Professionally-led support groups for cancer patients: an intervention in search of a model

Professionally led support groups for people living with advanced or metastatic cancer: a systematic scoping review of effectiveness and factors critical to implementation success within real-world healthcare and community settings

PURPOSE

To examine the effectiveness of professionally led support groups for people with advanced or metastatic cancer, and identify factors critical to implementation success within real-world settings.

METHODS

Databases (MEDLINE; PsychINFO; CINAHL) and grey literature were searched for empirical publications and evaluations. Articles were screened for eligibility and data systematically extracted, charted and summarised using a modified scoping review methodology. Implementation factors were mapped using Proctor's implementation framework and the Consolidated Framework for Implementation Research 2.0.

RESULTS

A total of 1691 publications were identified; 19 were eligible for inclusion (8 randomised controlled trials, 7 qualitative studies, 2 cohort studies, 2 mixed methods studies). Most (n=18) studies focused on tumour-specific support groups. Evidence supported professionally led support groups in reducing mood disturbances (n=5), distress (i.e. traumatic stress, depression) (n=4) and pain (n=2). Other benefits included social connectedness (n=6), addressing existential distress (n=5), information and knowledge (n=6), empowerment and sense of control (n=2), relationships with families (n=2) and communication with health professionals (n=2). Thirteen studies identified factors predicting successful adoption, implementation or sustainment, including acceptability (n=12; 63%), feasibility (n=6; 32%) and appropriateness (n=1; 5%). Key determinants of successful implementation included group leaders' skills/experience, mode of operation, travelling distance, group composition and membership and resourcing.

CONCLUSIONS

Professionally led tumour-specific support groups demonstrate effectiveness in reducing mood disturbances, distress and pain among patients. Successful implementation hinges on factors such as leadership expertise, operational methods and resource allocation.

IMPLICATIONS FOR CANCER SURVIVORS

Professionally led support groups may fill an important gap in supportive care for people with advanced or metastatic cancer.

Illustrating the Multi-Faceted Dimensions of Group Therapy and Support for Cancer Patients

In cancer support groups, choice of therapy model, leadership style, and format can impact patients’ experiences and outcomes. Methodologies that illustrate the complexity of patients’ group experiences might aid in choosing group style, or testing therapeutic mechanisms. We used this naturalistic study as a beginning step to explore methods for comparing cancer group contexts by first modifying a group-experience survey to be cancer-specific (Group Experience Questionnaire (GEQ)). Hypothesizing that therapist-led (TL) would differ from non-therapist-led (NTL), we explored the GEQ’s multiple dimensions. A total of 292 patients attending three types of groups completed it: 2 TL groups differing in therapy style ((1) Supportive-Expressive (SET); (2) The Wellness Community (TWC/CSC)); (3) a NTL group. Participants rated the importance of “Expressing True Feelings” and “Discussing Sexual Concerns” higher in TL than NTL groups and “Discussing Sexual Concerns” higher in SET than other groups. They rated “Developing a New Attitude” higher in TWC/CSC compared to NTL. In addition, we depict the constellation of group qualities using radar-charts to assist visualization. These charts facilitate a quick look at a therapy model’s strengths and weaknesses. Using a measure like the GEQ and this visualization technique could enable health-service decision making about choice of therapy model to offer.

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

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

Gendered Cybersupport: A Thematic Analysis of Two Online Cancer Support Groups

Within the last few years numerous support groups have emerged on the Internet, presenting new opportunities for patients to communicate with health care professionals and other patients. The present study examines discourse within online cancer support groups, increasing our understanding of sex differences in cybersupport. Two reproductive cancer groups were chosen for this investigation, the Ovarian Problems Mailing List (OPML) and the Prostate Problems Mailing List (PPML), making sex of the patient recognizable. Phenomenological thematic analysis was employed to describe and interpret messages sent and received. Analyses for the two groups were compared. Generally, it was found that the two online listservs provided opportunities for cancer patients to receive support, within western society's accepted forms of gendered communication.

