Background: Colorectal cancer is the second leading cause of cancer death in the United States. Surgery resulting in temporary or permanent stoma is a standard treatment for colorectal cancer. Patients facing stoma surgery are at risk for anxiety and distress.
Objective: To examine the effect of a multidisciplinary team approach on anxiety and distress among patients preparing for colorectal stoma surgery.
Methods: This quasi-experimental pilot study assessed participants (N = 18) for anxiety and distress 1 week before surgery. Results of the Problem List associated with the National Comprehensive Cancer Network Distress Thermometer guided the oncology nurse navigator to refer patients to the appropriate member of the multidisciplinary stoma team. Participants were reassessed for anxiety, distress, and patient satisfaction after surgery.
Results: A significant decrease in anxiety was detected presurgery (M = 8.2, SD = 5.5) to postsurgery (M = 4.7, SD = 3.9) (t  = 2.4; P = .03). A nonsignificant decrease in distress was detected from presurgery (M = 4.9, SD = 3.12) to postsurgery (M = 3.7, SD = 3) (t  = 1.6; P = .13).
Conclusion: Results of this study suggest that this team approach can diminish anxiety and may have an influence on distress. Further research is recommended.
Colorectal cancer is the fourth most diagnosed cancer in the United States, representing 7.9% of all new cases.1 It is also the second leading cause of cancer death in the United States.1 Surgery is a standard treatment for colorectal cancer and can result in a temporary or permanent ostomy, with 10% of surgical cases resulting in permanent ostomy.2 Although colorectal surgery may have a curative intent, a resulting stoma can be a serious stressor.3 Having a stoma can place patients at risk for anxiety and depression and can have a negative impact on body image, sexual functioning, and relationships with others.3-7
Anxiety is a common response to a cancer diagnosis and can interfere with quality of life.8 Specific quality-of-life issues associated with having a stoma after surgery for colorectal cancer can intensify anxiety. Some of these issues include body image changes, worry about leakage, noises, odors, embarrassment, and skin irritation.2 Screening for anxiety using an instrument such as the Generalized Anxiety Disorder-7 (GAD-7) before surgery allows caregivers to address patient concerns regarding what to expect throughout the treatment process.9
Distress is another common response to a diagnosis of cancer. The National Comprehensive Cancer Network (NCCN) has declared distress the sixth vital sign of cancer care.10 Distress is a barrier to care and can result in associated physical and psychological symptoms.11 Patients anticipating colorectal cancer surgery resulting in a stoma encounter a greater distress response than patients not requiring stoma surgery.6 Administering the NCCN Distress Thermometer (DT) and accompanying Problem List at the time of preadmission testing (approximately 1 week before surgery) allows caregivers to identify and address common barriers to care.12 The gastrointestinal oncology nurse navigator (ONN), as part of a multidisciplinary stoma team (MST), can screen for anxiety and distress in patients who will have a temporary or permanent ostomy. The purpose of this pilot study was to examine the effect of an MST approach on anxiety and distress among patients preparing for colorectal stoma surgery. In addition, satisfaction with care provided by the MST was evaluated.
This quasi-experimental study was approved by the hospital’s Institutional Review Board.
Participants (Sample and Setting)
The study (N = 18) took place at a 434-bed Magnet redesignated community hospital in the southeastern United States. Eligibility criteria included a colorectal cancer diagnosis with a planned surgical resection resulting in temporary or permanent ostomy and age at least 18 years. Exclusion criteria were non–cancer-related stoma and non–English-speaking patients. As this was a pilot study aiming to inform future research, a priori sample size was not calculated.
Patients were recruited by the principal investigator at their preadmission testing visit, approximately 1 week before surgery. After obtaining informed consent, participants completed the GAD-7 and the NCCN-DT and associated Problem List on paper. Results of the GAD-7 and the NCCN-DT were used pre- and postintervention as assessments of anxiety and distress. The Problem List associated with the NCCN-DT guided the ONN in arranging referral to appropriate healthcare professionals on the MST. At the time of discharge, approximately 3 to 4 days after surgery, a member of the research team visited participants to administer the GAD-7, NCCN-DT and associated Problem List, and an investigator-designed patient satisfaction survey.
