Screening is “the identification of people with cancer requiring prehabilitation” and it should:

• occur as early as possible from diagnosis
• be aligned to the Holistic Needs Assessment (HNA)
• include physical fitness, nutrition and psychological risk factors
• use validated tools to identify the need for more detailed individualised assessment and intervention

Screening in practice:

• should be undertaken by registered health and care professionals (registered, enhanced, advanced, consultant) or unregistered health and care professionals (supportive, assistive) through delegated authority
• implementation and effectiveness audited as part of a quality assurance and improvement framework
• a set of standardised screening methods should be defined and used consistently

This should be offered to everyone and:

• is useful as a screening tool to identify the needs for prehabilitation interventions in people with cancer
• can identify physical, emotional, psychological and practical needs
• can prompt signposting or referral to relevant services
• can start a conversation about needs
• encourages people with cancer and health and care professionals to anticipate problems and intervene early to mitigate them
• can help inform the development of a ‘Personalised Care and Support Plan’ (see following module)

The electronic HNA, or E-HNA, supports the completion of the tool on a touch-screen tablet or can enable individuals to complete in advance of discussions. If completed independently, everyone should still be offered to the opportunity to discuss their HNA with a health care professional regardless of how this has been completed or what the findings are.

Other screening tools:

• can be used alongside the HNA
• screen more specifically
  • physical fitness
  • nutrition
  • psychological support
• irrespective of which tool is used, it is important that the same tool is used in all settings for any particular person, and that it is used from the earliest opportunity to risk stratify and direct care.

“Consider which tool you would use and why in your healthcare setting.”

The international physical activity questionnaire (IPAQ)

• developed to measure health-related physical activity in populations
• used in the Manchester ‘Prehab4Cancer’ initiative

The Scottish Physical Activity Screening Questionnaire (Scot-PASQ)

• Provides a framework for meaningful physical activity conversations between health professionals and patients, and enables description of activity levels and informs what physical activity support is needed
• Used as part of the Scottish National Physical Activity Pathway (NPAP), a set of steps a healthcare professional can take to encourage the people in their care to be more active

godin-shephard leisure-time physical activity questionnaire (GSLTPAQ)

• Used to assess leisure time physical activity and exercise in oncology research

General practice physical activity questionnaire (GPPAQ)

• used in primary care to assess the physical activity levels of adults (16 to 74 years).
• provides a simple, 4 level physical activity index (PAI).
• helps practitioners decide when to offer interventions to increase physical activity

Physical activity stage of change assessment tool

• used to gauge how motivated a patient is to engage and adhere to a physical activity intervention
• provides those doing the screening with specific strategies and goals relative to the patient’s particular stage of change
• developed by Exercise is Medicine® Australia, empowering primary healthcare providers to effectively counsel patients about physical activity leading to sustained behaviour change

Wearable Technology Monitors

• are increasingly used to obtain objective measures of physical activity
• can help identify whether or not a person meets a specific threshold for physical activity
• potential for their use for screening and assessment of activity and exercise

Duke activity status index (DASI)

• a self-reported measure of activities of daily living
• provides an estimate of functional capacity

Clinical Frailty Score – sometimes referred to as the ‘Rockwood Score’

• a self-reported measure
• summarises overall level of fitness/ frailty of an older adult after clinician evaluation

“Consider which tool you would use and why in your healthcare setting.”

Malnutrition Universal Screening Tool (MUST)

• a five-step screening tool to identify adults who are malnourished or at risk of malnutrition (undernutrition) or obese
• uses current weight, unplanned weight loss and an acute disease effect
• includes management guidelines which can be used to develop a care plan
• used widely in hospitals, community and other care settings and can be used by all care workers

The Royal Marsden Nutrition Screening Tool

• more specifically aimed at people with cancer than MUST
• considers the acute disease effect including nutrition impact symptoms e.g., taste and smell alterations, swallowing problems, abdominal pain
• sensitive for identifying patients who are malnourished or at risk of malnutrition in the inpatient setting

Patient Generated Subjective Global Assessment questionnaire (PG-SGA short form)

• screening tool to identify those most at risk (NB: the full PG-SGA is actually an assessment tool)
• high sensitivity and specificity in detecting those at risk of malnutrition
• widely used in other oncology and patient settings and has performed well against other tools such as the Malnutrition Screening Tool and the Mini nutritional assessment

“Consider which tool you would use and why in your healthcare setting.”

At a universal level (Level 1 psychological support) there are no formal screening tools. Holistic Needs Assessment would act as a screening tool here. A positive screen on the HNA would be any item identified in the emotional concern domain and also an awareness of items in other domains that may contribute to anxiety and/or depression. A universal awareness of the psychological impact of cancer and ability to recognise distress and signpost appropriately. If symptoms of anxiety and depression were identified by a level 1 practitioner this should promptly be escalated to a level 2 practitioner for further assessment.

At a targeted level (Level 2 and 2 plus psychological support) NICE 2004 describes practitioners at this level to screen for distress at key points in the patent pathway e.g., around diagnosis, during treatment, episodes as treatment ends, at recurrence. HNAs can be a useful clinical tool for initiating a conversation which may identify psychological or emotional difficulties.

At Level 2 plus screening could include an HNA, clinical conversation and a supportive listening appointment.

EuroQol 5 Dimensions 3 level screening tool (EQ5D-3L)

• descriptive system comprises the following five dimensions; mobility, self-care, usual activities, pain/discomfort, anxiety/depression
• each dimension has 3 levels; no problems, some problems, extreme problems
• respondent is asked to indicate their health state by ticking the box next to the most appropriate statement in each of the five dimensions.
• EQ5D is a validated screening tool being used in the Quality of Life (QoL) metric pilots for cancer being undertaken by NHS England

Brief Fatigue Inventory

• Helps understands the extent to which fatigue interferes with a person’s daily life
• Someone could report relatively low levels of fatigue but with a significant impact on their lives; others may report higher levels but are better able to manage

European Organisation for Research and Treatment of Cancer quality of life core questionnaire (EORTC QLQ-FA12)

• EORTC QLQ-FA12 is a longer set of questions than the Brief Fatigue Inventory
• assesses physical, cognitive and emotional aspects of cancer-related fatigue

Patient Activation Measure (PAM)

• The Patient Activation Measure measures an individual confidence in their ability to self-manage health and wellbeing.  It can be used to understand the way in  which people engage health services and may be used to help predict trends in health service utilisation/behaviours.
• PAM is much broader than wellbeing – although there is overlap, you could be highly activated but still depressed and it should not be used to assess in a mental health crisis.
• endorsed by NHS England and the Kings Fund (license is required for use)
• higher PAM scores equate to lower health care costs

“Consider which tool you would use and why in your healthcare setting.”