Long-term effects of educational and peer discussion group interventions on adjustment to breast cancer

Development of the Psychosocial Distress Questionnaire-Breast Cancer (PDQ-BC): a breast cancer-specific screening instrument for psychosocial problems

PURPOSE

The aim of the present study was to develop a short, easy-to-use, and acceptable psychosocial screening instrument specific for breast cancer patients.

METHODS

Before the start of adjuvant chemotherapy, 164 (98.8%) women completed the Psychosocial Distress Questionnaire-Breast Cancer (PDQ-BC) as part of routine care. The PDQ-BC consists of questions about psychological risk factors (i.e., trait anxiety and (lack of) social support), psychosocial problems (i.e., state anxiety and depressive symptoms), social problems, physical problems, body image, financial problems, sexual problems, clinical factors (type of surgery, adjuvant treatment other than chemotherapy and psychiatric morbidity), and demographic factors (marital status, age, and age of children).

RESULTS

On average, patients indicated that they needed 5 min to complete the PDQ-BC. All subscales were significantly correlated with each other, except the correlations of social support with physical problems and body image. Confirmatory factor analysis supported the internal structure of the PDQ-BC (comparative fit index = 0.95 (χ(2)(24) = 43.3), p = 0.009; non-normed fit index = 0.91; root mean square error of approximation = 0.073). The internal consistency (Cronbach's alphas) of the subscales trait anxiety, state anxiety, depressive symptoms, body image, social problems, and physical problems were 0.88, 0.85, 0.86, 0.79, 0.42, and 0.69, respectively.

CONCLUSION

The PDQ-BC is an easy-to-complete, acceptable, non-burdensome, and short screening instrument for routine use in breast cancer patient care. This instrument facilitates a greater awareness of the concerns and needs for breast cancer patients care during treatment with chemotherapy and the follow-up. It is linked to a good referral system to guide allocation to the different levels of psychosocial care providers.

'All in the same boat'? Patient and carer attitudes to peer support and social comparison in Motor Neurone Disease (MND)

This paper explores attitudes to peer support among people with Motor Neurone Disease (MND) and their family carers. It reports findings from a secondary analysis of data from two UK interview studies conducted by the authors. The process of secondary analysis is reported in detail. 48 people with MND and 22 carers were interviewed in 2005-2007. The authors identified narrative extracts on peer support from their own datasets and exchanged them for independent thematic analysis. Subsequent discussion, drawing on literature on support groups and social comparison, led to an exploration of two overarching themes: valuing camaraderie and comparison, and choosing isolation. Findings suggest that social comparison theory is a useful framework for analysing attitudes to MND support groups, but that on its own it is insufficient. 'Valuing camaraderie and comparison' explains how support groups offer practical and social support, as well as beneficial opportunities for social comparison. Seeing others coping well with the condition can provide hope, while downward comparison with those worse off can also make people feel better about their own situation. However, most people are also shocked and saddened by seeing others with the condition. Tension of identity can occur when group membership starts to define the individual as 'a person with MND, rather than the person I am that happens to have MND'. Choosing isolation can be a deliberate defensive strategy, to protect oneself from witnessing one's possible future. Levels of involvement may change over time as people struggle with their changing needs and fears.

A naturalistic evaluation of psychosocial interventions for cancer patients in a community setting

We used a naturalistic methodology to examine associations between change in cancer patients' emotional functioning and their use of interventions in a community organization. One-hundred ninety-two patients completed measures at baseline and 6 months later. During this time, they utilized the organization's various interventions as they wished. Attendance at educational events was associated with decreased well-being. Use of art therapy groups was not associated with decreases in negative emotion but was consistently associated with increases in positive emotion. Improved functioning on some measures was associated with use of psychoeducational groups, expressive/supportive groups, movement classes, healing arts, and a buddy-matching service.

The impact of a multimedia informational intervention on psychosocial adjustment among individuals with newly diagnosed breast or prostate cancer: a feasibility study

OBJECTIVE

To examine the impact of an 8-week cancer multimedia informational intervention on health-related outcomes among individuals newly diagnosed with cancer.

METHODS

Using a pre-/post-quasi-experimental design, participants with breast or prostate cancer (n=250) were conveniently recruited from four oncology ambulatory clinics and completed questionnaires at three points (enrolment, 1-2 weeks post-intervention, and 3 months later).

RESULTS

Repeated-measure analyses showed that, when compared to controls, the intervention significantly improved satisfaction with cancer information over time for women (p<.001), prevented deterioration in functional quality of life (p=.030) and marginally improved perceived oncologist informational support (p=.051). There were no significant differences in psychosocial adjustment among men. Unlike previously suggested, the intervention did not have a differential impact according to levels of personal resources (self-esteem, mastery, and optimism). However, for all outcomes and regardless of group, participants high in personal resources reported better adjustment across time.

CONCLUSION

Even though the hypotheses were only partially supported, the findings provide preliminary evidence that multimedia interventions can be supportive.

PRACTICE IMPLICATIONS

With increasing numbers of new cancer diagnoses, cancer survivors and more limited health care resources, further research is needed to evaluate potential benefits of health information technology in providing support to individuals facing cancer.

Psychological effects and mediators of a group multi-component program for breast cancer survivors

This study evaluated the short-term impact of YWCA Encore, a mixed-modality group exercise and information support program for breast cancer patients situated in the community setting. Australian post-surgical breast cancer patients (N = 162) were assigned to either the 8-week Encore intervention or a Waitlist control. Intervention impact was assessed in terms of quality of life, cancer-specific distress, and social support. Changes in familiarity with exercise, self-efficacy and social support were tested as mediators of the intervention impact on quality of life. Overall adherence and satisfaction with the program were high. Significant enhancements at follow-up for quality of life and social support were evident for intervention compared with control participants. Familiarity with exercise and self-efficacy satisfied the requirements for mediation of quality of life. These findings provide evidence for psychosocial benefits of YWCA Encore multi-component program and support the use of such community-based programs for breast cancer survivors. The role of exercise familiarity and self-efficacy as probable mediators of the multi-component intervention is a critical finding and highlights the need for future investigations into the underlying mediating processes of similar interventions for cancer patients.

Effects of internet use on health and depression: a longitudinal study

Background

The rapid expansion of the Internet has increased the ease with which the public can obtain medical information. Most research on the utility of the Internet for health purposes has evaluated the quality of the information itself or examined its impact on clinical populations. Little is known about the consequences of its use by the general population.

