《Supportive Care in Cancer》：Preliminary feedback from adult oncology clinic providers on a psychosocial screening tool for young adult patients with cancer
心理社会筛查的整合已被确认为标准医疗实践，尽管其成功实施在很大程度上依赖于医护人员的积极参与。本研究旨在调查医护人员对将心理社会筛查工具整合到一家主要服务于血液系统恶性肿瘤患者的综合性癌症中心标准医疗实践中的认知。方法：青少年与年轻成人心理肿瘤筛查工具（Adolescent and Young Adult Psycho-Oncology Screening Tool, AYA-POST）或青少年与年轻成人心理肿瘤 survivorship 筛查工具（Adolescent and Young Adult Psycho-Oncology Survivorship Screening Tool, AYA-S-POST）作为更广泛的程序开发项目的一部分，被应用于移植与细胞治疗（Transplant and Cellular Therapies, TCT）门诊的患者中。随后，研究人员设计了调查问卷以评估医护人员将AYA筛查工具整合到临床护理中的认知。调查项目改编自先前的一项研究。随后分析了医护人员对整合适龄心理社会筛查的认知信息。结果：在符合条件的20名医护人员（8名医师和6名高级执业提供者）中，有14名对AYA筛查工具提供了反馈。共有13名医护人员（92.9%）在医疗就诊期间与年轻成人患者讨论过该筛查工具。总体而言，TCT医护人员对AYA筛查工具持中立至积极的认知。结论：本研究结果显示，高流量成人肿瘤门诊的医护人员对在医疗点整合适龄心理社会筛查普遍持积极态度。鉴于医护人员的可接受性，对年轻成人进行常规筛查或可使其更好地持续满足其未竟需求，并提升其肿瘤医疗质量。
adolescents and young adults diagnosed with cancer, abbreviated as AYAs, aged 15-39, constitute a unique and growing patient population with distinct supportive care and treatment needs. A cancer diagnosis during this developmental period may interrupt numerous developmental processes and milestones, such as independence, educational or vocational plans, marriage, and having children, among others. An established body of research recognizes that AYAs require developmentally tailored treatment for their medical and psychosocial needs. While these factors call for AYA-specific healthcare programming to address unmet needs, most AYAs receive care in general adult oncology settings as opposed to AYA-specific settings. The model of care in adult settings, however, is not tailored to AYAs' needs and oftentimes overlooks family involvement, lacks supportive services, stretches their capacities for health literacy and self-advocacy, and can feel isolating. Moreover, many oncology providers treating AYAs in adult settings are unaware of the specialized care considerations or misjudge their psychosocial needs entirely, likely due to the widespread lack of AYA-specific training. This lack of awareness may contribute to the disparities in oncology treatment outcomes and higher levels of distress among AYAs compared to other age groups, a phenomenon called "the AYA Gap." This gap highlights the necessity for practical tools that can assist providers in identifying and addressing the unmet care needs of AYAs where they are treated.
Psychosocial screening integration has been recognized as a standard of care, though successful implementation relies heavily on provider engagement. Psychosocial screening includes standardized tools to identify distress, unmet needs, and guide timely referrals to support services. Psychosocial screening at regular intervals in oncology treatment has been advised by the National Comprehensive Cancer Network (NCCN), the American College of Surgeons Commission on Cancer (CoC), and the American Society of Clinical Oncology (ASCO) as a standard of care. The NCCN has led this charge by developing and validating the Distress Thermometer (DT) and Problem Checklist (PC) as screening tools for clinical use. However, these tools were validated in an older adult population (mean age > 40 years old) and lack AYA developmentally salient concerns. To address these limitations, the NCCN Adolescent and Young Adult Oncology Guidelines were the first to formally recognize AYAs as a distinct cancer population and recommend comprehensive psychosocial assessment early in the course of care.
In efforts to reduce "the AYA Gap," AYA-specific tools, such as the AYA Psycho-Oncology Screening tool (AYA-POST) and AYA Survivorship Psycho-Oncology Screening Tool (AYA-S-POST), have been adapted from the NCCN DT and PC framework outlined in the NCCN AYA Oncology Guidelines. These age-specific concerns include items relating to autonomy, isolation, education, employment, finances, relationships, and fertility.
