Efficacy of psychosocial intervention with cancer patients

Non-medical interventions to enhance return to work for people with cancer

BACKGROUND

People with cancer are 1.4 times more likely to be unemployed than people without a cancer diagnosis. Therefore, it is important to investigate whether programmes to enhance the return-to-work (RTW) process for people who have been diagnosed with cancer are effective. This is an update of a Cochrane review first published in 2011 and updated in 2015.

OBJECTIVES

To evaluate the effectiveness of non-medical interventions aimed at enhancing return to work (RTW) in people with cancer compared to alternative programmes including usual care or no intervention.

SEARCH METHODS

We searched CENTRAL (the Cochrane Library), MEDLINE, Embase, CINAHL, PsycINFO and three trial registers up to 18 August 2021. We also examined the reference lists of included studies and selected reviews, and contacted authors of relevant studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs on the effectiveness of psycho-educational, vocational, physical or multidisciplinary interventions enhancing RTW in people with cancer. The primary outcome was RTW measured as either RTW rate or sick leave duration measured at 12 months' follow-up. The secondary outcome was quality of life (QoL).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed RCTs for inclusion, extracted data and rated certainty of the evidence using GRADE. We pooled study results judged to be clinically homogeneous in different comparisons reporting risk ratios (RRs) with 95% confidence intervals (CIs) for RTW and mean differences (MD) or standardised mean differences (SMD) with 95% CIs for QoL.

MAIN RESULTS

We included 15 RCTs involving 1477 people with cancer with 19 evaluations because of multiple treatment groups. In this update, we added eight new RCTs and excluded seven RCTs from the previous versions of this review that were aimed at medical interventions. All included RCTs were conducted in high-income countries, and most were aimed at people with breast cancer (nine RCTs) or prostate cancer (two RCTs). Risk of bias We judged nine RCTs at low risk of bias and six at high risk of bias. The most common type of bias was a lack of blinding (9/15 RCTs). Psycho-educational interventions We found four RCTs comparing psycho-educational interventions including patient education and patient counselling versus care as usual. Psycho-educational interventions probably result in little to no difference in RTW compared to care as usual (RR 1.09, 95% CI 0.96 to 1.24; 4 RCTs, 512 participants; moderate-certainty evidence). This means that in the intervention and control groups, approximately 625 per 1000 participants may have returned to work. The psycho-educational interventions may result in little to no difference in QoL compared to care as usual (MD 1.47, 95% CI -2.38 to 5.32; 1 RCT, 124 participants; low-certainty evidence). Vocational interventions We found one RCT comparing vocational intervention versus care as usual. The evidence was very uncertain about the effect of a vocational intervention on RTW compared to care as usual (RR 0.94, 95% CI 0.78 to 1.13; 1 RCT, 34 participants; very low-certainty evidence). The study did not report QoL. Physical interventions Four RCTs compared a physical intervention programme versus care as usual. These physical intervention programmes included walking, yoga or physical exercise. Physical interventions likely increase RTW compared to care as usual (RR 1.23, 95% CI 1.08 to 1.39; 4 RCTs, 434 participants; moderate-certainty evidence). This means that in the intervention group probably 677 to 871 per 1000 participants RTW compared to 627 per 1000 in the control group (thus, 50 to 244 participants more RTW). Physical interventions may result in little to no difference in QoL compared to care as usual (SMD -0.01, 95% CI -0.33 to 0.32; 1 RCT, 173 participants; low-certainty evidence). The SMD translates back to a 1.8-point difference (95% CI -7.54 to 3.97) on the European Organisation for Research and Treatment of Cancer Quality of life Questionnaire Core 30 (EORTC QLQ-C30). Multidisciplinary interventions Six RCTs compared multidisciplinary interventions (vocational counselling, patient education, patient counselling, physical exercises) to care as usual. Multidisciplinary interventions likely increase RTW compared to care as usual (RR 1.23, 95% CI 1.09 to 1.33; 6 RCTs, 497 participants; moderate-certainty evidence). This means that in the intervention group probably 694 to 844 per 1000 participants RTW compared to 625 per 1000 in the control group (thus, 69 to 217 participants more RTW). Multidisciplinary interventions may result in little to no difference in QoL compared to care as usual (SMD 0.07, 95% CI -0.14 to 0.28; 3 RCTs, 378 participants; low-certainty evidence). The SMD translates back to a 1.4-point difference (95% CI -2.58 to 5.36) on the EORTC QLQ-C30.

AUTHORS' CONCLUSIONS

Physical interventions (four RCTs) and multidisciplinary interventions (six RCTs) likely increase RTW of people with cancer. Psycho-educational interventions (four RCTs) probably result in little to no difference in RTW, while the evidence from vocational interventions (one RCT) is very uncertain. Psycho-educational, physical or multidisciplinary interventions may result in little to no difference in QoL. Future research on enhancing RTW in people with cancer involving multidisciplinary interventions encompassing a physical, psycho-educational and vocational component is needed, and be preferably tailored to the needs of the patient.