Objective

Is use of the Internet by the general population for health purposes associated with a subsequent change in psychological well-being and health? Are the effects different for healthy versus ill individuals? Does the impact of using the Internet for health purposes differ from the impact of other types of Internet use?

Methods

Data come from a national US panel survey of 740 individuals conducted from 2000 to 2002. Across three surveys, respondents described their use of the Internet for different purposes, indicated whether they had any of 13 serious illnesses (or were taking care of someone with a serious illness), and reported their depression. In the initial and final surveys they also reported on their physical health. Lagged dependent variable regression analysis was used to predict changes in depression and general health reported on a later survey from frequency of different types of Internet use at an earlier period, holding constant prior depression and general health, respectively. Statistical interactions tested whether uses of the Internet predicted depression and general health differently for people who initially differed on their general health, chronic illness, and caregiver status.

Results

Health-related Internet use was associated with small but reliable increases in depression (ie, increasing use of the Internet for health purposes from 3 to 5 days per week to once a day was associated with .11 standard deviations more symptoms of depression, P = .002). In contrast, using the Internet for communication with friends and family was associated with small but reliable decreases in depression (ie, increasing use of the Internet for communication with friends and family purposes from 3 to 5 days per week to once a day was associated with .07 standard deviations fewer symptoms of depression, P = .007). There were no significant effects of respondents’ initial health status (P = .234) or role as a caregiver (P = .911) on the association between health-related Internet use and depression. Neither type of use was associated with changes in general health (P = .705 for social uses and P = .494 for health uses).

Conclusions

Using the Internet for health purposes was associated with increased depression. The increase may be due to increased rumination, unnecessary alarm, or over-attention to health problems. Additionally, those with unmeasured problems or those more prone to health anxiety may self-select online health resources. In contrast, using the Internet to communicate with friends and family was associated with declines in depression. This finding is comparable to other studies showing that social support is beneficial for well-being and lends support to the idea that the Internet is a way to strengthen and maintain social ties.

The effectiveness of a psycho-educational group after early-stage breast cancer treatment: results of a randomized French study

BACKGROUND

Many women with breast cancer need psychological help to cope more effectively after treatment. Cognitive and behavioural techniques are not yet well established in France. A multi-site randomized study was conducted to evaluate the effects of a psycho-educational group intervention in this population.

METHODS

Two hundred and three patients, recruited after primary treatment, were randomly assigned either to a treatment group (psycho-educational intervention) or to a waiting-list control group. The 8-week programme of 2 h sessions comprised of thematic discussions, information and training in stress management techniques. Evaluation at baseline, after 8 sessions, and 1 month after programme completion, included evaluations using the STAI, POMS, MAC, EORTC QLQ-C30 and EORTC QLQ-BR23 breast module scales.

RESULTS

We observed a significant reduction in anxiety (STAI, POMS) among group participants, a reduction in anger, depression and fatigue (POMS), a significant improvement in vigor and interpersonal relationships (POMS), in emotional and role functioning, in health status and fatigue level (EORTC QLQ-C30). In contrast, coping strategies (MAC) were not significantly different between groups. No group-related negative effects were observed and the global satisfaction levels were very high.

CONCLUSION

This study demonstrates the feasibility and effectiveness of a psycho-educational intervention, which can accelerate the reduction of those negative affects which are present at the end of treatment. It represents an excellent complement or an alternative to individual psycho-oncologic therapeutic support, widely proposed in France, and should now be tested in groups with other types of cancer and at other disease phases.

Effectiveness of education for gastric cancer patients: a controlled prospective trial comparing interactive vs. lecture-based programs

OBJECTIVE

Although patient education may enhance knowledge, coping with illness, and quality of life among cancer patients, it is uncertain which didactic method is most effective. We compared the impact of an interactive, patient-oriented group program to a lecture-based, information-only program in gastric cancer patients.

METHODS

In this prospective, controlled trial, 121 gastric cancer patients attending inpatient rehabilitation after surgical treatment received either the interactive intervention or lectures providing information. The outcomes were patients' disease-related knowledge, active coping with illness, and quality of life (QoL) at the end of their stay and 6 and 12 months thereafter.

RESULTS

Both groups improved their knowledge and QoL during rehabilitation; however, knowledge was significantly higher in the interactive group compared to the lecture group. This difference was maintained at the 6- and 12-months follow-ups. In addition, the interactive group proved superior to the lecture group regarding active coping with illness and QoL at the end of rehabilitation, but not during follow-up.

CONCLUSIONS

A structured, interactive patient education program proved superior to lecture-based provision of information in regards to short-term and long-term knowledge as well as short-term coping and QoL.

PRACTICE IMPLICATIONS

In gastric cancer patients, interactive patient education seems preferable over lectures.

Responsiveness of the EQ-5D in breast cancer patients in their first year after treatment

BACKGROUND/AIM

The EQ-5D is a generic health-related quality of life (HRQoL) measure that is used for the purpose of economic evaluations of health interventions. Therefore, it has to be responsive to meaningful changes in health in the patient population under investigation. The aim of this study was to investigate the responsiveness of the EQ-5D in breast cancer patients in their first year after treatment.

METHODS

The subscale global health of the disease-specific HRQoL measure EORTC QLQ-C30 was used as a reference instrument to determine meaningful changes in health and identify subgroups of patients: patients reporting a moderate-large deterioration, small deterioration, a small improvement, moderate-large improvement, or no change in health status. Responsiveness was evaluated by calculating standardized response means (SRMs) in the five subgroups of patients and performing analysis of variance procedures. The two HRQoL measures were filled out two weeks and one year after finalizing curative treatment for breast cancer (n = 192).

RESULTS

The EQ-5D was able to capture both improvements and deteriorations in HRQoL. SRMs of the EQ VAS and EQ-5D Index were close to zero in the subgroup reporting no change and increased and decreased adequately in the subgroups reporting small and moderate changes. Additional analysis of variance procedures showed that the EQ-5D was able to differentiate between subgroups of patients with no change and moderate-large deterioration or improvement in health.

CONCLUSION

The EQ-5D seems an appropriate measure for the purpose of economic evaluations of health intervention in breast cancer patients after treatment.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN74071417.

