Education and peer discussion group interventions and adjustment to breast cancer

Psychosocial and sexual functioning of survivors of breast cancer

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

Group and individual treatment strategies for distress in cancer patients

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

Audiotaped social comparison information for cancer patients undergoing radiotherapy: differential effects of procedural, emotional and coping information

The present study focused on the effects of social comparison information on subjective understanding of radiation therapy, validation of emotions, and self-efficacy of cancer patients undergoing radiation therapy. The effects of three different audiotapes, containing different kinds of social comparison information, were examined. On the procedural tape a man and woman discussed their illness and radiation treatment, on the emotion tape they focused on the emotional aspects of these issues, and on the coping tape they focused on the way they had been coping. The effects of these tapes were measured on subjective understanding about radiation therapy, validation and recognition of emotions, self-efficacy, and mood. The results indicate positive effects of the tapes, especially of the procedural and the coping tape. These audiotapes increased understanding of radiation therapy, self-efficacy and the feeling of validation of emotions. Therefore, these tapes may be an important supplement to existing patient education information. Possible explanations and practical implications are discussed.

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

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

Education and support needs of younger and older cancer survivors

This study examined the use, satisfaction with, and need for cancer education and support services in northeastern Pennsylvania. Responses of 243 younger survivors (40 to 64 years) were compared with 295 older survivors (> or = 65 years). Programs attended and desired were related to cancer type and age. The almost 20% of respondents who had attended programs, primarily younger survivors, expressed high levels of satisfaction. Younger survivors reported non-attendance because of lack of interest. Older survivors' non-attendance reasons included difficulty with travel (N = 259, chi(2) = 12.081, p =.002), no identified need for information, and dislike for time of offerings (evenings). Education/support programs should be targeted to the age of people being served, as well as incidence, prevalence, expected trajectory, and prognosis of cancer types in the service area.

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

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

Evaluation of an internet support group for women with primary breast cancer

BACKGROUND

Women with breast carcinoma commonly experience psychologic distress following their diagnosis. Women who participate in breast cancer support groups have reported significant reduction in their psychologic distress and pain and improvement in the quality of their lives. Web-based breast cancer social support groups are widely used, but little is known of their effectiveness. Preliminary evidence suggests that women benefit from their participation in web-based support groups.

METHODS

Seventy-two women with primary breast carcinoma were assigned randomly to a 12-week, web-based, social support group (Bosom Buddies). The group was semistructured, moderated by a health care professional, and delivered in an asynchronous newsgroup format.

RESULTS

The results indicate that a web-based support group can be useful in reducing depression and cancer-related trauma, as well as perceived stress, among women with primary breast carcinoma. The effect sizes ranged from 0.38 to 0.54. Participants perceived a variety of benefits and high satisfaction from their participation in the intervention

CONCLUSIONS

This study demonstrated that the web-based program, Bosom Buddies, was effective in reducing participants' scores on depression, perceived stress, and cancer-related trauma measures. The effect size of the intervention was in the moderate range. Although web-based social support groups offer many advantages, this delivery mechanism presents a number of ethical issues that need to be addressed.

Counterbalancing patient demands with evidence: results from a pan-Canadian randomized clinical trial of brief supportive-expressive group psychotherapy for women with systemic lupus erythematosus

OBJECTIVE

To evaluate the effect of Brief Supportive-Expressive Group Psychotherapy as an adjunct to standard medical care in reducing psychological distress, medical symptoms, and health care costs and improving quality of life in women with systemic lupus erythematosus (SLE).

METHODS

A randomized clinical trial was conducted with 133 SLE female patients from 9 clinics across Canada. Clinical and psychosocial measures were taken at baseline, posttreatment, and 6 and 12 months posttreatment. Outcomes assessed were psychological distress, quality of life, disease activity, health service utilization, and diminished productivity.

RESULTS

Intention-to-treat analyses revealed that there were no clinically important group differences on any of the outcome measures.

CONCLUSION

Although both groups improved over time on several measures (e.g., decreases in psychological distress, stress, and emotion-oriented coping), these changes could not be attributed to the psychotherapeutic intervention. Thus, evidence does not support the referral of these patients to this type of intervention.

The Living with Cancer Education Programme. II. Evaluation of an Australian education and support programme for cancer patients and their family and friends

A diagnosis of cancer can have major adverse physical, psychosocial and economic consequences for both the individual diagnosed with cancer and their family and friends. The provision of adequate information and support to individuals affected by cancer plays a key role in facilitating better adjustment and coping. Psychoeducational group programmes are an effective way of meeting this need. This paper reports on the results of an evaluation of an Australian education and support programme for individuals with cancer and their family and friends - the Living with Cancer Education Programme (LWCEP). Data are presented based on the evaluation of 152 programmes involving 1460 participants conducted between 1994 and 2000. Participant responses related to changes in self, general coping abilities and satisfaction with the programme are reported. Results showed high satisfaction with the programme and significant improvement in coping abilities, knowledge and communication and relationships with significant others and health professionals among both groups of participants. These findings highlight several important issues for professionals involved in the psychosocial care of cancer patients and their family and friends.

