Supportive Care in Cancer

, Volume 19, Issue 7, pp 871–881

Evidence for interventions to improve psychological outcomes in people with head and neck cancer: a systematic review of the literature

Authors

    • Psycho-oncology Co-operative Research Group (PoCoG)The University of Sydney
    • Improving Palliative Care through Clinical Trials (ImPaCCT) South Western Sydney Clinical School, Faculty of Medicine,University of NSW (UNSW)
    • Department of Palliative CareBraeside Hospital
  • B. Britton
    • Psycho-oncology ServiceCalvary Mater Hospital
    • Centre for Brain and Mental Health ResearchUniversity of Newcastle
  • K. Clover
    • Psycho-oncology ServiceCalvary Mater Hospital
    • Centre for Brain and Mental Health ResearchUniversity of Newcastle
  • N. M. Rankin
    • Psycho-oncology Co-operative Research Group (PoCoG)The University of Sydney
    • Health research consultant
Review Article

DOI: 10.1007/s00520-011-1119-7

Cite this article as:
Luckett, T., Britton, B., Clover, K. et al. Support Care Cancer (2011) 19: 871. doi:10.1007/s00520-011-1119-7

Abstract

Purpose

In addition to cancer-related distress, people with head and neck cancer (HNC) endure facial disfigurement and difficulties with eating and communication. High rates of alcohol use and socio-economic disadvantage raise concerns that patients with HNC may be less likely than others to participate in and adhere to psychological interventions. This article aims to inform future practice and research by reviewing the evidence in support of psychological interventions for this patient group.

Methods

We searched CENTRAL, Medline, Embase, PsycINFO and CINAHL in December 2009. Relevant studies were rated for internal and external validity against the criteria of the Agency for Healthcare Research and Quality (AHRQ) US Preventive Services Task Force. Wherever possible, outcomes were evaluated using effect sizes to confirm statistically significant results and enable comparison between studies. Meta-analysis was planned according to criteria in the Cochrane Handbook for Systematic Reviews. Levels of evidence for each intervention type were evaluated using AHRQ criteria.

Results

Nine studies met inclusion criteria. One study was rated ‘good’ for internal validity and four for external validity. Psycho-education and/or cognitive–behavioural therapy were evaluated by seven studies, and communication skills training and a support group by one study each. Significant heterogeneity precluded meta-analysis. Based on a study-by-study review, there was most support for psycho-education, with three out of five studies finding at least some effect.

Conclusions

Research to date suggests it is feasible to recruit people with HNC to psychological interventions and to evaluate their progress through repeated-outcome measures. Evidence for interventions is limited by the small number of studies, methodological problems, and poor comparability. Future interventions should target HNC patients who screen positive for clinical distress and be integrated into standard care.

Keywords

Head and neck cancerPsychological interventionsSystematic reviewDistressAnxiety DepressionQuality of life

Introduction

Head and neck cancer (HNC) is an umbrella term for cancers arising in the nasal cavity, sinuses, lips, mouth, salivary glands, throat, or larynx [1]. HNC is more common in men and is associated with heavy alcohol use and smoking. Indeed, a quarter or more of oropharyngeal, esophageal, and laryngeal cancers worldwide can be attributed to alcohol [2], and around half of HNC patients continue to use alcohol post-diagnosis [3]. Smoking and heavy alcohol use are associated with psychological distress [4], suggesting premorbid vulnerability among people with HNC. Associations between HNC and socio-economic disadvantage [5] and between disadvantage and distress, both in the general population [4] and in cancer patients [6], add to the risk for this patient group. These interacting factors raise concerns that HNC patients may have particular need of psychological interventions but be less likely than other cancer patients to participate and adhere. Concerns are all the greater because HNC and its treatment confer specific stressors over and above those associated with cancer more generally, including disfigurement, changes in sexuality, and difficulties with eating and communication [715]. Depression, in particular, seems to increase during treatment, with a third or more patients presenting at or above clinical levels by treatment end [16, 17].

Rationale for the current review

Systematic reviews have found at least some evidence to support psychological interventions in samples with mixed cancer types [1820]. But, a recent review-of-reviews highlighted the need to establish evidence for interventions in specific cancer groups and men in particular [21]. HNC patients are a group for whom interventions and delivery may need to be adapted to produce optimal outcomes. The only previous review dedicated to psychological interventions in HNC was non-systematic and identified just a few studies with HNC-only samples [22].

