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  Best Evidence


     This page describes the evidence base for psychological interventions (including screening) in cancer. In short are psycho-oncology and psychosocial interventions worthwhile? psychooncology_trials.xls


     Overviews & Meta-Analyses | Economic Evaluations | Screening Implementation | Interventional RCTs  | Consensus Guidelines | Spreadsheet of 670 Psychosocial Studies | 


Date / Rating

Overviews & Meta-Analyses


2009 [new]

Characteristics and methodological quality of 25 years of research investigating psychosocial interventions for cancer patients

Moyer A, Sohl SJ, Knapp-Oliver SK, et al. Ca Treatment Reviews Volume: 35 Issue: 5 Pages: 475-484 2009

The considerable amount of research examining psychosocial interventions for cancer patients makes it important to examine its scope and methodological quality. This comprehensive overview characterizes the field with as few exclusions as possible. A systematic search strategy identified 673 reports comprising 488 unique projects conducted over a 25 year time span. Although the literature on this topic has grown over time, the research was predominantly conducted in the United States (57.0%), largely with breast cancer patients (included in 70.5% of the studies). The intervention approach used most frequently was cognitive behavioral (32.4%), the treatment goal was often improving quality of life generally (69.5%), and the professionals delivering the interventions were typically nurses (29.1%) or psychologists (22.7%). Overall, there was some discrepancy between the types of interventions studied and the types of supportive services available to and sought by cancer patients. Strengths of this research include using randomized designs (62.9%), testing for baseline group equivalence (84.5%), and monitoring treatment, which rose significantly from being used in 48.1-64.4% of projects over time. However, deficiencies in such areas as examining treatment mechanisms and the adequacy of reporting of methodology, essential for useful syntheses of research on these interventions, remain to be addressed. Methodological challenges related to the complexity of this applied research, such as participants seeking treatment outside of research, contamination, and reactions to randomization, also were apparent. Future research could benefit from closer interactions between academic and voluntary sectors and expanding the diversity of participants

2009 [new]


Psychosocial interventions and quality of life in gynaecological cancer patients: a systematic review

Hersch J, Juraskova I, Price M, et al. Psycho-oncology Volume: 18 Issue: 8 Pages: 795-810 Published: AUG 2009

Objective: Women with gynaecological cancer are at risk of poor quality of life outcomes. Although various psychosocial interventions have been developed to address these concerns, such interventions have not yet been systematically evaluated in this population. The current review provides an up-to-date and comprehensive summary of the evidence regarding the effectiveness of psychosocial interventions in women with gynaecological cancers. Methods: Relevant studies were identified via Medline, CINAHL, and PsycINFO databases (1980 to June 2008), reference lists of articles and reviews, grey literature databases, and consultations with physicians and other experts in the field. Only controlled trials comparing a psychosocial intervention with a control group in a gynaecological cancer population, with at least one quality of life variable as a main outcome, were included in the review. Two authors independently assessed trial quality and extracted data. Results: Twenty-two studies involving 1926 participants were included. There was substantial variability in study quality and results. Evidence was mixed regarding intervention effects on social and sexual functioning, distress, depression, anxiety, attitude to medical care, self-esteem and body image. Interventions generally did not improve physical or vocational outcomes. Conclusions: There was limited evidence in support of healing touch, whereas information-based interventions seemed largely unable to provide meaningful benefits. Cognitive-behavioural interventions had some positive effects. Counselling appeared to be the most promising intervention strategy for addressing quality of life concerns for women with gynaecological cancers.



Psychosocial Interventions for Anxiety and Depression in Adult Cancer Patients: Achievements and Challenges

Paul B. Jacobsen and Heather S. Jim CA Cancer J Clin 2008;58;214-230

Psychosocial care is increasingly recognized as an essential component of the comprehensive care of the individual with cancer. Improving care is important; however, ensuring that the care made available has been shown to be effective is just as important. Accordingly, the goal of this review is to describe an evidence-based approach to the psychosocial care of adults with cancer. The focus is on anxiety and depression because a considerable body of research has examined the impact of psychosocial interventions on these outcomes. After describing the sources, assessment, and prevalence of anxiety and depression in adults with cancer and presenting existing clinical practice guidelines for their management, previous publications that systematically reviewed evidence of the efficacy of psychosocial interventions are summarized. The use of these publications to derive specific recommendations for the use of psychosocial interventions in the management of anxiety and depression is then illustrated. In addition, examples are provided of interventions that are effective against anxiety and depression and have good potential for dissemination in routine clinical practice. The review concludes with a discussion of future directions for the continued development of an evidence-based approach to the psychosocial care of people with cancer. (CA Cancer J Clin 2008;58:214–230. )



"Does one size fit all?" moderators in psychosocial interventions for breast cancer patients: a meta-analysis.

Zimmermann T, Heinrichs N, Baucom DH.

Ann Behav Med. 2007 Nov-Dec;34(3):225-39.


BACKGROUND: A variety of psychosocial interventions have been developed to promote better adjustment to breast cancer (BC) and their efficacy has been demonstrated repeatedly. However, the effect sizes (ES) vary considerably across studies. PURPOSE: This article intends to shed light on potential moderators of intervention efficacy for BC patients, such as the intervention type (e.g., education, supportive), the composition of the sample (only BC patients or BC mixed with other cancer types), and the practitioner of the intervention (psychologist, non-psychologist). METHODS: Fifty-six randomized-controlled studies investigating the effectiveness of psychosocial interventions with adult BC patients were meta-analytically reviewed. RESULTS: The overall ES of d = 0.26 was similar to previous meta-analyses and moderated by several variables. The ES varied notably based on the composition of the sample, the profession offering the intervention, and the type of intervention. Studies with samples consisting of only BC patients and studies with nonpsychologist-led interventions showed lower ES. Psychoeducation yielded the strongest ES. These moderators maintained their significance even when controlling for the nature of the control group, the format of the intervention, the timing of the intervention, or the stage of disease. CONCLUSIONS: These results suggest that among current interventions, psychoeducation is a treatment of choice for BC patients, preferably prior to surgery and led by individuals with a medical expertise. Other psychosocial interventions appear most effective when administered individually and led by a psychologist. In addition, there is a need for improved psychosocial interventions to enhance the present ES for women with BC.



The effect of psychosocial factors on breast cancer outcome: a systematic review.

Falagas ME, Zarkadoulia EA, Ioannidou EN, Peppas G, Christodoulou C, Rafailidis PI.

Breast Cancer Res. 2007;9(4):R44. 

INTRODUCTION: We sought to review the available evidence regarding the effect of psychosocial factors on the survival of breast cancer patients. METHODS: We systematically searched the PubMed and PsycINFO databases to identify relevant studies. RESULTS: We identified 31 studies examining the association of various psychosocial parameters with overall breast cancer survival/disease free survival and 6 studies examining whether psychological intervention influences the disease outcome. Of the 31 studies summarized in this overview, 25 (80.6%) showed a statistically significant association between at least one psychosocial variable and disease outcome. Parameters associated with better breast cancer prognosis are social support, marriage, and minimizing and denial, while depression and constraint of emotions are associated with decreased breast cancer survival; however, the role of these factors has not been verified in all studies. CONCLUSION: Most of the studies show a significant relationship between psychosocial factors and survival, but the actual psychosocial variables related to survival are not consistently measured across studies and the findings for many of the psychosocial variables with survival/recurrence are not consistent across studies. Thus, more research is warranted regarding the role of social support, marriage, minimizing and denial, depression and constraint of emotions on breast cancer survival.



Psychosocial interventions for depression, anxiety, and quality of life in cancer survivors: meta-analyses.

Osborn RL, Demoncada AC, Feuerstein M.

Int J Psychiatry Med. 2006;36(1):13-34.