Given the multifaceted nature of the physiological and psychological problems faced by these patients, a team approach to resolving patients’ concerns may be effective. The approach examined in this study includes the following: identification of appropriate MST members, use of the Problem List associated with the NCCN-DT, and involvement of the ONN. Healthcare professionals for this team were identified based on their essential roles in caring for these patients. The MST includes an ONN, behavioral health nurse practitioner, ostomy nurse, social worker, case manager, dietitian, and colorectal surgeon. These individuals are available to provide services described in Table 1 at any time in a patient’s hospital stay. The Problem List associated with the NCCN-DT consists of 39 items examining 5 domains. Guided by the Problem List, the ONN scheduled the appropriate MST member to provide care based on patient needs.
Measures used in this study are the GAD-7, NCCN-DT and associated Problem List, and an investigator-designed patient satisfaction questionnaire. In addition, demographic information related to age, gender, temporary or permanent ostomy, cancer site, stage of cancer, and whether patients have had neoadjuvant chemotherapy or radiation was collected.
The 7-item GAD-7 measures anxiety over the past 2 weeks. Responses to a 4-point Likert-type scale are as follows: “not at all” (0 points), “several days” (1 point), “more than half the days” (2 points), and “nearly every day” (3 points). Total score ranges from 0 to 21. The score is categorized as minimal anxiety (0-4); mild anxiety (5-9); moderate anxiety (10-14); and severe anxiety (15-21). Use of the GAD-7 scale is recommended by the American Society of Clinical Oncology for screening and assessment of anxiety and depression in patients with cancer.13 The GAD-7 has a Cronbach’s alpha of 0.89 and demonstrated diagnostic accuracy in cancer patients.14
The NCCN-DT and associated Problem List identifies and addresses psychological distress in individuals with cancer. This 1-item, 11-point Likert scale consists of a visual graphic of a thermometer with a score range from 0 (no distress) to 10 (extreme distress). A distress score of 4 or higher indicates moderate to severe distress pointing to the need to administer the accompanying 39-item Problem List. The associated Problem List identifies participant needs in the areas of practical, family, emotional, spiritual/religious, and physical problems.14,15 The NCCN-DT is effective in identifying distress and its sources in the cancer population.15 Sensitivity and specificity analysis demonstrates that the single-item NCCN-DT accurately measures distress among cancer patients when compared with longer measures, namely the 14-item Hospital Anxiety and Depression Scale and the 18-item Brief Symptom Inventory.16
The investigator-designed Baptist Health Lexington Patient Satisfaction Questionnaire (BHLex-PSQ) was administered at discharge to assess how the MST met participants’ needs before and after surgery. The 5-item BHLex-PSQ was administered on the day of discharge from the hospital. Participants responded to a Likert scale as follows: “strongly disagree” (1 point), “disagree” (2 points), “agree” (3 points), and “strongly agree” (4 points). The BHLex-PSQ assesses satisfaction with education, resources, attention to anxiety, involvement with decision-making, and overall experience. Total score ranges from 5 to 20.
Data analysis was conducted using SPSS v25. Demographic information was analyzed using frequencies and percentages. Dependent t tests were calculated to examine differences between the pre- and postintervention groups for the variables of anxiety and distress. Patient satisfaction postintervention was also examined.
Participants (N = 18) ranged in age from 40 to 79 years (M = 60). See Table 2 for participant demographics. A dependent t test comparing anxiety presurgery (M = 8.2, SD = 5.5) with postsurgery (M = 4.7, SD = 3.9) revealed a significant decrease in scores (t  = 2.4; P = .03). A dependent t test revealed a nonsignificant decrease in distress from presurgery (M = 4.9, SD = 3.12) to postsurgery (M = 3.7, SD = 3) (t  = 1.6; P = .13). Given the number of items on the Problem List (N = 39) and the small sample size (N = 18), it was not appropriate to use inferential statistics on the items of the NCCN-DT Problem List. However, examination of items on the NCCN-DT showed a decrease related to fear (preintervention n = 9, postintervention n = 5), nervousness (preintervention n = 11, postintervention n = 5), fatigue (preintervention n = 7, postintervention n = 3), and problems with sleep (preintervention n = 7, postintervention n = 3). At discharge, participants indicated they were satisfied with the 5 variables listed in Table 3 in the patient satisfaction questionnaire (M range = 3.2-3.7 of 4).