Objectives

We undertook a systematic review of the literature on psychological interventions in HNC with the aim of informing future practice and research. More specifically, we aimed to establish:
  1. 1.

    Which sub-groups of people with HNC have been included in intervention studies;

     
  2. 2.

    Whether rates of participation in and adherence to interventions and research have demonstrated feasibility;

     
  3. 3.

    Which types of psychological intervention have been used and how these have been delivered;

     
  4. 4.

    Which outcomes have been targeted and what evidence there has been for improving these.

     

Method

Procedure

Eligibility criteria

To be included, articles had to report:
  1. 1.

    Psychological interventions carried out with people living with or surviving HNC;

     
  2. 2.

    Evaluation of such interventions with patient-reported outcome measures (PROMs) assessing anxiety, depression or distress. A broad definition of distress was adopted in accordance with clinical practice guidelines developed by the National Comprehensive Cancer Network (NCCN) [23]. As such, distress was taken to include coping and adjustment, fear of recurrence or death, life satisfaction and existential/spiritual wellbeing as well as outcomes shown to be especially impacted by HNC such as body image, psychosexuality and self-esteem. Results from multi-dimensional health-related quality of life (HRQoL) questionnaires assessing emotional/psychological wellbeing/functioning or overall/global quality of life were also included.

     
Specific exclusions related to:
  1. 1.

    Reports of psychological interventions that included participants with HNC among a more heterogeneous sample and did not report results specific to a HNC sub-group;

     
  2. 2.

    Reports of interventions aimed at improving psychological outcomes in persons caring for someone with HNC;

     
  3. 3.

    Reports of outcomes relating to social functioning or support or behaviours such as smoking;

     
  4. 4.

    Studies where psychological outcomes as defined above were not stated targets of the intervention reported. This included studies where medical treatments targeting physical wellbeing or symptoms were found to also impact emotional wellbeing as measured by a multi-dimensional HRQoL questionnaire;

     
  5. 5.

    Studies with an overall sample size of less than ten, which was considered too small for meaningful analysis.

     

Information sources

In December 2009, systematic searches were undertaken of CENTRAL, Medline, Embase, PsycINFO and CINAHL databases.

Search

Search terms are described in box 1. In all databases, searches for ‘head and neck cancer/neoplasms’ include a subordinate search for relevant, individual tumour types. No publication date limits were set. The Ovid platform was searched for papers citing each article that met the review’s inclusion criteria. The reference lists of all relevant articles were searched to identify further studies of interest. In addition, we searched the reference lists of recent reviews of psychosocial issues in HNC [7, 12, 13, 22, 24, 25] and psychological interventions in cancer more generally [1821, 26, 27].

Box 1. Example of database search terms

MEDLINE

MeSH descriptor ‘head and neck neoplasms’ explode

MeSH descriptor ‘psychological’ explode and ‘psychological’ keyword

MeSH descriptor ‘depression’ explode and ‘depression’ keyword

MeSH descriptors ‘anxiety’ and ‘anxiety disorders’ explode and ‘anxiety’ keyword

‘Distress’ keyword

MeSH descriptor ‘psychological’ explode and ‘psychological’ keyword OR MeSH descriptor ‘depression’ explode and ‘depression’ keyword; OR MeSH descriptors ‘anxiety’ and ‘anxiety disorders’ explode and ‘anxiety’ keyword; OR ‘distress’ keyword

MeSH descriptor ‘head and neck neoplasms’ explode; AND MeSH descriptor ‘psychological’ explode and ‘psychological’ keyword OR MeSH descriptor ‘depression’ explode and ‘depression’ keyword; OR MeSH descriptors ‘anxiety’ and ‘anxiety disorders’ explode and ‘anxiety’ keyword; OR ‘distress’ keyword

MeSH descriptor ‘Intervention studies’ explode and ‘intervention’ key word

MeSH descriptor ‘head and neck neoplasms’ explode; AND MeSH descriptor ‘psychological’ explode and ‘psychological’ keyword OR MeSH descriptor ‘depression’ explode and ‘depression’ keyword; OR MeSH descriptors ‘anxiety’ and ‘anxiety disorders’ explode and ‘anxiety’ keyword; OR ‘distress’ keyword; AND MeSH descriptor ‘Intervention studies’ explode and ‘intervention’ key word

Study selection

The titles and abstracts of returned articles were screened for eligibility by one reviewer; full-text articles were obtained where more information was needed.

