Ontada Research Shows Relationship Between NCCN Distress Thermometer Scores and OS in Common Cancers

The National Comprehensive Cancer Network (NCCN) distress thermometer, created a generation ago to help oncologists flag psychosocial stress issues that might need intervention,¹ can signal mortality risk across several common cancers, making it a simple tool for risk stratification and long-term monitoring, according to real-world data presented recently.²

Data from Ontada were found in the abstract “Distress Thermometer Scores and Outcomes in Metastatic Breast, Colorectal, and Lung Cancer: Real-World Evidence from a Large US Community Oncology Setting,” which was presented at ISPOR 2026 in Philadelphia, held May 17-20, 2026.²

The NCCN distress thermometer is an easy-to-use screening tool that asks patients to rate their overall level of distress from 0 to 10 over the previous week, similar to a pain scale. Scores of 0 to 3 in a domain can be managed with self-administered coping strategies, but scores of 4 to 10 show clinically meaningful stress that may require referral to other providers. The thermometer is often paired with a 34-item checklist that covers sources of distress across 5 domains: practical (insurance, housing, finances, and work); family and social; emotional (feelings of depression, fear, or grief); physical (pain, nausea, loss of sleep or appetite); and spiritual (loss of faith or religious concerns).³

The distress thermometer gained renewed importance with the arrival of the Enhanced Oncology Model (EOM) in 2023, as participating practices—including those in The US Oncology Network—looked to this validated tool as a way to measure social determinants of health, initially among the EOM’s required elements.⁴

According to the Ontada findings presented at ISPOR, the distress thermometer may offer more than a window into concerns around social determinants of health. This retrospective cohort study looked at adults with metastatic breast, colorectal, or non–small cell lung cancer (NSCLC) who completed the Distress Thermometer questionnaire in the iKnowMed electronic health record (EHR) between January 2023 and December 2025.² For this study, scores were categorized as mild (1-3), moderate (4-6), and severe (7-10). Prognostic value OS was assessed using multivariable time-dependent Cox models adjusted for demographic and clinical factors.²

Among the findings²:

• Severe distress was independently associated with shorter survival in NSCLC, but in metastatic breast and colorectal cancer, physical concerns emerged as the dominant prognostic domain. “These findings suggest that both distress severity and the underlying problem domains matter, and that the pathways linking psychosocial burden to outcomes may differ by cancer type,” the authors wrote.
• Improvement in scores over time was associated with better OS in metastatic CRC, regardless of baseline status. The authors interpreted this finding to show that the thermometer is a “dynamic longitudinal marker,” rather than a static marker at baseline, which shows the need to continue assessments throughout the care journey.
• Score thresholds of 4 or higher and 7 or higher identified patients at higher risk of mortality independent of other factors, which offers additional support for this simple assessment as a “pragmatic tumor-agnostic risk stratification tool.”²

The Ontada team concluded that the “scores and problem-list domains capture patient-reported burden and predict overall survival across metastatic breast, colorectal, and lung cancer in routine clinical practice. These findings support routine [Distress Thermometer] screening as a pragmatic tool for risk stratification and longitudinal monitoring to inform supportive care in community oncology settings.”

For additional insights, The American Journal of Managed Care^® (AJMC^®) sought input from Jessica Paulus, ScD, vice president for Real World Research at Ontada, who was senior author and presenter of the study. Paulus’ responses to AJMC’s questions appear below.

AJMC: Describe how both the overall distress thermometer scores and the specific scores in domains matter when using this tool.

Paulus: One of the key findings from our study is both the overall distress score and the underlying domains (ie, physical, spiritual, financial) to provide important and distinct information. At a very high level, the overall distress thermometer score, particularly thresholds greater than 4 or greater than 7, was strongly associated with overall survival across all 3 cancer types we analyzed.

It could function, with more evaluation, as a potential risk stratification tool, but when examined more closely at the domains, you start to see that what is driving the overall distress also matters, and it varies by cancer type, which is not surprising. For example, physical concerns emerged as the dominant prognostic domain in metastatic breast and colorectal cancer, but severe overall distress was a stronger signal in non–small cell lung cancer.

For those who are clinically familiar with those 3 diseases, in spite of the fact they're all metastatic diseases, and how they manifest and impact the patient, some of those findings would not be surprising. The takeaway is that the total score can tell you who is at higher risk, but the domains may help you understand why and how to best intervene to support the patient.

AJMC: Physical concerns proved to be important indicators in breast cancer and colorectal cancer. This seems intuitive, but how does having the distress thermometer measure help practices to respond to individual patients?

Paulus: What the distress thermometer provides is a way to first systematically and consistently capture that information across patients. Instead of relying on what comes up in conversation, the embedded NCCN distress thermometer creates a structured way to identify patients who are experiencing significant physical burden and may need additional support. From a very practical perspective, that could allow practices to identify patients who might benefit from earlier symptom management or potentially palliative care. It could also allow practices to prioritize limited supportive care resources and ensure that concerns don't go unrecognized in busy clinical settings.

What's important is that The US Oncology Network moved the NCCN distress thermometer from a paper form to an electronic format embedded in the electronic medical record, iKnowMed, about 3 years ago, which allows this tool to be measurable and actionable at scale. It's not required for all patients, but it is something that has a lower barrier to use at the bedside, which can really enable scaling across big groups of patients.

AJMC: How is risk stratification based on distress thermometer scores utilized in day-to-day practice? Does having the patient’s score allow physicians or social workers to initiate conversations more readily?

Paulus: That's exactly what the distress thermometer can and should function as in day-to-day practice as a trigger for action, rather than just a documentation tool. Thresholds like greater than or equal to 4 or greater than or equal to 7 can be used to flag patients who might need additional evaluation or referral, which could mean involvement of a social worker, behavioral health supports, or symptom management support, depending on what's driving the distress. Importantly, like a lot of screening tools, it can help facilitate communication.

Having a documented score gives clinicians and care teams a way to have open conversations more directly. It could provide a structured entry point for physicians to ask, “I noticed that your distress score is high today, can you tell me more about what's going on?”

What our findings add is that distress is not just relevant for the patient experience but is also associated with outcomes that change over time, which is very critical for what patients care about most—their long-term health span and their life span broadly. Incorporating the distress thermometer into routine care allows providers to both identify risk earlier, monitor response over time, and act earlier on potential escalating distress for patients.

References

1. National Comprehensive Cancer Network Clinical Guidelines. Version 1.2026 Distress Management. Accessed May 25, 2026. https://www.nccn.org/docs/default-source/patient-resources/nccn_distress_thermometer.pdf
2. Su Z, Aguilar K, Pasha S, et al. Distress thermometer scores and outcomes in breast, colorectal, and lung cancer: real-world evidence from a large US community oncology setting. Presented at: ISPOR 2026; May 17-20, 2026; Philadelphia, PA. Poster No. PCR99. https://bit.ly/4tUmtA8
3. Cutillo A, O'Hea E, Person S, Lessard D, Harralson T, Boudreaux E. The distress thermometer: cutoff points and clinical use. Oncol Nurs Forum. 2017;44(3):329-336. doi: 10.1188/17.ONF.329-336
4. Mattina C. The US Oncology Network demonstrates the power of partnerships in social barriers to care. Am J Manag Care. 2024;30(Spec No. 14):SP1107.