The effect of group psychosocial support on survival in metastatic breast cancer

Depressive symptoms after breast cancer surgery: relationships with global, cancer-related, and life event stress

For women with breast cancer, rates of depression are the third highest of any cancer diagnostic group. Stress, defined as life events or perceptions of stress, is associated with depressive symptoms. However, little is known about the relationships between different types of stress and these symptoms in women with breast cancer. This relationship was tested in 210 women assessed after initial surgical treatment for regional breast cancer. Using Hierarchical Multiple Regression, three types of stress were examined: the occurrence of five stressful life events in the year prior to cancer diagnosis, perceptions of global stress, and perceptions of cancer-related traumatic stress. Other potentially relevant correlates of depressive symptoms were also examined, including the personality trait neuroticism, sociodemographics, and disease/treatment characteristics. Fifty-three percent of the variance in depressive symptoms was accounted for by three stress variables (perceptions of global and cancer-related traumatic stress and the life event-major financial difficulty) and two control variables (neuroticism and racial group). Specifically, global stress perceptions coupled with cancer-related intrusive thoughts and financial concerns along with the tendency towards negativity (neuroticism) may conspire to heighten a women's risk for depressive symptoms. Assessing multiple sources of stress would improve our ability to identify women 'at risk' for depressive symptoms and provide appropriate intervention.

Failure of higher-dose paclitaxel to improve outcome in patients with metastatic breast cancer: cancer and leukemia group B trial 9342

PURPOSE

Cancer and Leukemia Group B Protocol 9342 was initiated to determine the optimal dose of paclitaxel administered as a 3-hour infusion every 3 weeks to women with metastatic breast cancer.

PATIENTS AND METHODS

Four hundred seventy-four women with metastatic breast cancer who had received one or no prior chemotherapy regimens were randomly assigned to one of three paclitaxel dosing regimens-175 mg/m(2), 210 mg/m(2), or 250 mg/m(2)-each administered as a 3-hour infusion every 3 weeks. Women completed self-administered quality of life and symptom assessment questionnaires at baseline and after three cycles of treatment.

RESULTS

No evidence of a significant dose-response relationship was demonstrated over the dose range assessed. Response rates were 23%, 26%, and 21% for the three regimens, respectively. A marginally significant association (P =.04) was seen between dose and time to progression; however, in a multivariate analysis, the difference was even less apparent. No statistically significant difference was seen in survival. Neurotoxicity and hematologic toxicity were more severe on the higher dose arms. There was no significant difference in quality of life on the three arms.

CONCLUSION

Higher doses of paclitaxel administered as a 3-hour infusion to women with metastatic breast cancer did not improve response rate, survival, or quality of life. There was a slight improvement in time to progression with higher dose therapy, which was offset by greater toxicity. When a 3-hour infusion of paclitaxel is administered every 3 weeks, 175 mg/m(2) should be considered the optimal dose.

Group interventions for patients with cancer and HIV disease: Part II. Effects on immune, endocrine, and disease outcomes at different phases of illness

There has been great interest in the potential impact of group interventions on medical outcomes. This article reviews the effects of professionally-led groups on immune activity, neuroendocrine function, and survival among patients with cancer or HIV disease. We examine findings concerning different types of group services at different phases of illness. Results are mixed, but the most prominent changes in immune and endocrine activity were associated with structured group interventions for patients with early-stage disease. These findings offer provocative illustrations of relevant mind-body interactions, but their clinical importance has yet to be demonstrated empirically. Group interventions have not been tied consistently to improved survival rates for patients with advanced cancer; few studies as yet have focused on survival outcomes among patients with early-stage cancer or HIV disease.

Major Depression, Adjustment Disorders, and Post-Traumatic Stress Disorder in Terminally Ill Cancer Patients: Associated and Predictive Factors

Purpose

Few studies have been conducted to elucidate the psychological distress of terminally ill cancer patients. This study attempted to determine the prevalence of adjustment disorders (AD), major depression (MD), and post-traumatic stress disorder (PTSD) among terminally ill cancer patients, to identify factors that contribute to them, and to determine how they change longitudinally.

Patients and Methods

Consecutive terminally ill cancer patients were recruited. Patients were assessed for psychiatric disorders by structured clinical interview twice: once at the time of their registration with a palliative care unit (baseline), and again at the time of their palliative care unit admission (follow-up). Possible contributed biomedical and psychosocial factors were evaluated.

Results

The proportions of patients diagnosed with AD, MD, and PTSD at baseline (n = 209) were 16.3%, 6.7%, and 0% respectively, whereas at follow-up (n = 85), 10.6% were diagnosed with AD and 11.8% with MD. Lower performance status, concern about being a burden to others, and lower satisfaction with social support were significantly associated with AD/MD at baseline. There were changes in the diagnosis of AD and MD in 30.6% of the patients. Only the Hospital Anxiety and Depression Scale at the baseline was significantly predictive of AD/MD at follow-up.

Conclusion

The factors underlying psychological distress are multifactorial. Early intervention to treat subclinical anxiety and depression may prevent subsequent psychological distress.

Breast cancer: evaluation of the Common Journey Breast Cancer Support Group

BACKGROUND

Most studies of cancer support groups have focused on the effects of groups established for research purposes, from the exclusive perspective of the group participants.

