278 Psychosocial Oncology cancer prognosis as opposed to a poor prognosis (Dunkel- Schetter, 1984). Despite the strong importance of social sup- port in the lives of breast cancer patients, approximately 33% of them do not feel they have adequate social support (Peters- Golden, 1982). In studies with breast cancer patients, social support has been found to be related to psychological, social, and physical bene“ts (Moyer & Salovey, 1996; Royak- Schaler, 1991; Stanton & Snider, 1993). Speci“cally, com- munication and shared decision making with the person•s spouse enhance adjustment to mastectomy, including the sex- ual relationship (Royak-Schaler, 1991; Wortman & Dunkel- Schetter, 1979). The physical bene“ts of social support have been noted in the research literature as well. These bene“ts have even been identi“ed at the cellular level in a sample of breast cancer patients. For example, patients• perceptions of the quality of emotional support provided by signi“cant others were the most important predictors of natural killer cell activity, an immunological defense against neoplastic cells (Moyer & Salovey, 1996). Studies with adult cancer patients suggest that those who are unmarried have a decreased overall sur- vival because they seek help later and at a more advanced dis- ease stage. In addition, they have a higher likelihood of being untreated for cancer. After adjustment for both factors, there remains a poorer treatment response by unmarried individu- als (Anderson, 1994). Therefore, it appears that social support can act as a moderator in the relationship between stress and health outcomes in cancer patients (Helgelson et al., 1998). Summary Although cancer can be a potentially devastating experience, research has identi“ed various coping variables to be signi- “cantly associated with positive psychological adaptation. Such factors include a “ghting spirit or optimism and effec- tive problem-solving ability. Conversely, avoidance and denial have been found to be correlated with poor psycho- logical outcome, although the “ndings regarding denial are somewhat equivocal. In addition, research has focused on the manner in which a person seeks cancer-related information and its relationship to distress. Of great signi“cance are the “ndings that link various coping reactions to improved health and disease outcome. Social support has also been a major focus of research with speci“c regard to its role as a buffer of the negative ef- fects of the cancer experience, both in terms of psychologi- cal adaptation, as well as actual health outcome. The latter has included studies focusing on overall treatment response, as well as on the cellular level regarding immunological variables. Thus far, this overview of the “eld of psychosocial oncol- ogy has focused on the etiological role that various lifestyle activities play regarding cancer development, as well as the psychosocial impact of cancer and its treatment. The follow- ing section focuses on the next logical step: psychosocial interventions that address this negative impact. PSYCHOSOCIAL INTERVENTIONS FOR CANCER PATIENTS Given the previous description of the literature documenting the negative psychosocial consequences of cancer, the impor- tance of developing effective interventions to improve the quality of life of cancer patients appears obvious. In fact, Redd (1995) suggests that an important factor responsible in part for the birth of psychosocial oncology as a “eld was the publishing of certain studies that underscored the successful use of behavioral procedures to control the anticipatory side effects of cancer chemotherapy, such as nausea and vomiting (e.g., Morrow & Morrell, 1982). Moreover, during the past two decades, a suf“ciently large number of intervention stud- ies have been conducted engendering a number of qualitative and quantitative review articles (e.g., Andersen, 1992; Dreher, 1997; Fawzy, Fawzy, Arndt, & Pasnau, 1995; Meyer & Mark, 1995; Trijsburg, van Knippenberg, & Rijpma, 1992). The general conclusion that the majority of these reviews reached underscores the ef“cacy of a wide variety of psychosocial in- terventions geared to improve the quality of life of adult can- cer patients. For example, Meyer and Mark (1995) conducted a meta-analysis of 62 treatment-control comparisons and found the bene“cial and signi“cant effect size d s were .24 for emotional adjustment measures, .19 for functional adjustment measures, .26 for measures of treatment- and disease-related symptoms, and .28 for compound and global measures. However, similar to a qualitative literature review regarding earlier published studies (Watson, 1983), signi“cant differ- ences among varying types of treatment approaches (e.g., behavioral versus supportive group therapy) were not found. Because a comprehensive review of the treatment out- come literature for cancer patients is beyond the scope of this chapter, the reader is directed to the listed review articles. However, in this section, we present a brief overview of this literature to illustrate the type and variety of interventions investigated. Educational Interventions The goal of educational interventions is to reduce cancer patients• distress and improve their sense of control that may Psychosocial Interventions for Cancer Patients 279 be undermined by lack of knowledge and feelings of un- certainty. For example, Messerli, Garamendi, and Romano (1980) argued that a patient•s fear, anxiety, and distress would decrease as a function of increased medical knowl- edge and information accessibility. With these types of inter- ventions, patient education has involved a variety of venues, including written materials, “lms, audiotapes, videotapes, and lectures. The protocols studied included topics cover- ing technical aspects of the disease and its treatment, poten- tial side effects, navigating the medical system, and the physician-patient relationship. An early study investigating the bene“ts of an educational approach was conducted by Jacobs, Ross, Walker, and Stockdale (1983). Patients with Hodgkin•s disease participat- ing in the education sample were mailed a 27-page booklet that included disease-related information. Three months later, compared to a no-education control, these individuals were found to show a decrease in depressive and anxiety symptoms, as well as an increase in their knowledge about Hodgkin•s disease. Focusing on a population of Egyptian patients diagnosed with bladder cancer, Ali and Khalil (1989) also found a re- duction in anxiety symptoms as a function of a psychoeduca- tional intervention. More speci“cally, compared to a control group, patients receiving the education protocol were found to be signi“cantly less anxious three days after surgery and prior to discharge. Pruitt et al. (1992) focused on a group of newly diag- nosed cancer patients undergoing radiation treatment in order to assess the effects of a three-session (1 hour each) education intervention. Their protocol involved information about radiation therapy and cancer, coping strategies, and communication skills. Patients receiving this intervention, as compared to a control condition, were found three months subsequent to show lower levels of depression, although no differences between groups were found regarding level of knowledge. More recently, Hack et al. (1999) conducted a multicenter study whereby patients were provided the choice to receive an audiotape of the initial consultation session with their oncologist. Such an approach was hypothesized to impact positively on the physician-patient