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CHAPTER 12
Psychosocial Oncology
ARTHUR M. NEZU, CHRISTINE MAGUTH NEZU, STEPHANIE H. FELGOISE,
AND LAUREN M. GREENBERG
CANCER: A BASIC PRIMER 271
BEHAVIORAL RISK FACTORS 274
PSYCHOSOCIAL EFFECTS OF CANCER
PSYCHOSOCIAL INTERVENTIONS
FOR CANCER PATIENTS 277
FAMILY AND CAREGIVER ISSUES 283
SUMMARY AND FUTURE DIRECTIONS 286
REFERENCES 287
275
Like most wars, the war on cancer leaves casualties, scars,
and lives in need of healing in its wake. It has only been
during the past two decades that health and mental health
professionals have focused on the psychosocial needs of
cancer patients and their families (Nezu, Greenberg, &
Nezu, 2010). An increasing awareness of the significant
emotional, interpersonal, family, vocational, and functional
problems such individuals experience, and how these problems potentially affect their overall health, quality of life,
and even health outcome, has led to the creation of the field
of psychosocial oncology or psycho-oncology. According
to Holland (1990), the two major areas of interest characterizing this cancer subspecialty are “(a) the impact of cancer
on the psychological function of the patient, the patient’s
family, and staff; and (b) the role that psychological and
behavioral variables may have in cancer risk and survival”
(p. 11). In addition, an important outgrowth of these areas
of scientific inquiry involves developing and evaluating the
efficacy of psychosocial interventions geared to improve a
cancer patient’s quality of life (Baum & Andersen, 2001;
Feuerstein, 2007). This chapter provides an overview of
this field, beginning with a brief description of cancer itself.
What Is Cancer?
The first description of cancer began with the earliest recordings of history during ancient Egyptian times
(American Cancer Society, 2010). Later, the resemblance
of fingerlike spreading projections of tumors to a crab probably led Hippocrates, the Greek physician, to describe these
tumors using the Greek words carcinos and carcinoma,
which was later translated to the word cancer.
Although cancer is often thought of as a single disease,
it is actually a generic term encompassing a group of more
than 100 diseases in which the damaged DNA of a cell
causes it to grow out of control. The various types of
cancer cells can be classified into five broad categories:
carcinoma (the most common type, a cancerous tumor that
begins in the skin or tissues that line or cover internal
organs); sarcoma (a cancerous tumor that originates in
certain tissues, such as bone or muscle); leukemia (cancer
in the blood or blood-forming organs); lymphoma and
myeloma (cancers that begin in the cells of the immune
system, such as white blood cells and plasma cells); and
central nervous system cancers (those that begin in the
tissues of the brain and spinal cord).
The common feature of all types of cancer is the uncontrollable growth and accumulation of abnormal cells. Normal cells behave according to a genetically predetermined
set of rules unique to the particular cell type (e.g., skin,
blood, brain). These normal cells divide, mature, die, and
are replaced systematically. Cancer cell growth differs
from normal cell growth. Due to damaged DNA, instead
of dying, cancer cells continue to grow and form abnormal
CANCER: A BASIC PRIMER
In this section, we provide a brief overview of important
concepts related to oncology. This includes a description
of the different types of cancers, cancer statistics, stages
of cancer, and the major forms of cancer treatment.
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cells that grow more rapidly, in a disorderly fashion, and
do not mature correctly. These cells can grow into malignant tumors that replace normal surrounding tissue and
spread throughout the body. Whether due to hereditary or
environmental causes, cancer involves a malfunction of
genes that control cell growth and division. The uncontrolled spread of abnormal cells, or metastasis, can affect
the functioning of other organs, potentially leading to
death.
Cancer Statistics
More than 1.5 million new cases of cancer were expected
to be diagnosed in the United States in 2010. This estimate
excludes basal and squamous cell skin cancers (more than
2 million people were treated for these in 2006) and
carcinoma in situ (noninvasive cancer) of any site except
the urinary bladder. Cancer is the second-most-common
cause of death in the United States, surpassed only by
heart disease, and the leading cause of death worldwide
(Ferlay et al., 2010). In the United States, cancer accounts
for nearly one in every four deaths, and in 2010, more
than 560,000 Americans were expected to die of cancer
(American Cancer Society, 2010). Slightly less than half
of all men and one third of all women in the United States
will develop cancer at some point in their lives, with about
78% of all cancers diagnosed in persons age 55 or older.
Gender
According to the estimated new cancer cases and deaths
for 2010, incidence and mortality rates for cancer of all
sites are slightly higher for men than women (American
Cancer Society, 2010). Recent data indicate U.S. women
have a slightly higher prevalence rate for a combination of
all cancer sites (Edwards et al., 2010). This suggests that
more women are living with a history of cancer than men,
even though women are slightly less likely to be diagnosed
with cancer, which is probably due to the higher mortality
rates for males.
According to the American Cancer Society (2010),
about 50% of males are at a lifetime risk for developing
invasive cancer of any type, and about one in four men
are at risk of dying from cancer. The most common
newly diagnosed cases of cancer in men are expected to
be prostate cancer and lung/bronchus. Lung/bronchus and
prostate cancer types also involve the most life-threatening
cancer diseases for males.
For females, about 33% are at risk of developing an
invasive cancer of any type during their lifetime, with one
in five being at risk of dying from cancer of any type.
The highest rate of new cases for 2010 was estimated to
be for breast cancer and lung/bronchus cancer. Similarly,
lung/bronchus and breast cancers are associated with the
highest mortality rates for cancer in women.
Race/Ethnicity
The incidence of cancer is variable across not only cancer types but also races/ethnicities (Edwards et al., 2010).
When combining all cancer sites, cancer incidence is highest among Black men and Blacks in general. Non-Hispanic
and White women represent the highest overall incidence
rates among women. Native American and Alaskan natives
have the lowest overall incidence rates of cancer. Mortality
rates remain the highest for Black men and women and the
lowest for Asian Americans and Pacific Islanders.
Eliminating disparities in cancer burden among various
minority groups (e.g., based on race/ethnicity, socioeconomic status, sex, sexual orientation, and residence) is a
major prospective goal set by the American Cancer Society for the year 2015. Although the causes of such health
disparities are multiple and complex, one contributing factor is social barriers to high-quality cancer prevention,
early detection, and treatment services (American Cancer
Society, 2010).
Improvement in Survival Rates
Either cancer-free or still undergoing treatment, approximately 11.4 million Americans with a history of cancer
were alive in 2006. The 5-year relative survival rate for all
cancers has increased, up from 50% for those diagnosed
in 1975 to 1977 to 68% for those diagnosed between 1999
and 2005 (American Cancer Society, 2010). Mortality rates
for all cancers combined have also decreased in the past
two decades, with slightly larger decreases for men than
women (Edwards et al., 2010). Earlier diagnoses and better treatments have contributed to such increased survival
rates, although these rates vary widely by cancer types and
stage at diagnosis.
Overall cancer incidence rates for all racial/ethnic
groups and both sexes combined has decreased by 0.7%
per year during 1999 to 2006 (Edwards et al., 2010).
Trends during the most recent periods reveal decreased
incidence rates in the two most common cancers (prostate
and lung/bronchus) in men and the most common cancer
in women (breast) but an increase in the second-mostcommon cancer (lung) among women.
Cancer Stages
Staging is the process of defining the extent or seriousness
of a given cancer type, as well as a means to denote the
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degree of spread of the cancer cells from the site of origin
to other parts of the body. To plan appropriate treatment
and estimate prognosis, the extent or severity of the cancer
is commonly assessed using a staging method based on
primary tumor size, location, and metastasis. The TNM
staging model refers to the extent of the primary tumor
(T ), the degree to which lymph nodes have been affected
(N ), and the presence of distant metastasis, or spread to
other organs (M ). Another consideration for some cancer
types may be the cell type or tumor grade (i.e., how
closely the cells resemble normal cells).
Once this has been determined, cancers are classified
into five stages ranging from the early stage, 0 , when
cancer is in situ (i.e., abnormal cells are not beyond the
layer at which they developed) to the late stage, IV (i.e.,
cancer has spread from the primary site to distant organs
or lymph nodes). In addition, some cancer types include
stages that are subdivided (e.g., IIA, IIB). Generally, the
higher the stage, the more advanced the cancer. Practically,
a cancer in the early stages is likely to be small and confined
to a primary site. When cancer is in an advanced stage, it
is likely to be large and metastasized to lymph nodes or
other structures.
