Effects and moderators of psychosocial interventions on quality of life, and emotional and social function in patients with cancer: An individual patient data meta-analysis of 22 RCTs.

OBJECTIVE: This individual patient data (IPD) meta-analysis aimed to evaluate the effects of psychosocial interventions (PSI) on quality of life (QoL), emotional function (EF), and social function (SF) in patients with cancer, and to study moderator effects of demographic, clinical, personal, and intervention-related characteristics. METHODS: Relevant studies were identified via literature searches in 4 databases. We pooled IPD from 22 (n = 4217) of 61 eligible randomized controlled trials. Linear mixed-effect model analyses were used to study intervention effects on the post-intervention values of QoL, EF, and SF (z-scores), adjusting for baseline values, age, and cancer type. We studied moderator effects by testing interactions with the intervention for demographic, clinical, personal, and intervention-related characteristics, and conducted subsequent stratified analyses for significant moderator variables. RESULTS: PSI significantly improved QoL (ß = 0.14,95%CI = 0.06;0.21), EF (ß = 0.13,95%CI = 0.05;0.20), and SF (ß = 0.10,95%CI = 0.03;0.18). Significant differences in effects of different types of PSI were found, with largest effects of psychotherapy. The effects of coping skills training were moderated by age, treatment type, and targeted interventions. Effects of psychotherapy on EF may be moderated by cancer type, but these analyses were based on 2 randomized controlled trials with small sample sizes of some cancer types. CONCLUSIONS: PSI significantly improved QoL, EF, and SF, with small overall effects. However, the effects differed by several demographic, clinical, personal, and intervention-related characteristics. Our study highlights the beneficial effects of coping skills training in patients treated with chemotherapy, the importance of targeted interventions, and the need of developing interventions tailored to the specific needs of elderly patients.

Effects and moderators of coping skills training on symptoms of depression and anxiety in patients with cancer: Aggregate data and individual patient data meta-analyses.

PURPOSE: This study evaluated the effects of coping skills training (CST) on symptoms of depression and anxiety in cancer patients, and investigated moderators of the effects. METHODS: Overall effects and intervention-related moderators were studied in meta-analyses of pooled aggregate data from 38 randomized controlled trials (RCTs). Patient-related moderators were examined using linear mixed-effect models with interaction tests on pooled individual patient data (n = 1953) from 15 of the RCTs. RESULTS: CST had a statistically significant but small effect on depression (g = -0.31,95% confidence interval (CI) = -0.40;-0.22) and anxiety (g = -0.32,95%CI = -0.41;-0.24) symptoms. Effects on depression symptoms were significantly larger for interventions delivered face-to-face (p = .003), led by a psychologist (p = .02) and targeted to patients with psychological distress (p = .002). Significantly larger reductions in anxiety symptoms were found in younger patients (pinteraction < 0.025), with the largest reductions in patients <50 years (ß = -0.31,95%CI = -0.44;-0.18) and no significant effects in patients ≥70 years. Effects of CST on depression (ß = -0.16,95%CI = -0.25;-0.07) and anxiety (ß = -0.24,95%CI = -0.33;-0.14) symptoms were significant in patients who received chemotherapy but not in patients who did not (pinteraction < 0.05). CONCLUSIONS: CST significantly reduced symptoms of depression and anxiety in cancer patients, and particularly when delivered face-to-face, provided by a psychologist, targeted to patients with psychological distress, and given to patients who were younger and received chemotherapy.

Breast cancer in younger women: effects on interpersonal and family relations.

Although breast cancer can have a stressful impact on women of all ages, young women may be particularly vulnerable to the negative effects of the disease. Based on a developmental perspective, this article reviews studies on the emotional impact of breast cancer on young women, their spouses, children, and the marital relationship. Studies indicate that younger women experience more emotional distress than older women, although the inverse relationship between age and emotional distress is not consistent across all studies. Although age does not appear to have a direct relationship to husbands' adjustments, younger husbands reported more problems carrying out domestic roles and a greater number of life stresses than older husbands. Studies on the impact of breast cancer on children are limited in number and scope but indicate that the effects of breast cancer vary according to the developmental level of the child. Directions for further research on young women and their families are suggested.

Factors affecting couples' adjustment to recurrent breast cancer.