Data collection

Data were extracted by one reviewer using a checklist of data items.

Data items

Data were extracted from each report concerning the characteristics of the sample (nationality, age, gender, diagnoses and cancer stages), intervention (type, treatment context, delivery, duration, number of sessions, measures of fidelity or adherence) and design and methodology of the study used to evaluate it (including group allocation, outcomes and PROMs). We also extracted baseline and outcome data (mean scores and standard deviations) from measures of interest and results from analyses used to examine intervention effects.

Where results were reported from the same study in more than one publication, the reports were reviewed in combination to extract all the information required.

Risk of bias in individual studies

The internal and external validity of each study was evaluated independently by two reviewers according to an adaptation of the online procedures provided by the AHRQ US Preventive Services Task Force [28]. These procedures require a rating of “good’, “fair” or “poor’ to be allocated to the internal and external validity of each study against specified criteria relating to its methodology and the generalizability of its findings. Unlike some other checklists, procedures offered by the AHRQ are not limited to randomised controlled trials (RCTs). Adaptations were as follows. Because psychological outcomes are necessarily patient-reported, the AHRQ’s requirement that outcomes be masked was not enforced. When rating external validity, we used cancer services in the Australian public health system as the referent. We expanded the ‘providers’ criterion to include not only the availability of staff skills but also staff time and any other resources required by interventions. Any disagreements between the two reviewers were resolved through discussion.

Summary measures

Each intervention was classified according to categories adapted from a list compiled by Jacobsen and Jim (2008) [21] from guidelines for the management of distress published by the NCCN [23] and National Breast Cancer Centre and National Cancer Control Initiative of Australia [29] (see Table 1).
Table 1

Types of common psychosocial interventions adapted from Jacobsen and Jim (2008) [21] p. 217

Behavioural therapy

Focuses on identifying problematic behaviours and replacing them with more adaptive behaviours

Cognitive therapy

Focuses on recognising and changing maladaptive thought patterns to reduce negative emotions and facilitate psychological adjustment

Cognitive–behavioural therapy (CBT)

Focuses on recognising and changing maladaptive thought patterns and behaviours to reduce negative emotions and facilitate psychological adjustment

Communication skills training

Used to modify verbal and nonverbal interactions with the goals of reducing interpersonal conflict and increasing the accuracy of information exchanged

Education/psycho-education

Provision of information through print, audiovisual, or interpersonal channels designed to increase knowledge of a subject area and reduce uncertainty

Family therapy/counselling

Focuses on modifying problematic interactions within a family through conjoint sessions with family members

Problem-solving therapy

Focuses on generating, applying, and evaluating solutions to identified problems

Stress management (including relaxation) training

Techniques for releasing physical or mental tension that may involve meditative activities, progressive tensing and relaxing of muscle groups, or use of guided imagery

Support group

Meetings that may or may not be facilitated by a professional at which individuals discuss issues of common concern

Supportive-expressive group therapy

Focuses on expression of emotions in a supportive group environment to reduce negative emotions and promote psychological adjustment

Synthesis of results

Meta-analysis was planned according to the criteria laid out in the Cochrane Handbook for Systematic Reviews [30] and heterogeneity assessed using chi-square via the Cochrane Collaboration’s Review Manager (RevMan) software. It was anticipated that interventions and study sampling procedures, designs and outcomes would be too heterogeneous to enable meta-analysis. Where meta-analysis was not possible, effect sizes (ESs) and 95% confidence intervals calculated by RevMan were still used as a standard unit for comparing between results of different studies. Conventionally, an ES of 0.2 is considered small, 0.5 moderate and 0.8 large [31]. Where more than one time-point was compared with baseline, we focused on the comparison between baseline and the latest follow-up where attrition was <20% to evaluate whether interventions had lasting effects.

Finally, the AHRQ guidelines [28] were used to evaluate the level of evidence for each type of intervention.

Results

Study selection

Initial database searches returned 1,358 articles. Of these, ten articles met the review’s inclusion criteria, reporting outcomes from evaluation of nine interventions. Two articles reported studies with sample sizes of less than ten [32, 33]. A further evaluation, of a social rehabilitation programme for patients with HNC, was reported only in a PhD thesis [34] that could not be obtained for review. Finally, several studies included patients with HNC within more heterogeneous samples and did not report results specific to a HNC group.

