Abstract
Context
Little research has explored coping skills practice in relation to symptom outcomes in psychosocial interventions for cancer patients and their family caregivers.
Objectives
To examine associations of coping skills practice to symptom change in a telephone symptom management (TSM) intervention delivered concurrently to lung cancer patients and their caregivers.
Methods
This study was a secondary analysis of a randomized pilot trial. Data were examined from patient-caregiver dyads (n=51 dyads) that were randomized to the TSM intervention. Guided by social cognitive theory, TSM involved four weekly sessions where dyads were taught coping skills including: a mindfulness exercise, guided imagery, pursed lips breathing, cognitive restructuring, problem solving, emotion-focused coping, and assertive communication. Symptoms were assessed, including patient and caregiver psychological distress and patient pain interference, fatigue interference, and distress related to breathlessness. Multiple regression analyses examined associations of coping skills practice during the intervention to symptoms at 6 weeks post-intervention.
Results
For patients, greater practice of assertive communication was associated with less pain interference (β=−0.45, p=0.02) and psychological distress (β=−0.36, p=0.047); for caregivers, greater practice of guided imagery was associated with less psychological distress (β=−0.30, p=0.01). Unexpectedly, for patients, greater practice of a mindfulness exercise was associated with higher pain (β=0.47, p=0.07) and fatigue interference (β=0.49, p=0.04); greater practice of problem solving was associated with higher distress related to breathlessness (β=0.56, p=0.01) and psychological distress (β=0.36, p=0.08).
Conclusion
Findings suggest the effectiveness of TSM may have been reduced by competing effects of certain coping skills. Future interventions should consider focusing on assertive communication training for patients and guided imagery for caregivers.
Keywords: lung cancer, family caregivers, psychosocial interventions, symptom management, cognitive-behavioral, intervention components
Introduction
Cancer is often conceptualized as a “dyadic disease” that can profoundly impact the patient and his or her family caregiver.1,2 Thus, numerous psychosocial interventions have focused on improving outcomes for cancer patient-caregiver dyads.3,4 Dyadic interventions have shown small to moderate effects on prevalent issues, including patient and caregiver psychological distress (i.e., depressive and anxiety symptoms)1,4 and patient pain,5,6 fatigue,7 and distress related to breathlessness.8 Unfortunately, little is known about the effective components of these complex interventions. Studies exploring intervention components in relation to outcomes have been limited in cancer9–11 and non-cancer medical populations,12 despite being an important step in developing efficacious interventions.13,14
Some studies have explored associations between intervention components (e.g., participant coping skills practice) and outcomes in non-dyadic psychosocial interventions for cancer patients.9–11 First, Andersen and colleagues9 analyzed an RCT testing a group-based intervention for breast cancer survivors. Greater practice of relaxation exercises was associated with less psychological distress and nurse-rated symptoms post-intervention. Reduction in symptoms was also predicted by use of assertive communication with medical providers. Similarly, Cohen and Fried11 randomized breast cancer patients to either group-based cognitive-behavioral therapy or relaxation training. Greater practice of the skills taught in both conditions was related to post-intervention reductions in psychological distress, sleep difficulties, and fatigue. Lastly, Chan and colleagues10 examined an RCT testing a psychoeducation and progressive muscle relaxation program for patients with advanced lung cancer. Greater practice of progressive muscle relaxation was related to reduced breathlessness intensity and fatigue post-intervention. These studies provide preliminary evidence that coping skills practice is related to reductions in certain symptoms. To our knowledge, however, no studies have explored these associations in a dyadic intervention for cancer patients and caregivers.
The objective of the present study was to examine associations between coping skills practice and symptom change in a telephone symptom management (TSM) intervention delivered concurrently to lung cancer patients and their caregivers.16 TSM focused on patient and caregiver well-being and the management of patient symptoms through a blend of cognitive-behavioral and emotion-focused strategies. Each session included social cognitive theory-based determinants of behavior change,21,22 such as enhancing knowledge of symptoms and coping skills, setting coping skills practice goals, assessing barriers to practice, modeling adaptive coping behavior, and enhancing social support.
In a pilot RCT, four sessions of TSM were compared to four sessions of an education/support condition, and no significant between-group differences were found for the main outcomes.16 However, this global analysis did not allow us to determine if certain coping skills were related to improved outcomes. We thus conducted a secondary analysis of this pilot trial. Based on social cognitive theory21,22 and previous research,9–11 we hypothesized that greater practice of coping skills (i.e., noticing sounds and thoughts, guided imagery, pursed lips breathing, cognitive restructuring, problem solving, emotion-focused coping, and assertive communication) during the intervention would be related to fewer symptoms for patients (i.e., pain interference, fatigue interference, distress related to breathlessness, and psychological distress) and caregivers (i.e., psychological distress) at 6 weeks post-intervention.
Methods
Participants and Setting
Study procedures have been reported previously.16 All procedures were approved by the Indiana University Institutional Review Board (Clinicaltrials.gov number NCT01993550). Lung cancer patients and their family caregivers were recruited between March 2013 and April 2015 from three medical centers in Indianapolis, IN. Patient inclusion criteria included: 1) age ≥ 18 years; 2) at least 3 weeks post-diagnosis of lung cancer; 3) at least moderate severity for one or more symptoms at recruitment, including: anxiety, depressive symptoms, pain, fatigue, or breathlessness; 4) a consenting family caregiver; and 5) adequate English fluency. Patient exclusion criteria included: 1) significant psychiatric or cognitive impairment; 2) previously providing feedback on the intervention;23 3) current participation in another psychosocial study; or 4) receiving hospice care. Caregiver inclusion criteria included: 1) age ≥ 18 years; 2) living with the patient or visiting regularly; and 3) adequate English fluency. Caregiver exclusion criteria included: 1) current participation in another psychosocial study; 2) previously providing feedback on the intervention;23 or 3) significant psychiatric or cognitive impairment.