OBJECTIVE: The purpose of this meta-analysis was to investigate the effects of cognitive behavioral therapy (CBT) and patient education (PE) on commonly reported problems (depression, anxiety, pain, physical functioning, and quality of life (QOL)) in adult cancer survivors. METHODS: Meta analyses of randomized controlled trials of CBT and PE were conducted. MEDLINE, PSYCHINFO and the Cochrane Database were searched from 1993-2004. The effects of individual versus group interventions and short (<8 months) versus long (>8 months) term follow up are also reported. RESULTS: Fifteen studies met quality criteria. The sample size was 1,492 adult cancer survivors with an age range of 18-84. 790 were randomly assigned to intervention groups and 702 to control groups. CBT varied in duration from 4 weekly one-hour sessions to 55 weekly two-hour sessions. PE ranged from a single 20-minute session to 6 weekly one-hour sessions. Follow up ranged from 1 week to 14 months. CBT was effective for depression (ES = 1.2; 95% CI = 0.22-2.19), anxiety (ES = 1.99; 95% CI = 0.69-3.31), and QOL (ES = 0.91; 95% CI = 0.38-1.44). QOL was improved at both short and (ES = 1.45, 95% CI = .43-2.47) and long term (ES = .26; 95% CI = .06-.46) follow up. PE was not related to improved outcomes. CONCLUSIONS: CBT is related to short-term effects on depression and anxiety and both short and long term effects on QOL. Individual interventions were more effective than group. Various CBT approaches provided in an individual format can assist cancer survivors in reducing emotional distress and improving quality of life.



Are psychological interventions effective and accepted by cancer patients? I. Standards and levels of evidence.

Andrykowski MA, Manne SL.

Ann Behav Med. 2006 Oct;32(2):93-7.  

Different standards and levels of evidence for evaluating the effectiveness of psychological interventions for managing distress in cancer patients are presented and discussed. We conclude that the strongest evidence comes from systematic qualitative and quantitative (i.e., meta-analyses) reviews of the relevant literature and that the most appropriate standard of evidence is the "preponderance of evidence" rather than "beyond a reasonable doubt." Results of four selected qualitative and quantitative systematic reviews of the literature are described. The preponderance of evidence furnished by these systematic reviews, particularly that gleaned from meta-analyses, suggests that psychological interventions are effective in managing distress in cancer patients. Although effectiveness may vary as a function of the specific nature of the intervention, overall, effectiveness appears strongest for anxiety-related outcomes and when participants are prescreened for distress. Different standards and indexes for evaluating evidence regarding the acceptability of psychological interventions with cancer patients are presented and discussed. The use of simple study accrual rates as an index of intervention acceptability is deemed inappropriate. We suggest alternative indexes of acceptability and conclude that sufficient information does not exist at the present time to draw the conclusion that contemporary psychological interventions for managing distress in cancer patients are unacceptable.



Are psychological interventions effective and accepted by cancer patients? I. Standards and levels of evidence.

Andrykowski MA, Manne SL.

Ann Behav Med. 2006 Oct;32(2):98-103  

We begin our discussion of the efficacy of psychological interventions for cancer patients by defining basic terms. We define efficacy using evidence-based medicine guidelines. According to these guidelines, an intervention is considered efficacious if two or more randomized clinical trials report positive and significant outcomes. Using this guideline as well as other evidence-based medicine criteria, we rate five recent intervention studies published in top-tier journals. The results of this review suggested that there is sufficient evidence to conclude that cognitive-behavioral interventions are effective in reducing and managing psychological distress in cancer patients and are accepted by these patients.



Lepore SJ, Coyne JC.

Psychological interventions for distress in cancer patients: a review of reviews.

Ann Behav Med. 2006 Oct;32(2):85-92

We review a decade of review articles concerning psychosocial interventions for cancer patients. We find a distinct progression in the tone of interpretations of the literature, as better quality studies accumulate and the sophistication of reviews improves. The current literature does not make a compelling case for the value of these interventions for the typical cancer patient. The bulk of the literature reviews in this field take a narrative rather than a systematic approach, and serious compromises in standards are necessary to muster an adequate set of studies for review. The more rigorous the review, the less likely it is to conclude there is evidence that psychological interventions are effective.


Williams S,Dale J. The effectiveness of treatment for depression/depressive symptoms in adults with cancer:a systematic review. Br J Cancer 2006; 94:372–390.

F1000 Factor 3.0

Depression is common in cancer patients, and this often remains undetected and untreated. Depression has been associated with poorer quality of life, in addition to increased impairment of immune response and poorer survival in cancer patients. Previous systematic reviews and meta-analyses of the efficacy of interventions for cancer patients with depression have failed to distinguish between caseness for depression and depressive symptoms. The findings from this systematic review show that there is limited trial data on the efficacy of prescribed antidepressants in reducing the incidence of major depression and depressive symptoms in cancer patients. Contrary to previous reviews that failed to distinguish between depressive symptoms and depression, this review found very little data from clinical trials (without the possibility of confounding factors) to demonstrate that psychotherapeutic interventions are effective in reducing depression in cancer patients. A number of small-scale, single-centre trials indicated that psychotherapeutic interventions (especially cognitive behavioural therapy) can have effects on depressive symptoms in cancer patients. However, given the methodological limitations of studies to date, lack of evidence should not be interpreted as implying lack of efficacy. In conclusion, there is a need for adequately powered studies of pharmacological and psychotherapeutic studies, which are targeted at cancer patients with a diagnosis of depression and include monitoring of the use of other pharmacological/psychotherapeutic and complementary and alternative medicine interventions. Keywords: depression, systematic review, psychotherapeutic interventions, pharmacological interventions


Uitterhoeve RJ,Vernooy M,Litjens M,etal. Psychosocial interventions for patients with advanced cancer—a systematic review of the literature.Br J Cancer 2004;91:1050–1062.

Advanced cancer is associated with emotional distress, especially depression and feelings of sadness. To date, it is unclear which is the most effective way to address these problems. This review focuses on the effects of psychosocial interventions on the quality of life (QoL) of patients with advanced cancer. It was hypothesised that patients will benefit from psychosocial interventions by improving QoL, especially in the domain of emotional functioning. The review was conducted using systematic review methodology involving a systematic search of the literature published between 1990 and 2002, quality assessment of included studies, systematic data extraction and narrative data synthesis. In all, 10 randomised controlled studies involving 13 trials were included. Overall interventions and outcome measures across studies were heterogeneous. Outcome measures, pertaining to the QoL dimension of emotional functioning, were most frequently measured. A total of 12 trials evaluating behaviour therapy found positive effects on one or more indicators of QoL, for example, depression. The results of the review support recommendation of behaviour therapy in the care of patients with advanced cancer.



Effects of psychosocial interventions on quality of life in adult cancer patients: meta analysis of 37 published controlled outcome studies.

Rehse B, Pukrop R.

Patient Educ Couns. 2003 Jun;50(2):179-86.

The present meta analysis summarized the results of 37 published, controlled studies that investigated the effectiveness of psychosocial interventions on quality of life (QoL) in adult cancer patients. The overall effect size of psychosocial interventions and the effect of potential moderating variables such as type and duration of intervention, sociodemographic and clinical parameters, characteristics of QoL measurement, and methodological quality of the selected studies were calculated using a meta analysis model suggested by Hunter and Schmidt. The overall effect size was 0.31 (correlation equivalent delta) which corresponds to a standardized mean difference of d=0.65 (N=3120 cancer patients). The most important moderating variable was duration of psychosocial intervention with durations of more than 12 weeks being significantly more effective than interventions of shorter duration. The meta analytical findings support the usefulness of psychosocial interventions for improving QoL in adult cancer patients.



Systematic review of psychological therapies for cancer patients: overview and recommendations for future research.

Newell SA, Sanson-Fisher RW, Savolainen NJ.