[Interventions to support the return-to-work process after cancer: a literature review]

Returning to work after cancer can be challenging for cancer survivors and little is known about interventions designed to support survivors returning to work.

PURPOSE

The objective of this review was to identify interventions designed to support the return-to-work process after a cancer diagnosis.

METHODS

A literature review was performed mainly done by consulting bibliographical databases. Systematic analysis and interpretation of the results were then performed.

RESULTS

Twenty-two articles were identified. The first finding is that very few interventions are specifically devoted to return to work after cancer and are usually administered in the clinical setting by healthcare practitioners. The activities proposed to support return to work in these interventions are individual counselling, provision of information and support groups. These activities are provided by various multidisciplinary teams composed of one or more professionals: occupational physicians, social workers and nurses. A second finding is that even with the use of experimental and quasi-experimental approaches, no effect was observed on return to work.

CONCLUSION

This integrative review highlights two recommendations for the development of future interventions. First, to improve the efficacy of future interventions on return to work of cancer survivors, these interventions must be developed and supported by an intervention theory. Second, future interventions must include and mobilize workplaces.

Research and Practice Roles for Counseling Psychologists in Health Care Settings

This article reviews applications of counseling psychology to problems of physical health. Three areas of application are considered, chosen to illustrate ways in which traditional emphases of counseling psychology-counseling and psychoeducational models of direct service, counseling skills training, and consultation -can be used to prevent or remediate problems of physical health and illness. In addition to describing these applications, special issues of psychological practice in health care settings are considered, with particular emphasis on stresses on ethics and service delivery guidelines, decision-making criteria within medical settings, and multidisciplinary conflicts.

Interventions to enhance return-to-work for cancer patients

BACKGROUND

Cancer patients are 1.4 times more likely to be unemployed than healthy people. Therefore it is important to provide cancer patients with programmes to support the return-to-work (RTW) process. This is an update of a Cochrane review first published in 2011.

OBJECTIVES

To evaluate the effectiveness of interventions aimed at enhancing RTW in cancer patients compared to alternative programmes including usual care or no intervention.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, in the Cochrane Library Issue 3, 2014), MEDLINE (January 1966 to March 2014), EMBASE (January 1947 to March 2014), CINAHL (January 1983 to March, 2014), OSH-ROM and OSH Update (January 1960 to March, 2014), PsycINFO (January 1806 to 25 March 2014), DARE (January 1995 to March, 2014), ClinicalTrials.gov, Trialregister.nl and Controlled-trials.com up to 25 March 2014. We also examined the reference lists of included studies and selected reviews, and contacted authors of relevant studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of the effectiveness of psycho-educational, vocational, physical, medical or multidisciplinary interventions enhancing RTW in cancer patients. The primary outcome was RTW measured as either RTW rate or sick leave duration measured at 12 months' follow-up. The secondary outcome was quality of life.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, assessed the risk of bias and extracted data. We pooled study results we judged to be clinically homogeneous in different comparisons reporting risk ratios (RRs) with 95% confidence intervals (CIs). We assessed the overall quality of the evidence for each comparison using the GRADE approach.

MAIN RESULTS

Fifteen RCTs including 1835 cancer patients met the inclusion criteria and because of multiple arms studies we included 19 evaluations. We judged six studies to have a high risk of bias and nine to have a low risk of bias. All included studies were conducted in high income countries and most studies were aimed at breast cancer patients (seven trials) or prostate cancer patients (two trials).Two studies involved psycho-educational interventions including patient education and teaching self-care behaviours. Results indicated low quality evidence of similar RTW rates for psycho-educational interventions compared to care as usual (RR 1.09, 95% CI 0.88 to 1.35, n = 260 patients) and low quality evidence that there is no difference in the effect of psycho-educational interventions compared to care as usual on quality of life (standardised mean difference (SMD) 0.05, 95% CI -0.2 to 0.3, n = 260 patients). We did not find any studies on vocational interventions. In one study breast cancer patients were offered a physical training programme. Low quality evidence suggested that physical training was not more effective than care as usual in improving RTW (RR 1.20, 95% CI 0.32 to 4.54, n = 28 patients) or quality of life (SMD -0.37, 95% CI -0.99 to 0.25, n = 41 patients).Seven RCTs assessed the effects of a medical intervention on RTW. In all studies a less radical or functioning conserving medical intervention was compared with a more radical treatment. We found low quality evidence that less radical, functioning conserving approaches had similar RTW rates as more radical treatments (RR 1.04, 95% CI 0.96 to 1.09, n = 1097 patients) and moderate quality evidence of no differences in quality of life outcomes (SMD 0.10, 95% CI -0.04 to 0.23, n = 1028 patients).Five RCTs involved multidisciplinary interventions in which vocational counselling was combined with patient education, patient counselling, and biofeedback-assisted behavioral training or physical exercises. Moderate quality evidence showed that multidisciplinary interventions involving physical, psycho-educational and vocational components led to higher RTW rates than care as usual (RR 1.11, 95% CI 1.03 to 1.16, n = 450 patients). We found no differences in the effect of multidisciplinary interventions compared to care as usual on quality of life outcomes (SMD 0.03, 95% CI -0.20 to 0.25, n = 316 patients).

