A prospective, longitudinal study of the relationship of psychological work to duration of survival in patients with metastatic cancer

Nursing, psychotherapy and advanced cancer: A scoping review

PURPOSE

Many individuals with advanced cancer have unmet psychological needs and often lack access to supportive care. Psychotherapy for adults with advanced cancer is a promising way to address some of the challenges in meeting these care needs. Nurses are the largest cohort of healthcare workers who can practice as psychotherapists and are positioned ideally to integrate these interventions as part of routine care. The purpose of this scoping review is to map the literature on psychotherapeutic interventions among adults with advanced cancer and to explore the nursing role in this body of evidence.

METHODS

We conducted a scoping review for relevant quantitative, qualitative, and mixed methods studies. The content of included studies was analyzed and grouped based on two broad categories that describe how nursing's role was mentioned, described, and utilized: 1. Nurses are not the interventionist/psychotherapist and, 2. Nurses are mentioned as the interventionist/psychotherapist.

RESULTS

Eighty-six studies were included. Overall, majority of studies did not mention a role for nursing in any capacity. Some studies mentioned a non-interventionist role for nursing in the research study. Fourteen studies mentioned nurses as interventionists/psychotherapists. These studies focused on feasibility, acceptability and patient related outcomes of brief psychotherapies. Dignity therapy was the most common psychotherapy in studies where nurses were utilized as interventionists, followed by life review and supportive expressive therapies. Very few studies discussed nursing's role in this area and nursing's capacity to deliver this form of care.

CONCLUSION

There is paucity in nursing research focused on psychotherapy for adults with advanced cancer. It is feasible and acceptable for nurses to deliver brief psychotherapies to adults with advanced cancer, and the integration of these techniques in everyday practice has great potential that must be explored. The development of this knowledge base is needed to support future education, research, and practice policy agendas.

Fighting for Life: A Qualitative Analysis of the Process of Psychotherapy-Assisted Self-Help in Patients With Metastatic Cancer

This exploratory study is an attempt to define psychological attributes related to longer survival in patients with meta-static cancers. Previous published analyses have been limited in two ways. First, they have almost always been carried out on patients not receiving therapy; we have followed people receiving a year of group therapy, on the assumption that if mental qualities are to affect cancer progression, substantial mental change would be needed to alter the established balance between the cancer cells and host regulatory mechanisms. Second, the methods typically used to characterize patients’ psychology have been self-report inventories, and many decades of research with such methods have largely failed to produce a consensus on what mental qualities, if any, promote survival. By contrast, we have used qualitative methods, allowing a much more in-depth analysis of the patients, without preliminary assumptions as to what would be important.

The present report describes the results of a detailed qualitative analysis of data collected from 22 participants over a year of weekly group therapy. Using grounded methods, categories were derived from the extensive verbal data (comprising patients’ written homework and therapists’ notes), and linked in a model of change. By applying ratings to some of these categories, and combining these ratings, we derived a quantitative estimate of patients’“involvement in self-help.” Rankings on degree of involvement corresponded quite closely with the quality of patients’ experience and with their survival duration.

There was a great range in degree of involvement, and various subgroupings could be discerned. Nine of the participants were classed as “highly involved,” meaning that they devoted regular daily time, often several hours, to such self-help strategies as relaxation, mental imaging, meditation, cognitive monitoring and journalling. All but 1 of these patients enjoyed a good quality of life and lived at least 2 years. Two of them have remained in complete remission for 7 years. At the other end of the scale, 8 patients showed little application to the work, being either unconvinced that it would help them or hampered by psychological problems such as low self-esteem. None of these was rated as having a good quality of life, and only 1 lived more than 2 years, although, as a group, their medicalprognoses were no more unfavorable at the onset of therapy than for the “high involvement” group. The different subgroups and aspects of the model are illustrated by representative quotations.

