 |
|
Supportive-Expressive Group Therapy and Distress in Patients With Metastatic Breast Cancer
A Randomized Clinical Intervention Trial
Catherine Classen, PhD;
Lisa D. Butler, PhD;
Cheryl Koopman, PhD;
Elaine Miller, RN, MPH;
Sue DiMiceli, BA;
Janine Giese-Davis, PhD;
Patricia Fobair, LCSW, MPH;
Robert W. Carlson, MD;
Helena C. Kraemer, PhD;
David Spiegel, MD
Arch Gen Psychiatry. 2001;58:494-501.
ABSTRACT
| |
Background Metastatic breast cancer carries with it considerable psychosocial morbidity.
Studies have shown that some patients with metastatic breast cancer experience
clinically significant anxiety and depression and traumatic stress symptoms.
Supportive-expressive group psychotherapy was developed to help patients with
cancer face and adjust to their existential concerns, express and manage disease-related
emotions, increase social support, enhance relationships with family and physicians,
and improve symptom control.
Methods Of 125 women with metastatic breast cancer recruited into the study,
64 were randomized to the intervention and 61 to the control condition. Intervention
women were offered 1 year of weekly supportive-expressive group therapy and
educational materials. Control women received educational materials only.
Participants were assessed at baseline and every 4 months during the first
year. Data at baseline and from at least 1 assessment were collected from
102 participants during this 12-month period, and these participants compose
the study population.
Results Primary analyses based on all available data indicated that participants
in the treatment condition showed a significantly greater decline in traumatic
stress symptoms on the Impact of Event Scale (effect size, 0.25) compared
with the control condition, but there was no difference in Profile of Mood
States total mood disturbance. However, when the final assessment occurring
within a year of death was removed, a secondary analysis showed a significantly
greater decline in total mood disturbance (effect size, 0.25) and traumatic
stress symptoms (effect size, 0.33) for the treatment condition compared with
the control condition.
Conclusion Supportive-expressive therapy, with its emphasis on providing support
and helping patients face and deal with their disease-related stress, can
help reduce distress in patients with metastatic breast cancer.
INTRODUCTION
IT IS ESTIMATED that 22% to 50% of patients with breast cancer meet
criteria for a psychiatric diagnosis of depression,1, 2
3% to 19% meet criteria for posttraumatic stress disorder,3, 4, 5, 6, 7
and 33% meet criteria for acute stress disorder.8
Advanced disease seems to be the most stressful time for patients with breast
cancer9, 10, 11, 12
and places them at higher risk for emotional distress.13
In recent years there has been growing recognition that receiving a
diagnosis of cancer or cancer recurrence can lead to a traumatic stress response.3, 4, 5, 6, 7, 8, 14, 15, 16
The DSM-IV17 now includes
being diagnosed as having a life-threatening illness as meeting the criterion
of "exposure to an extreme traumatic stressor" in the psychiatric diagnosis
of posttraumatic stress disorder, suggesting that reducing trauma symptoms
should be a goal of clinical interventions for patients with cancer. Although
a full posttraumatic stress syndrome might afflict only a minority of breast
cancer patients, most investigators3, 4, 7, 16, 18, 19
have found that clinically significant symptoms are relatively common. Given
that adjustment to metastatic disease is often more difficult than adjustment
to the initial diagnosis,14 the need to find
effective treatments for trauma symptoms in metastatic patients is all the
more pressing.
Support groups have the potential to be a potent and cost-effective
form of psychosocial treatment for patients with cancer. There have been several
randomized investigations that have examined the effectiveness of group interventions
and have shown positive effects on psychosocial adjustment,20, 21, 22, 23, 24, 25, 26, 27, 28
physical status,20, 25, 29, 30
and survival.30, 31, 32
Most randomized group intervention studies have involved brief interventions21, 22, 23, 24, 25, 26, 27
and have included a focus on education,21, 22, 24, 25, 26, 27, 33
coping strategies,21, 22, 23, 24, 25, 26, 27
and emotional support.22, 23, 24, 26, 27
Some have also included stress management23, 24, 25, 26, 27
or behavioral training such as hypnosis or progressive relaxation.22, 23, 24, 26, 27
Most interventions were structured, with a predetermined schedule of topics
to be addressed.
The supportive-expressive method used in the present study differs in
being relatively more extensive and intensive.20, 31, 34, 35, 36
Supportive-expressive group therapy contains many of the elements seen in
the brief interventions described previously and is unstructured and existentially
based. The rationale for the existential orientation presumes that living
with a terminal illness amplifies existential concerns of death, meaning,
freedom, and isolation.36, 37 Thus,
one aim of the group intervention is to give patients an opportunity to discuss
these concerns. The treatment strategy is to facilitate discussion of issues
that are uppermost in patients' minds rather than imposing the topics to be
discussed. In previous research,20, 38
this intervention was shown to result in a reduction in mood disturbance,
maladaptive coping responses, phobias, and the experience of pain. However,
this previous research did not assess trauma symptoms.
The supportive-expressive group method has been applied by others39, 40 and has been shown to reduce mood disturbance
in human immunodeficiency virus–infected individuals.40
A hybrid version of this intervention, however, was not found to benefit patients
with metastatic breast cancer.28, 32
The present analysis has 2 aims. One is to test the hypothesis that
1 year of supportive-expressive group therapy will reduce mood disturbance,
thereby replicating earlier findings.20 The
second aim is to test the hypothesis that 1 year of supportive-expressive
group therapy will reduce trauma symptoms of intrusion and avoidance.