Responsiveness of the EQ-5D in breast cancer patients in their first year after treatment

Background/aim

The EQ-5D is a generic health-related quality of life (HRQoL) measure that is used for the purpose of economic evaluations of health interventions. Therefore, it has to be responsive to meaningful changes in health in the patient population under investigation. The aim of this study was to investigate the responsiveness of the EQ-5D in breast cancer patients in their first year after treatment.

Methods

The subscale global health of the disease-specific HRQoL measure EORTC QLQ-C30 was used as a reference instrument to determine meaningful changes in health and identify subgroups of patients: patients reporting a moderate-large deterioration, small deterioration, a small improvement, moderate-large improvement, or no change in health status. Responsiveness was evaluated by calculating standardized response means (SRMs) in the five subgroups of patients and performing analysis of variance procedures. The two HRQoL measures were filled out two weeks and one year after finalizing curative treatment for breast cancer (n = 192).

Results

The EQ-5D was able to capture both improvements and deteriorations in HRQoL. SRMs of the EQ VAS and EQ-5D Index were close to zero in the subgroup reporting no change and increased and decreased adequately in the subgroups reporting small and moderate changes. Additional analysis of variance procedures showed that the EQ-5D was able to differentiate between subgroups of patients with no change and moderate-large deterioration or improvement in health.

Conclusion

The EQ-5D seems an appropriate measure for the purpose of economic evaluations of health intervention in breast cancer patients after treatment.

Trial registration

Current Controlled Trials ISRCTN74071417.

The gains and pains of being a cancer support group leader: a qualitative survey of rewards and challenges

Rewards derived from leading a cancer support group are poorly understood yet may be crucial to offset the challenges and difficulties of this role. This study sought to obtain the views of a representative sample of Australian cancer support group leaders (CSGLs) concerning the perceived rewards and challenges of their role. All CSGLs identified by the state-based Cancer Councils were invited to participate by postal questionnaire. Qualitative methods were used to analyze responses to open-ended questions concerning rewards and challenges. A total of 300 CSGLs returned the questionnaire (response rate = 66%) with 272 providing qualitative comments. Four parallel themes emerged from the qualitative analysis: (i) Personal, (ii) Relationship, (iii) Group, and (iv) Community rewards and challenges. These were integrated into a model depicting key positive and negative aspects of the CSGL's role, to provide direction for future training and ongoing support of CSGLs.

Peer-to-peer communication, cancer prevention, and the internet

Online communication among patients and consumers through support groups, discussion boards, and knowledge resources is becoming more common. In this article, the summary of a workgroup discussion, we discuss key methods through which such web-based peer-to-peer communication may affect health promotion and disease prevention behavior (exchanges of information, emotional and instrumental support, and establishment of group norms and models). We also discuss several theoretical models for studying online peer communication, including social theory, health communication models, and health behavior models. Although online peer communication about health and disease is very common, research evaluating effects on health behaviors, mediators, and outcomes is still relatively sparse. We suggest that future research in this field should include formative evaluation and studies of effects on mediators of behavior change, behaviors, and outcomes. It also will be important to examine spontaneously emerging peer communication efforts to see how they can be integrated with theory-based efforts initiated by researchers.

Improving the health and well-being of cancer survivors: past as prologue

During the past two decades, there have been a number of unsuccessful replication attempts of our finding that group psychotherapy improves cancer survival. One explanation for this failure is that the wrong phenomenon has been studied. Rather than focusing on the effects of the psychotherapeutic relationship, perhaps, the focus should have been on the social support provided and networks developed by these groups. Since the late 1970s, a growing body of research indicates the importance of social networks and social support on reductions in not only all cause mortality, but also disease specific mortality including cancer. We have learned about how the health, well-being, and ultimate survival of cancer patients is improved by social support and social networks. The social milieu within which we live can provide resources that facilitate reintegration into society. These resources at the individual level, such as one's perception of social and emotional support, at the level of one's social ties with family and friends, and at the community level appear to improve survival across disease conditions including cancer. Even though, the mechanisms by which these endpoints are achieved remain elusive, there is much that can be done. The challenge of our time is to translate what we already know into programs to improve quality of life and to focus research toward increasing our understanding the mechanisms.

Supportive-expressive group therapy for primary breast cancer patients: a randomized prospective multicenter trial

OBJECTIVE

The aim is to evaluate the effectiveness of a manualized 12-week supportive-expressive group therapy program among primary breast cancer patients treated in community settings, to determine whether highly distressed patients were most likely to benefit and whether therapist's training or experience was related to outcome.

METHOD

Three hundred and fifty-three women within one year of diagnosis with primary breast cancer were randomly assigned to receive supportive-expressive group therapy or to an education control condition. Participants were recruited from two academic centers and nine oncology practices, which were members of NCI's Community Clinical Oncology Program (CCOP) and were followed over 2 years.

RESULTS

A 2x2x19 analysis of variance was conducted with main effects of treatment condition, cohort, and baseline distress and their interactions. There was no main effect for treatment condition after removing one subject with an extreme score. Highly distressed women did not derive a greater benefit from treatment. Therapist training and psychotherapy experience were not associated with a treatment effect.

CONCLUSIONS

This study provides no evidence of reduction in distress as the result of a brief supportive-expressive intervention for women with primary breast cancer. Future studies might productively focus on women with higher initial levels of distress.

Economic evaluation alongside a clinical trial of psycho-educational interventions to improve adjustment to survivorship among patients with breast cancer

PURPOSE

There is little economic research on psychosocial interventions. We aimed to collect data alongside a randomized trial to compare the costs and benefits of three psycho-educational strategies to improve transition to cancer survivorship.

METHODS

We evaluated the incremental delivery costs per unit increase in energy (using the Medical Outcomes Study vitality scale) or decrease in distress (from the Revised Impact of Events Scale) in the 6 months postintervention. We also evaluated 1-year post-treatment health care costs.

RESULTS

The costs of the control, video, and video plus counseling arms were $11.30, $25.85, and $134.47 per person, respectively. The video costs were $2.22 per unit increase in energy compared with control; among women who were the least prepared for transition, the video was more effective, resulting in even lower costs. The video cost $7,275 per unit change in distress versus control, but costs were lower in the subgroup least prepared for transition ($355). The counseling arm was more expensive and less effective than the video for virtually all end points. However, in one group, women more prepared for transition, counseling cost $1,066 per unit decrease in distress compared with the video. Health care costs tended to increase as intervention intensity increased.