relationship, as well as to provide the cancer patient with the opportunity to review the information discussed during the consultation. Although a trend was observed regarding a decrease in anxiety for pa- tients who chose to receive the audiotape, this change was not statistically signi“cant. However, at a six-week follow-up as- sessment, patients receiving the tape recalled signi“cantly more information and were found to report a higher degree of satisfaction with the physician-patient relationship. Cognitive-Behavioral Interventions A. Nezu, Nezu, Friedman, and Haynes (1997) de“ned cognitive-behavior therapy (CBT) as an empirical approach to clinical case formulation, intervention, and evaluation that focuses on the manner in which behavior, thoughts, emotions, and biological events interact with each other regarding the process of symptom, disorder, and disease de- velopment and maintenance. As such, CBT, as applied to psychosocial oncology, incorporates a wide array of inter- vention strategies that focus on identifying and changing those behavioral, cognitive, and affective variables that me- diate the negative effects of cancer and its treatment. Many strategies under the CBT rubric are theoretically based on principles of respondent and operant conditioning, such as contingency management, biofeedback, relaxation training, and systematic desensitization, whereas other strategies are more cognitive in nature, based on information-processing models, and include techniques such as cognitive distraction, cognitive restructuring, guided imagery, and problem- solving therapy. Applications of CBT for cancer patients have addressed both speci“c negative symptoms (e.g., antic- ipatory nausea, pain), as well as overall distress and quality of life. CBT for Anticipatory Nausea Clinically, a negative side effect of emetogenic chemother- apy is anticipatory nausea and vomiting. From a respondent conditioning conceptualization, this occurs when previously neutral stimuli (e.g., colors and sounds associated with the treatment room) acquire nausea-eliciting properties due to repeated association with chemotherapy treatments and its negative aftereffects. Investigations conducted in the early 1980s by Burish and Lyles (1981; Lyles, Burish, Krozely, & Oldham, 1982) found progressive muscle relaxation com- bined with guided imagery to be effective in reducing antici- patory nausea and vomiting among samples of patients already experiencing such symptoms. Morrow and Morrell (1982) further found systematic desensitization to be another effective CBT approach for these symptoms. Further, in a subsequent study, Morrow and Morrell (1982) replicated their earlier “ndings and also observed no differences in the magnitude of the effects of systematic desensitization as a function of what type of professional delivered the interven- tion (i.e., psychologist, nurse, or physician). Research also has indicated that conducting CBT prior to receiving chemotherapy may prevent anticipatory nausea and vomit- ing, as well as fostering improved posttreatment emotional well-being (Burish, Carey, Krozely, & Greco, 1987). 280 Psychosocial Oncology CBT for Pain CBT strategies that have been suggested as being potentially effective clinically for the reduction of cancer-related pain in- clude relaxation, guided imagery and distraction, and cogni- tive coping and restructuring (Breitbart & Payne, 1998). However, actual investigations assessing their ef“cacy have been few and provide somewhat con”icting results. The “rst study to empirically evaluate CBT for cancer-related pain fo- cused on oral mucositis pain related to the chemotherapy treatment a group of patients received prior to a bone marrow transplantation (Syrjala, Cummings, & Donaldson, 1992). CBT (which in this study included relaxation training, cogni- tive restructuring, and cognitive coping training) was not ef- fective in reducing pain as compared to control participants, whereas patients receiving hypnosis did report signi“cantly less pain. However, in a subsequent study conducted by this same group of investigators, CBT was found to be effective in reducing cancer-related pain (Syrjala, Donaldson, Davis, Kippes, & Carr, 1995). More recently, Liossi and Hatira (1999) compared the effects of hypnosis and CBT as pain management interventions for pediatric cancer patients un- dergoing bone marrow aspirations. Their results indicated that both treatment conditions, as compared to a no-treatment control condition, were effective in reducing pain and pain- related anxiety. CBT for Emotional Distress CBT protocols have also been increasingly implemented as a means to decrease cancer patients• psychological distress (e.g., depression, anxiety) and to improve their overall emo- tional well-being and quality of life. This trend began with a landmark study conducted by Worden and Weisman (1984). Two interventions were evaluated, both focused on the devel- opment of problem-solving skills as a means to promote ef- fective coping and adaptation among newly diagnosed cancer patients. One condition involved discussing the problems a speci“c cancer patient was experiencing without teaching speci“c skills, whereas the second focused on fostering general problem-solving skills and also included relaxation training. Both conditions were found to engender decreases in psychological distress as compared to a nonrandomized control condition. Despite this methodological limitation, their study did have a major impact on the “eld of psychoso- cial oncology (Jacobsen & Hann, 1998). Behavioral stress management strategies (e.g., relaxation, guided imagery) have been found to be especially effective in reducing emotional distress and improving cancer patients• quality of life (e.g., Baider, Uziely, & De-Nour, 1994; Bridge, Benson, Pietroni, & Priest, 1988; Decker, Cline-Elsen, & Gallagher, 1992; Gruber et al., 1993). Multicomponent CBT protocols have also been found to be effective. For example, Telch and Telch (1986) evaluated the differential effects of a group-administered, multicomponent CBT coping skills training protocol, as compared to a supportive group therapy condition, and a no-treatment control. Their coping skills training included instruction in (a) relaxation and stress man- agement, (b) assertive communication, © cognitive restruc- turing and problem solving, (d) management of emotions, and (e) planning pleasant activities. Results indicated that patients receiving the CBT protocol consistently fared sig- ni“cantly better than participants in the other two conditions. In fact, patients in the supportive group therapy condition evidenced little improvement, whereas untreated patients demonstrated signi“cant deterioration in their overall psy- chological adjustment. Another multicomponent CBT-based investigation in- cluded patients who were newly diagnosed with malignant melanoma (Fawzy, Cousins, et al., 1990; Fawzy, Kemeny, et al., 1990). The cancer patients were assigned to one of two conditions: a structured group intervention and a no- treatment control. The six-week CBT-oriented intervention was comprised of four components: health education, stress management, problem-solving training, and group support. At the end of the six weeks, patients receiving the structured intervention began showing reductions in psychological distress as compared to the control patients. However, six months posttreatment, such group differences were very pronounced. More impressively, “ve years following the in- tervention, treated patients continued to show signi“cantly lower levels