Psychosocial challenges for patients with advanced lung cancer: interventions to improve well-being

Introduction

A diagnosis of lung cancer, the second leading cancer in incidence among men and women and leading cause of cancer death,¹ is associated with high symptom burden, poorer prognosis, and stigma associated with links to smoking behaviors.^2–5 Such factors increase psychological distress and negative social impacts of the disease on patients and their families.² Thus, improving psychosocial well-being to enhance the quality of life (QOL) is a primary goal at all stages of lung cancer during treatment and survivorship.⁵ Research has shown that psychological distress, such as that occurs during depressive episodes, can be a prognostic indicator of poorer clinical outcomes and survival for patients with cancer.^{2, 6} Despite this observation, lung cancer remains understudied in the area of psychosocial care as compared to other cancers,² even with the recognition of unmet supportive needs.⁷ Therefore, the purpose of this article is to provide a current overview about research-based psychosocial interventions to support wellness for patients with advanced lung cancer across the survivorship spectrum with a discussion of findings in the context of trends in the field and updated evidence.

A growing literature documents psychosocial-oriented interventions to support mental health for patients with cancer.^6,8,9 Such interventions include a wide-ranging host of options such as cognitive-behavioral therapies (CBTs), problem-solving approaches, mind–body and alternative therapies, supportive group-based treatments, and education focused modalities.^9–11 While research demonstrates that many of the approaches are efficacious in managing psychological symptoms and in promoting facets of well-being, studies persist with methodological problems such as samples that did not have distress prior to intervention induction, lack of randomization and blinding, variability in identified interventions and outcomes, and other potential bias.^8,10,12 In general, barriers associated with the inclusion of patients with lung cancer in the intervention studies include the presence of high symptom burden and the challenges associated with access to study sites that require physical presence at the designated times. Patients with lung cancer are recognized to have higher needs for comprehensive supportive care, and given both poor physical function and psychological distress, may need interventions that are multimodal in nature.^7,13,14

Methods

A data base search was conducted using the terms lung cancer and psychosocial interventions with CINAHL, Medline, psychINFO, Scopus, Cochrane, and PubMed search engines. To maintain up-to-date findings, only articles published in the past 10 years (2007–2017) were included in the review. Inclusion criteria comprised articles that targeted 1) testing of psychosocial research interventions in lung cancer; 2) a lung cancer sample; 3) English language in full-text articles (no conference abstracts); and 4) outcomes focused on improving wellness and positive psychological indices. Exclusion criteria included 1) articles that focused on psychosocial interventions for mixed cancer groups; 2) articles that focused on smoking cessation interventions; and 3) articles that described proposed protocols (no data). Initially, 4701 citations were recovered. After a reiterative and systematic evaluation with removal of duplicate articles, 20 articles were incorporated in the final review. This article includes a review of psychosocial interventions for patients with lung cancer with appraisal of 1) type of intervention; 2) sample characteristics; 3) research design and methods; 4) instruments used; and 5) outcomes. Table 1 provides a summary of major findings of the 20 articles in the above mentioned areas. Major psychosocial intervention categories incorporated in the review include CBTs, psycho-education, mind–body, exercise, and supportive or palliative care typologies.

