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Transcript of Psycho-oncology
What is psycho-oncology?
The nature and course of cancer
Relationship and relevance of psychological factors to cancer
Impact of cancer on family/carers
2. Enhance your knowledge (and inform your practice) of evidence-
based psycho-oncology assessment and intervention
3. Provide information on useful self-help, online and community
resources Our aims Concerned with the psychological, social, behavioural, and ethical aspects of cancer What is Psycho-oncology? Quick quiz… “Cancer”
Diverse group of 100+ diseases in which some of the body’s cells become abnormal and begin to multiply out of control as a result of genetic changes (mutations)
These abnormal cells can form an invasive (malignant) tumour which can invade and damage the surrounding areas, spread to other parts of the body, and cause death. Not all tumours are invasive; some are benign tumours (do not spread, rarely life-threatening)
Cancers are distinguished from each other by the place in the body in which the disease begins (e.g., lung cancer, breast cancer) Psycho-oncology How many of us have been touched by cancer? The Nature of Cancer New cancer diagnoses are required to be reported to state-based cancer registries
A total of 108 368 new cases of cancer (62 019 males and 46 349 females) were diagnosed in Australia in 2007 – highest number registered to date (excluding basal and squamous cell carcinomas of the skin)
68% were diagnosed in people aged 60 years +
Incidence rate of the most commonly diagnosed cancers increased from 1982 to 2007, including the rate of melanoma of the skin; prostate cancer; bowel cancer in males; and lung cancer and breast cancer in females.
Cancer was estimated to be the leading burden of disease in Australia in 2010, accounting for 19% of the total burden
Australian Institute of Health and Welfare Prevalence A prognosis is an estimate of the likely course and outcome of a disease. The prognosis of a patient diagnosed with cancer is often viewed as the chance that the disease will be treated successfully and that the patient will recover.
Many factors can influence the prognosis of a person with cancer, including:
Type and location of the cancer
Stage of the disease (the size of the tumour, and the extent to which the cancer has spread in the body)
The cancer’s grade (how abnormal the cancer cells look under a microscope—an indicator of how quickly the cancer is likely to grow and spread)
Biological and genetic properties of the cancer cells
Patient’s age and overall general health
Extent to which the patient’s cancer responds to treatment.
National Cancer Institute – www.cancer.gov General Course Cancer accounted for 3/10 deaths registered in Australia in 2007, making it one of the most common causes of death in that year
A total of 39 884 deaths from cancer occurred in 2007, an average of 109 deaths every day. However, the age-standardised mortality rate has decreased significantly by 16% from 1982 to 2007
Decreases in the rate of death were observed for the most common causes of cancer deaths, the exception being lung cancer in females Mortality There are various approaches to treating cancer, many of which involve combinations of therapies to provide the most effective treatment
Surgery - relieves discomfort from tumors obstructing organs or causing bleeding. Often used in combination with radiotherapy and/or chemotherapy to make sure any cancer cells remaining are destroyed.
Radiotherapy - uses high energy radiation to destroy cancer cells or impede growth. Commonly delivered externally, through the skin. However, can be administered internally. Radiotherapy is used as a curative treatment and to relieve discomfort associated with incurable cancer
Chemotherapy – almost always used with other treatments as not curative for most solid cancers alone. Act by killing cells that divide rapidly, one of the main properties of most cancer cells.
Hormone therapy – may involve taking medications that interfere with the activity of the hormone or stop the production of the hormones. May involve surgical removal of a gland. These treatments are commonly used for prostate, breast or uterine cancers
Australian cancer council Medical Treatments Psycho-oncology addresses the two major psychological dimensions of cancer:
The psychological responses of patients (or their families/carers) to cancer at all stages of the disease
The psychological, behavioural and social factors that may influence the disease process Relevance of psychological factors You receive a cancer diagnosis, are facing an uncertain future, must begin an invasive and demanding treatment regime, suffer symptoms and side-effects that cause you significant physical discomfort
Will you be able to continue to work or study given the time-consuming nature of your treatment plus the physical symptoms you suffer?
Who will pay your bills, buy the groceries, run your household, take care of your home, drive you to your appts if you can’t drive yourself?
What impact will this have on your family? What extra responsibilities will they be required to take on (practically, financially, emotionally)? What does your romantic relationship look like? How will you manage your own concerns in addition to your family’s concerns?
What activities do you enjoy doing in your leisure time now? Will you be able to continue these during your illness? What activities will you do for fun? Will you have the energy/desire to get out?
Will you be able to maintain your social relationships? Will they survive? How will you feel amongst your healthy friends at this time?
How will you cope emotionally? First, lets imagine… Common psychological reactions:
Diagnosis - anxiety, anger, shame, depression; denial, fatalistic beliefs, grief & loss, existential concerns
Treatment: anticipatory anxiety, fears about treatment; exaggerated pessimism, passivity leading to noncompliance with health-protective behaviors, body image concerns, PTSD symptoms
Each patient will experience a range of practical, psychological and emotional challenges as a result of their diagnosis and treatment-related adverse effects.
