The OECI model: the experience of INT Milan with a focus on the integration of psycho-oncology support


The procedure for Organisation of European Cancer Institutes (OECI) accreditation identified the formation of MDTs for the diagnosis and scheduling of primary treatment with integration of supportive care as a key strength at Istituto Nazionale Tumori (INT). The opportunities for improvement highlighted by the OECI peer review inspired a study on the evaluation of psychological distress, with a view to integrating this evaluation into global patient management and to defining standardized criteria for the provision of psychological services. This article describes the OECI accreditation experience at INT and the study conducted between January and May 2015 on the evaluation of patients’ distress levels during cancer treatment, defining a score-based cutoff point that triggers the intervention of a psychologist. The Distress Thermometer was used as a tool for evaluating psychological distress, performed by nurses on admitting the patient. A total of 261 questionnaires were completed by patients admitted to the medical oncology and hematology departments, with an average distress value of 4.1, and 60% of patients experiencing clinically detectable emotional distress. Emotion-related problems had a significant association with a greater level of distress, while there were few reports of relationship issues as a cause of distress. As a result of the improvement initiative supported by the psychological distress evaluation study, we validated the screening questionnaire to be included at the initial patient evaluation stage with a cutoff point triggering the intervention by a psychologist at a score of ≥7.

Tumori 2015; 101(Suppl. 1): 25 - 32

Article Type: REVIEW



Anna Roli, Claudia Borreani, Marco Bosisio, Elisabetta Bianchi, Vittorio Montefusco, Giorgia Gobbi, Marco Platania, Filomena Lavecchia, Marco Milanesi, Valeria Anselmi, Cecilia Melani, Giuseppe De Leo

Article History


Financial support: This work was financially supported by the Ministry of Health-Italian Government within the Finalized Research Project Code: RF-2009-1532731. (Coord.: A Paradiso, F Belardelli).
Conflict of interest: The authors declare no conflict of interest.

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Implementing a quality system with common standards, peer reviews, and a platform for comparative analysis of ­European oncology institutes is the objective of the accreditation and designation (A&D) program of the Organisation of European Cancer Institutes (OECI) to ensure equal access to and quality of cancer care for European citizens.

The experience with the OECI A&D model highlighted that quality development in oncology research, care, and training is especially associated with the use and measurement of multidisciplinary integration of the various areas for fostering quality outcomes that form the basis for decisions pertaining to clinical governance.

Accreditation process at the Fondazione IRCCS Istituto Nazionale dei Tumori, Milan

The A&D program at Fondazione IRCCS Istituto Nazionale dei Tumori (INT), Milan, Italy, as part of the research project “Tailored Accreditation Model for Comprehensive Cancer Centers: Validation through the Applicability of the Experimental OECI-Based Model to the Network of Cancer IRCCS of the Alliance Against Cancer,” started on June 1, 2013, and the Quality Accreditation certificate was issued on February 12, 2015, together with the classification of INT as a Comprehensive Cancer Center (CCC). Figure 1 shows a timeline of the INT’s accreditation process and a report on compliance with the OECI standards.

Timeline of the Fondazione IRCCS Istituto Nazionale dei Tumori’s accreditation process and a report on compliance with the Organisation of European Cancer Institutes (OECI) standards.

Multidisciplinary teamwork emerged during the accre­ditation process as one of the core criteria of the OECI model. At INT, this principle was well-represented in care and research. In the care area, it is the basis for the global management of the patient that integrates diagnosis and treatment scheduling with early intervention of supportive care as part of a multidisciplinary approach; in the research area, multidisciplinary teamwork is the key asset of the cooperation between units and professional groups for clinical research.

Integration of supportive care in the care pathway: improvement plan

The quality of cancer treatments depends on careful coordination among multiple treatments, exchange of technical information, and regular information flow among all parties involved in the treatment, including patients, cancer specialists, other specialist disciplines, and supportive care (1).

The optimum decision-making process in the diagnosis, care, and support of cancer patients is associated with the creation of multidisciplinary teams (MDTs) including a growing number of specialists and healthcare professionals with ever larger areas of intervention where shared decisions are required at all stages of care.

The MDTs allow for continual collaborative consultation during the entire treatment pathway, which includes the evaluation of the psychosocial aspect of cancer patients during the treatment period. The concept of teamwork is essential for the multidisciplinary approach to function effectively as it requires communication and collaboration between clinicians and supportive care professionals. Patient involvement is necessary to ensure patient-focused care as well as comprehension of the diagnosis and treatment options by patients and their families (2).

At INT, the peer review of our multidisciplinary approach to care, which stresses strong integration of supportive care in disease care pathways for accreditation, had a dual outcome.