of anxiety, depression, and total mood distur- bance (Fawzy, Fawzy, & Canada, 2001). Their intervention was later adapted to be applied to a Japanese population and found to be effective for Japanese women with breast cancer (Hosaka, 1996). Greer et al. (1992) evaluated the effectiveness of an indi- vidually administered CBT intervention geared to improve emotional well-being. Their protocol included coping skills training, cognitive restructuring, and relaxation training. At a four-month follow-up assessment point, CBT participants were found to be experiencing less emotional distress than patients in the no-treatment control condition. Such bene“- cial treatment effects were further found to be evident at a one-year follow-up point (Moorey et al., 1994). Problem-Solving Therapy (PST) for Cancer Patients Although training individuals to be more effective problem solvers to improve their ability to cope with stressful life Psychosocial Interventions for Cancer Patients 281 events and dif“cult problems, such as cancer, has been in- cluded as part of various multicomponent CBT treatment packages (e.g., Fawzy, Cousins, et al., 1990; Telch & Telch, 1986), it has never been empirically evaluated as a sole inter- vention. As such, A. Nezu, Nezu, Felgoise, et al. (2001; see also A. Nezu et al., 1998), based on previous research that highlighted the ef“cacy of PST for major depression (e.g., A. Nezu, 1986; A. Nezu & Perri, 1989) conducted a study whereby adult cancer patients who were experiencing signif- icant distress (e.g., depression) were randomly assigned to one of three conditions: (a) ten 1.5 hr sessions of individual PST; (b) ten 1.5 hr sessions of PST provided simultaneously to both the patient and his or her designated signi“cant other (e.g., spouse, family member); and © waiting-list control. The condition that involved a signi“cant other was included to assess the enhanced effects of •formalizingŽ a social support system where the role of the signi“cant other was conceptualized as a •problem-solving coach.Ž Results at posttreatment across self-report, clinician-ratings, and ratings by the signi“cant other provided evidence in support of the ef“cacy of PST for decreasing emotional distress and im- proving the overall quality of life of patients with cancer. Speci“cally, patients in both treatment conditions were found to evidence signi“cant improvement as compared to indi- viduals in the wait-list control„no dif ferences were found between these two conditions. However, at a six-month follow-up assessment, on approximately half of the measures assessed, patients who received PST along with a signi“cant other continued to improve signi“cantly beyond those indi- viduals receiving PST by themselves. Group Therapy Approaches The potential strengths of group psychotherapy for cancer patients are threefold: (a) it can provide for a milieu in which people with similar experiences can provide emotional sup- port to each other, (b) it is cost-effective for the patient, and © it is time-ef“cient for the mental health professional (Spira, 1998). However, research evaluating these approaches provides limited evidence for their ef“cacy to reduce distress and improve psychological adjustment (Helgelson & Cohen, 1996). Further, the empirical literature suggests that group therapy protocols that focus primarily on providing peer sup- port and emphasize the shared expression of emotions are less effective than either educational protocols (e.g., Helgelson, Cohen, Schulz, & Yasko, 1999) or programs teaching coping skills (Edelman, Craig, & Kidman, 2000). One study that is often cited as underscoring the ef“cacy of a •supportive-expressiveŽ group therapy protocol was conducted by Spiegel, Bloom, and Yalom (1981). Their investigation included 86 women with metastatic breast cancer who were randomly assigned to one of two condi- tions: a weekly group therapy program or a no-treatment control. The group therapy program included supportive in- teraction among the participants, encouragement to express one•s emotions, and discussion of cancer-related problems. At 100 and 200 days after entry into the protocol, trends were observed regarding improvements in mood only for the treated patients. However, at a 300-day evaluation, treated patients reported signi“cantly less anxiety, depression, con- fusion, and fatigue, as well as fewer phobias and less mal- adaptive coping responses as compared to the control group. Despite these positive results, concerns about a high drop-out rate (i.e., at 300 days, only 16 women remained in the therapy condition and 14 women remained in the control condition) point to the tentative nature of these “ndings (e.g., Edelman et al., 2000; Fox, 1998). On the other hand, Spiegel et al. (1999) published another study that does supports the ef“- cacy of this approach, as well as highlighting the feasibility of implementing such a protocol in community settings across the United States. Telephone Counseling Despite the literature documenting the ef“cacy of psychoso- cial interventions for cancer patients, a major obstacle to the potential utilization of such protocols is accessibility. In re- sponse to such barriers, various programs using the telephone as a communication tool have been developed to provide health education, referral information, counseling, and group support (Bucher, Houts, Glajchen, & Blum, 1998). Few stud- ies, however, have been reported in the literature that have empirically evaluated the ef“cacy of such approaches, al- though at present, two different studies are underway, one assessing the effects of a multicomponent CBT intervention (Marcus et al., 1998), and the second evaluating interpersonal psychotherapy (which focuses on role transitions, interper- sonal con”icts, and grief precipitated by cancer) for breast cancer patients (Donnelly et al., 2000). In addition, a recently completed investigation evaluating the effects of a combined face-to-face (two sessions) and telephone (four sessions) problem-solving-based intervention provides support for its ef“cacy in reducing cancer-related dif“culties for young breast cancer patients (Allen et al., 2001). Effects of Psychosocial Interventions on Health Outcome This review strongly underscores the ef“cacy of a variety of psychosocial interventions for cancer patients with speci“c 282 Psychosocial Oncology regard to reducing speci“c psychological (e.g., depression, anxiety) and physical (e.g., anticipatory nausea and vomiting; pain) cancer-related symptoms, as well as improving their overall adjustment and emotional well-being. A logical next question is: Do psychosocial interventions have any impact on health outcome? For example, do they actually affect the course or prognosis of the disease? As noted earlier, various psychosocial variables have been found to be associated with survival, such as coping and social support. Moreover, as more research highlights the interplay between psychological and medical symptoms (e.g., A. Nezu, Nezu, & Lombardo, 2001), such a question appears both legitimate and impera- tive. For example, psychosocial treatments may affect the course of cancer by (a) improving patient self-care (e.g., reduce behavioral risk factors), (b) increasing patients• com- pliance with medical treatment, or © in”uencing disease re- sistance regarding certain biological pathways, such as the immune system (Classen, Sephton, Diamond, & Spiegel, 1998). To date, the literature providing answers to this question remains equivocal, that is, three studies provide data support- ing the notion that