Each patient’s life may be further disrupted by changes in role and family functioning, occupational or employment status, and financial status. Some patients will have to come to terms with progressive illness and approaching death, others may be faced with the physical, emotional and social challenges of survival.
Kangas, Henry Couper, Pollard Australian Cancer Council;
National Health and Medical Research Council - Clinical practice guidelines for the psychosocial care of adults with cancer Psychological responses to cancer Risk Factors Aim: previous meta-analysis found prevalence of psychological illness to be the same as in the general population. New studies with advanced methodology have been published since; therefore, an updated meta-analysis was needed to determine necessity of prof psychosocial care of cancer patients
Systematic review of studies investigating prevalence of nonpsychotic psychopathology in cancer patients in acute care hospital settings with structured clinical interviews Prevalence of Mental Illness
Meta-analysis – Singer, Das-Munshi & Brahler (2010) Results (based on 8 studies)
Prevalence ranged from 23% - 53%
Met criteria for at least 1 DSM diagnosis??
Heterogeneity in prevalence rates – theorized to be due to different cancer populations, e.g.,
elderly vs younger patients
Tumors in different locations
Different stages of cancer
(unable to explore heterogeneity due to small number of studies Meta-analysis – Singer, Das-Munshi & Brahler (2010) Prevalence of mental illness in general population: 95% CI = 19% - 21%
5/8 studies produced confidence intervals that were above this range
Overall prevalence: 95% CI = 26% - 36%
Suggests higher rate of mental illness in cancer patients than general population. Around 1/3 of cancer patients in acute care hospitals are suffering mental health disorders & need appropriate treatment Meta-analysis – Singer, Das-Munshi & Brahler (2010) Limitations
Use of clinical interviews based on DSM diagnoses
Patients in acute care settings only
Comparison sample was under 65 years, yet cancer is more prevalent elderly
Doesn’t specify types of psychological illness
Provision of useful and valid recommendations
Provided clinical implications of findings (i.e., need for professional psychosocial clinicians and standard screening for psychological distress in patients)
Recommended further research to identify reasons for prevalence heterogeneity
Provided simple recommendations regarding provision of psycho-social care (e.g., support offered by nurses, oncologists etc) ??? Meta-analysis – Singer, Das-Munshi & Brahler (2010) Across broad range of cancer and treatment types, changes in the romantic relationship of couples facing cancer is common (71.3% in patients, 74.6% in partners)
Higher rate of positive changes (over 50%) than negative changes (less than 20%)
Women more likely to perceive negative changes then men, particularly when they are in the partner role.
Negative relationship changes significantly associated with lower QOL and higher anxiety and depression
Drabe, Wittmann, Zwahlen, Buchi & Jenewein (2012) Psychological responses to cancer
– Relationship Changes Majority of cancer survivors report good general health 5 years or more after treatment. However many cancer survivors continue to experience cancer-related difficulties
Specific physical impairments have been reported, and have a sustained impact on patient functioning and QOL
Fatigue or lack of stamina
Decreased participation in activities
Greater risk of long term physical effects in older patients
Prevalence estimates of psychological distress in cancer survivors:
Depression: 0% to 58%
Anxiety: 6% to 23%
PTSD: 0% - 32%
Stein, Syrjala & Andrykowski (2008) Psychological responses to cancer
- Cancer survivors Major impact of cancer-related financial worries and difficulties on family lifestyle activities, roles and relationships
Contributes to relationship breakdown and psychosocial burden to sufferer and carers
Families tend to avoid discussing financial issues in early part of cancer journey – focus energy on fighting illness. Any difficult issues tend not to be discussed for the sake on maintaining optimism and positivity
Implications for health professionals and social workers – financial situation must be addressed early to prevent subsequent debt, bankruptcy, lifestyle restrictions, family breakdown and general psychological distress
Amir, Wilson, Hennings & Young (2011) Psychological responses to cancer
- Financial Impacts Systematic review of difficulties faced by family carers of cancer patients
Stenberg, Ruland & Miaskowsky (2010)
19 466 adult carers of cancer patients, internationally
Identified 200 problems and burdens related to caregiving responsibilities
Anxiety, depression, fear, uncertainty, sexual issues, challenging emotional reactions to carer role, relationship with patient
Social problems and need for information
Financial, work/education, role strain, isolation/relationships, managing patient’s medical treatment, access to information,
Physical health problems
Sleep, pain, fatigue, appetite/weight, indigestion
Physical, social or emotional problems – in combination
Quality of life
Responsibilities and impact on daily life
Direct care of patient (e.g., bathing, providing medication), indirect care of patient (running errands, filling in forms), other carer responsibilities (child care, other family responsibilities), impact on carer’s daily life, changes in routine and lifestyle Psychological responses to cancer
– Impact on family / carers Can a “fighting spirit” help?
