Psychosocial Interventions for Patients With Head and Neck Cancer - Part 2
There are several distinct categories of interventions that have been employed for patients with cancer, namely, education, emotional support, and psychotherapy. Fawzy suggested that psychosocial interventions provide an overall positive effect on quality of life, although some interventions have failed to achieve the desired results.  For example, Pruitt et al undertook a prospective, randomized controlled trial to determine whether education would reduce psychological distress in newly diagnosed cancer patients.  Thirty-one patients who were assessed to be at high risk with high levels of distress were randomly assigned to three 1-hour information sessions about radiation therapy, cancer, coping strategies, and communication skills, or to a standard no intervention control group. Measures were taken at baseline and 1 and 3 months later. Depression decreased in the intervention group but there were no changes in affective state or knowledge levels.
Conversely, Greer et al. reported on a prospective, randomized controlled trial comparing the quality of life of 156 patients with cancer (various cancer sites except cerebral tumor and nonmelanoma skin tumors) receiving psychotherapy based on the premise of CBT to patients receiving no therapy.  This brief cognitive behavioral treatment program specially designed for individual patients with cancer demonstrated that patients receiving therapy had significantly lower scores on helplessness, anxious preoccupation, depression, and fatalism and significantly higher scores on fighting spirit at the end of 8 weeks of therapy. At 4 months, this improvement continued. Moorey et al. reported on the long-term effect of this intervention program on the same cohort.  At 1-year follow-up, 19% of patients receiving therapy were still clinically anxious compared to 44% of patients in the control group. A similar trend was noted concerning depression, 11% of patients receiving therapy were depressed as compared to 18% of patients in the control group. More recently, Davidson has suggested that CBT is emerging as the most therapeutic and cost-effective approach for adult patients with cancer with psychological morbidity. 
Fawzy alluded to the quest for interventions to help individual patients with cancer to cope with this life crisis. [17,18] Also, clinicians and researchers have highlighted the need for psychosocial intervention for patients with head and neck cancer. [73,74] However, when the body of literature is examined for effective intervention programs for these patients, there is a significant dearth of research and clinical work.
More than 20 years ago, Fiegenbaum developed a practical social skills training program for patients with facial disfigurement following treatment for head and neck cancer.  Although this was with a small sample ( N = 17), under experimental or control group conditions, data relating to pretraining and posttraining measures, including 2 years after therapy, were collected. Patients in the experimental group had 10 training sessions of 2 hours duration, which covered disfigurement-related issues and also problems with speech and eating. In the experimental group, data showed significant reduction in social anxiety and improvements in self-confidence, and these improvements were maintained over the 2-year follow-up period. Despite the methodological shortcomings from the small sample size, possibly accounting for an unrepresentative biased sample and thus limiting the generalizability of the findings, these data have been pivotal in influencing other research studies for patients with disfigurements.
Robinson et al designed a similar social interaction skills workshop for a heterogeneous sample of participants with acquired and congenital disfigurements ( N = 64).  Measures of psychological well-being using standardized scales were taken prior to a workshop and at 6 weeks and 6 months follow-up. Mean scores of social avoidance and distress were significantly lower than preworkshop levels and reduced slightly further at 6 months follow-up For example, on the Social Avoidance and Distress Scale,  the preworkshop mean score was 15.4, the 6 weeks postworkshop mean score was 13.5 ( P < .05), and the 6 months postworkshop mean score was 13.2 ( P < .01). However, with the lack of a control group measure, it is difficult to ascertain whether the affective changes were resulting from the opportunity of meeting other people with disfigurement rather than the practice and application of social skills explored within the workshop.
Clarke designed a social rehabilitation program to promote coping in patients with head and neck cancer.  Eight head and neck nurse specialists, following training in managing psychosocial issues for patients with head and neck cancer, delivered this program. Within this cohort, clear gains were measured in reducing social embarrassment and, subsequently, facilitating social functioning. This consequently had a positive impact on quality of life as measured by standardized global and disease-specific tools with good psychometric properties. Despite the small sample size, comparison of mean pretest and posttest scores using the Wilcoxon test demonstrated a trend toward significance for reduced anxiety and depression as measured by the HADS. However, this study had obvious limitations, notably the small sample size ( N = 16) and the lack of a control group.
