This meta-analysis examined whether effects of psychosocial interventions on psychological distress in cancer patients are conditional upon pre-intervention distress levels. Published articles and unpublished dissertations between 1980 and 2005 were searched for interventions reporting the Hospital Anxiety and Depression Scale (HADS) or the Spielberger State-Trait Anxiety Inventory (STAI). Multilevel mixed-effects modeling was used to meta-analyze effect-sizes separately for the HADS (27 trials, 2424 patients) and STAI (34 trials, 2029 patients). Pre-intervention distress significantly moderated intervention effects, explaining up to 50% of the between-study effect-size variance: effects on anxiety and depression were generally negligible when pre-intervention distress was low and pronounced when it was high. These results could not be explained by differences in intervention type, setting, dose, and whether intervention was targeted at distressed patients. Psychosocial interventions may be most beneficial for cancer patients with elevated distress. Future research should identify which treatment components are most effective for these patients to facilitate optimal treatment tailoring and cost-effective health care. KeywordsAnxiety; depression; cancer; psychosocial; intervention; meta-analysis A considerable number of trials have tested psychosocial interventions designed to reduce emotional distress and improve the quality of life of adult cancer patients. The overall efficacy of these interventions is vigorously debated (Stefanek et al., 2006). Studies have yielded mixed results, and previous systematic and meta-analytic reviews have drawn disparate conclusions about whether psychosocial treatment is generally beneficial (Meyer and Mark, 1995;Rehse and Pukrop, 2003;Tatrow and Montgomery, 2006) or ineffective Newell et al., 2002) in reducing distress among cancer patients. Thus, it appears crucial to examine potential determinants of differential treatment efficacy, that is, to identify for whom and under what conditions interventions prove successful or not (King et al., 2008).Intervention studies have commonly included cancer patients regardless of their current emotional well-being Sheard and Maguire, 1999). However, there is substantial heterogeneity in the psychological sequelae of cancer diagnosis. While 20-40% of patients show clinically meaningful anxiety and depression, many report only transient emotional disruption and overall adjust quite well to the illness (van't Spijker et al., 1997;Zabora et al., 2001). For that reason, it has been argued that the efficacy of intervention might well increase if it was selectively provided for those who are most in need because they Sheard and Maguire, 1999;Stanton, 2005).In recent years, evidence has emerged suggesting greater benefits of psychosocial interventions among patients who show elevated distress (Andersen et al., 2004;Boesen et al., 2005;Carmack Taylor et al., 2007;Given et al., 2004;Goodwin et al., 2001;Taylor et al., 2003) or lack psychoso...

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% to 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. Key termscancer; psychosocial; intervention; treatment; quality of life Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. NIH Public Access Author ManuscriptCancer Treat Rev. Author manuscript; available in PMC 2010 August 1. Interventions for Cancer PatientsAt most recent report, more than 11 million Americans were living with cancer. 1 Cancer's diagnosis, treatment, and aftermath present challenges that can contribute to psychological morbidity and can compromise quality of life. Diagnosis involves many stressors and can provoke worries about functioning, social value, finances, burden on one's family, and death. 2,3 Cancer treatments produce side effects, such as fatigue, nausea, and changes in appearance and functioning that can be difficult to cope with. [4][5][6][7] After treatment is complete, stressors involve continued med...

Careful reviews and meta-analyses have made valuable contributions to understanding the efficacy of psychosocial interventions for cancer patients. An important next step is to determine the mediators that explain the influence of efficacious interventions on outcomes. This systematic review summarizes tests of mediating variables from twenty-two projects conducted from 1989–2010. Although all authors provided some type of rationale for considering particular mediating relationships, the investigations varied widely with respect to the extent to which formal theoretical constructs were tested, the type and goals of the interventions studied, and the broad types of outcomes and potential mediators examined. Although there was some evidence supporting selected mediating relationships, with positive findings often found when mediating variables represented behaviors targeted by an intervention, the findings were mixed. Expanding the focus of research to include mechanisms in psychosocial oncology intervention research is necessary for providing a unified picture of how mediating relationships may be operating in this field.

Conducting rigorous psychosocial intervention research with cancer patients has many challenges including encouraging them to join studies, asking them to engage in interventions or be part of control conditions, and to provide data over follow-up assessments. Here, we highlight valuable insights regarding such challenges provided by investigators studying psychosocial interventions for cancer patients. Handling these skillfully has important implications for the internal and external validity of this research and the ethical treatment of participants. Challenges noted in research reports included in a systematic review of 25 years of research (comprising 488 unique projects) investigating interventions designed to enhance cancer patients' quality of life were compiled. Among the difficulties mentioned was the fact that patients may not feel the need for psychosocial interventions and thus may not be interested in joining an intervention study. Patients who do feel the need for such interventions may be deterred from joining trials by the prospect of being randomized to a non-preferred group; if they do join a trial, participants may be disappointed, drop out, or seek compensatory additional assistance if they are assigned to a control group. Apart from randomization, other aspects of research may be off-putting to participants or potential participants, such as the language of consent forms or the intrusiveness of questions being asked. Potential remedies, such as research awareness interventions, monetary incentives, partnering with cancer support organizations, and using designs that take preferences into account merit consideration and further research inquiry.

Few experimental studies have been conducted to investigate the effect of disease characteristics, such as visibility, on the stigmatization of cancer. The current study tested the reactions of undergraduates to vignettes that manipulated the visibility of cancer and the context in which help was needed by an individual with cancer. Results showed that participants were less willing to help the target individual when the cancer was visible and the context allowed stigmatization to be subtle. Further research should consider the relationships among disease attributes, the specific context where help is needed, and the stigmatization of individuals with cancer.