Study characteristics

Table 2 summarises the samples, intervention types, intervention delivery, designs and outcomes across the nine studies.
Table 2

Characteristics of the nine samples, interventions and studies

Sample

Patients with various HNC diagnoses

89% (8)

Patients with oral cancer

11% (1)

Intervention typea

Education/psycho-education

55% (5)

CBT

33% (3)

Support group

22% (2)

Communication skills training

22% (2)

SET (group)

11% (1)

Stress management

22% (2)

Intervention deliverya

Nurse-led

67% (6)

Psychologist/therapist-led

22% (2)

Multi-disciplinary

22% (2)

Design

RCTs

22% (2)

Pre-/post- with concurrent controls and allocation

56% (5)

Pre-/post- with no controls

11% (1)

Post-test only with controls

11% (1)

Patient-reported outcomesa

HRQoL

78% (7)

Anxiety and depression

67% (6)

Depression only

11% (1)

Other, non-psychological measure

44% (4)

Percentages indicate the proportion of the nine interventions or studies which the characteristic describes while the number in brackets is the number of interventions or studies

CBT cognitive–behavioural therapy, SET supportive-expressive therapy, RCTs randomised controlled trials, HRQoL health-related quality of life

aSome interventions or studies used more than one

Table 3 describes the samples and interventions involved in each study.
Table 3

Key characteristics of nine head and neck cancer samples and psychological interventions

Ref

Sample

Intervention

Sample size at baseline, N

Description

Response rate (%)

%F

Mean age

Type

Delivery

Duration

N of sessions

Fidelity/adherence

[43]

184

US out-patients with stages 1 to 4 cancer of the oral cavity, oropharynx/hypopharynx or larynx

51

16

57

CBT

Nurse-led, individual

NR

9 to 11

Visits to each site by primary investigator to deliver booster training

[42]

17

German out-patients with heterogeneous HNC diagnoses not otherwise specified whose most recent surgery was less than 4 years previous

54

NR

56

CST

Behaviour therapist-led groups

10 week

10

NR

[36]

47

Swedish out-patients on active treatment with stage 1 to 4 cancer of the salivary glands, sinus, larynx, tonsil, hypopharynx, epipharynx or tongue

52

38

53 I; 65 C

CBT+SM

Psychologist-led groups

10 months

22

8/13 of intervention group participated in >1 session

 

14

Swedish patients in rehabilitation post-primary treatment or during relapse with stages 1 to 4 cancer of the hypopharynx, larynx tonsils or oral cavity (and spouses)

33

21

57

SET+PE

Physician and nurse-led groups+individual appointments with other disciplines

1 week

‘Intensive’

NR

[37]

19

Canadian in-patients undergoing curative surgery for oral cancer

NR

30 I; 44 C

53 I; 60 C

PE

Nurse-led, individual

Pre- and post-operative

2

NR

[35]

144

Swedish out-patients undergoing radiotherapy or chemotherapy post-surgery for stages 1 to 4 cancer of the pharynx, larynx or oral cavity

68

19 I; 27 C

60 I; 61 C

PE+SG

Nurse-led, individual

1 year

Mean 20

‘Most patients came to the cancer support team on all planned visits, and many requested extra visits’

[38]

54

Irish out-patients who had completed treatment for mostly advanced cancer of the oral cavity, larynx or pharynx

89

28 I; 24 C

51% over 61

CBT+PE+CST

Clinical nurse specialist, individual home visits

4–12 (mean, 8 weeks)

2–6 (mean 4)

CBT training given

[44]

47

US out-patients attending a tertiary Veterans Affairs Medical Center at least 3 months post-treatment for cancer of the oral cavity, oral pharynx, larynx, hypopharynx, nose/cheek or temporal bone

NR

0

66

SG

Multi-disciplinary groups

Up to 3 year

2–17 (mean 6)

NR

[3941]

101

Canadian Jewish out-patients with heterogeneous HNC diagnoses

52

Sig. more males

NR

PE+SM

Nurse-led, choice of (1) small group and/or (2) one-to-one; or (3) home alone

NR

NR

NR

%F proportion female, C comparison group, CBT cognitive–behavioural therapy, CST communication skills training, I intervention group, NR not reported, PE psycho-education, SET supportive-expressive therapy (group), SG support group, SM stress management

