Psychosocial Distress

Prevalence and Predictors of Distress
Screening
        Model screening programs
        Self-report screening instruments
Psychosocial Assessment
Psychosocial Interventions for Distress
        Randomized trials of group interventions for breast cancer
        Problem-solving, focused, individual psychotherapy
        Self-administered stress management training for chemotherapy
        Brief orientation and tour of a medical oncology clinic
        Mindfulness-based stress reduction for survivors of breast cancer
        Hypnosis and relaxation prior to excisional breast biopsy
        Presurgical stress management in prostate cancer patients who are undergoing radical prostatectomy
        Use of online information
        Can psychosocial interventions increase survival?

Distress has been defined as “an unpleasant experience of an emotional, psychological, social, or spiritual nature that interferes with the ability to cope with cancer treatment. It extends along a continuum, from common normal feelings of vulnerability, sadness, and fears, to problems that are disabling, such as true depression, anxiety, panic, and feeling isolated or in a spiritual crisis.”[1] Standards of care have been developed for the management of psychosocial distress.[2]

The National Comprehensive Cancer Network (NCCN) [1] has the broad goal of establishing standards of care so that all patients experiencing psychosocial distress will be accurately and routinely identified, recognized, and treated. These guidelines include recommendations for the following:

• Screening.
• Triage.
• Initial evaluation.

Also included are referral and treatment guidelines for each participating profession:

• Mental health (psychology and psychiatry).
• Social work.
• Palliative care.
• Pastoral care.

The times most likely to require screening include the following periods during the illness when distress is most likely to occur:

• Shortly after diagnosis.
• At start of treatment (surgery, radiation, and chemotherapy).
• At conclusion of a long course of treatment.
• Periodically during posttreatment and remission.
• At time of recurrence.
• With transition to palliative care.

(Refer to the Overview section of this summary for more information.)

Although many screening instruments have been tested with cancer patients (see Table 1), the NCCN Distress Thermometer (DT) has been the most widely investigated. The psychometric properties of the DT (a 0–10 visual analogue scale, in the form of a thermometer labeled with “No Distress” at 0, “Moderate Distress” at the midpoint, and “Extreme Distress” at 10) have been investigated.[3] The measure was found to have reasonable convergent and divergent validity when compared to two more well-established, multidimensional symptom inventories. This very brief rapid-screening procedure was found to have a moderate ability to accurately detect distress as defined by scores indicative of “caseness” on the two-symptom inventories. When specific cutoff scores were tested to maximize sensitivity and specificity, no single cutoff that maximized accuracy of classification was discovered. Thus, it was recommended that varying cutoff scores result in different referral recommendations, such that low scores result in no referral, moderate scores result in an optional referral, and high scores result in a strong recommendation for further interventions.

A few studies have investigated the prevalence of distress as measured by the DT.[3-8] Prevalence rates range from 22% to 58%. Different cutoff scores have been used, with most studies using a cutoff score of 4 or 5.

Pooled results from multiple studies suggest that approximately 40% of cancer patients report significant distress.[9] Patients with lung, pancreatic, and brain cancers seem more likely to report distress, but in general, type of cancer is only modestly associated with distress.

In regard to prevalence of distress along the clinical course, one study of 236 newly diagnosed breast cancer patients (awaiting their initial consultation with a surgical oncologist) found that 41% reported distress scores higher than 5 on the DT. In this same group of women, 11% reported symptoms suggestive of major depression, and 10% reported symptoms of posttraumatic stress.[10]

In a study of 321 women with newly diagnosed stage I to stage III breast cancer, the ability of the single-item DT to specifically predict depression, as measured by a self-report questionnaire of the nine Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) symptoms for major depressive disorder, was investigated. Sensitivity and specificity characteristics were evaluated, and the optimal cutoff score of 7 was identified, resulting in a sensitivity of 0.81 and a specificity of 0.85 for detecting depression. Therefore, individuals scoring 7 or above should undergo a more thorough psychosocial evaluation.[11]

Regarding predictors of distress, in a large sample (N = 380) of patients with mixed cancer diagnoses, those reporting a score of 4 or higher on the DT were more likely to be women, to have poorer functional performance (self-reported Karnofsky Performance Scale), and to have reported (on the Problem List that accompanies the DT) problems with housing, dealing with children, dealing with partner, depression, fears, nervousness, sadness, worry, and 14 of 20 physical ailments.[4]

In regard to predictors of posttreatment distress, a longitudinal, observational study of 151 women with early-stage breast cancer found that physical symptoms and side effects experienced during treatment were predictive of posttreatment cancer-related distress, amounting to 6% of the total 24% of variance accounted for.[12] In addition, demographic variables associated with this posttreatment cancer-related distress included younger age, nonwhite racial status, and less formal education. Clinical variables associated with distress included having a mastectomy rather than lumpectomy, receiving hormonal treatment, and the presence of a diagnosable mental disorder at the time of recruitment into the study.

Screening and assessment have been viewed as two distinct processes.[13,14] Screening is a rapid method of identifying patients with psychosocial distress, typically done by using brief self-report questionnaires administered by non–mental-health professionals with the goal of determining who needs referral for more extensive assessment.[15] The psychosocial assessment of the cancer patient is a more in-depth clinical interview focused on factors relevant to coping and adaptation. Mental health professionals do the assessment interview with the goal of determining how well a patient is adjusting.[13]

Various comprehensive cancer centers have developed models for screening for psychosocial distress. Although there are notable differences, most models involve the following sequential steps:

• Screening administration.
• Scoring and evaluation.
• Referral.