The Effectiveness of Support Groups in Asian Breast Cancer Patients: An Integrative Review

Cancer support group has been studied as an intervention to improve patient psychosocial well-being. The effectiveness of support groups among Asian breast cancer (BC) patients has been unclear and received limited attention to the evidence of its effectiveness. The social-cognitive processing theory underlies the principles of support groups and advocates that a positive, supportive social environment can improve cognitive processing. The purpose of this paper is to present an integrative review of research evidence on the effectiveness of cancer support groups with Asian BC patients. Empirical studies related to support group among Asian and Asian American BC patients published between 1982 and April 2014 are reviewed. There are 15 studies selected (12 from the Asian-Pacific region and 3 from Western countries). The review includes 1 qualitative study, 3 descriptive studies, 1 mixed method design, and 10 experimental or quasi-experimental studies. The support group intervention activities include psycho-educational program such as health education, problem-solving, and stress management. These studies support the effectiveness of support group in alleviating psychological distress and supporting quality of life of Asian BC women. Overall, there is limited research on the use and effectiveness of support groups with Asians cancer patients in Asia and in Western countries. Without accounting for Asian immigrants overseas, the Asian population is expected to grow from 4.3 to 5.3 billion by 2050. As cancer patients become more diverse due to global emigration, more rigorous studies examining the effectiveness of psychosocial intervention among transcultural cancer patients are needed.

Group Interventions for Patients with Cancer and HIV Disease: Part I: Effects on Psychosocial and Functional Outcomes at Different Phases of Illness

Group interventions for individuals facing cancer or HIV disease have drawn considerable attention among researchers and clinicians over the past 20 years. There is growing evidence that group services may be helpful, but which interventions are most effective for participants at which phases in the trajectory of disease has been less clear. Moreover, professionals working in different intervention settings (e.g., primary prevention vs. clinical care) and different disease sites (cancer vs. HIV disease) often have little awareness of relevant advances in other fields. Efforts to integrate findings in the literature may accelerate research and advance the standard of clinical care. The current article, the first in a series of four special reports, critically evaluates the efficacy of group interventions led by professional or trained facilitators for individuals confronted by cancer or HIV, across the spectrum of illness from elevated risk through advanced disease. We examine psychosocial and functional outcomes for different interventions directed toward different patient subgroups, trace common themes, highlight limitations, and offer recommendations for further research.

Requests for health education from Chinese cancer patients during their recovery period: a cross-sectional study

To determine the prevalence of posttreatment patient requests for health information from Chinese cancer patients during their recovery period, a cross-sectional, descriptive study using a mailed survey was conducted among 374 patients selected randomly. The survey addressed what types of information patients actually wanted but did not receive from their care providers. Questionnaires from 360 patients were received and analyzed. Approximately 76.0% of the patients did not receive health information and expressed the need for the information. The information about how to reduce emotional distress (90.1%), rehabilitation (76.2%), disease symptoms (59.3%), and nutritional support (56.8%) were paramount among patients' concerns. Only 12.8% hoped to acquire information on sexual health. Health information for cancer patients at the recovery stage in China is poor. A tripartite involvement of the hospital-family-community and the combined intervention related to physical sequelae and psychosocial factors are needed at the recovery stage.

Is there an "ideal cancer" support group? Key findings from a qualitative study of three groups

The objective of this study was to study differently composed cancer support groups to generate insights into what groups are attractive to the widest range of participants, and how they might be best structured and composed. This study applied a qualitative design utilizing participant observation at three cancer support groups (a group for women with metastatic cancer, a colorectal cancer support group, and a group for Chinese cancer patients) and in-depth interviews (N = 23) with group members as the primary data collection methods. Despite the diverse composition of the groups, their perceived benefits were similar, and informants highlighted the information, acceptance, and understanding they received in the support group environment. However, gender and cultural differences were found in attendance patterns and the desired content of group meetings. Importantly, participants' motivations for attending cancer support groups also changed as they moved through the treatment trajectory: over time the need for information was at least partially replaced by a need for support and understanding. This study supports prior research findings that there is no ideal support group, nor is there a "magical formula" for attracting and retaining a diverse audience. However, including an educational component in support groups may increase the participation of currently underrepresented populations such as men and patients from culturally diverse backgrounds.