J Natl Cancer Inst. 2002 Apr 17;94(8):558-84

Many cancer patients use psychological therapies because they expect them to cure their cancer or to improve their recovery. Despite these high expectations, both patients and oncologists report being moderately to very satisfied with the results of psychological therapies. Previous reviews of the literature have concluded that psychological therapies may help cancer patients in various ways, ranging from reducing the side effects of cancer treatments to improving patients' immune function and longevity. However, because those reviews lacked methodologic rigor, we critically and systematically reviewed all identifiable publications about psychological therapies used by cancer patients to provide an objective and scientific evaluation of nontraditional therapies. We identified 627 relevant papers that reported on 329 intervention trials by searching MEDLINE, Healthplan, Psychlit, and Allied and Complementary Medicine databases and in the bibliographies of the papers identified. Despite increased use of randomized, controlled trial designs over time, the methodologic quality of the intervention trials, on 10 internal validity indicators, was generally suboptimal, with only one trial achieving a quality rating of "good" for its methodology. Using effectiveness results from 34 trials with psychosocial outcomes, 28 trials with side effect outcomes, 10 trials with conditioned side-effect outcomes, and 10 trials with survival or immune outcomes, we make only tentative recommendations about the effectiveness of psychological therapies for improving cancer patients' outcomes. Nevertheless, by exploring the relative effectiveness of the different intervention strategies for each outcome and follow-up period, we suggest the specific therapies that should be considered for further investigation. In addition, we suggest how future trials can maximize their internal validity by describing the minimal reporting standards that should be required in this field.


Barsevick AM,Sweeney C,Haney E,Chung E.A systematic qualitative analysis of psychoedu-cational interventions for depression in patients with cancer.Oncol Nurs Forum 2002;29:73–84.

Purpose/Objectives: To determine whether research based recommendations can be made about the clinical management of depression in patients with cancer. Data Sources: Reports of scientific studies, qualitative or quantitative systematic reviews of scientific studies, and practice guidelines published from 1980-2000. Data Synthesis: In all, 36 pieces of evidence supported the conclusion that psychoeducational interventions benefit depressive symptoms. Evidence included two well-conducted meta-analyses and nine well-designed randomized clinical trials with large samples (N > 100). With regard to intervention content, 70% of behavior therapy studies and 66% of counseling studies drew conclusions that supported the hypothesis. In addition, 58% of studies that tested behavior therapy or counseling in combination with cancer education had positive results. Conclusions: The evidence supports the conclusion that psychoeducational interventions reduce depressive symptoms in patients with cancer and that behavior therapy or counseling alone or in combination with cancer education is beneficial. Implications for Nursing Practice: Nurses can select from a variety of educational, behavioral, and counseling techniques to prevent or manage depression in their patients.



Psychosocial interventions for cancer: review and analysis using a three-tiered outcomes model.

Owen JE, Klapow JC, Hicken B, Tucker DC.

Psychooncology. 2001 May-Jun;10(3):218-30

This study describes a three-tiered measurement model for psychosocial interventions with cancer patients and compares this model to extant measurement strategies. Progress has been made toward demonstrating that psychosocial interventions reduce depression, anxiety, functional impairment, and symptoms. However, Chambless and Hollon (1998) note that the literature on psychosocial interventions for cancer fails to meet criteria for establishing treatment "efficacy" and does not address issues of cost-effectiveness. The lack of a timely model of clinical outcomes may be hindering demonstration of efficacy and wider implementation of these interventions. Outcomes assessed by 65 interventions were classified as Global Health Outcomes (medical endpoints, health-related quality of life (HRQOL), or resource utilization), Dimensions of HRQOL (distress, symptoms, functional ability, or interpersonal well-being), or Mechanisms of Action (evaluation of psychological or physiological processes). A total of 28% of reviewed studies assessed Global Outcomes, 82% assessed Dimensions of HRQOL, and 49% assessed Mechanisms of Action. While most studies assessed patients' symptoms and distress, measurements of resource utilization, HRQOL, and interpersonal HRQOL were under-reported. A greater emphasis on treatment costs, quality of life, and mediating/moderating processes associated with improvement in outcomes could inform decisions regarding allocation of health-care resources and lead to more widely available and efficient interventions for patients. Copyright 2001 John Wiley & Sons, Ltd.



The effectiveness of relaxation training in reducing treatment-related symptoms and improving emotional adjustment in acute non-surgical cancer treatment: a meta-analytical review.

Luebbert K, Dahme B, Hasenbring M.

Psychooncology. 2001 Nov-Dec;10(6):490-502.

Cancer patients often have to deal with severe side effects and psychological distress during cancer treatment, which have a substantial impact on their quality of life. Among psychosocial interventions for reducing treatment-related side effects, relaxation and imagery were most investigated in controlled trials. In this study, meta-analytic methods were used to synthesize published, randomized intervention-control studies aiming to improve patients' treatment-related symptoms and emotional adjustment by relaxation training. Mean weighted effect sizes were calculated for 12 categories, treatment-related symptoms (nausea, pain, blood pressure, pulse rate) and emotional adjustment (anxiety, depression, hostility, tension, fatigue, confusion, vigor, overall mood). Significant positive effects were found for the treatment-related symptoms. Relaxation training also proved to have a significant effect on the emotional adjustment variables depression, anxiety and hostility. Additionally, two studies point to a significant effect of relaxation on the reduction of tension and amelioration of the overall mood. Intervention features of the relaxation training, the time the professional spent with the patient overall (intervention intensity) and the schedule of the intervention (offered in conjunction with or independent of medical treatment to the cancer patient) were relevant to the effect of relaxation on anxiety. The interventions offered independently of medical treatment proved to be significantly more effective for the outcome variable anxiety. Relaxation seems to be equally effective for patients undergoing different medical procedures (chemotherapy, radiotherapy, bone marrow transplantation, hyperthermia). According to these results relaxation training should be implemented into clinical routine for cancer patients in acute medical treatment. Copyright 2001 John Wiley & Sons, Ltd.



The effect of psychological interventions on anxiety and depression in cancer patients: results of two meta-analyses.

Sheard T, Maguire P.

Br J Cancer. 1999 Aug;80(11):1770-80. 

The findings of two meta-analyses of trials of psychological interventions in patients with cancer are presented: the first using anxiety and the second depression, as a main outcome measure. The majority of the trials were preventative, selecting subjects on the basis of a cancer diagnosis rather than on psychological criteria. For anxiety, 25 trials were identified and six were excluded because of missing data. The remaining 19 trials (including five unpublished) had a combined effect size of 0.42 standard deviations in favour of treatment against no-treatment controls (95% confidence interval (CI) 0.08-0.74, total sample size 1023). A most robust estimate is 0.36 which is based on a subset of trials which were randomized, scored well on a rating of study quality, had a sample size > 40 and in which the effect of trials with very large effects were cancelled out. For depression, 30 trials were identified, but ten were excluded because of missing data. The remaining 20 trials (including six unpublished) had a combined effect size of 0.36 standard deviations in favour of treatment against no-treatment controls (95% CI 0.06-0.66, sample size 1101). This estimate was robust for publication bias, but not study quality, and was inflated by three trials with very large effects. A more robust estimate of mean effect is the clinically weak to negligible value of 0.19. Group therapy is at least as effective as individual. Only four trials targeted interventions at those identified as at risk of, or suffering significant psychological distress, these were associated with clinically powerful effects (trend) relative to unscreened subjects. The findings suggest that preventative psychological interventions in cancer patients may have a moderate clinical effect upon anxiety but not depression. There are indications that interventions targeted at those at risk of or suffering significant psychological distress have strong clinical effects. Evidence on the effectiveness of such targeted interventions and of the feasibility and effects of group therapy in a European context is required.



Sellick SM,Crooks DL. Depression and cancer: an appraisal of the literature for prevalence, detection,and practice guideline development for psychological interventions. Psychooncology 1999;8:315–333.

This paper reviews the current literature concerning the prevalence and incidence of depression in the general population and within the population of people living with cancer where depression is defined using current standards and guidelines. Reviews of recent work where the treatment of depression was the focus of study are also presented. Finally, studies that have specifically addressed the psychological treatment of depression among cancer patients are critically reviewed. Suggestions for practice guideline development of psychological interventions are offered based on the review.



[Psycho-oncologic interventions--critical review][Article in German] Larbig W.

Psychother Psychosom Med Psychol. 1998 Sep-Oct;48(9-10):381-9.


