Living with hope: developing a psychosocial supportive program for rural women caregivers of persons with advanced cancer

Background

Hope is defined by caregivers as the inner strength to achieve future good and to continue care giving. Pilot test findings of a Living with Hope Program (LWHP) suggested it is an acceptable and feasible intervention for use by family caregivers. Although it shows promise in potentially increasing hope and quality of life, further testing and development is needed. Questions remain as to: a) what are the mechanisms through which the LWHP affects outcomes and b) how long it is effective? The overall purpose of this time series mixed method study is the further development and testing of the LWHP by:

a. Determining the mechanisms of the LWHP by testing a LWHP conceptual model in which self-efficacy, and loss/grief are hypothesized intermediary variables for changes in hope, and subsequently quality of life among rural women caring for persons with advanced cancer, and;

b. Exploring the longitudinal effects of the LWHP on hope, quality of life and health services utilization among rural women caring for persons with advanced cancer.

Methods/Design

Using a time-series embedded mixed method design, data will be collected from 200 rural women caregivers. Following the collection of baseline and outcome variables, the intervention (LWHP) is applied to all subjects. Subjects are followed over time with repeated measures of outcome variables (1 wk, 2 wk, 3, 6 and 12 months). The journals that are completed as part of the LWHP comprise the qualitative data. Health services utilization data will be collected from the Saskatchewan Health Administrative Database for all subjects one year prior and one year after study enrolment.

Path analysis will be used to test the model post LWHP, at 1 and 2 weeks. Two-factor ANCOVA will determine patterns over time and Cortazzi's narrative analysis will be used to analyze subjects journals completed as part of the LWHP.

Discussion

Data Collection began January 2009 and is expected to be completed within 2 years time. Monthly meetings with data collectors and site collaborators have been instrumental in revisions to the original study protocol such as identifying and adding additional study sites.

Trial Registration

Trial Registration; Clinical Trials.Gov. NCT01081301

Decreasing psychological distress in cancer inpatients using FLEX Care®: a pilot study

While the incidence of psychological distress among people receiving treatment for cancer in outpatient treatment settings has received attention by researchers, few studies have investigated the incidence of psychological distress in inpatient settings. Similarly, efficacy or effectiveness studies describing psychosocial interventions with cancer patients in inpatient settings are all but absent from the research literature. The purpose of this study was to screen for psychological distress among persons receiving inpatient treatment for cancer and to then test the efficacy of a communications model known as FLEX Care®, used to enhance routine psychosocial care, in an effort to reduce measurable levels of psychological distress. Following the vetting of more than 400 potential participants, 35 met rigorous screening criteria and also consented to participate in this randomized pre-post control group study. The intervention group received the FLEX Care®-enhanced routine psychosocial intervention, while the control group received the routine psychosocial intervention alone. Mean scores for psychological distress were found to be nearly twice as high in the study sample as those levels reported in outpatient studies. Additionally, participants who received the FLEX Care®-enhanced psychosocial intervention experienced a significant reduction in psychological distress in contrast to participants in the control setting. The findings from this study underscore the need to screen for symptoms of psychological distress in inpatient settings and lend preliminary support to the use of personalized psychosocial intervention strategies that can be used as adjuvant to routine psychosocial care in the inpatient setting to reduce psychological distress.

Psychosocial outcomes and service use among young adults with cancer

At the crossroads between pediatric and older adult groups, young adults with cancer may be underserved or inadequately or inappropriately served by existing support services. Empirical evidence has not established well the extent to which utilization of psychosocial support services delivered throughout a continuum of care results in desired outcomes. If self-efficacy is demonstrated to play a significant role in promoting quality of life and psychological well-being in young adult cancer patients, then a cancer-specific self-efficacy model can serve as an evidence-based framework for developing, implementing, and testing new interventions. A focus on self-efficacy has the potential to promote young adults' abilities to remain active and independent, seek and understand medical information, manage stress, cope with treatment-related side effects, maintain a "positive attitude," regulate emotions, and seek social support. Future research should aim to identify which patients represent at-risk targets for intervention, as well as the most appropriate time points along the continuum of care at which patients/survivors are most likely to benefit from delivery/utilization of psychosocial support services.

Reappraisal in the eighth life cycle stage: A theoretical psychoeducational intervention in elderly patients with cancer

Elderly patients with cancer face unique physical and psychiatric challenges in coping with their illness. Optimal psychosocial therapy for older cancer patients requires recognizing certain enhanced psychological capacities such as coping better with illness, which is associated with older age. This strength can be combined with the most appropriate cognitive coping strategies to develop a model intervention. This paper describes such a model, which integrates Erik Erikson's eighth and final psychosocial developmental life stage, in which the task is to achieve ego integrity (equanimity) or to experience despair (sadness, regrets), with Susan Folkman's cognitive coping paradigm, which utilizes reappraisal. This theoretical model addresses older cancer patients who are struggling with depression, isolation, and despair related to aging and illness, and utilizes cognitive reappraisal in a group setting to foster relatedness, acceptance of illness, and a sense of meaningful integration.