Using the multidisciplinary approach examined in this study appears to benefit patients undergoing colorectal stoma surgery. The ONN played an important role in this approach by reviewing the Problem List associated with the NCCN-DT. She also interacted with other team members to be certain that care was provided. Anxiety, a major cause for concern in this population, was reduced pre- and postsurgery using the MST. Distress decreased, but findings were not significant. Although there were insufficient data to analyze using inferential statistics, an examination of the Problem List associated with the NCCN-DT revealed decreases in fear, nervousness, fatigue, and problems with sleep. Findings from this study support prior work examining psychosocial and physiological intervention among patients undergoing colorectal surgery resulting in a stoma.17
Results of this pilot project suggest additional research on the MST is warranted. In addition, further work on identifying specific interventions within the MST that serve to increase the comfort level of these patients by decreasing anxiety might be useful.
- National Cancer Institute. Cancer Stat Facts: Colorectal Cancer. https://seer.cancer.gov/statfacts/html/colorect.html. Accessed February 9, 2022.
- Vonk-Klaassen SM, de Vocht HM, den Ouden ME, et al. Ostomy-related problems and their impact on quality of life of colorectal cancer ostomates: a systematic review. Qual Life Res. 2016;25:125-133.
- Jin Y, Zhang J, Zheng MC, et al. Psychosocial behaviour reactions, psychosocial needs, anxiety and depression among patients with rectal cancer before and after colostomy surgery: a longitudinal study. J Clin Nurs. 2019;28:3547-3555.
- Mols F, Lemmens V, Bosscha K, et al. Living with the physical and mental consequences of an ostomy: a study among 1–10-year rectal cancer survivors from the population-based PROFILES registry. Psychooncology. 2014;23:998-1004.
- Popek S, Grant M, Gemmill R, et al. Overcoming challenges: life with an ostomy. Am J Surg. 2010;200:640-645.
- Song L, Han X, Zhang J, Tang L. Body image mediates the effect of stoma status on psychological distress and quality of life in patients with colorectal cancer. Psychooncology. 2020;29:796-802.
- Verweij NM, Hamaker ME, Zimmerman DD, et al. The impact of an ostomy on older colorectal cancer patients: a cross-sectional survey. Int J Colorectal Dis. 2017;32:89-94.
- National Cancer Institute. Adjustment to Cancer: Anxiety and Distress (PDQ) – Health Professional Version. www.cancer.gov/about-cancer/cop ing/feelings/anxiety-distress-hp-pdq. Updated June 23, 2021. Accessed February 9, 2022.
- Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166:1092-1097.
- Bultz BD, Carlson LE. Emotional distress: the sixth vital sign – future directions in cancer care. Psychooncology. 2006;15:93-95.
- Ownby KK. Use of the Distress Thermometer in clinical practice. J Adv Pract Oncol. 2019;10:175-179.
- National Comprehensive Care Network. NCCN Guidelines for Patients. Distress During Cancer Care. www.nccn.org/patients/guidelines/content/PDF/distress-patient.pdf. Published March 11, 2020. Accessed February 9, 2022.
- 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.
- Esser P, Hartung TJ, Friedrich M, et al. The Generalized Anxiety Disorder Screener (GAD-7) and the anxiety module of the Hospital and Depression Scale (HADS-A) as screening tools for generalized anxiety disorder among cancer patients. Psychooncology. 2018;27:1509-1516.
- Cutillo A, O’Hea E, Person S, et al. The Distress Thermometer: cutoff points and clinical use. Oncol Nurs Forum. 2017;44:329-336.
- Jacobsen PB, Donovan KA, Trask PC, et al. Screening for psychologic distress in ambulatory cancer patients. Cancer. 2005;103:1494-1502.
- Lim SH, Chan SWC, Lai JH, He HG. A qualitative evaluation of the STOMA psychosocial intervention programme for colorectal cancer patients with stoma. J Adv Nurs. 2019;75:108-118.