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Cognitive Behavioral Stress Management of CancerOriginsEarly approaches to cognitive stress intervention focused on helping police officers cope with stress (), and a cognitive behavioral stress management training for treating migraine (). A report published in 1986 compared a program of cognitive behavioral stress management (CBSM) to aerobic training and weight training, for the treatment of Type A personalities (). Significantly greater reduction in behavioral reactivity was seen with CBSM but not physiological reactivity. In 1989, a study was published on stress management based upon transactional stress and group treatment theory (). The treatment was conducted over 8 weeks at 2 hours per week, and consisted of instruction in cognitive-behavioral skills of relaxation, cognitive restructuring, and assertiveness in a small group setting. Compared to wait list controls, those who received treatment showed significant reductions in stress. Cognitive behavioral stress management techniques stepped up to a higher level with the publication of a seminal paper in 1991 that showed psychological cushioning of both stress and immune reactivity in gay men who had just learned that they were HIV-positive (). In this RCT, five weeks before notification of their HIV status, 47 asymptomatic gay men were assigned to an assessment only control group or to a CBSM program. Three days before and one week after notification, blood samples and psychological measurements were taken. Compared to baseline, seropositive controls showed significantly increased depression and slight decreases in proliferative reaction to mitogens and lymphocyte counts. The CBSM group showed no significant increases in depression; and they demonstrated significant increases in CD4 and NK cell counts, and a slight increase in proliferative reaction to mitogens. The RCT’s authors hypothesized that these benefits may have been due to increased relaxation or willingness to participate in the intervention guidelines. ProgramDeveloped by Michael Antoni, Gail Ironson, and their colleagues at the University of Miami (, , , ), multimodal cognitive behavioral stress management (CBSM) helps alter cognitive appraisals, teaches new coping strategies and relaxation, and encourages access to social support. It may improve the quality of life and even improve immune responses in people with cancer (, , , ). CBSM is based upon social support theory that stress is easier to handle in a positive social context. The 10-week CBSM program is a mixture of emotion-focused and problem-focused coping strategies. Sessions are typically 90 minutes of didactic expressive supportive therapy followed by 30 minutes of relaxation. Groups usually consist of 4 to 8 individuals. The CBSM intervention is often referred to as GET SMART (Group-Experienced Therapy for Stress Management and Relaxation Training). B-SMART is the program tailored for breast cancer. Various stress management techniques are presented and the group participants are encouraged to discuss these techniques and associate them with the stressors they may be experiencing. One or more group activity, such as role playing, group interactions or in-session worksheets, is introduced in each session and the participants are encouraged to practice these relevant techniques. CBSM includes:
Breast Cancer and CBSMResults are quite consistent with improving quality of life and cortisol measurements, but not always consistent with improving immune system status. Mechanisms behind these changes are just being investigated (). Here are a few of the important studies. Reported in 2000, effects of a 10-week cognitive behavioral stress management (CBSM) were assessed in an RCT of 34 women with early stage (I or II) breast cancer (). Within 8 weeks of surgery, 24 were assigned to CBSM and 10 to a waiting list control. Blood samples for cortisol were drawn at the same time each day just before and just after the CBSM or wait-list control intervention. In an examination of positive responses to trauma, after the interventions, the women were also asked to assess how much positive contribution breast cancer had made to their lives. These assessments included increased appreciation of life, personal growth, and shifting priorities. Results suggested that the CBSM influenced positive assessments, which in turn decreased cortisol. In a study reported in 2001, a group of 100 women with stage 0 to II breast cancer who received CBSM was evaluated (). Compared to controls, prevalence of moderate depression was reduced, but no change in other parameters of emotional distress was seen. Increased optimism and increased perception of positive contribution were seen at the 3-month follow-up, and the greatest increases were seen in the group with the lowest baseline optimism. As an addendum to the 2001 study ([), in 2004, results of an RCT was published on the effect of CBSM on emotional well being and immune functions in women with early-stage breast cancer who had recently undergone surgery (). Eighteen women participated in the 10-week CBSM intervention and 11 were controls. The subset of