AUTHORS' CONCLUSIONS

We found moderate quality evidence that multidisciplinary interventions enhance the RTW of patients with cancer.

Aspects of psychological intervention with breast cancer patients

The paper makes a chronological review of the literature in the area of psychological intervention with cancer patients, focussing particularly on breast cancer as this is the disease which has attracted most attention from mental health profesionals. Initially, surveys which identify psychological distress in cancer patients are reviewed, as it is felt that these may have contributed the impetus for intervention. In the second half of the paper, interventions are classified and reviewed.

Pink Ribbon Pin-Ups: photographing femininity after breast cancer

Many treatments for breast cancer are traumatic, invasive and harshly visible. In addition to physical trauma, breast cancer is often associated with a variety of psychosocial issues surrounding romantic relationships, sexuality and feminine identity. Pink Ribbon Pin-Ups was a pin-up girl calendar wherein all the models were women who were living with, or had survived, breast cancer. The project's purpose was to raise funds and awareness for breast cancer research and to create a space where survivors could explore and express their post-cancer sexuality. This study uses an observational approach, paired with semi-structured interviews, to explore the ways that breast cancer survivors perceive their post-cancer body and the subsequent impact on relationships and feminine identity. By examining contemporary discussions regarding breast cancer, body image and the objectification of women, it is concluded that although this photographic approach may be at odds with some modern breast cancer activism, it does appear to meet the expressed needs of a particular group of women living with the disease.

Interventions to enhance return-to-work for cancer patients

BACKGROUND

Cancer survivors are 1.4 times more likely to be unemployed than healthy people. It is therefore important to provide cancer patients with programmes to support the return-to-work process.

OBJECTIVES

To evaluate the effectiveness of interventions aimed at enhancing return-to-work in cancer patients.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, in The Cochrane Library Issue 2, 2010), MEDLINE, EMBASE, CINAHL, OSH-ROM, PsycINFO, DARE, ClinicalTrials.gov, Trialregister.nl and Controlled-trials.com to February 2010, reference lists of included articles and selected reviews, and contacted authors of relevant articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and controlled before-after studies (CBAs) of the effectiveness of psychological, vocational, physical, medical or multidisciplinary interventions enhancing return-to-work in cancer patients. The primary outcome was return-to-work measured as either return-to-work rate or sick leave duration. Secondary outcome was quality of life.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials, assessed the risk of bias and extracted data. We pooled studies with sufficient data, judged to be clinically homogeneous in different comparisons. We assessed the overall quality of the evidence for each comparison using the GRADE approach.

MAIN RESULTS

Fourteen articles reporting 14 RCTs and 4 CBAs were included. These studies involved a total of 1652 participants. Results indicated low quality evidence of similar return-to-work rates for psychological interventions compared to care as usual (odds ratio (OR) = 2.32, 95% confidence interval (CI) 0.94 to 5.71). No vocational interventions were retrieved. Very low evidence suggested that physical training was not more effective than care as usual on improving return-to-work (OR = 1.20, 95% CI 0.32 to 4.54). Eight RCTs on medical interventions showed low quality evidence that functioning conserving approaches had similar return-to-work rates as more radical treatments (OR = 1.53, 95% CI 0.95 to 2.45). Moderate quality evidence showed multidisciplinary interventions involving physical, psychological and vocational components led to higher return-to-work rates than care as usual (OR = 1.87, 95% CI 1.07 to 3.27). No differences in the effect of psychological, physical, medical or multidisciplinary interventions compared to care as usual were found on quality of life outcomes.

AUTHORS' CONCLUSIONS

Moderate quality evidence showed that employed patients with cancer experience return-to-work benefits from multidisciplinary interventions compared to care as usual. More high quality RCTs aimed at enhancing return-to-work in cancer patients are needed.

Coping with sexual concerns after cancer: the use of flexible coping

INTRODUCTION

Although cancer treatment commonly has a negative impact on sexual functioning, sexual concerns are still largely undertreated in routine cancer care. The medical model that guides current approaches to sexual care in cancer does not adequately address key patient needs.

METHODS

In this paper, we describe a broader approach to understanding and treating sexual concerns in cancer that focuses on the construct of flexibility in behavioral and cognitive coping strategies. We previously presented this model in the context of general medical conditions. We now adapt this model to the context of cancer, focusing on issues related to the benefits of flexible coping, interventions that shift perspectives following cancer, and on coping as a couple.

RESULTS

We argue that coping flexibly with sexual concerns is likely to lead to improvements in mood and sexual and relationship satisfaction. We present clinical applications of the flexible coping model, including suggestions for assessment and sexual concerns and methods of introducing flexible coping into both the content and process of clinical interactions with patients.

DISCUSSION

Finally, we discuss areas for future research, including the development of a validated instrument, the use of electronic methods of assessment, and intervention trials directly addressing flexibility in coping.