First, the multidisciplinary approach was seen as a key strength of the INT’s organizational treatment model, which envisages MDTs for the diagnosis and scheduling of primary treatment integrated with supportive care (psycho-oncology, rehabilitation, care support, clinical nutrition, social support, spiritual support, smoking cessation clinic, art therapy laboratory) and includes patient empowerment (Fig. 2).

Second, the peer review identified an opportunity for improvement in the extension of the initial screening stage into early patient management by supportive care disciplines, with enhancement of the role of nurses in the activation of services.

The multidisciplinary approach.

Supportive care is broadly considered by the OECI standards within various areas: the viewpoints examined by the OECI model allow complete evaluation of both the static and dynamic aspects of integration within the patient care pathway.

The opportunities for improvement identified by the peer review in the supportive care disciplines were the basis for an action plan on psychological needs management through systematic screening for all patients admitted. This plan was designed according to the plan, do, check, act (PDCA) model and was divided into 2 phases:

A study on psychological distress evaluation in patients undergoing cancer treatment at the medical oncology and hematology departments

The translation of the study results into practice, with definition of the criteria and methods for early evaluation of psychological distress for cases where the psychologist is not in the core team for the initial patient evaluation (1)

Evaluation of psychological distress in patients undergoing cancer treatment


The decision to tackle a theme regarding psycho-oncology as an action to improve supportive care was based on the rationale that the psychological aspect of the disease plays an important role in the patient’s clinical history. Its influence has been demonstrated in many aspects of the disease and its treatment, such as symptoms, quality of life, capacity to face the disease, patient involvement in decisions, level of satisfaction, and treatment compliance (3-4-5-6-7).

Offering adequate support to patients with cancer also implies an ability to detect any psychological and emotional problems early on and to provide an appropriate response to the identified needs. Patients with cancer do not need only diagnostic and therapeutic services; they also have emotional requirements that must be adequately managed within the care process. The scientific literature demonstrates that a considerable number of patients with cancer develop psychological distress symptoms due to anxiousness and/or depression (8). Anxiety/depression-related disorders are described in 30% and 40% of cancer patients, respectively (9).

A psychological disorder that is not detected and not appropriately treated leads to an avoidable increase in the patient’s suffering. Furthermore, it can deteriorate communication between patient and clinicians, and potentially interfere with care pathways.

Developments in psychological diagnosis made it possible to separate specific mental disorders from various forms of psychological distress that can appear as a consequence of severe disease. It is important to have simple tools available to identify and separate normal mood swings and changes in personal experiences from the psychological symptoms that may appear in difficult or stressful situations (10, 11).

In 1997, the National Comprehensive Cancer Network (NCCN) (12, 13) first defined specific guidelines that include assessment and management of psychological distress in oncology: distress was proposed as the sixth vital sign to be monitored regularly as part of clinical activity, along with the classic physiologic parameters such as body temperature, heart and breathing rate, blood pressure, and pain.

One of the key tools used in the literature for the psychological distress screening procedure is the Distress Thermometer (DT) (14). This tool, developed by the NCCN in the United States, has been translated and adapted to the Italian cultural environment (15-16-17-18). The DT quickly measures the level of emotional suffering of the patient and its possible roots (physical, spiritual, and practical causes, as well as family- or relationship-related causes). Various studies show that it is a diagnostically accurate and valid method in the cancer setting (19, 20).

The study’s objective was to evaluate the distress level of inpatients during cancer treatment (in the medical oncology and hematology departments) and to define a cutoff score as a trigger for involvement of a psychologist.


During the period from January to May 2015, 261 patients were recruited who had been admitted into the hematology (ETMO) and medical oncology (OM1) departments of the Foundation.

Measurement tools

Psychological distress was measured via the DT (21). This tool comprises 2 sections: the first one is a visual analogue scale (in the shape of a thermometer), alongside a scale with verbal responses (no distress/extreme distress) and a numeric scale (0-10); the second section includes a list of problems grouped into 5 categories. The patient must report his or her level of distress on the scale and subsequently indicate which of the problems listed caused distress in the last week.

A score greater than 4 (21) indicates a clinically significant level of discomfort that may be indicative of the need for psychological consultation, whereas a score less than 4 can be managed as part of normal care provided by the department. The responses to the checklist of problems provide indications on the cause of the distress.

The primary sociodemographic variables (age and sex) are collected via the details form on the questionnaire (DT) filled out by the patient. The primary clinical variables (diagnosis, therapy line, disease stage) are collected by access to the patient’s clinical records.

Evaluation procedure

The questionnaire, which was handed over together with the informed consent form, was given to the patients by nurses on admission and collected by them in the following days.

Statistical analysis

The data were analyzed in an aggregated and anonymous form using descriptive and inferential statistics, where appropriate. Given the observational nature of the study, calculation of the sample size was not necessary and no hypothesis was being tested.