A family-based program of care for women with recurrent breast cancer and their family members

PURPOSE/OBJECTIVES

To evaluate the FOCUS Program (family involvement, optimistic attitude, coping effectiveness, uncertainty reduction, and symptom management), a family-based program of care for women with recurrent breast cancer and their family caregivers.

DATA SOURCES

Randomized clinical trial.

SETTING

Midwest region of the United States.

DATA SYNTHESIS

The family-based program of care consisted of five components: family involvement, optimistic attitude, coping effectiveness, uncertainty reduction, and symptom management. The program was delivered in three home visits and two follow-up phone calls over a five-month period of time.

CONCLUSIONS

Patients with recurrent breast cancer and their family members reported high satisfaction with the FOCUS Program. Although the FOCUS Program had a number of strengths, limitations of the program also were identified that need to be addressed in future family-based interventions.

IMPLICATIONS FOR NURSING

A need exists for family-based programs of care that enable both patients and their family members to manage the multiple demands associated with recurrent breast cancer.

Lessons learned: Outcomes and methodology of a coping skills intervention trial comparing individual and group formats for patients with cancer

OBJECTIVE

Nucare, a short-term psychoeducational coping skills training intervention was evaluated in a randomized controlled clinical trial (RCT) of 225 newly diagnosed breast and colon cancer patients.

METHOD

Measures of psychosocial distress, well being and optimism were evaluated every four months during a one-year period. Patients were randomized to one of four arms: Nucare presented in an individual basis; Nucare presented in a group format; a non-directive supportive group; and a no-intervention control. The interventions were provided in five sessions of ninety minutes each.

RESULTS

Patients with breast cancer who received Nucare presented in an individual format showed more significant improvements in well-being over time compared to those in the control and group arms.

CONCLUSIONS

We were unable to develop functioning groups within the RCT. Partial explanations for the latter finding include the structural limitations of the RCT: the groups were small, difficult to schedule and patients indicated that they would have preferred to choose whether or not to participate in a group. The positive changes in women with breast cancer who received Nucare persisted at 12 months.

Biobehavioral outcomes following psychological interventions for cancer patients

Psychological interventions for adult cancer patients have primarily focused on reducing stress and enhancing quality of life. However, there has been expanded focus on biobehavioral outcomes--health behaviors, compliance, biologic responses, and disease outcomes--consistent with the Biobehavioral Model of cancer stress and disease course. The author reviewed this expanded focus in quasiexperimental and experimental studies of psychological interventions, provided methodologic detail, summarized findings, and highlighted novel contributions. A final section discussed methodologic issues, research directions, and challenges for the coming decade.

Mind and cancer: does psychosocial intervention improve survival and psychological well-being?

The aim of this review was to evaluate the scientific evidence for an effect of psychosocial intervention on survival from cancer and well-being and in particular on anxiety and depression. A literature search yielded 43 randomised studies of psychosocial intervention. Four of the eight studies in which survival was assessed showed a significant effect, and the effect on anxiety and depression was also inconsistent, indicating three possible explanations: (i) only some of the intervention strategies affect prognosis and/or well-being and in only certain patient groups; (ii) the effect was weak, so that inconsistent results were found in the generally small study populations; or (iii) the effect was diluted by the inclusion of unselected patient groups rather than being restricted to patients in need of psychosocial support. Thus, large-scale studies with sound methods are needed in which eligible patients are screened for distress. Meanwhile, the question of whether psychosocial intervention among cancer patients has a beneficial effect remains unresolved.

Stress response syndromes and cancer: conceptual and assessment issues

Stress response syndromes have begun to receive research attention in cancer, including melanoma, Hodgkin's disease, breast cancer, and mixed-diagnosis samples. This paper focuses on conceptual and assessment issues in the application of the trauma model to adaptation to cancer. Among the central considerations: differentiating cancer from other traumatic events, the utility of conceptualizing stress responses along a continuum in this population, diagnostic issues, and preliminary recommendations for therapeutic interventions.

Biobehavioral outcomes following psychological interventions for cancer patients

Psychological interventions for adult cancer patients have primarily focused on reducing stress and enhancing quality of life. However, there has been expanded focus on biobehavioral outcomes--health behaviors, compliance, biologic responses, and disease outcomes--consistent with the Biobehavioral Model of cancer stress and disease course. The author reviewed this expanded focus in quasiexperimental and experimental studies of psychological interventions, provided methodologic detail, summarized findings, and highlighted novel contributions. A final section discussed methodologic issues, research directions, and challenges for the coming decade.