PARTICIPANTS AND METHODS
PARTICIPANTS
Study participants were 125 women with confirmed metastatic or locally
recurrent breast cancer randomized into the study between January 1991 and
December 1996. Because only 2 of the women included in the analyses had locally
recurrent disease without metastasis, we refer to all participants as having
metastatic breast cancer. Women were recruited through the Oncology Day Care
Center at Stanford University Medical Center, Stanford, Calif; letters to
community oncologists; brochures distributed in the community; and notices
in local newspapers and breast cancer newsletters. Recruitment yielded 28
patients from Stanford's Oncology Day Care Center, 37 from community oncologists
(includes patients from Kaiser Medical Center, San Francisco Bay Area, Calif),
and 6 from oncology social workers. Fifty-four women were self-referred. A
total of 155 women initially entered the study; 30 dropped out before randomization
(12 because of disease progression, 7 who were found to be ineligible after
their medical records were reviewed, and 11 who decided that they did not
want to continue in the study).
All participants gave written informed consent for participation in
a protocol approved by the Stanford University School of Medicine Human Subjects
Committee. Women were eligible for the study if they had documented metastatic
or recurrent breast cancer, had a Karnofsky score of at least 70%,41 were proficient enough in English to be able to respond
to questionnaires and participate in a support group, and were living in the
Greater San Francisco Bay Area. A patient with a Karnofsky score of 70% is
able to care for herself but unable to carry on normal activity or do active
work. We did not include women with positive supraclavicular lymph nodes as
the only metastatic lesion at the time of initial diagnosis; active cancers
within the past 10 years other than breast cancer, basal cell or squamous
cell carcinomas of the skin, in situ cancer of the cervix (severe cervical
intraepithelial neoplasia or squamous intraepithelial lesion II), or melanoma
with a Breslow depth less than 0.76 mm; or other concurrent medical conditions
likely to affect short-term survival.
BASELINE ASSESSMENTS AND RANDOMIZATION
Baseline assessments were conducted at our Stanford, San Francisco,
and San Jose sites and included measures of distress, coping, social support,
physical activity, and immune and endocrine function. On completion of baseline
testing, participants were randomized to intervention or control conditions
using the adaptive randomization biased coin-design method to ensure comparability
of medical status in treatment and control conditions.42
The adaptive randomization method used the following variables: (1) dominant
site of metastasis at study entry (chest wall/regional lymph nodes, bone,
or viscera), (2) estrogen receptor status (positive, negative, or unknown),
(3) disease-free interval (time from initial diagnosis of breast cancer to
first metastasis or recurrence: <1 year, 1 to 3 years, or >3 years), (4)
age at study entry (<50 years or  50 years), (5) systemic treatment
received since metastasis (none, chemotherapy only, hormonal therapy only,
or chemotherapy and hormonal therapy), and (6) institution (Stanford's Oncology
Day Care Center, Kaiser Medical Center, or a community oncologist). Sixty-four
women were randomized to the intervention arm of the study and 61 to the control
arm.
Only 102 women were included in the data analysis because 23 of the
125 women randomized into the study did not complete any postbaseline assessments:
15 of these 23 participants were too ill to complete questionnaires (4 treatment
and 11 control participants), 2 were too busy (both control participants),
4 withdrew from the study because they were not assigned to a support group,
1 withdrew because she did not like the support group, and 1 assigned to the
treatment condition withdrew for no stated reason. All women included in the
analyses had metastatic breast cancer except for 2 women who had breast recurrences
after breast-conserving therapy as their only site of recurrent metastatic
disease. Data from all participants who provided at least 1 follow-up point
were included in the analyses. The design of this study required that all
data for women randomized to treatment were subject to analysis (if at least
2 assessments were completed), regardless of their group attendance. In the
present analyses, 1 participant randomized to the treatment group never actually
attended a group, although she completed follow-up assessments. Two other
participants randomized to the treatment group did not attend for a year or
more after randomization, although they completed follow-up assessments. Two
participants dropped out of the groups after 1 or 2 sessions, and both continued
to complete follow-up assessments. Demographic and medical variables of participants
are described in Table 1.
|
|
|
|
Table 1. Characteristics of 102 Patients With Metastatic Breast Cancer*
|
|
|
INTERVENTION CONDITION
When recruited into the study, participants were promised 1 year of
group therapy if randomized to the treatment group and were encouraged to
remain in the group for at least 1 year. There were 3 treatment groups, 1
at each geographic site, and they met weekly for 90-minute sessions. The size
of the groups varied over time because of women's dying and rolling recruitment,
with the size ranging from 3 to 15 participants in any given group. The intended
duration of treatment was 1 year. However, because participants were recruited
over several years and because once randomized to the treatment condition
they joined existing groups, these groups continued for several years. Participants
were invited to remain in the groups for as long as they wanted. Some participants
have been attending group meetings since the first year of the study and thus
have participated in the groups for as long as 8 years. Most women continued
participating for as long as their health permitted.
The therapy sessions were facilitated by 2 therapists. Therapists included
a psychiatrist, psychologists, and social workers. The supportive-expressive
therapy model involved the creation of a supportive environment in which participants
were encouraged to confront their problems, strengthen their relationships,
and find enhanced meaning in their lives. The intervention was unstructured,
with therapists trained to facilitate discussion of the following themes as
the material emerged and in an emotionally expressive rather than a didactic
format: (1) fears of dying and death, including dealing with the deaths of
group members; (2) reordering life priorities; (3) improving support from
and communication with family and friends; (4) integrating a changed self
and body image; and (5) improving communication with physicians.36, 43
Through sharing of their experiences, group members also became role models
for one another, teaching each other coping strategies that they found to
be effective in managing the illness. Psychoeducation was provided in a similar
fashion, with group members sharing knowledge they gathered about the illness
and related issues. Neither coping strategies nor psychoeducation was taught
in a didactic manner. Each session ended with a self-hypnosis exercise to
help patients manage stress and deal with pain. Patients were encouraged to
use this exercise at home. A major purpose of the therapy sessions was to
create a close-knit group that would serve to counter feelings of isolation
and enhance social support. This expanded their social network, provided role
models for coping with the illness, and enhanced self-esteem through their
providing concrete help to others in a similar situation.36
Leaders kept members focused on issues central to their diagnoses of metastatic
breast cancer and on facing and grieving for their losses.
