The mental health burden of cancer
It is estimated that from 2001 to 2011 the number of newly diagnosed cases of cancer will increase by 29% in women and 32% in men . Cancer is the leading cause of burden of disease and injury in Australia, accounting for nearly one-fifth of the total disease burden . The diagnosis and subsequent treatment of cancer is a major life stress that is followed by a range of well described psychological, social, physical and spiritual difficulties . While over time most people diagnosed with cancer go on to adjust effectively to their changed life circumstances without clinical intervention, approximately 35% will experience persistent clinically significant distress such as anxiety and depression, adjustment disorders, fears about cancer recurrence, and post traumatic stress reactions, that for some will worsen over time [4, 5]. As well, many partners of cancer patients report high levels of psychological distress, sometimes even greater than that of the patients [6, 7]. The most powerful prospective predictor of longer term distress is current distress [8, 9], hence there is a clinical imperative to identify patients and family members experiencing high distress and refer those people to accessible targeted psychosocial therapies .
A range of measures are available to screen for high psychosocial distress. Memorial Sloan Kettering Cancer Center, New York developed a simple single item Brief Distress Thermometer (BDT) and accompanying Problem Checklist  that has now been incorporated into clinical practice guidelines for psychosocial care after cancer and relevant consumer materials [12, 13]. The BDT is free of charge; and easy to administer and interpret; and has comparable accuracy with longer distress screening instruments such as the 14 item Hospital Anxiety and Distress Scale and the 18 item Brief Symptom Inventory [14, 15]. As such, the BDT is well suited for large-scale and repeated distress screening. There is also a well-established body of evidence demonstrating that psychosocial interventions increase wellbeing, improve adjustment and coping and reduce psychological distress in people affected by cancer [10, 16]. A range of effective intervention approaches have been described using varying delivery formats, and these include cognitive behavioural therapy, relaxation techniques, psycho-education, supportive psychotherapy, and family and couples therapy. As well, in North America and Australia clinical practice guidelines for psychosocial care have been developed that provide recommendations for intervention [10, 12, 13, 17]. However, despite the availability of guidelines and tools, evidence-based psychosocial care is the exception rather than the norm. Clinicians tend to overlook patients' psychosocial needs, often do not recognise depression and other psychiatric illnesses in their patients, and have limited response skills for managing patients' distress [8, 18–21]. Routine screening for psychological distress is uncommon in acute treatment centres reducing the likelihood of detecting highly distressed patients and providing them with timely support . Compounding this, while some psychosocial care is likely to be delivered to patients at diagnosis, it is uncommon at the time of treatment completion and will seldom include family members. For example, in a sample of 439 cancer patients treated at a tertiary cancer centre in Queensland, psychosocial care information was provided to only half of patients at diagnosis, and at the completion of treatment to less than one third . Psychosocial care services that are responsive and accessible across the illness experience and beyond the acute treatment setting are urgently needed.
Community-based approaches to psychosocial intervention
Increasingly, community based non-government organisations have taken on a role as providers of support services for cancer patients and their families. The most prominent and easily accessed of these are tele-based information and support services or helplines that are now available in the UK, Netherlands, Australia and North America [22–25]. Cancer helplines provide a potential assessment and referral point for patients and family members for psychosocial intervention both during and beyond their treatment experience within the acute health care setting. In Australia the Cancer Council Cancer Helpline is provided through a national toll free number (131120) and managed by each state Cancer Council. Telephone delivery provides a broad reach that addresses barriers to access such as geography, ill health, and cost. The Helpline service is staffed by nurses and allied health professionals who have experience and/or qualifications in oncology and who undergo additional training in psycho-oncology and decision support [26, 27]. Helpline operators provide brief cancer information and emotional support typically in a single contact that includes an average of 8 minutes of verbal contact time followed by mailed written patient education materials. The service is underpinned by a constantly updated and extensive data base of community and hospital based services to facilitate referral across sectors. The use of a centralised call centre enables standardisation of procedures to be easily achieved with constant quality assurance, outcome monitoring and data collection built into the operational system. Policies and procedures to address issues such as confidentiality and duty of care are in place and are consistent with Australian Psychological Society professional standards and medicolegal obligations .
With regards to psychosocial intervention, population-based approaches need to address not only access, but also the costs of delivery that may impede dissemination. For example, individualised cognitive behaviour therapy has been found in meta-analyses to reduce anxiety and depression after cancer with follow up periods of up to eight months . While these results are impressive, this approach will require specialist psychological staff, infrastructure to support delivery, and compliance by patients with routinised therapy sessions. In comparison, minimal contact approaches to psychological care with the use of self management materials for people with sub-threshold depression have been found to reduce the later incidence of major depression in patients in primary care . Efficacious self management has been defined as where individuals are able to monitor their own condition and undertake the necessary cognitive, behavioural and emotional responses to effect a satisfactory quality of life . Self management interventions have been shown to have consistent positive effects on mood across a range of chronic illnesses  and so have great potential as a cost effective method of providing psychological support to people affected by cancer. Proposed advantages of self management approaches are equity, accessibility and choice . However, it is not yet clear for which distressed patients a minimal contact approach would be efficacious, and for whom more in depth individualised approaches are necessary. For example, it may be that patients and carers with borderline distress will return to pre-morbid functioning with minimal contact approaches while clinically distressed people will require more in depth care to achieve similar benefits. This is a research question that is of critical importance in order to guide the cost-effective delivery of psychosocial oncology care services for the population.
For practical capacity for immediate translation into the community, psychosocial distress screening and intervention should be nested within an available service infrastructure. The Cancer Helpline provides a unique service infrastructure with demonstrated feasibility for the delivery of well-evaluated tools to diagnose psychosocial distress and depression/anxiety in people with cancer in our community, and their family members and carers; and potential for the delivery of psychosocial interventions. The Cancer Helpline has unique broad access intervention capacity. The service has national coverage with uniform service standards; is promoted in national patient and clinician educational materials as a contact for evidence-based cancer support and information; national media coverage about cancer consistently uses the Cancer Helpline as a referral point for the public; the use of a tele-based delivery mode with a toll free contact number addresses geographical, disability, illness and cost barriers to access; the service is community based and accessible at any point in the illness continuum. Each year nationally over 30,000 patients and carers contact the Helpline. However, research is needed to extend the Helpline to include in depth psychosocial intervention; and to assess the relative efficacy of minimal contact approaches with individualised care. The present study will evaluate the relative efficacy and cost-effectiveness of these two approaches to psychosocial intervention for people distressed by cancer that are suitable for immediate population-based translation.