Effects of psychotherapy on cancer survival

The possibility that psychotherapy could extend survival time for cancer patients has attracted attention among clinical investigators interested in the mind-body connection, among cancer patients seeking the best possible outcome and among the general public. A small number of randomized trials have been conducted, and they have produced conflicting results. Does emotional support affect the course of cancer? What physiological pathways might mediate such an effect? Given what we now know, should we change the standard of care for cancer patients?

Five years later: a cross-sectional comparison of breast cancer survivors with healthy women

Although a number of studies have focused on initial adjustment to cancer, less is known about long-term survival issues. The present study compared breast cancer survivors with age-matched healthy controls (N=328) in terms of more subtle indicators of psychological well-being as well as their general quality of life 5 yrs post-diagnosis. Results indicated survivors generally perceive the world as less controllable and more random compared to healthy women. However, survivors perceive the same control over their daily lives as healthy women. Beliefs about personal control are most strongly associated with quality of life in both groups of women. Survivors also indicated that they derived some benefits from their experience with cancer, but these benefits had only a modest impact on quality of life. However, the belief that the experience had lasting harmful effects was associated with poor quality of life for survivors. In both groups, a continued search for meaning in life had a negative impact on quality of life. The strongest and most consistent correlate of quality of life for both survivors and healthy women was having a sense of purpose in life.

Early quality of life in patients with localized prostate carcinoma: an examination of treatment-related, demographic, and psychosocial factors

BACKGROUND

Men with localized prostate carcinoma are faced with important treatment decisions, and quality of life (QoL) information has become a crucial element of decision making. The first objective of this study was to compare the early, health-related QoL (HRQoL) of men with localized prostate carcinoma who were treated with radical prostatectomy, external beam radiotherapy, or brachytherapy. A second objective was to identify demographic and psychosocial variables that predict HRQoL.

METHODS

Two-hundred fifty-six men with localized prostate carcinoma were interviewed within 7 weeks of treatment initiation. The interview included measures of prostate-specific HRQoL (the University of California-Los Angeles Prostate Cancer Index), general HRQoL (the SF-36), and psychosocial variables.

RESULTS

After adjusting for covariates, treatment group differences were found for both prostate specific HRQoL and general HRQoL. Men who underwent prostatectomy reported more urinary and sexual problems and more general physical dysfunction compared with men who were treated with either form of radiation therapy. Men who were treated with brachytherapy reported the fewest problems in sexual function and the least general physical dysfunction. Few treatment group differences were found in mental functioning. Both demographic factors and psychosocial factors predicted HRQoL. Older men and African-American men reported more physical problems than younger men and Caucasian men, respectively. A supportive social environment, high self-efficacy, and high self-esteem were predictive of better HRQoL.

CONCLUSIONS

Shortly after undergoing treatment for localized prostate carcinoma, men who underwent radical prostatectomy, older men, and African-American men are at heightened risk for experiencing prostate-specific and general deficits in HRQoL. Having psychosocial resources from which to draw may enhance HRQoL.

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

The authors report a 3-year follow-up of the effects of 8-week support group interventions on the quality of life of women with early stage breast cancer. Shortly after diagnosis, women were randomly assigned to 1 of 4 conditions: control, education, peer discussion, and education plus peer discussion. The education group intervention focused on providing information to enhance control over the illness experience, whereas the peer discussion group intervention focused on providing emotional support through the expression of feelings. Consistent with the results that emerged 6 months after the interventions (V. S. Helgeson, S. Cohen, R. Schulz, & J. Yasko, 1999), the authors found that the benefits of the education intervention were maintained over a 3-year period (N=252), although effects dissipated with time. The authors continued to find no benefits of the peer discussion intervention, either alone or in combination with education.

Psychosocial aspects of the organ transplant experience: what has been established and what we need for the future

This article briefly describes the current status and limitations of the organ transplant process that has now become a routine medical procedure. The article discusses how transplantation is not a cure for end-stage organ disease but an alternative form of treatment with both potential medical and psychosocial problems. Both transplant candidates and recipients encounter psychosocial problems. The article examines how these psychosocial problems affect transplant patients prior to transplant, immediately following surgery, and posttransplant. The psychosocial problems include psychiatric diagnoses, individual and family adjustment and relationship problems, sexual dysfunction, return-to-work (RTW) difficulties, and compliance problems and variables related to noncompliance. The article also reviews the special problems of pediatric and adolescent transplant recipients. The need for empirically supported interventions is noted in each of the problem areas. The author outlines problems with previous research studies that hamper solid interpretations of the data, and discusses literature suggesting that the psychosocial problems of transplant candidates and recipients are likely to be underreported. The article concludes with recommendations about the need to switch research efforts toward intervention studies in the problem areas already solidly identified by the literature.

