Background: Health related social needs (HRSN) impact cancer outcomes and patient experience, but their integration into routine cancer care is highly variable. To expand the implementation-centered evidence base for effective HRSN assessments, we studied a scalable HRSN screening tool to identify distress and complex symptom burden in patients with cancer. Methods: We prospectively tracked HRSN screenings (using the National Comprehensive Cancer Network [NCCN] Distress Thermometer [DT]) of patients at varying points during their cancer care between 07/2023-12/2023 at seven multi-site community oncology practices within the US Oncology Network. DT responses were used to evaluate the positive finding rate, types of distress reported, and correlations between distress areas and concerns reported. Results: Overall, 219,720 unique patients with cancer received 269,666 HRSN screenings using the NCCN DT; 27% had a distress score ≥1 and 38.5% reported a concern (of whom, 58.2% reported >1). Co-occurring concerns that were most correlated (Pearson correlation coefficient) were emotional & practical concerns in 49% of screenings, physical & practical 44%, emotional & social 37% and social & practical concerns 36%. Emotional symptoms most frequently reported together were sadness/depression + worry/anxiety 47%, loss of interest + sadness/depression 44%, and loneliness & sadness/depression 38.5%. Regarding complex symptom burden, the physical and psychosocial symptoms that were most correlated were fatigue & sleep 43%, pain & fatigue 40%, pain & sleep 38%, anxiety/worry & fatigue 37%, anxiety/worry & sleep 36%. Fatigue and pain, the two most frequently reported concerns were strongly correlated with emotional and practical concerns like sleep, worry or anxiety, memory or concentration, loss or change of physical abilities, sadness or depression, loss of interest or enjoyment, changes in eating, ability to take care of self, feelings of worthlessness or being a burden, etc. Concerns with the strongest correlations are reported in the table. Conclusions: Distress and its components impact multiple cancer outcomes making their rapid identification and consequent action key to high-quality cancer care. The findings highlight the NCCN DT as a scalable approach to integrate HRSN screening and to identify complex symptom burden in the real-world practice.