Cancer Health Empowerment for Living without Pain (Ca-HELP): study design and rationale for a tailored education and coaching intervention to enhance care of cancer-related pain

Background

Cancer-related pain is common and under-treated. This article describes a study designed to test the effectiveness of a theory-driven, patient-centered coaching intervention to improve cancer pain processes and outcomes.

Methods/Design

The Cancer Health Empowerment for Living without Pain (Ca-HELP) Study is an American Cancer Society sponsored randomized trial conducted in Sacramento, California. A total of 265 cancer patients with at least moderate pain severity (Worst Pain Numerical Analog Score >=4 out of 10) or pain-related impairment (Likert score >= 3 out of 5) were randomly assigned to receive tailored education and coaching (TEC) or educationally-enhanced usual care (EUC); 258 received at least one follow-up assessment. The TEC intervention is based on social-cognitive theory and consists of 6 components (assess, correct, teach, prepare, rehearse, portray). Both interventions were delivered over approximately 30 minutes just prior to a scheduled oncology visit. The majority of visits (56%) were audio-recorded for later communication coding. Follow-up data including outcomes related to pain severity and impairment, self-efficacy for pain control and for patient-physician communication, functional status and well-being, and anxiety were collected at 2, 6, and 12 weeks.

Discussion

Building on social cognitive theory and pilot work, this study aims to test the hypothesis that a brief, tailored patient activation intervention will promote better cancer pain care and outcomes. Analyses will focus on the effects of the experimental intervention on pain severity and impairment (primary outcomes); self-efficacy and quality of life (secondary outcomes); and relationships among processes and outcomes of cancer pain care. If this model of coaching by lay health educators proves successful, it could potentially be implemented widely at modest cost.

Trial Registration

[Clinical Trials Identifier: NCT00283166]

Illness cognitions in head and neck squamous cell carcinoma: predicting quality of life outcome

Goals of work

This paper presents an observational study of the longitudinal effects of cancer treatment on quality of life (QoL) in patients treated for head and neck squamous cell carcinoma (HNSCC), and evaluated the contribution of patients' baseline illness cognitions to the prediction of QoL 2 years after diagnosis.

Patients and methods

One hundred seventy-seven patients eligible for primary treatment for HNSCC completed the Illness Perception Questionnaire-Revised at baseline and the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire-30 at baseline, at 1-year and 2-year follow-ups.

Main results

Compared to baseline, patients reported better emotional functioning at both follow-ups (p < 0.001), worse social functioning at 12 months (p < 0.05), and better global health status at 24 months (p < 0.05). Patients' own implicit common sense beliefs about their illness added small but significant amounts of variance to the prediction of QoL after 2 years. Less belief in own behavior causing the illness predicted better functioning and better global health. Strong illness identity beliefs predicted worse functioning and worse global health. Negative perceptions about the duration of the illness (chronic timeline beliefs) and more negative perceived consequences also predicted worse QoL.

Conclusions

Our results on the negative perceptions about the duration of the illness, perceived consequences, and high symptom awareness predicting worse QoL illustrate the detrimental effects of uncertainty and negative expectations about the future course of the illness. The identification of these cognitive factors provides possible targets for counseling strategies to assist patients in long-term adjustment to HNSCC.

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.

Antecedents of domain-specific quality of life after colorectal cancer

OBJECTIVE

The present study prospectively assessed the influence of medical, socio-demographic, psychological, and lifestyle variables on physical, social/family, emotional, functional well-being and colorectal cancer-specific concerns in a population-based sample of colorectal cancer survivors.

METHODS

Participants (n=1822) were assessed at 6 and 24 months post-diagnosis. Predictor variables assessed at 6 months included socio-demographic and medical variables, symptoms/side-effects, body mass index, physical activity, optimism, social support, and cancer threat appraisal. Quality of life (QOL) was assessed at 6 and 24 months post-diagnosis using the Functional Assessment of Cancer Therapy - Colorectal (FACT-C).

RESULTS

For each QOL subscale and for the overall FACT-C scale, 6 month scores were the strongest predictor of QOL scores at 24 months post-diagnosis (e.g. beta=0.447, p < 0.001 for overall QOL). Socio-demographic, medical, and psychosocial variables, but not lifestyle variables, differentially predicted domain specific QOL. Only cancer threat appraisal was associated with all five QOL domains.

CONCLUSION

Cancer threat appraisal presents as a potentially modifiable variable for interventions seeking to improve QOL. Symptom management and lifestyle strategies to ameliorate the effects of co-morbidities, disease stage and troublesome symptoms such as faecal incontinence on QOL should also be included.