The basic and demographic characteristics of the patients enrolled were summarized with averages (± standard deviation) for continual variables and with frequency and percentage tables for discrete variables. The χ2 test or Fisher exact test were used, where appropriate, to study the relationship between the categorical variables.


A total of 261 questionnaires were filled out: 162 by patients admitted to the medical oncology department (62%) and 99 by patients admitted to the hematology department (38%). The average level of psychological distress was 4.1. This value relates both to the total sample and to the patients of the 2 departments (Tab. I).

Relationship between distress and patient characteristics

No distress Distressa p Value
No. % No. %
a Cutoff ≥4.
b Medical oncology patients.
 Male 64 50.0 64 50.0 0.001
 Female 39 30.5 89 69.5
Age, y
 <30 8 38.1 13 61.9 NS
 30-50 21 40.4 31 59.6
 51-70 49 42.2 67 57.8
 >70 27 37.5 45 62.5
 I 33 37.1 56 62.9 NS
 II 20 40.0 30 60.0
 III 21 53.8 18 46.1
 IV 7 58.3 5 41.7
 V - - 4 100
 ≥VI 2 50.0 2 50.0
 Neoadjuvant 3 27.3 8 72.7
 Adjuvant 8 38.1 13 61.9
 No therapy 2 18.2 9 81.8
Stage of diseaseb
 Localized 8 32.0 17 68.0 NS
 Relapse - - 4 100
 Advanced 4 28.6 10 71.4
 Metastatic 46 42.9 61 57.1
 Palliative care - - 2 100
 Multiple myeloma 7 58.3 5 41.7 NS
 Leukemia 1 20.0 4 80.0
 Melanoma - - 1 100
 Hodgkin lymphoma 4 44.4 5 55.6
 Non-Hodgkin lymphoma 24 38.7 38 61.3
 Breast 5 15.6 27 84.4
 Lung 15 46.9 17 53.1
 Colorectal 10 47.6 11 52.4
 Pancreas 1 16.7 5 83.3
 Stomach 1 12.5 7 87.5
 Esophagus 2 66.7 1 33.3
 Bladder - - 3 100
 Uterus 3 75.0 1 25.0
 Salivary glands - - 4 100
 Peritoneum 2 50.0 2 50.0
 Thymus 2 50.0 2 50.0
 Biliary 2 40.0 3 60.0
 Seminoma 4 80.0 1 20.0
 Others 10 52.6 9 47.4

Considering the distress scores compared to the cutoff values of ≥4, 60% of patients were experiencing clinically significant emotional distress (Fig. 3). By comparing the distribution of the distress scores between the 2 departments and dividing the distress above the cutoff into 2 levels (medium and high), it emerged that in the medical oncology unit the percentage of distress is noticeably greater (31%) than in the hematology unit (26%).

Emotional distress of patients in the medical oncology and hematology (ETMO) and medical oncology (OM1) departments.

By analyzing the relationship between distress and the sociodemographic and clinical variables (Tab. II), it appears that 70% of women report significantly greater distress than men (50%; p = 0.001). There are no significant associations for age, treatment line, disease stage, and diagnosis. However, there is a greater percentage of distress (not statistically significant) in patients following first- and second-line therapy (compared to subsequent lines).

Relationship between distress and patient problems

Problems Distress, % Chi-square All, %
No Yesa p<0.05 p<0.01 p<0.001
a Cut-off ≥4.
The psychologist is a member of the core team for pediatric cancer treatment, for prostate cancer, and for liver and bone marrow transplants.
 Childcare 3.1 8.6 6
 Housing 2.1 7.1 5
 Financial 10.5 16.3 14
 Study/work 6.3 12.5 10
 Transport 8.4 14.6 12
 With partner 2.1 7.9 5.5
 With children 2.1 5.1 3.9
 With others 4.1 6.5 5.5
 Depression 5.6 20.3 * 14.2
 Fear 15.6 55.6 * 39.6
 Nervousness 26.1 47.4 * 38.7
 Sadness 10.9 47.1 * 32.6
 Worry 59.2 72.5 * 67.3
 Loss of interest 8.1 24.8 * 18.1
Spiritual aspects
 Problems with faith 2.1 2.9 2.6
 Sleep 18.6 49.6 * 36.7
 Pain 26.1 33.3 30.3
 Washing/dressing 7.4 12.4 10.4
 Nausea 13.9 24.6 * 20.3
 Fatigue 60.0 67.6 64.5
 Movement 17.9 21.5 20.0
 Breathing 13.8 21.1 18.1
 Mouth ulcers 6.3 6.0 6.1
 Eating 7.4 13.3 10.9
 Digestion 12.6 23.5 * 19.1
 Constipation 15.9 26.8 * 24.0
 Urination 7.6 6.1 6.8
 Fever 7.3 9.0 8.3
 Skin dryness/itching 28.1 38.8 34.5
 Blocked nose 17.9 18.9 18.5
 Tingling of the hands/feet 36.0 25.5 29.9
 Feeling bloated 15.5 23.9 20.3
 Sexual problems 7.2 10.6 9.2
 Diarrhea 6.2 10.9 9.0
 Memory/concentration 15.6 25.2 21.3
 Self-perception 6.4 25.9 * 18.0