Fifty-one dyads were randomized to TSM, and 75% completed three or four sessions. There was 31% attrition from allocation to 6 weeks post-intervention. Half of the attrition (8/51 dyads) was attributed to the patients’ declining health or death, and the other half was attributed to lack of interest. Additional study flow information has been reported previously.16
Procedures
This study used a within-subjects design to analyze data from participants who were randomized to TSM in a pilot RCT.16 Assessments (i.e., baseline and 2 and 6 weeks post-intervention) were conducted by a research assistant who was blinded to the participants’ study condition. The current analyses explore symptom changes from baseline to 6 weeks post-intervention, as we were interested in potential sustained effects of coping skills practice.
Telephone Symptom Management (TSM)
Additional details about TSM are presented in the Supplemental Materials. Briefly, TSM was a manualized symptom management intervention, consisting of four weekly 45-minute sessions delivered by licensed clinical social workers. Patients and caregivers participated in the intervention concurrently by speakerphone. Each participant received a notebook with handouts and other study materials (e.g., a CD with guided relaxation exercises).
Each TSM session focused on different coping skills, and regular practice was emphasized. In session 1, three coping skills were described and practiced: noticing sounds and thoughts (a mindfulness exercise); guided imagery; and pursed lips breathing. Session 2 focused on coping with distressing thoughts based on the type of thought, including: 1) cognitive restructuring for unrealistic thoughts; 2) problem solving for realistic thoughts about a controllable situation; and 3) emotion-focused strategies (e.g., emotional processing) for realistic thoughts about uncontrollable situations. Session 3 focused on assertive communication. Session 4 focused on scheduling pleasant activities, pacing activities, and a plan for continued coping skills practice.
Measures
Sociodemographic and Medical Information
Participant demographics were self-reported at baseline and medical information was collected via medical record review.
Coping Skills Practice
During sessions 2 through 4, participants were asked to report the number of times they each practiced specific coping skills in the past week. The therapist reviewed any skills that participants did not recall. The present analysis only includes coping skills practice data from session 4 because this captured the majority of the skills taught in TSM. Practice of the following coping skills was assessed: noticing sounds and thoughts, guided imagery, pursed lips breathing, cognitive restructuring, problem solving, emotion-focused coping, and assertive communication.
Outcome Measures
All outcome measures were well-validated for use with cancer patients and their caregivers. Patient symptoms were assessed using: 1) the pain interference subscale of the Brief Pain Inventory – Short Form;25,26 2) the fatigue interference subscale of the Fatigue Symptom Inventory;27 and 3) an item assessing distress related to breathlessness from the Memorial Symptom Assessment Scale.28 Patient and caregiver psychological distress was assessed using the Patient Health Questionnaire (PHQ-8)29,30 and the Generalized Anxiety Disorders scale (GAD-7).30,31 The PHQ-8 and GAD-7 scores were highly correlated (r = 0.65 to 0.87) and were combined for an overall measure of psychological distress.
Statistical Analyses
Preliminary analyses were conducted to characterize the data. A Winsorization transformation was applied to reduce the influence of eleven outliers (i.e., scores > 3 SD) in the coping skills practice data.33 No outliers were identified for the outcome measures. Missing data were imputed in LISREL 8.835 using the Markov Chain Monte Carlo (MCMC) method.36 An MCMC imputation algorithm included all of the outcomes, coping skills, and two auxiliary variables denoting the reason for attrition. Ten datasets were imputed for patient variables and ten datasets were imputed for caregiver variables.
Analyses of associations between coping skills practice and symptom change were planned before data collection began. Multiple regression analyses were conducted in SPSS37 to examine associations of coping skills practice to symptoms at 6 weeks post-intervention, while controlling for the baseline level of the respective symptom. Five regression models were tested. Patient and caregiver variables were examined in separate regressions due to the sample size, which precluded the use of dyadic analyses.38 The regressions were conducted on each imputed dataset; the results were then averaged using guidelines developed by Rubin.39 Previous studies reported moderate associations between coping skills and outcomes, with β weights ≥ 0.30.9–11 Thus, we noted moderate associations regardless of the p-value, given that statistical significance can be heavily influenced by factors such as sample size.40
Results
Descriptions of Participants, Coping Skills Practice, and Outcome Measures
Participant characteristics are presented in Tables 1 and 2. Descriptive statistics for coping skills practice and outcomes are presented in Tables 3 and 4.
Table 1.