Social workers as patient navigators for breast cancer survivors: what do African-American medically underserved women think of this idea?

Patient navigation (PN) is a new initiative in health care aimed at reducing disparities by assisting patients in overcoming barriers within the health care system. As PN programs grow around the country, it is important to consult the key stakeholders in the development of these programs. The purpose of this qualitative study was to discuss the needs of medically underserved cancer patients and allow them the opportunity to provide input on models of care to meet their needs. Four focus groups were conducted in three major cities across Tennessee. Research participants (n = 36) were recruited by the staff in area cancer support programs and treatment programs across the state and through recruitment flyers at various treatment centers and community organizations. Findings revealed four key themes in the development of PN programs: (1) the PN needs to address access to quality care issues; (2) the PN needs to address the emotional and practical concerns of the cancer survivor, (3) the PN needs to address family concerns; (4) the PN needs to be involved across the continuum of care from time of diagnosis into long-term survivorship. Oncology social workers have a unique opportunity to meet the needs of medically underserved cancer patients through the PN movement. Our profession is a key stakeholder in this movement. We need to advocate for trained oncology social workers to actively pursue the role of patient navigators to ensure that the needs of medically underserved cancer survivors and their families are met.

Coping and quality of life after tumor surgery: personal and social resources promote different domains of quality of life

Personal and social resources facilitate the adaptation to critical life events. The present study investigates whether general self-efficacy beliefs and received social support elevate cancer patients' physical, emotional, and social well-being directly, or whether these effects are rather mediated by active or meaning-focused coping. Gastrointestinal, colorectal, and lung cancer patients were approached at 1 month and at 6 months after surgery (N=175). Structural equation models indicate that self-efficacy at 1 month after surgery exerted a positive direct effect on all three domains of health-related quality of life at 6 months after surgery, but indirect effects through active and meaning-focused coping were also observed. Initial received support elevated later emotional well-being, but not the other two quality of life domains. This effect was not mediated by coping. Results suggest the development of interventions to increase optimistic self-beliefs and coping skills in tumor-surgery patients.

Describing and predicting psychological distress after colorectal cancer

BACKGROUND

Psychological distress in cancer survivors can be detrimental to treatment adherence and self-care tasks and is associated with poor health behaviors and decreased overall quality of life. The prevalence, course, and predictors of psychological distress after the diagnosis of colorectal cancer are to date not well described.

METHODS

A prospective survey of 1822 colorectal cancer patients was undertaken assessing psychological distress and hypothesized predictors including optimism, cancer threat appraisal, social support, and physical activity at 6 and 12 months postdiagnosis. Logistic regression identified correlates of psychological distress at 12 months postdiagnosis.

RESULTS

The prevalence of global psychological distress was low: 8.3% and 6.7% at 6 and 12 months postdiagnosis, respectively. When baseline measures of independent variables were included in a logistic regression model, distress at 6 months postdiagnosis (odds ratio [OR]=10.84), comorbidities (OR=1.64), optimism (OR=0.93), cancer threat appraisal (OR=0.92), and social support (OR=0.94) were significantly associated with distress at 12 months postdiagnosis. A second logistic regression model that included concurrent measures of cancer threat appraisal, social support, and physical activity found that distress at 6 months postdiagnosis (OR=12.49), comorbidities (OR=1.64), optimism (OR=0.94), and concurrent cancer threat appraisal (OR=0.85) were significantly associated with distress at 12 months postdiagnosis.

CONCLUSIONS

Distress screening at regular intervals is needed to efficiently detect colorectal cancer patients who require in-depth psychological intervention. Threat appraisal is a modifiable variable that should be included in interventions for colorectal cancer survivors. Further research is needed to investigate the potential for physical activity to reduce distress after cancer.

The development of an evidence-based physical self-management rehabilitation programme for cancer survivors

OBJECTIVE

This paper describes the development of a physical training programme for cancer patients. Four related but conceptually and empirically distinct physical problems are described: decreased aerobic capacity, decreased muscle strength, fatigue and impaired role physical functioning. The study aimed to identify the optimal content for an exercise programme that addresses these four physical problems, based on the highest level of evidence available. The study further aimed to review the evidence available on the delivery of the programmes. The final goal was to develop a programme in which content and delivery are based on the best available evidence.

METHODS

Literature searches (PUBMED and MEDLINE, to July 2006) on content looked for evidence about the efficacy of exercise on aerobic capacity, muscle strength, fatigue and impaired role physical functioning. Literature searches on delivery looked for self-management and/or self-efficacy enhancing techniques in relation to outcome, adherence to and/or adoption of a physically active lifestyle.