Cancer Treatment
Medical treatment for cancer varies according to site
and severity and includes such general types as surgery,
radiation, chemotherapy, biological therapy, bone marrow
transplant, and other specific variations of these interventions. The treatments may be used as primary treatments
or an adjuvant treatment, which is delivered after the primary treatment has been implemented. For example, a
woman may have surgery to remove a tumor of the breast
(primary treatment), followed by chemotherapy to destroy
the remaining cancer cells (adjuvant therapy). Neoadjuvant therapy involves treatment that is given prior to the
primary treatment to control known or possible sites of
metastasis. Prophylactic treatment is utilized when there
is a site that is at high risk for cancer development.
Surgery
Surgery is the oldest, most frequent treatment for cancer
and an important part of the staging process. This method
is used to remove a primary tumor, surrounding tissue, and
affected lymph nodes. Surgery may also be performed to
remove tumors that are metastatic, recurrent, or residual.
Surgery may also be prophylactic, as in cases where
women with breast cancer have their other breast removed
to reduce the risk of cancer recurrence.
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Chemotherapy
This type of cancer treatment uses drugs to stop or slow
the growth of cancer cells to cure, control, or ease cancer
symptoms. Chemotherapy, unfortunately, can also harm
healthy cells that grow quickly, such as those that cause
hair to grow, although these effects may improve or disappear when treatment is discontinued. Chemotherapy can
be delivered through injection, intra-arterially, intraperitoneally, intravenously, topically, or orally. Although it
can be used as a singular treatment, it is often an adjuvant
treatment to surgery or radiation therapy. Common side
effects of chemotherapy include fatigue, nausea, vomiting,
and sexual and appetite changes.
Radiation
This cancer treatment, also called radiotherapy, destroys
cancer cells and prevents them from spreading. Radiation
is given in high doses to cure cancer, cease, or slow the
proliferation of cancer. Similar to chemotherapy, radiation
can also harm nearby healthy cells. Although normal cells
may be repaired, the effects of radiation are accumulative.
Patients may experience fatigue, hair loss, anemia, oral
changes (e.g., dry mouth), nausea and vomiting, and sexual
changes, depending on the location of the treatment. Radiation is commonly used in addition to other treatments. For
example, it may be given prior to surgery to shrink the size
of the tumor (i.e., neoadjuvant therapy) or after surgery to
diminish the remaining cancer cells. It can also be used in
combination with chemotherapy to enhance the effects of
the treatment or as a palliative method to reduce symptoms
and prevent problems such as blindness or loss of bowel
and bladder control. Newer radiation technology (i.e., proton therapy) is being developed to better target cancer cells,
thereby potentially improving treatment and decreasing the
long-term adverse effects of radiation therapy.
Biological Therapy
This treatment modality, also called immunotherapy, biotherapy, or biological response modifier (BRM) therapy, uses the body’s immune system to stop, control,
or suppress cancer growth. Biological therapies involve
interferons, interleukins, colony-stimulating factors, monoclonal antibodies, vaccine gene therapy, and nonspecific
immunomodulating agents to defend the body against
attacks from cancer cells. Side effects include rashes,
swelling, and flulike symptoms (e.g., fever, nausea, chills,
vomiting, fatigue, bone pain).
Bone Marrow Transplantation
Hematopoietic or blood-forming stem cells, found in
bone marrow, bloodstream, or umbilical cord blood, are
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immature cells that can transform into blood cells. Bone
marrow transplantation (BMT) and peripheral bloodstream stem cell transplantation (PBSCT) restore stem
cells that were destroyed as a result of chemotherapy
and/or radiation therapy. After high-dose drug or radiation treatment, a cancer patient receives stem cells that
travel to the bone marrow and produce the necessary new
blood cells that carry oxygen, fight infection, and prevent
bleeding. BMT and PBSCT are most frequently used to
treat leukemia and lymphoma and are most effective when
in remission.
BEHAVIORAL RISK FACTORS
Only about 5 to 10% of all cancers are clearly hereditary.
The remaining cancers are caused by mutations resulting
from various internal (e.g., hormones) or external factors (e.g., sunlight). Behavioral risk factors refer to those
lifestyle activities that increase the likelihood that a person will develop cancer. Such factors include tobacco,
alcohol, diet, and exposure to sun. Additional psychosocial variables that have been investigated regarding their
causal link to cancer include socioeconomic status and
personality.
Tobacco
According to the American Cancer Society (2010), tobacco
use was estimated to cause about 171,000 U.S. cancer
deaths in 2010. Tobacco accounts for nearly 5 million
deaths worldwide per year (Ezzati, Lopez, Rodgers, Vander
Hoorn, & Murray, 2002). Smoking accounts for approximately 30% of total cancer deaths in the developed world
and 90% of all lung cancer deaths (Stein & Colditz, 2004).
In addition, smokers have an increased risk for developing at least 15 differing types of cancer, including lung,
oral cavity, pharynx, larynx, esophageal, pancreatic, head
and neck, stomach, and renal cancer (U.S. Department
of Health and Human Services, 2004). On the positive
side, ceasing tobacco use has been found to be beneficial
with regard to cancer risk. For example, after 10 years of
nonsmoking, the risk for lung cancer mortality decreases
between 30 and 50%. Moreover, a 50% reduction in cancer risk of the esophagus and oral cavity has been found
after only 5 years of smoking cessation (U.S. Department
of Health and Human Services, 2004).
Alcohol
Although the specific biological underpinnings linking
alcohol and increased risk for cancer are unclear at present
(Boffetta & Hashibe, 2006), studies have shown a definite
association. For example, a meta-analysis of 235 studies that included over 117,000 cases suggested a strong
trend in increased risk for cancers of the oral cavity and
pharynx, esophagus, and larynx (Bagnardi, Blangiardo,
La Vecchia, & Corrao, 2001). Less strong direct relations
were found regarding cancers of the stomach, colon and
rectum, liver, breast, and ovary.
Diet and Obesity
A link between poor diet, excess body weight, and cancer
has been demonstrated in a wide variety of investigations
(Renehan, Robert, & Dive, 2008). For example, estimates
suggest that approximately one third of the cancer deaths
that occur in the United States each year are a function
of poor nutrition, limited physical activity, and obesity
(American Cancer Society, 2010). Increased cancer risk
has also been linked to various dietary deficiencies, such as
low intake of fruits and vegetables, fiber, and micronutrients (e.g., riboflavin, iron). In addition, excessive pickling,
smoking, and salting of foods has been associated with
increased cancer risk. In general, research suggests that
being obese is responsible for approximately 14% of cancer deaths among men and 20% of cancer deaths in women
(Stein & Colditz, 2004). Lack of physical activity has also
been found to increase the risk of certain cancers, such
as colon, breast, and endometrial cancers (International
Agency for Research on Cancer, 2002). On the positive
side, losing weight appears to reduce the risk of breast
cancer and to reduce cancer mortality (American Cancer
Society, 2010).
Sun Exposure
Ultraviolet radiation from the sun, in particular UVB (radiation lying between 280 and 320 nanometers of the solar
spectrum), has been linked to increased risk for skin cancer (melanomas and nonmelanomas). In addition to being
carcinogenic, UVB is an immunosuppressor, potentially
leading to DNA damage. The incidence of melanoma has
increased more rapidly than any other type of cancer in
the United States (Stein & Colditz, 2004). UVA radiation,
which is between 320 and 400 nanometers of the solar spectrum, because it was thought to be noncarcinogenic, is the
basis for commercial tanning salon sun lamps. However,
research continues to demonstrate that indoor tanning is
associated with significant risks, strongly underscoring the
role of artificial UV radiation in cutaneous carcinogenesis
(Levine, Sorace, Spencer, & Siegel, 2005).
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Socioeconomic Status
Research that cuts across many varying populations
around the world provides the following conclusions: (a)
depending on the specific cancer site, in general, a direct
and inverse relationship exists between socioeconomic
status (SES) and cancer incidence; and (b) across cancer
sites, the relationship between SES and cancer survival
is positive, that is, as SES decreases, so does the rate
of cancer survival (Ward et al., 2004). Socioeconomic
factors influence tobacco use, poor nutrition, physical
inactivity, and obesity, thus increasing the risk of cancer
(Institute of Medicine, 2003).
Personality
Personality characteristics have been suggested as a potential risk factor for developing cancer. However, research
generally suggests a lack of convincing evidence in support of this hypothesis. For example, in a large-scale study
that initially included over 30,000 residents in Japan, no
associations between any scale on the Eysenck Personality
Questionnaire–Revised and the risk of cancer were identified (Nakaya et al., 2003). Such a lack of associations
were also found in a Finnish sample (Lillberg, Verkasalo,
Kaprio, Helenius, & Koskenvuo, 2002) and a Danish sample (Bleiker, Hendriks, Otten, Verbeek, & van der Ploeg,
2008).