AIM

This Roy Adaptation Model-based programme evaluation project focused on identifying the experiences of both participants in and facilitators of a community hospital-sponsored breast cancer support group.

DESIGN

Repeated measures survey methodology.

METHODS

Ten women with breast cancer and two Registered Nurse group facilitators participated in the programme evaluation project. Qualitative data were analysed using content analysis. Themes extracted from the data were categorized according to the Roy Adaptation Model modes of adaptation. The group participants completed Initial and End of Year Interview Guides and Group Voices Forms; the group facilitators completed the Facilitators' Voices Form. The Institutional Review Committee of a community hospital approved the programme evaluation project.

RESULTS

The Common Journey Breast Cancer Support Group is a community hospital-sponsored cancer support group established to meet the informational, emotional support, and social support needs of women with breast cancer who reside in a rural state in the New England region of the USA. Responses of participants and facilitators, which reflected all four of the Roy model modes of adaptation, indicated that the combination of information and emotional and social support was effective.

CONCLUSIONS

Nurses and other health professionals who establish community-based cancer support groups should consider formal evaluation of the outcomes, from the perspectives of both participants and facilitators, and should publish the results. The results of this programme evaluation project are limited to one breast cancer support group with a small number of female participants and two facilitators. Results cannot be generalized to support groups for other types of cancer or to cancer support groups for men.

RELEVANCE TO CLINICAL PRACTICE

Nurses and other health professionals should consider establishing and facilitating community hospital-sponsored support groups for women with breast cancer, which have the potential to meet the women's informational, emotional support, and social support needs.

Comorbid mental disorders account for the role impairment of commonly occurring chronic physical disorders: results from the National Comorbidity Survey

Most health and work productivity studies have focused on individual conditions without considering comorbidity. We illustrate the implication of this neglect by examining the effects of comorbid mental disorders on role impairment (number of sickness absence and work cut-back days in the past month) among people with chronic physical disorders. A nationally representative household survey of 5877 respondents assessed current mental and physical disorders and role impairments. Four physical disorders were sufficiently common to be studied: hypertension, arthritis, asthma, and ulcers. All 4 physical disorders were associated with significant role impairments in bivariate analyses. However, further analysis showed that these impairments were almost entirely confined to cases with comorbid mental disorders. Effectiveness trials in workplace samples are needed to evaluate the cost-effectiveness of treating comorbid mental disorders among workers with chronic physical disorders.

End-of-life care in geriatric psychiatry

Depression, anxiety and delirium are relatively common during the final stages of terminal disease, and each can profoundly impact the quality of those last days for both patient and involved family. In this article the authors review the assessment and treatment of each syndrome in the context of palliative care for older adults. Treatment of mental disorders at the end of life warrants special consideration due to the need to balance the benefits of treatment against the potential burden of the intervention, especially those that might worsen quality of life. Dementia and the complications of depression and behavioral disturbance within dementia are also discussed. Finally, caregivers of dying patients are vulnerable to stress, depression, grief, and complicated bereavement. Interventions for caregivers who are debilitated by these states are briefly summarized.

The race gap in support group participation by breast cancer survivors: real or artifact?

Addressing methodological weaknesses of previous research, this study assesses whether African American women are, in fact, less likely to participate in breast cancer support groups than are White women. Of the breast cancer survivors, 958 (26% African Americans, 73% Caucasian) completed interviews concerning demographic characteristics, other support networks, effects of illness on home and spiritual life, and support group participation. Contrary to previous research, no race difference was found in support group participation. This research suggests more effort needs to be paid to sampling techniques and other methodological factors to adequately reflect the experiences and needs of breast cancer survivors, specifically African American women.

Cancer supportive care, improving the quality of life for cancer patients. A program evaluation report

GOALS OF WORK

As medical care for cancer has become more specialized in diagnosis, treatment has become more technical and fragmented. In order to help cancer patients and their families, we developed a coordinated program called the Stanford Cancer Supportive Care Program (SCSCP) at the Center for Integrative Medicine at Stanford Hospital and Clinics. The Stanford Cancer Supportive Care Program was initiated in 1999 to provide support for cancer patients, addressing the need for improved physical and emotional well-being and quality of life. This paper is a program evaluation report.

PATIENTS AND METHODS

The number of patient visits grew from 421 in 1999 to 6319 in 2002. This paper describes the utilization of the SCSCP program as assessed by 398 patient visit evaluations during a 9-week period, January 2002 to March 2002. During this time we collected attendance records with demographic data and anonymous questionnaires evaluating each program. Patients were asked to evaluate how the program helped them regarding increase of energy, reduction in stress, restful sleep, pain reduction, sense of hopefulness, and empowerment.

MAIN RESULTS

Over 90% of the patients using the SCSCP felt there was benefit to the program. Programs were chosen based on a needs assessment by oncologists, nurse managers, social workers, and patients. Massage, yoga, and qigong classes had the highest number of participants. Qualitative data showed benefit for each program offered.

CONCLUSIONS

This evaluation of a free cancer supportive care program initiated in a hospital outpatient setting provides initial evidence of patient satisfaction and improvement in quality of life.

