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In this issue of JNCCN, Schuurhuizen et al1 provide an opportunity to examine some assumptions about screening and intervening for psychosocial distress among patients with cancer. In their study, 349 individuals with metastatic colorectal cancer were cluster randomized by hospital to either a stepped care intervention for distress or usual care. Although “elevated”distress wasmore prevalent than expected (at least partly due to a low cutpoint on theHospital Anxiety andDepression Scale2 to improve sensitivity), so few individuals in the stepped care arm exposed themselves to active intervention that a futility analysis was performed. The study stopped recruitment when it was determined that .33,000 participants would be needed to give the study adequate power to detect the observed effect size. Results of this study, in conjunction with a relative lack of high-quality evidence for routine approaches to distress intervention,3,4 add more weight to the need to examine current practices and assumptions. In particular, it may be worthwhile to examine how screening for distress differs from biomedical screening and intervention, how the construction and context of distress might complicate efforts to improve patient outcomes, andwhy the assumption that “if we build it, they will come” appears to be less the case than was anticipated. Screening and intervening for distress differs from biomedical screening in a number of ways. Screening, in general, focuses on detecting relatively nonsymptomatic conditions that would otherwise not be identified but require effective intervention (eg, hypertension). Distress, however, does not align with this model. Unlike biomedical screening, distress screening rests on the assumption that patients recognize their distress, can report it and its sources, and are willing to do so. However, most approaches to distress screening are “top-down,”5 relying on patients meeting a predetermined threshold that prompts further assessment and intervention. In essence, these approaches prioritize expert opinion as to what distress means, what level requires intervention, and usually what that the intervention consists of. Uptake of interventions among screened patients is often modest, at best,6 and the usual approaches to screening are likely to identify many individuals as distressed who are unlikely to accept psychosocial intervention. Anunintendedconsequenceof top-downapproaches todistress screening is that they not only overidentify individuals as distressedwhowill ultimately reject intervention but also can prevent individuals whodesire intervention fromobtaining it simply because they fail to meet some arbitrary cutpoint. Data are now starting to emerge in other populations showing that these “non-distressed” but help-desiring individuals make up a large proportion of those who desire intervention.7,8 This has sparked interest in “bottom-up” approaches and hybrid models4 that rely more on structured patient reports of unmet needs and their desire for intervention. These models potentially streamline triage to intervention and allow individuals who do not meet screening criteria to obtain the intervention they want. Schuurhuizen et al1 included expressed “need for psychosocial care” as a possible criterion to trigger intervention, which is a potential improvement but assumes that the participant wants a psychosocial intervention rather than some other type of care. There are several potential reasons why patients may not avail themselves of services offered to reduce their distress; one that is often neglected that patientsmay not

If We Build It, They Will Come: Rethinking Some Assumptions About Screening and Intervening for Distress