Psychosocial intervention for adults with cancer: a meta-analysis

Cancer affects a significant number of people and their families. In addition to physical symptoms, people with cancer experience considerable levels of psychosocial distress. Psychosocial oncology has been developed to address this distress. In this meta-analysis, psychosocial interventions for adults with cancer were systematically reviewed. A central finding was the dearth of clinical trials published by social work researchers and clinicians. Small intervention effects were noted for some psychosocial interventions, particularly those in which a focus on stress and coping were included; however, the poor quality of reporting negated conclusive results. The synthesis of research conducted and reported with methodological rigor may inform social work practice, with the ultimate goal of improving the quality of patient care and the quality of patient outcomes. The implications for social work clinicians and researchers are discussed.

Determinants of participation in cancer support groups: the role of health beliefs

BACKGROUND

Although considerable attention has been directed toward cancer support groups, little is known about how often these services are actually used in clinical practice or the factors that influence participation.

PURPOSE

Drawing in part on the Health Belief Model, this study examined group participation and its correlates among 425 patients with diverse malignancies treated at a large academic oncology center.

METHOD

Patients were surveyed regarding utilization rates, health beliefs, and medical and demographic characteristics.

RESULTS

Only a small number of patients reported having participated in groups (8.0%). Consistent with the model, in univariate analyses, participation was significantly related to greater perceptions of illness severity (p < .0001), greater perceived benefits (p < .01), fewer perceived barriers (all p < .01), and greater cues for action (i.e., recommendation by family/friends, p < .000001). In multivariate analyses controlling for disease site and other covariates, the strongest predictors included recommendation by family/friends (OR = 5.04; CI = 1.98-12.81), perceived seriousness of the illness (OR = 4.07; CI = 1.42-11.60), and geographical residence (OR = 2.74; CI = 1.09-6.93).

CONCLUSION

Results suggest that participation might be increased by involving the patient's support network, improving access in underserved rural communities, addressing illness appraisals, and increasing outreach to certain diagnostic groups.

Prostate Cancer Support Groups

This article provides an overview of research literature related to cancer support groups, with particular reference to prostate cancer groups. Randomized studies of cancer support groups primarily focus on short-term psychoeducational and/or supportive/expressive groups for women with breast cancer. Many of these studies suggest that the interventions lead to a pronounced improvement in psychological functioning and may in some instances increase longevity. Regarding prostate cancer support group members, information and education are especially valued. Open-ended, psychoeducational groups with large meetings, expert speakers, and structured, efficient organizations appear most beneficial to prostate cancer group members. The literature only partially answers a number of significant questions, including the types of group most appropriate for people with specific diseases, process variables most significant to the success of groups, and specific factors that are barriers to group involvement by certain populations.

Patient Preferences Regarding Cancer Group Psychotherapy Interventions: A View From the Inside

Group interventions for cancer patients have commanded notable interest among investigators, but utilization rates are low and little is known about the features that patients themselves deem most important. The authors examined the views of potential participants, among 425 patients with diverse malignancies. A large number (64.6%) expressed interest, although few had attended a group. Preferences were strongest for interventions convened during diagnostic or active treatment periods rather than later, and those focusing on medical education or health-promotion, rather than emotional support or coping. Most were amenable to drop-in formats and to heterogeneous membership. In subgroup analyses, preferences were associated with disease site and not strongly related to psychosocial or demographic predictors. Understanding patient preferences may be critical for successful program development and utilization.

Meta-review of high-quality systematic reviews of interventions in key areas of liaison psychiatry

BACKGROUND

When planning and delivering a liaison psychiatry service it is important to have an understanding of the research evidence supporting the use of interventions likely to be delivered by the service.

AIMS

To identify high-quality systematic reviews for all interventions in three defined areas of liaison psychiatry, to summarise their clinical implications and to highlight areas where more research is needed. The three areas were the psychological effects of physical illness or treatment, somatoform disorders and self-harming behaviour.

METHOD

Computerised database searching, secondary reference searching, hand-searching and expert consultation were used to identify relevant systematic reviews. Studies were reliably selected, and quality-assessed, and data were extracted and interpreted by two reviewers.

RESULTS

We found 64 high-quality systematic reviews. Only 14 reviews included meta-analyses.

CONCLUSIONS

Many areas of liaison psychiatry practice are not based on high-quality evidence. More research in this area would help inform development and planning of liaison psychiatry services.