Change Is Complex: Rethinking Research on Psychosocial Interventions and Cancer

The widely discussed 1989 study by Spiegel and colleagues, which suggested that a psychosocial group intervention affected survival in metastatic breast cancer, was not replicated by Goodwin and colleagues in 2001. We analyze methodological issues in both studies, including issues of sampling, randomization, interpretation, and the adequacy and validity of psychosocial constructs and measures to assess hypothesized ingredients of change. The notion of psychogenicityis introduced, conceived as the ability of psychosocial interventions to elicit changes hypothesized to be linked to desired medical outcomes. These considerations lead to the conclusion that there is insufficient evidence to be able to generalize from either study for or against the notion that psychosocial interventions can affect survival in breast cancer. The failure to incorporate into research designs a comprehensive understanding of how coping patterns and related factors may interact with psychosocial interventions to influence cancer progression, and to address hypothesized mediating mechanisms is discussed. Finally, strategies are proposed for future biopsychosocial and intervention research in the field of biopsychooncology.

Group Psychological Therapy: An Integral Part of Care for Cancer Patients

Adjuvant psychological therapy can help cancer patients in 2 main ways. It has, first, a well-documented capacity to alleviate distress and thus improve quality of life. However, if this kind of assistance is to be made available to the majority of cancer patients, a number of problems need to be solved: administrators need to become aware of the evidence for efficacy of psychosocial care for cancer patients; the treatment needs to be advocated in a manner that would benefit patients rather than being left to the patient to request it; and, for reasons of economy, large, classroom-style, psychoeducational classes may need to be offered in place of small support groups. Furthermore, to allow for individual differ ences in preferences and abilities, a variety of modes of help should ideally be made available. The author discusses how the provision of coping strategies can be organized in a progressive way to encourage development of greater coping skills. An example of such a stepwise program is given, all aspects of which have been researched and made available in manuals over some 20 years. The possibility of prolonging life with this kind of therapy is still controversial. While ran domized controlled trials have become the method of choice to investigate this question, reasons are given for strongly preferring more exploratory modes of research at the pres ent early stage of knowledge. The central task is seen as understanding the states of mind that promote healing or longer life, something that cross-sectional, psychometric research has not been able to accomplish. As an alternative, prospective, longitudinal designs are needed, with detailed interview-style analyses of patients' mental attributes. An example is given of one such study. Furthermore, it is suggested that we consider much more intensive therapies of this kind, since the impact of mind on body will logically be related to the extent of psychological change experienced.

Group Interventions for Patients with Cancer and HIV Disease: Part III. Moderating Variables and Mechanisms of Action

Growing evidence supports the value of group interventions for individuals who are at risk for or have developed cancer or HIV disease. However, information is more limited concerning how these services can be delivered in an optimal manner, and what processes contribute to their benefits. Parts I and II of this review examined the efficacy of different interventions for individuals at different phases of illness, ranging from primary prevention to late-stage disease, in both psychosocial and biological domains. The current paper examines some of the factors other than phase of illness that might influence group treatment effects (e.g., intervention parameters, participant characteristics), and explores mechanisms of action.

A cognitive-existential intervention to improve existential and global quality of life in cancer patients: A pilot study

OBJECTIVE

We developed a specific cognitive-existential intervention to improve existential distress in nonmetastatic cancer patients. The present study reports the feasibility of implementing and evaluating this intervention, which involved 12 weekly sessions in both individual and group formats, and explores the efficacy of the intervention on existential and global quality of life (QoL) measures.

METHOD

Some 33 nonmetastatic cancer patients were randomized between the group intervention, the individual intervention, and the usual condition of care. Evaluation of the intervention on the existential and global QoL of patients was performed using the existential well-being subscale and the global scale of the McGill Quality of Life (MQoL) Questionnaire.

RESULTS

All participants agreed that their participation in the program helped them deal with their illness and their personal life. Some 88.9% of participants agreed that this program should be proposed for all cancer patients, and 94.5% agreed that this intervention helped them to reflect on the meaning of their life. At post-intervention, both existential and psychological QoL improved in the group intervention versus usual care (p = 0.086 and 0.077, respectively). At the three-month follow-up, global and psychological QoL improved in the individual intervention versus usual care (p = 0.056 and 0.047, respectively).