psychosocial interventions extend the life of cancer patients, whereas three investigations lacked an ef- fect on survival. With regard to the “rst group of studies, the investigation described by Spiegel et al. (1981) evaluating the effects of supportive-expressive group therapy was not originally designed to evaluate survival effects. However, 10 years after their study was completed, these authors col- lected survival data for all participants (Spiegel, Bloom, Kraemer, & Gottheil, 1989). To their admitted surprise, women receiving the group therapy program lived an aver- age of 36.6 months from time of initial randomization as compared to the control patients who lived an average of 18.9 months. This difference was found to be both statisti- cally and clinically signi“cant. Similar to the Spiegel et al. (1981) study, the investigation also previously described (Fawzy et al., 1993) with malig- nant melanoma patients, was also not originally designed to speci“cally assess differences in survival rates as a function of the differing experimental conditions. However, they did “nd six years later that the treatment group experienced longer survival as compared to control participants, as well as a trend for a longer period to recurrence for the treated patients (Fawzy et al., 1993). Richardson, Shelton, Krailo, and Levine (1990) reported on the effects of three treatment approaches geared to im- prove treatment compliance for patients newly diagnosed with hematologic malignancies: (a) education and a home visit by a nurse; (b) education and a shaping program designed to foster better adherence in taking medication; and © education, shaping, and a home visit. With regard to survival rates, these researchers found that assignment to any of these treatment conditions, as compared to a control group, signi“cantly predicted survival. The three studies that found no difference on survival as a function of participating in a psychosocial intervention in- clude (a) a study that provided intensive individual supportive counseling to men in a Veterans Administration hospital with tumors across several sites (Linn, Lin, & Harris, 1982); (b) an investigation that included 34 women with breast cancer who participated in a program that provided individual counseling, peer support, family therapy, and stress management training (Gellert, Maxwell, & Siegel, 1993); and © a study that fo- cused onthe effects of three different supportive group therapy conditions (Ilnyckyj, Farber, Cheang, & Weinerman, 1994). In summary, whereas three studies provide no evidence to support the enhanced survival rates for cancer patients re- ceiving psychosocial treatment, three studies, in fact, do offer such data. However, methodological issues across all these investigations further add to the tentativeness of any “rm conclusions (Classen et al., 1998). Effects of Psychosocial Interventions on Immune Functioning One possible mediator of the positive effects of psychosocial interventions on improved health, as well as emotional well- being, is the immune system. In part, support for this hypoth- esis emanates from research indicating alterations regarding certain measures of immune functioning in humans experi- encing stressful events (Herbert & Cohen, 1993), as well as studies demonstrating changes in immune functioning as a result of receiving psychosocial treatment. For example, the study described earlier by Fawzy, Kemeny and colleagues (1990) indicated that at the end of the six-week intervention, patients receiving the treatment evidenced signi“cant in- creases in the percentage of large granular lymphocytes. Six months posttreatment, this increase in granular lymphocytes continued and increases in natural killer cells were also evi- dent. Relaxation training has also been found to lead to higher lymphocyte counts and higher white blood cell numbers even in cancer patients receiving myelosuppressive therapy (Lekander, Furst, Rotstein, Hursti, & Fredrikson, 1997). Although research investigating the link between immunologic parameters and psychosocial variables in cancer patients is in its nascent stage and, therefore, can only be viewed as suggestive at this time (see Bovbjerg & Valdimarsdottir, 1998), such a framework provides an Family and Caregiver Issues 283 exciting area for future research and a possible means of ex- plaining one pathway between behavioral factors and cancer- related health outcome. Prevention Issues All of the interventions discussed so far are geared to impact on health and mental health parameters after a person is di- agnosed with cancer. However, treatment strategies can also affect behavioral risk factors, thus attempting to prevent cancer to some extent. Some of the behavioral risk factors mentioned earlier include smoking, alcohol, diet, and sun exposure. Reviews of the relevant treatment literature bases concerning some of these behaviors is contained in other chapters of this volume, and therefore will not be repeated here. With regard to sun exposure, some interventions have led to increased knowledge of skin cancer and awareness of protective measures; however, programs have had only lim- ited success with increasing preventive behaviors in at-risk groups (Cohen & Baum, 2001). Prevention strategies are also important for individuals considered at high risk due to genetic and familial factors. For example, a positive family history of breast cancer is an important risk factor for breast cancer in women (Slattery & Kerber, 1993). As such, “rst-degree relatives of women with breast cancer may also be at risk for psychological distress. With this in mind, Kash, Holland, Osborne, and Miller (1995) evaluated the ef“cacy of a group psychoeducational intervention for women at high risk for breast cancer. Their protocol included breast cancer education and risk communi- cation, coping skills training, and group social support. As compared to no-treatment control participants, patients undergoing the group therapy program exhibited signi“cant improvements in knowledge and risk comprehension and a signi“cant decrease in perceived barriers to mammography. More importantly, group therapy participants increased hav- ing mammograms, clinical breast examinations, and breast self-examinations during the year following treatment as compared to the control subjects. Schwartz et al. (1998) evaluated a brief PST intervention as a means to reduce distress among women with a “rst- degree relative recently diagnosed with breast cancer. Results indicated that whereas patients in both the PST and an educa- tional control group exhibited signi“cant decreases in psychological distress, such differences did not differ as a function of treatment condition. However, for participants in the PST condition who were found to regularly practice the PST techniques, differences in decreased cancer-speci“c distress were signi“cantly greater as compared to control participants and those PST subjects only infrequently using the problem-solving skills. Summary Overall, research has amply demonstrated that a variety of psychosocial interventions are effective in reducing speci“c cancer-related physical (e.g., pain, nausea, and vomiting) and emotional (e.g., depression, anxiety) symptoms, as well as enhancing the overall quality of life of cancer patients. Such treatment programs include educational interventions, a wide array of cognitive-behavioral interventions, and group psy- chotherapy protocols. Using the telephone to increase acces- sibility to such programs has also begun to show promise. Among these various