Following information on diagnosis, therapy and prognosis, supportive psycho-oncological interventions may be performed. General targets of psychological intervention are to help coping with disease problems and family-related problems and to reduce symptoms related to disease and therapy such as pain, anticipatory nausea and vomiting, stress, anxiety, depression and feeling of helplessness. A number of different kinds of controlled interventions may contribute significantly to both psychological and physical health outcomes in cancer patients. This review confirms the efficacy of education, individual psychotherapy, group interventions and behavioural training in reducing disease- related and therapy-related symptoms, depression and anxiety, thus improving psychological functioning and the quality of life. The multidimensional evaluation of psychooncological interventions including immunological parameters, the question of differential indication of psychological interventions in cancer patients' and the influence of psychological predictors on the course of different cancer diseases and survival rates are significant aspects that merit further research.


Critical review of psychosocial interventions in cancer care.

Fawzy FI, Fawzy NW, Arndt LA, Pasnau RO.

Arch Gen Psychiatry. 1995 Feb;52(2):100-13.

The need for a large variety of psychosocial interventions is enhanced as increasing numbers of patients with cancer have longer survival. This article reviews the four interventions used most commonly: (1) education, (2) behavioral training, (3) individual psychotherapy, and (4) group interventions. It examines the outcomes of each type of intervention. This comprehensive review of the intervention literature reveals the availability of a wide range of options for patients with cancer and their potential psychological and physical health benefits.



[Effectiveness of psychosocial management of cancer patients--a critical review of empirical studies (status: December 1990)]

Frischenschlager O, Brömmel B, Russinger U.

Psychother Psychosom Med Psychol. 1992 Jun;42(6):206-13. German.


41 empirical studies evaluating psychosocial care of cancer patients, published between 1975 and 1990 are presented. Only those studies were selected that examined adult patients and controlled the effects of psychotherapeutic interventions. 35 studies reported significant effects on coping, mood states or quality of life. 6 articles were inquiries into the efficiency of intervention on time of survival, 3 measured the impact on the immune system.


       Economic Evaluations




Economic evaluation alongside a clinical trial of psycho-educational interventions to improve adjustment to survivorship among patients with breast cancer.

Mandelblatt, JS; Cullen, J; Lawrence, WF; et al.

JOURNAL OF CLINICAL ONCOLOGY Volume: 26 Issue: 10 Pages: 1684-1690 Published: 2008

 PURPOSE: There is little economic research on psychosocial interventions. We aimed to collect data alongside a randomized trial to compare the costs and benefits of three psycho-educational strategies to improve transition to cancer survivorship. METHODS: We evaluated the incremental delivery costs per unit increase in energy (using the Medical Outcomes Study vitality scale) or decrease in distress (from the Revised Impact of Events Scale) in the 6 months postintervention. We also evaluated 1-year post-treatment health care costs. RESULTS: The costs of the control, video, and video plus counseling arms were $11.30, $25.85, and $134.47 per person, respectively. The video costs were $2.22 per unit increase in energy compared with control; among women who were the least prepared for transition, the video was more effective, resulting in even lower costs. The video cost $7,275 per unit change in distress versus control, but costs were lower in the subgroup least prepared for transition ($355). The counseling arm was more expensive and less effective than the video for virtually all end points. However, in one group, women more prepared for transition, counseling cost $1,066 per unit decrease in distress compared with the video. Health care costs tended to increase as intervention intensity increased. CONCLUSION: There are no standards for evaluating cost-effectiveness of trials with psychosocial end points. In this trial, the educational video was the most cost-effective way to improve transition to survivorship. It will be important to confirm whether there is an increased use of services after such interventions and if this represents appropriate use of rehabilitative and supportive care or over-use.



Economic analysis of psychosocial group therapy in women with metastatic breast cancer

Lemieux, J; Topp, A; Chappell, H; et al. BREAST CANCER RESEARCH AND TREATMENT Volume: 100 Issue: 2 Pages: 183-190 Published: 2006

PURPOSE: Metastatic breast cancer is associated with psychological distress in one-third of patients. We examined the impact of group psychosocial support on health care costs in metastatic breast cancer. Psychosocial interventions have been shown to reduce psychological distress in these patients. In other diseases, depression and anxiety have been associated with higher health care system resource utilization. METHODS: Data on health care system resources utilization were collected as part of a Canadian multicenter randomized controlled trial of a supportive-expressive group support in metastatic breast cancer. Costs were obtained from one tertiary care hospital in Toronto. A cost minimization analysis was conducted since there was no survival difference; the primary endpoint of the study. Cost-effectiveness analyses were conducted for mood and pain. RESULTS: Total health care utilization costs (including costs of the group therapy intervention) for the intervention and control groups were $31,715 and $28,189, respectively per patient. The difference in total costs between groups ($3,526) was not statistically significant (P = 0.53). The cost-effectiveness analysis for mood showed the intervention group to have an increased cost of $5,550 per patient for an effect size of 0.5 on the POMS scale. The corresponding cost for pain was $4,309. An exploratory analysis on patients who were more distressed at baseline showed a non-significant decrease in cost in favor of the intervention arm (difference of $3,911 P = 0.66). CONCLUSION: Psychosocial intervention, in the form of supportive-expressive group support for metastatic breast cancer, does not lower health care system resource utilization.



Benefits of psychosocial oncology care: improved quality of life and medical cost offset.

Carlson, Linda E; Bultz, Barry D Health Qual Life Outcomes Volume: 1 Pages: 8 Published: 2003

 The burden of cancer in the worldwide context continues to grow, with an increasing number of new cases and deaths each year. A significant proportion of cancer patients at all stages of the disease trajectory will suffer social, emotional and psychological distress as a result of cancer diagnosis and treatment. Psychosocial interventions have proven efficacious for helping patients and families confront the many issues that arise during this difficult time. This paper reviews the literature detailing the extent of distress in patients, the staffing needed to treat such levels of distress, and the efficacy of psychosocial treatments for cancer patients. This is followed by a summary of the literature on medical cost offset in mental health, other medical populations, and in cancer patients, which supports the notion that psychosocial interventions are not only effective, but also economical. Conclusions support taking a whole-person approach, as advocated by a growing number of health care professionals, which would not only help to treat the emotional and social aspects of living with cancer, but also provide considerable long-term cost savings to overburdened health-care systems.


       Screening Implementation Studies




Assessment is not enough: a randomized controlled trial of the effects of HRQL assessment on quality of life and satisfaction in oncology clinical practice.

Rosenbloom SK, Victorson DE, Hahn EA, Peterman AH, Cella D.

Psychooncology. 2007 Dec;16(12):1069-79.

The potential benefits of health-related quality of life (HRQL) assessment in oncology clinical practice include better detection of problems, enhanced disease and treatment monitoring and improved care. However, few empirical studies have investigated the effects of incorporating such assessments into routine clinical care. Recent randomized studies have reported improved detection of and communication about patients' concerns, but few have found effects on patient HRQL or satisfaction. This study examined whether offering interpretive assistance of HRQL results would improve these patient outcomes. Two hundred and thirteen participants with metastatic breast, lung or colorectal cancer were randomly assigned to one of three conditions: usual care; HRQL assessment or HRQL assessment followed by a structured interview and discussion. Interviews about patients' assessment responses were conducted by a research nurse, who then presented HRQL information to the treating nurse. HRQL and treatment satisfaction outcomes were assessed at 3 and 6 months. No significant differences were found between study conditions in HRQL or satisfaction. Results suggest that routine HRQL assessment, even with description of results, is insufficient to improve patient HRQL and satisfaction. It is suggested that positive effects may require supplementing assessment results with specific suggestions for clinical management changes



Boyes A, Newell S, Girgis A, Mcelduff P, Sanson-Fisher R. Does routine assessment and real-time feedback improve cancer patients' psychosocial well-being? European Journal of Cancer Care 2006; 15 (2): 163-171.

This study examined the effectiveness of giving medical oncologists immediate feedback about cancer patients' self-reported psychosocial well-being in reducing those patients' levels of anxiety, depression, perceived needs and physical symptoms. Cancer patients attending one cancer centre for their first visit were allocated to intervention (n = 42) or control (n = 38) groups. All patients completed a computerized survey assessing their psychosocial well-being while waiting to see the oncologist. Intervention patients' responses were immediately scored and summary reports were placed in each patient's file for follow-up. A total of 48 participants (25 intervention and 23 control) completed the survey four times. Intervention patients who reported a debilitating physical symptom at visit 2 were significantly less likely to report a debilitating physical symptom at visit 3 compared with control patients (OR = 2.8, P = 0.04). Reductions in levels of anxiety, depression and perceived needs among intervention patients were not significantly different to control patients. Repeated collection and immediate feedback of patient-reported health information to oncologists has potential to improve patients' symptom control, but has little impact upon emotional well-being, including those at high risk. Future research should consider providing the feedback to other health professionals and patients, and monitor the impact on the process of individual patient care.