Most screening for psychosocial distress is focused on the individual patient; however, some family-focused screening procedures are being developed.[16]

Administration of a screening instrument involves a brief 5- to 10-minute process in which each patient answers a series of simple, straightforward questions about distress, either orally or via a self-report questionnaire or computer. Answers are scored and evaluated on the basis of previously determined criteria. If scores are above the defined criteria, then a formal referral to the appropriate discipline (social work, psychology, psychiatry, palliative care, pastoral care) is made. Distress management then begins with a more comprehensive face-to-face psychosocial assessment interview [13] by a qualified health care professional (e.g., social worker, psychologist, psychiatrist, palliative care specialist, pastoral counselor).

Few empirical studies have evaluated the impact of structured screening programs. In two randomized, longitudinal, intervention studies, no significant differences in quality of life were found.[17,18] In one of these studies, however, a subgroup of moderately to severely depressed patients showed a significant reduction in depression following the intervention. Thus, further empirical evaluation of the effectiveness of screening programs is needed. The following examples will help to illustrate the process.

Memorial Sloan-Kettering Cancer Center has experimented with a distress thermometer modeled after those used to measure pain.[1] The descriptive anchor points on the thermometer include the following:

• “No distress” at a rating of 0.
• “Moderate distress” at a rating of 5.
• “Extreme distress” at a rating of 10.

Patients are asked, “How would you rate your distress today, on a scale of 0 to 10?” Accompanying the thermometer is a problem list that helps to identify which potential sources of stress are relevant. The patient is asked to check those problems of most relevance. Categories of problems include the following:

• Practical (e.g., housing, insurance, transportation).
• Physical (e.g., pain, nausea, fatigue).
• Family or support (e.g., partner, children, friends).
• Emotional (e.g., worry, sadness, depression, anger).
• Spiritual/religious (e.g., relating to God, loss of faith).

The primary oncology team (oncologist, nurse, palliative care specialist, social worker) is responsible for administering and evaluating a patient’s response to this brief screening and arranging for referral, when necessary. Preliminary testing of this procedure used a cutoff score of 5 or higher as requiring further evaluation. Initial needs assessments have shown that 20% to 35% of patients report significant levels of distress.

At Johns Hopkins Cancer Center, all new patients are given an 18-item version of the Brief Symptom Inventory (BSI),[19] which lists 18 problems people sometimes experience (e.g., faintness or dizziness, no interest in things, loneliness, nausea or upset stomach). They are asked, “How much were you distressed by” each of the 18 problems “during the past 7 days including today?” The procedure is automated and utilizes existing clerical and support staff to distribute and retrieve the inventory during the first or second visit.[14] After computerized scoring is completed, professional staff is involved when offers for services are being provided. Those screened as having high distress are referred to a social worker for immediate follow-up, while those screened as having low distress are referred to the psychosocial orientation program. This is a structured educational program designed to enhance the adaptation of patients by providing information about a range of psychosocial programs (e.g., disease-specific support groups, psychoeducational presentations).

The Oncology Symptom Control Research group at Community Cancer Care typically screens all incoming patients with the Zung Self-Rating Depression Scale (ZSDS).[20,21] The ZSDS is a 20-item self-report depression screen that has been used to detect depression and more general distress; single items are also used to screen for conditions such as fatigue.[22] Staff typically administer the screen while patients are in the waiting room. Scores are analyzed immediately after completion so that the medical oncologists can be briefed on any pertinent issues. In addition, patients scoring in the moderate range or higher are identified for further follow-up and more extensive interviews and assessment by the staff psychiatrist or psychologist. Also, patients who trigger single items of interest such as fatigue are interviewed and followed for possible inclusion in a number of symptom-control research trials.

The NCCN single-item, rapid-screening instrument asks patients to rate their distress on a scale of 0 (“no distress”) to 10 (“extreme distress”). On an accompanying problem list they are asked to indicate what has been a problem for them in the past week. Studies [3-5,23,24] have tested the ability of the single-item measure to accurately identify patients in distress. In general, these ultrashort screening methods have demonstrated only modest overall accuracy. They are best for ruling out distress, anxiety, and depression but performed poorly at confirming distress, anxiety, or depression. Many other self-report questionnaires have been used as screening instruments (see Table 1); in general, they also are better for ruling out distress and perform poorly at confirming distress. Thus, most screening instruments will yield a high number of false-positive results and therefore need to be followed by a more extensive psychosocial assessment interview.

Self-report screening instruments must be scored, evaluated, and discussed with each patient. Triage—the process of communicating screening results, discussing each patient’s needs, and determining the best course of further action—is key to the successful use of screening. In fact, screening without availability of appropriate treatment resources is considered unethical. The NCCN standards of care [1] suggest distress rated as mild might result in a referral to a local self-help group or management by the primary oncology team only. Distress rated as moderate to severe warrants referral to other appropriate professionals (psychologists, psychiatrists, social workers, palliative care specialists, or pastoral counselors), depending on the nature of the distress.

The primary oncology team (oncologist, nurse, palliative care specialist, social worker, and counselor) is responsible for successful triage. In some studies a significant percentage of patients who report moderate to high levels of distress refuse further assessment.[6,7,31,32] Thus, it is important to consider how the primary oncology team can introduce the need for further psychosocial assessment.

