All health and care professionals should be able to provide a universal level of psychological support (Level 1 psychological support, NICE, 2004) as set out below:

• Be able to recognise psychological distress and respond appropriately and with compassion
• Avoid causing psychological harm through omission or commission
• Know when to refer on for targeted or specialist psychological support

At a universal level there are no formal screening or assessment tools.

Holistic Needs Assessment can act as an informal screening tool here. A positive screen on the HNA would be any item identified in the emotional concern domain and also an awareness of items in other domains that may be indicative of psychological difficulties including, but not limited to, signs of anxiety or low mood.

Observations or conversations may also indicate a patient has additional psychological needs – for example, during attendance of an oncology clinic.

If signs of psychological needs or distress are identified, this should promptly be escalated to a registered professional working at a targeted level for further assessment.

At a targeted level (Level 2 psychological support, NICE 2004) registered health and care professionals should be able to screen for distress at key points in the patient pathway – e.g. around diagnosis, during and after treatment, at recurrence, or when supporting people living with cancer including those with a life-limiting diagnosis.

HNAs can be undertaken by professionals working at this level and are a useful tool for initiating a clinical conversation that may identify psychological or emotional factors and a need for further assessment.

At a targeted level assessment tools include:

• Patient Health Questionnaire-9 (PHQ-9)
• General Anxiety Disorder – 7 (GAD-7)

It is advised that those undertaking targeted assessment attend psychological skills training and supervision, which supports interpretation of these measures and may facilitate onwards referral to a specialist psychological support service where required.

Patient Health Questionnaire-9 (PHQ-9)

Score interpretation and interventions

Additional clinical considerations

• Item 9 on the questionnaire (thoughts of self-harm or suicide): any score >0 warrants immediate clinical attention, regardless of total score
• Monitoring: PHQ-9 is useful for tracking response to treatment over time – typically reassessed every 2–4 weeks
• Cultural and contextual factors – the PHQ-9 is not a cancer-specific measure of psychological need and responses may be conflated by a range of other factors, including the physical impact of treatment. Always interpret scores alongside clinical judgment, patient context, and through consultation with a Practitioner Psychologist or attendance at psychological skills supervision

General Anxiety Disorder – 7 (GAD-7)

Score interpretation and interventions

Additional clinical considerations:

• Score ≥10 is often used as a threshold for identifying cases likely to benefit from clinical intervention
• Functional impact: always assess how symptoms affect daily functioning—this can guide urgency and type of support
• Co-occurring conditions: anxiety often overlaps with depression; consider using PHQ-9 alongside GAD-7 for a fuller picture
• Cultural and contextual factors: the PHQ-9 is not a cancer-specific measure of psychological need and responses may be conflated by a range of other factors, including the physical impact of treatment. Always interpret scores alongside clinical judgment, patient context, and through consultation with a Practitioner Psychologist or attendance at psychological skills supervision

• An initial assessment is conducted at the start of therapy and should include outcome measures as appropriate
• PHQ-9 and GAD-7 may be completed as core outcome measures pre/post therapy, however it is recognised that interventions at this level may not be targeting anxiety or depression per-se
• Interventions delivered at this level are person-centred and tend to be unimodal. They should be delivered by trained and registered psychological therapists. The selection of measures should therefore also be informed by the therapy on offer and the associated evidence-base

• An initial assessment is conducted at the start of therapy and should include outcome measures as appropriate
• PHQ-9 and GAD-7 may be completed as core outcome measures pre/post therapy, however it is recognised that interventions at this level may not be targeting anxiety or depression per-se
• Psychological interventions delivered at this level are formulation-driven and may be delivered directly or indirectly. They should be provided by suitably trained, qualified and accredited by mental health specialists (most commonly Clinical Psychologists or other Practitioner Psychologists) working within the scope of a relevant professional competency framework. Further detail is outside the scope of this guidance

• Consider using additional measures relevant to psychological factors and outcomes in cancer prehabilitation and care. These may include measures of quality of life, functional impairment, social support, or self-efficacy, and should take into account a person’s understanding of their condition and the treatment being offered
• Consider using other difficulty/symptom-based measures (e.g. to assess for symptoms of PTSD or other psychological difficulties) and/or other process-based measures relevant to the therapy being offered. These should be selected based on an individualised, formulation-driven approach and in accordance with the available evidence
• Idiosyncratic rating scales may be used to measure the effectiveness or outcome of a psychological intervention – for example, Subjective Units of Distress (SUDs) or Goal-Based Outcome Measures (GBOMs)

• The EuroQol 5 Dimensions 3 level screening tool (EQ5D-3L) is a validated screening tool being used in the Quality of Life (QoL) metric pilots for cancer being undertaken by NHS England
• The European Organisation for Research and Treatment of Cancer quality of life core questionnaire (EORTC QLQ-FA12)

• Brief Fatigue Inventory
• Wong-Baker FACES Pain Rating Scale
• McGill pain questionnaire
• Edmonton symptom assessment scale
• Visual analogue scale
• Verbal Rating Scale (VRS)

• Patient Activation Measure (PAM)
• Self efficacy for Managing Chronic Disease (SEMCD) Scale