Garssen (2004) – review of 70 prospective studies
No psychological factor consistently demonstrated an influence on the initiation or progression of cancer
However, some trends emerged:
“Influences that cannot be totally dismissed” - helplessness and repression seemed to contribute to an unfavorable prognosis, while denial/minimizing seemed to be associated with a favorable prognosis (effect has not been confirmed in all studies)
With even less convincing evidence - Some indications found for a role of social support, loss events, and marital status.
The role of life events (in general), distress, having psychological problems or a psychiatric diagnosis, fighting spirit, stoic acceptance/fatalism, active coping, personality factors in general, and locus of control in particular, is doubtful. Impact of psychological factors on cancer initiation or progression Psycho-oncology - some background information Psycho-oncology Evidence based assessments
Evidence based interventions
Comprehensive description intervention Areas to assess when interviewing clients with cancer
Medical status (stage, treatment, prognosis)
History and course of current and past medical conditions
Cancer risk factors (behavioral, genetic, environmental)
Current family situation
Family of origin
Alcohol and substance abuse use (past and present)
Knowledge and beliefs surrounding cancer diagnosis
Identify cancer and non-cancer related stressors
Assess current coping strategies
Social support (family, friends, membership in religious and other organizations)
Psychological functioning/psychiatric history:
Assess current mood (objective and subjective ratings)
Past psychological history (therapy or counseling, psychiatric diagnosis and/or medications)
Family history of psychiatric illness Clinical interview
(Kilbourne & Dourning, 2003) Advanced disease
Poorly controlled pain
(Chochinov, Wilson, Enns Kathol, Noyes, Williams & Mutgi, 1990) Risk factors to assess.. The vegetative signs of depression (fatigue, lack of appetite, weight loss) are not helpful in patients with advanced illness, and indicators of emotional well being may be more useful.
Eliciting a sense of pervasive hopelessness, worthlessness or guilt can help identify patients at risk for major depression. An important associated issue that may contribute to a sense of hopelessness is the presence of unrelieved symptoms, particularly pain.
Terminally-ill individuals who suffer from depression are at high risk of suicide and suicidal ideation, and they have an increased desire for a hastened death. Passive suicidal ideation (I'd be better off dead) should be distinguished from active suicidal ideation (I'd be better off dead and this is how I'm going to do it). Clinical tips when assessing depression in clients with cancer (Kilbourne & Durning, 2003) Psycho-oncology assessment...
Instrument selection considerations (Pirl, 2010) Goal of using instrument: acceptability and brevity may be critical in clinical care
Population: general population, people being treated for cancer, types of cancers, long term cancer survivors
Psychometrics: Validity/reliability for use with intended population
Burden of instrument: time, location, aid required
Scoring Common assessment tools (Pirl, 2010) Assessment tools – cancer specific (www.pocog.org.au) Scales: Functional scales: physical; role; emotional; cognitive; social Symptom scales/items: fatigue; nausea and vomiting; pain; dyspnoea; insomnia; appetite loss; constipation; diarrhoea; financial difficulties
Items: 30Administration method: Self-administered; interview-administered; telephone administered; computer touch screen administered
Recall time period: Past week
Response options: 4- and 7-point scales
Cost: Free for non-commercial use EORTC QLQ-C30
European Organisation Research and Treatment of Cancer Across cancers -
Scott NW, Fayers PM, Aaronson NK, et al, on beholf of the EORTC Quality of Life Group and the Quality of Life Cross-Cultural Meta-Analysis Group. Differential item functioning (DIF) in the EORTC QLQ-C30: a comparison of baseline, on-treatment and off-treatment data. Qual Life Res. 2009;Feb 27.
King MT. The interpretation of scores from the EORTC quality of life questionnaire QLQ-C30. Quality of Life Research. Dec 1996;5(6):555-67
Osoba D, Rodrigues G, Myles J, Zee B, Pater J. Interpreting the significance of changes in health-related quality-of-life scores. Journal of Clinical Oncology. 1998 Jan;16(1):139-44
In specific cancers -
Doyle C, Crump M, Pintilie M, Oza AM. Does palliative chemotherapy palliate? Evaluation of expectations, outcomes, and costs in women receiving chemotherapy for advanced ovarian cancer. Journal of Clinical Oncology. Mar 1 2001;19(5):1266-74
Gulbrandsen N, Hjermstad MJ, Wisloff F, Nordic Myeloma Study G. Interpretation of quality of life scores in multiple myeloma by comparison with a reference population and assessment of the clinical importance of score differences. European Journal of Haematology. Mar 2004;72(3):172-80
Nordin K, Steel J, Hoffman K, Glimelius B. Alternative methods of interpreting quality of life data in advanced gastrointestinal cancer patients. British Journal of Cancer. Nov 2 2001;85(9):1265-72 Evidence
Assesses: Anxiety, depression, general distress
Items: 14 (7 items – depression, 7 items – anxiety)
Administration method: Self-administered
Recall time period: Past 7 days
Response options: 4-point scale Hospital Anxiety and Depression Scale (HADS) Snaith and Zigmond (1983) Razavi et al., 1990), correlation .70 with clinical-administered assessment of depressive symptoms.