A randomized, controlled trial of vicarious experience through peer support for male first-time cardiac surgery patients: impact on anxiety, self-efficacy expectation, and self-reported activity

OBJECTIVES

The purpose of this study was to determine whether vicarious experience, in which former patients exemplify the active lives they are leading, reduces anxiety and increases self-efficacy expectation and self-reported activity in patients after cardiac surgery.

DESIGN

A randomized, controlled trial was used to evaluate an intervention that linked volunteers who had recovered from cardiac surgery in dyadic support with patients about to undergo similar surgery. The linking was achieved by means of visits during the hospitalization and recovery period.

SUBJECTS

Fifty-six first-time male patients undergoing coronary artery bypass graft (CABG) surgery, with a mean age of 56.5 years, were randomly assigned to an experimental (n = 27) or control group (n = 29).

OUTCOME MEASURES

Anxiety was measured at 48 hours and 24 hours before surgery, and again at 5 days and 4 weeks after surgery. Self-efficacy expectation and self-reported activity were both evaluated at 5 days and 4 weeks after surgery.

RESULTS

Only the experimental group showed a significant decrease in anxiety during hospitalization. At all measurement times after the first intervention, the experimental group reported significantly lower levels of anxiety compared with the control group. The experimental group reported significantly higher levels of self-efficacy expectation and self-reported activity for general activities, walking, and climbing stairs evaluated at 5 days, and for general activities at 4 weeks after surgery.

CONCLUSIONS

Vicarious experience provided through dyadic support is effective in helping patients undergoing cardiac surgery cope with surgical anxiety and in improving self-efficacy expectations and self-reported activity after surgery. Dyadic support is a valuable tool for recovery from cardiac surgery that needs to be maintained and explored through nursing practice and research.

Gender-linked personality traits predict mental health and functional status following a first coronary event

Three gender-linked traits were examined with respect to adjustment to a coronary event: agency, a focus on the self; communion, a focus on others; and unmitigated communion, an extreme focus on others to the exclusion of the self. Participants (n = 65) were interviewed 1 week and 4 months after a 1st coronary event. Hypotheses were that agency should predict improved health, communion should be unrelated to health, and unmitigated communion should predict worse health over time. Outcomes included depression, anxiety, and well-being (as measured by the Profile of Mood States; D. McNair, M. Lorr, & L. Droppleman, 1971); mental and physical functioning (SF-36; J. E. Ware, K. K. Snow, M. Kosinski, & B. Gandek, 1993); and cardiac symptoms. Results confirmed hypotheses. In addition, unmitigated communion was linked with poor health behavior and negative social interactions, which partly explained the link of unmitigated communion with depression and cardiac symptoms.

Trauma history as a predictor of psychologic symptoms in women with breast cancer

PURPOSE

To identify predictors of psychiatric problems in women with early-stage breast cancer.

PATIENTS AND METHODS

One hundred sixty women with early-stage breast cancer were recruited from three treatment centers. They filled out self-report questionnaires, including a medical history and demographic survey, the Trauma History Questionnaire, Life Event Questionnaire, Brief Symptom Inventory, Beck Depression Inventory, and Duke-UNC Functional Social Support Questionnaire, and were evaluated using the Structured Clinical Interview for DSM-III-R.

RESULTS

Hierarchical regression analyses indicated that four of five variable sets made a significant incremental contribution to outcome prediction, with 35% to 37% of the variance explained. Outcomes were predicted by demographic variables, trauma history variables, precancer psychiatric diagnosis, recent life events, and perceived social support. Cancer treatment variables did not predict outcome.

CONCLUSION

The findings highlight the important roles of trauma history and recent life events in adjustment to cancer and have implications for screening and treatment.

Group support interventions for women with breast cancer: who benefits from what?

Research on the benefits of social support groups has been inconclusive. One reason is that individual differences in intervention responses have rarely been examined. The authors determined the extent to which individual difference variables moderated the effects of an information-based educational group and an emotion-focused peer discussion group on the mental and physical functioning of women with breast cancer (n = 230). The authors administered the SF-36 (S.E. Ware, K.K. Snow, M. Kosinski, & B. Gandek, 1993), a multidimensional quality of life instrument, pre- and postintervention. Educational groups showed greater benefits on the physical functioning of women who started the study with more difficulties compared with less difficulties (e.g., lacked support or fewer personal resources). Peer discussion groups were helpful for women who lacked support from their partners or physicians but harmful for women who had high levels of support. Implications of these results for clinical interventions are discussed.