Coping with Chemotherapy

Most of the progress in cancer treatment can be attributed to the development of effective chemotherapeutic agents. Over 40 drugs with anti-neoplastic effects are approved for clinical use in the United States and are used to treat more than 30 different forms of cancer. However, many of these agents routinely produce nausea, vomiting, fatigue, and pain reactions that increase emotional distress and interfere with physical, social, and role functioning. Psychosocial interventions such as progressive muscle relaxation training with guided imagery, systematic desensitization, and biofeedback have been shown to improve the quality of life, and some have continued to show beneficial effects after chemotherapy administration.

Coping with Chemotherapy is a self-administered stress management training (SSMT) program that requires limited professional time and experience to deliver. Targeting adult cancer patients before they undergo their first chemotherapy treatment, the intervention provides instruction in abdominal breathing, coping self-statements (positive thinking), and progressive muscle relaxation.

Coping with Chemotherapy consists of a kit of instructional materials, including a DVD and a CD, providing training on three stress management techniques - paced deep breathing, progressive muscle relaxation with guided imagery, and the use of coping self-statements (positive thoughts) - for use before and after the start of chemotherapy. Patients are instructed to view the DVD and then follow the instructions in the accompanying booklet regarding further training and practice. The CD has a specific training exercise on progressive muscle relaxation with guided imagery. Sources and manifestations of stress during chemotherapy and potential benefits of stress management training are described. Testimonials by former chemotherapy patients are also included.

The time required to implement Coping with Chemotherapy includes:

• A 10-minute meeting with a clinician before the initiation of chemotherapy to receive the kit and verbal instructions
• A 5-minute meeting with the same clinician just before the first chemotherapy cycle to answer questions and encourage use of the stress management techniques after chemotherapy begins
• 15 minutes to view the DVD with accompanying instructional booklet
• 35 minutes to hear the CD
• 40-45 minutes daily to practice techniques

The intervention targets adults diagnosed with cancer and scheduled to undergo their first cycle of intravenous chemotherapy.

The intervention is suitable for implementation in outpatient oncology clinics.

The Coping with Chemotherapy kit of instructional resources includes:

• DVD, including a 12-page instructional booklet and accompanying diary workbook to record practice of techniques

• CD for progressive muscle relaxation with guided imagery

• Services of a clinician for 15 minutes over two appointments - 10 minutes to distribute the kit and 5 minutes for follow-up questions and encouragement just before the first chemotherapy infusion

A randomized control study compared the effects of the SSMT program, a professionally administered stress management training (PSMT) program, and psychosocial usual care only (UCO) on three outcome variables (quality of life, depression, and anxiety) across three successive cycles of chemotherapy. Quality of life (QOL) was evaluated by the Medical Outcomes Study 36-Item Short Form (SF-36), a self-report instrument with eight subscales. Depression was evaluated by the Center for Epidemiologic Studies Depression Scale (CES-D), a 20-item questionnaire that generates a total score reflecting the severity of depression in the previous week. Anxiety was evaluated by the State-Trait Anxiety Inventory A-State Scale (STAI-S), also a 20-item questionnaire that generates a total score reflecting the current level of anxiety.

Participants in the study were identified after having consulted with a medical oncologist regarding chemotherapy plans and then randomized into the SSMT program, PSMT program, and the usual care psychosocial support group. All participants were assessed at baseline and at three follow-up time points to evaluate the post-training effects on outcome variables over time.

Key Findings
A total of 411 patients were randomized to one of the three treatment groups out of which 382 remaining eligible participants (average age 56 years, range=26-88 years) completed at least one of the follow-up assessments and were included in the quality-of-life outcome analyses. The majority of participants were White (90%), female (76%), undergoing chemotherapy for breast cancer (58%), and married (71%). Fourteen percent had a history of using relaxation and abdominal breathing prior to study entry. There were no significant baseline differences among the three treatment groups on any demographic or medical variables.

• For the QOL outcome, the SSMT intervention had its greatest positive impact on the patient's mental well-being at each follow-up assessment, compared to the UCO control condition. There was a significant improvement in mental health over time (p<.0001) and fewer role limitations from emotional problems (p=.006 and p=.05) that carried over to the mental component summary score of the SF-36 scale (p<.0001 and p=.0007).

• Positive improvement from the baseline assessment in the mental component summary score of the SF-36 best illustrates the overall improvement in mental functioning for the SSMT participants compared to the UCO control participants (See Figure 1).

• Reported depression ratings (as assessed by the CES-D scale) decreased significantly at each follow-up assessment in the SSMT program group compared to the UCO control group (p<.0001).

• Reported anxiety ratings (as assessed by the STAI-S scale) decreased significantly at each follow-up assessment in the SSMT program group, compared to the UCO control group (p<.0001).

• In contrast to the SSMT program, the PSMT program did not result in any significant improvements in quality of life, depression, or anxiety over the UCO control condition.

• There was a generalized increase in the use of techniques across both the SSMT and PSMT groups in the interval between the first and second chemotherapy cycles to the interval between the second and third cycles (p=.004). This was sustained across the time interval between the third and fourth chemotherapy cycles (See Figure 4).