Loading
The guideline answer is stepped care: education for everyone, named talking therapies for moderate symptoms, more intensive therapy for severe ones, and medication after those rather than before. The English four-level model that cancer services were built around, published by NICE in 2004, has been retired and nothing has replaced it in the same form.
The clinical recommendation is clear and recent. The ASCO 2023 update, built on 17 systematic reviews and a further 44 randomised controlled trials published from 2013 to 2021, recommends "a stepped-care model, that is, provide the most effective and least resource-intensive intervention based on symptom severity". Every patient should be offered education about depression and anxiety. For moderate depressive symptoms the named options are cognitive behaviour therapy, behavioural activation, mindfulness-based stress reduction, structured physical activity or an empirically supported psychosocial intervention; for moderate anxiety, cognitive behaviour therapy, behavioural activation, structured physical activity, acceptance and commitment therapy or psychosocial interventions. For severe symptoms of either, cognitive therapy, behavioural activation, cognitive behaviour therapy, mindfulness-based stress reduction or interpersonal therapy. Medication is for people who cannot access first-line treatment, prefer it, have responded to it before, or have not improved on psychological management, because the panel found the pharmacological evidence inconsistent.
In England the structure that services were designed around was the four-level model of psychological support published in the NICE cancer service guideline Improving supportive and palliative care for adults with cancer, published 24 March 2004. NICE has since retired it. The retirement notice on the guideline page states that NICE "has retired this cancer service guideline because the recommendations are no longer being kept up to date and may no longer reflect best practice", that retired guidance "has no status, and the health and care system is not expected to follow it", and that it remains available as a document for reference only. Many hospital psychological services still describe themselves in its terms. A reader told that they are being offered level two support is being told something about a model that no longer has formal status.
What is still current in England is the general mental health guidance rather than anything cancer-specific: the NICE clinical guideline on depression in adults with a chronic physical health problem, published in 2009, and the 2022 guideline on depression in adults, both of which use a stepped structure. Routes in are the general practitioner, self-referral to NHS Talking Therapies where it is available, the hospital's own psychological service where it has one, and the clinical nurse specialist, who in practice is the person most likely to make the referral happen.
The structural problem this front keeps running into. The treatments with the best evidence in this file are therapist-delivered and finite: eight sessions of cognitive behavioural therapy for insomnia, five sessions for fear of recurrence, a collaborative care programme delivered by a nurse. None of them is expensive by the standards of cancer treatment; the blended fear-of-recurrence programme cost 466 euros a person. What is missing is not evidence but a commissioned route, and the gap between the two is the single clearest finding of this facet. OnCo could not find a health service that commissions a named service for fear of recurrence; the evidence that screening without a service attached changes nothing is on the distress-screening record alongside this one.
What to ask for, as a reader. Whether the hospital has a psychological service and what its referral criteria are; whether a clinical nurse specialist can refer directly; whether the local talking therapies service takes self-referrals, which in England it generally does; and, if the problem is specifically fear of recurrence, whether a therapist trained in the contemporary cognitive approaches is available, because the meta-analysis found those did better than the traditional kind.
Stepped care allocates scarce therapist time by severity: everyone receives information, most people need no more, and intensity increases only when a measured symptom does not improve. It works when each step has somewhere to step up to. Where the higher steps are unfunded, stepped care becomes a sorting process with no destination, which is the failure mode the distress-screening evidence describes.
Query for this technology: (TITLE:"Getting psychological help after cancer: the stepped-care model, and what is actually commissioned" OR ABSTRACT:"Getting psychological help after cancer: the stepped-care model, and what is actually commissioned") AND (cancer OR tumor OR tumour OR oncology OR carcinoma OR lymphoma OR leukemia OR leukaemia OR myeloma OR sarcoma OR melanoma OR glioma). Results are unfiltered search hits about Getting psychological help after cancer: the stepped-care model, and what is actually commissioned, not a curated reading list.
Shares The National Cancer Survivorship Initiative in England, and the Recovery Package, Screening for distress: what the thermometer can and cannot do, Treating fear of recurrence: the randomised trials, their effect sizes, and where the treatment is available, Anxiety after cancer, in survivors and in their partners and the tags rejuvenation, survivorship, psychosocial.
Shares Post-traumatic stress after cancer: what is measured, and how much of it is measurement, Mindfulness-based stress reduction and cognitive therapy, Psycho-oncology and distress screening, Quality of life and the tags rejuvenation, survivorship, psychosocial.
Shares Write a rehabilitation prescription at the end of treatment, and fund it like a drug, Living with a stoma, and living after an amputation, Rehabilitation is recommended everywhere and commissioned almost nowhere, Quality of life and the tags rejuvenation, survivorship, psychosocial.
Shares Paid survivor peer-navigators as a recognised health workforce role, Psycho-oncology and distress screening, Quality of life, Survivorship care and late-effects surveillance and the tags rejuvenation, survivorship, psychosocial.
Shares Mindfulness-based stress reduction and cognitive therapy, Cognitive behavioural therapy for insomnia (CBT-I), Quality of life, Survivorship care and late-effects surveillance and the tags rejuvenation, survivorship, psychosocial.
Shares Treating fear of recurrence: the randomised trials, their effect sizes, and where the treatment is available, Psycho-oncology and distress screening, Quality of life, Survivorship care and late-effects surveillance and the tags rejuvenation, survivorship, psychosocial.
Shares Anxiety after cancer, in survivors and in their partners, Psycho-oncology and distress screening, Not enough oncologists, nurses, pathologists, physicists, Quality of life and the tags rejuvenation, survivorship, psychosocial.
Shares A changed face and voice: body image after head and neck cancer treatment, Living with a stoma, and living after an amputation, Psycho-oncology and distress screening, Quality of life and the tags rejuvenation, survivorship, psychosocial.