CONTROL CONDITION
To ensure full participation and cooperation, we offered a self-directed
education intervention to women randomized to the control condition. To control
for the effect of education, the educational materials were also offered to
the women randomized to the treatment condition. Thus, all participants were
offered educational materials after baseline testing and after each follow-up
session. They were given a list of materials to select from and to take home
on loan. The selection of 30 books, 15 pamphlets, 5 videotapes, and 7 audiotapes
covered a wide range of topics related to breast cancer, including medical
information, coping with adverse effects of chemotherapy and radiation, pain
control, lymphedema, menopause, nutrition, breast self-examination, body image,
sexuality, emotional coping, social support, shared personal experiences,
photography, poetry, artwork, humor, politics and history of breast cancer,
chronic illness, inspiration, spirituality, hospice, and death. They were
also given a 1-year membership to a consumer health library in their community.
At each follow-up visit, participants were asked if they had used the educational
materials. Thirty-two control patients and 35 treatment patients answered
yes to this question at least once. Control patients answered yes a total
of 57 times (range, 1-4 times each). Treatment patients answered yes on 64
occasions (range, 1-5 times each).
MEASURES
Postbaseline assessments were conducted every 4 months during the first
year and every 6 months thereafter. For the first 2 years of the study, baseline
and postbaseline assessments were completed on computers at our Stanford and
San Francisco offices. After that, questionnaires were administered in a paper-and-pencil
format so that they could be completed at home.
The Profile of Mood States (POMS)44 was
used to assess mood disturbance over time. This measure was chosen because
it was used in the original study20 and showed
significant group differences in change over time between a supportive-expressive
therapy group and a no-treatment control group. Participants were asked to
indicate the extent to which 65 mood-descriptive adjectives (eg, "tense,"
"angry," "sad," and "clear-headed") described how they felt during the past
week. Ratings were made on a 5-point Likert-type scale ranging from "not at
all" to "extremely." A total mood disturbance score was calculated based on
each of the 6 subscales: anxiety, depression, hostility, confusion, vigor,
and fatigue. This measure has been shown to have excellent psychometric properties.44 The Cronbach  for the 102 women used in the
analysis for the POMS total score was .93 at baseline.
The Impact of Event Scale (IES)45 was
used to assess change over time in trauma symptoms. The IES is a 15-item measure
designed to assess symptoms of intrusion and avoidance that can occur in response
to a potentially traumatic event, such as being diagnosed as having breast
cancer. The 2 subscales measuring intrusion and avoidance symptoms can be
combined to give an IES total score. In this study, participants were asked
to estimate the frequency of experiencing intrusive and avoidant symptoms
during the past 7 days in response to having cancer. Participants indicated
the extent to which they experienced these symptoms on a 4-point scale ranging
from "not at all" to "often." This measure has been used with a variety of
populations, including patients with breast cancer,3, 16
and has been demonstrated to be a valid and reliable measure.46
The Cronbach for the 102 participants in the present study was .87
for IES total score.
In the present study, the POMS total score is correlated with the IES
total score at r = 0.60 (P<.001).
These measures are moderately correlated, sharing 36% of the variance. Although
the IES shares some variance with the POMS, we chose to include the IES in
this analysis because of the recent literature demonstrating that traumatic
stress symptoms are prevalent in patients with cancer.
ANALYSIS
Slopes analyses were used for testing our hypotheses.47
Each participant with a prerandomization baseline measure and at least 1 postbaseline
assessment had a slope constructed across assessments regressed on time using
months as the unit of time. These outcome slopes became the dependent measure
in a 2 (treatment vs control) x 3 (geographic sites) analysis of covariance.
The primary analyses were conducted on the POMS total mood disturbance scores
and the IES total scores based on slopes computed for each participant's first
year in the study. Another set of secondary analyses were conducted based
on slopes of the total scores for the POMS and IES calculated for the first
year of the intervention but excluding the final assessment if it occurred
within 12 months of death. Primary and secondary analyses were also conducted
on the subscales for each measure. The final assessment was excluded for participants
who died within a year of that assessment because of previous research demonstrating
that there is a significant rise in distress before death (L.D.B.; C.K.; M.
J. Cordova, PhD; R. W. Garlan, MS; S.D.; and D.S.; unpublished observations;
1999). In slopes analysis, the end points have a greater effect on the slope
relative to other assessment points. Consequently, the spike in distress and
trauma symptoms just before death has the potential to obscure the overall
trend. Thus, the effect of proximity to death on the slope is removed in this
analysis. Because change in mood disturbance is typically associated with
initial levels, each analysis of variance included the intercept as a covariate.
We included the intercept rather than the baseline itself because the intercept
is the best estimate of the true baseline value. All hypothesized treatment
vs control relationships were tested with 2-tailed tests, and = .05
was used. Effect sizes were calculated based on the standardized mean difference
between the group means.48 t Tests were also conducted to determine whether patients who dropped
out differed significantly in their baseline POMS and IES scores from the
completers of their assigned group, and no significant differences were found.