CONCLUSION

There are no standards for evaluating cost-effectiveness of trials with psychosocial end points. In this trial, the educational video was the most cost-effective way to improve transition to survivorship. It will be important to confirm whether there is an increased use of services after such interventions and if this represents appropriate use of rehabilitative and supportive care or over-use.

Cancer related fatigue: a focus on breast cancer and Hodgkin's disease survivors

BACKGROUND AND PURPOSE

Fatigue is one of the most common and troubling symptoms in cancer survivors. In this paper we review information about cancer related fatigue in survivors of breast cancer and Hodgkin's disease, discuss some of the potential biological mechanisms for this problem in cancer survivors, and briefly discuss potential interventions.

FINDINGS

Cancer-related fatigue persists long after cancer treatments end, and is associated with more intensive treatments (combined chemotherapy and radiation therapy) in these cancers. Fatigue prior to the onset of treatment is a strong predictor of persistent fatigue. Studies in breast cancer survivors suggest elevated levels of pro-inflammatory cytokines in association with persistent fatigue, as well as abnormalities in the hypothalamic-pituitary axis. Psychosocial and physical activity interventions have been shown in some studies to alleviate fatigue.

CONCLUSIONS

Recognizing the syndrome of cancer-related fatigue is a high priority for the many cancer survivors who continue to experience this complaint as a chronic health problem.

Systematic review of peer-support programs for people with cancer

OBJECTIVE

To identify models of peer support for cancer patients and systematically review evidence of their effectiveness in improving psychosocial adjustment.

METHODS

CINAHL (Cumulative Index to Nursing and Allied Health Literature), MEDLINE and PsychINFO databases were used to identify relevant literature published from 1980 to April 2007. Data on characteristics of the peer-support program, sample size, design, measures, and findings were extracted and papers were also rated with respect to research quality (categories 'poor', 'fair' or 'good').

RESULTS

Forty-three research papers that included data from at least 1 group were reviewed in detail, including 26 descriptive papers, 8 non-randomized comparative papers, and 10 papers reporting eight randomized controlled trials (RCTs). Five models of peer support were identified: one-on-one face-to-face, one-on-one telephone, group face-to-face, group telephone, and group Internet.

CONCLUSION

Papers indicated a high level of satisfaction with peer-support programs; however, evidence for psychosocial benefit was mixed.

PRACTICE IMPLICATIONS

One-on-one face-to-face and group Internet peer-support programs should be given priority when considering ways to offer peer support. Nevertheless, the other models discussed in this review should not be dismissed until further research is conducted with a wide range of cancer populations.

Behavioral symptoms in patients with breast cancer and survivors

Behavioral symptoms are a common adverse effect of breast cancer diagnosis and treatment and include disturbances in energy, sleep, mood, and cognition. These symptoms cause serious disruption in patients' quality of life and may persist for years after treatment. Patients need accurate information about the occurrence of these adverse effects as well as assistance with symptom management. This review considers four of the most common behavioral sequelae of breast cancer, namely fatigue, sleep disturbance, depression, and cognitive impairment. Research on the prevalence, mechanisms, and treatment of each symptom is described, concluding with recommendations for future studies.

A qualitative analysis of reasons for leaving, or not attending, a cancer support group

Factors that influence participation and long-term retention in cancer support groups were examined, through a study of 87 individuals who had dropped out of a cancer support group, and 26 individuals who had never attended such groups, using a combination of interviews and open-ended questionnaire responses. Support group attrition or non-attendance was positioned as resulting from both individual and group factors. Individual factors included resisting or leaving behind a cancer patient identity, presence of existing support, practical issues, and styles of coping. Group factors included mismatches between the group and the individual, lack of knowledge or nonreferral to groups, and problems within individual groups. These disparate factors underlying support group non-attendance need to be taken into consideration when planning support services, when developing programs of education, or when referrals to cancer support groups are made.

Transition from treatment to survivorship: effects of a psychoeducational intervention on quality of life in breast cancer survivors

PURPOSE/OBJECTIVES

To examine the effectiveness of a psychoeducational intervention on quality of life (QOL) in breast cancer survivors in post-treatment survivorship.

DESIGN

A randomized controlled trial.

SETTING

An academic center collaborating with a regional cancer center in the southeastern United States.

SAMPLE

256 breast cancer survivors.

METHODS

Women were randomly assigned to the experimental or wait control group. The Breast Cancer Education Intervention (BCEI) study was delivered in three face-to-face sessions and five monthly follow-up sessions (three by telephone and two in person). The control group received four monthly attention control telephone calls and the BCEI at month 6. Data were collected at baseline, three and six months after the BCEI for the experimental group, and one month after the BCEI (at month 7) for the wait control group.

MAIN RESEARCH VARIABLES

Primary endpoints were overall QOL and physical, psychological, social, and spiritual well-being.

FINDINGS

No differences in QOL were reported at baseline between groups. The experimental group reported improved QOL at three months, whereas the wait control group reported a significant decline in QOL. The experimental group reported continued maintenance of QOL at six months. Although the wait control group reported improved QOL at six months, significant differences continued to exist between the groups.

CONCLUSIONS

The BCEI was an effective intervention in improving QOL during the first year of breast cancer survivorship. Treatment effects were durable over time.

IMPLICATIONS FOR NURSING

Post-treatment survivorship has not been empirically studied to a large degree. The BCEI is one of the few interventions demonstrating effectiveness among survivors after primary treatment, suggesting that oncology nurses may be uniquely positioned to provide safe passage using education and support.

Cancer support groups: a critical review of empirical studies

Support groups for adults affected by cancer are widely offered by local community and national agencies in North America. This type of psychosocial intervention is defined in terms of its structure and functions, and its theoretical underpinnings and models of practice are described. Forty-four empirical studies of professionally led cancer support groups are summarized and critically reviewed. These studies include 32 outcome evaluations of randomized controlled trials, two process evaluations, and 10 consumer satisfaction studies. The findings reveal high levels of consumer satisfaction, and the outcome evaluations substantiate the morale and other quality of life benefits short of prolonging life. Discussion centers on priorities for future research and practice.

