In psycho-oncology, early identification of psychological vulnerabilities of patients with cancer is one of the essential pillars of comprehensive and patient-centered care, because the experience of cancer is not only associated with physical changes and medical treatments, but can also trigger a wide range of emotional, cognitive, behavioral, and social reactions in the individual. Anxiety, depression, fear of recurrence, sleep disturbances, worries about the future, body image changes, communication problems, impairment of family roles, and concerns related to job and economic performance are among the problems that may appear at different stages of the disease. However, the severity and nature of these reactions are not the same in all patients, and some people show greater psychological vulnerability to the pressures of cancer diagnosis and treatment. For this reason, relying on clinical observation or voluntary patient visits to identify mental health problems cannot always reveal the true needs of patients, highlighting the need for the use of systematic Distress screening.
Distress is a broad concept in the field of cancer and usually refers to an unpleasant and multidimensional psychological, social, and sometimes spiritual experience that can be caused by illness, physical symptoms, treatment, family problems, economic problems, or concern about the future. The importance of this concept in psycho-oncology is that Distress is not necessarily equivalent to a specific psychiatric disorder and can range from a normal and expected reaction to a level of distress that requires professional evaluation and intervention. Therefore, Distress screening should not be carried out solely for the purpose of diagnosing depression or anxiety, but should be considered as the first step in identifying patients who may require a more rigorous psychological assessment, social support, education, psychological interventions, or specialist referral.
Systematic Distress screening makes it possible to assess psychological status on a regular basis and at specific points in the course of treatment. Early diagnosis of cancer, initiation of treatment, surgery, chemotherapy, radiation therapy, end of treatment, follow-up period, and even years after treatment can be periods when the patient's distress level changes. Therefore, a single assessment at the beginning of treatment cannot reveal the patient's psychological status throughout the course of the disease. The systematic approach is based on the principle that screening should be part of the routine process of cancer care, and that its results should be linked to the clinical decision and the specific path of referral and intervention.
One of the well-known tools for this purpose is the Distress Thermometer , which allows the patient to report their level of distress on a simple scale and at the same time identify possible problems in the physical, family, emotional, practical and social domains. The importance of such tools lies in their simplicity and usability in clinical settings, but the result of the screening alone should not be interpreted as a definitive diagnosis of a psychological disorder. A high score can indicate the need for further investigation and it is necessary for the specialist to determine the clinical meaning of the result according to the medical condition, stage of the disease, physical symptoms, psychological history and social conditions of the patient. Therefore, screening and specialized evaluation are two complementary stages and do not replace each other.
From a theoretical perspective, the value of Distress screening in psycho-oncology has to do with identifying vulnerability before the problem exacerbates. A patient who shows significant signs of anxiety, sleep disturbance, financial anxiety, social isolation, or intense fear of the future in the early stages of treatment may experience increased distress and reduced participation in the treatment process in the absence of appropriate intervention. Screening can manifest these symptoms at a time when they have not yet become a stable and severe pattern. As a result, early intervention can prevent the accumulation of psychological problems and help the patient develop appropriate coping skills before the disease pressure increases.
The importance of screening becomes even more important when we notice that many patients may not report their psychological problems to the treatment team. Some patients may think that anxiety and fear are an inevitable part of cancer and that it is not necessary to express it. Others may be concerned about the social stigma associated with receiving psychological services or think that bringing up emotional problems will distract the treatment team from the physical illness. In contrast, systematic screening sends a clear message that mental health is a formal part of cancer care and that the patient has a valid and accepted space to express their emotional and social problems.
At the clinical level, screening results can help categorize the patient's needs and determine the appropriate course of care. Patients with lower Distress may mainly require routine education, information, and support, while patients with moderate or high Distress can be referred to a psychologist, psychiatrist, social worker, or psycho-oncologist for a more specialized evaluation. The important thing is that the severity of Distress should not be the only criterion for decision-making, and the context of distress is also important. For example, distress caused by uncontrolled pain, financial difficulties, lack of family support, or severe complications of treatment may require an intervention different from clinical anxiety or depression.