approaches, CBT interventions have been more often the focus of empirical investigations, and thus, have tended to emerge as the more effective and versa- tile overall therapeutic model. In addition to improving cancer patients• emotional well- being, data suggests that psychosocial interventions can also lead to improved survival by affecting the course of the can- cer itself. One biological pathway that has been identi“ed as a potential mechanism by which this can occur is the immune system. However, additional studies have noted a lack of an affect on survival rates as a function of participating in psy- chosocial treatment. Moreover, the literature providing evi- dence to support a link between behavioral variables and health outcome as mediated by the immune system is only in its infancy with regard to cancer. Therefore, substantial addi- tional research is necessary before the nature of these rela- tionships can be clearly elucidated. Psychosocial interventions have also been developed for at-risk groups (e.g., “rst-degree relative of women with breast cancer) or people engaging in risky cancer- engendering behaviors (e.g., excessive sun exposure) as a means of reducing risk and preventing cancer. FAMILY AND CAREGIVER ISSUES In addition to the effects on patients themselves, the experi- ence of cancer and its treatment can change the lives of family members, and in particular, the primary caregiver (e.g., spouse). With shifts in health care economics, espe- cially during the end of the twentieth century, more care and recovery of cancer patients takes place at home, therefore, having a potentially greater impact on the roles and responsi- bilities of family members (Houts, Nezu, Nezu, & Bucher, 1996; Laizner, Yost, Barg, & McCorkle, 1993). This shift in 284 Psychosocial Oncology caretaking has also increased professionals• attention to the vital roles, participation, and impact the experience of cancer has on families and caregivers as they become the extension of the health care team (Friedman, 1999). Impact of Cancer on Caregivers The potential demands and subsequent burden on caregivers is signi“cant. For example, in a study by Barg et al. (1998), 61% of a sample of 750 caregivers reported that caregiving was the center of their activities. In addition, 58% of this sample indicated that to provide care, caregivers were re- quired to give up many other activities. For the majority of caregivers (62%), their responsibilities to the patient warranted 24-hour-per-day availability, whereas 42% of the sample provided 6 to 40 hours of care per week. Because caregivers are laypersons who usually have not had professional training in preparation for caring for an in- dividual with cancer, such demands and responsibilities can lead to signi“cant distress. For example, in the Barg et al. (1998) sample, 89% of the caregivers reported feeling •stressedŽ by their responsibilities. In addition, the caregivers who experienced more stress also reported signi“cantly low- ered self-esteem, less family support, more negative impact on their schedules, more negative impact on their physical health, and more caregiving demands than nonstressed caregivers. Psychological Distress In a study conducted by Kelly et al. (1999), 67% percent of a sample of caregivers of spouses with various cancer diag- noses reported •high to very highŽ illness-related distress levels. In general, studies of spouses of cancer patients, many in the terminal stage of care, have reported eating disorders, sleep disturbances, anxiety, and depression due to the stresses of caregiving (Kristjanson & Aschercraft, 1994). Impact on Health The stress of caregiving has also been shown to have negative biological (immunologic, cardiovascular, metabolic) conse- quences for family caregivers (Vitaliano, 1997). For example, 62% of a sample of 465 caregivers reported declines in health resulting from their caregiving experiences (Barg et al., 1998). Whereas some research (e.g., Hinds, 1985; Oberst, Thomas, Gass, & Ward, 1989) has identi“ed signi“cant rela- tionships between patients• and caregivers• physical health, as well as patients• physical health and caregivers• emotional reactions, other studies have found that the physical health of the cancer patients across varying cancer diagnoses and stages did not directly impact the health of the caregiver. In fact, the patients• emotional well-being has been found to be a better predictor of caregiver distress. For example, in a study of 196 patient-caregiver dyads, patient depression, and not the patient•s medical status, mediated the relationship between patient dependencies, symptom distress, and patient immobil- ity on caregivers•physical health (Given et al., 1993). Unmet Caregivers’ Needs In addition to the impact on their psychological and physical health, caregivers have also reported that many of their needs as caregivers continue to go unmet (Houts et al., 1986). For example, Hinds (1985) interviewed 83 family caregivers and found that 53% of this sample identi“ed several areas of un- resolved psychosocial needs. In a different sample, 16% of 45 caregivers reported serious unmet needs, where 49% con- sidered unmet informational needs to be a signi“cant prob- lem (Wright & Dyck, 1984). Interestingly, Sales, Schulz, and Biegel (1992) found that younger caregivers reported more psychological and personal needs than older caregivers. Psychosocial Interventions for Caregivers As a function of the increased vulnerability to negative psy- chological and physical effects of the cancer-related caregiv- ing role, various intervention strategies have been developed to help these individuals. Such strategies include both psy- choeducational and problem-solving approaches. Psychoeducational Interventions Derdiarian (1989) evaluated a psychoeducational interven- tion that provided medical, counseling, and referral infor- mation to caregivers. This was followed by two telephone calls to check the adequacy of the information. This protocol was compared to •standard care.Ž The aim was to measure the caregivers•satisfaction with the information received and their perceived coping with the consequences of the diagno- sis (i.e., behaviors indicating problem solving and emotional regulation). The results of this investigation showed sig- ni“cant decreases in perceived need for information and increases in satisfaction and coping as a function of partici- pating in the experimental intervention. Problem-Solving Approaches Several problem-solving interventions have been developed for caregivers of persons with cancer. For example, using a Summary and Future Directions 285 randomized design, Toseland, Blanchard, and McCallion (1995) evaluated a protocol including six individual counsel- ing sessions that included both support and training in problem-solving and coping skills. Caregivers in a control group received standard medical care. Initial overall results comparing the intervention to usual treatment showed no dif- ference on a wide range of measures. However, posthoc analyses evaluating the interaction of distressed and moder- ately burdened caregivers by condition showed favorable outcomes for patients in the treatment condition. Speci“cally, distressed caregivers who participated in the intervention reported signi“cant improvement in their physical role and social functioning. In addition, burdened caregivers signi“- cantly improved their ability to cope with pressing problems. Houts et al. (1996) and Bucher, Houts, Nezu, and Nezu (1999) described a problem-solving approach to family care- giver