Cancer genetic risk assessment for individuals at risk of familial breast cancer

BACKGROUND

The recognition of an inherited component to breast cancer has led to an increase in demand for information, reassurance, and genetic testing, resulting in the creation of genetics clinics for familial cancer. The first step for patients referred to a cancer genetic clinic is a risk assessment.

OBJECTIVES

To evaluate the impact of cancer genetic risk assessment services on patients at risk of familial breast cancer.

SEARCH STRATEGY

The specialised register maintained by the Cochrane Breast Cancer Group was searched. We also searched MEDLINE, EMBASE, CINAHL, PsycLIT, CENTRAL, DARE, ASSIA, Web of Science, SIGLE and LILACS. The searches covered the period 1985 to February 2005. We also hand-searched relevant journals.

SELECTION CRITERIA

Trials looking at interventions for cancer genetic risk assessment delivery for familial breast cancer were considered for inclusion. Trials assessed outcomes such as understanding of risk, satisfaction and psychological well-being. Studies were excluded if they concerned cancers other than breast cancer or if participants were not at risk of breast cancer. Trials concerning the provision of information or education were also excluded as it was intended to review these separately. Participants could be individuals of any age or gender, with or without a known BRCA mutation, but without a previous history of breast cancer or any other serious illness.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. Additional information was sought from investigators as necessary. Due to the heterogeneity of both the interventions and outcomes, data were analysed descriptively.

MAIN RESULTS

Fifty-eight papers were identified as relevant to the review, 54 of these were subsequently excluded. The three included trials (pertaining to five papers), provide data on 1251 participants and assessed the impact of cancer genetic risk assessment on outcomes including perceived risk, and psychological distress. This review suggests that cancer genetic risk assessment services help to reduce distress, improve the accuracy of the perceived risk of, and increase knowledge about, breast cancer and genetics. The health professional delivering the risk assessment does not appear to have a significant impact on these outcomes.

AUTHORS' CONCLUSIONS

This review found favourable outcomes for patients' risk assessment for familial breast cancer. However, there were too few papers to make any significant conclusions about how best to deliver cancer genetic risk assessment services. Further research is needed assessing the best means of delivering cancer risk assessment, by different health professionals, in different ways and in alternative locations.

Follow-up after curative treatment for breast cancer: Why do we still adhere to frequent outpatient clinic visits?

Follow-up after curative treatment for breast cancer consists of frequent outpatient clinic visits, scheduled at regular intervals. Its aim is primarily to detect local disease recurrence, or a second primary breast cancer, but also to provide information and psychosocial support. The cost-effectiveness of these frequent visits is being questioned however, leading to a search for less intensive follow-up strategies, such as follow-up by the general practitioner, patient-initiated or nurse-led follow-up or contact by telephone. These strategies are generally considered to be safe, but they are not yet widely accepted in clinical practice. Since brief interventions based on self-education and information have been shown to be able to improve quality of life, we hypothesise that these interventions may lead to a better acceptance of reduced follow-up by both patients and professionals.

Women's Perceptions of the Effectiveness of Telephone Support and Education on Their Adjustment to Breast Cancer

PURPOSE/OBJECTIVES

Social support is believed to be important in helping women adjust to breast cancer. Reports have suggested limited positive effects of social support on well-being, mood disturbances, and relationships with significant others for women who receive telephone support. Women's perceptions of the role of social support in recovery, however, has had limited study. The purpose of this study was to describe women's perceptions of their emotional and interpersonal adaptations to breast cancer after their involvement in a randomized clinical trial in which one group received educational materials and telephone support from oncology nurses and another group received educational materials only.

RESEARCH APPROACH

Content analysis was used to discover women's perceptions of their emotional and interpersonal adaptation to breast cancer following their participation in a study in which one group received educational materials and telephone support from oncology nurses and another group received educational materials only.

SETTING

All participants were interviewed by telephone in their homes.

PARTICIPANTS

77 of 106 women with breast cancer from a randomized clinical trial were interviewed about their expectations of their adaptations and the effectiveness of the experimental and social support intervention delivered by telephone.

METHODOLOGIC APPROACH

Telephone interviews were recorded on audiotape and transcribed for analysis. Structured interviews were completed by a non-nurse interviewer. Frequency counts were obtained from the responses to items and comments were clustered for themes.

MAIN RESEARCH VARIABLES

Emotional and interpersonal adaptations to breast cancer, educational materials, and telephone support from oncology nurses.

FINDINGS

Fifty-four percent of the women who received the telephone support interventions reported improvement in attitude, whereas 43% of the interviewed women in the control group reported improvement. Only three participants, all in the control group, reported worsened emotional status. The percentage of those reporting improved or unchanged physical status was about equal in each group. The majority of participants in both groups indicated that their levels of involvement in activities remained the same or increased. Forty-six percent of participants in the intervention group reported improved relationships with their spouses compared to 38% in the control group. Women from both groups indicated that the diagnosis of cancer had caused them to review their lives and make changes in their relationships and activities.

CONCLUSIONS

Participants who received telephone support for one year, in addition to educational materials, reported improvement in their attitudes toward their breast cancer and better relationships with their significant others.

INTERPRETATION

The women's perceptions are consistent with quantitative results from the clinical trial. This article reports additional evidence that telephone support is an effective alternative to support groups and may be appropriate for those with limited access to such groups because of geography, work demands, or family situations.

Psychosocial Concerns and Interventions for Cancer Survivors

In light of the increasing population living with a history of cancer in the United States, it is important to attend to quality of life and health in this group, and to develop effective interventions to address psychosocial and physical concerns across the course of the cancer trajectory. The goals of this article are to document the need for attention to psychosocial domains; offer a brief overview of the current status of the empirical literature on effects of psychosocial interventions with cancer survivors, relying on systematic reviews and meta-analyses conducted in the last decade; highlight recent examples of randomized, controlled psychosocial intervention trials directed toward cancer survivors after the completion of primary medical treatments (ie, the re-entry phase and beyond); and identify directions for application and research.

