The complexities of cancer treatment present a myriad of life-altering impacts for patients. These impacts can be addressed only if health care systems have been designed to detect and address all of these challenges. One significant, but often hidden, challenge is distress. This reaction to the myriad obstacles that cancer presents can impact the quality of life, and influence outcomes, of patients with cancer. Health systems have been slow to address these problems, and a prime example is the implementation of a distress screening and management system. This case study summarizes distress screening in a community oncology clinic compared to a Department of Veterans Affairs (VA) oncology clinic. The community clinic responded to accreditation and grant-driven initiatives, whereas the VA responded to mental health and integrated primary care initiatives. This case study explores the history and the ongoing challenges of distress screening in these community-based health care systems.