Patient and Caregiver Characteristics at Baseline
| Patients (n = 51) | Caregivers (n = 51) | |
|---|---|---|
| Sex, n (%) | ||
| Male | 23 (45.10) | 14 (27.45) |
| Female | 28 (54.90) | 37 (72.55) |
| Age | ||
| Mean (SD) | 63.47 (7.68) | 56.33 (14.09) |
| Range | 45 – 85 | 20 – 76 |
| Race, n (%) | ||
| Non-Hispanic White | 45 (88.24) | 44 (86.27) |
| Missing | 0 (0.00) | 1 (1.96) |
| Employment status, n (%) | ||
| Employed full-time or part-time | 9 (17.65) | 23 (45.10) |
| Retired | 25 (49.02) | 16 (31.37) |
| Unemployed/other | 17 (33.33) | 11 (21.57) |
| Missing | 0 (0.00) | 1 (1.96) |
| Household income, n (%) | ||
| $0 – $20,999 | 10 (19.61) | 8 (15.69) |
| $21,000 – $50,999 | 12 (23.53) | 11 (21.57) |
| $51,000 – $99,999 | 13 (25.49) | 17 (33.33) |
| $100,000 or more | 7 (13.73) | 9 (17.65) |
| Missing | 9 (17.65) | 6 (11.76) |
| Years of education | ||
| Mean (SD) | 12.92 (2.22) | 13.94 (2.85) |
| Range | 9 – 19 | 8 – 20 |
| Married/living with partner, n (%) | 35 (68.63) | 41 (80.39) |
| Smoking status, n (%) | ||
| Never smoked (or smoked < 100 cigarettes) | 6 (11.76) | 27 (52.94) |
| Formerly smoked | 34 (66.67) | 16 (31.37) |
| Currently smoke | 11 (21.57) | 8 (15.69) |
| Caregiver’s relationship to the patient, n (%) | ||
| Spouse/partner | 32 (62.75) | |
| Son/daughter | 9 (17.65) | |
| Other family member or friend | 10 (19.61) | |
| Caregiver lives with the patient, n (%) | 37 (72.55) | |
SD = standard deviation.
Table 2.
Patient Medical Information at Baseline (n =51)
| Study site, n (%) | |
| Indiana University Simon Cancer Center | 39 (76.47) |
| Roudebush VA Medical Center | 10 (19.61) |
| Eskenazi Health hospital in Indianapolis | 2 (3.92) |
| Type of lung cancer, n (%) | |
| NSCLC | 44 (86.27) |
| SCLC | 7 (13.73) |
| Stage of cancer, n (%) | |
| Stage I–III NSCLC | 25 (49.02) |
| Stage IV NSCLC | 19 (37.25) |
| Limited-stage SCLC | 3 (5.88) |
| Extensive-stage SCLC | 4 (7.84) |
| Time since diagnosis in years | |
| Median (SD) | 0.57 (2.12) |
| Range | 0.07 – 11.99 |
| Missing, n (%) | 1 (1.96) |
| Treatments received, n (%) | |
| Chemotherapy | 27 (52.94) |
| Radiation | 13 (25.49) |
| Chemoradiation | 12 (23.53) |
| Surgery | 24 (47.06) |
| Patients’ ECOG score | |
| Mean (SD) | 1.43 (0.92) |
| Range | 0 – 3 |
SD = standard deviation; NSCLC = non-small cell lung cancer; SCLC = small cell lung cancer; ECOG = Eastern Cooperative Oncology Group.
Table 3.
Descriptive Statistics for Patient and Caregiver Coping Skills Practice (n = 38 Dyads)
| Coping skill | Patients | Caregivers |
|---|---|---|
| Noticing sounds and thoughts | ||
| Mean (SD) | 5.63 (5.60) | 5.34 (6.42) |
| Range | 0 – 23 | 0 – 24 |
| Guided imagery | ||
| Mean (SD) | 4.61 (5.18) | 3.95 (3.54) |
| Range | 0 – 22 | 0 – 14 |
| Pursed lips breathing | ||
| Mean (SD) | 10.47 (13.70) | 5.95 (8.33) |
| Range | 0 – 51 | 0 – 32 |
| Cognitive restructuring | ||
| Mean (SD) | 6.75 (8.52) | 6.41 (8.59) |
| Range | 0 – 30 | 0 – 32 |
| Problem solvinga | ||
| Mean (SD) | 3.85 (4.38) | 3.26 (4.66) |
| Range | 0 – 16 | 0 – 17 |
| Emotion-focused coping | ||
| Mean (SD) | 4.75 (4.77) | 4.93 (4.87) |
| Range | 0 – 17 | 0 – 19 |
| Assertive communication | ||
| Mean (SD) | 4.83 (4.50) | 4.29 (3.88) |
| Range | 0 – 17 | 0 – 16 |
SD = standard deviation. Coping skills practice was assessed at the beginning of intervention session 4 and represents the amount of practice in the previous week. All statistics computed after outliers were transformed.
One patient response was missing for this coping skill (n = 37).
Table 4.
Descriptive Statistics for Patient and Caregiver Outcomes
| Outcome | Baseline | 6 Weeks Post-intervention |
|---|---|---|
| Patient pain interference | ||
| n | 51 | 34 |
| α | 0.96 | 0.95 |
| Mean (SD) | 2.27 (2.75) | 2.66 (2.77) |
| Range | 0 – 10 | 0 – 9 |
| Patient fatigue interference | ||
| n | 50 | 35 |
| α | 0.94 | 0.94 |
| Mean (SD) | 22.43 (17.19) | 20.11 (17.09) |
| Range | 0 – 60 | 0 – 66 |
| Patient distress related to breathlessness | ||
| n | 51 | 35 |
| αa | -- | -- |
| Mean (SD) | 1.22 (1.12) | 1.20 (1.23) |
| Range | 0 – 4 | 0 – 4 |
| Patient psychological distress | ||
| n | 50 | 35 |
| α | 0.89 | 0.91 |
| Mean (SD) | 12.43 (8.78) | 10.77 (8.13) |
| Range | 0 – 39 | 1 – 39 |
| Caregiver psychological distress | ||
| n | 50 | 35 |
| α | 0.93 | 0.93 |
| Mean (SD) | 11.76 (10.26) | 9.83 (9.35) |
| Range | 0 – 41 | 0 – 36 |
α = alpha coefficient; SD = standard deviation. The variability in sample size is due to missing items.