The purpose of this study was to identify factors that affect the adjustment of women and their husbands to recurrent breast cancer and to examine the mutual effect that partners have on one another. An exploratory study was designed to determine the relationship between four predictor variables (support, uncertainty, symptom distress, hopelessness) and women's and husbands' adjustments. The sample consisted of 155 subjects; 81 women, who had a first recurrence of breast cancer, and 74 husbands. Multiple standardized instruments with established reliability and validity were used to measure the study variables. The independent variables were measured with the Social Support Questionnaire, the Mishel Uncertainty in Illness Scale, McCorkle Symptom Distress Scale and the Beck Hopelessness Scale. The dependent variable, psychosocial adjustment, was measured with the Brief Symptom Inventory and the Psychosocial Adjustment to Illness Scale. The results indicated that the independent variables accounted for 43% of the variance in women's distress and 32% of the variance in husbands' distress; they also explained 66% of the variance in women's role adjustment problems and 57% of the variance in husbands' role problems. Symptom distress and hopelessness accounted for the most variance in women's and husbands' levels of adjustment. A significant and positive relationship was found between women's and husbands' adjustment scores, indicating that partners have a mutual influence on one another. The findings suggest that there are multiple factors that influence couples' adjustment to recurrent breast cancer, and that these factors need to be taken into consideration when planning care for women and their partners.

Couples' patterns of adjustment to colon cancer.

The objectives for this longitudinal study were to: (a) compare colon cancer patients' and their spouses' appraisal of illness, resources, concurrent stress, and adjustment during the first year following surgery; (b) examine the influence of gender (male vs female) and role (patient vs spouse caregiver) on study variables; (c) assess the degree of correlation between patients' and spouses' adjustments; and (d) identify factors that affect adjustment to the illness. Fifty-six couples were interviewed at one week post diagnosis, and at 60 days and one year post surgery. Based on a cognitive-appraisal model of stress, the Smilkstein Stress Scale was used to measure concurrent stress; the Family APGAR, Social Support Questionnaire, and Dyadic Adjustment Scale were used to measure social resources; the Beck Hopelessness Scale and Mishel Uncertainty in Illness Scales were used to measure appraisal of illness; and the Brief Symptom Inventory and Psychosocial Adjustment to Illness Scale were used to measure psychosocial adjustment. Repeated Measures Analysis of Variance indicated that spouses reported significantly more emotional distress and less social support than patients. Gender differences were found, with women reporting more distress, more role problems, and less marital satisfaction, regardless of whether they were patient or spouse. Both patients and spouses reported decreases in their family functioning and social support, but also decreases in emotional distress over time. Moderately high autocorrelations and modest intercorrelations were found among and between patients' and spouses' adjustment scores over time. The strongest predictors of patients' role adjustment problems were hopelessness and spouses' role problems. The strongest predictors of spouses' role problems were spouses' own baseline role problems and level of marital satisfaction. Interventions need to start early in the course of illness, be family-focused, and identify the couples at risk of poorer adjustment to colon cancer.

Models of helping and coping in cancer care.

This paper provides a theoretical analysis of four models of helping and coping as they relate to cancer care. The four conceptual models focus on the issue of whether or not patients should be viewed as responsible for the cause or the treatment of their cancer. The moral model, characterized by the holistic health movement, holds patients responsible for both causing and resolving health problems. The compensatory model, exemplified by cancer education programs, attributes low responsibility to patients for causing health problems but high responsibility for resolving them. The medical model views patients as neither responsible for causing nor for resolving health problems. The enlightenment model, typified by the healing movement, holds people responsible for causing their health problems, but not for resolving them. An attempt is made to examine existing programs in cancer care in light of these models. The present analysis addresses the following questions. Why is each of these models appealing? Why are they sometimes embraced by patients or health care providers? What are the benefits and disadvantages of using each of these models with cancer patients? What happens when the health care provider and patient hold different models regarding the patient's responsibility or participation in the cause of the disease or its treatment? Further research is needed to determine the conditions under which a particular model results in better health outcomes for patients, and to assess how factors such as extent of disease or type of cancer influence the patient's choice of a model.

The impact of breast cancer on patients and husbands.