Table 1 Review of studies

Results

CBTs

CBTs are grounded in approaches that help patients change distorted fears and cognitions, and modify nonadaptive coping behaviors.¹⁵ CBT participants learn how to monitor and reframe nonrational thoughts and beliefs that contribute to depressive and/or anxious affect.³ Further, patients learn alternatives to avoid anxiety provoking situations via analysis of triggers and incremental exposures.¹⁵ In the studies primarily incorporating CBT interventions, other treatment modalities were also included. Porter et al evaluated the efficacy of a caregiver-assisted coping skills training intervention grounded in cognitive-behavioral principles for 233 patients with lung cancer (limited to stage I–III non-small-cell lung cancer [NSCLC] or limited-stage small-cell lung cancer [SCLC]) who were undergoing medical treatment.¹⁶ The intervention included fourteen 45-minute telephone-delivered sessions and involved cognitive restructuring, problem solving, communication, relaxation, and activity-rest cycle training. Participants were randomized to the intervention group or to an education/support comparison group.¹⁶ Participants in both the groups appeared to derive some benefit in modifying depressive symptoms and improving QOL from the respective interventions.¹⁶ Similarly, Mosher et al evaluated a briefer telephone-delivered symptom management CBT (six 45-minute sessions) for symptomatic patients (included stage I–IV NSCLC and SCLC in treatment) and their caregivers.¹⁷ Also using random assignment, the experimental group was compared to an education/support group. The symptom management intervention included cognitive restructuring, problem solving, emotion-focused self-soothing, pleasant activities, and relaxation training.¹⁷ Neither of these two randomized pilot studies identified outcome differences from the tested experimental interventions,^16,17 and the Mosher et al’s study did not improve symptom outcomes.¹⁷ Further, both of the studies had problematic attrition rates, 27% posttesting and 40% at the 4-month follow-up for the first¹⁶ and 40% at 6 weeks for the second study.¹⁷

A study that utilized a pre-post design combined 6 weeks of telephone-delivered manualized CBT with acceptance-based content in a sample of 25 patients with lung cancer, stage not determined.³ The rationale for strengthening CBT with acceptance-based treatment is to help the patient change their relationship to and increase tolerance to distressing thoughts and symptoms.³ The study outcomes targeted psychological distress and lung cancer stigma perceptions. Improvement was detected in psychological and cancer-related distress and stigma, although QOL perceptions declined.³

Utilizing an evidenced-based CBT for anxiety, a small (n=32) pre-post pilot study was conducted to manage dyspnea among symptomatic patients with advanced lung cancer.¹⁸ Perceived breathlessness is anxiety provoking for patients and contributes to psychological distress and even panic disorder.¹⁸ The intervention also incorporated training in relaxation strategies and breath meditation.¹⁸ The study had low attrition rates and the findings suggested improvements in QOL, dyspnea, and depressive symptoms.¹⁸

Psycho-educational interventions

Psycho-educational interventions provide targeted information to help patients manage unmet needs.^7,19 Schofield et al conducted a randomized control trial (RCT) to determine the effectiveness of a multifaceted supportive intervention that was tailored to meet the unmet needs of patients with advanced lung cancer who were preparing for palliative radiation and/or chemotherapy.²⁰ Multidisciplinary in nature, the intervention consisted of six manualized educational modules and self-care pamphlets that addressed unmet needs that patients identified during initial consultation. The provided information included diverse topics such as communicating with others, managing emotional distress, and sleep problems. The study did not find significant differences between participants who received the experimental intervention and the standard care (control group) on management of unmet needs, psychological distress, health-related quality of life (HRQOL), and anxiety/depression symptoms.²⁰

A psychosocial intervention grounded in self-determination theory evaluated the effectiveness of a dyadic approach to reduce psychological distress and improve self-efficacy among patients with advanced lung cancer and their caregivers.²¹ The aim of the pilot RCT was to build self-competence, autonomy, connectedness, and belonging, factors that are associated with enhanced psychological well-being. The intervention was delivered via telephone in six weekly sessions tailored in accordance with the dyadic personalized needs.²¹ Findings were promising with improved psychological indices for the intervention group and strong effect sizes for patient competence and relatedness.²¹

Chan et al conducted an RCT that compared a psycho-education intervention targeting a problematic symptom cluster (shortness of breath, anxiety, fatigue) during palliative radiation therapy to a usual care condition.¹⁹ The intervention consisted of education on symptom management and self-care strategies, and coaching on progressive muscle relaxation. After participant training, a relaxation audiotape and written materials were provided.¹⁹ The intervention was identified as well received (94% completed) with a significant pattern of change in the symptom cluster over time compared to the control condition.¹⁹ In a study that incorporated a posttest design, a multifaceted education intervention that aimed at providing nutritional information, exercise, and relaxation techniques to patients newly diagnosed with lung cancer and eligible to receive chemotherapy was compared to a standard care condition.²² Despite the study limitations, results suggested comparative benefits relative to managing treatment side effects, lowered depressive symptoms, and better perceived performance status in the intervention group.²²