How the mind hurts and heals the body

The author reviews some of the social and behavioral factors acting on the brain that influence health, illness, and death. Supported with data from several areas of research, his proposal for understanding health and illness provides both the concepts and the mechanisms for studying and explaining mind-body relationships. The brain is the body's first line of defense against illness, and the mind is the emergent functioning of the brain. This mind-body approach incorporates ideas, belief systems, and hopes as well as biochemistry, physiology, and anatomy. Changing thoughts imply a changing brain and thus a changing biology and body. Belief systems provide a baseline for the functioning brain upon which other variables act and have their effects.

Predialysis psychoeducational intervention and coping styles influence time to dialysis in chronic kidney disease

BACKGROUND

Consensus endorses predialysis intervention before the onset of end-stage renal disease. In a previous study, predialysis psychoeducational intervention (PPI) extended time to dialysis therapy by a median of 6 months. We undertook to replicate and extend this finding by examining hypothesized mechanisms.

METHODS

We used an inception-cohort, prospective, randomized, controlled trial with follow-up to evaluate an intervention that included an interactive 1-on-1 slide-supported educational session, a printed summary (booklet), and supportive telephone calls once every 3 weeks. Participants were sampled from 15 Canadian (tertiary care) nephrology units and included 297 patients with progressive chronic kidney disease (CKD) expected to require renal replacement therapy (RRT) within 6 to 18 months. The main outcome was time to dialysis therapy (censored at 18 months if still awaiting RRT).

RESULTS

Time to dialysis therapy was significantly longer (median, 17.0 months) for the PPI group than the usual-care control group (median, 14.2 months; Cox's proportional hazards analysis, controlling for general nonrenal health, P < 0.001). Coping by avoidance of threat-related information (called blunting) was associated with shorter times to dialysis therapy (P < 0.032). A group x blunting interaction (P < 0.069) indicated: (1) time to dialysis therapy was shortened in the usual-care group, especially when patients coped by blunting; but (2) time to dialysis therapy was extended with PPI, even among patients who coped by blunting. Knowledge acquisition predicted time to dialysis therapy (r = 0.14; P < 0.013). Time to dialysis therapy was unrelated to depression or social support.

CONCLUSION

PPI extends time to dialysis therapy in patients with progressive CKD. The mechanism may involve the acquisition and implementation of illness-related knowledge. Routine follow-up also may be especially important when patients cope by avoiding threat-related information.

Psychological interventions for women with metastatic breast cancer

BACKGROUND

There have been conflicting results from systematic reviews of psychological interventions for patients with cancer, some showing benefits for patients and others not. One early study appeared to show significant survival benefits as well as psychological benefits from a psychological intervention given to women with metastatic breast cancer. Some further studies have been undertaken, again with conflicting results.

OBJECTIVES

To assess the effects of psychological interventions (educational, individual cognitive behavioural or psychotherapeutic, or group support) on psychological and survival outcomes for women with metastatic breast cancer.

SEARCH STRATEGY

We searched the Cochrane Breast Cancer Group Trials Register (September 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2003), MEDLINE (1966-October 2003), CancerLit (1983-2000), CINAHL (1982-October 2003), PsycInfo (1974-November 2003), and SIGLE (1980-November 2003).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of psychological interventions for women with metastatic breast cancer. Studies were included even if they were not 'intention to treat', owing to the nature of the patient group under study and the likely high loss of follow-up data.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two reviewers. Data about the nature and setting of the intervention, and the relevant outcome data were extracted, along with items relating to methodological quality.

MAIN RESULTS

Five primary studies were identified, all group psychological interventions. Two of these were cognitive behavioural interventions and three evaluated support-expressive group therapy. The five studies of group psychological therapies for women with metastatic breast cancer showed very limited evidence of benefit arising from these interventions. Although there was evidence of short-term benefit for some psychological outcomes, in general these were not sustained at follow-up. A clearer pattern of psychological outcomes could not be discerned as a wide variety of outcome measures and durations of follow-up were used in the included studies. The possible longer survival times in women allocated to receive psychological intervention in the early study have not been replicated in the subsequent four studies (including one by members of the first study group), and overall the effects of these interventions on survival are not statistically significant (for example, odds ratio for 5 year survival 0.83 (95% confidence interval [CI] 0.53 - 1.28).

REVIEWERS' CONCLUSIONS

There is insufficient evidence to advocate that group psychological therapies (either cognitive behavioural or supportive-expressive) should be made available to all women diagnosed with metastatic breast cancer. Any benefits of the interventions are only evident for some of the psychological outcomes and in the short term. The possibility of the interventions causing harm is not ruled out by the available data.

Supportive-expressive group therapy: The transformation of existential ambivalence into creative living while enhancing adherence to anti-cancer therapies

Supportive-Expressive Group Therapy (SEGT) has been developed and manualised in the research setting, but there have been few clinical accounts of its utility. In this qualitative review of its application in the Melbourne-based randomised control trial (RCT) for women with advanced breast cancer, SEGT is considered from the perspective of the structure and framework of therapy, its therapists, the issues that develop in exploring its common themes and what constitutes a well functioning group. Groups move through identifiable developmental phases. The mature group process transforms existential ambivalence into creative living, evidenced by humour, celebration, assertiveness, altruism, new creative pursuits and eventually courageous acceptance of dying. Challenges and pitfalls include avoidance, non-containment of ambivalence, intolerance of difference, anti-group phenomena and splitting. A key element is the medicalization of the group culture whereby members and co-therapists explore health beliefs and attitudes about care. This promotes compliance with anti-cancer treatments, including both the initiation of and perseverance with chemotherapy. This mechanism could prove to be a potentially important pathway in promoting longer survival.