Risk of bias within studies

Ratings of internal and external validity are summarised in Table 4. Response rates for the seven studies where this was reported ranged from 33% to 89% (mean 57%). Adherence was reported for only two interventions and was good in one [35] but poor in the second [36]. Attrition on outcome measures was ≤20% in all but two [35, 36] of the eight studies that used pre- and post-measures [3543].
Table 4

Summaries of ratings of internal and external validity of the nine studies

References

IV rating

Issues

EV rating

Issues

[43]

Good

Few details on concealment; contamination possible; only p values available

Fair

Excluded severely depressed and those with severe alcohol problems; 40% response rate; moderate demands on skills and time—trained nurse required to run 9 to 11 sessions

[42]

Poor

Ad hoc measures for some outcomes; lack of controls for social exposure, functioning and support; contamination possible

Fair

Moderate demands on skills and time—two trained behaviour therapists required to run ten sessions over 10 weeks

[36]

Poor

Group allocation depended on distance from centre and groups differed according to age and cancer site and stage; attrition 24%; only 8/13 attended >1 session; contamination possible

Fair

Moderate demands on skills and time—psychologist required to run 22 sessions over 10 months

 

Poor

No comparison group

Poor

Highly resource-intensive individualised, multi-disciplinary 1-week intervention for both patients and caregivers

[37]

Fair

Age, surgery and MMSE scores differed between groups; trend for usual care group to be more disfigured; contamination possible

Good

None

[35]

Fair

Group allocation depended on distance from centre; attrition 33%; lack of control for social support; contamination possible

Good

None

[38]

Fair

Group allocation by self-selection; contamination possible

Poor

Large demand on skills and time and transport resources—specialist nurse trained in several intervention types required to make home visits

[44]

Poor

Post-test only

Good

None

[3941]

Fair

Groups differed on sex and age

Format 1: good

None

   

Format 2: fair

Moderate demands on skills and time—trained nurse required to run individual sessions

   

Format 3: good

None

IV internal validity, EV external validity, MMSE Mini-Mental State Examination

Results of individual studies

Table 5 summarises designs, outcome measures and results for each study.
Table 5

Summary of designs, methodologies and findings from nine studies evaluating psychological interventions for people with head and neck cancer

Reference

Sample size at baseline

Intervention

Design

Allocation

Outcomes

Measures

Results reported

ES [95% CIs]

[43]

184

CBT

RCT

Randomized

Depression

CES-D [51]

Difference in percent improved p = 0.668 NS

ID

[42]

17

CST

Pre-/post- with concurrent controls and allocation

Matched-group allocation, though logistics also played a role

Self-insecurity

Unnamed German questionnaire [52]

General insecurity p < 0.05 (pre-/post-); anxiety to demand p < 0.025 (exp/control); inability to reject p < 0.05 (pre-/post-) and p < 0.01 (exp/control)

ID

     

Contact anxiety

Unnamed German questionnaire [52]

Anxiety in social situations p < 0.01 (pre-/post-) and p < 0.05 (exp/control); contact anxiety p < 0.01 (pre-/post-) and p < 0.05 (exp/control)

ID

     

Self-image/self-ideal image

Ad hoc

No significant differences (not reported further)

ID

     

Evaluation of treatment effects

Ad hoc

Significant results were found (not reported further)

ID

[36]

47

CBT+SM

Pre-/post- with concurrent controls and allocation*

Based on distance from cancer centre

HRQoL

EORTC QLQ-C30 [53]

At 1 year f/up EF and Global QOL improved ≥10 points in the intervention group compared with only EF for controls. At baseline, controls had scores better by ≥10 points on EF

ID

     

Anxiety or depression

HADS [54]

At 1 year f/up, number in intervention group scoring >7* on either HADS-A or HADS-D = 1 (13%) compared with 6 (24%) controls. At baseline, 6 (75%) in the intervention group scored >7 compared with 6 (24%) controls

ID

 

14

SET+PE

Pre-/post- with no control group

N/A

HRQoL

EORTC QLQ-C30 [53]

At 4 week f/up neither EF nor Global QOL ≥ 10 points better compared with before rehab

ID

     

Anxiety or depression

HADS [54]

At 4 week f/up, number scoring >7* on either HADS-A or HADS-D = 2 (14%) compared with 4 (29%) before rehab

ID

[37]

19

PE

RCT

Randomized

Depression

CES-D [51]