RESULTS

Evidence on the effectiveness of exercise in cancer patients varies and increases when moving from muscle strength (RCT level), fatigue and physical role functioning to aerobic capacity (all at the meta-analysis level). Effect sizes for aerobic capacity were moderate, while effect sizes for fatigue and physical role functioning were zero and/or small. Many of the studies have significant methodological shortcomings. There was some evidence (meta-analyses) that self-management programmes and self-efficacy enhancing programmes have beneficial effects on health outcomes in a variety of chronic diseases, on the quality of life in cancer patients, and on exercise adherence and later exercise behaviour.

CONCLUSION

Limited data are available on the effectiveness of exercise for cancer patients. Although evidence supports the positive effects of exercise on exercise capacity during and after completion of cancer treatment, the effects for fatigue and role functioning are ambiguous. Evidence on the effectiveness of progressive exercise training on muscle strength is promising. In addition, some evidence supports the positive effects of self-management programmes and self-efficacy enhancing programmes on health outcomes, exercise adherence and later exercise behaviour.

PRACTICE IMPLICATIONS

The resulting programme was developed on the basis of the highest quality of evidence available regarding content and delivery. The content is based on information obtained from the present review, and on the recommendations of the American College of Sports Medicine. Potential advantages of the programme include: (a) tailored physical training towards focusing on the patient's established problems and (b) delivery of the training as a self-management programme that might have beneficial effects on health outcome, exercise adherence and a long-term physically active lifestyle.

"Does one size fit all?" moderators in psychosocial interventions for breast cancer patients: a meta-analysis

BACKGROUND

A variety of psychosocial interventions have been developed to promote better adjustment to breast cancer (BC) and their efficacy has been demonstrated repeatedly. However, the effect sizes (ES) vary considerably across studies.

PURPOSE

This article intends to shed light on potential moderators of intervention efficacy for BC patients, such as the intervention type (e.g., education, supportive), the composition of the sample (only BC patients or BC mixed with other cancer types), and the practitioner of the intervention (psychologist, nonpsychologist).

METHODS

Fifty-six randomized-controlled studies investigating the effectiveness of psychosocial interventions with adult BC patients were meta-analytically reviewed.

RESULTS

The overall ES of d = 0.26 was similar to previous meta-analyses and moderated by several variables. The ES varied notably based on the composition of the sample, the profession offering the intervention, and the type of intervention. Studies with samples consisting of only BC patients and studies with nonpsychologist-led interventions showed lower ES. Psychoeducation yielded the strongest ES. These moderators maintained their significance even when controlling for the nature of the control group, the format of the intervention, the timing of the intervention, or the stage of disease.

CONCLUSIONS

These results suggest that among current interventions, psychoeducation is a treatment of choice for BC patients, preferably prior to surgery and led by individuals with a medical expertise. Other psychosocial interventions appear most effective when administered individually and led by a psychologist. In addition, there is a need for improved psychosocial interventions to enhance the present ES for women with BC.

Relationships between felt age and perceived disability, satisfaction with recovery, self-efficacy beliefs and coping strategies

Subjective age is related to health and to life satisfaction, and adaptation to stressful life events is associated with self-efficacy beliefs and coping. The present study on cancer survivors addressed two objectives: the relationship between felt age and perceived disability and satisfaction with recovery, and the feeding back of felt age on general self-efficacy beliefs and coping strategies. Data were collected one and six months after surgery. Individuals with younger age identities reported lower levels of perceived disability and avoidance-oriented coping and higher levels of satisfaction with recovery, self-efficacy and meaning-focused coping than individuals with older age identities. Individuals with decreased or stable felt age indicated increased meaning-focused coping or avoidance-oriented coping, respectively. Explanations for these associations are discussed.

Chemotherapy-Related Change in Cognitive Function: A Conceptual Model

PURPOSE/OBJECTIVES

To develop a conceptual model of chemotherapy-related changes in cognitive function.

DATA SOURCES

MEDLINE, CINAHL, HealthStar, and PsycINFO databases.

DATA SYNTHESIS

Patients undergoing chemotherapy often complain of forgetfulness, absentmindedness, and an inability to focus when performing a variety of daily tasks. Changes in cognitive function have been referred to by the colloquial term "chemo-brain." The authors conducted an examination of the literature to investigate relationships among concepts and to synthesize current knowledge.

CONCLUSIONS

Cognitive function, defined as higher-order mental processes, may be altered along two distinct and interacting pathways: (a) the cancer diagnosis, which can lead to anxiety, stress, distress, and depression; and (b) the direct physiologic effects of cancer treatment. The Chemotherapy-Related Change in Cognitive Function conceptual model is informed by a review of literature that illustrates antecedents, moderators, mediators, and consequences that may be relevant to this issue.

IMPLICATIONS FOR NURSING

When a patient presents with cognitive complaints, the problems can be evaluated for intervention when an overall understanding exists of chemotherapy-related cognitive changes based on a conceptual model that continues to be informed through well-conceptualized and well-designed research.