PSYCHOSOCIAL EFFECTS OF CANCER
Considerable medical progress has been made in treating
this set of diseases. Many forms are curable, and there is
a sustained decline in the overall death rate from cancer
when one focuses on the impact on the total population. For example, the 5-year relative survival rate for
all cancers diagnosed between 1999 and 2005 was 68%
as compared to 50% spanning the years 1975 to 1977
(American Cancer Society, 2010). Because of improvements in medical science, more people are living with
cancer than ever before. However, although the extensive
medical needs of such patients may be well attended to,
psychosocial and emotional needs are often overlooked
and not adequately met (Feuerstein, 2007; Nezu, Lombardo, & Nezu, 2006). Almost every aspect of a person’s
life can be affected, as cancer engenders many stressors
and can lead to a significantly compromised quality of
life. Even for people who historically have coped well
with major negative life events, cancer and its treatment
greatly increase the stressful nature of even routine daily
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tasks (Nezu & Nezu, 2007). Moreover, not only is psychological distress in and of itself a worthy target to address
in treatment but also research has demonstrated that such
distress is associated with higher cancer incidence, poorer
survival, and higher cancer mortality (Chida, Hamer, Wardle, & Steptoe, 2008). This section focuses on the various
psychosocial consequences of having cancer.
Depression
Depression is a common experience among cancer patients.
However, the reported prevalence varies considerably from
study to study (e.g., major depressive disorder ranges from
3 to 38%; Massie, Lloyd-Williams, Irving, & Miller, 2011).
It is likely that this large variability is a function of the lack
of standardization in measurement and diagnostic criteria,
suggesting the need for improved methodological rigor to
more accurately determine depression prevalence rates.
In terms of cancer type, Christensen et al. (2009) recently
found a 13.7% prevalence of major depression 12 to 16
weeks after surgery among a sample of 3,321 Danish cancer
patients diagnosed with early-stage breast cancer. Higher
incidence of depression was found for younger (17.9%
for 18- to 35-year-old) versus older (11.2% for 60- to
69-year-old) women. Among women with ovarian cancer,
Arden-Close, Gidron, and Moss-Morris (2008) identified a
strong relationship between higher levels of depression and
younger age, more advanced disease, higher levels of physical symptoms, and shorter time since diagnosis. Among
patients with head and neck cancer, a review of 52 studies
found that depression rates ranged from 13 to 40% at the
time of diagnosis, 25 to 52% during medical treatment, and
9 to 27% 3 years postdiagnosis (Haisfield-Wolfe, McGuire,
Soeken, Geiger-Brown, & De Forge, 2009).
Factors associated with greater prevalence of depression
are a higher level of physical disability, advanced disease
stage, and the presence of pain (Williamson & Schulz,
1995). Also, higher rates of depression have been associated with the side effects of medications and treatment for
cancer. Chemotherapy and oncological surgical procedures
are a source of possible iatrogenically induced depression
in cancer patients because of the negative side effects that
may include body image disturbances and physical symptoms (Newport & Nemeroff, 1998).
Numerous studies have also investigated various psychosocial risk factors for developing depression among
cancer patients. Some of the risks identified are premorbid coping skills, social isolation, first-degree relatives
with a history of cancer and depression, a personal history of depression, a personal history of alcohol or other
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substance abuse, and socioeconomic pressures (Newport &
Nemeroff, 1998).
The consequences of being depressed in addition to
the diagnosis of cancer can be severe. For example, Watson, Haviland, Greer, Davidson, and Bliss (1999) found
that depression level was significantly related to increased
mortality at a 5-year follow-up among a cohort of breast
cancer survivors. A similar association was identified
among patients with lung cancer (Buccheri, 1998) and
patients undergoing stem cell transplantation (Loberiza
et al., 2002).
Suicide
Suicidal ideation and the act of suicide are higher among
cancer patients than in the general population and other
medically ill cohorts (Rockett, Wang, Lian, & Stack,
2007). For example, cancer patients are approximately
twice as likely to commit suicide than the general population (Levi, Bulliard, & La Vecchia, 1990). Further, cancer
was the sole physical illness that was found to be significantly associated with death by suicide in a recent review
of U.S. mortality rates (Rockett et al., 2007). Risk factors
for increased suicidal ideation and behavior among cancer patients include feelings of being a burden to others,
depression and hopelessness, pain, lack of social support, existential issues, and fear of the future (Breitbart,
Pessin, & Kolva, 2011).
Delirium
Delirium is a common psychiatric problem among cancer patients because of the direct effects of cancer on the
central nervous system (CNS) and the indirect CNS complications of the disease and medical treatment (Agar &
Lawlor, 2008). Its prevalence is particularly high among
terminal cancer patients but frequently goes undetected
(Fang et al., 2008). Symptoms are agitation, impaired cognitive function, altered attention span, and a fluctuating
level of consciousness. Ljubisavljevic and Kelly (2003)
found the following factors to be significant predictors of
delirium among a sample of individuals admitted to an
inpatient oncology unit: advanced age, cognitive impairment, low albumin levels, bone metastases, and the presence of a hematological malignancy.
Body Image Problems
Body image is one of the most profound psychological
consequences from cancer treatments affecting patients
with a variety of disease sites. The scars and physical
disfigurement serve as reminders of the painful experience
of cancer and its treatment. The stress and depression
that may be a result of body image concerns can further
affect other areas of the patient’s and family’s life, such as
sexual intimacy, psychological disorders, and self-esteem.
In women who have had breast surgery, concerns range
from distress over scars to feelings of decreased sexual attractiveness and restrictions of use of certain items
of clothing. In a study with women who had breastconserving surgery, 25% had serious body image problems (Sneeuw et al., 1992). Among a group of 546 women
age 22 to 50 who underwent breast cancer treatment, over
half reported experiencing two or more body image problems some of the time or at least one problem much of the
time (Fobair et al., 2006). Of this cohort, for those women
who were sexually active, greater body image problems
were found to be related to having a mastectomy and
possible reconstruction, loss of hair due to chemotherapy, concerns about gaining weight, poorer mental health,
lower self-esteem, and the partner’s problems in understanding a woman’s emotions.
Sexual Functioning Difficulties
Estimates of sexual functioning problems vary depending on the type of cancer, but they appear to be common
across cancer sites. For breast cancer survivors, the percentage of women who report sexual difficulties range
from 50 to 56% (Fobair & Spiegel, 2009).
In a study of cancer patients undergoing a BMT, 47%
were found to have a global sexual dysfunction, and 60%
had abnormalities of at least one parameter of sexual dysfunction (Marks, Crilley, Nezu, & Nezu, 1996). Common
sexual functioning problems among cancer patients include
loss of sexual desire in both men and women, erectile dysfunction in men, and dyspareunia (painful intercourse) in
women. Studies suggest that sexual dysfunctions continue
years after treatment (Fobair et al., 2006), indicating a large
impact on a patient’s quality of life (Marks, Friedman, DelliCarpini, Nezu, & Nezu, 1997).
Physical factors from the cancer treatment itself can
contribute greatly to the patient’s sexual dysfunctions.
Chemotherapy, radiation, surgery, opiate and pain medications, antidepressants, and antipsychotic medications can
cause sexual dysfunctions, as well as infertility, in patients.
For example, in men receiving prostatectomies, 85 to 90%
experience erectile impotence (von Eschenbach, 1986).
Loss of sexual desire may be a result of fatigue, pain, or
weakness secondary to the cancer treatment; depression;
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body image concerns; and feelings of guilt or misbelief
about the development and spread of cancer (Schover,
1997).
PSYCHOSOCIAL INTERVENTIONS
FOR CANCER PATIENTS
“Health is determined not just by biological processes but
by people’s emotions, behaviors, and social relationships”
(Institute of Medicine, 2008, p. xi). For over 30 years,
researchers have been interested in examining the psychological and social issues related to cancer, such as those
involved in prevention, diagnosis, treatment, and survivorship (Holland & Weiss, 2010). Researchers have aimed
to identify the needs of cancer patients and their families,
as well as the impact of psychosocial factors on disease
onset and progression, an individual’s functioning, and the
ability to preserve quality of life. In addition, psychosocial
interventions have been developed to address these types
of concerns. Because cancer is not a single disease but
rather a collection of over 100 types, identifying effective interventions for cancer is particularly challenging
compared to other kinds of chronic illness. Further complicating research, the disease varies not only by site but
also by stage (e.g., early, advanced). Levels of distress,
varying by type and stage of cancer and by individual,
may stem from various sources of stress, including those
that existed prior to a cancer diagnosis, the cancer diagnosis itself, unpleasant symptoms of cancer, quality of life,
concerns regarding a disruption of life plans, disease recurrence and progression, and end-of-life issues (Institute of
Medicine, 2008). The goal of psychosocial interventions is
to help cancer patients and their families optimize health
care and manage the psychological, behavioral, and social
facets of cancer and to promote improved health.