The assessment of psychosocial adaptation should follow screening in which distress is identified. The psychosocial assessment is typically a semistructured interview during which the professional evaluates how well an individual patient, a patient’s family, and other significant people in a patient’s life are adapting to the current demands of the illness. In general, this assessment process will consider a wide variety of factors relevant to overall adaptation. (Refer to the General Factors Influencing Adjustment section of this summary for more information.)

A successful transition from screening to assessment involves clear communication between the oncology team and the patient. Although there is no single best way to talk to patients about psychosocial needs, clinical experience suggests some important concepts. First, most patients will respond to the recommendations of health care professionals who exhibit trust, expertise, warmth, care, and concern.

Choice of words is important. Words that suggest the stigma of serious mental illness, such as psychiatric, psychological, mental disorder, maladjustment, or mental illness, should be avoided—in favor of words such as distress, concerns, worries, uncertainties, or stressors from the illness or its treatment. Suggestions for word choice include the following:

• The questionnaire you filled out helps us to understand you as a whole person, and we want to provide the best care possible for you—physically, emotionally, socially, and spiritually.

• As you may realize, a serious illness can affect the quality of your life in many ways (emotionally, socially, work, relationships, finances, energy). There is much more to this illness than just the physical, and we want to be sure we are addressing these other dimensions of your life.

• Your concerns and worries are very understandable, given your illness and its treatment. We don’t want to ignore the (emotional, social, spiritual) aspects of your experience right now.

• We have found that many patients benefit greatly from a chance to talk further about their concerns with a (social worker, mental health professional, palliative care specialist, or pastoral counselor), and we would like to schedule that for you.

• For further explanation, we suggest an interview that lasts about 45 minutes with a professional who will:
  • Listen closely to you.

  • Want to know about your experiences with your illness.

  • Ask about you, your family and friends, and other support persons.

  • Ask about how you have been adjusting to your illness and may encourage you to continue (and give you feedback about) successful coping strategies you are already using.

  • Have suggestions about additional ways to address your concerns.

The efficacy of psychosocial interventions in adult cancer patients is supported by an extensive literature.[33][Level of evidence: IV];[34-36][Level of evidence: I] Reviews have concluded that, in general, psychosocial interventions for cancer patients have shown positive benefits.

Psychosocial interventions have generally been defined as nonpharmacologic interventions that include a variety of psychological and educational components. Typical components include the following:

• Relaxation training.
• Cognitive and behavioral coping strategies.
• Cancer education/information sessions.
• Group social support.

Interventions have included various combinations of these components, have varied in length (single session to multiple weekly sessions), and have been administered in both individual and group formats. The most common patient population has been U.S. Caucasian women of middle to higher socioeconomic status who have breast cancer; however, some studies include mixed cancer diagnoses, and studies from European countries have appeared.[33] Outcome measures have varied and have included the following:[33,34]

• Emotional adjustment (e.g., depression, anxiety).
• Functional impairment (e.g., return to work, social roles).
• Disease-related symptoms (e.g., nausea/vomiting, fatigue, pain).
• Health behaviors (e.g., diet, smoking, exercise).
• Immune system functioning.

A biobehavioral model [33] hypothesizing psychological, behavioral, and biologic pathways from cancer stressors to disease outcome has guided much of this research; however, the most common outcome measured has been emotional adjustment.

Although positive benefits have been found, their clinical significance has been questioned. Reviewers have offered varying conclusions regarding the size of these positive effects,[34][Level of evidence: I] ranging from negligible for depression, to small for overall emotional outcomes, to moderate for anxiety.[35][Level of evidence: I]

Effect sizes may be related to the timing of the intervention and patient selection procedures. For most patients, levels of psychosocial distress are highest during the earliest days of their cancer experience and, for many, dissipate quickly. Thus, if interventions are offered later in the cancer experience (weeks or months after diagnosis and treatment), patients may be experiencing less distress than they would have experienced if interventions had been offered earlier, making large effects more difficult to detect.[37][Level of evidence: II]

In one study,[38] 249 breast cancer patient-partner dyads were randomly assigned to one of four groups:

• A control group receiving standard disease management.
• A standardized psychoeducation group.
• A group receiving telephone counseling.
• A group receiving psychoeducation plus telephone counseling.

Patients and partners who received the study interventions had less side-effect distress and severity as well as higher levels of psychological well-being than those who received standard care. In addition, the study supports the efficacy of low-cost, replicable interventions by video and telephone to achieve these physical and psychological benefits.[38]

Two meta-analytic reviews [34,35][Level of evidence: I] report the following effect sizes:

• 0.19 for depression [35] and functional adjustment.[34]

• 0.24 for emotional adjustment.[34]

• 0.26 for treatment- or disease-related symptoms.[34]

• 0.28 for global measures of outcome.[34]

• 0.36 for anxiety.[35]

These positive effect sizes indicate that the average patient receiving the intervention is better off than between 57% and 65% of those not receiving the intervention.

In summary, it appears that when psychosocial interventions are offered to patients who are found to be experiencing distress (e.g., anxiety, depression), the efficacy of the intervention is very strong. Thus, the overall positive benefit for psychosocial interventions seems to be greater with those who seem to need it most.[34,35]

The four studies described below are representative of randomized clinical trials testing the efficacy of small-group psychosocial interventions for U.S. women with early-stage breast cancer. Note that the studies vary in total treatment time, from 8 hours [39][Level of evidence: I] to 20 hours [37,40][Level of evidence: II] to 27 hours,[41][Level of evidence: I] and have a variety of intervention components.