RESULTS
EFFECTS OF GROUP THERAPY ON MOOD DISTURBANCE
Primary Analysis
Using the General Linear Model procedure, the difference between treatment
and control groups did not reach statistical significance (F1,95
= 1.69, P = .20). The mean slope of change in POMS
scores over time significantly differed by site (F2,95 = 3.94, P = .02), but there were no significant site x treatment
interactions (F2,95 = 1.88, P = .16).
As expected, the baseline POMS score was significantly related to the mean
slope of POMS scores, with women with the greatest mood disturbance at baseline
improving the most during the 12 months after randomization in the treatment
and control conditions (F1,95 = 27.30, P<.001).
Secondary Analysis
When we excluded the final follow-up assessment occurring within 1 year
of death, women in the treatment condition showed a significantly greater
decline in the mean slope of POMS scores (F1,85 = 5.34, P = .02) compared with those in the control condition, with an effect
size of 0.25. Exclusion of the final follow-up assessment because it occurred
within 1 year of death resulted in 4 control women and 6 treatment women being
dropped from the analysis. These 10 women had only 2 assessments, with the
second assessment occurring within 1 year of death. The results of the secondary
analyses on the POMS are presented in Figure
1.
|
|
|
|
Figure 1. Profile of Mood States total mood
disturbance (POMS TMD) mean scores and mean slopes as a function of condition
and time (fit to real time in months). Secondary analysis corrects for last
assessment before death. C indicates control group; T, treatment group.
|
|
|
EFFECTS OF GROUP THERAPY ON TRAUMATIC STRESS SYMPTOMS
Primary Analysis
Group therapy treatment showed a statistically significant reduction
in trauma symptoms compared with the control group (Figure 2). Women in the group therapy condition showed a significantly
greater decline in mean IES total scores (F1,90 = 4.63, P = .03) compared with those in the control condition, with an effect
size of 0.25. Furthermore, there was a significant difference in the slope
of IES total scores across the sites (F2,90 = 4.39, P = .02) but no significant site x treatment interactions (F2,90 = 0.57, P = .57). The baseline IES total
score was significantly related to the slope of change on the IES (F1,90 = 34.79, P<.001), with the women who
at baseline reported the highest traumatic stress symptoms on the IES showing
the greatest reduction of symptoms over time.
|
|
|
|
Figure 2. Impact of Event Scale (IES) mean
total scores and mean slopes as a function of condition and time (fit to real
time in months). C indicates control group; T, treatment group.
|
|
|
Secondary Analysis
Although we found a treatment effect for the IES when all assessments
were included, we chose to examine what the magnitude of the effect would
be when we excluded the final follow-up assessment occurring within 1 year
of death. We found that women in the treatment condition again showed a significantly
greater decline in the mean slope of the IES total scores (F1,81
= 6.01, P = .01) compared with those in the control
condition, with an effect size of 0.33. Although the magnitude of the effect
is stronger when the final follow-up assessment just before death is excluded,
we did not test to see whether it is statistically significantly stronger
than when these assessments are included. Three control participants and 6
treatment participants were lost to the analysis because they had only 2 assessment
points, with the second occurring within 1 year of death.
Table 2 shows the baseline
scores for the POMS and the IES and their subscales by condition, along with
the values for the slopes and effect sizes.
|
|
|
|
Table 2. Baseline POMS TMD and IES Total Scores, Slopes, and Effect
Sizes for Primary and Secondary Analyses*
|
|
|
COMMENT
This study evaluated the effectiveness of 1 year of supportive-expressive
group psychotherapy for reducing mood disturbance and traumatic stress symptoms
in women with metastatic breast cancer. The primary analyses, which included
all available assessments, indicated that there was a treatment effect for
trauma symptoms but not mood disturbance. When follow-up assessments undertaken
within 1 year of the patient's death were excluded in the secondary analyses,
there was a significant decline in trauma symptoms and mood disturbance for
the treatment condition compared with the control condition. The magnitudes
of these effects were small to moderate. In the primary and secondary IES
analyses, additional analyses of the subscales showed that the overall reduction
in symptoms in the intervention group was carried by a strong and significant
decline in avoidance symptoms.
Coping with cancer-related trauma symptoms has been recognized as a
troublesome aspect of living with metastatic breast cancer for some patients.3, 4, 16, 49 Although
supportive-expressive group psychotherapy36, 43
was not developed specifically to address the treatment needs of a traumatized
sample, it contains ingredients thought to be critical to treatment for trauma,
a focus on coping with life threat, coupled with exposure to the feared stimuli
and integration of the traumatic material into the patient's life.50, 51, 52 Supportive-expressive
group psychotherapy directly challenges patients' tendencies to withdraw and
avoid the implications of their condition. The importance of reducing avoidance
in cancer patients has been confirmed in several studies.53, 54, 55, 56
In the present study, exclusion of the death-proximal assessments increased
the significance of the POMS and the IES findings. This finding underscores
the implications of a recent study (L.D.B. et al, unpublished observations,
1999) that examined the course of mood disturbance and other psychosocial
outcomes in the subset of this metastatic sample who had died and found a
marked increase in distress at the last assessment before death, regardless
of condition. This may have implications for other studies28, 57
that did not find significant treatment effects of group psychotherapy in
patients with advanced cancer, particularly those in longer-term studies,
in which the proportion of patients who die is typically higher.
The small to moderate effect sizes may raise questions regarding the
cost-effectiveness of this intervention. Given the importance of alleviating
distress in this population, however, these modest differences in outcome
suggest that there is clinical value in the intervention.
The primary analysis of the POMS in the present study represents an
attempt to replicate the treatment effect on mood disturbance in the original
study reported by this laboratory.20 The present
study used the same treatment protocol, and the treatment was administered
or supervised by one of the primary therapists of the original study (D.S.),
so we think it is unlikely that the outcome difference is accounted for by
a failure to adequately adhere to the treatment protocol.