education entitled the Prepared Family Caregiver Course that was adapted from the D•Zurilla and Nezu (1999; A. Nezu et al., 1998) problem-solving therapy model. The course was taught over three two-hour group sessions and in- cluded prepared instructional videotapes to guide interactive practice exercises along with an instructor•s manual (Bucher et al., 1999). The Home Care Guide for Cancer (Houts, Nezu, Nezu, Bucher, & Lipton, 1994), an informational resource consistent with this model, was also a key element to this training. The premise for the problem-solving approach was based on the idea that successfully solving problems increases a person•s sense of mastery or control, which, in turn, con- tributes to positive mental health. Further, information, and a framework in which to gather additional information and solve problems, can allay the uncertainty caregivers often feel (i.e., Have I done everything that I can do?) (Houts et al., 1996). Caregivers are provided with information about a se- ries of medical (e.g., fatigue, hair loss) and psychosocial (e.g., depression, loneliness) problems, and are trained to (a) better de“ne the problem; (b) know when to obtain pro- fessional help; © learn to deal with, as well as prevent, a problem; (d) identify obstacles when they arise and plan to overcome them; and (e) effectively implement a problem- solving plan and adjust it if the initial attempts are not suc- cessful. Results from a program evaluation study including a sample of 41 caregivers indicated that 78% of these partici- pants reported an improvement in their feelings of burden and stress (Houts et al., 1996). In addition, 48% and 58%, respectively, reported using their plans for tiredness and de- pression in their caregiving. Further program evaluation in- vestigations of the Prepared Family Caregiver Course reveal a generally high level of satisfaction with and interest in using the information and problem-solving skills taught to family caregivers, hospice volunteers, home health aides, nurses, and people with cancer (Bucher et al., 1999). Well- controlled studies are necessary prior to making de“nitive conclusions about the potential ef“cacy of such an approach. However, preliminary results provide promising support. Summary Cancer and its treatment can have a profound impact on fam- ily members. Due to recent changes in health care delivery and economics, there has been a signi“cant shift in caregiving responsibility from the professional health care team to family caregivers, such as the patient•s spouse. This shift increases the potential demands and responsibilities for such individu- als. As such, caregivers experience an increased vulnerability to both psychological and medical dif“culties. In response to these problems, researchers have begun to develop and evalu- ate psychosocial interventions geared to improve the caregiv- ing skills of such individuals, as well as decrease their burden and improve their quality of life. Because such research is in its nascent stage, increased attempts to develop ef“cacious programs are particularly needed. SUMMARY AND FUTURE DIRECTIONS Cancer is the second leading cause of death in the United States, surpassed only by heart disease. Despite its preva- lence as a medical disease, only about 5% to 10% of all can- cers are clearly hereditary. A variety of lifestyle activities have been identi“ed as potential risks for cancer, such as smoking, alcohol abuse, diet, and excessive exposure to the sun. Because such factors are behavioral in nature, the rele- vance of psychology for the “eld of psychosocial oncology is clear. Not only is this emerging sub“eld of oncology con- cerned with the role of cancer-related behavioral risk factors, but also the identi“cation of ef“cacious means to reduce such risk factors, as well as to better understand and impact posi- tively on the negative psychosocial consequences of cancer, such as emotional distress and decreased quality of life. The past few decades have seen an increase in interest by psy- chologists in this “eld and the development of effective strategies of meeting these goals. Based on our review of the literature, we offer several rec- ommendations for future research that are focused mainly on intervention studies: 1. More research should be conducted regarding efficacious interventions to improve the quality of life of cancer pa- tients and their families. Although a substantial body of 286 Psychosocial Oncology research already exists, we need to know more about what types of treatment approaches are effective for what types of patients as a function of type of cancer, stage of cancer, SES, ethnic background, level of stress experienced, and other important patient-relevant psychosocial variables. Because of the signi“cant personal, medical, and eco- nomic impact cancer and its treatment represents, more research evaluating the ef“cacy of a wide range of psy- chosocial strategies should be conducted in the future. 2. More research should be conducted regarding the effects of psychosocial interventions on health outcome (i.e., pro- longed survival). Currently, the literature is equivocal in its ability to indicate whether psychosocial treatments can have an impact on health outcome, particularly with regard to prolonging the life of a cancer patient. As men- tioned earlier, many of the studies that either provide sup- port for or against such a hypothesis were not designed to speci“cally address this question. Well-controlled investi- gations capable of addressing such a question requires extensive resources. However, preliminary results suggest that such efforts may be worthwhile. 3. Improve the methodological rigor of the research. Because a thorough critical analysis of the reviewed liter- ature was beyond the scope of this chapter, we did not document the many methodological limitations identi“ed across the studies. We will not belabor the point, except to list speci“c recommendations: (a) include adequate control groups; (b) use manualized protocols; © include treatment integrity (i.e., therapist adherence and compe- tence) measures; and (d) use more multimodal assessment procedures (e.g., multitrait, multimethod approaches) for outcome measurement. In addition, special care needs to be taken in describing each population under study in detail to better allow for meaningful comparisons across studies. 4. Conduct component analyzes of the intervention studies. The majority of the randomized outcome studies reviewed simply compared an intervention to either an alternative treatment approach (e.g., education) or a control condition (e.g., waiting-list). Additional research strategies should be implemented to help answer the question: •Which treatment components are responsible for the actual im- provement in symptoms?Ž Future research needs to be more explicit in delineating speci“c treatment strategies and provide for an assessment of the speci“c impact of a particular intervention on a given hypothesized mecha- nism of action and its resulting impact on changes of interest. In that manner, a more comprehensive and micro- analytic understanding of cause-effect relationships can be obtained. Such research strategies include dismantling, constructive, and parametric approaches. In addition, matching studies (i.e., matching treatment strategies with identi“ed patient vulnerabilities, for example, problem- solving therapy for the depressed cancer patient with iden- ti“ed problem-solving de“cits) also fall in this category . 