Velikova G, Booth L, Smith AB, Brown PM, Lynch P, Brown JM, Selby PJ. Measuring quality of life in routine oncology practice improves communication and patient well-being: A randomized controlled trial. Journal of Clinical Oncology 2004 22 (4): 714-724.

PURPOSE: To examine the effects on process of care and patient well-being, of the regular collection and use of health-related quality-of-life (HRQL) data in oncology practice. PATIENTS AND METHODS: In a prospective study with repeated measures involving 28 oncologists, 286 cancer patients were randomly assigned to either the intervention group (regular completion of European Organization for Research and Treatment of Cancer-Core Quality of Life Questionnaire version 3.0, and Hospital Anxiety and Depression Scale on touch-screen computers in clinic and feedback of results to physicians); attention-control group (completion of questionnaires, but no feedback); or control group (no HRQL measurement in clinic before encounters). Primary outcomes were patient HRQL over time, measured by the Functional Assessment of Cancer Therapy-General questionnaire, physician-patient communication, and clinical management, measured by content analysis of tape-recorded encounters. Analysis employed mixed-effects modeling and multiple regression. RESULTS: Patients in the intervention and attention-control groups had better HRQL than the control group (P =.006 and P =.01, respectively), but the intervention and attention-control groups were not significantly different (P =.80). A positive effect on emotional well-being was associated with feedback of data (P =.008), but not with instrument completion (P =.12). A larger proportion of intervention patients showed clinically meaningful improvement in HRQL. More frequent discussion of chronic nonspecific symptoms (P =.03) was found in the intervention group, without prolonging encounters. There was no detectable effect on patient management (P =.60). In the intervention patients, HRQL improvement was associated with explicit use of HRQL data (P =.016), discussion of pain, and role function (P =.046). CONCLUSION: Routine assessment of cancer patients' HRQL had an impact on physician-patient communication and resulted in benefits for some patients, who had better HRQL and emotional functioning



Health-related quality-of-life assessments and patient-physician communication: a randomized controlled trial.

Detmar SB, Muller MJ, Schornagel JH, Wever LD, Aaronson NK.

JAMA. 2002 Dec 18;288(23):3027-34.

CONTEXT: There has been increasing interest in the use of health-related quality-of-life (HRQL) assessments in daily clinical practice, yet few empirical studies have been conducted to evaluate the usefulness of such assessments. OBJECTIVE: To evaluate the efficacy of standardized HRQL assessments in facilitating patient-physician communication and increasing physicians' awareness of their patients' HRQL-related problems. DESIGN: Prospective, randomized crossover trial. SETTING: Outpatient clinic of a cancer hospital in the Netherlands. PARTICIPANTS: Ten physicians and 214 patients (76% women; mean age, 57 years) undergoing palliative chemotherapy who were invited to participate between June 1996 and June 1998. INTERVENTION: At 3 successive outpatient visits, patients completed an HRQL questionnaire (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30). The responses were computer scored and transformed into a graphic summary. Physicians and patients received a copy of the summary before the consultation. MAIN OUTCOME MEASURES: Audiotapes of the consultations were content analyzed to evaluate patient-physician communication. Physicians' awareness of their patients' health problems was assessed by comparing physicians' and patients' ratings on the Dartmouth Primary Care Cooperative Information Functional Health Assessment (COOP) and the World Organisation Project of National Colleges and Academics (WONCA) charts. RESULTS: The HRQL-related issues were discussed significantly more frequently in the intervention than in the control group (mean [SD] communication composite scores: 4.5 [2.3] vs 3.7 [1.9], respectively (P =.01). Physicians in the intervention group identified a greater percentage of patients with moderate-to-severe health problems in several HRQL domains than did those in the control group. All physicians and 87% of the patients believed that the intervention facilitated communication and expressed interest in its continued use. CONCLUSION: Incorporating standardized HRQL assessments in daily clinical oncology practice facilitates the discussion of HRQL issues and can heighten physicians' awareness of their patients' HRQL.



McLachlan SA, Allenby A, Matthews J, et al

Randomized trial of coordinated psychosocial interventions based on patient self-assessments versus standard care to improve the psychosocial functioning of patients with cancer.

Journal of Clinical Oncology 2001; 19 (21): 4117-4125.

PURPOSE: To determine whether making patient-reported cancer needs, quality-of-life (QOL), and psychosocial information available to the health care team, allowing coordinated specifically targeted psychosocial interventions, resulted in reduced cancer needs, improved QOL, and increased satisfaction with care received. METHODS: Self-reported cancer needs, QOL, and psychosocial information was collected from 450 people with cancer, using standardized questionnaires via a touch-screen computer. For a randomly chosen two thirds, this information was made available to the health care team who coordinated targeted psychosocial interventions. Information from the remaining one third was not seen. Patients were assessed 2 and 6 months after randomization for changes in their cancer needs, QOL, and psychosocial functioning and satisfaction with overall care received. RESULTS: There were no significant differences between the two arms with respect to changes in cancer needs, QOL, or psychosocial functioning between the baseline and follow-up assessments, nor with respect to satisfaction with care. However, for the subgroup of patients who were moderately or severely depressed at baseline, there was a significant reduction in depression for the intervention arm relative to the control arm at the 6-month assessment (P =.001). CONCLUSION: Making patient-reported cancer needs, QOL, and psychosocial data available to the health care team at a single consultation together with coordinated psychosocial interventions does not seem to reduce cancer needs nor improve QOL, psychosocial functioning, or satisfaction with the care received. However, identification of patients with moderate or severe levels of depression may be valuable in reducing subsequent levels of depression.



Taenzer P, Bultz BD, Carlson LE, Speca M, DeGagne T, Olson K, Doll R, Rosberger Z. Impact of computerized quality of life screening on physician behaviour and patient satisfaction in lung cancer outpatients. Psychooncology. 2000 May-Jun;9(3):203-13.

The purpose of this paper was to determine if providing patient specific Quality of Life (QL) information to clinic staff before a clinic appointment improved patient care in a lung cancer outpatient clinic. Patients were sequentially assigned to either a usual care control group or the experimental group, which completed a computerized version of the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 questionnaire in order to provide the clinic staff with QL information prior to the clinic appointment. The control group completed the EORTC QLQ-C30 paper version after the clinic appointment. Outcome measures were patient satisfaction, the degree to which issues identified on the QL questionnaire were addressed in the appointment, and a chart audit, which measured charting of QL issues and actions taken by the clincian relating to QL. In the experimental group, more QL issues identified by the patient on the EORTC QLQ-C30 were addressed during the clinic appointment than in the control group. As well, marginally more categories were charted and a trend towards more actions being taken was seen in the experimental group. Patients reported being equally and highly satisfied with the treatment in both groups. The clinical implication is that the computerized administration of the EORTC QLQ-C30 questionnaire and providing staff with a report highlighting patient-specific QL deficits is a simple, time-effective and acceptable means of improving patient-provider communication in a busy outpatient clinic. Large trials studying its effectiveness in different patient populations and regions would further elucidate the nature of this effect and potentially improve the overall quality of care that patients receive.


      Large (n>100) Interventional RCTs


2008 [hot!]



Health-related quality of life and distress in cancer patients: results from a large randomised study.

