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The use of the Distress Thermometer and the Hospital Anxiety and Depression Scale for screening of anxiety and depression in Italian women newly diagnosed with breast cancer



Distress is a factor that can adversely affect quality of life in breast cancer patients. A rapid and non-invasive tool to accurately detect distress is therefore important. The aims of the study were (1) to describe the women’s experiences after having received a breast cancer diagnosis and while awaiting primary surgery, in terms of anxiety and depression, (2) to evaluate the use of the Distress Thermometer (DT) in newly diagnosed breast cancer patients, and (3) to define an optimal cutoff score for the DT for this population.


This study involved 436 newly diagnosed patients in the pre-surgery phase. Consent forms and questionnaires were delivered by nurses during the pre-surgery check-ups, in the time between the 4 weeks post-diagnosis and the 2 weeks before surgery. Receiver operating characteristic analysis was used to evaluate the diagnostic accuracy of the DT compared to the Hospital Anxiety and Depression Scale (HADS) and to define an optimal cutoff score for the DT in this specific population.


The results showed that the DT is a fast, easy, and well-accepted screening tool in the Italian context of women newly diagnosed with breast cancer, performing well in relation to the HADS. The proposed cutoff score for DT screening in the clinical setting is 4 versus 5.


The DT is recommended as a first step in screening, always followed by a more detailed evaluation of psychological functioning.

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  1. 1.

    IARC’s Global Cancer Observatory (2018). The online GLOBOCAN 2018 database. http://gco.iarc.fr/. Accessed 23 August 2019

  2. 2.

    AIRTUM Working Group (2018) I numeri del cancro 2018. Il Pensiero Scientifico Editore, Roma

  3. 3.

    Cordova MJ, Giese-Davis J, Golant M, Kronenwetter C, Chang V, Spiegel D (2007) Breast cancer as trauma: posttraumatic stress and posttraumatic growth. J Clin Psychol Med Settings 14(4):308–319

  4. 4.

    Nakatani Y, Iwamitsu Y, Kuranami M, Okazaki S, Yamamoto K, Watanabe M, Miyaoka H (2012) Emotional suppression and psychological responses to a diagnosis of breast cancer. Shinrigaku kenkyu: Jpn J Psychol 83(2):126–134. https://doi.org/10.4992/jjpsy.83.126

  5. 5.

    Wang HH, Chung UL (2012) Healthy lifestyle changes during the period before and after cancer diagnosis among breast cancer survivors. Asian Pac J Cancer Prev 13(9):4769–4772. https://doi.org/10.7314/APJCP.2012.13.9.4769

  6. 6.

    Mehnert A, Koch U (2007) Prevalence of acute and post-traumatic stress disorder and comorbid mental disorders in breast cancer patients during primary cancer care: a prospective study. Psycho-Oncology: J Psychol Soc Behav Dimens Cancer 16(3):181–188. https://doi.org/10.1002/pon.1057

  7. 7.

    Rabin C, Pinto B (2006) Cancer-related beliefs and health behavior change among breast cancer survivors and their first-degree relatives. Psycho-Oncology: J Psychol Soc and Behav Dimens Cancer 15(8):701–712. https://doi.org/10.1002/pon.1000

  8. 8.

    Loeffler S, Poehlmann K, Hornemann B (2018) Finding meaning in suffering?—meaning making and psychological adjustment over the course of a breast cancer disease. Eur J Cancer Care 27(3):e12841. https://doi.org/10.1111/ecc.12841

  9. 9.

    Little M, Sayers E (2004) While there’s life…: hope and the experience of cancer. Soc Sci Med 59(6):1329–1337. https://doi.org/10.1016/j.socscimed.2004.01.014

  10. 10.

    Khan F, Amatya B, Pallant JF, Rajapaksa I (2012) Factors associated with long-term functional outcomes and psychological sequelae in women after breast cancer. Breast 21(3):314–320. https://doi.org/10.1016/j.breast.2012.01.013

  11. 11.