Mind–body interventions

Mind–body interventions such as mindfulness-based programs, yoga, and tai-chi integrate a holistic approach that emphasizes the connectedness between mental states and physiological balance.²³ Mindfulness-based programs incorporate training in meditation and mindfulness practices to improve stress management and reduce depressive and anxious symptoms for patients with cancer.¹¹ Kabat-Zinn developed the original mindfulness-based stress reduction (MBSR) training program which has subsequently been implemented in both healthy and clinical populations.²⁴ In general, mindfulness programs aim to help participants cultivate heightened awareness of the current mental and bodily experience with a nonjudgmental, accepting, and open attitude.¹¹ While testing of MBSR and other mindfulness-based interventions in cancer has been increasing, their application to patients with lung cancer remains limited.²⁵ Two pilot studies were identified which tested a mindfulness intervention to improve psychological indices and HRQOL parameters for patients with lung cancer.^25,26 Both studies included small sample sizes of patients with advanced disease with one using a pre-post²⁵ and the other an RCT design.²⁶ Both studies included patients with advanced disease who were in treatment with no significant benefits noted for reductions in anxiety and depressive symptoms in one.²⁵ In the pilot RCT, findings demonstrated clinically significant effect sizes suggesting promise and need for further research with larger sample sizes.²⁶ A larger scale MBSR RCT to manage psychological distress in lung cancer patients is in progress.²⁷

Yoga involves many schools and traditions that share a common thread of coordinating the mind and body via use of breathing, postures, movement, and meditative practices.^28,29 Yoga programs have been piloted for patients with lung cancer,²⁹ including two studies that incorporated caregivers.^30,31 In the two yoga studies involving couples, both included patients with stage I–1IIB NSCLC who were receiving radiation therapy.^30,31 Both studies incorporated a one-arm pre-post study design with one involving a couple-based Vivekananda Yoga (VKC) program that was piloted with 28 patient–partner dyads.³⁰ The VKC program incorporated light seated movements and breathing exercises along with partner engaged poses, relaxation, and meditation training. Fifteen sessions were offered two to three times weekly over a 5- to 6-week period while the patients were receiving radiation therapy.³⁰ The second study involving 10 dyads incorporated Tibetan yoga, which similarly incorporated breath awareness, mindfulness meditation training, and Tsa Lung exercises, described as ancient contemplative gentle movements tied to breath work.³¹ Both studies incorporated patient-reported outcomes including psychological distress, symptom and HRQOL parameters, and cited promising mental health benefits from active participation.^30,31

Tai Chi is an ancient Asian practice that involves integrating breath, meditation, and constant aerobic-type exercise movements.³² Tai Chi is based on the Chinese concept of qi recognized as vital life energy that when balanced in the body contributes to balance, improved cardiovascular and immune function, and stress management.³² Although limited studies have examined the benefits of Tai Chi for improving psychosocial functioning in lung cancer, a pilot study involving 32 post-thoracotomy patients with NSCLC suggested that a 16-week Tai Chi intervention impacted cortisol levels (a marker of stress).³²

One study evaluated the feasibility and potential effectiveness of biofeedback-assisted stress management (BFSM) to manage stressors in seven patients with NSCLC who were receiving chemotherapy.³³ The study evaluated heart rate variability biofeedback, inter-beat intervals of heart rate reflecting sympathetic and parasympathetic nervous system activity reflecting vagal nerve action. The aim was to train patients to increase their heart rate variability, evidence of balancing the autonomic nervous system by decreasing heightened sympathetic nervous system activation, utilizing biofeedback during relaxation exercises. The study aimed to recruit 16 patients but was terminated prematurely due to high attrition with only one participant completing all the prescribed BFSM sessions.³³ Although the study was not successful, data suggested positive findings with patients learning to increase heart rate variability.³³