5. Identify important moderators of treatment efficacy. Identi“cation of important moderator variables (e.g., race, age, gender, cultural background, severity of symptoms, number of symptoms) can potentially lead to better match- ing of a given treatment for a particular patient, as well as the development of more effective interventions per se. 6. Identify important mechanisms of action. Future research should also address the relationship between outcome (e.g., psychological well-being, improved health) and a variety of variables (e.g., cognitive, emotional, behavioral, im- mune system) hypothesized to contribute to the etiopatho- genesis and course of that outcome. In this manner, salient treatment targets can be identi“ed and more empirically- based decisions about treatment design can be made. 7. Improve treatment implementation and access. Related to the issue of health economics, future research should also attempt to save costs directly related to implementing psy- chosocial interventions. Having a doctoral-level psychol- ogist, for example, providing individual or group therapy to cancer patients and their families is likely to be viewed as having too high a price to the health care delivery sys- tem. As such, studies geared to assess alternative means of conducting psychosocial interventions should be con- ducted in the future. For example, additional methods exist to conduct such treatment approaches besides the tra- ditional use of a single therapist in face-to-face situations. Use of videos, computers, the Internet, or telemedicine support systems represent further possibilities regarding ways to cut costs, as well as to increase accessibility to patients not living close to a major medical center. REFERENCES Ali, N., & Khalil, H. (1989). Effects of psychoeducational interven- tion on anxiety among Egyptian bladder cancer patients. Cancer Nursing, 12, 236…242. Allen, S. M., Shah, A. C., Nezu, A. M., Nezu, C. M., Mor, V., Ciambrone, D., et al. (2001). A problem-solving approach to stress reduction among younger women with breast cancer: A randomized controlled trial. Providence, RI: Brown University. Alter, C. L., Pelcovitz, D., & Axelrod, A. (1996). Identi“cation of PTSD in cancer survivors. Psychosomatics, 37, 137…143. References 287 American Cancer Society. (2000). Cancer facts and figures. American Cancer Society. Andersen, B. L. (1992). Psychological interventions for cancer patients to enhance the quality of life. Journal of Consulting and Clinical Psychology, 60, 552…568. Anderson, B. L. (1994). Surviving cancer. Cancer Supplement, 74, 1484…1494. Anderson, B. L., Woods, X. A., & Copeland, L. J. (1997). Sexual self-schema and sexual morbidity among gynecologic cancer survivors. Journal of Consulting and Clinical Psychology, 65, 221…229. Andrykowski, M. A., Redd, W. H., & Hat“eld, A. K. (1985). Devel- opment of anticipatory nausea: A prospective analysis. Journal of Consulting and Clinical Psychology, 53, 447…454. Baider, L., Uziely, B., & De-Nour, A. K. (1994). Progressive muscle relaxation and guided imagery in cancer patients. General Hospital Psychiatry, 16, 340…347. Balfour, J. L., & Kaplan, G. A. (1998). Social class/socioeconomic factors. In J. C. Holland (Ed.), Psycho-oncology (pp. 78…90). New York: Oxford University Press. Barg, F. K., Pasacreta, J. V., Nuamah, I. F., Robinson, K. D., Angeletti, K., Yasko, J. M., et al. (1998). A description of a psychoeducational intervention for family caregivers of cancer patients. Journal of Family Nursing, 4, 394…414. Barraclough, J. (1994). Cancer and emotion. New York: Wiley. Baum, A., & Andersen, B. L. (Eds.). (2001). Psychosocial interven- tions for cancer. Washington, DC: American Psychological Association. Beck, A. T., Kovacs, M., & Weissman, A. (1975). Hopelessness and suicidal behavior: An overview. Journal of the American Med- ical Association, 234, 1146…1149. Billings, A. G., & Moos, R. H. (1981). The role of coping responses and social resources in attenuating the stress of life events. Journal of Behavioral Medicine, 4, 139…157. Bloom, J. R. (1982). Social support, accommodation to stress and adjustment to breast cancer. Social Science and Medicine, 16, 1329…1338. Bovbjerg, D. H., & Valdimarsdottir, H. B. (1998). Psychoneuroim- munology: Implications for psycho-oncology. In J. C. Holland (Ed.), Psycho-oncology (pp. 125…134). New York: Oxford University Press. Brandenberg, Y., Bolund, C., & Sigurdardottir, V. (1992). Anxiety and depressive symptoms at different stages of malignant melanoma. Psycho-oncology, 1, 71…78. Breitbart, W. (1987). Suicide in cancer patients. Oncology, 1, 49…53. Breitbart, W., & Cohen, K. R. (1998). Delirium. In J. C. Holland (Ed.), Psycho-oncology (pp. 564…576). New York: Oxford University Press. Breitbart, W., & Krivo, S. (1998). Suicide. In J. C. Holland (Ed.), Psycho-oncology (pp. 541…547). New York: Oxford University Press. Breitbart, W., & Payne, D. K. (1998). Pain. In J. C. Holland (Ed.), Psycho-oncology (pp. 450…467). New York: Oxford University Press. Bridge, L. R., Benson, P., Pietroni, P. C., & Priest, R. G. (1988). Relaxation and imagery in the treatment of breast cancer. British Medical Journal, 297, 1169…1172. Bucher, J. A., Houts, P. S., Glajchen, M., & Blum, D. (1998). Telephone counseling. In J. C. Holland (Ed.), Psycho-oncology (pp. 758…766). New York: Oxford University Press. Bucher, J. A., Houts, P. S., Nezu, C. M., & Nezu, A. M. (1999). Improving problem-solving skills of family caregivers through group education. Journal of Psychosocial Oncology, 16, 73…84. Bukberg, J. B., Penman, D. T., & Holland, J. C. (1984). Depression in hospitalized cancer patients. Psychosomatic Medicine, 46, 199…212. Burgess, C., Morris, T., & Pettingale, K. W. (1988). Psychological response to cancer diagnosis. II: Evidence for coping styles (coping styles and cancer diagnosis). Journal of Psychosomatic Research, 32, 263…272. Burish, T. G., & Carey, M. P. (1986). Conditioned aversive responses in cancer chemotherapy patients: Theoretical and developmental analysis. Journal of Consulting and Clinical Psychology, 54, 593…600. Burish, T. G., Carey, M. P., Krozely, M. K., & Greco, F. A. (1987). Conditioned side effects induced by cancer chemotherapy: Pre- vention through behavioral treatment. Journal of Consulting and Clinical Psychology, 55, 42…48. Burish, T. G., & Lyles, J. N. (1981). Effectiveness of relaxation training in reducing adverse reactions to cancer chemotherapy. Journal of Behavioral Medicine, 4, 65…78. Byrd, B. L. (1983). Late effects of treatment of cancer in children. Pediatric Annals, 12, 450…460. Carey, M. P., & Burish, T. G. (1988). Psychological side effects in chemotherapy patients. Psychological Bulletin, 104, 307…325. Carver, C. S., Pozo, C., Harris, S. D., Noriega, V., Scheier, M. F., Robinson, D. S., et al. (1993). How coping mediates the effect of optimism on distress: A study of women with early stage breast cancer. Journal of Personality and Social Psychology, 65, 375…390. Cella, D. F. (1987). Cancer survival: Psychosocial and public issues. Cancer Investigation, 5, 59…67. Cella, D. F., & Tross, S. (1986). Psychological adjustment to sur- vival from Hodgkin•s disease. Journal of Consulting and Clini- cal Psychology, 54, 616…622. Chochinov, H. M., Wilson, K. G., Enns, M., & Lander, S. (1998). Depression, hopelessness, and suicidal ideation in the terminally ill. Psychosomatics, 39, 366…370. Cinciripini, P. M., Gritz, E. R., Tsoh, J. Y., & Skaar, K. L. (1998). Smoking cessation and cancer prevention. In J. C. Holland (Ed.), Psycho-oncology (pp. 27…44). New York: Oxford University Press. 