    Mehnert A, Hartung TJ, Friedrich M, Vehling S, Braehler E, Haerter M, Faller H (2017) One in two cancer patients is significantly distressed: prevalence and indicators of distress. Psycho-Oncology 27:75–82. https://doi.org/10.1002/pon.4464

  12. 12.

    Morel N, Dayan J, Piolino P, Viard A, Allouache D, Noal S, Levy C, Joly F, Eustache F, Giffard B (2015) Emotional specificities of autobiographical memory after breast cancer diagnosis. Conscious Cogn 35:42–52. https://doi.org/10.1016/j.concog.2015.04.016

  13. 13.

    Pierrisnard C, Baciuchka M, Mancini J, Rathelot P, Vanelle P, Montana M (2018) Body image and psychological distress in women with breast cancer: a French online survey on patients’ perceptions and expectations. Breast Cancer 25(3):303–308. https://doi.org/10.1007/s12282-017-0828-2

  14. 14.

    Faretta E, Civilotti C (2016) EMDR therapy in psycho-oncology: a bridge between mind and body. J EMDR Pract Res 10(3):138–152. https://doi.org/10.1891/1933-3196.10.3.138

  15. 15.

    Basak F, Hasbahceci M, Guner S, Sisik A, Acar A, Yucel M, Kilic A, Bas G (2015) Prediction of anxiety and depression in general surgery inpatients: a prospective cohort study of 200 consecutive patients. Int J Surg 23:18–22. https://doi.org/10.1016/j.ijsu.2015.09.040

  16. 16.

    Miller SJ, Schnur JB, Weinberger-Litman SL, Montgomery GH (2014) The relationship between body image, age, and distress in women facing breast cancer surgery. Palliat Supportive Care 12(5):363–367. https://doi.org/10.1017/S1478951513000321

  17. 17.

    Drageset S, Lindstrøm TC, Giske T, Underlid K (2011) Being in suspense: women’s experiences awaiting breast cancer surgery. J Adv Nurs 67(9):1941–1951. https://doi.org/10.1111/j.1365-2648.2011.05638.x

  18. 18.

    Drageset S, Lindstrøm TC, Giske T, Underlid K (2012) “The support I need”: women’s experiences of social support after having received breast cancer diagnosis and awaiting surgery. Cancer Nurs 35(6):E39–E47. https://doi.org/10.1097/NCC.0b013e31823634aa

  19. 19.

    Boehmke MM, Dickerson SS (2006) The diagnosis of breast cancer: transition from health to illness. Oncol Nurs Forum 33:1121–1127

  20. 20.

    van't Spijker A, Trijsburg RW, Duivenvoorden HJ (1997) Psychological sequelae of cancer diagnosis: a meta-analytical review of 58 studies after 1980. Psychosom Med 59(3):280–293

  21. 21.

    Drageset S, Lindstrøm TC, Giske T, Underlid K (2016) Women’s experiences of social support during the first year following primary breast cancer surgery. Scand J Caring Sci 30(2):340–348. https://doi.org/10.1111/scs.12250

  22. 22.

    Ghirardello D, Munari J, Testa S, Torta R, Veglia F, Civilotti C (2018) Italian adaptation of the brief modified experiences in close relationships scale in a sample of cancer patients: factor analysis and clinical implications. Res Psychother: Psychopathol Process Outcome 21:209–217. https://doi.org/10.4081/ripppo.2018.319

  23. 23.

    Bultz BD, Groff SL, Fitch M, Blais MC, Howes J, Levy K, Mayer C (2011) Implementing screening for distress, the 6th vital sign: a Canadian strategy for changing practice. Psycho-Oncology 20(5):463–469. https://doi.org/10.1002/pon.1932

  24. 24.

    Absolom K, Holch P, Pini S, Hill K, Liu A, Sharpe M, Richardson A, Velikova G, Supportive NCRICOMPASS, Collaborative PCR (2011) The detection and management of emotional distress in cancer patients: the views of health-care professionals. Psycho-oncology 20(6):601–608. https://doi.org/10.1002/pon.1916

  25. 25.

