Introduction
Traditionally, a structured hospital-based group intervention consisting of health education, stress management or behavioral training, psychosocial group support and problem-solving was viewed as being the most effective in promoting a positive change in affective state and long-term coping in cancer patients (Fawzy et al., Reference Fawzy, Cousins, Fawzy, Kemeny, Elashoff and Morton1990). However, a recent meta-analysis has confirmed that the addition of creative therapies to hospital-based cancer support programs (e.g. art therapy, dance therapy, music therapy) is effective in reducing anxiety, depression, pain and fatigue and improving the cancer patient's quality of life (Puetz, Morley and Herring, Reference Puetz, Morley and Herring2013).
For cancer survivors living in rural, regional and remote areas it can often be difficult to access hospital-based services (Grimison et al., Reference Grimison, Phillips, Butow, White, Yip and Sardelic2013). A possible solution could be to provide a structured psychosocial intervention for cancer survivors outside of the hospital environment in a community setting. The aim of this study was to evaluate the benefit (if any) of providing psychosocial training in a community based setting to women who have received a diagnosis of breast cancer.
Method
Participants
A convenience sample of 37 women participated in the following evaluation. The age of women ranged between 30 and 65 years; however, the majority of women were between 40–50 years of age (n = 35). Participation was available to all women 18 years or older with adequate knowledge of spoken English and who reported at some stage to have been diagnosed with breast cancer. Exclusion criteria included verbally admitting to a history of psychopathology requiring hospitalization.
The disease phase of breast cancer survivors included: currently undergoing treatment (n = 8), remission <6 months (n = 9), remission <12 months (n = 9) and remission >12 months (n = 11). Participants reported to have (some) ongoing support from at least one family member (n = 36), although, one cancer survivor claimed she preferred to live in relative isolation (n = 1). No participant displayed evidence of physical dependency requiring full-time care.
Subject participation was obtained by informed consent and no financial or other incentives were provided to any participant in return for participation in this study. Informed consent was provided prior to any personal data being collected. Moreover, all women were aware they could withdraw their consent to participate at any time without withdrawing their participation in the psychosocial education program.
The program was approved by the Donvale Living and Learning Community Centre management committee. The procedures employed in this study were consistent with ethical guidelines for human research set by the National Statement on Ethical Conduct in Human Research (2007) and with the Helsinki Declaration of 1975, as revised in 2008.
Measures
Profile of Mood States (POMS) is a 65-item questionnaire used to measure psychological adjustment (McNair, Lorr and Droppleman, Reference McNair, Lorr and Droppleman1992). Information about six mood factors can be elicited: (Tension/Anxiety, Depression/Dejection, Anger/Hostility, Fatigue/Inertia, Vigor/Activity and Confusion–Bewilderment).
General Health Questionnaire (GHQ) is a 60-item questionnaire used to measure psychological maladjustment. The GHQ-60 addresses two major classes of phenomena: whether the person has the ability to carry out “healthy” functions and the appearance of new and distressing phenomena. A 28-item version of the questionnaire (GHQ-28) can be used to assess four mood factors: Severe depression; Social dysfunction; Anxiety; and Sleep disturbance (Goldberg and Williams, Reference Goldberg and Williams1988).
Community-based psychosocial program
The community based psychosocial program was conducted at the Donvale Living and Learning Community Centre (Springvale Road, Donvale, Victoria, Australia). The aim of the community based psychosocial education program was to reduce the reporting of somatic symptoms and psychosocial sequelae of cancer and its treatment and enhance adjustment and acceptance. Consistent with the research evidence available for hospital-based cancer support programs (e.g. Fawzy et al., Reference Fawzy, Cousins, Fawzy, Kemeny, Elashoff and Morton1990 ; Puetz et al., Reference Puetz, Morley and Herring2013 ) the intervention consisted of 8 x 3-hour weekly sessions and included the following modules:
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• Relaxation
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• Thought stopping
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• Guided imagery
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• Progressive muscle relaxation (PMR)
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• Biofeedback
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• Medical art therapy
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• Health education
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• Spiritual support
Procedure
The program was delivered in a small group format consisting of 4–10 participants. A total of 7 psychosocial education groups were conducted over a period of 2 years. Each session was facilitated by the same provisionally registered psychologist under the supervision of a registered psychologist. Art therapy classes were delivered by a registered Art therapist.
As part of the data collection cancer survivors were asked to complete the GHQ-60 and POMS at the beginning of the program in week 1 and then again at the end of the program in week 8. Both questionnaires were designed to be self-administered and scored in accordance with procedures outlined in the respective administration manuals (Goldberg and Williams, Reference Goldberg and Williams1988; McNair et al., Reference McNair, Lorr and Droppleman1992).
At the completion of the 8-week program cancer survivors were invited to join an ongoing weekly evening support group that had previously been established at the community center.
Statistical analysis
The independent variables in this study were Pre and Post intervention. The dependent variables were GHQ-28 factors (Depression, Anxiety, Social Dysfunction, Somatic) and POMS factors (Tension/Anxiety, Depression/Dejection, Anger/Hostility, Vigor/Activity, Fatigue/Inertia, Confusion/Bewilderment. A 4 × 2 mixed design analysis of variance (ANOVA) with Group (Mild, Moderate, Severe, Very Severe) as the “between subjects” factor and Time (Pre, Post) as the “within subjects” factor was used to compare Pre and Post measures. Results were classed as significant if the probability was <.05.