Unfortunately, the multiple complexities involved in
conducting research with cancer populations have contributed to inconsistent reports about the overall effectiveness of psychosocial interventions. Such contradictory
findings, in part, have led some researchers to believe that
psychological interventions targeting distress in cancer
patients are ineffective, as well as not accepted by patients
(Coyne & Lepore, 2006; Coyne, Lepore, & Palmer, 2006).
For example, the Annals of Behavioral Medicine published a series of arguments and rebuttals representing
this debate. Coyne and colleagues contended that psychosocial interventions were ineffective and unaccepted
by patients, pointing to confirmatory bias and methodological flaws of past studies. In defense of psychosocial
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interventions, the opposing researchers (Andrykowski &
Manne, 2006; Manne & Andrykowski, 2006) pointed to
various qualitative and quantitative reviews that found a
sufficient “preponderance of evidence,” citing in particular five randomized controlled trials (RCTs) that demonstrated positive and significant results. Whereas Coyne
and Lepore recognized that an RCT by Nezu, Nezu, Felgoise, McClure, and Houts (2003) (described later in the
section on problem-solving therapy approaches) was, in
fact, one such methodologically sound study that did support the efficacy of a particular psychosocial intervention,
they considered this to be a rare occurrence and labeled
it a “black swan.”
Since this debate, additional RCTs have been published
that provide evidence for the effectiveness of psychosocial interventions. Several reviews and meta-analyses have
examined overall effectiveness but continue to report varying effect sizes. Although researchers have improved the
methodology of their studies to comply with CONSORT
guidelines, criticism about effectiveness remains (Coyne,
Thombs, & Hagedoorn, 2009). In recent years, numerous
reviews and meta-analyses have been published, only some
of which are cited in this section. Many researchers have
recognized the difficulty in proclaiming an overall effectiveness of psychosocial interventions and instead have
discussed effectiveness in terms of specific intervention
types and applicability to specific cancer type. A comprehensive review of psychosocial intervention outcome
literature in the field of psycho-oncology is beyond the
scope of this chapter. In this section, a brief overview of
the major types of psychosocial interventions studied in the
cancer population is however, provided, whereby the reader
is directed to various review articles and meta-analyses for
further information.
Psychoeducational Interventions
Psychoeducational interventions aim to reduce uncertainty,
feelings of inadequacy, confusion, helplessness, and loss
of control by supplying information about the disease
process, coping with the disease, and resources available
to cancer patients (Edwards, Hulbert-Williams, & Neal,
2008). Psychoeducational components have also been used
in combination with other psychosocial interventions (e.g.,
psychotherapy) and have been effective in reducing distress
when integrated with such interventions.
A recent review of the past 25 years of reports regarding
psychosocial interventions for cancer patients found that
educational and informational interventions represented
one fifth of past research (Moyer, Sohl, Knapp-Oliver, &
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Schneider, 2009). In their review, Jacobsen and Jim (2008)
found psychoeducational interventions to be effective in
preventing or relieving depression and anxiety in newly
diagnosed patients and patients undergoing surgery or
chemotherapy. According to these researchers, the benefits of psychoeducational interventions were probably
produced by a reduction in fear through preparation for
treatment and information about ways to cope with cancer
stress and treatment.
An example of a psychoeducational intervention is
provided by McQuellon and colleagues (1998), who
evaluated a multicomponent program to reduce anxiety, depression, and overall distress symptoms in cancer
patients. The study sample was 150 cancer patients who
were randomly assigned to either the intervention or usual
care conditions. The very brief intervention, lasting only
15 to 20 minutes, was a clinic tour, a description of clinic
procedures and general information about clinic operations, and a question-and-answer session with an oncology
counselor. Outcomes were assessed at the initial clinic
visit and at a follow-up visit 1 week later. Patients who
received the brief intervention reported significantly less
anxiety, less depressive symptomatology, and significantly
greater satisfaction with their care.
Cognitive-Behavioral Interventions
Cognitive-behavior therapy (CBT) interventions for cancer patients typically involve relaxation training, coping
skills training, and cognitive restructuring. These treatment
protocols focus on recognizing and altering maladaptive
thoughts and behaviors to ameliorate distress and promote
well-being. In their review of psychosocial interventions
over the past 25 years, Moyer and colleagues (2009) found
that one third of interventions utilized a primarily cognitive,
behavioral, or cognitive-behavioral modality. The following describes various CBT approaches targeting differing
cancer-related problems.
Anticipatory Nausea and Vomiting
Anticipatory nausea and vomiting (ANV) is a term used
to describe the fear of a conditioned negative response
(i.e., nausea and vomiting) often associated with patients
who have undergone chemotherapy. It occurs when previously neutral stimuli (e.g., colors and sounds associated
with the treatment room) acquire nausea-eliciting properties due to repeated association with chemotherapy treatment and its negative aftereffects. Anticipatory nausea
and vomiting have been linked to lower quality of life
in patients treated with chemotherapy (Figueroa-Moseley
et al., 2007). Behavioral techniques such as relaxation,
distraction, desensitization, and hypnosis have been found
useful in reducing ANV in cancer patients (Holland &
Alici, 2010). Progressive muscle relaxation and systematic desensitization procedures have been found especially effective in preventing and treating ANV (FigueroaMoseley et al., 2007). Research also supports the use
of these interventions when self-administered (Jacobsen
et al., 2002).
Pain
CBT models have also been applied to alleviate pain. Pain
experienced by cancer patients may stem from various
sources, including tumor progression and invasion, cancerrelated surgery, other diagnostic and therapeutic treatment
procedures, chemotherapy, radiotherapy, hormone therapy,
cancer-related infections, and musculoskeletal complaints
associated with inactivity and fatigue (Keefe, Abernethy, &
Campbell, 2005). Tatrow and Montgomery (2006) conducted a meta-analysis of CBT interventions for distress
and pain in breast cancer patients and found that although
the results were mixed, an overall effect size of 0.49 was
identified, thus indicating that individuals who received
CBT reported significantly less pain than controls.
Emotional Distress
There is an abundance of literature on the efficacy of
CBT interventions to improve emotional outcomes, where
measures of distress have included both specific (e.g.,
depression) and nonspecific (e.g., negative affectivity)
dimensions (Jacobsen & Jim, 2008). In general, more
recent CBT studies conducted with breast cancer patients
have utilized larger samples, randomized controlled
designs, a minimum of 3 months follow-up, and controls
for confounders of immune variables. These studies have
been based on interventions using CBT techniques to
target distress (e.g., stress management), to promote better
sleep quality, or in combination with health education to
facilitate improved quality of life (Andersen et al., 2004;
Antoni et al., 2001; Savard, Simard, Ivers, & Morin, 2005).
Osborn, Demoncada, and Feuerstein (2006), in conducting
a meta-analysis of such studies, found a large effect size
(d = 1.99) for CBT interventions in the posttreatment
periods.
A representative example of this literature is a study conducted by Antoni and colleagues (2001). In this investigation, 199 women with breast cancer who were 4 to 8 weeks
postsurgery were assigned either to a 10-week group-based
cognitive-behavioral stress management (CBSM) condition or to a 1-day psychoeducational control group. CBSM
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combined training in anxiety-reduction techniques, such
as progressive muscle relaxation, guided imagery, deep
breathing, and meditation, with other CBT techniques,
such as cognitive restructuring, coping skills training, and
interpersonal skills training. Women in the intervention
condition, as compared to the control, showed improvements in psychological adaptation, including decreased
cancer-specific intrusive thoughts, general anxiety symptoms, rates of depression, and interpersonal disruption, as
well as increased benefit finding, optimism, positive affect,
and positive states of mind. Importantly, these effects held
up to 12 months later (Antoni et al., 2006).
Fatigue
Fatigue has been identified as one of the most pervasive and distressing of symptoms experienced by cancer patients, especially those with advanced disease and
those being treated with chemotherapy or radiotherapy
(Ahlberg, Ekman, Gaston-Johansson, & Mock, 2003).