When integrated into clinical care, age-appropriate psychosocial screening for AYAs in oncology settings elicits clear benefits. For instance, patients may feel more empowered to speak up to their provider and discuss sensitive topics that may not otherwise be brought up. In addition to enhancing patient-provider communication and prompting necessary referrals, screening has the potential to improve treatment adherence and facilitate patient-centered care. Despite growing evidence of the benefits of screening, it remains under-implemented in practice. Zebrack and colleagues examined adherence to CoC recommendations across 55 cancer centers and found that only 67.6% of patients were marked as screened per their institution's protocol. These data highlight the importance of examining provider perceptions of screening, as they are a primary determinant in sustaining a psychosocial screening program.
Provider perceptions are central to sustained screening practices, and understanding their perspectives is essential to inform scalable and effective integration of AYA-specific screening. While oncology providers generally agree on the benefits of psychosocial screening, there is a paucity of literature evaluating AYA-specific tools. Patterson and colleagues were the first to evaluate the clinical utility of the AYA-POST from both patient and provider perspectives. However, this study was limited in that it was conducted in a specialized AYA care clinic where providers were trained in developmentally appropriate care, which reduces generalizability to adult oncology settings, where the overwhelming majority of AYAs receive their care.
Although existing literature highlights the benefits of AYA-specific screening, few studies have examined the benefit of utilizing age-appropriate tools in adult oncology settings, and furthermore, how adult oncology providers perceive and engage with these tools. Much of the research to date on provider perspectives has been conducted within specialized AYA programs, which may not translate to typical adult oncology clinics where providers are not attuned to AYA-specific developmental needs. As a result, providers' perspectives of the feasibility, utility, and integration of AYA screening remain underexplored in these settings. Accordingly, the present study sought to explore oncology providers' feedback on integrating AYA-specific psychosocial screening within an adult oncology clinic. Findings will inform strategies for improving screening integration and provider engagement with AYA-focused psychosocial care.
As part of a broader program development initiative, the AYA-POST or AYA-S-POST, adapted to prompt patients to prioritize their top three concerns, was integrated into routine care at the Transplant and Cellular Therapies (TCT) clinic from October 2024 to February 2025. Prior to integrating the AYA screening tool, the clinic's standard screening consisted of the PHQ-4; no other psychosocial screening tools were in routine use. This study was conducted in an adult clinic, limiting participant eligibility to young adult patients (YAs, ages 18-39). YAs with an oncologic diagnosis receiving care at the clinic were eligible to receive the psychosocial screening tool. Researchers screened eligible patients using a chart review to determine the appropriate version of the screening tool based on their treatment status (i.e., active treatment or survivorship). To minimize patient burden, the AYA screening tool was administered at monthly intervals, despite many patients attending weekly follow-up visits.
Providers received training approximately one month prior to roll-out. The research team trained the TCT providers and staff through multiple methods, including presentations during TCT weekly meetings, digital training materials, and ongoing in-clinic discussions and interactions during the study period. Broadly, the research team advised providers to attend to high-priority concerns indicated on the tool during the encounter, respond to clinically significant distress scores by discussing a psychology referral (distress scores 5 and above, as per clinical cut-off established by Patterson and colleagues), and make referrals to appropriate services.
During a routine oncology visit at the TCT clinic, front desk staff informed eligible YA patients that their provider requested for them to complete a brief paper screener prior to the visit while waiting to be roomed. Once roomed, completed screeners were placed in examination rooms for provider review during the encounter. Research team emailed TCT providers weekly with a personalized list of all the providers' eligible patients scheduled to receive a screening tool that week, as well as reminders for providers to screen YAs with the appropriate tool, discuss top concerns identified by the screener, and make referrals as needed.
To assess provider perceptions of integrating the AYA screening tool into clinic care, research personnel designed a survey. After searching through available and validated provider-facing measures and questionnaires, none was identified that appeared relevant or appropriate related to the use of a clinical screening tool. Accordingly, survey items for this study were drawn from Patterson and colleagues' study examining the clinical utility of the AYA-POST among providers who utilized the tool in an AYA-specific setting. Items assessed perceptions on clinical relevance, usefulness, practical benefits, and any feasibility barriers for continued use of the tool. The final survey consisted of 21 items. Eleven items assessed clinical utility, rated on a 5-point Likert scale (1 = "strongly disagree" to 5 = "strongly agree"). Ten items assessed perceived barriers to use, rated on a 5-point Likert scale (1 = "not a barrier" to 5 = "significant barrier").