The purpose of this descriptive study was fourfold: (a) to assess the adjustment concerns of patients and husbands after a mastectomy, (b) to describe their reactions to seeing the mastectomy incision, (c) to determine which phase of illness was most stressful for them, and (d) to identify factors that helped them cope with the illness. Tape-recorded interviews were conducted with 50 mastectomy patients and their husbands in the hospital just after surgery and 1 month later. Transcripts were content analyzed by two independent raters. Results indicated that survival concerns were the predominant worries reported by patients and husbands in the hospital and 1 month after surgery. Although most of the husbands reacted well to seeing their wives' mastectomy incision, a small group of husbands reported that it was a difficult experience. Patients and husbands indicated that emotional support, information, attitude, and religion were the factors that helped them cope with the illness during this time.

Coping with a breast biopsy: how healthcare professionals can help women and their husbands.

PURPOSE/OBJECTIVE: To examine the type of information women received from their physicians prior to breast biopsy, to describe women's and their husbands' levels of concern during this time, and to determine the type of help they want from healthcare professionals. DESIGN: Descriptive. SETTING: Homes of couples in the midwestern United States. SAMPLE: 300 women and 265 of their husbands interviewed approximately one week prior to biopsy. METHODS: Interviews using a semistructured questionnaire. MAIN RESEARCH VARIABLES: The type of information women and their husbands receive prior to biopsy, their levels of concern, and the type of help they want from healthcare professionals. FINDINGS: Most women were told prior to biopsy that their breast problem needed further assessment (56%) or was probably not cancer (36%). Only a small group of women were told prior to biopsy that they definitely had cancer (2%) or that their breast problem was suspicious (5%). The majority of women and their husbands reported high levels of concern awaiting the biopsy. Women identified several ways healthcare professionals could help, including providing educational materials, shortening the time between detection and biopsy, offering support, using a personalized approach, and involving family members. Husbands identified many of these interventions but also wanted information on how to help their wives. CONCLUSIONS: Breast biopsy generated a high degree of concern in women and their husbands. Their concerns remained high even though many women were told that they probably did not have cancer. IMPLICATIONS FOR NURSING PRACTICE: To minimize the adverse effects of a biopsy, healthcare professionals need to provide information and support, involve husbands, and shorten the biopsy waiting period.

Cancer and the family: strategies to assist spouses.

Research that has been conducted with spouses of cancer patients documents the nature of their stress, the duration of their stress, and the concerns that they confront over the course of the illness. A variety of intervention strategies have been used to assist spouses in dealing with the stressful effects of cancer. Two major categories of intervention strategies are providing information and offering support.

Psychologic consequences of breast cancer on partner and family.

Breast cancer can have psychologic consequences not only for patients but also for the entire family system. Research indicates a major impact on the husband, the marital relationship, the children, and family roles and responsibilities. Greater attention needs to be given to the family members to ensure that they get the support they need, and to enable them to maintain their supportive roles with the patient.

Social support in patients' and husbands' adjustment to breast cancer.

Data were obtained from 50 mastectomy patients and their husbands at 3 days and 30 days postsurgery to determine the nature of the relationship between social support and the adjustment of mastectomy patients and their husbands over time. Psychosocial adjustment was related to both patients' and husbands' levels of social support. Patients and husbands who reported higher levels of social support reported fewer adjustment difficulties at both 3 days and 30 days postsurgery. Patients and husbands differed significantly in the levels of support they perceived over time; husbands perceived less support from friends, nurses, and physicians. This study underscores the importance of assessing the support resources of both patients and husbands over time.

Psychological impact of the diagnosis of breast cancer on the patient and her family.

The diagnosis of breast cancer creates emotional distress for patients as well as family members. This article reviews studies on the psychological adjustment of women and their family members during the diagnosis, hospitalization, and early convalescence from breast surgery. Studies indicate that the diagnostic phase is an extremely stressful time for women, marked by high anxiety, uncertainty, and difficulty making decisions. The hospital phase is especially difficult for spouses, who must juggle work responsibilities with added home responsibilities and also spend time at the hospital supporting their wives. In the convalescent phase, patients and family members need to adjust to changes in family roles, cope with fears about recurrence, and learn to balance the needs of all family members. In order to provide high quality health care to breast cancer patients and their family members, physicians and nurses need to address the emotional as well as the physical aspects of recovery.

The impact of cancer in women on the family.

