Published in PLOS One on 2026-01-20, this study is presented as an attributed evidence briefing. The excerpts below are the original researchers’ words, reproduced under their Creative Commons Attribution licence. Health Signal has selected the abstract and, where needed, opening background paragraphs; the complete methods, results, limitations and references remain in the linked paper.
Original authors: Tejen Chavda, Abdulrazzaq Lawal, Anthonia Sowunmi, Bolanle Adegboyega, Adewumi Alabi, Chen-Chih Chung, Sylvia Shirima, Donaldson F. Conserve, Oluwaseun Adebayo Bamodu
Source: PLOS One • DOI 10.1371/journal.pone.0341221
Read the complete primary study ↗ · Creative Commons Attribution licence
From the researchers
Abstract
Psychological distress is highly prevalent among patients with metastatic breast cancer (MBC), yet validated screening tools remain scarce in low- and middle-income countries (LMICs). The Distress Thermometer (DT), a globally endorsed screening instrument, lacks robust validation in advanced-stage cancer populations within LMIC contexts, where cultural, linguistic, and healthcare system factors may significantly influence its diagnostic performance.
To assess the diagnostic validity of the Distress Thermometer in identifying clinically significant depressive symptoms among Nigerian women with metastatic breast cancer, using the Beck Depression Inventory-II (BDI-II) as the reference standard.
Cross-sectional diagnostic validation study employing receiver operating characteristic (ROC) analysis to evaluate DT performance, with optimal cutoff identified using Youden’s Index.
A total of 309 histologically confirmed de-identified metastatic breast cancer patients were consecutively recruited from the NSIA-LUTH Cancer Centre, Lagos, Nigeria, between September 2020 and February 2022. All participants completed the DT, BDI-II, and EORTC QLQ-C30/BR23 modules.
The mean DT score was 3.4 (SD ± 1.6), with 47.0% of participants meeting the NCCN threshold for clinically significant distress (DT ≥ 4). In contrast, only 15.9% had BDI-II scores ≥20, indicating moderate-to-severe depressive symptoms. The DT demonstrated diagnostic performance significantly worse than random classification, with an AUC of 0.414 (95% CI: 0.326–0.503), significantly below the threshold for acceptable diagnostic accuracy (p < 0.001). The Youden-optimal cutoff was DT ≥ 7.5, yielding a sensitivity of 2.0% and specificity of 98.5%. At the commonly used DT ≥ 4 threshold, sensitivity was 34.7% and specificity was 50.8%, indicating poor overall diagnostic utility.
In this sub-Saharan African cancer cohort, the Distress Thermometer performed poorly in detecting clinically significant depression in this Nigerian MBC cohort when benchmarked against the BDI-II. This may reflect construct mismatch, somatic symptom confounding, cultural factors, or disease-specific characteristics of advanced cancer populations. The DT should not be used as a depression-specific screening tool in advanced cancer populations in LMICs, though its utility for identifying general distress remains unclear given the methodological limitations of this study. The poor concordance observed likely reflects construct mismatch, somatic symptom confounding in the reference standard, and the fundamental challenges of depression assessment in advanced cancer populations using self-report instruments. These findings underscore the critical need for appropriate reference standards (structured clinical interviews) and highlight methodological considerations in validating psychosocial screening tools across different constructs and cultural contexts.
Introduction
Breast cancer represents the most frequently diagnosed malignancy worldwide and the leading cause of cancer-related mortality among women, accounting for approximately 11.7% of all new cancer cases and over 685,000 deaths annually [1]. The burden disproportionately affects women in low- and middle-income countries (LMICs), where late-stage presentation, limited treatment options, and poor survival outcomes compound the disease’s impact [2]. Beyond its physical manifestations, breast cancer imposes profound psychological and emotional challenges, particularly among patients with metastatic disease who face an incurable prognosis and complex treatment trajectories.
Reading this evidence
Use the full paper to check the study design, participant selection, comparator and outcome definitions before drawing a practical conclusion. An association does not by itself show cause and effect. A reported performance measure needs its denominator and uncertainty. A finding from a particular facility, sample or time period should retain that scope when it is discussed elsewhere.
This briefing makes the source accessible within the wider technology & industry desk. It does not assess an individual patient or certify a product. When considering relevance to another health system, examine the original authors’ account of context and limitations, then seek local implementation evidence. The related reporting below provides other studies to read alongside this one; it is a topic connection, rather than a claim that their results are directly comparable.
© 2026 Tejen Chavda, Abdulrazzaq Lawal, Anthonia Sowunmi, Bolanle Adegboyega, Adewumi Alabi, Chen-Chih Chung, Sylvia Shirima, Donaldson F. Conserve, Oluwaseun Adebayo Bamodu. Excerpts reproduced under CC BY. Selection, formatting and contextual notes by Health Signal. The researchers are the authors of the source study, not members of Health Signal’s staff.
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