Background: Patients with cancer and their caregivers are at an increased risk of psychosocial distress that can negatively impact health outcomes and quality of life. Several organizations including NCCN, American College of Surgeons Commission on Cancer, and ASCO, recommend routine psychosocial distress screening and referral. However, many patients are not routinely screened for psychosocial distress, leading to missed intervention opportunities. The NCCN Distress Thermometer (NCCN DT) is the most commonly used self-reporting tool, but its use varies significantly due to differences in practice, workflows, and resources. This systematic review aims to capture elements of the workflow in screening and referral using the NCCN DT, with the goal of providing building block(s) for the implementation that can be adapted to different settings. Methods: A systematic review of full-text manuscripts published from 2013 was conducted using MEDLINE, EMBASE, and CINAHL. Studies describing implementation protocols were included. Systematic reviews and commentary articles were excluded. Additionally, studies conducted outside the US, non-English publications, and studies assessing associations of distress scores with disease burden were excluded. Attributes related to the implementation of screening and referral pathways were extracted. Results: From an initial screening to 1,219 articles, 12 studies were included in the final analysis. There was variation in the targeted populations, with three cancer centers implementing NCCN DT screening and referral protocols system-wide, while others focused on specific cancer types/ clinics. Screening was conducted by various personnel, including medical assistants, front-end staff, and nurse/ nursing assistants, with differences in screening frequency, and mode (paper, telephone, and tablet). Different referral workflows based on distress severity were adopted in multiple studies (n=4), with an array of referral services employed. Conclusions: The implementation of NCCN DT screening and referral pathways varies across the literature. While standardization is desirable, some variation is essential to accommodate the differing availability of resources and personnel for effective screening and referral. This review identifies foundational blocks and considerations for developing customized NCCN DT screening and referral protocols that align with specific needs and available resources of the practice.