Systematic screening can also help improve communication between members of the treatment team. When a patient's psychological status is recorded in a standard form and reflected in the treatment record, the doctor, nurse, psychologist, and other team members can have a more shared picture of the patient's needs. This is especially important in multidisciplinary cancer care, as psychological problems are often intertwined with physical symptoms, complications of treatment, and social conditions. Collaboration between different disciplines can prevent the patient's psychological needs from being ignored due to the focus on physical therapy.
Research evidence in the field of psycho-oncology suggests that distress is a common phenomenon among patients with cancer, but the severity and associated factors vary based on the type of cancer, stage of the disease, treatment method, age, gender, marital status, family support, and history of psychological problems. Studies have also emphasized the importance of identifying people whose psychological and social needs are less visible in routine medical evaluations. However, screening is effective when it is accompanied by an appropriate response system, i.e., there is a clear pathway for assessment, referral, intervention and follow-up once Distress has been identified. Simply administering the questionnaire without providing the services needed cannot lead to a real improvement in care.
One of the important applications of Distress screening is the personalization of psycho-oncology services. In the new approaches, the goal is not to ensure that all patients receive the same psychological program, but rather that the level and type of intervention should be tailored to their individual needs. A patient with intense anxiety about the future may need anxiety and uncertainty management interventions, while another patient may experience their main problem in the form of sleep disturbances, family problems, body image changes, or sexual issues. Initial screening can open the way for a more accurate assessment of these needs and help design an intervention plan tailored to the individual's situation.
Despite the benefits of systematic screening, there are also challenges. One of the most significant challenges is cultural and linguistic differences in the expression of psychological distress. One patient may express their anxiety as physical worry, fatigue, pain, or insomnia, and another patient may describe the same experience with feelings of fear or sadness. Also, some psychological symptoms overlap with the complications of the illness or treatment itself, and their interpretation regardless of the medical context can lead to misperceptions. On the other hand, time constraints on staff, a shortage of mental health professionals in some treatment facilities, a lack of a coherent referral system, and concerns about increased workload can make screening programs difficult to implement.
Another limitation is that screening tools alone are not able to detect the complexity of a patient's psychological experience. A numerical score cannot represent all dimensions of meaning, concern, family relationships, beliefs, and social circumstances. Therefore, the use of standard tools should be accompanied by clinical dialogue and comprehensive evaluation. It is also best to consider screening as a recurring process, as the level of distress does not remain constant throughout the course of the disease. The patient may have a relatively stable condition at the time of diagnosis but experience significant distress when starting treatment or receiving subsequent imaging results.
To enhance the effectiveness of this approach, it is necessary to transform Distress screening from a single activity to a full-fledged care pathway. Designing clear guidelines for the timing of screening, designating those responsible for its implementation, training staff, defining referral thresholds, providing psychological services, and recording results in the electronic health record can help institutionalize this process. The use of digital technologies can also make it possible to complete remote screening, monitor Distress changes, and send alerts to the treatment team. However, technology should complement and not replace human communication and expert assessment.
Systematic Distress screening is one of the important tools for operationalizing psychological care in psycho-oncology and can reduce the gap between patients' actual needs and the clinical identification of psychological problems. The main value of this approach lies in revealing psychological vulnerability before it becomes a more severe problem and increasing the possibility of intervention tailored to the patient's needs. However, its success depends on the quality of the tool, appropriate replication of screening, clinical interpretation, the existence of a referral system, and actual access to specialist services. Therefore, Distress screening should not be limited to just implementing a scale and recording a score, but should be part of an integrated system of care in which mental health is continuously assessed and followed, just like physical health. Such an approach can play an important role in early identification of vulnerable patients, directing specialized resources, reducing the psychological burden of the disease, and improving the quality of life of cancer patients and their families.