    Testa S, Civilotti C, Di Fini G, Rossetto C, Boncinelli V, Veglia F (2016) Development of two equivalent short forms of the psychological general well-being index: PGWBI-A and PGWBI-B. TPM Testing, Psychometr, Methodol Appl Psychol 23:149–166

  26. 26.

    Roth AJ, Kornblith AB, Batel-Copel L, Peabody E, Scher HI, Holland JC (1998) Rapid screening for psychologic distress in men with prostate carcinoma: a pilot study. Cancer: Interdiscipl Int J Am Cancer Soc 82(10):1904–1908. https://doi.org/10.1002/(SICI)1097-0142

  27. 27.

    Grassi L, Johansen C, Annunziata MA, Capovilla E, Costantini A, Gritti P, Torta R, Bellani M, Italian Society of Psycho-Oncology Distress Thermometer Study Group (2013) Screening for distress in cancer patients: a multicenter, nationwide study in Italy. Cancer 119(9):1714–1721. https://doi.org/10.1002/cncr.27902

  28. 28.

    Cormio C, Caporale F, Spatuzzi R, Lagattolla F, Lisi A, Graziano G (2019) Psychosocial distress in oncology: using the distress thermometer for assessing risk classes. Support Care Cancer 20:1–7. https://doi.org/10.1007/s00520-019-04694-4

  29. 29.

    Donovan KA, Grassi L, McGinty HL, Jacobsen PB (2014) Validation of the distress thermometer worldwide: state of the science. Psycho-oncology 23(3):241–250. https://doi.org/10.1002/pon.3430

  30. 30.

    Schellekens MP, van den Hurk DG, Prins JB, Molema J, van der Drift MA, Speckens AE (2016) The suitability of the Hospital Anxiety and Depression Scale, Distress Thermometer and other instruments to screen for psychiatric disorders in both lung cancer patients and their partners. J Affect Disord 203:176–183. https://doi.org/10.1016/j.jad.2016.05.044

  31. 31.

    Zigmond AS, Snaith RP (1983) The hospital anxiety and depression scale. Acta Psychiatr Scand 67(6):361–370. https://doi.org/10.1111/j.1600-0447.1983.tb09716.x

  32. 32.

    Annunziata MA, Muzzatti B, Bidoli E, Flaiban C, Bomben F, Piccinin M, Gipponi KM, Mariutti G, Busato S, Mella S (2019) Hospital anxiety and depression scale (HADS) accuracy in cancer patients. Support Care Cancer:1–6. https://doi.org/10.1007/s00520-019-05244-8

  33. 33.

    Reuter K, Härter M (2001) Screening for mental disorders in cancer patients–discriminant validity of HADS and GHQ-12 assessed by standardized clinical interview. Int J Methods Psychiatr Res 10(2):86–96. https://doi.org/10.1002/mpr.103

  34. 34.

    Bener A, Alsulaiman R, Doodson LG, El Ayoubi HR (2016) Comparison of reliability and validity of the breast cancer Depression Anxiety Stress Scales (DASS-21) with the Beck Depression Inventory-(BDI-II) and Hospital Anxiety and Depression Scale (HADS). Int J Behav Res Psychol 4(4):197–203. https://doi.org/10.19070/2332-3000-1600035

  35. 35.

    Castelli L, Binaschi L, Caldera P, Torta R (2009) Depression in lung cancer patients: is the HADS an effective screening tool? Support Care Cancer 17(8):1129–1132. https://doi.org/10.1007/s00520-009-0604-8

  36. 36.

    Norton S, Cosco T, Doyle F, Done J, Sacker A (2013) The hospital anxiety and depression scale: a meta confirmatory factor analysis. J Psychosom Res 74(1):74–81. https://doi.org/10.1016/j.jpsychores.2012.10.010

  37. 37.