Similar methodological weakness, of a small sample size, were noted within 2 pilot studies designed to explore both the feasibility and efficiency of 2 psychosocial intervention approaches for patients with head and neck cancer at different stages of their disease trajectory.  The first study evaluated the effect of group psychological therapy, using a combination of cognitive and behavioral techniques, including relaxation, led by a psychologist for newly diagnosed patients. Quality of life, including psychiatric morbidity, was measured longitudinally for 1 year and compared with that of a control group. Thirteen patients started the group psychotherapy intervention, and 8 participants completed both the intervention and evaluation process. At 1-year follow-up, the intervention group had improved in most areas as compared to the control group ( N = 34). Significance testing was not performed because of the small sample size in this pilot study; however, the improvement noted on the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-head and neck cancer module 35 (EORTC QLQ-H&N35) of more than 10 points was evident in 10 of the 20 domains. In contrast, the control group findings revealed that only one domain improved more than l0 points. In addition, psychiatric morbidity as measured by the HADS was studied in both groups. At 1-year follow-up, the therapy group had improved markedly compared to the control group, with fewer patients considered as probable or possible cases of psychiatric morbidity.
The second pilot study investigated the effect of a 1-week psychoeducational program, for patients 1 year after diagnosis at a rehabilitation center for patients with cancer. Participants' quality-of-life scores were measured longitudinally from the time of diagnosis until 4 weeks after the intervention. According to the HADS scale, results demonstrated that the number of probable or possible cases for anxiety and depression was almost constant throughout the study, whereas the EORTC QLQ C30  and H&N35 depicted a pattern of improvement in the majority of functions and symptoms after the intensive short-term psychoeducational program, with the most evident changes in the eating domain. When considering the timeliness of an intervention, it is important to note that participants would have preferred the intervention at an earlier stage of their disease. However, these 2 pilot studies suggest that patients with head and neck cancer can benefit from psychosocial intervention.
The only larger, longitudinal, case-control study published that evaluated the effect of a psychosocial support program on HRQoL in patients with head and neck cancer was undertaken by Petruson et al.  One hundred forty-two newly diagnosed patients with head and neck cancer in Sweden were included in this study. Fifty-two participants in the study group were given additional emotional support and information on head and neck cancer, its treatment, and side effects repeatedly throughout the first year after diagnosis. Results highlighted that both the study and control groups did not differ at diagnosis and during treatment regarding HRQoL scores as measured by the EORTC QLQ H&N35 and HADS. At 1-year follow-up, the control group had a clinically and statistically better global quality-of-life score. However, at 3-year follow-up, participants of both groups had high levels of depression and treatment-related side effects were also prevalent in both groups.
It must be noted that the aim of the support team (consisting of a ward nurse from a head and neck unit and a dietitian) was to provide information and give emotional support. It has been suggested that the lower quality-of-life scores could possibly be explained by regular follow-up, causing some patients to develop a dependency.  Moreover, the team did not have any training in diagnosing or treating depression or other related psychological problems. Therefore, a time-limited intervention, using cognitive and behavioral techniques, delivered by professionals trained in detecting affective disorders may prove more beneficial in reducing psychosocial dysfunction and enhancing quality of life for patients with head and neck cancer. Nevertheless, the findings obtained provide a basis for further research and intervention development.
The design of a psychosocial intervention program to effectively meet the magnitude of needs for patients with head and neck cancer is clearly warranted and a major challenge. Today, many global and disease-specific research instruments have already been developed and validated for use with patients diagnosed with head and neck cancer, and these provide a timely opportunity for further research. Using these standardized tools, researchers can find out more about the difficulties experienced by patients with head and neck cancer and how they relate to their quality of life. With such knowledge, an appropriate intervention program can be developed and evaluated. The intervention program could be best evaluated using a randomized controlled trial. To this end, the first author (C.J.S.), under the supervision of the coauthors, has commenced work in this area.
This article was originally presented in Cancer Nurs. 2004;27(6):p434-441.
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