# Distress screening with the distress thermometer, and referral by need

Source: https://onco.cc/protocols/distress-screening-and-referral/  
OnCo record `distress-screening-and-referral` (Protocol). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Many people with cancer feel worried, low or overwhelmed, and money, work or caring for others add to it. Clinics often ask you to mark a scale from 0 to 10 for your distress in the past week and tick a list of problems. A score of 4 or more is a signal for the team to talk it through and offer help, such as a psychologist, social worker or chaplain. Screening only helps when someone acts on it.

## Summary

NCCN's standard is that distress should be recognised, monitored, documented and treated promptly at all stages of disease and in all settings, with screening at the first visit, at appropriate intervals and whenever the clinical picture changes (Version 3.2019, the latest full text that could be read; the Version 1.2026 tool page still pairs the 0 to 10 thermometer with a problem list). The tool is a single 0 to 10 distress thermometer for the past week with a problem list of physical, emotional, social, practical and spiritual concerns. In NCCN 2019 a score of 4 or more triggers a further assessment and referral by the problem found (mental health, social work or chaplaincy); a score below 4 is handled by the oncology team as expected distress. The cut-off is a convention with known limits: NCCN itself cites a study in which a cut-off of 4 gave 95 per cent sensitivity and only 45 per cent specificity shortly after a breast cancer diagnosis.

ASCO (2014, adapting the pan-Canadian guideline) recommends that every patient be evaluated for symptoms of depression and anxiety at periodic times across the course of care using validated measures. ASCO's 2023 update sets out stepped care: education about depression and anxiety for everyone; for moderate symptoms, cognitive behavioural therapy, behavioural activation, mindfulness-based stress reduction, structured physical activity or psychosocial interventions; for severe symptoms, psychological therapy; and medicines where first-line care is unavailable, preferred, previously effective or has not worked.

The evidence that screening helps is conditional. In a randomised trial in 1,134 new patients, full screening with a problem checklist and triage lowered distress at three months against the thermometer alone, and the best predictor of improvement was receiving a referral; NCCN also records a randomised trial with no difference at 12 months, and concludes that screening is not enough without follow-up referral and treatment. In England the equivalent is the holistic needs assessment within personalised care and support planning (Macmillan and NHS); NICE's 2004 supportive and palliative care service guidance is retired.

## Fields

- Kind: Protocol
- Last checked: 2026-11-11
- Also known as: distress thermometer; NCCN distress thermometer and problem list; screening for distress; sixth vital sign; psychosocial screening; holistic needs assessment; stepped care for anxiety and depression
- Tags: protocol; supportive-care; psychosocial

## Connected records

- technologies: [After treatment in the UK: personalised care, and follow-up you lead yourself](https://onco.cc/technologies/rejuv-access-survivorship-care-uk/), [Anxiety after cancer, in survivors and in their partners](https://onco.cc/technologies/rejuv-mind-anxiety-after-cancer/), [Cognitive behavioural therapy for fatigue and distress](https://onco.cc/technologies/cbt-fatigue-distress/), [Depression during and after cancer: the interview-based prevalence, and the care model that works](https://onco.cc/technologies/rejuv-mind-depression-after-cancer/), [Mindfulness-based stress reduction and cognitive therapy](https://onco.cc/technologies/mindfulness-based-interventions/), [Psycho-oncology and distress screening](https://onco.cc/technologies/psycho-oncology/), [Screening for distress: what the thermometer can and cannot do](https://onco.cc/technologies/rejuv-mind-distress-screening/)
- fronts: [Supportive Care & Survivorship](https://onco.cc/fronts/supportive-care/)
- institutions: [American Society of Clinical Oncology (ASCO)](https://onco.cc/institutions/asco/), [International Psycho-Oncology Society](https://onco.cc/institutions/ipos/), [Macmillan Cancer Support](https://onco.cc/institutions/macmillan-cancer-support/), [National Institute for Health and Care Excellence](https://onco.cc/institutions/nice/)
- terms: [Quality of life](https://onco.cc/terms/quality-of-life/)
- protocols: [End of treatment: treatment summary, survivorship care plan and handover to primary care](https://onco.cc/protocols/survivorship-care-plan-and-treatment-summary/)

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