Johansson B, Brandberg Y, Hellbom M, Persson C, Petersson LM, Berglund G, Glimelius B. Br J Cancer. 2008 Nov 18. FREE

To compare the effectiveness of individual support, group rehabilitation and a combination of the two in improving health-related quality of life (HRQOL) and psychological well-being in cancer patients during 24 months after diagnosis, as compared with standard care (SC). Furthermore, to compare the study sample and a random sample of the Swedish population with regard to HRQOL. A total of 481 consecutive patients, newly diagnosed with cancer, were randomly assigned to one of the four alternatives. Data on HRQOL and psychological well-being were collected at baseline and after 3, 6, 12 and 24 months. The interventions did not improve HRQOL or psychological well-being, as compared with SC. At 3 months, the study sample reported an HRQOL comparable with the normal population. Many cancer patients are able to manage their cancer-related concerns with the support available from SC. However, it is reasonable to assume that the findings suffer from a lack of data from especially vulnerable patients and a possible Hawthorne effect. It cannot be concluded that cancer patients have no need for additional psychosocial interventions. Future projects should include screening and target interventions for those at risk for significant and prolonged psychological distress.

2008 [hot!]


Psychologic intervention improves survival for breast cancer patients: a randomized clinical trial.

Andersen BL, Yang HC, Farrar WB, Golden-Kreutz DM, Emery CF, Thornton LM, Young DC, Carson WE 3rd.

Cancer. 2008 Nov 17;113(12):3450-3458.


BACKGROUND.: The question of whether stress poses a risk for cancer progression has been difficult to answer. A randomized clinical trial tested the hypothesis that cancer patients coping with their recent diagnosis but receiving a psychologic intervention would have improved survival compared with patients who were only assessed. METHODS.: A total of 227 patients who were surgically treated for regional breast cancer participated. Before beginning adjuvant cancer therapies, patients were assessed with psychologic and behavioral measures and had a health evaluation, and a 60-mL blood sample was drawn. Patients were randomized to Psychologic Intervention plus assessment or Assessment only study arms. The intervention was psychologist led; conducted in small groups; and included strategies to reduce stress, improve mood, alter health behaviors, and maintain adherence to cancer treatment and care. Earlier articles demonstrated that, compared with the Assessment arm, the Intervention arm improved across all of the latter secondary outcomes. Immunity was also enhanced. RESULTS.: After a median of 11 years of follow-up, disease recurrence was reported to occur in 62 of 212 (29%) women and death was reported for 54 of 227 (24%) women. Using Cox proportional hazards analysis, multivariate comparison of survival was conducted. As predicted, patients in the Intervention arm were found to have a reduced risk of breast cancer recurrence (hazards ratio [HR] of 0.55; P = .034) and death from breast cancer (HR of 0.44; P = .016) compared with patients in the Assessment only arm. Follow-up analyses also demonstrated that Intervention patients had a reduced risk of death from all causes (HR of 0.51; P = .028). CONCLUSIONS.: Psychologic interventions as delivered and studied here can improve survival. Cancer 2008. (c) 2008 American Cancer Society.

2008 [new]


Randomized controlled trial of collaborative care management of depression among low-income patients with cancer.

Ell K, Xie B, Quon B, Quinn DI, Dwight-Johnson M, Lee PJ.

J Clin Oncol. 2008 Sep 20;26(27):4488-96.

PMID: 18802161 [PubMed - indexed for MEDLINE


PURPOSE: To determine the effectiveness of the Alleviating Depression Among Patients With Cancer (ADAPt-C) collaborative care management for major depression or dysthymia. PATIENTS AND METHODS: Study patients included 472 low-income, predominantly female Hispanic patients with cancer age >or= 18 years with major depression (49%), dysthymia (5%), or both (46%). Patients were randomly assigned to intervention (n = 242) or enhanced usual care (EUC; n = 230). Intervention patients had access for up to 12 months to a depression clinical specialist (supervised by a psychiatrist) who offered education, structured psychotherapy, and maintenance/relapse prevention support. The psychiatrist prescribed antidepressant medications for patients preferring or assessed to require medication. RESULTS: At 12 months, 63% of intervention patients had a 50% or greater reduction in depressive symptoms from baseline as assessed by the Patient Health Questionnaire-9 (PHQ-9) depression scale compared with 50% of EUC patients (odds ratio [OR] = 1.98; 95% CI, 1.16 to 3.38; P = .01). Improvement was also found for 5-point decrease in PHQ-9 score among 72.2% of intervention patients compared with 59.7% of EUC patients (OR = 1.99; 95% CI, 1.14 to 3.50; P = .02). Intervention patients also experienced greater rates of depression treatment (72.3% v 10.4% of EUC patients; P < .0001) and significantly better quality-of-life outcomes, including social/family (adjusted mean difference between groups, 2.7; 95% CI, 1.22 to 4.17; P < .001), emotional (adjusted mean difference, 1.29; 95% CI, 0.26 to 2.22; P = .01), functional (adjusted mean difference, 1.34; 95% CI, 0.08 to 2.59; P = .04), and physical well-being (adjusted mean difference, 2.79; 95% CI, 0.49 to 5.1; P = .02). CONCLUSION: ADAPt-C collaborative care is feasible and results in significant reduction in depressive symptoms, improvement in quality of life, and lower pain levels compared with EUC for patients with depressive disorders in a low-income, predominantly Hispanic population in public sector oncology clinics



Individual psychosocial support for breast cancer patients: a randomized study of nurse versus psychologist interventions and standard care.

Arving C, Sjödén PO, Bergh J, Hellbom M, Johansson B, Glimelius B, Brandberg Y.

Cancer Nurs. 2007 May-Jun;30(3):E10-9..

In a prospective, randomized study, an individual psychosocial support intervention performed by specially trained oncology nurses, or psychologists, were compared with standard care. Consecutive primary breast cancer patients about to start adjuvant therapy (n = 179) were included. Data were supplied by the questionnaires European Organisation for Research and Treatment of Cancer Quality of Life Study Group Core Quality of life questionnaire with 30 questions (EORTC QLQ-C30) and Breast Cancer Module with 23 questions (BR23), the Hospital Anxiety and Depression Scale, Spielberger's State-Trait Anxiety Inventory, and the Impact of Event Scale before randomization and 1, 3, and 6 months later. Patient files provided data on utilization of psychosocial support offered in routine care. Global quality of life/health status, nausea and vomiting, and systemic therapy side effects were the subscales showing significant Group by Time interactions, favoring the interventions. Intervention groups improved statistically significantly more than the standard care group regarding insomnia, dyspnea, and financial difficulties. Nurse patients experienced less intrusion compared with the standard care group. All groups showed statistically and clinically significant improvements with time on several subscales. The intervention groups, however, improved to a greater extent. Fewer patients in the intervention groups used psychosocial hospital support compared with the standard care group. In conclusion, psychosocial support by specially trained nurses using techniques derived from cognitive behavioral therapy is beneficial for breast cancer patients and may be a realistic alternative in routine cancer care.



Long-term effects on cancer survivors' quality of life of physical training versus physical training combined with cognitive-behavioral therapy: results from a randomized trial.

May AM, Korstjens I, van Weert E et al

Support Care Cancer. 2008 Oct 25. [Epub ahead of print


BACKGROUND: We compared the effect of a 12-week group-based multidisciplinary self-management rehabilitation program, combining physical training (twice weekly) and cognitive-behavioral therapy (once weekly) with the effect of 12-week group-based physical training (twice weekly) on cancer survivors' quality of life over a 1-year period. MATERIALS AND METHODS: 147 survivors [48.8 +/- 10.9 years (mean +/- SD), all cancer types, medical treatment >/=3 months ago] were randomly assigned to either physical training (PT, n = 71) or to physical training plus cognitive-behavioral therapy (PT + CBT, n = 76). Quality of life and physical activity levels were measured before and immediately after the intervention and at 3- and 9-month post-intervention using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 questionnaire and the Physical Activity Scale for the Elderly, respectively. RESULTS: Multilevel linear mixed-effects models revealed no differential pattern in change of quality of life and physical activity between PT and PT + CBT. In both PT and PT + CBT, quality of life and physical activity were significantly and clinically relevantly improved immediately following the intervention and also at 3- and 9-month post-intervention compared to pre-intervention (p < 0.001). CONCLUSION: Self-management physical training had substantial and durable positive effects on cancer survivors' quality of life. Participants maintained physical activity levels once the program was completed. Combining physical training with our cognitive-behavioral intervention did not add to these beneficial effects of physical training neither in the short-term nor in the long-term. Physical training should be implemented within the framework of standard care for cancer survivors

2008 [hot!]