What is the state of the evidence on the mind–cancer survival question, and where do we go from here? A point of view

GOALS OF WORK

There is long history of anecdote and surmise linking psychosocial factors to cancer incidence and survival. However, over the past three decades, an increasing number of rigorous studies have investigated the possibility of a mind-cancer survival connection. The objective of this paper is (1) to review the past 30 years of psycho-oncology research on the mind-cancer survival question, (2) to review the methodological debate and interpretations of the research findings, and (3) to consider future research directions.

MAIN RESULTS

Over the past three decades, a small number of studies have been published. Some observational and quasi-experimental studies suggest the possibility that coping and psychological factors may influence disease outcomes, but clinical trials suggest that psychosocial interventions do not prolong survival. Methodological comment and interpretation about the significance of these trials vary. Some researchers view the mind-cancer survival question as resolved and negative, whereas others identify conceptual and methodological challenges and view the possible impact of psychosocial factors on survival as simply unproven. We take the position that the question is unanswered.

CONCLUSION

Recommended future research directions include: (1) more trials based on testable theories, targeted interventions, and greater specificity in the measurement model and (2) new research questions and more rigorous observational, prospective, and longitudinal studies, case studies, mixed methods, and innovative design approaches being developed by complementary and alternative medicine researchers. Further research is warranted on the mind-cancer survival question.

Perceived Benefits on Family Health of Small Groups for Families With Children

BACKGROUND

Thus far, international research on small groups has focused on health problems. Research on preventive, resource-, and family-oriented small groups and their impact on family health is scant.

OBJECTIVES

To describe the experiences of families with small children concerning resource-enhancing small support groups, and to identify the benefits to family health described by participating parents at the end of the group processes.

SAMPLE

The study population consisted of parents (n=123) attending 13 small groups. Participants included 63 mothers and 14 fathers (63% response rate).

METHODS

Data were collected through group interviews. Qualitative content analysis of latent content was the method of analysis.

RESULTS

Small groups provided the parents with knowledge about family life and encouraged them to seek information, made them feel refreshed, strengthened their social support networks, enhanced their awareness of their own resources and the different developmental needs at times of change in the family, and increased their confidence concerning their ability to cope.

CONCLUSIONS

Concepts from this study can be used in the future to construct instruments to evaluate the effectiveness of small groups from the perspective of families and family health. The findings add to our professional understanding of resource-oriented family work from the perspective of families.

Is self-efficacy a predictor of short-term post-surgical adjustment among Chinese women with breast cancer?

BACKGROUND

High self-efficacy (SE) is regarded as beneficial for cancer patients in facilitating adaptation and therefore desirable. However, this may not always be the case.

DESIGN

A longitudinal cohort study of women receiving breast cancer surgery. Path analysis examined impact of high and low baseline SE scores on outcome. Post hoc analysis stratified outcome expectations by SE.

METHODS

405/529 eligible Chinese women aged 28-79 years receiving breast cancer surgery in six regional Hong Kong hospitals were interviewed within 1 week of surgery. After assessing SE, incongruence between expectancy and outcome of surgery (E-OI), and psychological morbidity, 91% of women were followed for 1 month when psychological and social morbidity were assessed (follow-up).

RESULTS

After adjustment for demographic and histopathological factors, psychological morbidity was predicted by E-OI. Women with high E-OI had more impairment of sexuality and self-image. Women with high SE had better self-image and relationships with friends, but tended to underestimate the negative consequences of surgery on appearance. This increased E-OI and thereby psychological morbidity.

CONCLUSIONS

High post-surgical SE benefits early social adaptation, but also leads to under-estimating the negative impacts of surgery, impairing psychological adjustment. High SE can thereby contribute indirectly and significantly to increased psychological morbidity.

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.

Psychological interventions for distress in cancer patients: a review of reviews

We review a decade of review articles concerning psychosocial interventions for cancer patients. We find a distinct progression in the tone of interpretations of the literature, as better quality studies accumulate and the sophistication of reviews improves. The current literature does not make a compelling case for the value of these interventions for the typical cancer patient. The bulk of the literature reviews in this field take a narrative rather than a systematic approach, and serious compromises in standards are necessary to muster an adequate set of studies for review. The more rigorous the review, the less likely it is to conclude there is evidence that psychological interventions are effective.

Dispositional optimism as a predictor of men's decision-related distress after localized prostate cancer

This study investigated prospectively the relationship between optimism, threat appraisal, seeking support and information, cognitive avoidance, physical treatment side effects, and decision-related distress in 111 men with localized prostate cancer. Men were assessed at diagnosis and 2 and 12 months after treatment. Baseline decision-related distress predicted distress 2 and 12 months after treatment. Optimism was a significant prospective and concurrent predictor of decision-related distress, with the effect mediated by proximal cancer threat appraisal. Seeking support and information and cognitive avoidance were not associated with decision-related distress at any time point. For physical treatment side effects, concurrent urinary symptoms were predictive of decision-related distress 2 months after treatment. Results suggest that decision-related distress is generated by similar processes to that of the psychological distress that follows a cancer diagnosis. Screening for men with high decision-related distress for referral to in-depth decision support is suggested. Outcome expectations may present as a therapy target to increase the effectiveness of decisional support that is utility based.