Although mechanisms for the development and persistence
of cancer-related fatigue are only somewhat understood,
cognitive and behavioral problems are thought to contribute to the worsening and chronicity of such fatigue.
Researchers have examined the utility of CBT interventions with promising results (Kangas, Bovbjerg, & Montgomery, 2008). Jacobsen, Donovan, Vadaparampil, and
Small (2007), for example, conducted a systematic review
and meta-analysis of RCTs involving adult cancer patients
to evaluate the efficacy of psychological and activity-based
interventions with regard to cancer-related fatigue. Results
indicated that 50% of psychological interventions and 44%
of activity-based interventions of fair or better methodological quality demonstrated significant benefits for those
in intervention groups. Results revealed a small, but significant, intervention effect, displaying stronger evidence for
psychological interventions than for activity-based interventions.
Van der Lee and Garssen (2010) evaluated mindfulnessbased cognitive therapy in a sample of randomly assigned
cancer patients experiencing severe chronic fatigue 1
year after their last anticancer treatment. The participants in the intervention group received mindfulness-based
training, which combined elements of cognitive therapy and mindfulness-based stress management. Analyses yielded a posttreatment clinical improvement in 30%
of treated participants versus 4% of wait-list controls.
Results also indicated a significant reduction in fatigue
and improvement in well-being postintervention and at a
6-month follow-up.
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Problem-Solving Therapy (PST) for Cancer Patients
Multiple intervention studies have used components of
problem-solving therapy to reduce the physical and emotional effects of cancer for both patients and their families
(Jacobsen & Jim, 2008; McGregor & Antoni, 2009; Moyer
et al., 2009; Pitceathly et al., 2009). Problem-solving
therapy (PST) is an evidence-based, cognitive-behavioral
intervention that promotes the adoption and effective application of adaptive problem-solving attitudes and skills to
solve stressful problems in living (Nezu, 2004; Nezu &
Nezu, 2012; Nezu, Nezu, Houts, Friedman, & Faddis,
1999). In PST-tailored protocols for cancer patients, individuals are helped to cope more effectively with cancerrelated stressful problems by learning skills designed to
successfully resolve such problems and/or better manage their negative emotional reactions to such difficulties
(Nezu, Nezu, Friedman, Faddis, & Houts, 1998; C. M.
Nezu et al., 1999).
An example of an RCT that evaluated the efficacy of
PST for distressed cancer patients is the study referred to
earlier as the “black swan” by Coyne and Lepore (2006),
that is, the investigation conducted by Nezu and colleagues (2003). In this study, 132 adult cancer patients
were randomly assigned to one of three conditions: (1) ten
1.5-hour sessions of individual PST, (2) ten 1.5-hour sessions of PST provided simultaneously to both the cancer
patient and his or her designated significant other (e.g.,
spouse, partner, adult family member), or (3) a treatmentas-usual control. Results at posttreatment across several
self-reports, clinician ratings, and ratings by significant
others provide strong evidence in support of the overall efficacy of PST for decreasing emotional distress and
improving the overall quality of life of patients with
cancer. Specifically, participants in both treatment conditions demonstrated significant improvement as compared
to individuals in the control condition. At posttreatment,
no differences were found between these two PST-based
conditions. However, at a 6-month follow-up assessment,
on approximately half of the variables assessed, patients
who received PST along with a significant other continued to improve significantly beyond those individuals
receiving PST individually, highlighting the advantage of
formally including a collaborative person in treatment.
These positive effects of PST were not only statistically
significant but also highly clinically significant as well.
Moreover, analyses indicated that improvements in problem solving correlated significantly with decreases in psychological distress and improvements in overall quality
of life.
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During the past several years, several collaborative
care interventions have targeted depression among individuals suffering from various chronic illnesses, including
cancer. Collaborative care is a population-based health
services model that originally was developed to provide
evidence-based pharmacologic and psychosocial therapies
to persons with depression seen in primary care settings
(Katon & Seelig, 2008). Essentially, it is a stepped-care
approach whereby a depressed patient is offered a choice
of beginning treatment with antidepressant medication or
problem-solving therapy (PST). If those patients who initially chose the medication intervention did not respond
to optimal dosages, their antidepressants would be augmented or changed, or PST could be added. Similarly,
if PST as the first choice was not initially efficacious,
antidepressant medication could be added.
An example of such an approach to treat depressed
cancer patients is a study conducted by Ell and colleagues
(2008). Study patients were 472 low-income, depressed,
predominantly Latina patients with cancer who were randomly assigned to either the collaborative care intervention or enhanced usual care. At 12 months, 63% of the
intervention patients reported a 50% or greater reduction in depressive symptoms as compared to baseline, as
well as significantly greater quality-of-life outcomes and
enhanced emotional, functional, and physical well-being,
as compared to control participants, thus supporting the
overall efficacy of such a model of care.
Group Therapy Approaches
In the past, research evaluating group therapy interventions has tended to focus on supportive-expressive therapy modes with female breast cancer patients. Within the
cancer population, group therapy has gradually expanded
to include other psychotherapeutic models (e.g., CBT)
and other types of cancer populations (e.g., ovarian cancer). Sherman and colleagues (2004) describe the advantages of group therapy for cancer patients as providing
a forum for peer support, a sense of universalism and
shared experience, an opportunity to learn from others
experiencing similar challenges, less stigmatization, and
lowered cost. Their review of the group therapy literature
yielded the following conclusions: (a) brief psychoeducational groups for patients with limited disease produce
short-term benefits, although effects are discrepant regarding long-term improvement; (b) evidence for brief, lessstructured groups is even more muddled; and (c) long-term,
interactive groups for patients with advanced disease also
offer benefits but may require lengthier intervention for
effects to surface. Although many investigations employing group interventions target emotional functioning, outcomes also include medical knowledge, social functioning,
health-related quality of life, sleep, immune activity, and
symptom burden (Sherman et al., 2004).
Spiegel, Bloom, Kraemer, and Gottheil (1989) reported
improved survival, mood, pain, and coping skills in
metastatic breast cancer patients after a support group
intervention that involved building bonds, expressing emotions, “detoxifying death and dying,” redefining life priorities, increasing support of friends and family, improving
doctor–patient relationships and improving coping skills.
With regard to its efficacy on survival rates, unfortunately,
such results were not replicated (Fox, 1998). In reviewing
five randomized controlled trials of group therapy interventions for metastatic breast cancer patients, Edwards and
colleagues (2008) concluded that the collective findings
tended to mimic the results of the Sherman and colleagues
(2004) study; that is, although these interventions provided
short-term psychological improvements, they did not last
longer than a few months.
Therapeutic Processes
Researchers have also examined the potential impact of
shared generic commonalities among psychotherapeutic
interventions, such as empathy, therapeutic alliance, group
cohesion, collaboration, therapeutic openness, and therapeutic realizations. A recent systematic review of four
empirically supported relationship factors (i.e., therapeutic alliance, empathy, goal consensus/collaboration, and
group cohesion) found that therapist-rated rapport and
group cohesion were significantly related to positive outcomes (Schnur & Montgomery, 2010). Due to the paucity
of literature examining therapeutic relationship factors in
the cancer population, researchers suggest further investigation of these factors to ascertain their contribution
to psychotherapeutic outcomes. As part of a secondary
analysis of a previously conducted RCT, Manne and
colleagues (2010) investigated three nonspecific therapy
components (i.e., therapeutic alliance, therapeutic realizations, and therapeutic openness/involvement) in the
treatment of 203 women with gynecological cancers who
were initially randomly assigned to a supportive counseling intervention (SC) or a coping and communication
skills intervention (CCI). They found that these therapy
processes were, in fact, involved in predicting short- and
long-term treatment outcomes.
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Telephone and Internet Approaches
As technology evolves, so do the methods of communicating with patients. These advances to the health-care
system involve education, information, and support via
the telephone, Internet, and other techniques (e.g., CDROM) to facilitate disease prevention and management
(Stretcher, 2007). In addition to such health services, psychologists have adapted psychotherapeutic interventions
to incorporate such technologies. Due to the wide availability of these communication media, a growing number
of studies have been devoted to examining the utility of
these modalities (Mohr, Vella, Hart, Heckman, & Simon,
2008).
