessment of unmet needs came from the patient rather than from the clinician, our findings are more likely to reflect a "patient-reported outcome" and thus may be similarly reliable when compared with those obtained by using a validated survey (Bonevski et al., 2000; McDowell, Occhipinti, Ferguson, Dunn, & Chambers, 2010). Incorporation of an unmet needs questionnaire is an important consideration for future studies as well as for the regular, ongoing assessment of supportive care needs.

There are several limitations to our study. This was a nonrandomized study with a small sample size. Although the lack of randomization and modest number of participants limits our ability to determine causality, this study does succeed in generating several hypotheses. These hypotheses include that an in-person introduction to psychosocial services by an oncology social worker increases patient acceptance of available support services, enhances patient empowerment to seek such resources, and accelerates the evaluation and management of psychosocial issues. Such benefits could translate to decreased psychosocial distress and improved overall quality of life. Additional research is warranted to further evaluate the findings of this preliminary study. Another limitation of our study is that, as all new gynecologic oncology outpatients were included, not all study participants had a diagnosis of cancer, possibly limiting the applicability of our findings to cancer patients. In future, larger studies, information regarding both the presenting diagnosis and the post-evaluation diagnosis could be collected, so that data from the patients with a true cancer diagnosis could be analyzed separately. In addition, although age, marital status, ethnicity, and presenting diagnosis were taken into account, other demographic information, such as socioeconomic status (SES), was not routinely collected. As the largest class of unmet needs in our study was related to finances, it would be interesting to determine whether SES or differences in health insurance coverage correlate with psychosocial service use. Furthermore, although an in-person meeting with a social worker proved to be an effective intervention, it is not an easily sustainable practice without an adequately sized team of oncology-trained social workers. This is evidenced by the low rate of in-person introduction that we were able to achieve in our study with just one licensed clinical social worker serving as the liaison for multiple gynecologic oncology clinics and providers. A greater impact may be seen if more social workers can be involved in such a program. Finally, implementation of the phase II intervention by clinic nursing staff was inconsistent, which may have contributed to the absence of an appreciable effect seen on phase II psychosocial service referral rates. This low acceptance rate by health care staff of integrating distress and psychosocial service education into routine practice is in agreement with many other studies, with the most commonly cited reasons being a lack of awareness and time (Eakin & Strycker, 2001). Grassi and colleagues (2011) also noted difficulty achieving consistent administration of the screening questionnaire by health care staff, with only 53 percent of patients receiving the planned intervention. Of those that were screened, 23 percent were referred, similar to the rate of referral in our study when a patient met with a social worker during phase III. In an effort to mitigate this barrier, there has been interest in designating psychosocial distress as the "sixth vital sign," with routine assessment of distress in all patients, similar to that of temperature, blood pressure, pulse, respiratory rate, and pain (Bultz & Johansen, 2011). Also, as a component of ongoing initiatives to promote patient-centered care, the American College of Surgeons Commission on Cancer will require the integration of distress screening and monitoring for all patients at designated cancer centers by 2015 (American College of Surgeons Commission on Cancer, 2012). It is possible that with the incorporation of such measures, as well as upcoming studies focusing on the comprehensive training of multidisciplinary health professionals (Turner et al., 2011), there will be an improvement in the acceptance and implementation of distress detection and monitoring by health care staff, as well as an increased use of psychosocial services. The findings in this study indicate that the introduction of psychosocial services by an oncology-trained licensed clinical social worker to new gynecologic oncology outpatients is associated with a significantly increased referral rate and expedited evaluation. A supportive care program incorporating direct introduction of psychosocial services by a social worker has the potential to enhance patient awareness of available services, increase use of valuable supportive resources, and improve the experience of care.

doi: 10.1093/hsw/hlt006


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Yuko Abbott, MSW, LCSW, is multispecialty clinic social worker, Nina R. Shah, MD, is gynecologic oncology fellow, Kristy K. Ward, MD, is gynecologic oncology fellow, Michael T. McHale, MD, is associate professor, Edwin A. Alvarez, MD, is assistant adjunct professor, Cheryl C. Saenz, MD, is clinical professor, and Steven C. Plaxe, MD, is director, Division of Gynecologic Oncology, Department of Reproductive Medicine, University of California, San Diego, Moores Cancer Center, La Jolla, CA. Address correspondence to Nina R. Shah, Reproductive Medicine, University of California, San Diego, 3855 Health Sciences Drive #0987, La Jolla, CA 92093; e-mail:

Original manuscript received June 21, 2012

Final revision received July 27, 2012

Accepted August 7, 2012

Advance Access Publication May 9, 2013

Table 1: Demographics of New Patients Presenting to the Gynecologic
Oncology Clinic

Variable                   Phase I    Phase II   Phased I & II
                           (n = 52)   (n = 57)     (n = 109)

Mean age                     57.6       56.2         56.5
Marital status              n (%)      n (%)         n (%)
  Married (c)              24 (46)    29 (51)       53 (49)
  Single (d)               28 (54)    28 (49)       56 (51)
  Asian                    70 (13)     3 (5)         10(9)
  Black                     1 (2)      0 (0)         1 (1)
  Hispanic                 13 (25)    11 (19)       24 (22)
  White                    28 (54)    37 (65)       65 (60)
  Other/unknown             3 (6)      6 (1>)        9 (8)
Presenting diagnosis
  Precancerous condition    4 (8)      4 (7)         0 (0)
  Pelvic mass              20 (38)    16 (28)       36 (33)
  Cervical cancer           6 (12)     6 (11)       15 (14)
  Ovarian cancer            8 (15)     7 (12)       15 (14)
  Uterine cancer           10 (19)    14 (24)       28 (25)
  Vaginal cancer            1 (2)      0 (0)         2 (2)
  Vulvar cancer             0 (0)      0 (0)         1 (1)
  Genetic predisposition    3 (6)      6 (11)        8 (7)
  Other/unknown             0 (0)      4 (7)         4 (4)

Variable                   Phase III          p
                           (n = 87)

Mean age                     52.7      .23 (a), .07 (b)
Marital status               n (%)     .61 (a), .91 (b)
  Married (c)               43 (49)
  Single (d)                44 (51)
Race                                   .55 (a), .62 (b)
  Asian                      8 (9)
  Black                      3 (3)
  Hispanic                  24 (28)
  White                     46 (53)
  Other/unknown              6 (7)
Presenting diagnosis                   .55 (a), .14 (b)
  Precancerous condition     4 (5)
  Pelvic mass               26 (30)
  Cervical cancer           14 (16)
  Ovarian cancer            12 (14)
  Uterine cancer            12 (14)
  Vaginal cancer             1 (1)
  Vulvar cancer              3 (3)
  Genetic predisposition     8 (9)
  Other/unknown              7 (8)

(a) Comparing phases I, II, and III.

(b) Comparing the combined phases I and II and phase III.

(c) Includes married women and partnered single women.

(d) Includes single, divorced, separated, and widowed women.

Table 2: Rates of Referral for Psychosocial Services

Referral            Phases I & II   Phase III   Probability    p
                      (n =109)       (n=87)     of Referral

Patient-initiated      4 (3.7)      11 (12.6)       3.4       0.04
Overall                7 (6.4)      15 (17.2)       2.7       0.03

Table 3: A Comparison of Demographic
Variables Based on Referral Status

                       Referred   Not Referred    P
Variable                (n=22)      (n=174)

Mean age                 54.5         55.9       .82
Marital status           n (%)        n (%)      .02
  Married (a)           16 (73)      80 (46)
  Single (b)             6 (27)      94 (54)
Race                                             .49
  Asian                  0 (0)       18 (10)
  Black                  0 (0)        4 (2)
  Hispanic               7 (32)      41 (24)
  White                 13 (59)      98 (56)
  Other/unknown          2 (9)       13 (8)
Presenting diagnosis                             .08
  condition              1 (4.5)     11 (6)
  Pelvic mass            6 (27)      56 (32)
  Cervical cancer        5 (23)      21 (12)
  Ovarian cancer         4 (18)      23 (13)
  Uterine cancer         3 (14)      33 (19)
  Vaginal cancer         0 (0)        2 (2)
  Vulvar cancer          2 (9)        1 (1)
  predisposition         0 (0)       17 (10)
  Other/unknown          1 (4.5)     10 (6)

(a) Includes married women and partnered single women.

(b) Includes single, divorced, separated, and widowed women.
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Author:Abbott, Yuko; Shah, Nina R.; Ward, Kristy K.; McHale, Michael T.; Alvarez, Edwin A.; Saenz, Cheryl C
Publication:Health and Social Work
Article Type:Essay
Geographic Code:1USA
Date:May 1, 2013
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