Psychological responses to cancer: a case for cancer support groups

This study investigates the responses of patients and their carers to the diagnosis of cancer. The reporting of stress by patients, using linear analogue scales, and their psychological distress, as measured by the General Health Questionnaire, indicated benefits for members of a community-based cancer support group. The responses of carers revealed that the impact of the diagnosis was as great on them as on patients. Various mediators were considered and age was found to significantly influence the reporting of stress. The limitations and implications of the findings are discussed.

The Effects of Anxiety Management Training on Psychological Variables and Immune Parameters in Cancer Patients: A Pilot Study

The effect on psychological and immune function measures of a 6-week psychological intervention for anxiety states was evaluated in cancer patients who had already completed medical treatment for a tumor. Ten patients were treated with anxiety management and stress inoculation training while another ten served as a waiting list control group. The treated group showed a slight improvement in psychological variables but there were no group differences in immunological measures. Changes in the latter were, however, correlated with changes in psychological variables, notably, an increase in the T4/T8 ratio, with an improvement in the Quality of Life index.

Social support as a mediator of optimism and distress in breast cancer survivors

Breast cancer patients can experience emotional distress as a result of diagnosis and treatment. Higher levels of optimism and social support are associated with less emotional distress in cancer patients. This 12-month prospective study followed 69 women who had completed treatment for Stages 0-II breast cancer. At 3-month intervals, participants completed measures of mood disturbance, optimism, and social support. As hypothesized, affective social support mediated the relationship between optimism and distress in early-stage breast cancer survivors at baseline and 6 months but not at 1 year. In contrast, confidant social support did not mediate the optimism-distress relationship at any time point. Clinical and research implications of these findings are discussed.

Early psychological adjustment in breast cancer patients: a prospective study

OBJECTIVE

A significant proportion of breast cancer patients experiences psychiatric morbidity in the first year after a breast cancer diagnosis and/or beginning of treatment. This study attempted to identify and understand the risk factors for developing such problems.

METHODS

A consecutive series of 87 patients, aged 40-75 years, was assessed prior to diagnosis of breast cancer and followed-up approximately 8 weeks after beginning of cancer treatment and again 9 months after first follow-up. Assessments included measures of psychiatric morbidity using the General Health Questionnaire (GHQ-12), coping style using the Mental Adjustment to Cancer (MAC) Scale, symptom attribution, beliefs about breast cancer, social support, socio-demographic and clinical variables.

RESULTS

A total of 85.1% of patients completed both follow-ups. Pre-diagnostically, 32.2% of breast cancer patients scored as a GHQ-12 'case.' GHQ scores fell significantly between pre-diagnostic and both post-diagnostic assessments, especially in women who had thought they had cancer. Predictors of psychological morbidity at first follow-up included pre-diagnostic GHQ-12 score, lack of social support and feelings of 'personal responsibility/avoidance.' GHQ-12 'caseness' at second follow-up was predicted by lack of social support alone.

CONCLUSIONS

Overall, psychiatric morbidity is higher prior to, than following, a definitive diagnosis of breast cancer. Early reactions of this kind are predictive of post-treatment adjustment. However, only the presence of social support in this study seems to be associated with successful adjustment in the first year following a breast cancer diagnosis. Women at increased risk of psychological morbidity after a breast cancer diagnosis may be thus identifiable and targeted therapeutically.

Coping and distress among women under treatment for early stage breast cancer: comparing African Americans, Hispanics and non-Hispanic Whites

This study examined coping and distress in African American (n=8), Hispanic (n=53), and non-Hispanic White (n=70) women with early stage breast cancer. The participants were studied prospectively across a year beginning at the time of surgery. African American women reported the lowest levels of distress (particularly before surgery) and depression symptoms. Hispanic women reported the highest levels of self-distraction as a coping response, non-Hispanic Whites reported the highest use of humor. Hispanics reported the highest levels of venting, African Americans reported the lowest levels. African American and Hispanic women reported more religious coping than non-Hispanic Whites. The data also provided evidence of a maladaptive spiral of distress and avoidant coping over time. Although some ethnic differences were identified, findings also point to a great many similarities across groups.

Psychosocial intervention for lesbians with primary breast cancer

This study examined the effects of a Supportive-Expressive group therapy intervention offered to lesbians with early stage breast cancer. Twenty lesbians diagnosed with breast cancer in the previous 12-months were recruited and assessed at baseline, and at 3, 6, and 12 months after the group intervention. During the 12-week intervention, group members focused on the problems of a new diagnosis, coping with the illness and treatment, mood changes, coping responses and self-efficacy, improving relationships with family, friends and physicians, the impact of the illness on life, pain and sleep, and changes in body image and sexuality. A within-subject slopes analysis was conducted on data collected for each woman over the first year. As predicted, women reported reduced emotional distress, intrusiveness, and avoidance, and improved coping. There were significant changes in their social support, but in the unexpected direction. Instrumental support and informational support declined. However, conflict in family relations also declined, while trends were found towards more cohesiveness and expressiveness. Participants reported less pain and better sleep. There were no changes in body image, sexuality, or attitudes toward health-care providers. These results suggest that Supportive/Expressive group intervention appears to be helpful for lesbians with breast cancer.