Alpha coefficient was not computed for distress related to breathlessness because it was measured using one item.
Multiple Regression Results
Results from averaged multiple regression analyses are presented in Table 5. All of the regression models explained significant variability in symptoms at 6 weeks post-intervention, including 40% of patients’ pain interference, 44% of patients’ fatigue interference, 38% of patients’ distress related to breathlessness, 49% of patients’ psychological distress, and 64% of caregivers’ psychological distress. Consistent with our hypotheses, greater practice of assertive communication demonstrated significant, moderate associations with less pain interference (β=−0.45, p=0.02) and less psychological distress (β=−0.36, p=0.047) for patients; greater practice of guided imagery demonstrated a significant, moderate association with less psychological distress (β=−0.30, p=0.01) for caregivers. Contrary to our hypotheses, greater practice of noticing sounds and thoughts demonstrated a significant, moderate association with higher fatigue interference (β=0.49, p=0.04) and a non-significant, moderate association with higher pain interference (β=0.47, p=0.07). Additionally, greater practice of problem solving demonstrated a significant, moderate association with higher distress related to breathlessness (β=0.56, p=0.01) and a non-significant, moderate association with higher psychological distress (β=0.36, p=0.08) for patients. The remaining coping skills demonstrated small, non-significant associations with patient and caregiver outcomes.
Table 5.
Multiple Regressions of Coping Skills Practice Predicting Lung Cancer Patients’ Symptoms (n = 51) and their Family Caregivers’ Psychological Distress (n = 51).
| Outcome | Predictor | R2 | β | B | SE B | 95% CI for B | F (8,42) | t | p-Value | |
|---|---|---|---|---|---|---|---|---|---|---|
| Lower | Upper | |||||||||
| Patient pain interference | 0.40 | 3.58 | 0.02a | |||||||
| Pain interference at baseline | 0.41b | 0.43 | 0.38 | 0.15 | 0.70 | 3.23 | 0.02a | |||
| Noticing sounds and thoughts | 0.47b | 0.26 | 0.37 | < 0.01 | 0.51 | 2.06 | 0.07 | |||
| Guided imagery | −0.14 | −0.09 | 0.37 | −0.34 | 0.17 | −0.66 | 0.49 | |||
| Pursed lips breathing | −0.22 | −0.05 | 0.19 | −0.11 | 0.01 | −1.66 | 0.13 | |||
| Cognitive restructuring | 0.04 | 0.01 | 0.24 | −0.09 | 0.12 | 0.27 | 0.75 | |||
| Problem solving | 0.05 | 0.04 | 0.37 | −0.23 | 0.30 | 0.25 | 0.75 | |||
| Emotion focused coping | −0.04 | −0.03 | 0.34 | −0.24 | 0.17 | −0.26 | 0.70 | |||
| Assertive communication | −0.45b | −0.31 | 0.35 | −0.54 | −0.07 | −2.67 | 0.02a | |||
| Patient fatigue interference | 0.44 | 4.28 | < 0.01a | |||||||
| Fatigue interference at baseline | 0.50b | 0.48 | 0.35 | 0.24 | 0.72 | 4.06 | < 0.01a | |||
| Noticing sounds and thoughts | 0.49b | 1.53 | 0.84 | 0.13 | 2.93 | 2.21 | 0.04a | |||
| Guided imagery | −0.01 | −0.04 | 0.84 | −1.45 | 1.36 | −0.05 | 0.67 | |||
| Pursed lips breathing | −0.01 | −0.02 | 0.42 | −0.36 | 0.32 | −0.10 | 0.63 | |||
| Cognitive restructuring | −0.01 | −0.02 | 0.53 | −0.57 | 0.53 | −0.06 | 0.68 | |||
| Problem solving | 0.18 | 0.74 | 0.85 | −0.70 | 2.18 | 1.03 | 0.35 | |||
| Emotion focused coping | −0.22 | −0.82 | 0.76 | −1.97 | 0.33 | −1.46 | 0.24 | |||
| Assertive communication | −0.28 | −1.11 | 0.80 | −2.39 | 0.18 | −1.74 | 0.10 | |||
| Patient distress related to breathlessness | 0.38 | 3.28 | 0.01a | |||||||
| Distress related to breathlessness at baseline | 0.43b | 0.44 | 0.37 | 0.17 | 0.71 | 3.33 | < 0.01a | |||
| Noticing sounds and thoughts | < 0.01 | < 0.01 | 0.24 | −0.10 | 0.10 | −0.02 | 0.76 | |||
| Guided imagery | 0.27 | 0.06 | 0.24 | −0.04 | 0.17 | 1.27 | 0.24 | |||
| Pursed lips breathing | −0.01 | < 0.01 | 0.14 | −0.03 | 0.02 | −0.04 | 0.58 | |||
| Cognitive restructuring | −0.11 | −0.01 | 0.15 | −0.05 | 0.03 | −0.68 | 0.52 | |||
| Problem solving | 0.56b | 0.16 | 0.25 | 0.05 | 0.26 | 3.02 | 0.01a | |||
| Emotion focused coping | −0.29 | −0.07 | 0.21 | −0.16 | 0.01 | −1.80 | 0.10 | |||
| Assertive communication | −0.22 | −0.06 | 0.22 | −0.15 | 0.03 | −1.29 | 0.21 | |||
| Patient psychological distress | 0.49 | 5.14 | < 0.01a | |||||||
| Patient psychological distress | ||||||||||
| at baseline | 0.28 | 0.27 | 0.38 | 0.01 | 0.53 | 2.16 | 0.10 | |||
| Noticing sounds and thoughts | 0.18 | 0.28 | 0.59 | −0.40 | 0.96 | 0.82 | 0.46 | |||
| Guided imagery | 0.02 | 0.03 | 0.60 | −0.66 | 0.72 | 0.10 | 0.69 | |||
| Pursed lips breathing | 0.12 | 0.07 | 0.30 | −0.09 | 0.24 | 0.93 | 0.43 | |||
| Cognitive restructuring | 0.28 | 0.27 | 0.38 | −0.01 | 0.55 | 1.95 | 0.08 | |||
| Problem solving | 0.36b | 0.74 | 0.60 | 0.04 | 1.44 | 2.16 | 0.08 | |||
| Emotion focused coping | −0.20 | −0.37 | 0.54 | −0.93 | 0.19 | −1.37 | 0.28 | |||
| Assertive communication | −0.36b | −0.70 | 0.57 | −1.34 | −0.06 | −2.22 | 0.047a | |||
| Caregiver psychological distress | 0.64 | 9.72 | < 0.01a | |||||||
| Caregiver psychological distress at baseline | 0.67b | 0.71 | 0.35 | 0.50 | 0.92 | 7.12 | < 0.01a | |||
| Noticing sounds and thoughts | 0.02 | 0.04 | 0.57 | −0.59 | 0.68 | 0.08 | 0.73 | |||
