The NCCN single-item, rapid-screening instrument asks patients to rate their distress on a scale of 0 ("no distress") to 10 ("extreme distress"). On an accompanying problem list they are asked to indicate what has been a problem for them in the past week. Studies [4,6,7,24,25] have tested the ability of the single-item measure to identify patients in distress, investigated sensitivity and specificity in an effort to recommend a cutoff score, and identified prevalence rates.
One study  found the Distress Thermometer to have reasonable convergent and divergent validity when compared with two more well-established inventories (BSI and BSI-18; see Table 1 below) but did not recommend a specific cutoff score. A larger, multisite study (N = 380) found that a cutoff score of 4 resulted in acceptable sensitivity (.77, .70) and specificity (.68, .70) when compared with two other widely used yet longer self-report questionnaires (Hospital Anxiety and Depression Scale [HADS] and BSI; see Table 1 below).
Thus it appears that the single-item rapid-screening Distress Thermometer is comparable to other well-established self-report questionnaires (BSI, BSI-18, HADS) in accurately classifying patients with and without distress. The following table is a list of self-report screening instruments used for identification of psychosocial distress.
Table 1. Self-report Screening Instruments Used for Identification of Psychosocial Distress in Cancer Patients
| Title || Items (no.) || Time (min)|| Constructs Measured|
|Distress Thermometer & Problem List [12,15]|| Varies||2-3|| Distress and problems related to the distress |
|Brief Symptom Inventory (BSI) ||53 ||7-10 ||Somatization, anxiety, interpersonal sensitivity, depression, hostility, phobic anxiety, paranoid ideation, psychoticism, obsessive-compulsiveness |
|Brief Symptom Inventory (BSI-18) ||18||3-5||Somatization, depression, anxiety, general distress |
|Hospital Anxiety and Depression Scale (HADS) [26,27,28]|| 14 || 5-10 ||Symptoms of clinical depression and anxiety|
|Functional Assessment of Chronic Illness Therapy (FACIT; formerly the FACT) || 27|| 5-10|| 4 domains of quality of life: physical, functional, social/family, emotional well-being |
|Profile of Mood States (POMS) ||65|| 3-5 || 6 mood states: anxiety, fatigue, confusion, depression, anger, vigor |
|Zung Self-Rating Depression Scale ||20|| 5-10||Symptoms of depression|
Self-report screening instruments must be scored, evaluated, and discussed with each patient. Triage-the process of communicating screening results, discussing each patient's needs, and determining the best course of further action-is key to the successful use of screening. In fact, screening without availability of appropriate treatment resources is considered unethical. The NCCN standards of care  suggest distress rated as mild might result in a referral to a local self-help group or management by the primary oncology team only. Distress rated as moderate to severe warrants referral to other appropriate professionals (psychologists, psychiatrists, social workers, palliative care specialists, or pastoral counselors), depending on the nature of the distress.
The primary oncology team (oncologist, nurse, palliative care specialist, social worker, and counselor) is responsible for successful triage. In some studies a significant percentage of patients who report moderate to high levels of distress refuse further assessment.[8,9,32,33] Thus, it is important to consider how the primary oncology team can introduce the need for further psychosocial assessment.