Does psychosocial intervention improve survival in cancer? A meta-analysis

BACKGROUND

There is growing evidence that positive psychosocial intervention improves the wellbeing of cancer patients. Two meta-analyses conducted to date confirmed a significant small-to-moderate effect on quality of life. Previous randomized trials reported that psychosocial intervention also improved survival. However, more recent trials failed to detect a difference in survival. A systematic review of randomized trials that have examined the effectiveness of psychosocial intervention in cancer patients in terms of survival prolongation was conducted.

METHODS

Randomized trials published between 1966 and June 2002 were identified through the databases of MEDLINE, EMBASE, CancerLit, CINAHL, Cochrane Library and reference lists of relevant articles. Relevant data were abstracted. The results of randomized trials were pooled using meta-analyses to estimate the effect of treatment on overall survival at one and four years in all cancer patients and also in breast cancer patients with metastases.

RESULTS

Eight trials, which involved a total of 1062 patients (all cancer histologies), were identified. One- and four-year overall survival rates were obtained from eight trials and six trials, respectively. There was no statistically significant difference in the overall survival rates at one and four years [P = 0.6; RR 0.94 (95% CI 0.72, 1.22)] and [P = 0.5; RR 0.93 (95% CI 0.77, 1.13)], respectively. Four trials examined 511 metastatic breast cancer patients. Again, there was no statistically significant difference in the overall survival rates at one and four years [P = 0.3; RR 0.87 (95% CI 0.67, 1.14)] and [P = 0.3; RR 0.91 (95% CI 0.76, 1.10)], respectively.

CONCLUSIONS

Psychosocial intervention does not prolong survival in cancer. This meta-analysis can not rule out small effect sizes because of the small number of trials and small trial sizes.

Mind-Body Medicine in Ambulatory Care

Ambulatory medicine is a frequent clinical setting where practitioners can effectively apply Mind-body interventions ranging from basic stress management therapies to the sophisticated biomedical instrumentation of clinical biofeedback. Given the rather extensive and growing body of clinical research in this area, the intent of this article is to provide an evidence-based assessment of the evidence underlying the clinical efficiency of such interventions. Such an evidence-based approach can help ambulatory care providers to identify those Mind-body interventions with specific clinical indication so that they can be utilized both safely and effectively in ambulatory medicine.

Efficacy of Therapeutic Group by Telephone for Women With Breast Cancer

A pilot study was conducted to test the efficacy of a therapeutic group by telephone conference call for women with breast cancer. Sixty-six women with stage I or stage II breast cancer consented to participate in the study. Participants were randomly assigned to a usual psychosocial care or intervention group, using a permuted block method. Only 2 of 68 patients dropped out of the study, which included 27% African Americans. Assessments at 3 time periods (pretest, immediately after the intervention, and 3 months after the group ended) included evaluation of quality of life (QOL), mood, and immune function. ttests were performed to determine if differences on important variables existed at pretest. The intervention group had worse QOL and mood scores than did the control group on the pretests. A mixed-model repeated-measures procedure controlling for pretest differences was used to analyze data. A significant Group by Time interaction was found for spiritual well-being and mood. These differences were not in the expected direction. The intervention group showed improvement in QOL and mood during the intervention, but showed decompensation following the intervention. Conversely, the control group demonstrated stable or declining scores. This intervention is feasible and practical for women with breast cancer, especially African American participants. The puzzling results suggest several areas for future research, including a better conceptual fit with outcome measures, increasing dosage, and exploration of the value of emotional expression.

Psychosocial and sexual functioning of survivors of breast cancer

The literature documents that the majority of breast cancer survivors have adjusted well after their first 2 years since diagnosis. However, there is a subset of survivors reporting psychological distress, including depression and anxiety, involving approximately 30% by 4 years post-treatment, but widely ranging from 5% to 50%, depending on when diagnosed and time since treatment completion. Further, a large proportion of survivors report cancer-related problems long after treatment completion, including cancer-related distress involving body image, fear of recurrence, post-traumatic stress disorder (PTSD), and sexual problems. Those with long-term medical sequelae, such as lymphedema, have worse adjustment compared to those who do not. Future research directions are suggested.

Group and individual treatment strategies for distress in cancer patients

Many cancer patients experience distress during the course of their illness. Recently, the National Comprehensive Cancer Network recommended that all cancer patients receive evaluation and treatment of distress as a routine part of their care. For some patients, psychosocial interventions may be helpful, but which patients benefit from what type of psychosocial interventions is unclear. To highlight the importance of this problem, this article examines the prevalence of distress in cancer patients and reviews the evidence that supports that cancer patients benefit from group and individual treatment strategies. Several randomized studies have examined the effects of group or individual therapy on both the emotional and the physiological well-being of cancer patients. Both individual and group interventions that are structured have proved effective in reducing distress. Clearly, more investigation is warranted and future research is needed to advance the understanding of structured interventions, to examine support groups, and to tailor psychological interventions to meet individual needs of distressed cancer patients.