How does social comparison within a self-help group influence adjustment to chronic illness? A longitudinal study

Despite the growing popularity of self-help groups for people with chronic illness, there has been surprisingly little research into how these may support adjustment to illness. This study investigated the role that social comparison, occurring within a self-help group, may play in adjustment to chronic illness. A model of adjustment based on control process theory and response shift theory was tested to determine whether social comparisons predicted adjustment after controlling for the catalyst for adjustment (disease severity) and antecedents (demographic and psychological factors). A sample of 301 people with Ménière's disease who were members of the Ménière's Society UK completed questionnaires at baseline and 10-month follow-up assessing adjustment, defined for this study as functional and goal-oriented quality of life. At baseline, they also completed measures of the predictor variables i.e. the antecedents (age, sex, living circumstances, duration of self-help group membership, self-esteem, optimism and perceived control over illness), the catalyst (severity of vertigo, tinnitus, hearing loss and fullness in the ear) and mechanisms of social comparison within the self-help group. The social comparison variables included the extent to which self-help group resources were used, and whether reading about other members' experiences induced positive or negative feelings. Cross-sectional results showed that positive social comparison was indeed associated with better adjustment after controlling for all the other baseline variables, while negative social comparison was associated with worse adjustment. However, greater levels of social comparison at baseline were associated with a deteriorating quality of life over the 10-month follow-up period. Alternative explanations for these findings are discussed.

Uncertainty management intervention for older African American and caucasian long-term breast cancer survivors

The survivor uncertainty management intervention study is a randomized controlled study designed to test the efficacy of an intervention that combines training in audiotaped cognitive behavioral strategies to manage uncertainty about cancer recurrence with a self-help manual designed to help women understand and manage long-term treatment side effects and other symptoms. Specifically, women were taught to recognize their own personal triggers of uncertainty (places, events or surroundings, that bring back memories, feelings, or concerns about breast cancer), and then use coping skills such as relaxation, distraction, and calming self-talk to deal with uncertainty. Also, women were taught to use the manual as a resource for dealing with fatigue, lymphedema, pain and other symptoms. Treatment outcome data (Mishel et al., in press) indicated that the uncertainty management intervention resulted in improvements in cognitive reframing, cancer knowledge, social support, knowledge of symptoms and side effects, and coping skills when compared to a control condition. The purpose of the present paper was to report on the use and helpfulness of the intervention components by the 244 women who were in the intervention. Findings indicated that women regularly used the intervention components to deal with triggers of breast cancer recurrence and long-term treatment side effects and most women found the strategies very helpful.

A randomized, controlled trial of mindfulness-based art therapy (MBAT) for women with cancer

The purpose of this study was to gather data on the efficacy of a newly developed psychosocial group intervention for cancer patients, called mindfulness-based art therapy (MBAT). One hundred and eleven women with a variety of cancer diagnoses were paired by age and randomized to either an eight-week MBAT intervention group or a wait-list control group. Ninety-three participants (84%) completed both the pre- and post-study measurements. As compared to the control group, the MBAT group demonstrated a significant decrease in symptoms of distress (as measured by the Symptoms Checklist-90-Revised) and significant improvements in key aspects of health-related quality of life (as measured by the Medical Outcomes Study Short-Form Health Survey). This investigation of MBAT provides initial encouraging data that support a possible future role for the intervention as a psychosocial treatment option for cancer patients.

Benefits of the uncertainty management intervention for African American and White older breast cancer survivors: 20-month outcomes

In a 2 x 2 randomized block repeated measure design, this study evaluated the follow-up efficacy of the uncertainty management intervention at 20 months. The sample included 483 recurrence-free women (342 White, 141 African American women; mean age = 64 years) who were 5-9 years posttreatment for breast cancer. Women were randomly assigned to either the intervention or usual care control condition. The intervention was delivered during 4 weekly telephone sessions in which survivors were guided in the use of audiotaped cognitive-behavioral strategies and a self-help manual. Repeated measures MANOVAs evaluating treatment group, ethnic group, and treatment by ethnic interaction effects at 20 months indicated that training in uncertainty management resulted in improvements in cognitive reframing, cancer knowledge, and a variety of coping skills. Importantly, the 20-month outcomes also demonstrated benefits for women in the intervention condition in terms of declines in illness uncertainty and stable effects in personal growth over time.

Long-term telephone therapy outcomes for breast cancer patients

We present the results of a breast cancer clinical trial that tested two therapy interventions delivered by telephone. Women (N = 218) with Stages I, II, or III breast cancer were randomly assigned to breast cancer health education or emotional expression interventions, or to a standard care control condition. Outcome and process measures were obtained at baseline, 6-month and 13-month follow-ups. Oncology certified nurses conducted the therapies in six, 30-minute individual phone sessions. Women in the health education condition reported significantly better knowledge and less perceived stress compared to women in the emotional expression and control conditions. No treatment effects, however, were obtained for quality of life or mood, and all women generally improved on these measures over time. Secondary analyses showed that younger women and women with a more advanced stage of breast cancer reported significantly greater avoidant coping. The data show that telephone therapy is a viable delivery modality and that distress improves with time for most women. Overall, this study showed that neither of the two telephone interventions tested had a meaningful effect on quality of life or mood.

Dependable social relationships predict overall survival in Stages II and III breast carcinoma patients

OBJECTIVE

The effect of support, from dependable non-household relationships, on breast cancer progression was studied using a prospective, longitudinal design.

METHODS

Dependable social support was assessed in women with invasive breast carcinoma Stages II and III within 18 months after diagnosis. Disease outcome was monitored for 8 to 9 years. Cox regression analyses, including the Nottingham Prognostic Index (NPI) score of disease severity, tested the association between the number of dependable support persons and time to death.

RESULTS

Ninety participants listed between 1 and 16 dependable nonhousehold support persons (mean = 6, S.D. = 4). There were 21 recurrences and 16 deaths from breast cancer at the end of the study. The number of dependable supports predicted decreased mortality [RR = 0.41 (0.21-0.80), P = .01] after controlling for NPI. NPI predicted increased mortality [RR = 1.6 (1.0, 2.4), P = .05].

CONCLUSIONS

For patients with Stages II and III breast cancer, the number of dependable, nonhousehold relationships predicts decreased mortality, after accounting for disease severity.

Outcomes From the Moving Beyond Cancer Psychoeducational, Randomized, Controlled Trial With Breast Cancer Patients

Purpose

Evidence suggests that the re-entry phase (ie, early period after medical treatment completion) presents distinct challenges for cancer patients. To facilitate the transition to recovery, we conducted the Moving Beyond Cancer (MBC) trial, a multisite, randomized, controlled trial of psychoeducational interventions for breast cancer patients.