SIGNIFICANCE OF RESULTS

This pilot study confirms the relevance of the intervention and the feasibility of the recruitment and randomization processes. The data strongly suggest a potential efficacy of the intervention for existential and global quality of life, which will have to be confirmed in a larger study.

Lessons to be learned from 25 years of research investigating psychosocial interventions for cancer patients

Conducting rigorous psychosocial intervention research with cancer patients has many challenges including encouraging them to join studies, asking them to engage in interventions or be part of control conditions, and to provide data over follow-up assessments. Here, we highlight valuable insights regarding such challenges provided by investigators studying psychosocial interventions for cancer patients. Handling these skillfully has important implications for the internal and external validity of this research and the ethical treatment of participants. Challenges noted in research reports included in a systematic review of 25 years of research (comprising 488 unique projects) investigating interventions designed to enhance cancer patients' quality of life were compiled. Among the difficulties mentioned was the fact that patients may not feel the need for psychosocial interventions and thus may not be interested in joining an intervention study. Patients who do feel the need for such interventions may be deterred from joining trials by the prospect of being randomized to a nonpreferred group; if they do join a trial, participants may be disappointed, drop out, or seek compensatory additional assistance when they are assigned to a control group. Apart from randomization, other aspects of research may be off-putting to participants or potential participants, such as the language of consent forms or the intrusiveness of questions being asked. Potential remedies, such as research awareness interventions, monetary incentives, partnering with cancer support organizations, and using designs that take preferences into account merit consideration and further research inquiry.

Cancer-specific beliefs and survival in nonmetastatic colorectal cancer patients

BACKGROUND

Colorectal cancer (CRC) is the third leading cause of cancer mortality in the United States. Associations between cancer-specific beliefs (beliefs) and survival have been observed among other cancer populations, but similar research in CRC patients is virtually nonexistent, especially in racially diverse populations. The relationship between beliefs and survival was investigated in a cohort of African Americans and non-Hispanic whites with newly diagnosed nonmetastatic CRC, followed for up to 15 years.

METHODS

The authors analyzed data from a population-based cohort of 286 individuals (115 African Americans and 171 whites, approximately 52% women) diagnosed with nonmetastatic CRC in Connecticut, 1987 to 1991. Cox proportional hazards models were adjusted for sociodemographic (age, sex, race, education, income, occupational status, marital status) and biomedical (stage at diagnosis, histological grade, treatment) variables.

RESULTS

Not believing in the curability of cancer increased the risk of all-cause mortality (hazard ratio [HR], 1.59; 95% confidence interval [CI], 1.06-2.39) and CRC-specific mortality (HR, 1.65; 95% CI, 0.90-3.03; P=.10). These multivariate estimates were not altered by additional adjustment for insurance coverage, obesity, smoking, alcohol consumption, or comorbidity. Furthermore, the association between perceived curability and survival did not vary significantly by key sociodemographic or biomedical factors. Other beliefs were not associated with survival.

CONCLUSIONS

Among a racially diverse cohort of men and women with CRC, believing in the curability of cancer was independently associated with survival over a 15-year period. Confirmation of the role of cancer-specific beliefs on survival and study of the potential biobehavioral mechanisms is needed. Findings may inform the design of interventions for cancer survivors.

Close relationships and emotional processing predict decreased mortality in women with breast cancer: preliminary evidence

OBJECTIVE

To examine close relationships and emotional processing as predictors of breast cancer mortality.

METHODS

Ninety women were enrolled at 14 +/- 5 months after diagnosis of Stage II/III breast cancer. The Nottingham Prognostic Index (NPI) quantified disease severity. Cox proportional hazards analyses were used to predict mortality using standardized variables.