The effect of pain on survival

For patients suffering various diseases, increased pain hastens death by interfering with life-enhancing activities; if it hurts to eat, patients won't eat; if it hurts to move, they won't move. But survival simply cannot be enhanced by reducing pain because, even as some pain treatments have a beneficial effect on disease (spinal cord stimulation on coronary artery disease, for example), other pain treatments can have an adverse effect on survival. Thus, we must continue to investigate pain and its treatment even as we use the best possible techniques available to treat pain as aggressively as we would any other disease.

Coping effectiveness training for men living with HIV: results from a randomized clinical trial testing a group-based intervention

OBJECTIVE

This randomized clinical trial was designed to compare the effects of a theory-based coping effectiveness training (CET) intervention with an active informational control (HIV-Info) condition and a waiting-list control (WLC) condition on psychological distress and positive mood in HIV-seropositive gay men.

MATERIALS AND METHODS

The authors recruited 149 self-identified gay or bisexual men who were 21 to 60 years of age, reported depressed mood, and had CD4 levels of 200 to 700 cells/mm(3). CET and HIV-Info participants attended 10 90-minute group sessions during the 3-month intervention phase and six maintenance sessions over the remainder of the year. Participants were assessed at baseline and at 3, 6, and 12 months. Data were collected 1992 to 1994, before the introduction of HAART. Analyses were based on the 128 participants who completed the 3-month assessment.

RESULTS

After the 3-month intervention phase, when compared with HIV-Info, CET participants showed significantly greater decreases in perceived stress and burnout, and regression analyses indicated that significant increases in coping self-efficacy mediated the improvements in perceived stress and burnout. Compared with WLC, CET participants also showed significantly greater decreases in anxiety, and regression analyses indicated that significant increases in positive states of mind mediated the improvements in anxiety. Significant treatment group differences for positive morale were maintained at 6 and 12 months. In addition, optimism continued to increase in the CET and HIV-Info treatment groups during the maintenance phase.

CONCLUSIONS

CET can be an effective strategy for managing psychological distress and improving positive psychological states in patients confronting chronic illness.

Patients' rights, quality of life, and health care system performance

The purpose of this paper is to promote the development of a social contract between patient and clinician that permits patients to state how they want to live as they survive rather than what they are willing to lose to extend their survival. To do this, patients must have sufficient leverage to affect the nature of the care they receive. This leverage, it is proposed, can be achieved by first making a 'Declaration of Patients' Rights Relative to Their Quality of Life' and then evaluating the extent to which the patient's providers comply with this rights statement. The paper also reviews The World Health Report 2000 [Health Systems: Improving Performance Geneva: WHO, 2000] as an example of an alternative approach to defining a health care social contract and evaluating a health system's performance. Also discussed, were steps that could be taken to facilitate the integration of the patients' rights statement into medical practice and health care systems performance.

Cognitive-existential group psychotherapy for women with primary breast cancer: a randomised controlled trial

BACKGROUND

We conducted a randomised, controlled trial of cognitive-existential group therapy (CEGT) for women with early stage breast cancer receiving adjuvant chemotherapy with the aim of improving mood and mental attitude to cancer.

METHODS

Women were randomised to 20 sessions of weekly group therapy plus 3 relaxation classes or to a control arm receiving 3 relaxation classes. Assessments, independently done at baseline, 6 and 12 months, included a structured psychiatric interview and validated questionnaires covering mood, attitudes to cancer, family relationships, and satisfaction with therapy.

RESULTS

Three hundred and three of 491 (62%) eligible patients participated over 3 years. Distress was high pre-intervention: 10% were diagnosed as suffering from major depression, 27% from minor depression and 9% from anxiety disorders. On an intention-to-treat analysis, there was a trend for those receiving group therapy (n=154) to have reduced anxiety (p=0.05, 2-sided) compared to controls (n=149). Women in group therapy also showed a trend towards improved family functioning compared to controls (p=0.07, 2-sided). The women in the groups reported greater satisfaction with their therapy (p<0.001, 2-sided), appreciating the support and citing better coping, self-growth and increased knowledge about cancer and its treatment. They valued the CEGT therapy. Overall effect size for the group intervention was small (d=0.25), with cancer recurrence having a deleterious effect in three of the 19 therapy groups. Psychologists as a discipline achieved a moderate mean effect size (d=0.52).

CONCLUSION

CEGT is a useful adjuvant psychological therapy for women with early stage breast cancer. Interaction effects between group members and therapists are relevant to outcome. Group-as-a-whole effects are powerful, but the training and experience of the therapist is especially critical to an efficacious outcome.

Psychiatric aspects of women with breast cancer

Women with breast cancer face not only cancer-related taboos but also issues related to changes in sexuality, femininity, and fertility. Although increased emphasis on the woman's participation in the medical decision-making process has afforded her more treatment options, it also gives her more responsibility in determining her course of treatment through the continuum of cancer care. Patients must deal with a variety of issues related to social reintegration, long-term effects of cancer treatment, employment, disability, sexuality, family, and social networks. Screening for distress related to psychological, spiritual/religious, or social concerns can provide guidance for service delivery to those in need.