Cancer patients throughout the United States are provided free, nationally accessible resources, such as Web
sites and helplines. These resources provide education,
counseling, and emotional support, as well as other services (e.g., financial, legal, and transportation assistance)
to individuals and families affected by cancer (Institute of
Medicine, 2008). Although there is a dearth of research on
the effectiveness of such psychosocial services in comparison to face-to-face interventions, researchers have begun
to examine the efficacy of these methods. Telephonebased interventions have been employed as a means of
overcoming barriers (e.g., time constraints, transportation
problems, caregiving responsibilities, stigma concerns,
disability, living in a rural area) to the traditional method
of providing treatment face-to-face (Mohr et al., 2008). In
addition to the nationwide resources available to cancer
patients, psychologists have adapted psychotherapeutic
interventions to a format deliverable by telephone. Many
of these interventions have been developed to address
problems associated with cancer (e.g., fatigue and depression). Although telephone-based interventions are not the
primary method of delivery, some investigations, thus far,
have supported the value of this approach in reducing
symptom severity and distress and in improving selfmanagement (Ream, Richardson, Wiseman, Hughes, &
Forbes, 2009).
As an example of PST delivered by telephone, Allen
and colleagues (2002) conducted a study where PST was
provided to women with breast carcinoma as a means
of coping with a range of difficulties when diagnosed in
midlife. Specifically, six PST sessions were provided to 87
women with breast cancer; two were in person, and the
middle four were provided by a nurse over the phone.
Whereas PST was found generally to be an effective
approach, results were not as supportive of the efficacy
281
of this method of providing PST across all subjects.
More specifically, relative to the control group, patients
receiving PST who were characterized as “poor problem
solvers” at baseline experienced no changes in the number and severity of cancer-related difficulties. However,
patients with average or “good” problem-solving skills at
baseline were found to have improved mental health as
compared to controls as a function of the intervention.
Collectively, these results suggest that a more intensive
form of this intervention (e.g., more sessions, more faceto-face contact) may have been required for individuals
with particularly poor premorbid problem-solving ability.
More recently, Marcus and colleagues (2010)
conducted a large RCT evaluating the efficacy of a
telephone-counseling program with early-stage breast
cancer survivors. The intervention group received 16
telephone-counseling sessions over a 1-year period, along
with supplemental print materials. The intervention was
delivered by graduate students and consisted of cognitive,
behavioral, and stress management modules. The control
group received a resource directory of psychosocial
services for breast cancer. Distress, depression, sexual
dysfunction, and personal growth outcomes were assessed
at baseline and 3, 6, 12, and 18 months postenrollment.
Results indicated significant improvements in sexual dysfunction and personal growth from baseline to both 12 and
18 months for both groups, although the improvement was
greater for the intervention group. Both groups showed
significant reductions in depression and distress outcomes
over time, but when scores were dichotomized clinically,
only the intervention group showed a significant improvement in these outcomes from baseline to the 18-month
follow-up. Positive enrollment and retention rates were
reported as consistent with other telephone-based interventions, a benefit of using this telephone-based approach.
Researchers concluded that the telephone intervention was
a viable method of disseminating psychosocial services to
cancer survivors.
Another recent investigation examined the effect of
telephone-based information and support via phone calls
to male cancer patients referred to a cancer helpline by
an urologist, surgeon, or outpatient clinic (Livingston
et al., 2010). Newly diagnosed males with colorectal or
prostate cancer were randomized to one of three arms in
which they received four phone calls from the helpline,
received one call from the helpline, or were told to call
the helpline on their own initiative. These investigators
concluded that although men discussed treatment management and psychological/emotional issues during the calls,
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the intervention had little psychological impact. They further suggested that perhaps no differences among conditions occurred because this intervention did not target men
who reported elevated distress.
Mohr and colleagues (2008) performed a meta-analysis
of 12 telephone-based psychotherapeutic interventions for
depression in cancer patients and included studies comparing telephone-administered psychotherapy to treatment as
usual. Analyses revealed a significant reduction in depressive symptoms of patients receiving psychotherapy compared to individuals in the control group and a significant
change in depressive symptoms from pretreatment to posttreatment for the intervention groups. According to Mohr
and colleagues (2008), such findings support the use of
telephone-based psychotherapeutic interventions to reduce
symptoms of depression in cancer patients, with the added
benefit of lower attrition rates than those typically found
in face-to-face psychotherapeutic interventions.
Similar to the use of telephones, Web-based resources
offer patients the ability to access cancer-related information, social support, and health interventions through
a low-cost, widely available vehicle (Salzer et al., 2010).
Web-based interventions can include the use of e-mail to
contact a therapist, chat rooms and newsgroups to connect
with peers, and enhanced accessibility (Griffiths, Lindenmeyer, Powell, Lowe, and Thorogood, 2006). In addition,
the Internet can provide a method of delivering an intervention at a lower cost in a timely manner, in a way
that may be more convenient to users with less stigmatization, with increased control by both providers and
patients, and through a means that diminishes geographic,
time-, and mobility-based isolation barriers (Griffiths
et al., 2006).
Owen and colleagues (2005) examined the effect of a
self-guided, Internet-based coping skills training program
on the quality of life of 62 women diagnosed with earlystage breast cancer. Participants were randomized to either
a small online coping group or a wait-list control condition.
The treatment condition involved coping skills training
exercises, asynchronous online group discussion, information about and advice for managing physical symptoms,
various breast cancer resources, and a forum for sharing
artwork and poetry. The coping skills exercises lasted 12
weeks and aimed to facilitate the identification and expression of emotions and promotion of a positive appraisal
of cancer-related stress. Although limitations (e.g., low
power due to small sample) of the study must be considered when interpreting findings, researchers reported a
significant interaction of health status by treatment (i.e.,
women with poorer self-perceived health status showed
greater improvement in perceived health after receiving
the intervention).
Similar to the inconsistent findings about psychosocial
interventions in the cancer population, investigations of
Internet-based interventions yield results that are sensitive to intervention type, content, and population. Salzer
and colleagues (2010) conducted a pilot study examining psychological distress and quality of life in 78
recently diagnosed breast cancer patients. Women were
randomly assigned to an Internet peer support group that
was not moderated or an Internet-based educational control group. Contrary to the investigators’ hypotheses, those
in the Internet peer support condition did worse over
time on targeted outcomes. Further, no differences existed
between groups with regard to perceived social support,
self-efficacy, and hope.
Although the benefits of telecommunication technologies have been demonstrated, they also have disadvantages.
For example, Mohr and colleagues (2010) reported that,
among large groups of primary care patients interested
in behavioral treatment, 91.9% were interested or would
consider face-to-face intervention, compared to 64.6% for
telephone, and 48% for care via the Internet. Stretcher
(2007) stated that although the majority of adults in the
United States have Web access, the quality of much of the
information on the Internet can be problematic. Individuals
are often exposed to misinformation, are required to sort
through a plethora of information, and may lack privacy
in physical space, which could hamper the disclosure of
sensitive information.
Effects of Psychosocial Interventions on Health
Outcomes and Immune Functioning
In addition to its effects on psychological well-being and
quality-of-life dimensions, research has also attempted to
determine whether psychosocial interventions can actually
improve health outcomes, such as survival rates among
cancer patients. Unfortunately, the research remains tentative in its ability to provide a definitive answer (Nezu,
Nezu, Felgoise, & Peskin, 2003). For example, two oftencited studies (Fawzy et al., 1990; Spiegel, Bloom, &
Yalom, 1981) that initially found positive effects of psychological interventions on survival rates of cancer patients
were never replicated (Coyne, Stefanek, & Palmer, 2007).
However, on the other side of the debate, based on their
meta-analysis examining the effects of psychological interventions on survival time in cancer patients, Smedslund
and Ringdal (2004) suggested that a definite conclusion
regarding this issue is premature. Additional research that
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indirectly supports such a statement is a meta-analysis
indicating that psychosocial distress is associated with
higher cancer incidence, poorer survival, and higher cancer
mortality (Chida et al., 2008), suggesting that additional
research addressing the effects of psychosocial interventions on biological and health outcomes is warranted.
A more recent example of this type of research
was conducted by Andersen, Shelby, and Golden-Kreutz
(2007), who tested the effects of a psychological intervention on health outcomes, as well as the pathways
through which such change might occur. In this investigation, 227 postsurgery breast cancer patients were randomly
assigned to intervention or control groups and assessed for
psychological (distress), biological (immune), and health
outcomes (e.g., performance status, symptomatology) at
baseline and 4, and 12 months later. The intervention
incorporated various topics and techniques that had been
found effective in other studies (e.g., progressive muscle relaxation, positive coping, problem solving, and use
of social support). In support of their hypotheses, these
researchers found that their intervention both directly and
indirectly improved health outcomes as measured at the
12-month assessment point.