Methods

Breast cancer patients were registered within 6 weeks after surgery. After medical treatment, they completed baseline measures and were randomly assigned to standard National Cancer Institute print material (CTL); standard print material and peer-modeling videotape (VID); or standard print material, videotape, two sessions with a trained cancer educator, and informational workbook (EDU). Two primary end points were examined: energy/fatigue and cancer-specific distress. Secondary end points were depressive symptoms and post-traumatic growth. Perceived preparedness for re-entry was analyzed as a moderator of effects.

Results

Of 558 women randomly assigned to treatment, 418 completed the 6-month assessment and 399 completed the 12-month assessment. In analyses controlling for study site and baseline depressive symptoms, VID produced significant improvement in energy/fatigue at 6 months relative to CTL, particularly among women who felt less prepared for re-entry at baseline. No significant main effect of the interventions emerged on cancer-specific distress, but EDU prompted greater reduction in this outcome relative to CTL at 6 months for patients who felt more prepared for re-entry. Between-group differences in the primary outcomes were not significant at 12 months, and no significant effects emerged on the secondary end points.

Conclusion

A peer-modeling videotape can accelerate the recovery of energy during the re-entry phase in women treated for breast cancer, particularly among those who feel less prepared for re-entry.

Surviving cancer: a comparison of 5-year disease-free breast cancer survivors with healthy women

Women with breast cancer are one of the largest groups of cancer survivors. This research examined whether breast cancer has a long-term impact on quality of life (QOL) by comparing 5-year disease-free survivors to age-matched controls and by comparing women who sustained a recurrence to disease-free survivors. Controls were recruited using the neighborhood control methodology. QOL (physical, emotional, social, and spiritual) was assessed during in-person interviews. There were no differences between disease-free survivors (n = 267) and controls (n = 187) on many indicators of QOL. However, survivors reported more difficulties with physical functioning, more physical symptoms, and more faith than did controls (all ps < 0.05). Compared to disease-free survivors, survivors with a recurrence (n = 37) had a worse QOL on most indices, less positive affect, more general fatigue, and more intrusive and avoidant thoughts (all ps < 0.05). There were no differences between the two groups of survivors on indices of marriage, work experiences, or spirituality. These findings suggest that the QOL of long-term survivors who remain disease-free is comparable to that of women their age with the exception of physical functioning. Women who sustain a recurrence suffer an impaired QOL in some, but not all, domains.

Interventions to enhance physical and psychological functioning among younger women who are ending nonhormonal adjuvant treatment for early-stage breast cancer

PURPOSE

To conduct a clinical trial to determine if an educational intervention and a nutritional intervention could enhance physical and psychological functioning among younger women completing treatment for early-stage breast cancer.

PATIENTS AND METHODS

Younger women (50 years of age or younger, N = 252), within 2 months of having completed active nonhormonal adjuvant therapy, diagnosed with stage 0, I, or II breast cancer with 10 or fewer positive lymph nodes were randomly assigned to a three-arm clinical trial. Women in the control arm of the trial received standard medical care. Women in the two active arms received either an educational intervention, designed to provide information about their illness and enhance adjustment, or a nutritional intervention, designed to promote a more healthy diet. Primary end points included mental functioning, physical functioning, and depressive symptoms. Women were assessed before random assignment, 4 months later (immediately post-intervention), and 13 months later (9 months post-intervention).

RESULTS

Participants assigned to the two active treatment arms had significantly less depressive symptomatology and better physical functioning by 13-month follow-up (differences between the two active arms were nonsignificant). These effects were primarily accounted for by changes in intrusive thoughts, concerns regarding cancer recurrence and mortality, self-concept perceptions, and self-efficacy expectations. CONCLUSION Tailored psychosocial interventions can be effectively designed to enhance adjustment among younger women who are completing nonhormonal adjuvant therapy.

The effect of telephone social support and education on adaptation to breast cancer during the year following diagnosis

PURPOSE/OBJECTIVES

To find the most effective methods of providing social support for women diagnosed with breast cancer by testing the effectiveness of a telephone social support and education intervention to promote emotional and interpersonal adaptation to breast cancer.

DESIGN

Multisite, two-group experimental study with repeated measures.

SETTING

Arkansas and New Jersey.

SAMPLE

The Arkansas sample consisted of 106 women who entered the study two to four weeks postsurgery for nonmetastatic breast cancer and were randomly assigned to an experimental or control group. The comparison group consisted of 91 women from New Jersey who had participated in a previously completed study that used the same interventions and found that telephone support resulted in more positive, statistically significant adaptation to the disease.

METHODS

The experimental group received 13 months of telephone social support and education. Both groups received educational materials via a mailed resource kit. The Profile of Mood States; Visual Analogue Scale-Worry; Relationship Change Scale; University of California, Los Angeles, Loneliness Scale-Version 3; and the modified Symptom Distress Scale provided data regarding the variables of interest. Data analysis included descriptive statistics, t tests, and multivariate analysis of variance with repeated measures.

MAIN RESEARCH VARIABLES

Mood, worry, relationships with significant others, loneliness, and symptoms.

FINDINGS

Data analysis showed no significant differences between groups, and both improved on some of the outcomes. Significant time-by-location interaction effects were found when comparing the Arkansas and New Jersey samples, thereby supporting the need to consider regional differences when developing interventions.

CONCLUSIONS

The mailed educational resource kit alone appeared to be as effective as the telephone social support provided by oncology nurses in conjunction with the mailed resource kit.

IMPLICATIONS FOR NURSING

Mailed educational resource kits may be the most efficient and cost-effective way to provide educational support to newly diagnosed patients with breast cancer, but their effect may differ according to region.

A randomized intervention study for breast cancer survivors in Japan: effects of short-term support group focused on possible breast cancer recurrence

This study aimed to assess the effect on the mental health of breast cancer survivors in a support group providing an emotional and educational intervention focused on the recurrence of breast cancer. Seventy-eight breast cancer survivors were assigned randomly to an intervention group (n = 45) and a control group (n = 33), respectively. Intervention group members met weekly for 4 weeks for emotional and educational intervention focusing on recurrence of the cancer. Subjects were assessed at baseline and at 1 week and 1 month postintervention. The results indicated that there was no significant effect of the intervention in terms of state anxiety. There was a significant effect of the intervention on life satisfaction in the group scoring high at baseline, as indicated by the mean score changes. The effect was that among the groups scoring high on life satisfaction, the mean score in the intervention group remained unchanged, but in the control group it declined. That is, short-term intervention focusing on recurrence does not improve the mental health of breast cancer patients, but it may help maintain better mental health. Nurses should have proper education to be able to provide correct information about breast cancer and coping skills. Further research with long-term multipurpose support groups that take into account patients' characteristics are needed to provide effective support to women with breast cancer in Japan.