Depression and cancer: mechanisms and disease progression

Depression and cancer commonly co-occur. The prevalence of depression among cancer patients increases with disease severity and symptoms such as pain and fatigue. The literature on depression as a predictor of cancer incidence is mixed, although chronic and severe depression may be associated with elevated cancer risk. There is divided but stronger evidence that depression predicts cancer progression and mortality, although disentangling the deleterious effects of disease progression on mood complicates this research, as does the fact that some symptoms of cancer and its treatment mimic depression. There is evidence that providing psychosocial support reduces depression, anxiety, and pain, and may increase survival time with cancer, although studies in this latter area are also divided. Psychophysiological mechanisms linking depression and cancer progression include dysregulation of the hypothalamic-pituitary-adrenal axis, especially diurnal variation in cortisol and melatonin. Depression also affects components of immune function that may affect cancer surveillance. Thus, there is evidence of a bidirectional relationship between cancer and depression, offering new opportunities for therapeutic intervention.

Psychological distress and cancer survival: a follow-up 10 years after diagnosis

OBJECTIVE

This study tested the predictive role of psychological distress in cancer survival, while attempting to overcome several important methodological and statistical limitations that have clouded the issue.

METHODS

Measures collected on a range of emotional and cognitive factors in the early postdiagnostic period and at 4-month intervals up to 15 months after diagnosis were used to predict survival time up to 10 years among 205 cancer patients heterogeneous in disease site, status, and progression.

RESULTS

With the use of both baseline and repeated measures, depressive symptomology was the most consistent psychological predictor of shortened survival time, after controlling for several known demographic and medical risk factors.

CONCLUSIONS

Given the importance of depressive symptoms to cancer survival, discussion focuses on the possible mechanisms mediating this relationship, the importance of psychological screening of cancer patients, and need for further research.

The group psychotherapy and home-based physical exercise (group-hope) trial in cancer survivors: physical fitness and quality of life outcomes

Physical exercise has been shown to enhance quality of life (QOL) in cancer survivors using pretest-posttest designs and compared to usual care (i.e. no intervention). In the present study, we conducted a randomized controlled trial to determine if exercise could improve QOL in cancer survivors beyond the known benefits of group psychotherapy (GP). We matched 22 GP classes (N=108) on content and then randomly assigned 11 (n=48) to GP alone and 11 (n=60) to GP plus home-based, moderate-intensity exercise (GP+EX). Participants completed a physical fitness test and QOL measures (e.g. Functional Assessment of Cancer Therapy scales) at the beginning and end of GP classes (about 10 weeks). We had excellent recruitment (81%), retention (89%), and adherence (84%) rates and a modest contamination (22%) rate. Using intention-to-treat repeated measures analyses of variance, we found significant Time by Condition interactions for functional well-being, fatigue, and sum of skinfolds. We also found borderline significant interactions for physical well-being, satisfaction with life, and flexibility. All interactions favored the GP+EX condition. We conclude that a home-based, moderate intensity exercise program may im-prove QOL in cancer survivors beyond the benefits of GP, particularly in relation to physical and functional well-being.

Quality of life in a randomized trial of group psychosocial support in metastatic breast cancer: overall effects of the intervention and an exploration of missing data

PURPOSE

To evaluate the effect of a standardized group psychosocial intervention on health-related quality of life (HrQOL) in women with metastatic breast cancer and to explore the effect of missing data in HrQOL analyses.

PATIENTS AND METHODS

Between 1993 and 1998, seven Canadian centers randomly assigned 235 eligible women to participate in a weekly, 90-minute, therapist-led support group that adhered to principles of supportive-expressive (SE) therapy or to a control arm (no SE). All women received educational material and any type of medical or psychosocial care deemed necessary. HrQOL data were prospectively collected using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30) at baseline, 4, 8, and 12 months. The primary HrQOL analyses compared scores in the two study arms. Analyses were limited to women with appropriate baseline HrQOL information (n = 215).

RESULTS

Baseline EORTC QLQ-C30 scores were not different between the two study arms (all P >.05). Primary analysis of all subscales failed to show a significant influence of the intervention on HrQOL (all P >.05). There was a significant deterioration over time in several functional scales of the EORTC QLQ-C30: global (P =.03), physical (P =.0002), role (P =.01), and cognitive functioning (P =.04); and in symptom scales: dyspnea (P =.007), appetite loss (P =.04), and fatigue (P =.003); these changes were independent of randomization allocation. Results were similar in additional analyses of overall HrQOL using a variety of approaches to handling missing data.

CONCLUSION

Supportive-expressive group therapy in patients with metastatic breast cancer does not appear to influence HrQOL, as measured by the EORTC QLQ-C30.

Psychological adjustment among African American breast cancer patients: one-year follow-up results of a randomized psychoeducational group intervention

The effectiveness of support group interventions for cancer patients has been established among White patients but has been virtually unstudied among minority patients. The current study represents the 1st randomized support group intervention targeted to African American women with breast cancer. Participants (N = 73) with nonmetastatic breast cancer were randomly assigned to an 8-week group intervention or an assessment-only control condition At 12 months, the intervention resulted in improved mood as well as improved general and cancer-specific psychological functioning among women with greater baseline distress or lower income. Subsequent research is needed to address effective methods of enrolling and following women with fewer psychosocial and financial resources, as they were the most likely to benefit from this particular intervention.