Affective disorders in advanced cancer

Depression is a common complication of advanced cancer. Methods of accurate assessment and recognition are available. Risk factors for the development of depression have been identified. Pharmacologic and nonpharmacologic treatments for depression are often effective even in patients with advanced cancer.

Concise screening questions for clinical assessments of terminal care: the needs near the end-of-life care screening tool

End-of-life care has benefited from the recognition that multiple dimensions exist to patient care needs. However, well-designed clinical tools to evaluate these multiple dimensions are few. Such tools are available for evaluations of pain and other specific areas, but clinicians need a sensitive and reliable set of bedside questions to assess and screen individual patients' overall care. We set out to develop a practical tool that we called the Needs at the End-of-Life Screening Tool (NEST). As part of a larger study, we conducted a series of focus groups and interviews with patients, family caregivers, and professionals followed by a survey of a nationally representative sample of 988 patients with a terminal diagnosis. From the former we derived a frame-work with a full range of identified dimensions that are important in end-of-life care. Dimensions were empirically tested using factor analysis of the patients' survey responses. We developed criteria for selecting questions within the dimensions. Modifications were made to the questions to suit the clinical context. Finally, to assist in their ready use at the bedside, we assigned questions to four core themes of palliative care. Thirteen questions resulted and were assigned themes corresponding, for mnemonic purposes, to each letter of NEST: for Needs (social), for Existential matters, for Symptoms and for Therapeutic matters. NEST is the first data-driven, comprehensive tool designed from an empirically validated framework and tested survey questions for clinical use in end-of-life care. Evaluation of its performance in another population is needed to complete NEST's fuller evaluation.

A systematic qualitative analysis of psychoeducational interventions for depression in patients with cancer

PURPOSE/OBJECTIVES

To determine whether research-based recommendations can be made about the clinical management of depression in patients with cancer.

DATA SOURCES

Reports of scientific studies, qualitative or quantitative systematic reviews of scientific studies, and practice guidelines published from 1980-2000.

DATA SYNTHESIS

In all, 36 pieces of evidence supported the conclusion that psychoeducational interventions benefit depressive symptoms. Evidence included two well-conducted meta-analyses and nine well-designed randomized clinical trials with large samples (N > 100). With regard to intervention content, 70% of behavior therapy studies and 66% of counseling studies drew conclusions that supported the hypothesis. In addition, 58% of studies that tested behavior therapy or counseling in combination with cancer education had positive results.

CONCLUSIONS

The evidence supports the conclusion that psychoeducational interventions reduce depressive symptoms in patients with cancer and that behavior therapy or counseling alone or in combination with cancer education is beneficial.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can select from a variety of educational, behavioral, and counseling techniques to prevent or manage depression in their patients.

Cognitive-behavioral stress management intervention decreases the prevalence of depression and enhances benefit finding among women under treatment for early-stage breast cancer

The authors tested effects of a 10-week group cognitive-behavioral stress management intervention among 100 women newly treated for Stage 0-II breast cancer. The intervention reduced prevalence of moderate depression (which remained relatively stable in the control condition) but did not affect other measures of emotional distress. The intervention also increased participants' reports that having breast cancer had made positive contributions to their lives, and it increased generalized optimism. Both remained significantly elevated at a 3-month follow-up of the intervention. Further analysis revealed that the intervention had its greatest impact on these 2 variables among women who were lowest in optimism at baseline. Discussion centers on the importance of examining positive responses to traumatic events--growth, appreciation of life, shift in priorities, and positive affect-as well as negative responses.

Psychosocial interventions for cancer: review and analysis using a three-tiered outcomes model

This study describes a three-tiered measurement model for psychosocial interventions with cancer patients and compares this model to extant measurement strategies. Progress has been made toward demonstrating that psychosocial interventions reduce depression, anxiety, functional impairment, and symptoms. However, Chambless and Hollon (1998) note that the literature on psychosocial interventions for cancer fails to meet criteria for establishing treatment "efficacy" and does not address issues of cost-effectiveness. The lack of a timely model of clinical outcomes may be hindering demonstration of efficacy and wider implementation of these interventions. Outcomes assessed by 65 interventions were classified as Global Health Outcomes (medical endpoints, health-related quality of life (HRQOL), or resource utilization), Dimensions of HRQOL (distress, symptoms, functional ability, or interpersonal well-being), or Mechanisms of Action (evaluation of psychological or physiological processes). A total of 28% of reviewed studies assessed Global Outcomes, 82% assessed Dimensions of HRQOL, and 49% assessed Mechanisms of Action. While most studies assessed patients' symptoms and distress, measurements of resource utilization, HRQOL, and interpersonal HRQOL were under-reported. A greater emphasis on treatment costs, quality of life, and mediating/moderating processes associated with improvement in outcomes could inform decisions regarding allocation of health-care resources and lead to more widely available and efficient interventions for patients.