Bjelland I, Dahl AA, Haug TT, Neckelmann D, Bjelland I, Dahl AA, et al. The validity of the Hospital Anxiety and Depression Scale. An updated literature review. J Psychosom Res. 2002 Feb;52(2):69-77.
Carroll BT, Kathol RG, Noyes R, Jr., Wald TG, Clamon GH. Screening for depression and anxiety in cancer patients using the Hospital Anxiety and Depression Scale. General Hospital Psychiatry. Mar 1993;15(2):69-74.
Lloyd-Williams M, Friedman T, Rudd N. An analysis of the validity of the Hospital Anxiety and Depression scale as a screening tool in patients with advanced metastatic cancer. Journal of Pain 22(6):990-996.
Moorey S, Greer S, Watson M, et al. The factor structure and factor stability of the hospital anxiety and depression scale in patients with cancer.[see comment]. British Journal of Psychiatry. Feb 1991;158:255-259.
Sellick SM, Edwardson AD. Screening new cancer patients for psychological distress using the Hospital Anxiety and Depression Scale. Psycho-Oncology Vol 16(6) Jun 2007, 534-542. 2007.
Skarstein J, Aass N, Fossa SD, Skovlund E, Dahl AA. Anxiety and depression in cancer patients: relation between the Hospital Anxiety and Depression Scale and the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire. Journal of Psychosomatic Research. Jul 2000;49(1):27-34.
Smith AB, Selby PJ, Velikova G, et al. Factor analysis of the Hospital Anxiety and Depression Scale from a large cancer population. Psychology 75(Pt 2):165-176.
Walker J, Postma K, McHugh GS, et al. Performance of the Hospital Anxiety and Depression Scale as a screening tool for major depressive disorder in cancer patients. Journal of Psychosomatic Research. Jul 2007;63(1):83-91.
Cancer, specific types -
Fossa S, Dahl AA. Short Form 36 and Hospital Anxiety and Depression Scale. A comparison based on patients with testicular cancer. J Psychosom Res. 2002;52(2):79-87.
Kramer JA. Use of the Hospital Anxiety and Depression Scale (HADS) in the assessment of depression in patients with inoperable lung cancer. Palliative Medicine. Jul 1999;13(4):353-354.
Love AW, Grabsch B, Clarke DM, Bloch S, Kissane DW. Screening for depression in women with metastatic breast cancer: a comparison of the Beck Depression Inventory Short Form and the Hospital Anxiety and Depression Scale. Australian 38(7):526-531.
Love AW, Kissane DW, Bloch S, Clarke D. Diagnostic efficiency of the Hospital Anxiety and Depression Scale in women with early stage breast cancer. Australian 36(2):246-250.
Rodgers J, Martin CR, Morse RC, Kendell K, Verrill M. An investigation into the psychometric properties of the Hospital Anxiety and Depression Scale in patients with breast cancer. Health 3:41. Evidence Types: Psychological constructs and styles
Psychological constructs and styles: Cognitive style
Number of items: 17
Scoring options: Total only
Administration method: Self-administered
Recall time period: Not specified
Response options: 5-point scale Benefit Finding Scale
Antoni et al (2001) Antoni MH, Lehman JM, Kilbourn KM, Boyers AE, Culver JL, Alferi SM, 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.[see comment]. 2001 Jan;20(1):20-32. Evidence... Decrease distress
Assist with adjustment to diagnosis
Increase quality of life
Address body-image concerns
Address concerns about recurrence
Tx of depression/anxiety
Improve family communication
Explore grief and bereavement Psychological intervention aims... Barsevick et al. (2002). Systematic review of psych intervention for depression:
36 RCT studies, + other quasi-experimental, descriptive and meta-analytic papers. Clear description of procedures, studies rated according to quality. Results not based substantially on small studies. Found:
Strong evidence that psycho-ed interventions reduce depressive symptoms
Behavioural therapy/counselling alone or in combination with cancer education is beneficial
Uitterhoeve et al (2004). Systematic review of psych intervention for QoL:
13 RCTs. Quality of studies independently assessed, some studies did have small sample sizes Found:
12/13 trials evaluating behaviour therapy found positive effects on one or more indicators of QoL (e.g., depression), supporting recommendations of behaviour therapy in the care of advanced cancer patients
Meyer & Mark (1995). Meta-analysis of psych intervention for a range of symptoms:
45 RCTs. Clear description of procedures, no consideration of study quality. No info on sample sizes!! Found:
Compound/global symptoms (symptoms across multiple categories): d = .28
Treatment & disease related symptoms (e.g., nausea, pain): d = .26
Emotional adjustment: effect size = .24
Functional adjustment (social, occupational): d= .19
Medical outcomes (tumor response, disease progression): non significant effect
These effects are slightly smaller than typical of effective psychological interventions, but within expectable range Does it help? Sheard & Maguire, (1999). Meta-analysis of psychological interventions for depression. Consideration given to study quality, procedures clearly described, results not reliant on small sample sizes.