    Bidstrup PE, Mertz BG, Dalton SO, Deltour I, Kroman N, Kehlet H, Rottmann N, Gärtner R, Mitchell AJ, Johansen C (2012) Accuracy of the Danish version of the ‘distress thermometer’. Psycho-Oncology 21(4):436–443. https://doi.org/10.1002/pon.1917

  38. 38.

    Baken DM, Woolley C (2011) Validation of the distress thermometer, impact thermometer and combinations of these in screening for distress. Psycho-oncology 20(6):609–614. https://doi.org/10.1002/pon.1934

  39. 39.

    Shim EJ, Shin YW, Jeon HJ, Hahm BJ (2008) Distress and its correlates in Korean cancer patients: pilot use of the distress thermometer and the problem list. Psycho-Oncology: J Psychol Soc Behav Dimens Cancer 17(6):548–555. https://doi.org/10.1002/pon.1320

  40. 40.

    Ransom S, Jacobsen PB, Booth-Jones M (2006) Validation of the distress thermometer with bone marrow transplant patients. Psycho-Oncology: J Psychol Soc and Behav Dimens Cancer 15(7):604–612. https://doi.org/10.1002/pon.993

  41. 41.

    Zweig MH, Campbell G (1993) Receiver-operating characteristic (ROC) plots: a fundamental evaluation tool in clinical medicine. Clin Chem 39(4):561–577

  42. 42.

    Grassi L, Travado L, Moncayo FL, Sabato S, Rossi E, SEPOS group (2004) Psychosocial morbidity and its correlates in cancer patients of the Mediterranean area: findings from the southern European psycho-oncology study. J Affect Disord 83(2–3):243–248. https://doi.org/10.1016/j.jad.2004.07.004

  43. 43.

    Annunziata MA, Giovannini L, Muzzatti B (2012) Assessing the body image: relevance, application and instruments for oncological settings. Supportive Care Cancer 20(5):901–907. https://doi.org/10.1007/s00520-011-1339-x

  44. 44.

    Scaruffi E, Franzoi IG, Civilotti C, Guglielmucci F, La Marca L, Tomelini M, Veglia F, Granieri A (2018) Body image, personality profiles and alexithymia in patients with polycystic ovary syndrome (PCOS). J Psychosom Obstet Gynecol 31:1–10. https://doi.org/10.1080/0167482X.2018.1530210

  45. 45.

    Ministero della Salute (2018).Tumore della mammella. http://www.salute.gov.it/portale/salute/p1_5.jsp?lingua=italiano&id=152&area=Tumori. Accessed 30 July 2019

  46. 46.

    Grassi L, Holland JC, Johansen C, Koch U, Fawzy F (2005) Psychiatric concomitants of cancer, screening procedures, and training of health-care professionals in oncology: the paradigms of psycho-oncology in the psychiatry field. Advances in psychiatry 2:59–66

  47. 47.

    Gradishar WJ, Anderson BO, Balassanian R, Blair SL, Burstein HJ, Cyr A, Elias AD, Farrar WB, Forero A, Giordano SH, Goetz MP, Goldstein LJ, Isakoff SJ, Lyons J, Marcom PK, Mayer IA, McCormick B, Moran MS, O'Regan RM, Patel SA, Pierce LJ, Reed EC, Salerno KE, Schwartzberg LS, Sitapati A, Smith KL, Smith ML, Soliman H, Somlo G, Telli M, Ward JH, Shead DA, Kumar R (2017) NCCN Guidelines Insights: Breast Cancer, Version 1.2017. J Natl Compr Canc Netw 15(4):433–451

  48. 48.

    Vodermaier A, Linden W, Siu C (2009) Screening for emotional distress in cancer patients: a systematic review of assessment instruments. J Natl Cancer Inst 101(21):1464–1488. https://doi.org/10.1093/jnci/djp336

  49. 49.

    Che-tuma MM (2018) An educational program for using the Distress Thermometer. Walden Dissertations and Doctoral Studies Collection, Florida

  50. 50.

