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.” Standards of care have been developed for the management of psychosocial distress.
The National Comprehensive Cancer Network  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:
- 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.)
Psychosocial Interventions for Distress
The efficacy of psychosocial interventions in adult cancer patients is supported by an extensive literature.[Level of evidence: IV];[4-6][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. white 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. Outcome measures have varied and have included the following:[3,4]
- 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  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,[Level of evidence: I] ranging from negligible for depression, to small for overall emotional outcomes, to moderate for anxiety.[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.[Level of evidence: II]
In one study, 249 breast cancer patient-partner dyads were randomly assigned to one of four groups:
- A control group that received standard disease management.
- A standardized psychoeducation group.
- A group that received telephone counseling.
- A group that received 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 results support the efficacy of low-cost, replicable interventions by video and telephone to achieve these physical and psychological benefits.
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.[4,5]
Randomized trials of group interventions for breast cancer
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 [Level of evidence: I] to 20 hours [7,10][Level of evidence: II] to 27 hours,[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. 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  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. 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 group. 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.
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.[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., they 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).
Problem-solving, focused, individual psychotherapy
A variety of individual psychosocial interventions have been studied. One study emphasized the development of problem-solving abilities.[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. 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.
Self-administered stress management training for chemotherapy
In a randomized trial of 411 mixed-diagnosis cancer patients,[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.
Brief orientation and tour of a medical oncology clinic
- 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.
Mindfulness-based stress reduction for survivors of breast cancer
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. 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:
- 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.
Hypnosis and relaxation prior to excisional breast biopsy
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 analog 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.[Level of evidence: II]
Presurgical stress management in patients who are undergoing radical prostatectomy
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).[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. A particular strength of this study is the use of a supportive attention group and a standard care group.
Use of online information
The Comprehensive Health Enhancement Support System (CHESS)  is an online resource for cancer patients. It has two components:
- Didactic material.
- Narrative information about medical, practical, and psychosocial issues.
This study addressed the relative appeal and value of these two components separately for white 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 white 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 white 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 white women.
Can psychosocial interventions increase survival?
The intriguing question of whether participation in a psychosocial group intervention can result in increased survival has been investigated since 1989. The original study  tested a supportive-expressive group therapy format for women with metastatic breast cancer, while another study  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  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, the United States, and Australia. Although all three studies found significant psychological benefits, no study could replicate the survival benefit.
Literature reviews, including three meta-analyses [26-28] and one systematic review, have concluded that previous research has failed to find an effect of psychotherapy on survival. One summary  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  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 an analysis 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  that continued research into this question is no longer warranted.
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