Majority of trials were preventative, patients not selected based on psychological functioning
20 trials (must have control condition) found preventative psych interventions in cancer patients do not have clinical effect upon depression (effect size = .19)
Four trials targeted interventions at those identified as at risk of, or suffering significant psychological distress, these were associated with clinically powerful effects (effect size = .85).
Williams & Dale. (2006). Systematic review of treatment for depression:
18 RCT, predominantly preventative (17/18). Study quality rated, not reliant on small studies. Found:
Across 18 trials, little evidence that psychological treatment is effective in reducing depression (preventatively).
However, a number of small-scale, single-centre trials showed psychotherapeutic interventions – particularly CBT – can have effects on depressive symptoms Does it help? (cont.) Level I Evidence is obtained from a systematic review of all relevant randomised controlled
Level II Evidence is obtained from at least one properly designed randomised controlled trial.
Level III-1 Evidence is obtained from well-designed pseudo-randomised controlled trials (alternate
allocation or some other method).
Level III-2 Evidence is obtained from comparative studies with concurrent controls and allocation not
randomised (cohort studies), case control studies, or interrupted
time series with a control group.
Level III-3 Evidence is obtained from comparative studies with historical control, two or more single-arm
studies, or interrupted time series without a parallel group.
Level IV Evidence is obtained from case studies, either post-test or pre- and post-test. Types of interventions on their impact on clients with cancer Demonstrated effectiveness of interventions for specific psychological problems.... Tailoring Cognitive Behavioral Treatment for Cancer Pain
Dalton, Keefe, Carlson, & Youngblood. (2004). Journal of Cognitive Psychotherapy, 13(3). 189-202.
Determine whether profile-tailored CBT is more effective than standard CBT/usual care, for patients with cancer-related pain.
Little research looking at CBT tailored to patient characteristics in this population. Few trials investigating which patients will benefit from which specific interventions.
131 patients receiving treatment at four sites randomly assigned to one of three groups. Elevated score on at least one Biobehavioral Pain Profile (BPP) (Dalton et al., 1994). Over 18, cancer-related chronic pain. CBT in psycho-oncology... 1. Patients who receive a CBT protocol matched to their BPP profile would report :
a) less pain intensity, fewer pain behaviours, greater responsiveness
to treatment, greater durability of response, less interference of pain with activities, less symptom distress
b) better mood, functioning, sleep, QOL
c) greater achievement of personal goals than those receiving
standard CBT or usual pain treatment
2. Effect of profile-tailored CBT would be sustained over time Hypotheses Three groups:
1. Profile tailored CBT
2. Standard CBT
3. Usual Care
Randomly assigned to group
CBT patients contacted by therapists
Data collection: pre, post, one-month, 6-month Design Karnofsky Performance Status Scale (Karnofsky et al., 1948): symptom severity, ability to care for self – used as global measure of stage of disease
Brief Pain Inventory (Daut, et al., 1983): pain intensity, interference, pain relief by medications in past 24 hrs
Symptom Distress Scale (McCorkle & Young, 1978): intensity of nausea, mood, appetite, insomnia, pain, mobility, fatigue, bowel pattern, concentration, appearance
Profile of Mood States (McNair et al., 1971): six mood states
Medical Outcomes Study Short-Form Health Surey (McHorney et al., 1993): general health status
Katz Index of Independence in ADLs Scale (Katz, 1983): ability to perform activities of daily living
Daily pain diary: intervention, 1 wk prior to 2 follow up ax
Patient Goals for Treatment, and Patient Goal Achievement Measures Treated by registered nurses trained in the treatment
Different nurses trained to implement treatment at each site
Trained during a two-day didactic experiential course
Role-plays, lecture, discussion, written instruction, detailed manuals, readings
Treatment sessions audiotaped and reviewed by principal investigator and co-investigator CBT groups Aims:
Teach relationship between pain, suffering and emotions
Teach symptom coping skills, problem-solving, relaxation, and self-control
To modify cognitive distortions associated with emotional distress
To modify distressing thoughts; promote personal control
1: Assessment of attitudes, beliefs, behaviours using semi- structured interview format
2-3: Relaxation and attention diversion/distraction
4-5: Dysfunctional thoughts and maladaptive behaviours that may occur in response to nociceptive events Standard CBT Matched based on scores on the Behavioural Pain Profile
Loss of Control
Health Care Avoidance
Past and Current Experience
Thoughts of Disease Progression Profile-Tailored CBT Positive results with chronic pain not related to cancer, depression and alcoholism
Evaluation of needs
Understanding role of physiologic origin of the pain, but also meaning of situation in which pain occurs, importance of competing sensory stimuli (current or historic), physiologic responses such as muscle tension. Patient-Treatment Matching Measures biobehavioral factors presumed to influence verbal report of pain, activity and medication use; and environmental situations and personal tributes (e.g. psychophysiologic factors) related to pain experience.