Investigators tested the efficacy of a 10-week, 2-hours-per-week group cognitive-behavioral stress management intervention.[37] One hundred newly treated women with breast cancer were randomly assigned to either the intervention or to a control condition. The psychosocial intervention consisted of ten 2-hour group sessions during which didactic material was presented, intermixed with a variety of experiential exercises and homework assignments. The overall intervention focused on learning to cope better with daily cancer-related stressors. Topics included the following:

• Progressive muscle relaxation with imagery.
• Cognitive restructuring.
• Interpersonal conflict resolution.
• Assertion training.
• Enhanced social support.

The control condition consisted of a day-long seminar in which participants received a condensed version of the intervention with significantly less time to interact within the group. Among intervention participants, results showed the following:

• A decrease in depression.
• No change in other measures of emotional distress.
• An increase in “benefit finding” (i.e., reporting that having breast cancer had made positive contributions to their lives) and optimism.

In a larger (N = 199) randomized study conducted by the same research group [40] on women with stage 0 to stage III nonmetastatic breast cancer, an intervention similar to that in the first study produced somewhat greater sustained decreases in cancer-related intrusive thoughts and sustained improvements in anxiety.

Another study examined an 18-week, 1.5-hours-per-week group intervention consisting of psychological strategies designed to reduce stress, enhance mood, alter health behaviors (diet, exercise, smoking), and enhance adherence to cancer treatments.[41] Outcome measures included emotional distress, health behaviors, and immune responses. Two hundred twenty-seven women, all of whom had received surgery for regional breast cancer, were randomly assigned to either the intervention group or an assessment-only control condition. Compared with the control group, the intervention group showed the following:

• Significantly less anxiety.
• Improved social support.
• Better dietary behaviors.
• Reduced smoking.
• Increase in symptom reduction and functional status.[42]

Immune responses in the intervention group were consistent with the psychological and behavioral changes. This study is a strong example of efforts to measure changes in a variety of biobehavioral (psychological, behavioral, immune) variables after a psychosocial intervention.

Other investigators evaluated an educational intervention consisting of 2-hour once-per-month group sessions for 4 consecutive months.[39][Level of evidence: I] Participants were 252 women younger than 50 years who had early-stage breast cancer, who had recently completed nonhormonal adjuvant treatment, and who were facing the transition from active treatment to posttreatment survivorship. They were randomly assigned to one of three groups:

• A standard medical care group.
• A nutrition education group.
• A psychosocial education group.

The psychosocial and nutrition education groups included information dissemination, discussion, and some activities/exercises. Topics rotated monthly, and participants could join a group at any time (i.e., the groups were open groups). In general, patient-to-patient interaction was minimal because sessions were more didactic presentations. The psychosocial education group presented topics relevant to younger women with breast cancer, such as the following:

• Talking with children about cancer.
• How to carry on with life after a diagnosis.
• Relationships/intimacy with partners.
• Hormones and cancer.
• Genetic bases of breast cancer.

The nutrition education group included information about choosing fruits, vegetables, and low-fat foods and how to consistently incorporate these foods into daily life. Shopping, low-fat cooking, eating out, and other related topics were presented. Results showed that patients in both of the intervention groups reported fewer depressive symptoms and better physical functioning at a 13-month follow-up. This study is an example of a more targeted intervention designed for a specific patient population (younger women with breast cancer) at a specific time in their treatment course (soon after completion of active treatment).

A variety of individual psychosocial interventions have been studied. One study emphasized the development of problem-solving abilities.[43][Level of evidence: II] In this study, the psychosocial intervention consisted of ten 1.5-hour weekly individual psychotherapy sessions (either with or without a significant other present) that focused on training to become an effective problem solver. Four rational problem-solving tasks were emphasized that included skills in the following areas:

• Better defining and formulating the nature of problems.
• Generating a wide range of alternative solutions.
• Systematically evaluating potential consequences of a solution while deciding on the optimal ones.
• Evaluating the eventual outcome after solution implementation.

Between-session homework with tasks relevant to each step was assigned, and patients received a written manual and were encouraged to refer to it as problems arose. One hundred thirty-two adult cancer patients with mixed cancer diagnoses were randomly assigned to two treatment groups and one wait-list control. The two treatment groups included individual problem-solving therapy alone and problem-solving therapy with a significant other (e.g., spouse, friend, adult child) present.

Overall results showed that participants in the two treatment groups were more effective problem-solvers and experienced less psychological distress and improved quality of life. No differences between treatment groups were found.[43] In this example, an individual psychotherapeutic intervention designed to increase a patient’s problem-solving abilities was shown to result in a better quality of life and less psychological distress.

In a randomized trial of 411 mixed-diagnosis cancer patients,[44][Level of evidence: I] traditional psychosocial care was compared with professionally administered and self-administered stress management for chemotherapy. The professional stress management consisted of a 60-minute individual educational session that included a review of common sources of chemotherapy-related stress and three specific stress-management techniques:

• Paced abdominal breathing.
• Progressive muscle relaxation with imagery.
• The use of coping self-statements.

The professional provided the patient with an audiotape of the individual session, prescribed daily practice of the three techniques, and met briefly with the patient before his or her first chemotherapy session.