There are ways in which the present study differs from the original
study that may be related to outcome differences. A variety of sociocultural
changes since the time of the first study, conducted in the 1970s, may have
altered characteristics of the potential participant population and thereby
affected aspects of patient recruitment. In the original study,20
all patients were referred by physicians (because support groups were uncommon
and their utility was untested), and some participants had to be encouraged
to participate. In the present study, more than 40% of participants were self-referred.
Because of the widespread dissemination of information in the past 20 years
regarding the benefits of cancer support groups, participants may also have
had expectations about outcome that were not present in earlier studies. Almost
three quarters of the present sample indicated a preference for randomization
to the treatment group at baseline, whereas there was no such preference in
the original study.20 Thus, it is possible that
the participants in the present study were more receptive to the intervention.
However, the control group also had greater access to outside support groups,
and this may have decreased the mood disturbance differences between the treatment
and control groups.
There are several limitations to the present study. Although the POMS
has demonstrated sensitivity to treatment-related changes in several short-
and longer-term outcome studies,20, 23, 26
the fact that it measures mood, a relatively transient characteristic susceptible
to influence by a variety of factors,58 may
make it a less than optimal measure of stable long-term psychosocial adjustment.
Another limitation is that participants in the present study were asked to
complete an extensive battery of measures at multiple assessment points. This
assessment burden may have precluded recruitment of participants who believed
that they were unable to meet these requirements and therefore may limit the
generalizability of the findings. Given the design of the study, we also have
no way of knowing what specific aspects of the intervention may have contributed
to the treatment effect. Finally, we cannot rule out the possibility that
the difficulty in showing a primary treatment effect on the POMS is due to
the intervention itself and not the measure.
In summary, we found that women with metastatic breast cancer in a supportive-expressive
group therapy intervention experienced a significantly greater decline in
traumatic stress symptoms in 1 year compared with women randomized to the
control condition. When the impact of the last assessment before death was
removed, both mood disturbance and traumatic stress symptoms declined significantly
more for participants in the treatment condition than for those in the control
condition. Future research should examine potential moderators and mediators
of these psychosocial treatment effects, determine whether group therapy affects
patients' adherence to medical treatment, and determine whether group psychotherapy
has a beneficial impact on longevity in patients with metastatic breast cancer,
as has been previously reported.31 Our laboratory
is currently conducting such a survival analysis in this sample.
AUTHOR INFORMATION
Accepted for publication September 25, 2000.
This work was supported by grant MH47226 from the National Institute
of Mental Health and by the National Cancer Institute, Bethesda, Md; the John
D. and Catherine T. MacArthur Foundation, Chicago, Ill; and the Fetzer Institute,
Kalamazoo, Mich.
Presented in part at the Annual Meeting of the American Psychological
Association, Boston, Mass, August 21, 1999.
We acknowledge California Pacific Medical Center, San Francisco, and
The Cancer Care Center at O'Conner Hospital, San Jose, Calif, for their generosity
in providing office space for assessments and group therapy.
From the Departments of Psychiatry and Behavioral Sciences (Drs Classen,
Butler, Koopman, Giese-Davis, Kraemer, and Spiegel and Mss Miller and DiMiceli),
Radiation Oncology (Ms Fobair), and Medicine/Oncology (Dr Carlson), Stanford
University School of Medicine, Stanford, Calif.
Corresponding author and reprints: Catherine Classen, PhD, Department
of Psychiatry and Behavioral Sciences, Stanford University School of Medicine,
Stanford, CA 94131-5718 (e-mail: classen{at}leland.stanford.edu).
REFERENCES
| |
1. Morris T, Greer HS, White P. Psychological and social adjustment to mastectomy: a two-year follow-up
study. Cancer. 1977;40:2381-2387.
FULL TEXT
|
ISI
| PUBMED
2. Lasry J-CM, Margolese RG, Poisson R, Shibata H, Fleischer D, Lafleur D, Legault S, Taillefer S. Depression and body image following mastectomy and lumpectomy. J Chronic Dis. 1987;40:529-534.
FULL TEXT
|
ISI
| PUBMED
3. Cordova MJ, Andrykowski MA, Redd WH, Kenady DE, McGrath PC, Sloan DA. Frequency and correlates of posttraumatic stress disorder–like
symptoms after treatment for breast cancer. J Consult Clin Psychol. 1995;63:981-986.
FULL TEXT
|
ISI
| PUBMED
4. Alter CL, Pelcovitz D, Axelrod A, Goldenberg B, Harris H, Meyers B, Grobois B, Mandel F, Septimus A, Kaplan S. Identification of PTSD in cancer survivors. Psychosomatics. 1996;37:137-143.
FREE FULL TEXT
5. Jacobsen PB, Widows MR, Hann DM, Andrykowski MA, Kronish LE, Fields KK. Posttraumatic stress disorder symptoms after bone marrow transplantation
for breast cancer. Psychosom Med. 1998;60:366-371.
FREE FULL TEXT
6. Andrykowski MA, Cordova MJ, Studts JL, Miller TW. Posttraumatic stress disorder after treatment for breast cancer: prevalence
of diagnosis and use of the PTSD Checklist–Civilian Version (PCL–C)
as a screening instrument. J Consult Clin Psychol. 1998;66:586-590.
FULL TEXT
|
ISI
| PUBMED
7. Green BL, Rowland JH, Krupnick JL, Epstein SA, Stockton P, Stern NM, Spertus IL, Steakley C. Prevalence of posttraumatic stress disorder in women with breast cancer. Psychosomatics. 1998;39:102-111.
FREE FULL TEXT
8. McGarvey EL, Canterbury RJ, Koopman C, et al. Acute stress disorder following diagnosis of cancer. Int J Rehabil Health. In press.