A randomized intervention study for breast cancer survivors in Japan: effects of short-term support group focused on possible breast cancer recurrence

This study aimed to assess the effect on the mental health of breast cancer survivors in a support group providing an emotional and educational intervention focused on the recurrence of breast cancer. Seventy-eight breast cancer survivors were assigned randomly to an intervention group (n = 45) and a control group (n = 33), respectively. Intervention group members met weekly for 4 weeks for emotional and educational intervention focusing on recurrence of the cancer. Subjects were assessed at baseline and at 1 week and 1 month postintervention. The results indicated that there was no significant effect of the intervention in terms of state anxiety. There was a significant effect of the intervention on life satisfaction in the group scoring high at baseline, as indicated by the mean score changes. The effect was that among the groups scoring high on life satisfaction, the mean score in the intervention group remained unchanged, but in the control group it declined. That is, short-term intervention focusing on recurrence does not improve the mental health of breast cancer patients, but it may help maintain better mental health. Nurses should have proper education to be able to provide correct information about breast cancer and coping skills. Further research with long-term multipurpose support groups that take into account patients' characteristics are needed to provide effective support to women with breast cancer in Japan.

Group interventions for patients with cancer and HIV disease: part IV. Clinical and policy recommendations

Group interventions have assumed a growing role in primary prevention and supportive care for cancer and HIV disease. Earlier sections of this Special Report examined empirical findings for these interventions and provided recommendations for future research. The current section offers brief recommendations for service providers, policymakers, and stakeholders. Group services now occupy an increasingly prominent place in primary prevention programs and medical settings. In previous sections of this Special Report (Sherman, Leszcz et al., 2004; Sherman, Mosier et al., 2004a, 2004b) we examined the efficacy of different group interventions at different phases of cancer or HIV disease, considered characteristics of the intervention and the participants that might influence outcomes, and discussed mechanisms of action. Methodological challenges and priorities for future research were highlighted. In this, the final section, we offer brief recommendations for service providers, policymakers, and other stakeholders. We consider some of the barriers that constrain use of empirically-based group interventions and note how these programs might be implemented more widely and effectively.

Oncology professionals and patient requests for cancer support services

OBJECTIVE

To examine the kinds of psychosocial support services that cancer patients most often request across a multidisciplinary sample of currently practicing U.S. oncological health care professionals (OHCPs) representative of a typical cancer care team.

PARTICIPANTS

Primary data collection. A randomly selected sample of 1,180 OHCPs (44% physicians, 24% nurses, 32% social workers) who were active members of their respective oncological associations completed a brief four-page mailed survey during the spring of 2001.

METHODS

Cross-sectional, descriptive study. Descriptive statistics were computed for all study variables. ANOVA procedures were used to examine demographic difference between respondents and non-respondents. Frequencies were calculated for patient inquires for cancer support services inquiries, and logistic regression was used to evaluate professional group differences on inquiries. Chi-square statistics were used to test for significant differences between professional groups.

RESULTS

Approximately 94% of OHCPs were asked about cancer-related support services by their patients. Quantitative data indicated that information and education about cancer (72%), support groups (65%), and hospice referral (52%) were paramount among patient concerns. Qualitatively, comments about transportation, lodging during treatment, and alternative medicine reflected the general sentiment that basic needs and opportunities for options may still be unmet. Patient inquiries for services varied significantly by professional group (p<.001).

CONCLUSION

This information reflects the need for a multidisciplinary perspective and will be useful for planning patient-based cancer education and support initiatives, refining existing programs, and targeting materials to specific oncological professionals.

Supportive-expressive group therapy: The transformation of existential ambivalence into creative living while enhancing adherence to anti-cancer therapies

Supportive-Expressive Group Therapy (SEGT) has been developed and manualised in the research setting, but there have been few clinical accounts of its utility. In this qualitative review of its application in the Melbourne-based randomised control trial (RCT) for women with advanced breast cancer, SEGT is considered from the perspective of the structure and framework of therapy, its therapists, the issues that develop in exploring its common themes and what constitutes a well functioning group. Groups move through identifiable developmental phases. The mature group process transforms existential ambivalence into creative living, evidenced by humour, celebration, assertiveness, altruism, new creative pursuits and eventually courageous acceptance of dying. Challenges and pitfalls include avoidance, non-containment of ambivalence, intolerance of difference, anti-group phenomena and splitting. A key element is the medicalization of the group culture whereby members and co-therapists explore health beliefs and attitudes about care. This promotes compliance with anti-cancer treatments, including both the initiation of and perseverance with chemotherapy. This mechanism could prove to be a potentially important pathway in promoting longer survival.