Health psychology: psychological adjustment to chronic disease

Chronic diseases carry important psychological and social consequences that demand significant psychological adjustment. The literature is providing increasingly nuanced conceptualizations of adjustment, demonstrating that the experience of chronic disease necessitates adaptation in multiple life domains. Heterogeneity in adjustment is apparent between individuals and across the course of the disease trajectory. Focusing on cancer, cardiovascular disease, and rheumatic diseases, we review longitudinal investigations of distal (socioeconomic variables, culture/ethnicity, and gender-related processes) and proximal (interpersonal relationships, personality attributes, cognitive appraisals, and coping processes) risk and protective factors for adjustment across time. We observe that the past decade has seen a surge in research that is longitudinal in design, involves adequately characterized samples of sufficient size, and includes statistical control for initial values on dependent variables. A progressively convincing characterization of risk and protective factors for favorable adjustment to chronic illness has emerged. We identify critical issues for future research.

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 clinical trial of group-based cognitive-behavioral stress management in localized prostate cancer: development of stress management skills improves quality of life and benefit finding

BACKGROUND

Recent literature has indicated that a significant percentage of oncology patients describe finding some benefit (e.g., improved personal growth, sense of meaning, and enhanced interpersonal relationships) in the cancer experience. However, few studies have investigated the role of group-based psychosocial interventions in improving benefit finding (BF), and virtually none have investigated these constructs in men.

PURPOSE

This study examined whether a cognitive-behavioral stress management (CBSM) intervention improves BF and quality of life (QoL) in men recovering from treatment for localized prostate cancer.

METHODS

Participants in this study were 191 men (M age = 65.1) treated with radiation or radical prostatectomy for clinically localized (i.e., Stage I or II) prostate cancer. Participants were primarily non-Hispanic White (40%) or Hispanic (41%), followed by Black (18%) and other ethnicity (1%), were an average of 65.1 years old (SD = 7.7), and earned an average of 47,800 US dollars annually (SD = 41,000 US dollars). Participants were randomized to either a 10-week group-based cognitive-behavioral stress management intervention or a half-day educational seminar as a control condition. All participants provided demographic information and completed the Positive Contributions Scale-Cancer to assess BF, the Functional Assessment of Cancer Therapy to measure quality of life, and a measure of perceived stress management skills. Structural equation modeling was utilized for all analyses.

RESULTS

Results indicated that the CBSM condition led to increases in BF and QoL and that these changes were mediated by the development of stress management skills.

CONCLUSIONS

Results support the use of group-based cognitive-behavioral interventions in promoting QoL and BF in this population.

Outcome expectations and self-regulation in cancer patients: Reliability, initial factor structure, and relationships with benefit finding

Objective:The purpose of this research was to investigate outcome expectation and self-regulation measures within a sample of cancer patients and to explore relationships of these variables with benefit finding. The outcome expectation and self-regulation measures were evaluated for reliability and initial factor structure.

Method:A convenience sample of 141 cancer patients completed study measures while waiting for appointments at a cancer center.

Results:The measures demonstrated good reliability (alphas = .88 and .92, for outcome expectation and self-regulation respectively). Initial factor structure suggested six outcome expectation factors (managing symptoms, expressing emotions, talking about cancer, learning about cancer, managing self-image, and managing needs) and one self-regulation factor. Gender and treatment status were related to outcome expectations but not self-regulation. Outcome expectations and self-regulation were significant predictors of benefit-finding,F(8, 80) = 3.1,p= .005.

Significance of the research:Measures of outcome expectations and self-regulation are reliable, are related to gender and clinical variables, and may be useful as predictors of cancer patients' ability to find benefits in their cancer experience.

The general self-efficacy scale: multicultural validation studies

General self-efficacy is the belief in one's competence to cope with a broad range of stressful or challenging demands, whereas specific self-efficacy is constrained to a particular task at hand. Relations between general self-efficacy and social cognitive variables (intention, implementation intentions, outcome expectancies, and self-regulation), behavior-specific self-efficacy, health behaviors, well-being, and coping strategies were examined among 1,933 respondents in 3 countries: Germany (n = 633), Poland (n = 359), and South Korea (n = 941). Participants were between 16 and 86 years old, and some were dealing with stressful situations such as recovery from myocardial events or tumor surgery. Perceived self-efficacy was measured by means of the General Self-Efficacy Scale (R. Schwarzer & M. Jerusalem, 1995). Meta-analysis was used to determine population effect sizes for four sets of variables. Across countries and samples, there is consistent evidence for associations between perceived self-efficacy and the variables under study confirming the validity of the psychometric scale. General self-efficacy appears to be a universal construct that yields meaningful relations with other psychological constructs.