A randomized, placebo-controlled trial of citalopram for the prevention of major depression during treatment for head and neck cancer.

Lydiatt WM, Denman D, McNeilly DP, Puumula SE, Burke WJ.

Arch Otolaryngol Head Neck Surg. 2008 May; 134(5):528-35.


OBJECTIVE: To determine whether prophylactic treatment with the antidepressant citalopram hydrobromide, compared with placebo, could prevent major depressive disorder in patients undergoing therapy for head and neck cancer (HNC). DESIGN: Prospective, randomized, placebo-controlled trial. SETTING: Academic medical center. PATIENTS: 36 subjects were randomized, and 23 completed the study. INTERVENTIONS: Subjects were randomized to receive 40 mg of citalopram hydrobromide or matching placebo (herein after, citalopram group and placebo group, respectively) for 12 weeks with a final visit at 16 weeks. MAIN OUTCOME MEASURES: The Hamilton Depression Rating Scale, psychiatric interview, and the University of Washington Quality of Life (UW-QOL) and Clinician Global Impression-Severity (CGI-S) scales. RESULTS: The numbers of subjects who met predefined cutoff criteria for depression during the 12 weeks of active study were 5 of 10 (50%) taking placebo and 2 of 12 (17%) taking citalopram (Fisher exact test, P = .17). No patients in the citalopram group became suicidal, compared with 2 in the placebo group. Global mood state at the conclusion of the study as measured by the CGI-S scale was rated as at least mildly ill in 15% of those receiving citalopram compared with 60% in the placebo group (Fisher exact test, P = .04). Quality of life, measured by the UW-QOL, deteriorated in both groups from baseline but less so in the citalopram group. CONCLUSIONS: This study reports data from the first depression prevention trial in HNC and suggests that prophylactic treatment may decrease the incidence of depression during HNC therapy. The clinical significance of the reduction in depression was best demonstrated by the CGI-S scale, which showed a notable difference in global psychiatric and physical well-being



Management of depression for people with cancer (SMaRT oncology 1): a randomised trial.

Strong V, Waters R, Hibberd C, Murray G, Wall L, Walker J, McHugh G, Walker A, Sharpe M.

Lancet. 2008 Jul 5;372(9632):40-8.

PMID: 18603157 [PubMed - indexed for MEDLINE]


BACKGROUND: Major depressive disorder severely impairs the quality of life of patients with medical disorders such as cancer, but evidence to guide its management is scarce. We aimed to assess the efficacy and cost of a nurse-delivered complex intervention that was designed to treat major depressive disorder in patients who have cancer. METHODS: We did a randomised trial in a regional cancer centre in Scotland, UK. 200 outpatients who had cancer with a prognosis of greater than 6 months and major depressive disorder (identified by screening) were eligible and agreed to take part. Their mean age was 56.6 (SD 11.9) years, and 141 (71%) were women. We randomly assigned 99 of these participants to usual care, and 101 to usual care plus the intervention, with minimisation for sex, age, diagnosis, and extent of disease. The intervention was delivered by a cancer nurse at the centre over an average of seven sessions. The primary outcome was the difference in mean score on the self-reported Symptom Checklist-20 depression scale (range 0 to 4) at 3 months after randomisation. Analysis was by intention to treat. This trial is registered as ISRCTN84767225. FINDINGS: Primary outcome data were missing for four patients. For 196 patients for whom we had data at 3 months, the adjusted difference in mean Symptom Checklist-20 depression score, between those who received the intervention and those who did not, was 0.34 (95% CI 0.13-0.55). This treatment effect was sustained at 6 and 12 months. The intervention also improved anxiety and fatigue but not pain or physical functioning. It cost an additional pound sterling 5278 (US$10 556) per quality-adjusted life-year gained. INTERPRETATION: The intervention-Depression Care for People with Cancer-offers a model for the management of major depressive disorder in patients with cancer and other medical disorders who are attending specialist medical services that is feasible, acceptable, and potentially cost



Assessment is not enough: a randomized controlled trial of the effects of HRQL assessment on quality of life and satisfaction in oncology clinical practice.

Rosenbloom SK, Victorson DE, Hahn EA, Peterman AH, Cella D.

Psychooncology. 2007 Dec;16(12):1069-79.

PMID: 17342789 [PubMed - indexed for MEDLINE]

The potential benefits of health-related quality of life (HRQL) assessment in oncology clinical practice include better detection of problems, enhanced disease and treatment monitoring and improved care. However, few empirical studies have investigated the effects of incorporating such assessments into routine clinical care. Recent randomized studies have reported improved detection of and communication about patients' concerns, but few have found effects on patient HRQL or satisfaction. This study examined whether offering interpretive assistance of HRQL results would improve these patient outcomes. 213 participants with metastatic breast, lung or colorectal cancer were randomly assigned to one of three conditions: usual care; HRQL assessment or HRQL assessment followed by a structured interview and discussion. Interviews about patients' assessment responses were conducted by a research nurse, who then presented HRQL information to the treating nurse. HRQL and treatment satisfaction outcomes were assessed at 3 and 6 months. No significant differences were found between study conditions in HRQL or satisfaction. Results suggest that routine HRQL assessment, even with description of results, is insufficient to improve patient HRQL and satisfaction. It is suggested that positive effects may require supplementing assessment results with specific suggestions for clinical management changes.



Effectiveness of aromatherapy massage in the management of anxiety and depression in patients with cancer: a multicenter randomized controlled trial.

Wilkinson SM, Love SB, Westcombe AM, et al

J Clin Oncol. 2007 Feb 10;25(5):532-9.

PURPOSE: To test the effectiveness of supplementing usual supportive care with aromatherapy massage in the management of anxiety and depression in cancer patients through a pragmatic two-arm randomized controlled trial in four United Kingdom cancer centers and a hospice. PATIENTS AND METHODS: 288 cancer patients, referred to complementary therapy services with clinical anxiety and/or depression, were allocated randomly to a course of aromatherapy massage or usual supportive care alone. RESULTS: Patients who received aromatherapy massage had no significant improvement in clinical anxiety and/or depression compared with those receiving usual care at 10 weeks postrandomization (odds ratio [OR], 1.3; 95% CI, 0.9 to 1.7; P = .1), but did at 6 weeks postrandomization (OR, 1.4; 95% CI, 1.1 to 1.9; P = .01). Patients receiving aromatherapy massage also described greater improvement in self-reported anxiety at both 6 and 10 weeks postrandomization (OR, 3.4; 95% CI, 0.2 to 6.7; P = .04 and OR, 3.4; 95% CI, 0.2 to 6.6; P = .04), respectively. CONCLUSION: Aromatherapy massage does not appear to confer benefit on cancer patients' anxiety and/or depression in the long-term, but is associated with clinically important benefit up to 2 weeks after the intervention.



Effect of sertraline on symptoms and survival in patients with advanced cancer, but without major depression: a placebo-controlled double-blind randomised trial.

Stockler MR, O'Connell R, Nowak AK, Goldstein D, Turner J, Wilcken NR, Wyld D, Abdi EA, Glasgow A, Beale PJ, Jefford M, Dhillon H, Heritier S, Carter C, Hickie IB, Simes RJ; Zoloft's Effects on Symptoms and survival Time Trial Group.

Lancet Oncol. 2007 Jul;8(7):603-12. Erratum in: Lancet Oncol. 2007 Jul 8;8(7):574.