9. Silberfarb PM, Maurer LH, Crouthamel CS. Psychosocial aspects of neoplastic disease, I: functional status of
breast cancer patients during different treatment regimens. Am J Psychiatry. 1980;137:450-455.
FREE FULL TEXT
10. Gotay CC. The experience of cancer during early and advanced stages: the views
of patients and their mates. Soc Sci Med. 1984;18:605-613.
11. Taylor SE, Lichtman RR, Wood JV, Bluming AZ, Dosik GM, Leibowitz RL. Illness-related and treatment-related factors in psychological adjustment
to breast cancer. Cancer. 1985;55:2506-2513.
FULL TEXT
|
ISI
| PUBMED
12. Mahon SM, Cella DF, Donovan MI. Psychosocial adjustment to recurrent cancer. Oncol Nurs Forum. 1990;17:47-52; discussion 53-54.
PUBMED
13. Massie MJ, Holland JC. Depression and the cancer patient. J Clin Psychiatry. 1990;51:12-17; discussion 18-19.
14. Cella DF, Mahon SM, Donovan MI. Cancer recurrence as a traumatic event. Behav Med. 1990;16:15-22.
ISI
| PUBMED
15. Stuber ML, Nader K, Yasuda P, Pynoos RS, Cohen S. Stress responses after pediatric bone marrow transplantation: preliminary
results of a prospective longitudinal study. J Am Acad Child Adolesc Psychiatry. 1991;30:952-957.
ISI
| PUBMED
16. Butler L, Koopman C, Classen C, Spiegel D. Traumatic stress, life events, and emotional support in women with
metastatic breast cancer: cancer-related trauma symptoms associated with past
and current stressors. Health Psychol. 1999;18:555-560.
FULL TEXT
|
ISI
| PUBMED
17. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition. Washington, DC: American Psychiatric Association; 1994.
18. Andrykowski MA, Cordova MJ. Factors associated with PTSD symptoms following treatment for breast
cancer: test of the Andersen Model. J Trauma Stress. 1998;11:189-203.
FULL TEXT
|
ISI
| PUBMED
19. McGarvey EL, Koopman C, Spiegel D, Canterbury RJ. Experiences of trauma following diagnosis of a life-threatening illness. Int J Rehabil Health. In press.
20. Spiegel D, Bloom JR, Yalom I. Group support for patients with metastatic cancer: a randomized outcome
study. Arch Gen Psychiatry. 1981;38:527-533.
FREE FULL TEXT
21. Johnson J. The effects of a patient education course on persons with a chronic
illness. Cancer Nurs. 1982;5:117-123.
PUBMED
22. Cain EN, Kohorn EI, Quinlan DM, Latimer K, Schwartz PE. Psychosocial benefits of a cancer support group. Cancer. 1986;57:183-189.
FULL TEXT
|
ISI
| PUBMED
23. Telch CF, Telch MJ. Group coping skills instruction and supportive group therapy for cancer
patients: a comparison of strategies. J Consult Clin Psychol. 1986;54:802-808.
FULL TEXT
|
ISI
| PUBMED
24. Cunningham AJ, Tocco EK. A randomized trial of group psychoeducational therapy for cancer patients. Patient Educ Counsel. 1989;141:101-114.
FULL TEXT
25. Berglund B, Bolund C, Gustafsson U, Sjoden P. A randomized study of a rehabilitation program for cancer patients:
the "starting again" group. Psychooncology. 1994;3:109-120.
26. Fawzy FI, Cousins N, Fawzy NW, Kemeny ME, Elashoff R, Morton D. A structured psychiatric intervention for cancer patients, I: changes
over time in methods of coping and affective disturbance. Arch Gen Psychiatry. 1990;47:720-725.
FREE FULL TEXT
27. Samarel N, Fawcett J, Tulman L. Effect of support groups with coaching on adaption to early stage breast
cancer. Res Nurs Health. 1997;20:15-26.
FULL TEXT
|
ISI
| PUBMED
28. Edmonds CVI, Lockwood GA, Cunningham AJ. Psychological response to long term group therapy: a randomized trial
with metastatic breast cancer patients. Psychooncology. 1999;8:74-91.
FULL TEXT
| PUBMED
29. Fawzy FI, Kemeny ME, Fawzy NW, Elashoff R, Morton D, Cousins N, Fahey JL. A structured psychiatric intervention for cancer patients, II: changes
over time in immunological measures. Arch Gen Psychiatry. 1990;47:729-735.
FREE FULL TEXT
30. Fawzy FI, Fawzy NW, Hyun CS, Elashoff R, Guthrie D, Fahey JL, Morton DL. Malignant melanoma: effects of an early structured psychiatric intervention,
coping, and affective state on recurrence and survival 6 years later. Arch Gen Psychiatry. 1993;50:681-689.
FREE FULL TEXT
31. Spiegel D, Bloom JR, Kraemer HC, Gottheil E. Effect of psychosocial treatment on survival of patients with metastatic
breast cancer. Lancet. 1989;2:888-891.
FULL TEXT
|
ISI
| PUBMED
32. Cunningham AJ, Edmonds CVI, Jenkins GP, Pollack H, Lockwood GA, Warr D. A randomized controlled trial of the effects of group psychological
therapy on survival in women with metastatic breast cancer. Psychooncology. 1998;7:508-517.
FULL TEXT
| PUBMED
33. Helgeson V, Cohen S, Schulz R, Yasko J. Education and peer discussion group interventions and adjustment to
breast cancer. Arch Gen Psychiatry. 1999;56:340-347.