RESULTS

Twenty-one subjects developed recurrent disease and 16 died during an 8-year follow-up. NPI predicted increased mortality: risk ratio (RR) = 1.60 (CI = 1.05-2.41). Decreased mortality was predicted by confiding marriage (CONF): RR = 0.31 (CI = 0.10-0.99), and number of dependable, nonhousehold supports (SUPP): RR = 0.41 (CI = 0.21-0.80). A composite measure of close relationships (standardized CONF + SUPP = SUPPCONF) had a strong protective effect: RR = 0.30 (CI = 0.13-0.69). Two emotion processing variables, acceptance of emotion and emotional distress (POMS-TOT) were found to be negatively correlated (r = -.49). Acceptance of emotion predicted decreased mortality (RR = 0.46 (CI = 0.24-0.86)) when analyzed together with emotional distress, but not separately. There was a trend for a protective effect of emotional distress: RR = 0.37 (CI = 0.12-1.09) in the same analysis. RRs for mortality in a multivariable analysis were: SUPPCONF: RR = 0.55 (CI = 0.30-1.00); acceptance of emotion: RR = 0.48 (CI = 0.25-0.91); and emotional distress: RR = 0.40 (CI = 0.14-1.19).

CONCLUSIONS

Two aspects of close relationships--marital confiding and dependable, nonhousehold supports--were protective against breast cancer progression. Acceptance of emotion, after controlling for emotional distress, also predicted decreased mortality. Analysis of close relationships together with emotion processing variables suggested unique protective effects against mortality, but a larger study is necessary to determine whether this is the case.

Spiritual life after cancer: connectedness and the will to meaning as an expression of self-help

This article uses a mixed quantitative/qualitative design to elicit the attitudes and experience of spirituality in a group of N = 11 heterogeneous cancer participants, who were interviewed regarding self-help practice. Part of this interview enquired about spirituality and was analysed separately from the larger body of data, becoming the Spiritual Interview. The authors argue for a conceptualisation of spirituality as a "will to meaning" and "connectedness." Further, they propose that it is the integration of spiritual life that is the crucial variable in assessing spirituality. Participants demonstrated a wide diversity of attitude and experience that supports the authors' contentions.

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.

Cancer-specific beliefs and survival: a population-based study of African-American and White breast cancer patients

OBJECTIVE

Beliefs about cancer and its treatment have been shown to influence cancer stage at diagnosis and, thus, prognosis. The association between these beliefs and survival is understudied, especially among racially/ethnically diverse populations. We investigated the relationship between cancer-specific beliefs and survival in a cohort of African-American and White women with newly diagnosed breast cancer followed for up to 15 years.

METHODS

We examined beliefs about cancer detection, treatment, and curability in a population-based cohort of 145 African-American and 177 White women diagnosed with breast cancer in Connecticut, US, between 1987 and 1989. Cox proportional-hazards models were adjusted for stage at diagnosis, other biomedical variables, socio-demographic and lifestyle factors.

RESULTS

In multivariate models, perceived cancer incurability was associated with a higher risk of death from any cause (hazards ratio (HR)=1.67, 95 confidence interval (CI)=1.11, 2.51). Further control for tumor characteristics, genetic alterations, access to care, and additional psychosocial factors did not alter these findings. Other cancer-specific beliefs examined here were not related to survival.

CONCLUSIONS

Perceived cancer incurability is independently associated with survival among breast cancer patients in fully adjusted models. The identification of the underlying mechanisms of this association has potential for translation into intervention strategies for cancer patients.

How psychological therapy may prolong survival in cancer patients: new evidence and a simple theory