Eligible participants were physicians (MD, DO) and Advanced Practice Providers (APPs; nurse practitioners, advanced practice registered nurses, physician assistants) at a large outpatient clinic within a comprehensive cancer center that primarily serves patients with hematologic malignancies. Both provider types were included, given that patients in this clinic typically alternate visits between physicians and APPs, resulting in comparable engagement with the psychosocial screening tool. Providers who did not treat YA patients during the study period were excluded.
Recruitment occurred following the full duration of the psychosocial screening tool program roll-out. Study team members approached eligible providers in clinic, described the study, and invited participation. Providers completed the survey in REDCap either on a clinic tablet or via QR code on a personal device. Of 20 eligible providers, 14 completed the survey. Non-participation was due to one decline, two who initially agreed but did not complete the survey due to time constraints, and three who were not present at the clinic during recruitment.
All data were collected and managed using Research Electronic Data Capture (REDCap) and stored on secure, Virtual Private Network-protected servers. Data was cleaned, managed, and analyzed using IBM SPSS Statistics, version 29.0.2.0. Incomplete or empty data lines were removed before running descriptive data analyses.
Eight physicians and six APPs (N = 14) provided feedback on the AYA screening tool, and all except for one (92.9%) reported using it in medical visits with a YA patient. During the time leading up to the day of data collection, the providers completed a median of six visits (IQR 3-12.75; range 1-17) where the YAs completed at least part of the psychosocial screener.
Overall, the TCT providers had neutral to positive (i.e., no negative) perceptions of the AYA screening tool. Specifically, they perceived that the screening tool covered important issues for AYAs (n = 12 "agreed" or "strongly agreed"), quickly identified problems for providers (n = 11), including identifying problems they may not have otherwise identified (n = 12), and that it was easy to interpret (n = 12).
Providers perceived that the AYA screening tool improved patient care (n = 12) and would be happy to administer the tool to future patients (n = 12). They believed that the screening tool helped patients express their needs (n = 12) and assisted providers in communicating and maintaining rapport (n = 10). The AYA screening tool assisted providers to make appropriate follow-up referrals for their psychosocial needs (n = 9) and manage distress in patients (n = 8). Notably, most providers did not think that administering the screener slowed down or interfered with clinical operations (n = 9).
They indicated the following as non-barriers (i.e., "not a barrier at all," "minor barrier") to using the AYA screening tool: not believing screening tools are useful in the first place (n = 13), not knowing how to identify distress (n = 13), being unclear who is responsible to screen for distress (n = 13), being uncomfortable with discussing distress with patients (n = 14), and being uncertain about distress treatment options (n = 12).
Barriers included not believing that interventions for distress are effective (n = 1, "significant barrier"), limited resources for patient referrals (n = 1, "significant barrier"), and lack of time (n = 1, "significant barrier"). And importantly, patients are too unwell or distressed to complete the screening tool (n = 1, "major barrier"), and patients are unwilling or reluctant to discuss their distress (n = 1, "significant barrier"; n = 1, "major barrier"). The one provider who has not yet used this tool with patients marked lack of time as a "moderate barrier."
Most YAs receive oncology care at adult oncology clinics. Thus, it is essential to understand oncology providers' perceptions about integrating age-appropriate psychosocial screening for YAs being treated in this setting. This study adds to the dearth of literature on provider perspectives to inform and enhance the quality-of-care YAs receive in adult oncology clinics at point of care. The adult oncology providers in the TCT clinic viewed the clinical integration of the AYA-specific psychosocial screener to be acceptable and feasible, while identifying very few barriers to integration. Providers particularly perceived the screener as helpful for identifying patient needs and facilitating communication while being easy to use. The barriers identified, while small in number, centered around communication difficulties with highly distressed patients, lack of resources, doubting efficacy, and time concerns. Overall, these data suggest that integrating psychosocial screening for YAs in adult oncology clinics is an acceptable and feasible way to help adult providers to better care for YA patients.