Need for supportive counselling--the professionals' versus the patients' perspective. A survey in a representative sample of 236 melanoma patients

BACKGROUND

The aim of the study was to identify melanoma patients who suffered significant distress and were judged to be in need of supportive counselling, on the one hand, and, on the other, to investigate patient interest in such support.

METHODS

Out of 236 melanoma patients, who constitute a representative sample of melanoma patients in Western Austria, 215 patients participated in the study and were assessed with regard to psychosocial distress, coping strategies, social networks and interest in receiving psychosocial support. Multiple logistic regression analyses were performed with regard to patient interest in receiving psychosocial support either from the attending oncologist or from a mental health professional.

RESULTS

65 patients (30.2%) experienced moderate and 30 patients (14.0%) severe distress, which was predominantly caused by tumour-related fears, tension and disturbance of emotional well-being. 83% of the severely distressed patients wanted psychosocial support from their oncologists, whereas only half of them were interested in additional support from a psychotherapist. In particular, patients who showed fear of tumour progression and felt that they were insufficiently informed about their disease preferred to consult their dermatologist for psychosocial support. On the other hand, patients with poor prognosis, receiving only low levels of support from their social network, and exhibiting a depressive coping style, showed interest in getting supplementary support from a psychotherapist.

CONCLUSIONS

These findings underline the importance of educating oncologists with a view both to improve their communication skills and to help them identify patients making poor adjustment to illness in order to offer them appropriate emotional support.

Group psychotherapy for recently diagnosed breast cancer patients: a multicenter feasibility study

As many as 80% of breast cancer patients report significant distress during initial treatment, yet there is little in the way of systematic psychotherapeutic interventions for women coping with the stress of a recent diagnosis of breast cancer. The literature on psychotherapeutic treatment of cancer patients provides uniform evidence for an improvement in mood, coping and adjustment as a result of group therapy. The present study examined the feasibility of implementing a manualized treatment, supportive-expressive group psychotherapy, in busy oncology practices across the US. This intervention was applied to women with primary breast cancer in a manner which tests not only the efficacy of the approach but also its accessibility to group therapists not previously experienced in its use. One hundred and eleven breast cancer patients within 1 year of diagnosis were recruited from ten geographically diverse sites of the National Cancer Institute's Community Clinical Oncology Program (CCOP) and two academic medical centers. Two therapists from each site were trained in supportive-expressive group psychotherapy. Training consisted of participation in a workshop, reading a treatment manual, and viewing explanatory videotapes. Each patient participated in a supportive-expressive group that met for 12 weekly sessions lasting 90 min. Assessment of mood disturbance was made at entry, 3, 6, and 12 months. Results indicated a significant 40% decrease in the Total Mood Disturbance (TMD) scores of the Profile of Mood States (POMS) (ANOVA F [2,174]=3.98, p<0.05). The total symptom score of the Hospital Anxiety and Depression Scale (HADS) was likewise significantly reduced over the 6-month period (F [2, 174]=5.2, p<0.01). Similarly, the total score of the Impact of Event Scale (IES) was significantly reduced (F [2,174]=4.0, p<0.05). There was substantial uniformity of treatment effect across sites. Outcome was independent of stage of disease (I vs. II). We conclude that this treatment program can be effectively implemented in a community setting and results in reduced distress among breast cancer patients.

Spouse support, coping, and mood among individuals with cancer

A model of the relations between spouse support, coping, and positive and negative mood was examined with 221 individuals with cancer using LISREL analyses. A moderating effect for patient life expectancy was predicted for disease prognosis. Results indicated that spouse criticism was associated with negative mood indirectly through avoidant coping strategies, and spouse support was associated with positive mood indirectly through positively-focused coping. Results did not support a moderating influence for life expectancy upon the association between spouse behaviors and patient coping. The results of this study are discussed in terms of their implications for psychosocial interventions to reduce psychological distress among individuals with cancer.

The effect of psychological interventions on anxiety and depression in cancer patients: results of two meta-analyses

The findings of two meta-analyses of trials of psychological interventions in patients with cancer are presented: the first using anxiety and the second depression, as a main outcome measure. The majority of the trials were preventative, selecting subjects on the basis of a cancer diagnosis rather than on psychological criteria. For anxiety, 25 trials were identified and six were excluded because of missing data. The remaining 19 trials (including five unpublished) had a combined effect size of 0.42 standard deviations in favour of treatment against no-treatment controls (95% confidence interval (CI) 0.08-0.74, total sample size 1023). A most robust estimate is 0.36 which is based on a subset of trials which were randomized, scored well on a rating of study quality, had a sample size > 40 and in which the effect of trials with very large effects were cancelled out. For depression, 30 trials were identified, but ten were excluded because of missing data. The remaining 20 trials (including six unpublished) had a combined effect size of 0.36 standard deviations in favour of treatment against no-treatment controls (95% CI 0.06-0.66, sample size 1101). This estimate was robust for publication bias, but not study quality, and was inflated by three trials with very large effects. A more robust estimate of mean effect is the clinically weak to negligible value of 0.19. Group therapy is at least as effective as individual. Only four trials targeted interventions at those identified as at risk of, or suffering significant psychological distress, these were associated with clinically powerful effects (trend) relative to unscreened subjects. The findings suggest that preventative psychological interventions in cancer patients may have a moderate clinical effect upon anxiety but not depression. There are indications that interventions targeted at those at risk of or suffering significant psychological distress have strong clinical effects. Evidence on the effectiveness of such targeted interventions and of the feasibility and effects of group therapy in a European context is required.