Developing a free supportive care program for cancer patients within an integrative medicine clinic

The cancer patient's journey not only includes a threat to one's life, but the need to face many medical and emotional challenges. The free Cancer Supportive Care Program (CSCP) within the Center for Integrative Medicine Clinic at Stanford University Hospital and Clinics has been identified as a successful model for helping patients to deal with these challenges. Its programs include informational lectures, support groups, chair massages, exercise, alternative modality classes, a Life Tapes Project, an informational website, and a bimonthly newsletter available free to anybody touched by cancer. Now in its third year, this program benefits from a blending of leadership resources, availability of space, institutional agreement on patient need and funds from private and corporate donations. By presenting the basic premises of the Cancer Supportive Care program and outlining specifics about the program, institutions in various national and international demographic regions may implement similar programs according to their resources and the needs of patients. It is our hope that the CSCP can become a model for the development of similar programs in various parts of the United States and abroad.

The psychiatric management of end-of-life pain and associated psychiatric comorbidity

Involvement by psychiatrists in the care of patients who are terminally ill has been limited historically; however, psychiatrists increasingly are participating in the care of these people who are facing the most challenging times of their lives. Pain management is considered to be an area of subspecialization for psychiatrists beyond their traditional role of being psychopharmacologists and psychotherapists. Biologically focused psychiatrists are able to address neuropsychiatric disorders, including pain and depression in the medically ill, and actively improve the quality of life for dying patients and their family members. This article provides a review of the recent literature that has addressed the involvement of psychiatrists in end-of-life care. Beginning with an example of the scientific aspects of cancer-related treatment from a patient's perspective, and into the major treatment considerations, this article addresses pain, its recognition, and management challenges when the end of life approaches. The prompt recognition of frequently overlooked and underestimated concomitant depressions, delirium, dementia, and other mental disorders is important for mental health specialists. The importance of psychiatric care for patients who are terminally ill and the role of psychiatrists in the phase of care also are discussed.

Stress, coping, and immune function in breast cancer

Research has found suggestive links between emotional distress and immune and neuroendocrine measures in cancer patients. Furthermore, several studies have reported that participation in psychological support groups is associated with better health outcomes for cancer patients. However, controversy exists surrounding these findings, and the mechanisms behind such effects are unclear. This article integrates current evidence from several lines of research concerning the relations among coping, psychological adjustment, cortisol and immune function, and disease progression in breast cancer patients. A biopsychosocial model is evaluated in which coping and psychological adjustment are associated with alterations in cortisol levels, immune function, and potential long-term medical outcomes in breast cancer patients. Although strong evidence suggests that coping and psychosocial intervention can improve psychological outcomes for breast cancer patients, potential effects on physiological outcomes remain speculative.

Racial/ethnic differences and potential psychological benefits in use of the internet by women with breast cancer

Many websites on the Internet offer information to breast cancer patients and are increasingly being used. The authors investigated the potential psychological benefits of Internet use and how it varied as a function of race/ethnicity among 180 white, African American, and Hispanic American breast cancer patients who used the Internet for medical information. Using standardized psychological measures, as measured by the Interpersonal Support Evaluation List (ISEL), Internet use among minorities was associated with greater overall, appraisal, and tangible social support (p's<0.05) but not belonging and self-esteem social support than among whites. No differences were observed for stress, depressive symptoms, loneliness, and coping. Since numerous studies suggest that social support may be related to survival, Internet use for breast health issues may have special clinical relevance to racial/ethnic minority groups.

Avoiding patient self-blame

There is need for shared responsibility between health care providers and patients. However, an unintended consequence of today's therapies that focus on mind/body interaction is the risk of patients' guilt and self-blame for contracting a disease (such as cancer) and/or for failing to heal themselves. This article suggests ways practitioners of complementary therapies can approach medical patients with a constructive attitude that minimizes the chance of unintentional psychological harm.

Healing the mind/body split: bringing the patient back into oncology

The effect on oncology of the doctrine of Cartesian dualism is examined. It is argued that (1) this doctrine continues to exert a baneful (though unacknowledged) influence on the practice of oncology, (2) Descartes's doctrine of a mind/body split is mistaken, and (3) mind and body (brain) are inextricably interwoven. A biopsychosocial model of disease is advocated. The role of psychooncology in healing the mind/body split by focusing research attention on the patient is outlined.

Health-related quality-of-life measurement in randomized clinical trials in breast cancer--taking stock

