By Sarah Conning, LCSW, OSW-C, APHSW-C

• Distress: A multifactorial, unpleasant experience of a psychologic (i.e., cognitive, behavioral, emotional), social, spiritual, and/or physical nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment (NCCN).
• Social Determinants of Health: The non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life (WHO).
• Social Risk Factors: “Specific adverse social conditions associated with poor health, such as social isolation or housing instability” (Alderwick and Gottlieb, 2019).

For more than 20 years, the concept of distress and the mandate to identify and address it among people facing cancer has been a defining paradigm for social work practice in oncology. The National Comprehensive Cancer Network first issued clinical practice guidelines for distress management in 1999. The 2008 Institute of Medicine report, Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs, proposed a treatment model for distress and declared psychosocial care as a standard of care in oncology, and distress screening as an accreditation standard for the American College of Surgeons Commission on Cancer went into effect in 2015.  Innovation and knowhow from within the social work profession has fueled the progress in this area over these past decades. Oncology social workers have been instrumental in the advocacy, program development, clinical practice and scholarship required to implement this important conceptual shift in the field of oncology. Long-time members of AOSW know well the learning, labor and collaboration that has filled our SWON listserv, private communications, and conference agendas on the topic of distress screening and management.
 
Today, a sister concept (related, but different) is gaining needed attention in oncology, that of social risk factors as drivers of cancer disparities. While greater attention to health disparities and the social determinants of health was building well before 2020, the pandemic has accelerated this trend by confronting us with the inequalities in our society and structures of care. Just this past fall, the National Cancer Institute surveyed its designated cancer centers and convened a virtual meeting to explore research priorities for addressing social risks in cancer care delivery, focusing on the key issues of food insecurity, housing instability, and transportation barriers. Likewise, recent changes to the NCCN distress thermometer reflect greater awareness of social risks including food insecurity. The need to detect and address social risk factors, defined as “adverse social conditions associated with poor health” (Alderwick and Gottlieb 2019), pushes us toward a new paradigm for oncology social work. Screening only for the subjective experience of distress is not sufficient. Once again, a consensus report provides a road map: The 2019 report, Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health, defines five health care sector activities to integrate social care, starting with awareness—the need to properly recognize and identify social risk factors among our patient populations.  
 
Of course, there is nothing new about social risk factors driving health disparities; social workers have been laboring in these fields for over 100 years. What is new is the moment in history where we find ourselves today, in which social risks (our wheelhouse) are center stage. It is a moment that calls for social work leadership at every level; we must stand up, not sit back. To go “beyond distress,” we can take everything we have learned about identifying and managing distress over these past 20+ years and adapt it with renewed vigor to the problems of social risk and health disparities. Along the way, we can envision and build the kind of health system and society we need. Our mandate as social workers has always been to address social problems and challenge social injustice. The field of oncology social work—including clinical practice, research, advocacy and administration—is made for this work.

Two recommendations:

1. First, if you haven’t already read the 2019 NASEM report, download it today: Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health. Convene a group of friends or colleagues and make a study of it.
2. Second, use our association! Just as AOSW has fed and fueled the work of identifying and managing cancer related distress, it will help us to make great strides in addressing social risks. The conferences, committees, SWON discussions, community connections and mentoring at the heart of our association will make all the difference in this work.

  
Alderwick, H. and Gottlieb, L. (2019) “Meanings and Misunderstandings: A Social Determinants of Health Lexicon for Health Care Systems” Milbank Quarterly June 2019 (volume 97).
 
Institute of Medicine 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. https://doi.org/10.17226/11993.
 
National Academies of Sciences, Engineering, and Medicine 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. https://doi.org/10.17226/25467
 
NCCN (2020) Distress During Cancer Care https://www.nccn.org/guidelines/guidelines-detail?category=3&id=1431
 
NCCN (2022) NCCN Guidelines v1.2022: Distress Management https://www.nccn.org/guidelines/guidelines-detail?category=3&id=1431