288 Psychosocial Oncology Classen, C., Sephton, S. E., Diamond, S., & Spiegel, D. (1998). Studies of life-extending psychosocial interventions. In J. C. Holland (Ed.), Psycho-oncology (pp. 730…742). New York: Oxford University Press. Cohen, L., & Baum, A. (2001). Targets for interventions to reduce cancer morbidity. In A. Baum & B. L. Anderson (Eds.), Psy- chosocial interventions for cancer (pp. 321…342). Washington, DC: American Psychological Association. Cramond, W. A. (1970). Psychotherapy of the dying patient. British Medical Journal, 3, 389…393. Decker, T., Cline-Elsen, J., & Gallagher, M. (1992). Relaxation ther- apy as an adjunct in radiation oncology. Journal of Clinical Psy- chology, 48, 388…393. DeFlorio, M., & Massie, M. J. (1995). Review of depression in cancer: Gender differences. Depression, 3, 66…80. Derdiarian, A. K. (1989). Effects of information on recently diag- nosed cancer patients• and spouses• satisfaction with care. Can- cer Nursing, 12, 285…292. Derogatis, L. R., Morrow, G. R., & Fetting, J. (1983). The preva- lence of psychiatric disorders among cancer patients. Journal of the American Medical Association, 249, 751…757. Donnelly, J. M., Kornblith, A. B., Fleishman, S., Zuckerman, E., Raptis, G., Hudis, C. A., et al. (2000). A pilot study of interper- sonal psychotherapy by telephone with cancer patients and their partners. Psycho-oncology, 9, 44…56. Dow, K. H. (1991). The growing phenomenon of cancer survivor- ship. Journal of Professional Nursing, 7, 54…61. Dreher, H. (1997). The scienti“c and moral imperative for broad- based psychosocial interventions for cancer. Advances: Journal of Mind-Body Health, 13, 38…49. Dunkel-Schetter, C. (1984). Social support and cancer: Findings based on patient interviews and their implications. Journal of Social Issues, 40, 77…79. D•Zurilla, T. J., & Nezu, A. M. (1999). Problem-solving therapy: A social competence approach to clinical intervention (2nd ed.). New York: Springer. Edelman, S., Craig, A., & Kidman, A. D. (2000). Group interven- tions with cancer patients: Ef“cacy of psychoeducational versus supportive groups. Journal of Psychosocial Oncology, 18, 67…85. Farberow, N. L., Schneidman, E. S., & Leonard, V. V. (1963). Sui- cide among general medical and surgical hospital patients with malignant neoplasm. Medical Bulletin, 9. Washington, DC: U.S. Veterans Administration. Fawzy, F. I., Cousins, N., Fawzy, N. W., Kemeny, M. E., Elashoff, R., & Morton, D. (1990). A structured psychiatric intervention for cancer patients: I. Changes over time in methods of coping and affective disturbance. Archives of General Psychiatry, 47, 720…725. Fawzy, F. I., Fawzy, N. W., Arndt, L. A., & Pasnau, R. O. (1995). Critical review of psychosocial interventions in cancer care. Archives of General Psychiatry, 52, 100…113. Fawzy, F. I., Fawzy, N. W., & Canada, A. L. (2001). Psychoeduca- tional intervention programs for patients with cancer. In A. Baum & B. L. Anderson (Eds.), Psychosocial interventions for cancer (pp. 235…267). Washington, DC: American Psychologi- cal Association. Fawzy, F. I., Fawzy, N. W., Hyun, C. S., Guthrie, D., Fahey, J. L., & Morton, D. L. (1993). Malignant melanoma: Effects of an early structured psychiatric intervention, coping and affective state on recurrence and survival 6 years later. Archives of General Psy- chiatry, 50, 681…689. Fawzy, F. I., Kemeny, M. E., Fawzy, N. W., Elashoff, R., Morton, D., Cousins, N., et al. (1990). A structured psychiatric interven- tion for cancer patients. II: Changes over time in immunologic measures. Archives of General Psychiatry, 47, 729…735. Fobair, P., Hoppe, R. T., Bloom, J., Cox, R., Varghese,A., & Spiegel, D. (1986). Psychosocial problems among survivors of Hodgkin•s disease. Journal of Clinical Oncology, 4, 805…814. Fox, B. H. (1998). A hypothesis about Spiegel et al.•s 1989 paper on psychosocial intervention and breast cancer survival. Psycho- Oncology, 6, 279…289. Fox, B. H., Stanek, E. J., Boyd, S. C., & Flannery, J. T. (1982). Suicide rates among cancer patients in Connecticut. Journal of Chronic Diseases, 35, 85…100. Friedman, S. H. (1999, August). Behavioral-analytic model of test construction: A measure of caregivers• cancer knowledge. Dissertation Abstracts International, 60 (02), 0869B. Ganz, P. A., Rowland, J. H., Desmond, K., Meyerowitz, B. E., & Wyatt, G. E. (1998). Life after breast cancer: Understanding women•s health-related quality of life and sexual functioning. Journal of Clinical Oncology, 16, 501…514. Gellert, G. A., Maxwell, R. M., & Siegel, B. S. (1993). Survival of breast cancer patients receiving adjunctive psychosocial support therapy: A 10-year follow-up study. Journal of Clinical Oncol- ogy, 11, 66…69. Given, C. W., Stommel, M., Given, B., Osuch, J., Kurtz, M., & Kurtz, J. C. (1993). The in”uence of cancer patients• symptoms and functional states on patients• depression and family care- givers• reaction and depression. Health Psychology, 12, 277…285. Greenberg, D. B. (1998). Radiotherapy. In J. C. Holland (Ed.), Psycho-oncology (pp. 269…277). New York: Oxford University Press. Greenlee, R. T., Murray, T., Bolden, S., & Wingo, P. A. (2000). Cancer statistics, 2000. CA: A Cancer Journal for Clinicians, 50, 7…33. Greer, S., Moorey, S., Baruch, J. D. R., Watson, M., Robertson, B. M., Mason, A., et al. (1992). Adjuvant psychological therapy for patients with cancer: A prospective randomized trial. British Medical Journal, 304, 675…680. Greer, S., Morris, T., & Pettingale, K. W. (1979). Psychological response to breast cancer: Effect on outcome. Lancet, 13, 785…787. References 289 Greer, S., Morris, T., Pettingale, K. W., & Haybittle, J. (1990). Psy- chological response to breast cancer and 15 year outcome. Lancet, 24, 49…50. Gruber, B. L., Hersh, S. P., Hall, N. R. S., Walerzky, L. R., Kunz, J. F., Carpenter, J. K., et al. (1993). Immunological responses of breast cancer patients to behavioral interventions. Biofeedback and Self-Regulation, 18, 1…21. Hack, T. F., Pickles, T., Bultz, B. D., Degner, L. F., Katz, A., & Davison, B. J. (1999). Feasibility of an audiotape intervention for patients with cancer: A multicenter, randomized controlled pilot study. Journal of Psychosocial Oncology, 17, 1…15. Hart, G. J., McQuellon, R. P., & Barrett, R. J. (1994). After treat- ment ends. Cancer Practice, 2, 417…420. Helgelson, V. S., & Cohen, S. (1996). Relation of social support to adjustment to cancer: Reconciling descriptive, correlational, and intervention research. Health Psychology, 15, 135…148. Helgelson, V. S., Cohen, S., & Fritz, H. L. (1998). Social ties and cancer. In J. C. Holland (Ed.), Psycho-oncology (pp. 99…109). New York: Oxford University Press. Helgelson, V. S., Cohen, S., Schulz, R., & Yasko, J. (1999). Educa- tion and peer discussion group interventions and adjustment to breast cancer. Archives of General Psychiatry, 56, 340…347. Helig, S. (1988). The San Francisco Medical Society euthanasia survey: Results and analysis. San Francisco Medicine, 61, 24…34. Henderson, P. (1997). Psychosocial adjustment of adult cancer survivors: Their needs and counselor interventions. Journal of Counseling and Development, 75, 188…194. Herbert, T. B., & Cohen, S. (1993). Stress and immunity in humans: A meta-analytic review. Psychosomatic Medicine, 55, 364…379. Hinds, C. (1985). The needs of families who care for patients with cancer at home: Are we meeting them? Journal of Advanced Nursing, 10, 575…581. Holland, J. C. (1982). Psychological aspects of cancer. In J. F. Holland & E. Frei III (Eds.), Cancer medicine (pp. 1175…1203). New York: Oxford University Press. Holland, J. C.