The majority of providers (i.e., 85%) believe that the AYA-specific screening tool improved patient care and being happy to use it again is consistent with studies evaluating provider perceptions of general psychosocial screening (i.e., not age-specific) in oncology. For example, providers in Smith et al. identified over three times as many advantages of screening than drawbacks. It is interesting to note that the adult providers in this study viewed the AYA-specific tool more positively than providers in a specialized AYA oncology clinic, of whom only about 40% felt that the tool directly helped them manage distress or improve overall care. This discrepancy, however, may more strongly reflect differences in available psychosocial resources and the extent of patient unmet needs than the value of screening. It is possible that since patients treated in adult oncology clinics are most likely to express an unmet need for psychosocial resources compared to pediatric and clinics with AYA specialty, psychosocial screening may be particularly valuable in adult settings. Additionally, providers in an AYA-specialized clinic may be more likely or equipped to address their psychosocial concerns compared to providers in adult clinics, regardless of a screening protocol.
Although perceived barriers were limited, several patterns emerged across studies. In this study, the most frequently endorsed barrier for providers was patients' reluctance or unwillingness to discuss distress, mirroring the second most frequently endorsed barrier in Patterson et al. Similarly, one provider in the TCT clinic noted that patients were too distressed or unwell to complete the screener, which reflects the main barrier reported in Patterson et al. Conversely, a well-documented barrier in the wider psychosocial oncology literature is a lack of time, which was not reported as an issue among AYA-specific providers, and only one in the current study indicated lack of time as a significant barrier.
Despite providers' overall positive views of screening, it remains under-implemented as reported by other studies. While speculative, other factors potentially contributing to low uptake or protocol nonadherence can be identified. BrintzenhofeSzoc and colleagues surveyed oncology social workers and found that perceptions of patient benefit and their knowledge of guidelines for psychosocial screening with AYAs positively predicted implementation. While the TCT providers in this sample generally perceived a benefit to patients, their knowledge of screening guidelines was not assessed, which may factor into implementation.
Regardless of provider beliefs and knowledge of guidelines, system-wide barriers may play a significant role in preventing the success of psychosocial screening, such as lack of institutional support, unclear protocols, insufficient psychosocial staffing, and lack of incentives. For example, the screening protocol outlined in the present study did not continue in the clinic after research was complete, largely because the screener could not be integrated into the EHR to allow clinical staff to continue the responsibility of carrying out the screening protocol readily.
The TCT providers were situated in a National Cancer Institute-designated comprehensive cancer center, which is a well-resourced environment. It is possible that their positive perceptions regarding the psychosocial screening were due to having personnel (e.g., Medical Assistants) and resources (e.g., psycho-oncology and support services for referrals) that made it feasible and acceptable to include in the point-of-care workflow without adding significant disruptions. It is worth noting that the TCT clinic is one of the busiest oncology clinics within this cancer center, with 50,429 visits from August 2024 to 2025 and 5057 being YAs. It is encouraging that these providers found the psychosocial screener to be feasible and helpful to integrate without many notable barriers. In conjunction with the limitation that the sample size was 14 TCT providers, future research should consider extending to sampling additional adult oncology clinics that see YAs consistently (e.g., neuro-oncology) to gain insight and generalizability.
Similar to other clinical research, the results of the current study were ecologically valid but limited by the variability of the real-time clinic (i.e., internal validity). Specifically, there were differences in individual provider integration and use of the psychosocial screening tool, including the use of the tool with patients (e.g., the way providers discussed the results with patients), variation in the number of YA patients seen by each provider (i.e., number of screeners the provider used in clinic), and type of patient each treated (e.g., providers specialized in treating specific diagnoses such as leukemia versus lymphoma). Another notable limitation was the lack of baseline assessment of provider perceptions; it is unclear how TCT providers perceived psychosocial screeners or the AYA screening tool specifically prior to the screener roll-out. Future research could build upon this study by obtaining baseline perceptions and knowledge of the providers, designing controls or protocols that would decrease variability and potential noise.
The findings of this study serve as preliminary data indicating that providers of a busy, adult oncology clinic treating YA cancer patients view age-appropriate psychosocial screening to be useful to improve clinical care and feasible to include in clinical operations. This moves the needle forward for the majority of YAs, who receive their care at adult oncology clinics. Additional research is needed to increase consistent implementation of age-appropriate screening and advance interventions that facilitate whole-person care for YAs beyond oncology treatment.