| Guided imagery | −0.30b | −1.01 | 0.60 | −1.75 | −0.28 | −2.78 | 0.01a | |||
| Pursed lips breathing | −0.01 | −0.01 | 0.45 | −0.41 | 0.40 | −0.08 | 0.77 | |||
| Cognitive restructuring | −0.28 | −0.38 | 0.41 | −0.68 | −0.08 | −2.44 | 0.10 | |||
| Problem solving | 0.23 | 0.59 | 0.59 | −0.09 | 1.26 | 1.77 | 0.14 | |||
| Emotion focused coping | −0.08 | −0.22 | 0.64 | −1.02 | 0.58 | −0.46 | 0.55 | |||
| Assertive communication | 0.03 | 0.11 | 0.67 | −0.79 | 1.00 | 0.19 | 0.63 | |||
Outcomes were assessed at 6 weeks post-intervention. Coping skills were assessed at the beginning of intervention session number 4.
Psychological distress refers to depressive and anxiety symptoms. Parameter estimates are averages of 10 imputed datasets, with SE adjusted to account for the variance between imputations. Due to averaging, some confidence intervals do not include zero despite having a p-value ≥ 0.05.
p-value < 0.05.
Moderate effect, defined as β weight ≥ +/− 0.30.
Discussion
The purpose of this study was to identify effective coping skills in a telephone-delivered symptom management (TSM) intervention for symptomatic lung cancer patients and their family caregivers. Linking coping skills to symptom outcomes may inform the development of highly efficacious interventions.13,14 Our hypotheses were based on social cognitive theory21,22 and previous research9–11 suggesting that greater practice of coping skills may reduce specific symptoms. We found that practice of certain coping skills during the intervention was associated with post-intervention improvement in some symptoms; however, practice of other skills demonstrated small, non-significant effects or moderate effects opposite of those hypothesized. These findings provide important information for symptom management interventions in this large, understudied population.
First, consistent with our hypotheses, greater practice of assertive communication during the intervention was associated with less pain interference and psychological distress for patients at 6 weeks post-intervention. Andersen and colleagues9 reported a similar effect in their component analysis of a psychosocial intervention for breast cancer patients. In TSM, dyads were taught to use assertive communication to obtain medical attention for symptoms as well as communicate thoughts and feelings and elicit social support. Prior studies have shown that eliciting social support can reduce multiple symptoms for cancer patients, including pain and psychological distress.8,41–43 Indeed, symptoms are often exacerbated when a patient does not receive sufficient practical assistance. Assertive communication training may improve symptom management in lung cancer patients.
Also consistent with our hypotheses, greater practice of guided imagery during the intervention was associated with less psychological distress for caregivers at 6 weeks post-intervention. Guided imagery is frequently taught in cognitive-behavioral interventions, which tend to produce short-term benefits for cancer caregivers.1,4,44 Few dyadic interventions have included caregivers of lung cancer patients;45 however, the current findings suggest guided imagery may be beneficial for managing psychological distress in this population.
The practice of two coping skills (i.e., noticing sounds and thoughts, problem solving) was associated with increases in certain symptoms for patients. These results should be interpreted cautiously as they are inconsistent with other studies.9–11 First, greater practice of noticing sounds and thoughts during the intervention was associated with higher pain and fatigue interference at 6 weeks post-intervention. This coping skill is derived from mindfulness-based therapies that encourage experiencing the present moment non-judgmentally and with acceptance.46 Mindfulness-based interventions are often much longer than TSM and focus exclusively on this approach.47–49 In TSM this skill may have heightened patients’ awareness of their symptoms, but may not have provided enough training for patients to experience less symptom interference. Second, greater practice of problem solving was associated with higher distress related to breathlessness and psychological distress for patients at 6 weeks post-intervention. Numerous dyadic interventions in cancer populations have included problem solving and demonstrated symptom reductions.1,4 However, these interventions rarely included lung cancer patients and taught a variety of coping skills. Without component analyses or dismantling studies it is impossible to disentangle individual coping skill effects. There are other explanations for the current findings, such as spurious associations. For example, breathlessness often increases concurrently with disease progression.50 Patients with worsening disease may increase their use of problem solving to address numerous concerns (e.g., treatment decisions), leading to a spurious association with breathlessness through deteriorating health. Further research is needed to determine whether aspects of mindfulness interventions and problem-solving approaches are beneficial for lung cancer patients.