In a subsequent analysis of this RCT, Andersen and
colleagues (2008) evaluated whether participants in the
intervention condition showed improved survival compared to patients in the control condition. At a median of
11 years later, patients in the intervention group showed a
reduced risk of breast cancer recurrence and reduced mortality caused by breast cancer. In addition, Andersen and
colleagues (2010) further examined differences in survival
after recurrence among the original study sample. Data
on psychological, social, adherence, health, and immune
(e.g., natural killer cell cytotoxicity and T cell proliferation) outcomes were collected from 41 participants 4,
8, and 12 months after diagnosis with recurring breast
cancer. They found that all patients experienced significant distress after a recurrence diagnosis, but thereafter,
only those in the intervention group improved. Results
also indicated that patients in the intervention condition
showed a reduced risk of death following recurrence, as
well as significantly higher immune indices compared to
those in the control group at 12 months.
Although such findings appear optimistic, the impact
of psychological interventions on survival needs further
investigation. The investigation conducted by Andersen
and colleagues (2008) employed an intervention consisting of multiple psychotherapeutic components over a
period of 1 year with one sample. It is unclear which
components of the intervention are necessary to produce
283
the demonstrated benefits and whether such improvements
are likely to be found in cancer populations other than
breast cancer. Replication of this study is needed. Moreover, prior to the publication of these findings, Coyne
and colleagues (2007) suggested that prior research that
had similar aims of examining increased survival after
psychological intervention were methodologically flawed.
Further, in criticizing the study by Andersen and colleagues (2008), Stefanek, Palmer, Thombs, and Coyne
(2009) reasserted their position that no support existed for
the survival benefits attributable to psychosocial intervention. As such, it would appear that the debate continues.
FAMILY AND CAREGIVER ISSUES
In addition to the effects on patients themselves, the
experience of cancer and its treatment can significantly
affect the lives of family members, in particular, the primary caregiver, such as a spouse or partner (McClure,
Nezu, Nezu, O’Hea, & McMahon, 2012). With shifts in
health-care economics, especially toward the end of the
20th century, more care and recovery of cancer patients
takes place at home, therefore with a potentially greater
impact on the roles and responsibilities of family members (Houts, Nezu, Nezu, & Bucher, 1996; Laizner, Yost,
Barg, & McCorkle, 1993). The Administration on Aging
(2008) estimates that more than 44 million individuals are
informal, unpaid caregivers to family or friends with disabilities or who need assistance with at least one activity
of daily living. Approximately 25% of the adult population can expect to serve others in such a capacity. The
estimated economic value of lay caregivers’ provision of
care is $306 billion annually. In response, this shift in
caretaking has also increased professionals’ attention to
the vital roles, participation, and impact that the experience of cancer has on families and caregivers as they
become the extension of the health-care team (Friedman,
1999).
Impact of Cancer on Caregivers
The potential demands and subsequent burden on caregivers are significant. For example, in a study by Barg
and associates (1998), 61% of a sample of 750 caregivers
reported that caregiving was the center of their activities. In addition, 58% of this sample indicated that to
provide care, caregivers were required to give up many
other activities. For the majority of caregivers (62%), their
responsibilities to the patient warranted 24-hour-per-day
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availability, whereas the remainder of the sample provided
6 to 40 hours of care per week.
Because caregivers are laypersons who usually have
not had professional training in preparation for caring
for an individual with cancer, such demands and responsibilities can lead to significant distress (Rivera, 2009).
For example, in the Barg and colleagues (1998) sample,
89% of the caregivers reported feeling stressed by their
responsibilities. In addition, the caregivers who experienced more stress also reported significantly lowered selfesteem, less family support, more negative impact on their
schedules, more negative impact on their physical health,
and more caregiving demands than nonstressed caregivers.
Reviews of the extant literature suggest there is emotional
convergence or positive relationships between patients’
and caregivers’ distress levels (Hodges, Humphris, &
Macfarlane, 2005; Naaman, Radwan, & Johnson, 2009).
Psychological Distress
In a study conducted by Keller, Heinrich, Sellschop, and
Beutel (1996), 67% percent of a sample of caregivers
of spouses with various cancer diagnoses reported high
to very high illness-related distress levels. Further, Glasdam, Jensen, Madsen, and Rose (1996) found significantly
high levels of anxiety in 18% of 102 spouses of cancer
patients, with an additional 32% of caregivers characterized as borderline cases. In addition, a recent study of 339
colorectal cancer patients found significant marriage by
gender interaction effects in predicting psychological distress (Goldzweig et al., 2009). Specifically, men expressed
more psychological distress than women, and unmarried
persons reported more distress than married patients. Fear
of recurrence is another manifestation of psychological
distress found in a sample of 101 caregivers of head and
neck cancer patients (Hodges & Humphris, 2009). Married women and unmarried men reported less distress than
unmarried woman and married men. Further, studies of
spouses of cancer patients, many in the terminal stage of
care, have reported eating disorders, sleep disturbances,
anxiety, and depression due to the stresses of caregiving
(Kristjanson & Aschercraft, 1994).
Distress in Parents of Children with Cancer
In a longitudinal study comparing pediatric cancer patients
and their parents with matched controls, mothers of cancer
patients were found to be more distressed than mothers of
noncancer patients during treatment (Robinson, Gerhardt,
Vannatta, & Noll, 2009). No differences were found posttreatment, although mothers of cancer patients perceived
their children to have more negative internalizing disorder
symptoms. Further, some effects were found to suggest
initial parental distress was related to later young adult
internalizing symptoms. This study is consistent with an
earlier meta-analysis (Pai et al., 2007) of 29 studies that
found that mothers and fathers of children with cancer
experienced greater distress than control groups. In addition, mothers reported greater distress than fathers at the
time of diagnosis and up to 1 year later. Further, mothers
perceived their families as having greater conflict when
a child had a cancer diagnosis compared to mothers of
healthy children.
Fewer studies address how families function when parents of small children have cancer. Studies have tended
to use qualitative methodology as a means to explore this
research area. For example, a qualitative study of families
with children age 2 to 9 describes reorganization, rituals, and attempts to create normalcy and stability for the
family (Buchbinder, Longhofer, & McCue, 2009). Children older than 7 and their parents with cancer diagnoses
participated in semistructured interviews that focused on
coping and adjustment to diagnoses and life changes
(Kennedy & Lloyd-Williams, 2009). Themes addressing
initial diagnoses, life changes, coping mechanisms, and
positive aspects of the experiences were evaluated. Of
note, children perceived having more responsibilities and
less time for social activities, although they learned to
place greater value on family members and intangible
aspects of life. In another study, 56 adolescents of mothers
with breast cancer participated in a quantitative study of
stress responses and psychological functioning (Edwards
et al., 2008). Findings suggested that male and female
adolescents experience a high rate of stress (33% and
45%, respectively) and psychological problems (28% and
32%, respectively) and that maternal depression is linked
to self-reported internalizing problems in adolescents.
Impact on Health
The stress of caregiving has also been shown to have
negative biological (e.g., immunologic, cardiovascular,
metabolic) consequences for family caregivers (Vitaliano,
1997). For example, 62% percent of a sample of 465
caregivers reported declines in health resulting from their
caregiving experiences (Haley, LaMonde, Han, Burton, &
Schonwetter, 2003). Whereas some research (e.g., Hinds,
1985; Oberst, Thomas, Gass, & Ward, 1989) has identified
significant relationships between patients’ and caregivers’
physical health, as well as patients’ physical health and
caregivers’ emotional reactions, other studies have found
that the physical health of the cancer patients across
varying cancer diagnoses and stages did not directly affect
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the health of the caregiver. In fact, the patients’ emotional
well-being has been found to be a better predictor of
caregiver distress. For example, in a study of 196 patientcaregiver dyads, patient depression, and not the patient’s
medical status, mediated the relationship between patient
dependencies, symptom distress, and patient immobility
on caregivers’ physical health (Given et al., 1993).
Unmet Caregivers Needs
In addition to the impact on their psychological and physical health, caregivers have also reported that many of their
needs as caregivers continue to go unmet (Houts, Nezu,
Nezu, & Bucher, 1996). For example, Hinds (1985) interviewed 83 family caregivers and found that 53% of this
sample identified several areas of unresolved psychosocial needs. Sixteen percent of a different sample of 45
caregivers reported serious unmet needs, where 49% considered unmet informational needs to be a significant problem (Dyck & Wright, 1985). Interestingly, Sales, Schulz,
and Biegel (1992) found that younger caregivers reported
more psychological and personal needs than older caregivers.
Psychosocial Interventions for Caregivers
As a function of the increased vulnerability to negative psychological and physical effects of the cancerrelated caregiving role, various intervention strategies
have been developed to help these individuals. Such
strategies include psychoeducational and problem-solving
approaches.