In the self-administered group, a professional met with each patient for approximately 10 minutes, provided him or her with a packet of instructional materials about coping with chemotherapy, and briefly instructed the patient on their use. These materials included all of the same information provided in the professionally administered group plus the following:

• A 15-minute videotape.
• A 12-page booklet.
• A 35-minute relaxation audiotape.

Patients in this group were instructed to first view the videotape and then review the booklet, following its instructions for further training, practice, and use of the various techniques.

Results of this novel approach found that patients in the self-administered intervention reported significantly better physical functioning, vitality, and mental health and fewer role limitations than those reported by either of the other two groups. Patients in the professionally administered group reported no better outcomes than patients in the traditional-care group. Costs of the self-administered group were found to be significantly lower than those of the other two groups.

A novel intervention tested the effects of a brief (15- to 20-minute) clinic tour for new patients in a medical oncology clinic.[45][Level of evidence: I] The tour included the following:

• An opportunity to see the phlebotomy, nursing, and chemotherapy areas.
• The distribution of written materials about clinic hours and procedures.
• A time to ask questions.

One hundred and fifty consecutively referred patients who had a variety of cancers were randomly assigned to either the clinic orientation condition or to standard care. Intervention patients showed less anxiety, less mood disturbance, and fewer depressive symptoms at a 1-week follow-up. In addition, these patients reported more knowledge of clinic procedures, more confidence in their physicians, and higher levels of satisfaction and hope. This is an example of how even a simple, minimal intervention can have positive benefits.

A randomized controlled trial of a 6-week mindfulness-based stress reduction intervention, compared with usual care, was conducted with 84 female survivors of breast cancer.[46] All participants were within 18 months of completion of surgery, chemotherapy, and/or radiation therapy and were thus in the transitional period from completion of active treatment to posttreatment survivorship. The intervention consisted of weekly 2-hour group sessions conducted by a psychologist who followed a standardized protocol to teach participants sitting meditation, body scan, walking meditation, and gentle yoga. All participants received a training manual and four audiotapes to support home practice and were encouraged to practice daily.

Results included the following:[46]

• The intervention group showed improvements in psychological measures (fear of recurrence, recurrence concerns, state-trait anxiety, and depression) and quality of life (physical functioning, role limitations, and energy).

• Those who practiced more frequently tended to show greater improvements.

In one study, a group of women scheduled for excisional breast biopsy (N = 90) were randomly assigned either to a brief session (15 minutes) of hypnosis and guided relaxation delivered by trained clinical psychologists on the day of surgery or to an attention-control empathic listening session of equal length. Presurgery distress was measured by the visual analogue scale and the short version of the Profile of Mood States. The hypnosis session markedly decreased anticipatory anxiety and increased relaxation measured just prior to the biopsy.[47][Level of evidence: II]

A three-arm, randomized, controlled trial (N = 159) of a two-session (60–90 minutes) individual stress management intervention administered 1–2 weeks before radical prostatectomy for men with prostate cancer was found to have a positive impact on a number of immune system parameters (higher natural killer cell cytotoxicity and circulating proinflammatory cytokines).[48][Level of evidence: I] Statistically significant differences in immune outcomes were found only in the intervention group over a supportive attention group and a standard care group.

Stress management tools included the following:

• Cognitive-behavioral interventions, including relaxation skills, diaphragmatic breathing, and guided imagery.
• Audiotapes for home practice.
• A written guide summarizing relevant information.
• Problem-focused coping strategies.

Improved immune outcomes were found at 48 hours postsurgery in the stress management group only.[48] A particular strength of this study is the use of a supportive attention group and a standard care group.

The Comprehensive Health Enhancement Support System (CHESS) [49] is an online resource for cancer patients that has been available for more than 5 years. It has two components:

1. Didactic material.
2. Narrative information about medical, practical, and psychosocial issues.

This study addressed the relative appeal and value of these two components separately for Caucasian and African American women who had been diagnosed with breast cancer (three-fourths of participants had early-stage disease). The average time spent online with either type of resource was slightly longer for African American women (didactic: 19.7 minutes, standard deviation [SD] = 31.10; narrative: 17.16 minutes, SD = 38.19) than for Caucasian women (didactic: 18.30 minutes, SD = 28.62; narrative: 15.78 minutes, SD = 36.60) but had substantially more effect.

Before using the resource, African American women were markedly lower in health care participation; after use, African American women increased health care participation markedly, regardless of type of resource, surpassing the level of health care participation by Caucasian women, particularly in regard to the effect of the didactic services. This result suggests that while the use of both the didactic and narrative CHESS resources is valuable for both groups, it is particularly useful for African American women; the narrative resource version appears to differentially have more impact for Caucasian women.

The intriguing question of whether participation in a psychosocial group intervention can result in increased survival has been investigated since 1989. The original study [50] tested a supportive-expressive group therapy format for women with metastatic breast cancer, while another study [51] tested a psychoeducational group intervention for patients with malignant melanoma. In both of these studies, a survival advantage was found in the intervention group. However, a critique of the first study [52] found that members of the control group had significantly shorter survival times than would have been expected, when compared with data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program, suggesting that the survival advantages may have resulted from inadvertent sampling errors.

Attempts to replicate the supportive-expressive group therapy findings were made in Canada,[53] the United States,[54] and Australia.[55] Although all three studies found significant psychological benefits, no study could replicate the survival benefit.