Results
The mean Total GHQ-60 score for the group Pre (M = 66.95, SD = 31.16) and Post (M = 43.97, SD = 26.14) intervention was compared. The results were significant (t (36) = 4.32, p < .01), which confirmed that the mean level of psychiatric morbidity was lower at the end of the 8-week psychosocial program.
Cancer survivors were divided into four groups according to degree of psychiatric morbidity. Criteria used to determine grouping were: Mild = GHQ-60 score of lowest – 41 (n = 9), Moderate = GHQ-60 score of 42 – 61 (n = 10), Severe = GHQ-60 score of 62 – 81 (n = 9) and Very Severe = GHQ-60 score of 82 – highest (n = 9). Descriptive statistics for the GHQ-28 factors and POMS factors for the four groups is graphically presented in Figures 1A and 1B, respectively.
Figure 1. Community based psychosocial program mean pre and post (A) GHQ-28 scores and (B) POMS factor scores with standard deviations for the four psychiatric morbidity groups (Mild, Moderate, Severe, Very Severe). (N = 37).
At the end of the 8-week psychosocial program the POMS: Tension/Anxiety and Fatigue/Inertia scores remained statistically unchanged in all groups; Depression/Dejection scores were significantly lower in the Very Severe group (p < .01); Confusion/Bewilderment scores were significantly lower in the Mild group (p < .05). Anger/Hostility scores were significantly lower in the Mild (p = .04) and Moderate (p = .05), groups; Vigor/Activity scores were significantly improved in the Very Severe group (p < .01); Additionally, GHQ-28: Depression scores in the Severe (p < .05) and Very Severe (p < .01) groups; Anxiety scores in the Mild (p < .05), Moderate (p < .01), Severe (p < .01) and Very Severe (p = .01) groups; Social Dysfunction scores in the Very Severe group (p < .05); and Somatic scores in the Mild group (p < .05), were all significantly lower.
Discussion
The results of this study have shown that a structured 8-week psychosocial program conducted in a community setting can promote a significant decrease in psychiatric morbidity and mood disturbance in breast cancer survivors. The data showed a significant reduction in the reporting of phenomena of a distressing nature and some (but not all) mood factors. Furthermore, a significant increase in energy levels was noted.
We observed a high degree of mood disturbance in breast cancer survivors prior to participating in the psychosocial program. However, following the completion of the 8-week intervention a significant reduction in the level of reported depression, anxiety and confusion was noted. Thus, the mood data here are comparable to what has been observed following a hospital-based structured group intervention (Fawzy et al., Reference Fawzy, Cousins, Fawzy, Kemeny, Elashoff and Morton1990).
In the present study many (but not all) women reported feeling overly tired and lacking in energy. Following the completion of the program the reported level of fatigue was unchanged in our sample of breast cancer survivors. However, a significant increase in the Vigor/Activity POMS mood factor and significant decrease in the GHQ-28 Social dysfunction factor was noted in the very-severe cancer group of cancer survivors. Thus, the data confirm that the community-based psychosocial program was effective in reducing social dysfunction, so despite cancer survivors in the very severe group being fatigued, participating in the psychosocial program encouraged them to feel less isolated and unmotivated.
Fawzy and colleagues (Reference Fawzy, Cousins, Fawzy, Kemeny, Elashoff and Morton1990) noted that a structured hospital-based group intervention consisting of health education, stress management, coping skills training and psychotherapy can significantly reduce the level of mood disturbance. However, the level of reported anger remained unchanged. In contrast, when women were divided into cancer severity groups it became clear that the level of Anger/Hostility was significantly lower postintervention in the mild and moderate cancer severity groups. A factor that may be responsible for the variability in the anger data is that the psychosocial program described here, unlike some hospital-based programs, included a creative therapy component. Art therapy can lead to increased awareness of the self and can induce feelings of relaxation and comfort (Peutz et al., Reference Puetz, Morley and Herring2013).
There was a high degree of variability in the mood data and this was not unexpected given that the cancer survivors in this study were all at different stages in treatment for their illness. The type of treatments cancer survivors had received following diagnosis also varied, with some undergoing mastectomy while the breast had been spared in others. A decision was made to omit controls for cancer stage and treatment because it was felt that a community-based program, especially one being delivered in a rural community where population numbers are small, needed to be robust enough to be able to provide support and assistance to all cancer survivors.
The psychosocial program assisted some cancer survivors more than others. In particular, it seemed to be highly beneficial to newly diagnosed cancer survivors and women undergoing cancer treatment. However, the program seems to be particularly successful at reducing anxiety in cancer women at all stages of the breast cancer journey.
Conclusions
The cancer support literature claims that a variety of psychosocial interventions delivered in a hospital-based environment is effective in alleviating mood disturbance in cancer survivors. Moreover, the addition of creative therapies to existing hospital-based cancer support programs can significantly assist in improving the cancer patient's quality of life. However, the findings here suggest that a similar result can also be achieved in the community by non-medically trained facilitators.
Acknowledgements
Conflict of interest: The author has no conflicts of interest with respect to this publication.
Supplementary material
An extended version is also available online under the Brief Clinical Report Supplementary Materials tab in the table of contents. Please visit http://dx.doi.org/10.1017/S1352465816000187
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