Psychoeducational Interventions
Deridiarian (1989) evaluated a psychoeducational intervention that provided medical, counseling, and referral
information to caregivers, followed by two telephone calls
to check the adequacy of the information. This protocol
was compared to standard care. The aim was to measure
the caregivers’ satisfaction with the information received
and their perceived coping with the consequences of the
diagnosis (i.e., behaviors indicating problem solving and
emotional regulation). The results of this investigation
showed significant decreases in perceived need for information and increases in satisfaction and coping as a function of participating in the experimental intervention.
Problem-Solving Approaches
Several problem-solving interventions have been developed for caregivers of persons with cancer. For example,
285
using a randomized design, Toseland, Blanchard, and
McCallion (1995) evaluated a protocol including six individual counseling sessions that included both support and
training in problem-solving and coping skills. Caregivers
in a control group received standard medical care. Initial overall results comparing the intervention to usual
treatment showed no difference on a wide range of measures. However, post hoc analyses evaluating the interaction of distressed and moderately burdened caregivers
by condition showed favorable outcomes for patients
in the treatment condition. Specifically, distressed caregivers who participated in the intervention reported significant improvement in their physical, role, and social
functioning. In addition, burdened caregivers significantly
improved their ability to cope with pressing problems.
Houts and colleagues (1996) and Bucher, Houts, Nezu,
and Nezu (1999) described a problem-solving approach
to family caregiver education called the “prepared family
caregiver course,” which was adapted from the D’Zurilla
and Nezu (1999; Nezu et al., 1998) problem-solving therapy model. The course was taught over three 2-hour group
sessions and included prepared instructional videotapes to
guide interactive practice exercises, along with an instructor’s manual (Bucher et al., 1999). The Home Care Guide
for Cancer (Houts, Nezu, Nezu, Bucher, & Lipton, 1994),
an informational resource consistent with this model, was
also a key element to this training.
The premise for the problem-solving approach was the
idea that successfully solving problems increases one’s
sense of mastery and control, which, in turn, contributes to
positive mental health. Further, information, and a framework in which to gather additional information and solve
problems, can allay the uncertainty caregivers often feel:
“Have I done everything that I can do?” (Houts et al.,
1996). Caregivers are provided with information about a
series of medical (e.g., fatigue, hair loss) and psychosocial (e.g., depression, loneliness) problems and trained to
(a) better define the problem; (b) know when to obtain
professional help; (c) learn to deal with, as well as prevent, a problem; (d) identify obstacles when they arise
and plan to overcome them; and (e) effectively implement a problem-solving plan and adjust it if the initial
attempts are not successful. Results from a program evaluation study including a sample of 41 caregivers indicated
that 78% of these participants reported an improvement
in their feelings of burden and stress (Houts et al., 1996).
In addition, 48% and 58%, respectively, reported using
their plans for tiredness and depression in their caregiving. Further program evaluation investigations of the prepared family caregiver course reveal a generally high level
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of satisfaction and interest in using the information and
problem-solving skills taught to family caregivers, hospice
volunteers, home health aides, nurses, and people with
cancer (Bucher et al., 1999). Obviously, well-controlled
studies are necessary prior to making definitive conclusions about the potential efficacy of such an approach.
However, preliminary results provide promising support.
SUMMARY AND FUTURE DIRECTIONS
Cancer is the second-leading-cause of death in the United
States, surpassed only by heart disease. Despite its prevalence as a medical disease, only about 5 to 10% of all
cancers are clearly hereditary. A variety of lifestyle activities have been identified as potential risks for cancer, such
as smoking, alcohol abuse, diet, and excessive exposure
to the sun. Because such factors are behavioral in nature,
the relevance of psychology for the field of psychosocial
oncology is clear. This emerging subfield of oncology is not
only concerned with the role of cancer-related behavioral
risk factors but also with the identification of efficacious
means to reduce such risk factors, as well as to better
understand and positively affect the negative psychosocial
consequences of cancer, such as emotional distress and
decreased quality of life. The past few decades have seen
an increase in interest by psychologists in this field and the
development of effective strategies of meeting these goals.
Based on our review of the literature, we offer several
recommendations for future research that are focused
mainly on intervention studies:
1. More research should be conducted regarding efficacious interventions to improve the quality of life of cancer patients and their families. Although a substantial
body of research already exists, we need to know more
about what types of treatment approaches are effective
for what types of patients as a function of type of cancer, stage of cancer, SES, ethnic background, level of
stress experienced, and other important patient-relevant
psychosocial variables. Because of the significant personal, medical, and economic impact cancer and its
treatment represent, more research evaluating the efficacy of a wide range of psychosocial strategies should
be conducted in the future.
2. More research should be conducted regarding the
effects of psychosocial interventions on health outcome
(i.e., prolonged survival). Currently, as described earlier, the literature is equivocal in its ability to indicate
whether psychosocial treatments can have an impact on
health outcome, particularly with regard to prolonging
the life of a cancer patient.
Many of the studies that provide support for or
against such a hypothesis were not designed to specifically address this question. Well-controlled investigations capable of addressing such a question require
extensive resources. However, preliminary results suggest that such efforts may be warranted.
3. Improve the methodological rigor of the research.
Because a thorough critical analysis of the reviewed literature was beyond the scope of this chapter, we did not
document the many methodological limitations identified across the studies. We will not belabor the point,
except to list specific recommendations: (a) include adequate control groups, (b) use manualized protocols, (c)
include treatment integrity (i.e., therapist adherence and
competence) measures, and (d) use more multimodal
assessment procedures (e.g., multitrait, multimethod
approaches) for outcome measurement. In addition, special care needs to be taken in describing each population
under study in detail to allow meaningful comparisons
across studies.
4. Conduct component analyses of the intervention studies. The majority of the randomized outcome studies
reviewed simply compared an intervention to either an
alternative treatment approach (e.g., education) or a
control condition (e.g., wait-list). Additional research
strategies should be implemented to help answer the
question: “Which treatment components are responsible for the actual improvement in symptoms?” Future
research needs to be more explicit in delineating specific treatment strategies and provide an assessment of
the specific impact of a particular intervention on a
given hypothesized mechanism of action and its resulting impact on changes of interest. In that manner, a
more comprehensive and microanalytic understanding
of cause–effect relationships can be obtained. Such
research strategies include dismantling, constructive,
and parametric approaches. In addition, matching studies (i.e., matching treatment strategies with identified
patient vulnerabilities, for example, problem-solving
therapy for the depressed cancer patient with identified
problem-solving deficits) also fall in this category.
5. Identify important moderators of treatment efficacy.
Identification of important moderator variables (e.g.,
race, age, gender, cultural background, severity of
symptoms, number of symptoms) can potentially lead
to better matching of a given treatment for a particular
patient, as well as the development of more effective
interventions per se.
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6. Identify important mechanisms of action. Future
research should also address the relationship between
outcome (e.g., psychological well-being, improved
health) and a variety of variables (e.g., cognitive,
emotional, behavioral, immune system) hypothesized
to contribute to the etiopathogenesis and course of that
outcome. In this manner, salient treatment targets can
be identified and more empirically based decisions
about treatment design can be made.
7. Improve treatment implementation and access. Related
to the issue of health economics, future research should
also attempt to save costs directly related to implementing psychosocial interventions. Having a doctorallevel psychologist, for example, providing individual
or group therapy to cancer patients and their families is
likely to be viewed as having too high a price to the
health-care delivery system. As such, studies geared
to assess alternative means of conducting psychosocial interventions should be conducted in the future.
For example, additional methods exist to conduct such
treatment approaches besides the traditional use of a single therapist in face-to-face situations. Use of videos,
computers, the Internet, or telemedicine support systems represent further possibilities regarding ways to
cut costs, as well as to increase accessibility to patients
not living close to a major medical center.
8. Bridge the gap in diversity-related health-care disparities. Despite improvements in medical science, huge
gaps in research and practice still remain for various
ethnic minority populations. As a consequence, Willett
(2004) suggested that such minority and disadvantaged
groups were less likely to benefit from knowledge
about cancer prevention and early detection for various
reasons (e.g., less access to healthy foods, cultural
beliefs about individual decision affecting one’s fate).
Kagawa-Singer, Dadia, Yu, and Surbone (2010) emphasize the necessity for improving health disparities in
cancer, such as racial differences in incidence, morbidity, avoidable suffering, and mortality. These authors
point to the insufficiencies of intervention research with
regard to minority populations. As such, future research
needs to reduce barriers in the delivery of evidencebased, high-quality cancer care to these diverse
populations.
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