Cognitive-existential group psychotherapy for women with primary breast cancer: a randomised controlled trial

BACKGROUND

We conducted a randomised, controlled trial of cognitive-existential group therapy (CEGT) for women with early stage breast cancer receiving adjuvant chemotherapy with the aim of improving mood and mental attitude to cancer.

METHODS

Women were randomised to 20 sessions of weekly group therapy plus 3 relaxation classes or to a control arm receiving 3 relaxation classes. Assessments, independently done at baseline, 6 and 12 months, included a structured psychiatric interview and validated questionnaires covering mood, attitudes to cancer, family relationships, and satisfaction with therapy.

RESULTS

Three hundred and three of 491 (62%) eligible patients participated over 3 years. Distress was high pre-intervention: 10% were diagnosed as suffering from major depression, 27% from minor depression and 9% from anxiety disorders. On an intention-to-treat analysis, there was a trend for those receiving group therapy (n=154) to have reduced anxiety (p=0.05, 2-sided) compared to controls (n=149). Women in group therapy also showed a trend towards improved family functioning compared to controls (p=0.07, 2-sided). The women in the groups reported greater satisfaction with their therapy (p<0.001, 2-sided), appreciating the support and citing better coping, self-growth and increased knowledge about cancer and its treatment. They valued the CEGT therapy. Overall effect size for the group intervention was small (d=0.25), with cancer recurrence having a deleterious effect in three of the 19 therapy groups. Psychologists as a discipline achieved a moderate mean effect size (d=0.52).

CONCLUSION

CEGT is a useful adjuvant psychological therapy for women with early stage breast cancer. Interaction effects between group members and therapists are relevant to outcome. Group-as-a-whole effects are powerful, but the training and experience of the therapist is especially critical to an efficacious outcome.

Psychosocial and educational aspects in prostate cancer patients

Prostate cancer was a neglected area in psycho-oncology. There is now a growing number of studies on the psychosocial aspects of having prostate cancer and the possibilities to reduce these problems in educational and group interventions. In this issue of Patient Education and Counseling, studies are presented on several psychosocial and educational aspects in prostate cancer patients: screening events and outcomes, assessing the unmet information, support and care delivery needs, reacting to the diagnosis of prostate cancer, informational needs of men on hormonal therapy, changes in health-related quality of life three months after the diagnosis, information-seeking behaviors and information needs of partners, quality of leaflets, video information in decision making, and patient perceptions and priorities in a rehabilitation program. Conclusions are presented on neglected research areas in psychosocial and educational aspects of living with prostate cancer.

Comorbidity of depression with other medical diseases in the elderly

A major factor in the context of evaluating depression in the elderly is the role of medical problems. With aging there is a rapid increase in the prevalence of a number of medical disorders, including cancer, heart disease, Parkinson's disease, Alzheimer's disease, stroke, and arthritis. In this article, we hope to bring clarity to the definition of comorbidity and then discuss a number of medical disorders as they relate to depression. We evaluate medical comorbidity as a risk factor for depression as well as the converse, that is, depression as a risk factor for medical illness. Most of the disorders that we focus on occur in the elderly, with the exception of HIV infection. This review focuses exclusively on unipolar disorder. The review summarizes the current state of the art and also makes recommendations for future directions.

Participation of oncological outpatients in psychosocial support

In total, 132 cancer patients in four oncology outpatient clinics in Hamburg completed a questionnaire consisting of a newly designed instrument for measuring psychosocial support. In this questionnaire, patients were asked about their knowledge of institutions offering support, their previous participation in psychosocial support, the reasons for participation and their experience with and attitude towards it. A second section consisted of standardized instruments: the EORTC QLQ-C30 questionnaire (Aaronson), the Brief Symptom Inventory (Derogatis and Melisaratos), the List of Physical Complaints (von Zerssen and Koller) and the Impact of Event Scale (Horowitz). Descriptive and variance-analytical methods were used for the analysis of results. Most respondents were women (88%). The largest group (72%) had a history of breast cancer. A total of 28% of the patients in the sample had participated in psychosocial support, about 4% of these in self-help groups. Participants in psychosocial support did not differ from non-participants in gender, but they were significantly younger. They showed considerably higher scores in emotional and physical distress than non-participants, their attitude towards psychosocial support was more positive, and they had more knowledge about institutions offering support than non-participants. The main reasons listed for their participation in psychosocial support were mental distress, a desire to obtain help, and the wish to cope with the illness. The main reason for not participating was sufficient support from the family, friends or doctors.