Using a family-stress framework, this paper analyzes the psychosocial impact of a woman's cancer on her family. More specifically, this paper explores the emotional distress that spouses and children of patients with breast cancer experience and discusses the role changes that are reported over time. Factors that put certain women and their family members at high risk of poorer adjustment to the woman's cancer also are identified. Finally, directions for future research and the implications of the research for clinical practice are discussed.

Adjustment of patients and husbands to the initial impact of breast cancer.

This study compared the psychosocial adjustment of 50 newly diagnosed breast cancer patients and their husbands at two points in time. Time 1 interviews were conducted approximately 3 days after surgery; Time 2 interviews were conducted 30 days later. Psychosocial adjustment was measured as a multidimensional construct using the Affects Balance Scale, the Brief Symptom Inventory, and the Psychosocial Adjustment to Illness Scale. Repeated measures analysis indicated that husbands' scores did not differ significantly from patients' scores on the adjustment measures that assessed level of mood and amount of symptom distress. Both patients and husbands reported levels of distress significantly above the level reported for the normal population. Patients and husbands differed only on the adjustment measure that assessed problems in carrying out various psychosocial roles, with patients reporting more role adjustment problems than husbands. Although both patients and husbands reported dramatic improvement in their levels of mood from Time 1 to Time 2, no significant change occurred in their levels of distress. Medical and demographic factors had little relationship to subjects' levels of adjustments at either time.

Family survivorship and quality of life following a cancer diagnosis.

The objectives of this study were: (a) to examine the quality of life of the family as a unit during the long-term survivor phase of illness and (b) to test a family model of factors that may influence family quality of life. The family survivorship model, which includes illness survival stressors (family stressors, fear of recurrence, and patient somatic concerns), resources (family hardiness and family social support), appraisal (family meaning of the illness), and the outcome, family quality of life, was used to guide this exploratory cross-sectional study. A random, stratified sample of 123 families (N = 246 individuals) was interviewed 1-5 years after treatment ended. The model explained 63% of the variance in family quality of life, with the strongest predictors being concurrent family stressors, family social support, family member fear of recurrence, family meaning of the illness, and patient employment status. The study findings suggest the importance of addressing cancer-related stressors, family resources, and family meaning as key factors related to family quality of life.

Couples' adjustment to breast cancer and benign breast disease: a longitudinal analysis.

A comprehensive comparison of couples' adjustment to benign (n = 73 couples) and malignant breast disease (n = 58 couples) at the time of diagnosis and at two follow-up assessments at 60 days and 1 year is reported. Specific objectives were to: (a) compare the concurrent stress, resources, appraisal, and patterns of adjustment of couples in the benign and malignant groups; (b) compare the psychosocial responses of patients versus spouses; and (c) determine the amount of correspondence in levels of adjustment reported by patients and their husbands over time. Multiple instruments with reported reliability and validity were used to measure study variables: Smilkstein Stress Scale, Dyadic Adjustment Scale, Family APGAR, Social Support Questionnaire, Mishel Uncertainty in Illness Scale, Beck Hopelessness Scale, Brief Symptom Inventory, and Psychosocial Adjustment to Illness Scale. Mixed design analyses of covariance (ANCOVA) were used to assess differences between and among couples and examine changes in study variables over time. Significant differences were found in the resources, appraisal, and patterns of adjustment reported by couples in the benign and malignant groups. Couples facing breast cancer reported greater decreases in their marital and family functioning, more uncertain appraisals, and more adjustment problems associated with the illness. In addition, there was a high degree of correspondence between the levels of adjustment reported by women with breast cancer and their husbands over time. Couples who reported high distress or a high number of role problems at diagnosis were likely to remain highly distressed at 60 days and 1 year. Study findings underscore the importance of assisting couples, not just patients, to manage the adjustment difficulties associated with breast cancer.

Adjustment of women and their husbands to recurrent breast cancer.

The psychosocial adjustment of women with recurrent breast cancer (N = 81) and their husbands (N = 74) were compared to determine if they report different levels of adjustment, support, symptom distress, hopelessness, and uncertainty. Women with recurrent breast cancer reported more emotional distress than their husbands, but both had a similar number of psychosocial role problems. Women and husbands differed in the amount of support and uncertainty they reported but not in the levels of symptom distress or hopelessness they perceived. Women, in contrast to their husbands, expressed more surprise that their cancer recurred and found the recurrent phase of illness more distressing than the initial diagnosis.