Literature reviews, including three meta-analyses [56-58] and one systematic review,[59] have concluded that previous research has failed to find an effect of psychotherapy on survival. One summary [60] reported on ten additional randomized controlled trials of various psychosocial interventions for patients with various types of cancers (although most were women with breast cancer). All ten studies noted improved psychosocial benefits. However, nine of the ten showed no significant differences in survival, while one [61] found a survival advantage of about 1 year. This one positive trial was able to stratify groups on a number of important variables (e.g., nodal status, estrogen receptor and progesterone receptor status, and menopausal status) and provided data in support of possible mechanisms such as enhanced immune functioning and patient compliance with stress reduction procedures. In a careful analyses of results, this study identified the complexity of factors involved in any survival benefit and the possibility that immune system-mediated benefits may contribute to increased survival, when other factors are carefully taken into account.

In summary, the preponderance of evidence indicates that despite evidence of improved quality of life, it seems unlikely that a psychosocial intervention has much chance of showing an independent contribution to survival time. This evidence has caused some to suggest [62] that continued research into this question is no longer warranted.

1. NCCN practice guidelines for the management of psychosocial distress. National Comprehensive Cancer Network. Oncology (Huntingt) 13 (5A): 113-47, 1999.  [PUBMED Abstract]
   
   
2. Fashoyin-Aje LA, Martinez KA, Dy SM: New patient-centered care standards from the commission on cancer: opportunities and challenges. J Support Oncol 10 (3): 107-11, 2012 May-Jun.  [PUBMED Abstract]
   
   
3. Hoffman BM, Zevon MA, D'Arrigo MC, et al.: Screening for distress in cancer patients: the NCCN rapid-screening measure. Psychooncology 13 (11): 792-9, 2004.  [PUBMED Abstract]
   
   
4. Jacobsen PB, Donovan KA, Trask PC, et al.: Screening for psychologic distress in ambulatory cancer patients. Cancer 103 (7): 1494-502, 2005.  [PUBMED Abstract]
   
   
5. Akizuki N, Akechi T, Nakanishi T, et al.: Development of a brief screening interview for adjustment disorders and major depression in patients with cancer. Cancer 97 (10): 2605-13, 2003.  [PUBMED Abstract]
   
   
6. Roth AJ, Kornblith AB, Batel-Copel L, et al.: Rapid screening for psychologic distress in men with prostate carcinoma: a pilot study. Cancer 82 (10): 1904-8, 1998.  [PUBMED Abstract]
   
   
7. Ibbotson T, Maguire P, Selby P, et al.: Screening for anxiety and depression in cancer patients: the effects of disease and treatment. Eur J Cancer 30A (1): 37-40, 1994.  [PUBMED Abstract]
   
   
8. Trask PC, Paterson A, Riba M, et al.: Assessment of psychological distress in prospective bone marrow transplant patients. Bone Marrow Transplant 29 (11): 917-25, 2002.  [PUBMED Abstract]
   
   
9. Carlson LE, Waller A, Mitchell AJ: Screening for distress and unmet needs in patients with cancer: review and recommendations. J Clin Oncol 30 (11): 1160-77, 2012.  [PUBMED Abstract]
   
   
10. Hegel MT, Moore CP, Collins ED, et al.: Distress, psychiatric syndromes, and impairment of function in women with newly diagnosed breast cancer. Cancer 107 (12): 2924-31, 2006.  [PUBMED Abstract]
    
    
11. Hegel MT, Collins ED, Kearing S, et al.: Sensitivity and specificity of the Distress Thermometer for depression in newly diagnosed breast cancer patients. Psychooncology 17 (6): 556-60, 2008.  [PUBMED Abstract]
    
    
12. Jim HS, Andrykowski MA, Munster PN, et al.: Physical symptoms/side effects during breast cancer treatment predict posttreatment distress. Ann Behav Med 34 (2): 200-8, 2007 Sep-Oct.  [PUBMED Abstract]
    
    
13. Nicholas DR, Veach TA: The psychosocial assessment of the adult cancer patient. Prof Psychol 31 (2): 206-15, 2000. 
    
    
14. Zabora JR: Screening procedures for psychosocial distress. In: Holland JC, Breitbart W, Jacobsen PB, et al., eds.: Psycho-oncology. New York, NY: Oxford University Press, 1998, pp 653-61. 
    
    
15. Zabora JR, Smith-Wilson R, Fetting JH, et al.: An efficient method for psychosocial screening of cancer patients. Psychosomatics 31 (2): 192-6, 1990 Spring.  [PUBMED Abstract]
    
    
16. Kissane DW, McKenzie M, McKenzie DP, et al.: Psychosocial morbidity associated with patterns of family functioning in palliative care: baseline data from the Family Focused Grief Therapy controlled trial. Palliat Med 17 (6): 527-37, 2003.  [PUBMED Abstract]
    
    
17. McLachlan SA, Allenby A, Matthews J, et al.: Randomized trial of coordinated psychosocial interventions based on patient self-assessments versus standard care to improve the psychosocial functioning of patients with cancer. J Clin Oncol 19 (21): 4117-25, 2001.  [PUBMED Abstract]
    
    
18. Maunsell E, Brisson J, Deschênes L, et al.: Randomized trial of a psychologic distress screening program after breast cancer: effects on quality of life. J Clin Oncol 14 (10): 2747-55, 1996.  [PUBMED Abstract]
    