women who participated in this additional component was somewhat younger than the mean age of the 100 women in the total set (47.52, SD = 6.39 vs. 51.95, SD = 9.77; t(108) = 2.27, p<0.05)). Psychological assessments were performed at three times: 4 to 8 weeks after surgery, which was just prior to the 10-week experimental period, just after the 10 weeks, and 3 months after the 10-week experiment. Immune functions were assessed at the time of the first and third psychological assessments. The control group received no interventions during the 10 weeks when the intervention group was receiving CBSM. However, after completion of the second assessment, they were offered (and 9 out of 11 accepted) a 1-day seminar that condensed the information presented in the CBSM. The chief difference was the amount of time, and the lack of therapeutic group format with concomitant emotional support. The study’s authors state that this 1-day seminar intervention did not alter the outcome or mediator variables as measured at the third assessment. The women who participated in CBSM vs. controls seemed to express greater benefit finding. The CBSM women also showed increased lymphocyte proliferation response to anti-CD3 at 3-months, and this proliferation was predicted by greater benefit finding. There was, however, no change in any lymphocyte subset (CD3, CD4, CD8, CD3- CD56+, or CD19. NK cells were not assessed. There was no apparent relationship of subsets with benefit finding or proliferative response. To this point, CBSM interventions have focused on women who are already experiencing overt cancer and have perturbations of the immune response. Results from these studies are somewhat difficult to interpret and to extrapolate to a healthy population. Recently, an RCT led by Bonnie McGregor of the Fred Hutchinson Cancer Research Center has been funded to examine the effects of CBSM on women who are stressed but healthy. Building on results from breast cancer studies using CBSM relative to immune responses, coping and social support, an RCT has begun to test the effect of stress management and relaxation training (SMART) to improve immune response to vaccine and distress among women who have an increased risk for breast cancer (resource). As discussed in several places in this text, certain types of stress can dampen the immune response. Of special concern in this regards, is the immune response to vaccines. For more information on psychological stress and immune responses, please follow the hyperlink or refer to the index. Of special interest related to breast cancer is the combination of stress in women who are most at risk for breast cancer and the advent of immunizations against breast tumors (, , ). Prostate Cancer and CBSMLess work has been done with men who have prostate cancer. More needs to be done, but so far results are promising. In an RCT, a 10-week CBSM was compared to a one-day seminar designed to improve quality of life (QOL) in 92-men afflicted with localized prostate cancer that had been treated with either radiation or radical prostatectomy (). The total predictors and covariates of QOL were able to account for 62.1% of the variance in post intervention QOL. The men who received the CBSM experienced significantly better QOL than the control group, and these improvements appeared to be related to better stress-management skills. Another RCT using CBSM assessed QOL and benefit affect in 191 men (mean age 65.1; 40% white, 40% Hispanic, 18% black, 1% other) treated with either radiation or radical prostatectomy for localized prostate cancer (). Controls received a one-day seminar as in the previous study. Positive Contributions Scale-Cancer was used to assess the benefit finding, a measurement survey was used to assess perceived stress-management skills, and the Functional Assessment of Cancer Therapy> was used to asses the QOL. CBSM seems to have increased benefit finding and QOL through the mediation of enhanced stress management skills How long do the benefits of CBSM last? The answer is as yet unknown for cancer patients. It might be reasonable to assume that if one continues to practice the precepts that are taught in the CBSM program the probability is good that benefits will be maintained. Psychological Interventions for Cancer PatientsEarly reviews for psychological interventions in cancer have been less than rigorous in their approaches (reviewed in ). However, recently a more scientific approach has been taken. An excellent two-part review has analyzed the evidence for benefits of psychological interventions for folks afflicted with cancer (, ). Their conclusions were, “sufficient evidence to conclude that cognitive-behavioral interventions are effective in reducing and managing psychological distress in cancer patients and are accepted by these patients.” Of course, not all psychological interventions are equal in their benefits. Based upon the references that we have cited, we believe that CBSM has a lot to offer. Including the possibility that immune enhancement may occur. And part of that is based upon the individuality of the participants. |
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