BACKGROUND: Depression, anxiety, fatigue, and impaired wellbeing are common, important, and closely related in advanced cancer. We aimed to identify the effects of an established antidepressant on these symptoms and survival in patients with advanced cancer who did not have major depression as assessed by clinicians. METHODS: Between July, 2001, and February, 2006, 189 patients with advanced cancer were randomly assigned sertraline 50 mg (n=95), or placebo (n=94), once per day. The primary outcome was depression as assessed by the Centre for Epidemiologic Studies Depression scale (CES-D); the main secondary outcomes were: anxiety as assessed by Hospital Anxiety and Depression Scales (HADS-A); overall quality of life and fatigue as assessed by Functional Assessment of Cancer Therapy General and Fatigue scales (FACT-G and FACT-F, respectively); and clinicians' ratings of quality of life by use of Spizter's Quality of Life Index (SQLI). Multiple measures were used for corroboration of the most important outcomes. Primary analyses were done by intention to treat and were based on scale scores at 4 weeks and 8 weeks. The benefits of sertraline compared with placebo are expressed on a range from +100 (ie, maximum benefit) to -100 (ie, maximum harm); a difference of 10 was deemed clinically significant. This clinical trial is registered at Current Controlled Trials website FINDINGS: Sertraline had no significant effect (scale, benefit over placebo [95% CI]) on depression (CES-D 0.4 [-2.6 to 3.4]), anxiety (HADS-A 2.0 [-1.5 to 5.5]), fatigue (FACT-F 0.3 [-4.3 to 4.9]), overall quality of life (FACT-G 1.7 [-1.3 to 4.7]), or clinicians' ratings (SQLI 2.0 [-2.5 to 6.5]), and the 95% CI ruled out a clinically significant benefit for all main outcomes. Sertraline was discontinued more often and earlier than was placebo (hazard ratio 1.46 [1.03-2.06], p=0.03). Recruitment was stopped after the first planned interim analysis in February 2006 (n=150) showed that survival was longer in patients assigned placebo than in patients assigned sertraline (unadjusted hazard ratio 1.60 [95% CI 1.04-2.45], log-rank p=0.04; adjusted hazard ratio 1.62 [1.06-2.41], Cox model p=0.02). However, at the final analysis in July 2006 of all patients (n=189) and with longer follow-up, survival did not differ significantly between the treatment groups (unadjusted hazard ratio 1.35 [0.95-1.91], log-rank p=0.09; adjusted hazard ratio 1.27 [0.87-1.84], Cox model p=0.20). The trial was closed because it had ruled out a significant benefit of sertraline. INTERPRETATION: Sertraline did not improve symptoms, wellbeing, or survival in patients with advanced cancer who do not have major depression, and should be reserved for those with a proven indication.



Satisfaction, utilisation and perceived benefit of individual psychosocial support for breast cancer patients--a randomised study of nurse versus psychologist interventions.

Arving C, Sjödén PO, Bergh J, Lindström AT, Wasteson E, Glimelius B, Brandberg Y.

Patient Educ Couns. 2006 Aug;62(2):235-43. Epub 2006 Feb 24.


OBJECTIVE: In a prospective, randomised study, individual psychosocial support performed by: (1) specially trained oncology nurses (INS) or (2) psychologists (IPS) were compared with respect to utilisation, satisfaction and perceived benefit. METHODS: Between December 1997 and December 1999, consecutive breast cancer patients (n=120) were included at start of adjuvant therapy (chemo-, endocrine and/or loco-regional radiotherapy). Data were collected by an extended version of the 'IPS-patient satisfaction questionnaire' within 1 week after termination of the support intervention. Questionnaires were also mailed to all patients 6, 12 and 18-24 months after inclusion. Levels of distress were collected with the Hospital Anxiety and Depression Scale (HADS) and Impact of Event Scale (IES) questionnaires. RESULTS: The patients were highly satisfied with the individual psychosocial support intervention they received, irrespective of which profession provided the support. However, the patients in the INS group reported higher levels of benefit regarding disease-related problems, regardless if the patients at baseline reported low or high levels of distress. CONCLUSIONS: Patients were highly satisfied with an individual psychosocial support intervention. In areas dealing with somatic aspects, the group intervened by nurses were more satisfied than the one by psychologists. PRACTICE IMPLICATIONS: Individual psychosocial support by specially trained nurses is a realistic alternative in routine cancer care.


      Consensus Guidelines / Statements


2008 [new]



Qaseem et al. Evidence-Based Interventions to Improve the Palliative Care of Pain, Dyspnea, and Depression at the End of Life: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med  2008; 148 (2): 141
[ Full text | PDF]

Recommendation 1: In patients with serious illness at the end of life, clinicians should regularly assess patients for pain, dyspnea, and depression. (Grade: strong recommendation, moderate quality of evidence.) Recommendation 2: In patients with serious illness at the end of life, clinicians should use therapies of proven effectiveness to manage pain. For patients with cancer, this includes nonsteroidal anti-inflammatory drugs, opioids, and bisphosphonates. (Grade: strong recommendation, moderate quality of evidence.) Recommendation 3: In patients with serious illness at the end of life, clinicians should use therapies of proven effectiveness to manage dyspnea, which include opioids in patients with unrelieved dyspnea and oxygen for short-term relief of hypoxemia. (Grade: strong recommendation, moderate quality of evidence.) Recommendation 4: In patients with serious illness at the end of life, clinicians should use therapies of proven effectiveness to manage depression. For patients with cancer, this includes tricyclic antidepressants, selective serotonin reuptake inhibitors, or psychosocial intervention. (Grade: strong recommendation, moderate quality of evidence.) Recommendation 5: Clinicians should ensure that advance care planning, including completion of advance directives, occurs for all patients with serious illness. (Grade: strong recommendation, low quality of evidence.)



Cancer Reform Strategy, (2007). Download

The Cancer Reform Strategy builds on the progress made since the publication of the NHS Cancer Plan in 2000 and sets a clear direction for cancer services for the next five years. It shows how by 2012 our cancer services can and should become among the best in the world.



Macmillan Cancer Support (2006) Worried Sick: The Emotional Impact of Cancer. Download

This report, presents a summary of the findings of a survey of 1,751 people taken between December 2005 and February 2006. These included 606 people with cancer, 550 people affected by cancer and 595 people not affected by cancer. The report aimed to find out the impact of cancer diagnosis on people with cancer and affected by it and if there are differences between the views and experiences of people living with or affected by cancer and those never affected by it. The report found that almost half of cancer patients (49%) experienced depression and over three quarters (75%) suffered anxiety - a fifth (19%) felt abandoned. More than four in 10 patients (45%) thought the emotional effects are the most difficult to cope with. The report looks in depth at the emotional, practical and relationship fallout that can follow a cancer diagnosis – problems that can continue even after the patient has recovered from the disease.



National Institute of Clinical Excellence (2004) Guidance on Cancer Services Improving Supportive and Palliative Care for Adults with Cancer.

The NICE Guidance on Improving Supportive and Palliative Care for Adults with Cancer (1) acknowledges there are insufficient numbers of trained professionals to provide psychological support and there is little co-ordination between professionals who are offering different types of psychological interventions. The guidance identifies a 4-tier model with: a. Level one: all health care and cancer professionals, b. Level two: health care professionals with additional experience in assessing psychological distress, c. Level three: trained psychological professionals including therapists and counsellors d. Level four: mental health specialists including psychologists, psychiatrists and clinical nurse specialists able to assess complex psychological problems.




National Breast Cancer Centre and National Cancer Control Initiative.Clinical Practice Guidelines for the Psychosocial Care of Adults with Cancer. Camperdown, Australia: National Breast Cancer Centre;2003 .Free PDF

The ‘Clinical Practice Guidelines for the Psychosocial Care of Adults with Cancer’ was launched by the Federal Minister of Health on 14th August 2003.1 Developed by the National Breast Cancer Centre and the National Cancer Control Initiative and approved by the National Health and Medical Research Council in April 2003, these guidelines are the first of their kind for health professionals who treat, or are involved with cancer patients at all stages of care from diagnosis, through to treatment and palliation. The guidelines are aimed particularly at general practitioners, and cancer specialists such as radiation and medical oncologists, surgeons, nurses, social workers, psychologists, psychiatrists, physiotherapists and occupational therapists. The guidelines are based on comprehensive and systematic reviews of the international research literature and an extensive consultative process to ensure their clinical relevance. They were informed by a multidisciplinary steering group with expertise across a wide range of cancers and health professions and included consumer representation.



Department of Health (2000) The NHS Cancer plan: a plan for investment, a plan for reform. Download

The Cancer Plan (4) identified and incorporated the need for psychological assessment, support and self-help.



NCCN practice guidelines for the management of psychosocial distress.National Comprehensive Cancer Network. Oncology (Williston Park) 1999;13:113–147.



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