Supportive Care in Cancer

, Volume 21, Issue 1, pp 119–127 | Cite as

How does the Distress Thermometer compare to the Hospital Anxiety and Depression Scale for detecting possible cases of psychological morbidity among cancer survivors?

  • Allison Boyes
  • Catherine D’Este
  • Mariko Carey
  • Christophe Lecathelinais
  • Afaf Girgis
Original Article



Use of the Distress Thermometer (DT) as a screening tool is increasing across the cancer trajectory. This study examined the accuracy and optimal cut-off score of the DT compared to the Hospital Anxiety and Depression Scale (HADS) for detecting possible cases of psychological morbidity among adults in early survivorship.


This study is a cross-sectional survey of 1,323 adult cancer survivors recruited from two state-based cancer registries in Australia. Participants completed the DT and the HADS at 6 months post-diagnosis.


Compared to the HADS subscale threshold ≥8, the DT performed well in discriminating between cases and non-cases of anxiety, depression and comorbid anxiety–depression with an area under the curve of 0.85, 0.84 and 0.87, respectively. A DT cut-off score of ≥2 was best for clinical use (sensitivity, 87–95 %; specificity, 60–68 %), ≥4 was best for research use (sensitivity, 67–82 %; specificity, 81–88 %) and ≥3 was the best balance between sensitivity (77–88 %) and specificity (72–79 %) for detecting cases of anxiety, depression and comorbid anxiety–depression. The DT demonstrated a high level of precision in identifying non-cases of psychological morbidity at all possible thresholds (negative predictive value, 77–99 %).


The recommended DT cut-off score of ≥4 was not supported for universal use among recent cancer survivors. The optimal DT threshold depends upon whether the tool is being used in the clinical or research setting. The DT may best serve to initially identify non-cases as part of a two-stage screening process. The performance of the DT against ‘gold standard’ clinical interview should be evaluated with cancer survivors.


Cancer Psychological distress Screening Sensitivity Specificity Survivor 



The research on which this paper is based was conducted as part of the Cancer Survival Study led by Allison Boyes and Afaf Girgis. Funding for this study was provided by the National Health and Medical Research Council (ID 252418), Cancer Council NSW, Hunter Medical Research Institute, Honda Foundation and University of Newcastle. The Victorian Cancer Registry (Cancer Council Victoria) and NSW Central Cancer Registry (NSW Department of Health and Cancer Institute NSW) assisted with case recruitment. Our sincere thanks to the cancer survivors who provided the survey data and Alison Zucca for research support.

Conflict of interest

None. The authors have full control of all primary data and agree to allow the journal to review the data relating to this paper if requested.


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Copyright information

© Springer-Verlag 2012

Authors and Affiliations

  • Allison Boyes
    • 1
  • Catherine D’Este
    • 1
    • 2
  • Mariko Carey
    • 1
  • Christophe Lecathelinais
    • 3
  • Afaf Girgis
    • 4
  1. 1.Priority Research Centre for Health BehaviourUniversity of Newcastle and Hunter Medical Research InstituteNewcastleAustralia
  2. 2.Centre for Clinical Epidemiology and BiostatisticsUniversity of NewcastleNewcastleAustralia
  3. 3.Hunter New England Population HealthWallsendAustralia
  4. 4.Ingham Institute for Applied Medical ResearchUniversity of New South WalesLiverpoolAustralia

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