Practice of other coping skills showed small, non-significant associations with patient and caregiver symptoms. TSM may have been too brief given the number of coping skills that were taught and the severity of participants’ symptoms. A meta-analysis of interventions with caregivers of cancer patients found that a higher dose (i.e., number of sessions and hours) of coping skills based interventions produced better coping efforts.4 However, intervention dose was positively associated with caregiver depressive symptoms4 and, in a meta-analysis of dyadic interventions,1 dose was unrelated to patient outcomes. Additionally, TSM was delivered via telephone which may have limited participants’ ability to learn skills that could be demonstrated in-person.
There are numerous strengths of this study that are worth noting. To our knowledge, this was the first study to report associations between coping skills practice and outcomes in a dyadic intervention for cancer patients and their caregivers. It included a rigorous longitudinal design with blind assessments of outcomes, in-depth training of staff, and fidelity monitoring. Additionally, data imputation with auxiliary variables was utilized to increase the accuracy of parameter estimates.34
Limitations of this study and future research directions should be noted. Associations between coping skills and outcomes are consistent with causality but may be attributed to spurious, reciprocal, or indirect effects.32 Only an RCT comparing individual coping skills can definitively support causal claims. Future studies should consider using a multiphase optimization strategy (MOST) design to identify and test intervention components.51 There was also an increased potential for error given the multiple analyses. Moreover, the relatively small sample size likely reduced the accuracy of the parameter estimates. Larger studies would allow for dyadic analyses, inclusion of covariates, and exploration of symptom clusters. Exploring coping skills in relation to symptom clusters would take into account the co-occurrence of cancer-related symptoms.52 Lastly, whether these findings generalize to a more geographically and ethnically diverse sample requires further investigation.
Our findings demonstrate the utility of analyzing intervention components in relation to outcomes in psychosocial interventions: competing and small effects of certain coping skills likely reduced the effectiveness of TSM. Future interventions should consider focusing on assertive communication training for lung cancer patients and guided imagery for their caregivers, as practice of these skills was associated with improved outcomes. In recent years, there has been an increased focus on brief, theory-driven symptom management interventions for cancer populations. Effective components of these interventions must be identified and tested in order to advance this field of study and, ultimately, reduce the burden of cancer.
Supplementary Material
Acknowledgments
Funding: This work was supported by grants 130526-PF-17-054-01-PCSM (PI: Winger), PEP-13-236-01-PCSM (PI: Mosher) from the American Cancer Society, an American Cancer Society Institutional Research grant (project PI: Mosher), and K07CA168883 (PI: Mosher) and K05CA175048 (PI: Champion) from the National Cancer Institute.
This material is the result of work supported with resources and the use of facilities at the Roudebush VA Medical Center in Indianapolis, IN. The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States Government. The study sponsors were not involved in the study design, the collection, analysis and interpretation of data, the writing of this report, or the decision to submit the article for publication.
The authors thank Susan Daily, BS, RT(T), Barbara A. Given, PhD, John McGrew, PhD, Richard Frankel, PhD, and the study therapists as well as the physicians and staff for their assistance with recruitment at the Indiana University Simon Cancer Center, Roudebush VA Medical Center, and Eskenazi Health hospital. The authors also thank the study participants for their time and effort.
Footnotes
Disclosures
The authors declare no conflicts of interest.
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
References
- 1.Badr H, Krebs P. A systematic review and meta-analysis of psychosocial interventions for couples coping with cancer. Psychooncology. 2013;22:1688–1704. doi: 10.1002/pon.3200. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Hagedoorn M, Sanderman R, Bolks HN, Tuinstra J, Coyne JC. Distress in couples coping with cancer: A meta-analysis and critical review of role and gender effects. Psychol Bull. 2008;134:1–30. doi: 10.1037/0033-2909.134.1.1. [DOI] [PubMed] [Google Scholar]
- 3.Li Q, Loke AY. A systematic review of spousal couple-based intervention studies for couples coping with cancer: Direction for the development of interventions. Psychooncology. 2014;23:731–739. doi: 10.1002/pon.3535. [DOI] [PubMed] [Google Scholar]