Psychophysiologic perspective of pain focuses on psychological attributes, environmental factors, and cognitive, affective and behavioural responses associated with individual response to nociception and treatment.
These responses linked to chronic pain may be influenced by meaning of primary event (primary appraisal), or by coping resources and options (secondary appraisal) Biobehavioural Pain Profile (BPP) Dalton et al., 1994 Positive self-statements
Modules designed to address patient characteristics based on BPP profiles. Strategies often used but have rarely been systematically selected in response to identified patient characteristics Profile-Tailored CBT Same approach normally used in clinic being treated
Generally included educational and supportive techniques
Did not meet with CBT therapists about pain problems Usual Care 53 Completed intervention
28 Completed all assessments..............issues?? Results Authors reported:
Pre to Post intervention:
T-CBT patients experienced substantial improvement from baseline to immediately post-intervention in worst pain, least pain, less interference of pain with sleep, and less confusion (than S-CBT)
Pre to 1-month Post intervention:
T-CBT patients saw greater improvement in less interference of pain with activities, walking, relationships, and sleep; less composite pain interference; and less mobility and confusion symptom distress.
S-CBT and usual care patients experienced little change
Pre to 6-month Post intervention
Compared to T-CBT patients, S-CBT patients showed greater improvement at 6-months post-intervention with less average pain, less pain now, better bowel patterns, lower summary symptom distress, better mental quality of life, and greater improvement in Karnofsky performance status (symptom distress & ability to care for self) Results Very high rates of attrition (due to death; disease progression, including hospitalization and/or transfer to hospice; and increased transportation problems, clinic and study treatment schedule conflicts, and personal commitments)
Patients with high ratings of pain interfering with enjoyment in life were less likely to complete study – potentially inflates intervention effects
Inconsistency in description of who dropped out
“Significantly more T-CBT patients (n = 5) left the study due to becoming pain-free than did S-CBT (n = 10) and usual care (n = 1) patients)”
Actually, it looks like less people in S-CBT dropped out? Either way, this differential drop out may bias the findings. Our concerns … Inflated chance of a type one error (finding a significant different when one doesn’t actually exist) - didn’t correct for number of analyses conducted as power of study would not support more stringent criteria. Used probability value of .10 (one tailed test)
No effect sizes reported
Very hard to work out which results related to which DVs (we didn’t want to rely on their discussion, wanted to see statistics for ourselves). Errors in reporting? Statistics don’t match up with their reported results? Our concerns continued… * 2 probability values were above .10 – either the authors reported them wrong (i.e., they were meant to say .04 instead of .4) or they were in error in terms of their reporting as a significant result??? Our interpretation of results In other words:
Reduction in worst pain experienced: T-CBT superior to S-CBT
Reduction in least pain experienced: T-CBT superior to S-CBT
Reduction in interference with walking: T-CBT superior to usual care (not S-CBT)
Reduction in interference with sleep: T-CBT superior to S-CBT
Improvement in Physical QoL: T-CBT superior to S-CBT
Increase in exercise tolerated: S-CBT superior to usual care
Increase in time spent with a friend: T-CBT superior to usual care (not S-CBT) 1. Based on pre-post results (which had less problems with attrition than
pre to 1-month post, yet still issues with type 1 error):
Potentially promising results for tailoring CBT to patient profile.