    
19. Derogatis LR, Melisaratos N: The Brief Symptom Inventory: an introductory report. Psychol Med 13 (3): 595-605, 1983.  [PUBMED Abstract]
    
    
20. Zung WW: Depression in the normal aged. Psychosomatics 8 (5): 287-92, 1967 Sep-Oct.  [PUBMED Abstract]
    
    
21. Zung WW: Factors influencing the self-rating depression scale. Arch Gen Psychiatry 16 (5): 543-7, 1967.  [PUBMED Abstract]
    
    
22. Kirsh KL, Passik S, Holtsclaw E, et al.: I get tired for no reason: a single item screening for cancer-related fatigue. J Pain Symptom Manage 22 (5): 931-7, 2001.  [PUBMED Abstract]
    
    
23. Dabrowski M, Boucher K, Ward JH, et al.: Clinical experience with the NCCN distress thermometer in breast cancer patients. J Natl Compr Canc Netw 5 (1): 104-11, 2007.  [PUBMED Abstract]
    
    
24. Keir ST, Calhoun-Eagan RD, Swartz JJ, et al.: Screening for distress in patients with brain cancer using the NCCN's rapid screening measure. Psychooncology 17 (6): 621-5, 2008.  [PUBMED Abstract]
    
    
25. Kugaya A, Akechi T, Okuyama T, et al.: Prevalence, predictive factors, and screening for psychologic distress in patients with newly diagnosed head and neck cancer. Cancer 88 (12): 2817-23, 2000.  [PUBMED Abstract]
    
    
26. Zigmond AS, Snaith RP: The hospital anxiety and depression scale. Acta Psychiatr Scand 67 (6): 361-70, 1983.  [PUBMED Abstract]
    
    
27. Love AW, Kissane DW, Bloch S, et al.: Diagnostic efficiency of the Hospital Anxiety and Depression Scale in women with early stage breast cancer. Aust N Z J Psychiatry 36 (2): 246-50, 2002.  [PUBMED Abstract]
    
    
28. Cella DF, Tulsky DS, Gray G, et al.: The Functional Assessment of Cancer Therapy scale: development and validation of the general measure. J Clin Oncol 11 (3): 570-9, 1993.  [PUBMED Abstract]
    
    
29. McNair DM, Lorr M, Droppleman LF: Profile of Mood States Manual. San Diego, Calif: Educational and Industrial Testing Service, 1992. 
    
    
30. Dugan W, McDonald MV, Passik SD, et al.: Use of the Zung Self-Rating Depression Scale in cancer patients: feasibility as a screening tool. Psychooncology 7 (6): 483-93, 1998 Nov-Dec.  [PUBMED Abstract]
    
    
31. Carroll BT, Kathol RG, Noyes R Jr, et al.: Screening for depression and anxiety in cancer patients using the Hospital Anxiety and Depression Scale. Gen Hosp Psychiatry 15 (2): 69-74, 1993.  [PUBMED Abstract]
    
    
32. Razavi D, Delvaux N, Farvacques C, et al.: Screening for adjustment disorders and major depressive disorders in cancer in-patients. Br J Psychiatry 156: 79-83, 1990.  [PUBMED Abstract]
    
    
33. Andersen BL: Biobehavioral outcomes following psychological interventions for cancer patients. J Consult Clin Psychol 70 (3): 590-610, 2002.  [PUBMED Abstract]
    
    
34. Meyer TJ, Mark MM: Effects of psychosocial interventions with adult cancer patients: a meta-analysis of randomized experiments. Health Psychol 14 (2): 101-8, 1995.  [PUBMED Abstract]
    
    
35. Sheard T, Maguire P: The effect of psychological interventions on anxiety and depression in cancer patients: results of two meta-analyses. Br J Cancer 80 (11): 1770-80, 1999.  [PUBMED Abstract]
    
    
36. Barsevick AM, Sweeney C, Haney E, et al.: A systematic qualitative analysis of psychoeducational interventions for depression in patients with cancer. Oncol Nurs Forum 29 (1): 73-84; quiz 85-7, 2002 Jan-Feb.  [PUBMED Abstract]
    
    
37. Antoni MH, Lehman JM, Kilbourn KM, et al.: Cognitive-behavioral stress management intervention decreases the prevalence of depression and enhances benefit finding among women under treatment for early-stage breast cancer. Health Psychol 20 (1): 20-32, 2001.  [PUBMED Abstract]
    
    
38. Budin WC, Hoskins CN, Haber J, et al.: Breast cancer: education, counseling, and adjustment among patients and partners: a randomized clinical trial. Nurs Res 57 (3): 199-213, 2008 May-Jun.  [PUBMED Abstract]
    
    
39. Scheier MF, Helgeson VS, Schulz R, et al.: Interventions to enhance physical and psychological functioning among younger women who are ending nonhormonal adjuvant treatment for early-stage breast cancer. J Clin Oncol 23 (19): 4298-311, 2005.  [PUBMED Abstract]
    
    
40. Antoni MH, Wimberly SR, Lechner SC, et al.: Reduction of cancer-specific thought intrusions and anxiety symptoms with a stress management intervention among women undergoing treatment for breast cancer. Am J Psychiatry 163 (10): 1791-7, 2006.  [PUBMED Abstract]
    