- 4.Northouse LL, Katapodi MC, Song L, Zhang L, Mood DW. Interventions with family caregivers of cancer patients: Meta-analysis of randomized trials. CA Cancer J Clin. 2010;60:317–339. doi: 10.3322/caac.20081. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Lin C-C, Chou P-L, Wu S-L, Chang Y-C, Lai Y-L. Long-term effectiveness of a patient and family pain education program on overcoming barriers to management of cancer pain. Pain. 2006;122:271–281. doi: 10.1016/j.pain.2006.01.039. [DOI] [PubMed] [Google Scholar]
- 6.Baucom DH, Porter LS, Kirby JS, et al. A couple-based intervention for female breast cancer. Psychooncology. 2009;18:276–283. doi: 10.1002/pon.1395. [DOI] [PubMed] [Google Scholar]
- 7.Badger TA, Segrin C, Figueredo AJ, et al. Psychosocial interventions to improve quality of life in prostate cancer survivors and their intimate or family partners. Qual Life Res. 2011;20:833–844. doi: 10.1007/s11136-010-9822-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Porter LS, Keefe FJ, Garst J, et al. Caregiver-assisted coping skills training for lung cancer: Results of a randomized clinical trial. J Pain Symptom Manage. 2011;41:1–13. doi: 10.1016/j.jpainsymman.2010.04.014. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Andersen BL, Shelby RA, Golden-Kreutz DM. RCT of a psychological intervention for patients with cancer: I. Mechanisms of change. J Consult Clin Psychol. 2007;75:927–938. doi: 10.1037/0022-006X.75.6.927. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Chan CW, Richardson A, Richardson J. Evaluating a complex intervention: A process evaluation of a psycho-education program for lung cancer patients receiving palliative radiotherapy. Contemp Nurse. 2012;40:234–244. doi: 10.5172/conu.2012.40.2.234. [DOI] [PubMed] [Google Scholar]
- 11.Cohen M, Fried G. Comparing relaxation training and cognitive-behavioral group therapy for women with breast cancer. Res Soc Work Pract. 2007;17:313–323. [Google Scholar]
- 12.Curran C, Williams AC, Potts HW. Cognitive-behavioral therapy for persistent pain: Does adherence after treatment affect outcome? European Journal of Pain. 2009;13:178–188. doi: 10.1016/j.ejpain.2008.06.009. [DOI] [PubMed] [Google Scholar]
- 13.Kazdin AE. Mediators and mechanisms of change in psychotherapy research. Annu Rev Clin Psychol. 2007;3:1–27. doi: 10.1146/annurev.clinpsy.3.022806.091432. [DOI] [PubMed] [Google Scholar]
- 14.Czaja SJ, Schulz R, Lee CC, Belle SH. A methodology for describing and decomposing complex psychosocial and behavioral interventions. Psychol Aging. 2003;18:385–395. doi: 10.1037/0882-7974.18.3.385. [DOI] [PubMed] [Google Scholar]
- 15.Andersen BL, Kiecolt-Glaser JK, Glaser R. A biobehavioral model of cancer stress and disease course. Am Psychol. 1994;49:389–404. doi: 10.1037//0003-066x.49.5.389. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Mosher CE, Winger JG, Hanna N, et al. Randomized pilot trial of a telephone symptom management intervention for symptomatic lung cancer patients and their family caregivers. J Pain Symptom Manage. 2016;52:469–482. doi: 10.1016/j.jpainsymman.2016.04.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Hopwood P, Stephens R. Symptoms at presentation for treatment in patients with lung cancer: Implications for the evaluation of palliative treatment. Br J Cancer. 1995;71:633–636. doi: 10.1038/bjc.1995.124. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Dudgeon DJ, Kristjanson L, Sloan JA, Lertzman M, Clement K. Dyspnea in cancer patients: Prevalence and associated factors. J Pain Symptom Manage. 2001;21:95–102. doi: 10.1016/s0885-3924(00)00258-x. [DOI] [PubMed] [Google Scholar]
- 19.Mosher CE, Bakas T, Champion VL. Physical health, mental health, and life changes among family caregivers of patients with lung cancer. Oncol Nurs Forum. 2013;40:53–61. doi: 10.1188/13.ONF.53-61. [DOI] [PubMed] [Google Scholar]
- 20.Rueda J-R, Solà I, Pascual A, Subirana Casacuberta M. Non-invasive interventions for improving well-being and quality of life in patients with lung cancer. Cochrane Database Syst Rev. 2011;9:CD004282. doi: 10.1002/14651858.CD004282.pub3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Bandura A. Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall; 1986. [Google Scholar]
- 22.Bandura A. Health promotion by social cognitive means. Health Educ Behav. 2004;31:143–164. doi: 10.1177/1090198104263660. [DOI] [PubMed] [Google Scholar]
- 23.Mosher CE, Ott MA, Hanna N, Jalal SI, Champion VL. Development of a symptom management intervention: Qualitative feedback from advanced lung cancer patients and their family caregivers. Cancer Nurs. 2017;40:66–75. doi: 10.1097/NCC.0000000000000350. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J. Self-management approaches for people with chronic conditions: A review. Patient Educ Couns. 2002;48:177–187. doi: 10.1016/s0738-3991(02)00032-0. [DOI] [PubMed] [Google Scholar]
- 25.Cleeland CS, Gonin R, Hatfield AK, et al. Pain and its treatment in outpatients with metastatic cancer. N Engl J Med. 1994;330:592–596. doi: 10.1056/NEJM199403033300902. [DOI] [PubMed] [Google Scholar]
- 26.Tittle MB, McMillan SC, Hagan S. Validating the brief pain inventory for use with surgical patients with cancer. Oncol Nurs Forum. 2003;30:325–330. doi: 10.1188/03.ONF.325-330. [DOI] [PubMed] [Google Scholar]