Awareness and barriers to use of cancer support and information resources by HMO patients with breast, prostate, or colon cancer: patient and provider perspectives

This study assessed patient awareness and use--as well as obstacles to use--of HMO- and community-based psychosocial support services designed for cancer patients. Participants were a randomly selected group of patients from a large Northwest HMO, with breast (N=145), prostate (N=151), or colon cancer (N=72), and their oncology and urology providers (N=29). Patient awareness was highest for HMO-based services (68-90%) and lower for community- (33%) or Internet-based (10-14%) services, and use rates were low across all services (range 2-8%). Providers reported referring 70% of their patients to HMO cancer support services, but their estimates of actual patient use of these services (40%) were inflated. Providers reported few barriers to referring patients to support services. The most commonly reported patient barriers to using such services were already having adequate support, lack of awareness of the service, and lack of provider referral. Results of regression analyses suggest that education, physician referral, social support, and spirituality may be important influences on use of cancer support services. This study takes a first step toward understanding patient use of existing cancer support services and suggests ways to increase participation in these services.

Health behavior changes after a cancer diagnosis: what do we know and where do we go from here?

Survival rates for certain types of cancer have improved over the past few decades. Changing unhealthy behaviors such as smoking, poor diet, and sedentary life-style among individuals who have been diagnosed with cancer may help to reduce cancer treatment sequelae, possibly reduce risk of recurrence for specific types of cancer, and reduce risk for other common diseases such as cardiovascular disease, obesity, and hypertension. This article reports the prevalence of each of these behaviors among those diagnosed with cancer and reviews interventions that have targeted these risk behaviors. There is considerable variation in the type of research questions asked, the methodologic quality of the research, sample sizes, and the outcomes observed across studies focusing on changing the three health risk behaviors. In the final section, we provide guidelines for researchers in developing health behavior interventions for individuals diagnosed with cancer and highlight challenges that should be addressed.

Distress, Coping, and Social Support Among Rural Women Recently Diagnosed with Primary Breast Cancer

This study examined distress, coping, and group support among a sample of rural women who had been recently diagnosed with breast cancer. We recruited 100 women who had been diagnosed with primary breast cancer at one of two time points in their medical treatment: either within a window up to 3 months after their diagnosis of breast cancer, or within 6 months after completing medical treatment for breast cancer. Their mean age was 58.6 years (SD = 11.6), and 90% were of white/European American ethnicity. Women completed a battery of demographic and psychosocial measures prior to being randomized into a psychoeducational intervention study, and then again 3 months later at a follow-up assessment. The focus of this article is on the women's self-reported psychosocial status at baseline. Many of the women experienced considerable traumatic stress regarding their breast cancer. However, this distress was not reflected in a standard measure of mood disturbance that is frequently used in intervention research (the Profile of Mood States). The average woman considered her diagnosis of breast cancer to be among the four most stressful life events that she had ever experienced. Also, women on average reported a high level of helplessness/hopelessness in coping with their cancer. On average, women felt that they "often" (but not "very often") received instrumental assistance, emotional support, and informational support. Women varied considerably in which kind of social group provided them with the most support, with as many reporting that they found the greatest support in spiritual/church groups or within their family units as with breast or general cancer groups. These results suggest that among these rural women with breast cancer, distress with the diagnosis of breast cancer must be carefully assessed, as women who are highly distressed about their breast cancer may not report general mood disturbance. Furthermore, the kinds of groups that rural women with breast cancer experience as most supportive need to be identified so that psychosocial interventions can be matched to breast cancer patients' individual needs.

