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According to the National Comprehensive Cancer Network (NCCN), distress is:

a multifactorial unpleasant emotional experience of a psychological (cognitive, behavioral, emotional), social, and/or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms and its treatment. Distress extends along a continuum, ranging from common normal feelings of vulnerability, sadness, and fears to problems that can become disabling, such as depression, anxiety, panic, social isolation, and existential and spiritual crisis.1

The above-mentioned definition looks beyond thinking in terms of diagnosable mood disorders such as major depression, and considers minor and subsyndromal states, such as adjustment disorders. This is notable because individuals presenting with mild-to-moderate levels of distress may also exhibit significant impairment in functioning2,3 and require psychological treatment just as those with diagnosable disorders do.3

Distress is common in cancer patients with prevalence rates for clinical distress varying by disease site ranging from rates as high as 43.4% in lung cancer to 29.6% for gynecological cancers.4 Rates are likely higher if minor and subsyndromal states are considered. Multiple sources of distress accompany a cancer diagnosis and reemerge at intervals of treatment, changes in disease status, and other markers along the cancer experience.1,4 Additionally, the needs and concerns of the patient impact the relationships in which the patient is involved.5,6

While some distress is normal, it is not benign. Psychological distress in cancer patients must be addressed, as failure to do so may compromise health and quality of life (QOL) outcomes. For example, untreated depression increases rates of noncompliance with difficult and complex chemotherapy and radiation treatment regimens.7,8 A recent meta-analysis concluded that depressive symptoms were rather consistently associated with a significant but small increase in mortality, independent of other known risk factors.9 The psychoneuroimmunological literature is replete with studies documenting various aspects of reduced immune function and dysregulated hypothalamic–pituitary axis and noradrenergic stress response activity in distressed patients. For example, patients with even mild-to-moderate levels of depression have reduced natural killer cell activity.10 Patients treated with interventions for psychosocial distress have been shown to improve quantitative and functional aspects of immunity as well as lower recurrence rates.11 Untreated psychological distress also may lead to social isolation and reduced QOL. Assessing distress in cancer patients and offering assistance when distress is significant may lower patients' vulnerability to these negative effects.12,13


The assessment of distress should become an integral part of routine oncological care; results can be used to alert available service staff to patient needs. Patients and their families can be made aware of resources available to assist them as they adjust to diagnosis and treatment. Hospitals and other cancer care facilities have a unique opportunity to intervene ...

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