ANOVA (group × time interaction across three time-points) p = 0.344 NS

−0.54 [−1.46, 0.38]*

     

Self-efficacy

SICPA [55]

ANOVA (Group × time interaction across three time-points) p = 0.108 NS

0.14 [−0.76, 1.05]

     

Anxiety

STAI [56]

State: ANOVA (group × time interaction across three time-points) p = 0.332 NS

−0.48 [−1.40, 0.43]*

       

Trait: ANOVA (group × time interaction across three time-points) p = 0.020

−0.87 [−1.82, 0.09]*

     

Body satisfaction

Ad hoc

ANOVA (group × time interaction across three time-points) p = 0.021

0.75 [−0.19, 1.68]

     

HRQoL

EORTC QLQ-C30 [53]

EF: ANOVA (group × time interaction across three time-points) p = 0.510 NS

−0.14 [−1.04, 0.77]

       

Global QOL: ANOVA (group × time interaction across three time-points) p = 0.148 NS

0.00 [−0.90, 0.90]

     

Wellbeing

ABS [57]

ANOVA (group × time interaction across three time-points) p = 0.074 NS

0.97 [0.01, 1.94]

     

Life satisfaction

ALHS [58]

ANOVA (group × time interaction across three time-points) p = 0.325 NS

−0.04 [−0.94, 0.86]

[35]

144

PE+SG

Pre-/post- with concurrent controls and allocation

Matched-group allocation, though logistics also played a role

HRQoL

EORTC QLQ-C30 [53]

EF: not reported

−0.25 [−0.59, 0.09]

       

Global QOL, p = 0.02 favouring controls

−0.57 [−0.92,−0.22]

     

Anxiety

HADS-A [54]

At 1 year f/up 24% in intervention vs 15% in control groups scored >7* on HADS-A compared with 33% vs 41% at baseline

ID

     

Depression

HADS-D [54]

At 1 year f/up 16% in intervention vs 18% in control groups scored >7* on HADS-D compared with 25% vs 28% at baseline (based on percent given in figure; percent given in text differs)

ID

[38]

54

CBT+PE+CST

Pre-/post- with concurrent controls and allocation

Self-selected

Anxiety

HADS-A [54]

p ≤ 0.05

−0.93 [−1.49,−0.36]*

     

Depression

HADS-D [54]

p ≤ 0.05

−0.96 [−1.53,−0.39]*

     

HRQoL

UWQoLv4 [59]

Mood, p ≤ 0.001

0.54 [0.00, 1.09]

       

Anxiety, p ≤ 0.05

0.99 [0.42, 1.56]

       

Overall QOL, p > 0.05

0.05 [−0.48, 0.59]

[44]

47

SG

Post-test only with controls

Self-selected

HRQoL

HNQOL [20]

Emotion, p < 0.001

N/A

[3941]

101

PE+SM

Pre-/post- with concurrent controls and allocation

Matched-group allocation, though logistics also played a role

HRQoL

EORTC QLQ-C30 [53]

EF, p = 0.85 NS

−0.07 [−0.46, 0.32]

       

Global QOL, p = 0.03

0.37 [−0.02, 0.77]

     

Anxiety

HADS-A [54]

p = 0.59 NS

−0.13 [−0.52, 0.26]*

     

Depression

HADS-D [54]

p = 0.06 NS

−0.33 [−0.73, 0.07]*

ABS Affect Balance Scale, ALHS Atkinson Life Happiness Scale, CBT cognitive–behavioural therapy, CES-D Center for Epidemiological Studies Depression Scale, CST communication skills training, EORTC QLQ-C30 European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire—Core (EF=emotional functioning), ES effect size (95% CIs=95% confidence intervals), HADS Hospital Anxiety and Depression Scale (HADS-A HADS anxiety, HADS-D HADS depression), HNQOL Head and Neck Cancer Quality of Life Instrument, ID insufficient data, I intervention group, NS not statistically significant at p < 0.05, PE psycho-education, QOL quality of life, RCT randomised controlled trial, SET supportive-expressive therapy (group), SG support group, SICPA Stanford Inventory of Cancer Patient Adjustment, SM stress management, UWQoLv4 University of Washington Quality of Life Questionnaire (Version 4)

*Higher score indicates worse anxiety or depression

Synthesis of results

As expected, meta-analysis was not possible due to significant heterogeneity (chi-square p < 0.10 [30]). Six out of the nine studies reported at least one statistically or clinically significant benefit for the intervention versus control group [3642, 44]. However, no study found significant effects across all outcomes. Effect sizes could be calculated for outcomes from four studies [35, 3741]. Ninety-five percent confidence intervals included zero in all cases except one study of a combined intervention where ESs ≥ 0.2 corroborated statistically significant results on two measures of anxiety [38]; statistically significant results for depression and mood in this study were not supported by ESs.