FREE FULL TEXT
34. Spiegel D, Bloom JR. Group therapy and hypnosis reduce metastatic breast carcinoma pain. Psychosom Med. 1983;45:333-339.
FREE FULL TEXT
35. Spiegel D, Glafkides MC. Effects of group confrontation with death and dying. Int J Group Psychother. 1983;33:433-447.
ISI
| PUBMED
36. Spiegel D, Classen C. Group Therapy for Cancer Patients: A Research-Based
Handbook of Psychosocial Care. New York, NY: Basic Books Inc Publishers; 2000.
37. Yalom ID. Existential Psychotherapy. New York, NY: Basic Books Inc Publishers; 1980.
38. Spiegel D, Bloom JR. Pain in metastatic breast cancer. Cancer. 1983;52:341-345.
FULL TEXT
|
ISI
| PUBMED
39. Goodwin PJ, Leszcz M, Koopmans J, Arnold A, Doll R, Chochinov H, Navarro M, Butler K, Pritchard KI. Randomized trial of group psychosocial support in metastatic breast
cancer: the BEST study. Cancer Treat Rev. 1996;22(suppl A):91-96.
40. Kelly JA, Murphy DA, Bahr GR, Kalichman SC, Morgan MG, Stevenson LY, Koob JJ, Brasfield TL, Bernstein BM. Outcome of cognitive-behavioral and support group brief therapies for
depressed, HIV-infected persons. Am J Psychiatry. 1993;150:1679-1686.
FREE FULL TEXT
41. Karnofsky DA, Burchenal JH. The clinical evaluation of chemotherapeutic agents in cancer. In: MacLead CM, ed. Evaluation of Chemotherapeutic
Agents. New York, NY: Columbia University Press; 1949.
42. Efron B. Forcing a sequential experiment to be balanced. Biometrika. 1971;58:403-417.
FREE FULL TEXT
43. Spiegel D, Spira J. Supportive/Expressive Group Therapy: A Treatment
Manual of Psychosocial Intervention for Women With Recurrent Breast Cancer. Stanford, Calif: Stanford University School of Medicine; 1991.
44. McNair DM, Lorr M, Droppleman LF. Edits Manual for the Profile of Mood States. San Diego, Calif: Educational & Industrial Testing Service; 1971/1981/1992.
Revised 1992.
45. Horowitz M, Wilner N, Alvarez W. Impact of Event Scale: a measure of subjective stress. Psychosom Med. 1979;41:209-218.
FREE FULL TEXT
46. Horowitz MJ, Field NP, Classen C. Stress response syndromes and their treatment. In: Goldberger L, Breznitz S, eds. Handbook of
Stress. 2nd ed. New York, NY: Free Press; 1993:757-773.
47. Gibbons RD, Hedeker D, Waternaux C, Kraemer HC, Greenhouse JB. Some conceptual and statistical issues in the analysis of longitudinal
psychiatric data. Arch Gen Psychiatry. 1993;50:730-750.
48. Cohen J. Statistical Power Analysis for the Behavioral Sciences. Hillsdale, NJ: Lawrence Erlbaum Associates Inc; 1977.
49. Hunter J, Leszcz M, McLachlan SA, Butler K, Esplen MJ, Gao J, Goodwin P. Psychological stress response in breast cancer. Paper presented at: Third World Congress of Psycho-Oncology; October
3-6, 1996; New York, NY.
50. Solomon SD, Gerrity ET, Muff AM. Efficacy of treatments for posttraumatic stress disorder: an empirical
review. JAMA. 1992;268:633-638.
FREE FULL TEXT
51. Brom D, Kleber RJ, Defare PB. Brief psychotherapy for post-traumatic stress disorder. J Consult Clin Psychol. 1989;57:607-612.
FULL TEXT
|
ISI
| PUBMED
52. Sherman JJ. Effects of psychotherapeutic treatments for PTSD: a meta-analysis of
controlled clinical trials. J Trauma Stress. 1998;11:413-435.
FULL TEXT
|
ISI
| PUBMED
53. Behan JM, Rodrigue JR. Predictors of coping strategies among adults with cancer. Psychol Rep. 1994;74:43-48.
ISI
| PUBMED
54. Feifel H, Strack S, Nagy VT. Coping strategies and associated features of medically ill patients. Psychosom Med. 1987;49:616-625.
FREE FULL TEXT
55. Bloom JR, Spiegel D. The relationship of two dimensions of social support to the psychological
well-being and social functioning of women with advanced breast cancer. Soc Sci Med. 1984;19:831-837.
56. Friedman LC, Nelson DV, Baer PE, Lane M, Smith FE. Adjustment to breast cancer: a replication study. J Psychosoc Oncol. 1990;8:27-40.
57. Linn MW, Linn BS, Harris R. Effects of counseling for late stage cancer. Cancer. 1982;49:1048-1055.
FULL TEXT
|
ISI
| PUBMED
58. Stone AA. Measurement of affective response. In: Cohen S, Kessler RC, Underwood LU, eds. Measuring
Stress: A Guide for Health and Social Scientists. New York, NY: Oxford
University Press; 1997:148-171.
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati  Twitter
What's this?
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
Screening for Emotional Distress in Cancer Patients: A Systematic Review of Assessment Instruments
Vodermaier et al.
JNCI J Natl Cancer Inst 2009;101:1464-1488.
ABSTRACT
| FULL TEXT
How Prostate Cancer Support Groups Do and Do Not Survive: British Columbian Perspectives
Oliffe et al.
Am J Mens Health 2008;2:143-155.
ABSTRACT
Behavioral Symptoms in Patients With Breast Cancer and Survivors
Bower
JCO 2008;26:768-777.