Cognitive Behavioral Therapy Techniques for Distress and Pain in Breast Cancer Patients: A Meta-Analysis

This meta-analysis is the first to examine cognitive behavioral therapy (CBT) techniques for distress and pain specifically in breast cancer patients. Twenty studies that used CBT techniques with breast cancer patients were identified and effect sizes were calculated to determine (1) whether CBT techniques have a significant impact on distress and pain, (2) if individual or group treatments are more effective, (3) whether severity of cancer diagnosis influences distress and pain outcomes, and, (4) if there is a relationship between CBT technique efficacy for distress and pain. Results revealed effect sizes of d = 0.31 for distress (p < 0.05) and .49 for pain (p < 0.05), indicating that 62 and 69% of breast cancer patients in the CBT techniques treatment groups had less distress and less pain (respectively) relative to the control groups. Studies with individual treatment approaches had significantly larger effects compared to studies that employed group approaches for distress (p = 0.04), but not for pain (p > 0.05). There were no significant differences in effects between those with or without metastases (p > 0.05). The correlation between effect sizes for distress and pain was not significant (p = 0.07). Overall, the results support the use of CBT techniques administered individually to manage distress and pain in breast cancer patients. However, more well-designed studies are needed.

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.

Randomized pilot of a self-guided internet coping group for women with early-stage breast cancer

BACKGROUND

Internet-based methods for provision of psychological support and intervention to cancer survivors hold promise for increasing the public impact of such treatments.

PURPOSE

The goal of this controlled pilot study was to examine the effect and potential mechanisms of action of a self-guided, Internet-based coping-skills training group on quality of life outcomes in women with early-stage breast cancer.

METHODS

Sixty-two women completed baseline evaluations and were randomized into either a small online coping group or a waiting-list control condition.

RESULTS

No main effects for treatment were observed at the 12-week follow up. However, there was a significant interaction between baseline self-reported health status and treatment, such that women with poorer self-perceived health status showed greater improvement in perceived health over time when assigned to the treatment condition. Linguistic analyses revealed that positive changes across quality of life variables were associated with greater expression of negative emotions such as sadness and anxiety, greater cognitive processing, and lower expression of health-related concerns.

CONCLUSIONS

These results demonstrate the potential efficacy of self-guided Internet coping groups while highlighting the limitations of such groups.

Effect of neutropenia on the impact of a cognitive-behavioral intervention for symptom management

BACKGROUND

Trials of cognitive-behavioral interventions (CBI) designed to reduce symptom severity or improve dimensions of quality of life seldom consider how the side effects of treatment or the complications imposed by the disease or treatment may moderate the impact of the trial on the designated outcome. To address this issue, the moderating effect of neutropenia on the impact of a CBI for reducing symptom severity was evaluated among patients with cancer undergoing chemotherapy.

METHODS

The authors described the impact of a randomized trial of a 10-contact, 20-week CBI on symptom severity, as well as the moderating effect of a neutropenic episode on symptom severity at 20 weeks. Severity scores were based on sum scores (0-10) for 15 symptoms.

RESULTS

There was an effect for age (younger) and group on severity at 20 weeks and an interaction between neutropenia and group. Among patients with no evidence of neutropenia, those in the experimental arm had a 9-point lower severity score at 20 weeks. Among patients who experienced neutropenia, differences in symptom severity by arm of the trial were < 3 points. Further, fatigue, fever, and pain were more prevalent among patients with neutropenia.

CONCLUSIONS

Patients who experienced neutropenia did not benefit from a CBI to lower symptoms. The overall effect of this intervention came almost exclusively from patients without neutropenia.

Does the theory of planned behavior mediate the effects of an oncologist's recommendation to exercise in newly diagnosed breast cancer survivors? Results from a randomized controlled trial

This randomized trial examined the effects of 2 oncologist-based exercise interventions--recommendation only (RO) and recommendation plus referral (RR)--versus usual care (UC) on social-cognitive constructs from the theory of planned behavior (TPB). The authors also examined whether the TPB mediated the significant effect of the RO intervention on exercise and explained the null effect of the RR intervention. Independent t tests revealed that both interventions had significant effects on TPB constructs; however, only the RO intervention impacted perceived behavioral control (PBC). Path analyses indicated that PBC was the only construct with a direct effect on exercise and that it mediated the effect of the RO intervention on exercise and explained the null effect of the RR intervention.