Exercise interventions

Regular exercise has been shown to yield benefits for mental health and QOL in both healthy and ill populations.³⁴ Growing research has examined the role of exercise in improving symptom management and QOL parameters in survivors of lung cancer.^35–38 Increasing psychosocial well-being has not been the primary focus of this research, but such outcomes may be included as part of a QOL index or part of a symptom assessment. Temel et al did examine mood and anxiety specifically as part of their assessment of feasibility of a structured 8-week hospital-based exercise program involving 25 newly diagnosed patients with advanced NSCLC who were undergoing anticancer treatments.³⁸ Participants did not demonstrate benefits in mood or QOL but had improved lung cancer symptom scores post-study.³⁸ A 6-week pilot hospital-based supervised exercise program that also incorporated progressive relaxation demonstrated that patients with advanced-stage NSCLC IIIb–IV undergoing chemotherapy who completed the program derived psychological benefit including reduced anxiety and improved emotional well-being.¹⁴ A small 6-week supervised hospital-based group exercise and relaxation program that required 4 hours of weekly attendance and a home-based component for patients with advanced lung cancer who were undergoing chemotherapy and radiation therapy indicated that participants (n=15) derived benefits on well-being.³⁹ The program had 78% adherence to the supervised component but limited adherence to the home-based unsupervised aspect.³⁹ This Danish study was qualitative in nature incorporating semistructured interviews and one focus group.³⁹ Another study that included patients with mostly stage I disease indicated effectiveness of home-based walking exercise on anxiety and depressive symptoms.⁴⁰

Supportive care/palliative care interventions

It has been recognized that early incorporation of an interdisciplinary supportive care approach to treatment is essential for patients with newly diagnosed lung cancer.^4,41 Three studies examining supportive care were evaluated. Palliative care management provides an interdisciplinary approach with a focus on comprehensive symptom management and support for psychological, spiritual, and social needs.⁴² Temel et al in a study that randomized 151 newly diagnosed patients with advanced lung cancer to either palliative or usual care found that patients receiving palliative care had better perceived QOL and longer survival despite less aggressive medical management.⁴³ In a study that examined the introduction of interdisciplinary supportive care to patients who received curative surgical resection, findings demonstrated that the patients receiving the intervention reported lower psychological distress and improved HRQOL 1-year following the surgical procedure.⁴⁴ The third study randomized patients with newly diagnosed or recurrent lung cancer to either supportive care or to a usual care condition.⁴⁵ The experimental arm met with a psychosocial nurse on a 1:1 basis (minimum of four meetings) and received follow-up referral based on specific needs if they had distress.⁴⁵ Patient outcomes were recorded at four time points following randomization (last 25 weeks). Only 50% of the sample completed the study. There were no differences between the experimental and the usual care condition on patient-reported outcomes including mental health indices and QOL parameters. Importantly, although overall survival was comparable between the two conditions, participants in the supportive care group were less likely to receive chemotherapy at the end of life.⁴⁵

Discussion

Although a growing number of studies have evaluated psychosocial interventions to improve patient well-being for patients with advanced lung cancer, there remains a strong need for further inquiry. Out of the 20 studies evaluated, nine used a randomized design to evaluate efficacy.^{16,17,19–21,26,40,43,45} Many of the studies incorporating one group or pre-post designs were feasibility pilots with very small sample sizes reducing their potential impact.^{3,18,25,29–31,33,39} Further, some of the pilot studies evaluated complex bundled interventions further reducing the overall effect.^19,22,39 To improve evaluation of outcomes, randomized studies comparing two active interventions could benefit from using three-group designs incorporating a usual care control. Although several of the studies address treatment fidelity, this remains a limitation in this research.