Information and support needs of callers to the Cancer Helpline, The Cancer Council Victoria

The broad aims of the present evaluation were, firstly, to describe the information and support needs of callers to a Cancer Helpline and, secondly, to describe the response of the service to these needs. A further aim was to use these results to develop strategies to improve the service. Anonymous caller information collected over a 6-year period was analysed. The setting of the study was the Cancer Helpline service operated by the Cancer Council Victoria within the state of Victoria, Australia. The caller profile was similar to that described in the literature, with the majority of callers being women, younger than the general cancer population and enquiring most commonly about breast cancer. Patients and their relatives called to obtain information about cancer diagnosis, treatment and management and to obtain psychological and emotional support. Callers received emotional support, were supplied with verbal and written information and were referred to a variety of support services. Some population groups are underrepresented in the data. Changes to the Helpline and other services over the 6-year period are described. The pattern of callers to the Cancer Helpline appears similar to that described in the USA and Europe. Many issues and challenges are common. The paper discusses additional strategies for meeting the information and support needs of those affected by cancer and describes current and suggested research areas.

Support group for cancer patients. Does it improve their physical and psychological wellbeing? A pilot study

In order to evaluate a structured support intervention programme, symptoms and quality of life (QOL) were studied in 61 consecutive cancer patients with different tumour diagnoses in relation to intervention and follow-up. The majority of the patients were female. The Edmonton symptom assessment scale (ESAS), the Norwegian fatigue questionnaire and the hospital anxiety and depression scale (HADS) were used. Data were analysed according to ANOVA and Tukey's honest significant difference (HSD) test. ESAS sickness score (P=0.0001), depression (P=0.0001), anxiety (P=0.0001) and QOL (P=0.0009) improved and the improvements in depression and anxiety were still significant after 3 months (P=0.02 respectively). Aspects of fatigue also improved significantly in 7 of 11 questions after the intervention (P< or =0.04) but these improvements were not observed after 3 months. Anxiety according to the HADS questionnaire improved significantly after the intervention (P=0.0006). The majority of the patients highly appreciated the possibility of sharing thoughts and troubles with others with similar experiences (59%). The programme was therefore found to improve QOL, and physical and psychological functions. Randomized studies in relation to immunological changes and follow-up are in progress.

Lay health workers in primary and community health care

BACKGROUND

Lay health workers (LHWs) are widely used to provide care for a broad range of health issues. However, little is known about the effectiveness of LHW interventions.

OBJECTIVES

To assess the effects of LHW interventions in primary and community health care on health care behaviours, patients' health and wellbeing, and patients' satisfaction with care.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care and Consumers and Communication specialised registers (to August 2001); the Cochrane Central Register of Controlled Trials (to August 2001); MEDLINE (1966- August 2001); EMBASE (1966-August 2001); Science Citations (to August 2001); CINAHL (1966-June 2001); Healthstar (1975-2000); AMED (1966-August 2001); the Leeds Health Education Effectiveness Database and the reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials of any intervention delivered by LHWs (paid or voluntary) in primary or community health care and intended to promote health, manage illness or provide support to patients. A 'lay health worker' was defined as any health worker carrying out functions related to health care delivery; trained in some way in the context of the intervention; and having no formal professional or paraprofessional certificated or degreed tertiary education. There were no restrictions on the types of consumers.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data onto a standard form and assessed study quality. Studies that compared broadly similar types of interventions were grouped together. Where feasible, the results of included studies were combined and an estimate of effect obtained.

MAIN RESULTS

Forty three studies met the inclusion criteria, involving more than 210,110 consumers. These showed considerable diversity in the targeted health issue and the aims, content and outcomes of interventions. Most were conducted in high income countries (n=35), but nearly half of these focused on low income and minority populations (n=15). Study diversity limited meta-analysis to outcomes for five subgroups (n=15 studies) (LHW interventions to promote the uptake of breast cancer screening, immunisation and breastfeeding promotion [before two weeks and between two weeks and six months post partum] and to improve diagnosis and treatment for selected infectious diseases). Promising benefits in comparison with usual care were shown for LHW interventions to promote immunisation uptake in children and adults (RR=1.30 [95% CI 1.14, 1.48] p=0.0001) and LHW interventions to improve outcomes for selected infectious diseases (RR=0.74 [95% CI 0.58, 0.93) p=0.01). LHWs also appear promising for breastfeeding promotion. They appear to have a small effect in promoting breast cancer screening uptake when compared with usual care. For the remaining subgroups (n=29 studies), the outcomes were too diverse to allow statistical pooling. We can therefore draw no general conclusions on the effectiveness of these subgroups of interventions.

AUTHORS' CONCLUSIONS

LHWs show promising benefits in promoting immunisation uptake and improving outcomes for acute respiratory infections and malaria, when compared to usual care. For other health issues, evidence is insufficient to justify recommendations for policy and practice. There is also insufficient evidence to assess which LHW training or intervention strategies are likely to be most effective. Further research is needed in these areas.

Perceived growth and decline following breast cancer: a comparison to age-matched controls 5-years later

Research indicates that individuals who experience stressful life events, such as a diagnosis of cancer, often experience both positive and negative changes as a result of their experiences, but little research has compared these changes with those of a control group who have experienced other stressful life events. We compared 184 5-year breast cancer survivors (Stages: I, II, and III; 95% Caucasian) with 184 age-matched controls in terms of perceived growth and decline that stem from stressful events. Survivors reported on their experience with cancer, whereas controls identified the most stressful event that happened to them 5 years ago. Survivors reported more growth (e.g. appreciation of life) and more decline (e.g. physical side effects) compared with controls. However, there were no group differences in reports of psychological stress. When survivors were compared with controls whose stressor was a personal health problem, many of the differences in growth between the two groups remained, but the differences in decline disappeared. These findings suggest that some growth is unique to breast cancer, but much of the decline associated with breast cancer is similar to the decline associated with other types of health problems.