2. Need more rigorous research Conclusions PSYCHOEDUCATION, SUPPORTS & RESOURCES
keep a diary of medical consultations and treatments
write down questions in order of importance
also write down information to inform the treating doctor
write down the answers provided
take someone to accompany and record information
get a second opinion
explore advanced health directive and options available
encourage open communication with family and friends Strategies to help ind with cancer: Strategies to help ind with cancer: Emotional/Behavioural:
expect social discomfort from others and rehearse responses
increase activity where possible and use relaxation strategies
challenge unhelpful thinking
encourage linkage to social support from those who understand
explore meaning and post trauma growth
problem solving skills
promote healthy lifestyle and selfcare
express and process difficult emotions
pain management skills The average carer spends about 40 hours per week providing care
It is important to acknowledge the emotional experiences of both the individual with cancer as well as that of the carer
Research shows that carers often experience higher levels of distress than the person with cancer Most individuals with cancer will require practical support with everyday tasks
More than 2.5 million unpaid family carers in Oz
More than 770,000 of these people are primary carers What supports may be required? Fear:
how the unwell person is feeling
confusion/misunderstanding about the treatment , prognosis , health professionals
responsibility of giving what can be lethal medication concoctions
feeling like everything is out of their control
not knowing what the future holds
the possibility that the person they’re caring for (most of the time a family member) could die
some carers feel more in control with education, while others feel overwhelmed by the information available Common reactions for carers: Anger and frustration:
having to be the carer (e.g., where there is no other viable carer)
the extra responsibilities and loss of previous life
other family and friends not doing more to help
having future plans interrupted
having little or no time for activities they used to enjoy
feeling the person they’re caring for does not seem to appreciate the hard work and sacrifices being made
Anger at the world, a sense of injustice Common reactions of carers
It is easy to become isolated as a carer
They may feel too busy to socialise
People may visit them less often because they think they have too much to do or they don’t know how to deal with the disease of the person they’re caring for
Maybe they did a lot with the person who has cancer and they miss this special time together
Even if they have many helpers they may feel alone and isolated
They may feel as though the main caring responsibility has fallen to them, and no-one quite understands what they are going through or how they feel Common reactions of carers
The demands, difficulties and limitations of looking after someone with cancer can be stressful
Symptoms of stress including physical signs, such as trouble sleeping, constant headaches, high blood pressure, heart problems, feeling tired, unwell and overly sensitive
If stress continues for a long time, it could lead to exhaustion and burnout
Many carers say they feel out of control or under extreme pressure all day, every day Common reactions for carers
Loss and grief:
following a dx of cancer
loss of an enjoyable part of their relationship with the unwell person
sense of longing for missing parts of their life (e.g., work, regular exercise, social events or intimacy)
uncertainty regarding future and financial changes
Guilt is a common emotions carers experience due to feeling angry and resentful of the unwell person
wanting a break from caring Common reactions for carers
being well, while the person they are caring for is sick
not doing a perfect job as a carer
caring can also be very rewarding due to a sense of satisfaction, achievement and personal growth
although the satisfaction may not be experienced on a day-to-day basis, some experience these emotions once the caring role ends and they are able to reflect on the positive and gratifying parts of their caring experience Common reactions for carers
Strategies to help carers cope:
Keeping a diary:
assists to give the carer perspective
release some of their worries or frustrations
acknowledge their feelings
online blogging allows to share experiences with other carers
self expectations of perfectionistic caring and allow room for mistakes
acceptance of conflicting emotions such as resentment, anger, guilt
Strategies to help carers cope: Accept offers of help:
getting in touch with others to alleviate isolation
increase recognition of early warning signs of stress
self permission to seek support and rest
challenge thoughts of guilt/weakness for taking breaks etc
Maintain/increase social contact :
use technology to stay in touch with others where physical travel and time do not permit
ask a family member or friend to keep others up to date
leave a message on the answering machine to keep others informed Practical tips for carers: rearrange furniture to make access easier and remove tripping hazards
talk to an OT about changes you can make/equipment available for hire (e.g., putting handrails on the stairs or in the bathroom, lifting etc)
if manual lifting is required, have an OT or physio to show them how to lift safely
keep the medication in its original packaging so to always know what type of drug is being administered when
use a tick sheet to keep track of doses administered
cook extra food and freeze it for another day
take extra care when preparing food because of weakened immune system (e.g., wash hands before food prep etc) 10/26/12 10/26/12 10/26/12 An Applied Summary Liz: Age 50, recent diagnosis of ovarian cancer, separated from husband, 2 adult sons, one grandchild.
Assess risk factors for poor adjustment (e.g., life stressors, poorly managed pain, availability of family/social support)
Targeted assessment tools relating to presenting problems
Distress – Cancer and Treatment Distress Scale
Anxiety & Depression – HADS
Functional assessment – EORTC QLQ C30
Conceptualisation of underlying mechanisms of distress: Treatment:
Provide and invite client to collaboratively conceptualise distress including feedback on assessment measures
Provide psychoeducation on CBT model
Check for understanding and perception of illness and perceptions of treatment
Provide psychoeducation on cancer illness, treatment and impact on psychological wellbeing
Normalise emotional distress
Link in with other services (inc cancer-specific services) for support where clinically relevant An Applied Summary
Promote healthy lifestyle using behavioural activation, activity scheduling, relaxation, mindfulness, healthy diet etc
Assist to evaluate unhelpful thought, expectations and beliefs
Facilitate the restructuring of unhelpful cognitions and inclusion of coping statements
Pain management skills where required
Explore and process distressing and conflicting emotions
Normalise grief response to loss of pre-existing lifestyle
Identify body image or self esteem issues related to fears of having a hysterectomoy and losing femininity
Identify external stressors related to family/friends poor coping through problem solving, goal-setting, communication etc
Review regularly for changes in mental state and risk An Applied Summary References Australian Cancer Council - http://cancer.org.au
Australian Institute of Health and Welfare - http://www.aihw.gov.au/
National Cancer Institute – www.cancer.gov
National Health and Medical Research Council - Clinical practice guidelines for the psychosocial care of adults with cancer
Maria Kangas, Jane L. Henry, Richard A. Bryan (2002). Posttraumatic stress disorder following cancer. Clinical psychology review, 22.