    
41. Andersen BL, Farrar WB, Golden-Kreutz DM, et al.: Psychological, behavioral, and immune changes after a psychological intervention: a clinical trial. J Clin Oncol 22 (17): 3570-80, 2004.  [PUBMED Abstract]
    
    
42. Andersen BL, Farrar WB, Golden-Kreutz D, et al.: Distress reduction from a psychological intervention contributes to improved health for cancer patients. Brain Behav Immun 21 (7): 953-61, 2007.  [PUBMED Abstract]
    
    
43. Nezu AM, Nezu CM, Felgoise SH, et al.: Project Genesis: assessing the efficacy of problem-solving therapy for distressed adult cancer patients. J Consult Clin Psychol 71 (6): 1036-48, 2003.  [PUBMED Abstract]
    
    
44. Jacobsen PB, Meade CD, Stein KD, et al.: Efficacy and costs of two forms of stress management training for cancer patients undergoing chemotherapy. J Clin Oncol 20 (12): 2851-62, 2002.  [PUBMED Abstract]
    
    
45. McQuellon RP, Wells M, Hoffman S, et al.: Reducing distress in cancer patients with an orientation program. Psychooncology 7 (3): 207-17, 1998 May-Jun.  [PUBMED Abstract]
    
    
46. Lengacher CA, Johnson-Mallard V, Post-White J, et al.: Randomized controlled trial of mindfulness-based stress reduction (MBSR) for survivors of breast cancer. Psychooncology 18 (12): 1261-72, 2009.  [PUBMED Abstract]
    
    
47. Schnur JB, Bovbjerg DH, David D, et al.: Hypnosis decreases presurgical distress in excisional breast biopsy patients. Anesth Analg 106 (2): 440-4, table of contents, 2008.  [PUBMED Abstract]
    
    
48. Cohen L, Parker PA, Vence L, et al.: Presurgical stress management improves postoperative immune function in men with prostate cancer undergoing radical prostatectomy. Psychosom Med 73 (3): 218-25, 2011.  [PUBMED Abstract]
    
    
49. Wise M, Han JY, Shaw B, et al.: Effects of using online narrative and didactic information on healthcare participation for breast cancer patients. Patient Educ Couns 70 (3): 348-56, 2008.  [PUBMED Abstract]
    
    
50. Spiegel D, Bloom JR, Kraemer HC, et al.: Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet 2 (8668): 888-91, 1989.  [PUBMED Abstract]
    
    
51. Fawzy FI, Fawzy NW, Hyun CS, et al.: Malignant melanoma. Effects of an early structured psychiatric intervention, coping, and affective state on recurrence and survival 6 years later. Arch Gen Psychiatry 50 (9): 681-9, 1993.  [PUBMED Abstract]
    
    
52. Fox BH: A hypothesis about Spiegel et al.'s 1989 paper on Psychosocial intervention and breast cancer survival. Psychooncology 7 (5): 361-70, 1998 Sep-Oct.  [PUBMED Abstract]
    
    
53. Goodwin PJ, Leszcz M, Quirt G, et al.: Lessons learned from enrollment in the BEST study--a multicenter, randomized trial of group psychosocial support in metastatic breast cancer. J Clin Epidemiol 53 (1): 47-55, 2000.  [PUBMED Abstract]
    
    
54. Classen C, Butler LD, Koopman C, et al.: Supportive-expressive group therapy and distress in patients with metastatic breast cancer: a randomized clinical intervention trial. Arch Gen Psychiatry 58 (5): 494-501, 2001.  [PUBMED Abstract]
    
    
55. Kissane DW, Love A, Hatton A, et al.: Effect of cognitive-existential group therapy on survival in early-stage breast cancer. J Clin Oncol 22 (21): 4255-60, 2004.  [PUBMED Abstract]
    
    
56. Newell SA, Sanson-Fisher RW, Savolainen NJ: Systematic review of psychological therapies for cancer patients: overview and recommendations for future research. J Natl Cancer Inst 94 (8): 558-84, 2002.  [PUBMED Abstract]
    
    
57. Chow E, Tsao MN, Harth T: Does psychosocial intervention improve survival in cancer? A meta-analysis. Palliat Med 18 (1): 25-31, 2004.  [PUBMED Abstract]
    
    
58. Smedslund G, Ringdal GI: Meta-analysis of the effects of psychosocial interventions on survival time in cancer patients. J Psychosom Res 57 (2): 123-31; discussion 133-5, 2004.  [PUBMED Abstract]
    
    
59. Edwards AG, Hailey S, Maxwell M: Psychological interventions for women with metastatic breast cancer. Cochrane Database Syst Rev (2): CD004253, 2004.  [PUBMED Abstract]
    
    
60. Kissane DW: Survival following psychotherapy interventions. In: Holland JC, Breitbart WS, Jacobsen PB, et al., eds.: Psycho-oncology. 2nd ed. New York, NY: Oxford University Press, Inc., 2010, pp 479-82. 
    
    
61. Andersen BL, Yang HC, Farrar WB, et al.: Psychologic intervention improves survival for breast cancer patients: a randomized clinical trial. Cancer 113 (12): 3450-8, 2008.  [PUBMED Abstract]
    
    
62. Coyne JC, Stefanek M, Palmer SC: Psychotherapy and survival in cancer: the conflict between hope and evidence. Psychol Bull 133 (3): 367-94, 2007.  [PUBMED Abstract]