- 27.Hann DM, Denniston MM, Baker F. Measurement of fatigue in cancer patients: Further validation of the Fatigue Symptom Inventory. Qual Life Res. 2000;9:847–854. doi: 10.1023/a:1008900413113. [DOI] [PubMed] [Google Scholar]
- 28.Portenoy RK, Thaler HT, Kornblith AB, et al. The Memorial Symptom Assessment Scale: An instrument for the evaluation of symptom prevalence, characteristics and distress. Eur J Cancer. 1994;30:1326–1336. doi: 10.1016/0959-8049(94)90182-1. [DOI] [PubMed] [Google Scholar]
- 29.Löwe B, Unützer J, Callahan CM, Perkins AJ, Kroenke K. Monitoring depression treatment outcomes with the Patient Health Questionnaire-9. Med Care. 2004;42:1194–1201. doi: 10.1097/00005650-200412000-00006. [DOI] [PubMed] [Google Scholar]
- 30.Kroenke K, Spitzer RL, Williams JB, Löwe B. The Patient Health Questionnaire somatic, anxiety, and depressive symptom scales: A systematic review. Gen Hosp Psychiatry. 2010;32:345–359. doi: 10.1016/j.genhosppsych.2010.03.006. [DOI] [PubMed] [Google Scholar]
- 31.Kroenke K, Spitzer RL, Williams JB, Monahan PO, Löwe B. Anxiety disorders in primary care: Prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146:317–325. doi: 10.7326/0003-4819-146-5-200703060-00004. [DOI] [PubMed] [Google Scholar]
- 32.Tabachnick B, Fidell L. Using multivariate statistics. 5. Boston, MA: Pearson; 2007. [Google Scholar]
- 33.Tukey JW. The future of data analysis. Ann Math Stat. 1962;33:1–67. [Google Scholar]
- 34.Collins LM, Schafer JL, Kam C-M. A comparison of inclusive and restrictive strategies in modern missing data procedures. Psychol Methods. 2001;6:330–351. [PubMed] [Google Scholar]
- 35.LISREL (Version 8.8) [computer program] Chicago, IL: Scientific Software International; 2008. [Google Scholar]
- 36.Schafer JL. Analysis of incomplete multivariate data. New York, NY: Chapman & Hall/CRC; 1997. [Google Scholar]
- 37.IBM SPSS Statistics for Windows (Version 23.0) [computer program] Armonk, NY: IBM Corp; 2015. [Google Scholar]
- 38.Kenny DA, Kashy DA, Cook WL. Dyadic data analysis. New York, NY: Guilford Press; 2006. [Google Scholar]
- 39.Rubin DB. Multiple imputation for nonresponse in surveys. Hoboken, NJ: John Wiley & Sons, Inc; 2004. [Google Scholar]
- 40.Wasserstein RL, Lazar NA. The ASA's statement on p-values: Context, process, and purpose. Am Stat. 2016;70:129–133. [Google Scholar]
- 41.Berger AM, Gerber LH, Mayer DK. Cancer-related fatigue. Cancer. 2012;118:2261–2269. doi: 10.1002/cncr.27475. [DOI] [PubMed] [Google Scholar]
- 42.Keefe FJ, Ahles TA, Sutton L, et al. Partner-guided cancer pain management at the end of life: A preliminary study. J Pain Symptom Manage. 2005;29:263–272. doi: 10.1016/j.jpainsymman.2004.06.014. [DOI] [PubMed] [Google Scholar]
- 43.Badr H, Taylor CLC. Social constraints and spousal communication in lung cancer. Psychooncology. 2006;15:673–683. doi: 10.1002/pon.996. [DOI] [PubMed] [Google Scholar]
- 44.Barlow DH. Clinical handbook of psychological disorders: A step-by-step treatment manual. New York, NY: Guilford Press; 2014. [Google Scholar]
- 45.Badr H, Smith CB, Goldstein NE, Gomez JE, Redd WH. Dyadic psychosocial intervention for advanced lung cancer patients and their family caregivers: Results of a randomized pilot trial. Cancer. 2015;121:150–158. doi: 10.1002/cncr.29009. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 46.Kabat-Zinn J, Hanh TN. Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York, NY: Delacorte Press; 2009. [Google Scholar]
- 47.Rush SE, Sharma M. Mindfulness-Based Stress Reduction as a stress management intervention for cancer care: A systematic review. J Evid Based Complementary Altern Med. 2017;22:348–360. doi: 10.1177/2156587216661467. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 48.Haller H, Winkler MM, Klose P, Dobos G, Kümmel S, Cramer H. Mindfulness-based interventions for women with breast cancer: An updated systematic review and meta-analysis. Acta Oncol. 2017:1–12. doi: 10.1080/0284186X.2017.1342862. [DOI] [PubMed] [Google Scholar]
- 49.Rouleau CR, Garland SN, Carlson LE. The impact of mindfulness-based interventions on symptom burden, positive psychological outcomes, and biomarkers in cancer patients. Cancer Manag Res. 2015;7:121–131. doi: 10.2147/CMAR.S64165. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 50.Weingaertner V, Scheve C, Gerdes V, et al. Breathlessness, functional status, distress, and palliative care needs over time in patients with advanced chronic obstructive pulmonary disease or lung cancer: A cohort study. J Pain Symptom Manage. 2014;48:569–581. doi: 10.1016/j.jpainsymman.2013.11.011. [DOI] [PubMed] [Google Scholar]
- 51.Collins LM, Murphy SA, Strecher V. The multiphase optimization strategy (MOST) and the sequential multiple assignment randomized trial (SMART): new methods for more potent eHealth interventions. Am J Prev Med. 2007;32:S112–S118. doi: 10.1016/j.amepre.2007.01.022. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 52.Xiao W, Chow KM, So WK, Leung DY, Chan CW. The effectiveness of psychoeducational intervention on managing symptom clusters in patients with cancer: A systematic review of randomized controlled trials. Cancer Nurs. 2016;39:279–291. doi: 10.1097/NCC.0000000000000313. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.