Reducing symptom limitations: a cognitive behavioral intervention randomized trial

Until now, little research has been conducted examining the reactive dimension, or the degree to which a symptom limits an individual's life, in a multiplicity of symptoms. This research examines how problem-solving therapy organizes an intervention to decrease symptom limitations. The purpose was threefold: to determine if a cognitive behavioral intervention decreases the impact of symptom limitations among individuals newly diagnosed with cancer, who are receiving chemotherapy; to determine, after adjusting for covariates, how symptom limitations change over time; and to describe which symptoms are most limiting. This randomized control trial was conducted in two comprehensive and four community cancer centers. Two hundred thirty-seven individuals, aged 31-87, newly diagnosed with solid tumor cancers, participated. The experimental group (118 individuals) received a 10-contact, 18-week cognitive behavioral intervention focused on cancer- and chemotherapy-related symptoms. The control group (119 individuals) received conventional care. Interviews occurred at baseline, 10, 20, and 32 weeks. Data analysis used a two-level hierarchical linear model. Participants receiving the cognitive behavioral intervention had lower scores of symptom limitation than did participants in the control group. At the onset of the study, younger patients reported more symptom limitations than their older counterparts; however, this was reversed by the end of the study. The cognitive behavioral intervention was key to decreasing symptom limitations. Findings also suggest that nursing interventions may be particularly helpful to younger individuals in managing cancer-related symptom limitations.

Psychoeducational Intervention for Patients With Cutaneous Malignant Melanoma: A Replication Study

Purpose

In 1993, a randomized intervention study among patients with malignant melanoma showed a significant decrease in psychological distress and increased coping capacity 6 months after the intervention and enhanced survival 6 years later. We applied a similar intervention with a few modifications in a randomized controlled trial among Danish patients with malignant melanoma and evaluated results on immediate and long-term effects on psychological distress and coping capacity.

Patients and Methods

A total of 262 patients with primary cutaneous malignant melanoma were randomly assigned to the control or intervention group. Patients in the intervention group were offered six weekly sessions of 2 hours of psychoeducation, consisting of health education, enhancement of problem-solving skills, stress management, and psychological support. The participants were assessed at baseline before random assignment and 6 and 12 months after surgery. The analyses of the main effects of the intervention were based on analyses of covariance.

Results

The patients in the intervention group showed significantly less fatigue, greater vigor, and lower total mood disturbance compared with the controls, and they used significantly more active-behavioral and active-cognitive coping than the patients in the control group. The improvements were only significant at first follow-up.

Conclusion

The findings of this study support the results of an earlier intervention study among patients with malignant melanoma and indicate that a psychoeducational group intervention for such patients can decrease psychological distress and enhance effective coping. However, this effect is short term and the clinical relevance is not obvious.

Evidence-based practice in stuttering: Some questions to consider

A recent forum in JFD (28/3, 2003) evaluated the status of evidence-based practice in fluency disorders, and offered recommendations for improvement. This article re-evaluates the level of support available for some popular approaches to stuttering therapy and questions the relative value placed on some types of programs endorsed by the forum. Evidence-based practice is discussed within the context of emerging concerns over its application to non-medical interventions and suggestions are made for grounding fluency interventions by reference to empirically supported principles of change. A popular, evidence-based intervention for stuttering in young children (the Lidcombe program) is evaluated within the suggested parameters.

EDUCATIONAL OBJECTIVES

After reading this article, the reader will be able to: (1) evaluate the status of evidence-based practice in fluency disorders; (2) list concerns about the impact of narrow interpretation of EBP on research and practice in the field of fluency disorders and other non-medical domains; (3) articulate the role of theory and basic research in selecting among and evaluating therapy approach options.

Benefits from an uncertainty management intervention for African-American and Caucasian older long-term breast cancer survivors

In a randomized controlled design, this study tested the efficacy of a theoretically based uncertainty management intervention delivered to older long-term breast cancer survivors. The sample included 509 recurrence-free women (360 Caucasian, 149 African-American women) with a mean age of 64 years (S.D.=8.9 years) who were 5-9 years post-treated for breast cancer. Women were randomly assigned to either the intervention or usual care control condition. The intervention was delivered during four weekly telephone sessions, in which study nurses guided cancer survivors in the use of audiotaped cognitive-behavioral strategies to manage uncertainty about recurrence, and a self-help manual designed to help women understand and manage long-term treatment side effects and other symptoms. Treatment outcome data on uncertainty management were gathered at pre-intervention and 10-months afterward. Repeated measures MANOVA evaluating treatment group, ethnic group, and treatment by ethnic interaction effects indicated that training in uncertainty management resulted in improvements in cognitive reframing, cancer knowledge, patient-health care provider communication, and a variety of coping skills. Results are discussed in terms of the importance of theory-based interventions for cancer survivors that target triggers of uncertainty about recurrence and in terms of ethnic differences in response to the intervention.