ABSTRACT
| FULL TEXT
The Use of Internet Cancer Support Groups by Ethnic Minorities
Im and Chee
J Transcult Nurs 2008;19:74-82.
ABSTRACT
Comparison of Participants and Non-Participants in a Randomized Psychosocial Intervention Study Among Patients With Malignant Melanoma
Boesen et al.
Psychosomatics 2007;48:510-516.
ABSTRACT
| FULL TEXT
Hope
Penson et al.
The Oncologist 2007;12:1105-1113.
ABSTRACT
| FULL TEXT
Older Breast Cancer Survivors: Factors Associated With Change in Emotional Well-Being
Clough-Gorr et al.
JCO 2007;25:1334-1340.
ABSTRACT
| FULL TEXT
Psychological treatments for chronic post-traumatic stress disorder: Systematic review and meta-analysis
BISSON et al.
Br. J. Psychiatry 2007;190:97-104.
ABSTRACT
| FULL TEXT
Reduction of Cancer-Specific Thought Intrusions and Anxiety Symptoms With a Stress Management Intervention Among Women Undergoing Treatment for Breast Cancer
Antoni et al.
Am. J. Psychiatry 2006;163:1791-1797.
ABSTRACT
| FULL TEXT
A Narrative View of Art Therapy and Art Making by Women with Breast Cancer
Collie et al.
J Health Psychol 2006;11:761-775.
ABSTRACT
Impacting Quality of Life for Patients With Advanced Cancer With a Structured Multidisciplinary Intervention: A Randomized Controlled Trial
Rummans et al.
JCO 2006;24:635-642.
ABSTRACT
| FULL TEXT
Effect of Individual Psychological Intervention in Chinese Women With Gynecologic Malignancy: A Randomized Controlled Trial
Chan et al.
JCO 2005;23:4913-4924.
ABSTRACT
| FULL TEXT
Psychoeducational Intervention for Patients With Cutaneous Malignant Melanoma: A Replication Study
Boesen et al.
JCO 2005;23:1270-1277.
ABSTRACT
| FULL TEXT
Support Groups in Breast Cancer: When a Negative Result Is Positive
Goodwin
JCO 2004;22:4244-4246.
FULL TEXT
Barriers to the Treatment of Depression in Cancer Patients
Greenberg
J Natl Cancer Inst Monogr 2004;2004:127-135.
ABSTRACT
| FULL TEXT
The Race Gap in Support Group Participation by Breast Cancer Survivors: Real or Artifact?
Michalec et al.
Eval Rev 2004;28:123-143.
ABSTRACT
Experience of Trauma, Distress, and Posttraumatic Stress Disorder Among Breast Cancer Patients
Palmer et al.
Psychosom. Med. 2004;66:258-264.
ABSTRACT
| FULL TEXT
Peer support groups in multiple sclerosis: current effectiveness and future directions
Uccelli et al.
Mult Scler 2004;10:80-84.
ABSTRACT
Professionally perceived effectiveness of psychosocial interventions for existential suffering of terminally ill cancer patients
Hirai et al.
Palliat Med 2003;17:688-694.
ABSTRACT
Group and Individual Treatment Strategies for Distress in Cancer Patients
Clark et al.
Mayo Clin Proc. 2003;78:1538-1543.
ABSTRACT
Integrative Tumor Board: Colon Cancer with Liver Metastases
Perlman and Hurst
Integr Cancer Ther 2003;2:190-195.
Quality of Life in a Randomized Trial of Group Psychosocial Support in Metastatic Breast Cancer: Overall Effects of the Intervention and an Exploration of Missing Data
Bordeleau et al.
JCO 2003;21:1944-1951.
ABSTRACT
| FULL TEXT
Use of the Internet and E-mail for Health Care Information: Results From a National Survey
Baker et al.
JAMA 2003;289:2400-2406.
ABSTRACT
| FULL TEXT
Psychological Distress and Pain Significantly Increase Before Death in Metastatic Breast Cancer Patients
Butler et al.
Psychosom. Med. 2003;65:416-426.
ABSTRACT
| FULL TEXT
Mind-Body Medicine: State of the Science, Implications for Practice
Astin et al.
J Am Board Fam Med 2003;16:131-147.
ABSTRACT
| FULL TEXT
Health-Related Quality-of-Life Measurement in Randomized Clinical Trials in Breast Cancer--Taking Stock
Goodwin et al.
JNCI J Natl Cancer Inst 2003;95:263-281.
ABSTRACT
| FULL TEXT
Advising Patients Who Seek Complementary and Alternative Medical Therapies for Cancer
Weiger et al.
ANN INTERN MED 2002;137:889-903.
ABSTRACT
| FULL TEXT
Complementary and Alternative Medicine Use Among Women With Breast Cancer
DiGianni et al.
JCO 2002;20:34s-38.
ABSTRACT
| FULL TEXT
Stress Response Syndromes and Cancer: Conceptual and Assessment Issues
Gurevich et al.
Psychosomatics 2002;43:259-281.
ABSTRACT
| FULL TEXT
The Effect of Group Psychosocial Support on Survival in Metastatic Breast Cancer
Goodwin et al.
NEJM 2001;345:1719-1726.
ABSTRACT
| FULL TEXT
Mind Matters -- Group Therapy and Survival in Breast Cancer
Spiegel
NEJM 2001;345:1767-1768.
FULL TEXT
Effect of sex and gender on psychosocial aspects of prostate and breast cancer
Kiss and Meryn
BMJ 2001;323:1055-1058.
FULL TEXT
Other Articles Noted
Evid. Based Nurs. 2001;4:E1-11.
FULL TEXT
Coping with Metastatic Breast Cancer: Group Support Helps
JWatch Women's Health 2001;2001:4-4.
FULL TEXT
|