Couper, Pollard & Clifton (2012). Depression and cancer. MJA Open, 1, Suppl 4, pg 13.
Singer, Das-Munshi & Brahler (2010) Prevalence of mental health conditions in cancer patients in acute care – a meta-analysis. Annals of Oncology, 21, 925.
Stein, Syrjala & Andrykowski (2008). Physical and Psychological Long-Term and Late Effects of Cancer. Cancer, 112, 2577–92.
Stenberg, Ruland & Miaskowsky (2010). Review of the literature on the effects of caring for a patient with cancer. Psycho-Oncology 19: 1013–1025
Drabe, Wittmann, Zwahlen, Buchi & Jenewein (2012)
Amir, Wilson, Hennings & Young (2011). The meaning of cancer: Implications for family finances and consequent impact on lifestyle, activities, roles and
Kim & Spillers (2010). Quality of life of family caregivers at 2 years after a relative’s cancer diagnosis. Psycho-Oncology 19: 431–440. Kilbourne & Durning, Oncology & Psycho-oncology. (ch 7 p.103 – 130). Handbook of Clinical Health Psychology. Edited by S. Llewelyn and P. Kennedy. C 2003 John Wiley & Sons, Ltd. ISBN 0-471-48544-6
W, Pirl. Ch. 17 - Psycho-Oncology edited by Jimmie C. Holland, William S. Breitbart, Paul B. Jacobsen, Marguerite S. Lederberg, Matthew J. Loscalzo, Ruth McCorkle (2010) References Williams S, Dale J. (2006). The effectiveness of treatment for depression/depressive symptoms in adults with cancer: a systematic review. Br J Cancer 2006; 94:372.
Devine EC,Westlake SK.The effects of psychoeducational care provided to adults with cancer: meta-analysis of 116 studies. Oncol.Nurs.Forum 1995;22:1369-81.16.
Sheard T and Maguire P.The effect of psychological interventions on anxiety and depression in oncology: results of two meta-analyses. 1996.Third World Congress of Psycho-Oncology. 3-6-1996.
Clinical practice guidelines for the psychosocial care of adults with cancer 15917.
Meyer TJ, Mark MM. Effects of psychosocial interventions with adult cancer patients: a meta-analysis of randomized experiments [see comments]. Health Psychol.1995;14:101-8.
Kathol, R., Noyes,R., Williams, J., Mutgi, A. (1990). Diagnosing depression in patients with medical illness. Psychosomatics: Journal of Consulation Liason Psychiatry, 31(4). 434-440.
Chochinov, H., Wilson, K., Enns, M., & Landers, S. (1998). Depression, Hopelessness, and suicidal ideation in the terminally ill. Psychosomatics, 39, 366-370.
Psycho-Oncology Co-operative Research Group (PoCoG). www.pocog.org.au
Barsevick, A., Sweeney, C., Haney, E., & Chung, E. (2002). A systematic qualitative analysis of psychoeducational interventions for depression in patients with cancer. Oncology Nurses Forum. 29, 73-84
Uitterhoeve, R., Vernooy, M., Litjens, M, Potting, K., Bensing, J., Mulder, P., & van Achterberg, T. (2004). Psychosocial interventions for patients with advanced cancer – a systematic review of the literature. British Journal of Cancer. 91 1050-1062
Clinical Practice guidelines for the psychosocial care of adults with cancer: National Health and Medical Research Council: NHMRC. 2003
Edelman, S., Bell, D., & Kidman, A. (1999). Group CBT versus supportive therapy with patients who have primary breast cancer. Journal of Cognitive Psychotherapy, 13(3). 189-202. Thank you!
Questions? Quality of trials
Only included studies that assessed all mental health disorders (not just selected symptoms)
Evaluation of mental health disorders using a validated, standardised, comprehensive instrument (SCID, CIDI, CIS, SCAN)
Results of all studies were based on diagnoses made by trained persons
Meta-analysis procedures seemed adequately described
Except prevalence => met criteria for 1 DSM diagnosis?
Description of included studies
Country, description of sample (cancer type, age), N, response rate, measurement instrument, qualifications of personnel,
Stage of cancer? (diagnosis, treatment, survival, prognosis?)
Power / sample size of included studies
Only one study in Uganda was based on sample size of 32, the rest included 78 – 689 participants
This article was not looking at effect sizes (which can be be biased by small sample sizes), but the representativeness of the sample may be questionable due to its small size Meta-analysis – Singer, Das-Munshi & Brahler (2010)