Only one of the studies incorporated the use of Patient-Reported Outcomes Measurement Information System (PROMIS) to evaluate psychological outcomes.²¹ Use of patient-reported outcome tools that are part of common data elements in psychosocial intervention studies is recognized as essential for cross study comparisons. However, a majority of the instruments used in the reviewed studies including the Functional Assessment of Cancer Therapy-Lung Module (FACT-L), Medical Outcomes Study short form-36 (SF-36), and the European Organization of Research and Treatment of Cancer Quality of Life (EORTC-QLQ-C30) are strongly validated, reliable, and commonly used in lung cancer research.⁴⁶

Many of the studies have targeted patients with advanced disease who are receiving chemotherapy and/or radiation, a time characterized by heightened treatment burden and lowered QOL. Given that most patients are diagnosed with advanced disease, this focus is understandable. However, complexity of the patients who have varying stages of disease and heterogeneous treatment and dosing regimens increases the need for adequate sample sizes and reduces the generalizability of study findings. Further, there is a lack of studies that include patients who are prescribed oral chemotherapy agents that require self-management of complex administration schedules in their samples.

While the need for multipronged approaches that target psychological distress in the context of physical symptom burden is of importance, it creates a challenge to determine both mechanisms and which aspect of the intervention impacts patient outcomes. Although mind–body modalities are psycho-physiological in nature and are aimed at building resilience in the face of distressing mental and physical symptoms, there is limited adoption of physiologic measurement parameters in this research. The one study incorporating heart rate variability indices was terminated due to attrition.³³

The role of informal caregivers in the management of lung cancer and their impact on the patients’ well-being is of strong relevance.^5,47,48 Six studies^{16,17,21,25,30,31} involved the partner or caregiver in the intervention protocols. Caregivers can derive benefits from learning mind–body strategies such as yoga and meditation which in turn can help them to better support the patient. Further, caregivers may also support and/or deliver the interventions in the home environment, thus improving patient access to supportive modalities and potentially reducing costs of care.⁴⁹ There is a growing demand for intervention research that includes informal caregivers at all phases of the lung cancer survivorship trajectory.

Several of the included studies were conducted internationally with samples from China, Taiwan, Hong Kong, Australia, and Europe. The lack of racial diversity continues to be highly problematic in psychosocial intervention research given the incidence of lung cancer in underserved populations. More studies that utilize an intentional recruitment design to gain more representative samples are imperative. The number of minority patients represented in the US research was in single digits,^{21,26,29–31,44} with only one study reporting a high of 11.6% African Americans.¹⁶

In light of the review findings, there has been growing awareness and concern associated with funding disparities for lung cancer research as compared to other less lethal malignancies such as breast cancer.⁵⁰ Challenges associated with gaining access to funding to conduct psychosocial intervention studies may be one barrier to advancing behavioral science in this regard. Given established causal relationships between cigarette smoking and lung cancer, public health policies aimed at heightening awareness about smoking hazards and denormalizing tobacco use are recognized to have increased the stigmatization associated with lung cancer.^50,51 Further, therapeutic nihilism, or the perception that treatment is of limited or no benefit, may have widespread adverse consequences for patients with lung cancer impacting both research and practice.^50,52 Researchers have called for an integrative approach with discourse between tobacco control and lung cancer investigators and practitioners to reduce stigma and nihilistic attitudes,⁵² a strategy that may positively impact implicit stereotyping and build compassion for patients coping with the disease.

Conclusion

The need for well-designed psychosocial intervention studies in the lung cancer population with active control groups continues to be a challenge. With high attrition rates and feasibility obstacles, research evidence in this area primarily relies on pilot studies and self-reported outcomes. Comparing findings across studies is problematic given variation in outcome measures that evaluate the major study constructs. Research that targets patients at specific points in the survivorship trajectory including end of life is warranted. Further, more studies in lung cancer populations that evaluate baseline psychological distress as an eligibility criteria are needed, a factor that may improve evaluation of intervention benefits over time.

Disclosure

The author reports no conflicts of interest in this work.

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