This article presents new data and attempts to draw together converging lines of evidence on the mental attributes that may favor prolonged survival in the face of metastatic cancer. The authors interviewed 10 individuals with medically incurable cancers who had outlived their prognoses by from 2.2 to 12.5 years (and have all survived, a further 2 more years in most cases, between interview and publication). The authors derived, by qualitative analysis, a number of themes common to most or all of them. Three major qualities emerged: "authenticity," or a clear understanding of what was important in one's life; "autonomy," the perceived freedom to shape life around what was valued; and "acceptance," a perceived change in mental state to enhanced self-esteem, greater tolerance for and emotional closeness to others, and an affective experience described as more peaceful and joyous. Previous descriptions of "remarkable survivors" have suffered from a serious limitation: the research to date has not clarified to what extent they differed psychologically from their many peers who did not survive. The authors attempted to address this question in 2 ways. Six of the subjects were part of a protocol (the Healing Journey study) in which patients belonged to a larger group, all of whom were medically assessed prospectively, by an expert panel. A prediction of the likely duration of survival was made for each of the patients in this study, and it could be shown that those who subsequently survived were not a random sample of the whole but displayed a much higher degree of early involvement in their psychological self-help than did most of their nonsurviving peers. They also compared long survivors with 2 other groups: 6 individuals with similar diseases who had not yet received psychological help and 6 individuals from the Healing Journey study whose survival duration was at the lower end of the whole group. The patients in these comparison groups also lacked many of the most salient qualities identified among the long survivors. Many of the attributes found in the long survivors were, however, also noted in the earlier reports of remarkable survivors in the literature, which suggests that the observations may be generalizable. Putting these joint findings together with the early work of Temoshok on "type C" adaptation as a risk factor for cancer, one can see that there is a mirrored symmetry between the psychological patterns possibly promoting disease and the changed adaptations that may lead to longer survival in some cases. The authors arrive at a commonsense hypothesis: to the extent that the progression of cancer, or other chronic disease, is favored by a distorted psychological adaptation such as type C, healing may be assisted by a reversal of that adaptation--in the case of cancer, toward greater authenticity of thought and action.

Quality of life of men treated with brachytherapies for prostate cancer

Background

Most studies of men undergoing treatment for prostate cancer examine physical symptoms as predictors of Quality of Life (QOL). However, symptoms vary by treatment modality in this population, and psychosocial variables, shown to be important to QOL, have rarely been examined. Litwin noted a need for analysis of QOL data in men treated for prostate cancer with different modes of therapy, as studies focusing on specific treatments will increase the homogeneity of research findings.

Methods

This cross-sectional study explored physical and psychosocial predictors of QOL in men receiving one of two types of radiation treatment for prostate cancer: Intensity Modulated Radiation Therapy (IMRT) + High Dose Rate (HDR) Brachytherapy or IMRT + seed implantation. Subjects completed a biographic questionnaire; quality of life measures, which were the eight subscales of the Medical Outcome Study Short Form Health Survey (SF-36); measures of physical symptoms including the Radiation Therapy Oncology Group and the European Organization for Research and Treatment of Cancer (RTOG/EORTC) and the Prostate Symptom Self-Report (PSSR); and measures of psychological factors, the Ways of Coping Scale (WOC), Perceived Stress Scale, the Anxiety Subscale of the SCL-90, and Strategies Used by Patients to Promote Health (SUPPH). Eight regression models including both physical and psychosocial variables were used to predict quality of life.

Results

Sixty-three subjects with complete data on all variables were studied. Treatment effect sizes were medium to large in predicting each of the quality of life subscales of the SF-36. Psychosocial variables were related to physical function, role function, bodily pain, general health, social function, emotional role, and mental health. Physical symptoms were related to subjects' perceived general health and mental health.

Discussion

The number of significant relationships among psychosocial variables and indicators of QOL exceeded the number of relationships among symptoms and QOL suggesting that psychosocial variables associate strongly with prostate cancer patients' reports of quality of life. Findings of the study may provide patients and families with knowledge that contributes to their understanding of quality of life outcomes of IMRT+ HDR and IMRT + seed implantation and their ability to make more informed treatment choices.

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

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

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

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

Complementary and alternative medicine in otolaryngology

The widespread interest in and use of complementary and alternative medicine (CAM) by patients in the United States has been established by multiple surveys. One-third of the U.S. population uses some form of CAM, and an estimated 23 billion dollars is spent annually on these therapies. Because of prevalent usage of CAM among patients, it is important that physicians have some knowledge of this subject. With this purpose in mind, this report reviews the current research on CAM as it relates to common disorders of the head and neck: rhinitis, sinusitis, tinnitus, vertigo, and head and neck oncology.