    Zebrack B, Kayser K, Bybee D, Padgett L, Sundstrom L, Jobin C, Oktay J (2017) A practice-based evaluation of distress screening protocol adherence and medical service utilization. J Natl Compr Cancer Netw 15(7):903–912. https://doi.org/10.6004/jnccn.2017.0120

  51. 51.

    Tonsing KN, Vungkhanching M (2018) Assessing psychological distress in cancer patients: the use of distress thermometer in an outpatient cancer/hematology treatment center. Soc Work Health Care 57(2):126–136. https://doi.org/10.1080/00981389.2017.1402844

  52. 52.

    Grassi L, Sabato S, Rossi E, Marmai L, Biancosino B (2009) Affective syndromes and their screening in cancer patients with early and stable disease: Italian ICD-10 data and performance of the distress thermometer from the Southern European Psycho-oncology Study (SEPOS). J Affect Disord 114(1–3):193–199. https://doi.org/10.1016/j.jad.2008.07.016

  53. 53.

    Head BA, Schapmire TJ, Keeney CE, Deck SM, Studts JL, Hermann CP, Scharfenberger JA, Pfeifer MP (2012) Use of the distress thermometer to discern clinically relevant quality of life differences in women with breast cancer. Qual Life Res 21(2):215–223. https://doi.org/10.1007/s11136-011-9934-3

  54. 54.

    Carlson LE, Groff SL, Maciejewski O, Bultz BD (2010) Screening for distress in lung and breast cancer outpatients: a randomized controlled trial. J Clin Oncol 28(33):4884–4891. https://doi.org/10.1200/JCO.2009.27.3698

  55. 55.

    Akizuki N, Yamawaki S, Akechi NT, Uchitomi Y (2005) Development of an impact thermometer for use in combination with the distress thermometer as a brief screening tool for adjustment disorders and/or major depression in cancer patients. J Pain Symptom Manag 29(1):91–99. https://doi.org/10.1016/j.jpainsymman.2004.04.016

  56. 56.

    Dabrowski M, Boucher K, Ward JH, Lovell MM, Sandre A, Bloch J, Carlquist L, Porter M, Norman L, Buys SS (2007) Clinical experience with the NCCN distress thermometer in breast cancer patients. J Natl Compr Cancer Netw 5(1):104–111. https://doi.org/10.6004/jnccn.2007.0011

  57. 57.

    Iskandarsyah A, de Klerk C, Suardi DR, Soemitro MP, Sadarjoen SS, Passchier J (2013) The distress thermometer and its validity: a first psychometric study in Indonesian women with breast cancer. PLoS One 8(2):e56353. https://doi.org/10.1371/journal.pone.0056353

  58. 58.

    Hegel MT, Collins ED, Kearing S, Gillock KL, Moore CP, Ahles TA (2008) Sensitivity and specificity of the distress thermometer for depression in newly diagnosed breast cancer patients. Psycho-Oncology: J Psychol Soc Behav Dimens Cancer 17(6):556–560. https://doi.org/10.1002/pon.1289

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Correspondence to Daniela Acquadro Maran.

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Relevance of the manuscript

In the context of the Italian public health system, screening procedures for psychological problems are fundamental to achieve the goal of providing the best possible holistic care. At the same time, this care must be provided with the best and most efficient use of the human and economic resources available. The DT is a fast, easy, and well-accepted screening tool in the Italian context of women newly diagnosed with breast cancer, performing well in relation to the HADS. The test is recommended as a first step in the screening procedure, always followed by a more detailed evaluation of the psychological functioning of the patient.

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Civilotti, C., Acquadro Maran, D., Santagata, F. et al. The use of the Distress Thermometer and the Hospital Anxiety and Depression Scale for screening of anxiety and depression in Italian women newly diagnosed with breast cancer. Support Care Cancer (2020). https://doi.org/10.1007/s00520-020-05343-x

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  • Breast cancer
  • Distress
  • Anxiety
  • Depression