Table II shows the relationship between the distress scores and the patients’ various problems. The problems significantly associated with a greater level of distress are emotion-related, where there are significant reports for all the problems listed (depression p = 0.002, fear p<0.001, nervousness p = 0.001, sadness p<0.001, worry p = 0.028, loss of interest p = 0.002). As for physical problems having significant associations, it appears that patients with clinically significant psychological distress more frequently reported problems relating to sleep (p<0.001), nausea (p = 0.048), difficulty with digestion (p = 0.038), constipation (p = 0.017), and self-perception (p<0.001).

The average number of problems reported is greater among those who have clinically significant distress (no distress: average problems = 4.6, SD = 3.5; distress: average problems = 7.5, SD = 3.5).

The distributions of scores relating to the problems reported by patients were then analyzed. The problems were divided according to the areas of distress included in the DT and compared by department. As regards practical problems (Fig. 4), it emerges that financial and transport problems are more frequently reported by patients as a cause of discomfort whether in OM1 (financial 13%, transport 11%) or in ETMO (financial 16%, transport 15%).

Practical problems. ETMO = medical oncology and hematology; OM1 = medical oncology.

Relationship problems (Fig. 5) were reported less as a cause of distress. However, there is a significant difference between the 2 departments: while in OM1, relationship problems were in general less frequent, with a greater percentage of problems with others (4.5%), in ETMO, problems were present in all types of relationship, especially with children (8.1%) The difference between problems with children in the 2 departments was statistically significant (p = 0.011).

Relationship problems. ETMO = medical oncology and hematology; OM1 = medical oncology.

The area of emotional problems (Fig. 6) was the most severe cause of distress in patients in both departments.

Emotional problems. ETMO = medical oncology and hematology; OM1 = medical oncology.


The OECI accreditation process enabled identifying certain strengths in the care organization model and opportunities for improvement in the initial screening phase with the aim of early involvement of supportive care, via MDTs collaborating during the entire patient treatment pathway.

The study, aimed at improving integration of psycho-oncology into the multidisciplinary care pathway, which includes the treatment of psychological distress in cancer patients, highlighted the capacity to detect psychological and emotional problems early on. The average level of distress (4.1) in our sample is comparable to that reported by other Italian studies performed in the cancer population (21).

The absence of correlation between the level of distress and the sociodemographic and clinical variables was confirmed by other studies (22-23-24), with the exception of the sex variable, which shows a significantly greater level of distress, in line with our sample, in women (25).

Similar to other studies, the level of distress correlates directly with the number of problems reported by patients. More specifically, distress is mainly related to emotions (depression, fear, nervousness, sadness, worry, and loss of interest), in line with other studies.

Some physical symptoms such as sleep disorders, nausea, constipation, and digestion problems correlate significantly with psychological distress and, as such, they should be analyzed from this point of view as well.

A comparison between the data from the 2 departments did not show any significant differences in terms of distress levels and the problems reported. Only the symptoms have different profiles, probably due to the type of disease or the relevant therapies.

The study’s results were translated into the patient treatment pathways through a presentation in the journal clubs of the medical oncology 1 and hematology units, which focused on the feasibility of systematic use of this screening tool and systematic involvement of a psychologist. A standard operating procedure was then drafted and applied in a pilot phase in both departments, involving the use of a psychological distress screening tool (DT) by nurses during the initial patient evaluation. The psychologist was called in case of distress score ≥7, for re-evaluating the need for and treatment of emotional problems associated with the experience of cancer both in the patient and the family.


The authors thank Marco Pierotti for support in the accreditation process and Daniela Majerna for article review.


Financial support: This work was financially supported by the Ministry of Health-Italian Government within the Finalized Research Project Code: RF-2009-1532731. (Coord.: A Paradiso, F Belardelli).
Conflict of interest: The authors declare no conflict of interest.
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  • Quality Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan - Italy
  • Hematology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan - Italy
  • Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, Milan - Italy
  • Scientific Directorate, Fondazione IRCCS Istituto Nazionale Tumori, Milan - Italy
  • President, Fondazione IRCCS Istituto Nazionale Tumori, Milan - Italy

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