Measurement of health-related quality-of-life (HRQOL) in randomized clinical trials in breast cancer has become common. In this review, we take stock of the contribution that HRQOL measurement in breast cancer clinical trials makes to clinical decision making regarding selection of optimal treatment. A series of MEDLINE searches was conducted to identify all randomized trials in breast cancer that included self-reported HRQOL or psychosocial outcomes. A total of 256 citations were identified that included HRQOL or psychosocial outcomes in breast cancer patients, and 66 of these involved randomized clinical trials of treatment. These 66 reports of breast cancer clinical trials of treatment are discussed in this review. Forty-six of the trials evaluated biomedical interventions, and 20 evaluated psychosocial interventions. Among the biomedical trials, eight trials evaluated HRQOL in primary management of breast cancer, seven trials evaluated HRQOL in adjuvant therapy of breast cancer patients, 20 trials involved metastatic breast cancer, eight trials involved symptom control/supportive care, and three trials evaluated different approaches to investigation or follow-up of breast cancer patients. Among the psychosocial trials, 13 trials evaluated HRQOL in adjuvant therapy of breast cancer patients, and their partners or spouses, six trials involved metastatic breast cancer, and one trial focused on symptom control. We found that the contribution of HRQOL measurement to clinical decision making depended on the clinical setting. In primary management of breast cancer, where medical outcomes of several treatment options are equivalent, HRQOL measurement provided added information for clinical decision making beyond that of traditional medical outcomes. In trials in the adjuvant setting, HRQOL measurement did not influence clinical decision making. In metastatic disease, HRQOL outcomes provided little information beyond that obtained from traditional medical outcomes, including toxicity. In the symptom control/supportive care setting, results of HRQOL questionnaires targeting specific symptoms (e.g., emesis) guided treatment decisions. In psychosocial intervention trials, psychosocial and/or HRQOL measurements often provided the only outcome information; therefore, selection of instruments that captured attributes likely to be altered by the intervention was essential. Until results of ongoing trials in breast cancer are available, caution is recommended in initiating new HRQOL studies unless treatment equivalency is expected, or unless the HRQOL questions target unique or specific issues that can only be addressed through patient self-report, including outcomes of psychosocial interventions.

Virtual connections: Internet health care

Shortly before his death in 1995, Kenneth B. Schwartz, a cancer patient at Massachusetts General Hospital (MGH), founded The Kenneth B. Schwartz Center at MGH. The Schwartz Center is a nonprofit organization dedicated to supporting and advancing compassionate health care delivery that provides hope to the patient, support to caregivers, and encourages the healing process. The Center sponsors the Schwartz Center Rounds, a monthly multidisciplinary forum where caregivers reflect on important psychosocial issues faced by patients, their families, and their caregivers, and gain insight and support from fellow staff members. The 20th century success of the Internet is now translating into changes in 21st century medical practice. The changes brought about by the Internet have at once facilitated and complicated the practice of medicine. Physicians and patients are challenged to take advantage of the increased opportunities afforded by Internet access while being mindful of its drawbacks and the limitations to virtual communication. The case of Karen Parles, one of the authors, is presented. Karen developed locally advanced lung cancer and used the Internet to research her diagnosis. She found the information on lung cancer limited and confusing, and, in response, developed a website devoted to empowering lung cancer patients in their search for information and support (http://www.lungcanceronline.org). Here we discuss issues surrounding patients' use of the Internet for health information and communication with health care providers. The value of information-seeking as a coping mechanism is debated, and concerns are raised regarding confidentiality of electronic communications and the logistics of physicians adopting e-mail as a mechanism for communicating with patients.

Stress management and psychoneuroimmunology in HIV infection

Does stress management affect psychological and immune functioning in persons with human immunodeficiency virus infections? Stress-management techniques, such as relaxation training and imagery, cognitive restructuring, coping-skills training, and interpersonal-skills training, may reduce anxiety, depression, and social isolation in HIV-infected persons by lowering physical tension and increasing a sense of control and self-efficacy. A psychoneuroimmunologic model is proposed wherein these psychological changes are hypothesized to be accompanied by an improved ability to regulate neuroendocrine functioning, which in turn may be associated with a partial normalization of immune system functions such as lymphocyte proliferation and cytotoxicity, providing more efficient surveillance of latent viruses that may contribute directly to increased HIV replication and generate opportunistic infections or cancer if left unchecked. Such a normalization of stress-associated immune system decrements are hypothesized to forestall or minimize increases in viral load and expression of clinical symptoms. This model is useful for testing the factors contributing to the health effects of stress-management interventions in HIV-infected persons. In this context, one general research strategy for testing the effects of stress-management interventions is to target them toward the more prevalent psychosocial challenges that HIV-infected people face at various points in the disease process; enroll an HIV-infected population (eg, HIV-positive homosexual and bisexual men) into a randomized trial; and monitor changes in cognitive, affective, behavioral, and social factors in parallel with hormonal, immunologic, viral, and clinical changes over the course of time. This article will review the major psychoneuroimmunologic findings that have emerged using this paradigm and suggest future research directions and clinical applications.

Psycho-oncology in a united Europe--changes and challenges

The paper provides an overview on the 11th scientific conference of the European Society for Psycho-Oncology (ESPO), which took place in June 2001, at Heidelberg, Germany. The main topics discussed during the conference were: (1) the state of the art of research on the effects of psychological interventions in cancer patients; (2) psychosocial aspects in the new field of cancer genetics; (3) recent developments in Quality of Life research; (4) Psycho-Oncology from an European perspective; and (5) children and cancer. The conference gave an impressive picture of the many achievements Psycho-Oncology in Europe has accomplished during the last years, in the clinical and scientific domain. With recent biomedical innovations Psycho-Oncology is facing new challenges. Despite these achievements limitations have become apparent. Identifying these limitations, future aims can be outlined. Among these, there is the need for methodological refinement, as well as for proof of clinical relevance of research results, in order to narrow the gap between research and practice.