Temporal differences in coping, mood, and stress with chemotherapy

This longitudinal study examined relations among mood, coping, perceived stress, and side effects from chemotherapy in 50 individuals with stages III and IV adenocarcinoma of the lung over four consecutive combination chemotherapy courses. Results indicated that perceived stress was moderately high only at the time of pretreatment, and four coping strategies were used: seeking social support, planful problem solving, self-control, and positive reappraisal. No relations existed between coping strategies and side effects from chemotherapy, coping and perceived stress, mood and side effects, and perceived stress and side effects. Seven side effects occurred: leukopenia, decreased activity, nausea, loss of appetite, fatigue, constipation, and taste changes. In summary, receiving chemotherapy is stressful at the time of pretreatment, so nursing interventions need to be concentrated at that point.

Surviving cancer: the importance of sexual self-concept

Sexual self-schemas are cognitive generalizations regarding sexual aspects of the self; they represent a core component of one's sexuality. We contend that individual differences in sexual self-view are an important cognitive diathesis for predicting sexual difficulty or dysfunction. We illustrate the role of sexual self-schemas in sexual behavior and responsiveness in healthy female and male samples. Next, we examine the diathetic properties of sexual self-schemas. Finally, we discuss an empirical test of the proposed diathesis-stress interaction, reviewing the role of women's sexual self-views on sexual morbidity following diagnosis and treatment for gynecologic cancer.

Physician-Assisted Suicide: The Influence of Psychosocial Issues

BACKGROUND: Physician-assisted suicide (PAS) is perhaps the most compelling and clinically relevant mental health issue in palliative care today. The desire for death, the consideration of suicide, the interest in PAS, and the relationship of these issues to depression and other psychosocial issues appear to be of paramount importance. METHODS: Psychiatric and psychosocial perspectives are used to understand the factors contributing to the interest in PAS, as well as to guide interventions in the clinical care of patients with advanced disease. RESULTS: Research and clinical experience suggest that attending to issues of depression, social support, and other psychosocial issues in addition to pain and physical symptom control are critical elements in interventions that are useful in reducing the distress of patients who desire hastened death. CONCLUSIONS: Psychosocial and psychiatric issues are among the most powerful predictors of desire for death and interest in PAS. Evaluation and intervention in these areas, particularly depression, is a critical component of compassionate care.

Social work with adult cancer patients: a vote-count review of intervention research

The meaning of a cancer diagnosis has changed in the past decades, bringing with it a myriad of psychosocial interventions to improve the psychological or functional status of those coping with the disease. Today, social workers in oncology need to be current with research in order to integrate empirical and practical knowledge. In an effort to assist in this process, we reviewed empirical studies to address the following questions: (1) When are patients likely to be willing to accept help? (2) Is there sufficient evidence to show that some types of psychosocial treatment are effective in improving psychological or physical functioning? (3) Are certain treatments preferable for some cancer patients depending on the type of cancer and stage of disease? Using a vote-count review of 40 intervention studies in psychosocial oncology, 36 documented some positive outcomes from treatments, 4 studies exhibited null findings, and no studies were found to have clearly negative results. Studies revealed the most positive results from interventions during the treatment phase, next from interventions at diagnosis, and lastly from interventions during the terminal stage. Individual and group formats showed a comparable level of efficacy. Interventions that included cognitive behavioral methods had the most consistently positive results. Those intervention studies where social workers were involved in the research were less successful at demonstrating efficacy. This difference was due primarily to the fact that social workers often did not include cognitive behavioral interventions in their research. Based on the results of this study, social workers might want to reevaluate their intervention strategies.

Organizing social work services with adult cancer patients: integrating empirical research

Today only half of those diagnosed with cancer will die of the disease, leaving enormous room for psychosocial interventions to improve the psychological or functional status of those coping with the disease. Therefore, social workers in oncology must be current with empirical research. In an effort to integrate current research into social work practice, we reviewed empirical studies with sound research designs to answer the following questions: (1) What portion of cancer patients are likely to need social work services? (2) What types of services do social workers provide to meet these needs? and (3) Who is likely to be (or not to be) the recipient of these services. Does intervention research include diverse (non-traditional, non-white and non-middle class) clients? The results show about one third of patients will be judged at high-risk for psychosocial problems but that only 15-25% of those who are diagnosed with cancer will eventually use psychosocial oncology services. Some have mainly instrumental, concrete needs, and others will use psychosocial counseling. A review of the inclusion of minorities and non-traditional, non-middle-class groups, shows that they are not adequately represented in current intervention research in psychosocial oncology. Methods for enlarging their access and participation are suggested.

