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NCCN Guidelines for Patients



Distress, Version 1.2017

Causes and risks

There isn’t one cause of distress. What causes

distress for one person with cancer may not be the

same for another person. For example, people who

are distressed may feel overwhelmed. Some have

many side effects from treatment. Others struggle

with worries or have money problems. Even if you

have been wise with your money, the costs related to

cancer can add up.

Anyone can become distressed but research has

found that some people are more likely than others.

The risk factors for higher levels of distress are listed


Guide 2

. A risk factor is anything that increases

the chance of an event. There is a wide range of risk

factors for distress.

You may have health-related risk factors. Some

people have symptoms from the cancer, from the

cancer treatment, or both. If your symptoms are

severe or long lasting, your chance of becoming

distressed is increased. Having another severe

illness, cognitive impairment, or limited access to

health care can also lead to distress.

You may have personal risk factors. Such factors

include being young, being a woman, and having

problems with communication. It may be a shock

to learn that you have cancer. Likewise, it may be

too much to deal with cancer and your everyday

duties. Your chance for becoming distressed is also

increased if you don’t know the words your treatment

team uses or you don’t have access to information.

Money may get even tighter. You may have less

money due to travel costs, insurance co-payments,

and missing work. With less money, your chance of

becoming distressed is increased.

Spiritual and social factors can contribute to distress.

You may have long-standing or new spiritual or

religious concerns in the context of having cancer.

Family conflicts, a lack of family support, and living

alone may increase the burden of having cancer

and lead to distress. Having young children is an

important responsibility. Raising children and dealing

with cancer at the same time can be very hard to do.

Higher levels of distress are linked to sexual and

physical abuse, substance use disorders (ie, alcohol,

drugs), and other mental disorders. If you have been

abused, you are more likely to become distressed at

some point during your cancer care. If you have had

a mental or substance use disorder, your chance of

being distressed is higher than someone who has



Distress can occur at any point in time during your

cancer journey. However, there are times when being

distressed is more likely. Read

Guide 3

for a list of

times of when you are more likely to be distressed.

Distress may result from learning you have cancer. It

may also occur beforehand when being assessed for

cancer. Transitions in care can also lead to distress.

Examples of a transition include being discharged

from the hospital or finishing all treatment. It can be a

big change when shifting from frequent doctor visits

during active treatment to less frequent visits during

follow-up care. Another common time point for being

distressed is learning that your health has worsened.

Ideally, you would be screened for distress at every

health care visit. However, it is very important that

you be assessed for distress at the time points listed

in Guide 3. Screening tools for distress are described

in Part 2 along with some of the benefits of distress



What is distress?

Causes and risks