BMC Cancer 2009, 9:189 http://www.biomedcentral.com/1471-2407/9/189 Background 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 [1]. Cancer is the leading cause of burden of disease and injury in Australia, accounting for nearly one-fifth of the total disease burden [2]. The diagnosis and subsequent treatment of cancer is a major life stress that is followed by a range of well described psy- chological, social, physical and spiritual difficulties [3]. 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 part- ners 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 clin- ical imperative to identify patients and family members experiencing high distress and refer those people to acces- sible targeted psychosocial therapies [10]. A range of measures are available to screen for high psy- chosocial distress. Memorial Sloan Kettering Cancer Center, New York developed a simple single item Brief Distress Thermometer (BDT) and accompanying Problem Checklist [11] that has now been incorporated into clini- cal 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 instru- ments 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 tech- niques, 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 availa- bility of guidelines and tools, evidence-based psychoso- cial 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 manag- ing patients' distress [8,18-21]. Routine screening for psy- chological distress is uncommon in acute treatment centres reducing the likelihood of detecting highly dis- tressed patients and providing them with timely support [8]. Compounding this, while some psychosocial care is likely to be delivered to patients at diagnosis, it is uncom- mon 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 [21]. Psychosocial care services that are responsive and accessible across the ill- ness experience and beyond the acute treatment setting are urgently needed. Community-based approaches to psychosocial intervention Increasingly, community based non-government organi- sations have taken on a role as providers of support serv- ices 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 poten- tial 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 Hel- pline is provided through a national toll free number (131120) and managed by each state Cancer Council. Tel- ephone 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 psy- cho-oncology and decision support [26,27]. Helpline operators provide brief cancer information and emotional support typically in a single contact that includes an aver- age 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 facili- tate referral across sectors. The use of a centralised call cen- tre enables standardisation of procedures to be easily achieved with constant quality assurance, outcome moni- toring and data collection built into the operational sys- tem. Policies and procedures to address issues such as confidentiality and duty of care are in place and are con- sistent with Australian Psychological Society professional standards and medicolegal obligations [28]. 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 Page 2 of 7 (page number not for citation purposes)