Due to the diversity of interventions evaluated, inconsistency in results and limitations in the design and methodologies of respective studies, it was decided that no intervention type was supported by a level of evidence defined by the AHRQ [28].

Discussion

Summary of the evidence

Our review highlights a paucity of research evaluating psychological interventions for HNC patients. Only nine studies were identified [3541, 43, 44], two of which were RCTs [37, 43] and three of which included samples of >100 patients [35, 3941, 43]. This situation can be contrasted with burgeoning evidence in the field of breast cancer where 34 RCTs were published between 1980 and 2004, 19 of which involved >100 patients [45].

What evidence is available demonstrates that it is feasible to recruit patients with a variety of HNC diagnoses to psychological interventions and to measure outcomes without serious levels of attrition. Only one study excluded patients because of alcohol or mental health problems [35]. Response rates were roughly comparable to studies of psychological interventions with other predominantly male cancer groups such as men with prostate cancer [4648]. Rates of adherence were seldom reported, but levels of attrition on outcome measures were acceptable in most cases. All but two [36, 38] interventions seemed feasible in an Australian public service setting, the context we used to evaluate external validity.

Of the intervention types, there is emerging support for psycho-education, with three [3741] out of five [3541] studies finding at least one statistically significant effect. These supportive studies were of ‘fair’ internal validity but yielded inconsistent results both across measures and between statistical significance and ES. In two studies, psycho-education was combined with either stress management or cognitive–behavioural therapy and communication skills training. Furthermore, randomised trials of psycho-education with simple parallel and factorial designs are needed to establish the efficacy of psycho-education alone and in combination with other interventions.

Future directions

The pool of studies reviewed here had a number of shortcomings that should be addressed in future research. Sampling was convenience in most cases; greater effort is needed to ensure the representativeness of future samples. Not only were most studies not randomised, but self-selection [38, 44] or logistical considerations (distance from clinic) [35, 36] determined group assignment in several cases. Measures of fidelity to treatment by therapists and adherence by patients were missing from reports of all studies; these variables provide essential indicators of ‘dose’ that assist the reader in interpreting results. Finally, as noted above, effect sizes and descriptive data for outcomes were missing from five studies and should be used to supplement p values in future reports.

Future HNC-focused studies might also benefit from recommendations made within the psycho-oncology literature more generally. First, future studies should focus on improving outcomes in patients with clinical levels of distress rather than all patients [21]. Second, future work should aim to integrate interventions into routine patterns of care [49] with the aim of reducing stigma, raising patient and staff awareness, and boosting participation and adherence. Both these recommendations would be supported by the use of routine screening for distress, as is advocated by the NCCN [23] and has been shown feasible in HNC out-patients [50]. Patient attendance for surgery, radiotherapy or chemotherapy presents obvious opportunities for both screening and intervention. Future studies following these recommendations are advised to use a multi-centre, cluster-randomised or stepped-wedge design to enable a systems approach to screening and intervention while avoiding contamination.

Review limitations

Limitations of the current review include our focus on psychological outcomes at the expense of impacts on social functioning or support, or behavioural outcomes. Also, ratings of external validity were necessarily carried out with reference to the authors’ experience of Australian cancer services, with the result that these ratings may not be generalisable to other countries or extend to all services within Australia.

Conclusion

Research to date suggests it is feasible to recruit people with HNC to psychological interventions and to evaluate their progress through repeated-outcome measures. However, evidence for interventions is limited by the small number of studies, methodological problems and poor comparability between interventions, designs and outcomes. Future interventions should target HNC patients who screen positive for clinical distress and be integrated into standard care.

Acknowledgements

We wish to acknowledge the support of the Psycho-oncology Co-operative Research Group (PoCoG), which provided the opportunity for the authors to collaborate on this review.

Conflict of interest

No organisation sponsored this research. No primary data were collected. The authors agree to allow the journal to review data subjected to secondary analysis in this article if requested.

Copyright information

© Springer-Verlag 2011