Telephone counseling of breast cancer patients after treatment: a description of a randomized clinical trial

The Telephone Counseling Trial for Breast Cancer Survivors is a randomized, controlled study designed to test the impact of a telephone-based counseling intervention on quality of life of early-stage breast cancer patients who have completed adjuvant treatment. A psychoeducational counseling model is utilized to promote adaptive coping to re-entry stressors and survivorship issues. Adaptation is fostered through the exploration of thematic materials, application of active coping strategies, encouragement of a personal expression of the breast cancer experience and the provision of psychological support. Patients are being recruited in collaboration with two NCI-designated clinical cooperative oncology groups: the Eastern Cooperative Oncology Group (ECOG) and the Southwest Cooperative Oncology Group (SWOG). The recruitment goal is 400 breast cancer survivors with Stage 1, Stage 2 and Stage 3 disease (with no greater than 10 positive lymph nodes involved). Patients are being enrolled by data managers on-site during their last treatment visit. The intervention is being delivered by the Cancer Information and Counseling Line (CICL) of the AMC Cancer Research Center. It includes 16 telephone outcalls which are delivered over a 12-month period. Primary outcome measures are quality of life, mood, social support, self-efficacy, and sexual functioning, assessed at baseline, 3, 6, 12 and 18 months follow-up. This article provides a description of the intervention protocol and study design. It is argued that this study could provide a model for developing and testing other psychosocial interventions within clinical cooperative groups nationwide.

Assessment and treatment of depression in the cancer patient

The prevalence, diagnosis, and treatment of depression in the cancer patient are reviewed. Although frequently encountered in the cancer patient population, depression often remains undiagnosed and untreated. This carries grave consequences in that depressed cancer patients experience a poorer quality of life, are less compliant with medical care, have longer hospital stays, and have higher mortality rates. Diagnostic assessment of depression in the cancer patient raises difficulties both upon phenomenological and etiological grounds. In particular, the presence of neurovegetative symptoms which may be secondary to either cancer or depression may cloud the diagnostic picture. Due to the serious consequences of unrecognized depression, a more sensitive inclusive approach to diagnosis is recommended in the clinical setting. Finally, the limited data regarding treatment of depression in patients with cancer is reviewed. This includes a discussion of both psychosocial and pharmacological interventions which are shown to alleviate depression, improve quality of life measures, improve immune function, and lengthen survival time.

Perceptions of control, physical exercise, and psychological adjustment to breast cancer in South African women

Psychological adjustment and locus of control were measured in 257 South African women both with and without breast cancer. Adjustment was defined as positive affect, negative affect, the balance between the two, satisfaction with various domains of life, and an overall sense of well-being. Health locus of control was measured separately for internal, external, and chance loci. The instrument's reliability was comparable to that reported for U.S. norms. The women with breast cancer reported significantly lower affect and had lower internal and higher external and chance perceptions of control. The more invasive the surgical treatment, the greater the negative impact on adjustment. Data suggested that using written instructions to stress the importance of exercise to rebuild arm strength immediately following the surgery had a long-lasting positive impact on affect. Side of intervention was also related to psychological adjustment. Significant differences across racial groups were found for both adjustment and health locus of control.

Concern about aspects of body image and adjustment to early stage breast cancer

OBJECTIVE

Several authors have suggested that patients adjust more poorly to breast cancer if they are heavily invested in body image as a source of their sense of self-worth. This prospective study examined this possibility, looking at two aspects of concern about body image as predictors of several indices of adjustment over the first postoperative year.

METHODS

At diagnosis (and again a year later) 66 women with early stage breast cancer reported how much they valued a) a sense of body integrity (or intactness) and b) a good physical appearance. The day before surgery, a week afterward, and at 3-month, 6-month, and 12-month follow ups, they reported on their mood. At presurgery and at follow ups they also rated their attractiveness and sexual desirability and reported on frequency of sexual interaction. At follow-ups they also indicated how much their illness and treatment were interfering with social and recreational activities.

RESULTS

Initial investment in appearance was related to distress across the postsurgical year. In contrast, investment in appearance made women more resilient against deterioration in their perceptions of attractiveness. Concern about body integrity did not strongly predict emotional distress, but it related to adverse impact on social and recreational activities in the follow-up period, to deterioration in feelings of sexual desirability, and to feelings of alienation from the self (feeling "not like yourself anymore").

CONCLUSIONS

Body image is often thought of in terms of physical appearance, but there is also a body image pertaining to integrity, wholeness, and normal functioning. People who are greatly concerned about either aspect of their body image are vulnerable to poorer psychosocial adjustment when confronting treatment for breast cancer. The poorer adjustment takes a different form, however, depending on the nature of the patient's body-image concern.