An integrated model of group treatment for cancer patients

Considerable evidence suggests that group interventions are a valuable resource for cancer patients, but few conceptual frameworks are available to guide decisions about which approaches might be most useful for which patients at what phases of illness. This article presents an integrative treatment model for group services. It describes different group interventions geared toward patients at different phases of illness to accommodate the shifting needs and concerns that evolve over the course of the disease. Recommendations are offered concerning further research and model development.

Negotiating cultural consensus in a breast cancer self-help group

This article describes a shared model of the breast cancer experience negotiated by the members of a spontaneously organized breast cancer self-help group in eastern North Carolina. In the course of sharing their personal experience narratives with one another, these women worked to negotiate points of agreement among the varying sources of knowledge and oftentimes conflicting belief systems they held about breast cancer. The synthetic model they created rejected many of the assumptions underlying the dominant biomedical view of cancer "survivorship," particularly its emphasis on the autonomous individual as decision maker and its attendant male-gendered sports and military imagery--assumptions that often implicitly structured the agendas and topics discussed in the formal, medically sanctioned support groups these women found unappealing. The implications for theories about the construction of shared cultural models and for continuing efforts to design support groups to meet the needs of a diverse patient population are explored.

Anxiety and the blues after breast cancer: how common are they?

A number of myths exist concerning the psychological impact of breast cancer. Primary among these is the belief that women with breast cancer have greater emotional disability than individuals with other diseases or the population at large. While research has shown that women cope remarkably well with a diagnosis of breast cancer, an understanding of the key periods of anxiety and primary stressors is crucial to the overall psychological and medical management plan. While psychopharmacologic therapy may be indicated for women with breast cancer, it is rarely sufficient and should be combined with effective psychosocial interventions such as group therapy.

Description of a group Cognitive Behaviour Therapy programme with cancer patients

Cognitive Behaviour Therapy (CBT) has already been shown to be highly effective in the treatment of various psychological disorders within mental health populations; however, it has not been widely tested in the treatment of cancer patients. In the last decade there has been growing interest in the application of CBT interventions within psycho-oncology, and some studies have reported on its efficacy, both with individuals and in group-therapy contexts. To date there have been few descriptions of how a CBT programme for cancer patient groups can be structured and delivered. We present a description of a 12-session CBT programme that has been developed by our centre, for delivery to cancer patient groups.

Breast cancer in older women: treatment, psychosocial effects, interventions, and outcomes

It is estimated that 48% of women with breast cancer are age 65 and older; yet, scant research focuses on this cohort. Recent advances in breast cancer management have raised many questions regarding appropriate treatment of older patients with cancer. Despite recent emphasis on medical interventions for older women, there is little focus on the unique clinical presentation and psychological sequelae of breast cancer in this population. While elderly women who survive breast cancer seem to cope better than their younger counterparts, their distress must not be overlooked. Interventions such as use of social support, spirituality, and exercise demonstrate therapeutic benefits for older women with cancer and should be explored. Nurses play a key role in educating and supporting older women with breast cancer and can help dispel many age-related myths and misconceptions.

Breaking the bad news: dilemmas in shared decision-making in medical practice

In a review of the literature, very little empirically based research was uncovered to guide the practice of health professionals who need to tell their patients bad news and help them to decide on their preferred treatment option. Various practising styles and guidelines are presented, and ethical and crosscultural challenges discussed. An enormous amount of research still needs to be done to discover the least stressful ways of dealing with these issues in health care settings.

Nursing intervention to increase hope and quality of life in newly diagnosed cancer patients

The aim of this study was to evaluate the effect of nursing intervention on hope and quality of life in cancer patients. The sample consisted of 96 newly diagnosed Norwegian cancer patients ages 26 to 78 years, the majority of them women (71%). Breast cancer was the predominant type of cancer in this sample. The study used an experimental design in which patients were randomly allocated to three different groups. The first group was the experimental group, for which the intervention was designed to increase hope. The second group (attention control group) participated in the "Learning to Live with Cancer" program. The last group was a control group. The Nowotny Hope Scale was used to measure hope, and the Ferrans and Powers Quality of Life Index and the Cancer Rehabilitation and Evaluation Systems, short form, were used to measure quality of life. The questionnaires were completed four times: twice before, then 2 weeks and finally 6 months after the intervention. The level of hope was significantly increased (p = 0.020) for the members of the hope group just after the intervention, but not after 6 months. Despite the patients' positive evaluation of the intervention, there was no impact on quality of life.

Behavioral research to enhance adjustment and quality of life among adults with cancer

The purpose of this article is to recommend future directions for behavioral research to enhance adjustment and quality of life for adults diagnosed with cancer. As context for the recommendations, the domain of behavioral research in psychosocial oncology is briefly described, the state of the science measuring quality of life is summarized, and research results from behavioral research on quality of life are reviewed.

Cognitive-existential group therapy for patients with primary breast cancer--techniques and themes

We describe a model of cognitive-existential group therapy designed to be integrated over 6 months with regimens of adjuvant chemotherapy given as conventional medical treatment to breast cancer patients with stage 1 and 2 disease. Our broad therapy goals are for members to develop a supportive network, work through grief over losses, improve problem solving and develop cognitive strategies to maximise coping, enhance a sense of mastery over life and re-evaluate priorities for the future. Specific group themes include death anxiety, fear of recurrence, living with uncertainty, understanding treatment with chemotherapy, radiotherapy and hormone regimens, the collaborative doctor-patient relationship, body and self image, sexuality, relationships with partner, friends and family, surgical reconstruction, life style effects and future goals. Active coping skills are developed through teaching formal problem solving and cognitive restructuring of automatic negative thoughts. Technical aspects of the therapy are discussed.

The online patient meeting

Studies have shown the importance of social support for health, and the value of patient support groups. Today we are seeing a further development of the idea of the patient meeting: online discussions on the internet and other computer networks. This paper reports on the online activities of patients with amyotrophic lateral sclerosis. The paper explores key questions in the evaluation of online patient meetings, such as the ability of patients to discuss their problems frankly, the availability and accuracy of advice, the spread and control of rumours.

Group psychological therapy for cancer patients: a point of view, and discussion of the hierarchy of options

OBJECTIVE

We present here a point of view about the logical role of group psychological therapies in the care of cancer patients, and propose a comprehensive, four-stage program that could be implemented at any large cancer treatment center.

METHOD

Our proposals rest on a review of the literature, and on our own experience with various kinds of psychological help for cancer patients, some of which is described.

RESULTS

It is clear that group psychological therapies improve the quality of life of many participating cancer patients, and there is preliminary evidence that it may prolong life in some cases. We describe five main kinds of adjuvant psychological therapy, arranging them on a hierarchy of increasingly active participation by the recipient, and noting the status of evidence for their efficacy. They are: providing information, emotional support, behavioral training in coping skills, psychotherapy (of various kinds), and more speculatively, spiritual/existential therapy.

CONCLUSIONS

We propose that it is time to consider psychological therapy as an adjuvant in cancer management, analogous to adjuvant chemotherapy. The main indication for advocating group psychological therapy to patients should, we argue, be an expert assessment that the patient is likely to benefit, and should not (as is usual at present) be restricted to either 1) those patients with overt psychopathology, or 2) those few who specifically request it.

A randomised comparison of two forms of a brief, group, psychoeducational program for cancer patients: weekly sessions versus a "weekend intensive"

There is considerable evidence that brief group psychoeducational programs for cancer patients, offering support and some training in coping skills, may have lasting beneficial effects on mood and quality of life.

OBJECTIVE

To compare two different formats of a brief, group psychoeducational program for cancer patients; a standard format of six weekly two-hour sessions or a "weekend intensive," involving the same content and contact time compressed into two days.

METHOD

Cancer patients were randomly assigned to either the standard weekly intervention (n = 77) or the weekend program (n = 79). Two assessment measures were used: Profile of Mood States (POMS) and Functional Living Index for Cancer (FLIC). Assessments were made before and after each intervention and at a nineteen-week follow-up.

RESULTS

While the two formats were found to be equivalent in their overall effects on mood and quality of life, there were some differences. There was a sudden, large improvement in mood by the end of the weekend version of the course (2-day time point) but this did not persist, and by the six-week point and again at nineteen-weeks, mood improvement was the same for both groups. Quality of life improvement seemed to be marginally greater with the six-weekly sessions (reaching statistical significance at the 6-week point).

CONCLUSIONS

The two formats produced similar improvements in both mood and quality of life. We discuss the need for further studies to find optimal ways of presenting such help for different patient groups.