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review
Psychological distress and intervention in cancer patients treated with radiotherapy
Mojca Šoštarič, Lilijana Šprah
Institute of Medical Sciences, Slovenian Academy of Science and Arts, Ljubljana, Slovenia
Background. Common side effects of treatment with radiation therapy (RT) often cause psychophysical distress in cancer patients. Anxiety, adjustment disorders and depression (which are according to many stud-ies experienced in about half of the oncological population) might originate some serious psychiatric forms of mood disorders and can even culminate in suicide, if not treated appropriately. There are some groups of cancer patients who are especially vulnerable and among them are cancer patients undergoing RT –they should receive special attention from medical staff. The purpose of this review is to present a variety of psy-chosocial interventions and illustrate some methods that are (or could be) used in psycho-oncology practice. Conclusions. A large body of literature suggests that the first intervention step should be effective screen-ing for patients in distress. In regard to these proposals the development of (computerized) screening pro-grammes is the first measure that ought to be taken. Moreover, further systematical research of traditional, non-traditional and complementary intervention strategies in cancer patients in distress would be necessary in order to provide reliable empirical results about the effectiveness of different approaches.
Key words: neoplasms –radiotherapy –psychology; mood disorders; adjustment disorders; distress, intervention, screening.
Introduction
The psychosocial oncology research studies indicated that significant proportion of can-cer patients at all stages of the disease have been confronted with psychosocial dis-tress.1,2 The prevalence of some psychiatric
Received 16 August 2004
Accepted 23 August 2004
Correspondence to: Mojca Šoštarič, BSc, Institute of Medical Sciences, Slovenian Academy of Science and Arts, Novi trg 2, P.O. Box 306, Sl –1001 Ljubljana, Slovenia; Phone: +386 1 470 64 47; Fax : +386 1 426 14 93; E-mail: smojca@zrc-sazu.si
illnesses (major depression, generalized anxi-ety, adjustment disorder) is higher in some groups of cancer patients (patients undergo-ing radiotherapy (RT) or palliative treatment, terminally ill patients and patients experienc-ing uncontrollable pain), which also implies an increased risk for suicidal behaviour.3,4
Some studies estimated that approximate-ly 20% of cancer patients need a psychiatrist for treating major depression or anxiety dur-ing their cancer experience. Additional 15% of cancer patients need the services of a psychologist for treating distress and 25% of pa-tients require the services of social workers to deal with financial and practical issues.5,6
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Since some reports emphasized that psy-chosocial interventions in cancer patients are not only effective but also economical, more attention should be focused on establishing routine psychosocial screening programs in order to asses psychological functioning, pri-marily anxiety and depression and overall Quality of Life (QoL).7-9 Cancer patients should be targeted around the time of initial diagnosis and treatment. They should be screened for distress and common problems during the treatment trajectory. The purpose is the identification of those cancer patients who experience significant distress at early stages of therapy in order to treat them proac-tively and avoid future psychosocial prob-lems.10-14
RT was one of the earliest cancer treat-ments and it still plays an important role in the care of cancer patients. It has been used in curative as well as in palliative cancer treat-ment in order to achieve a local control over the tumour with minimum side effects. Despite astonishing progress of modern RT technique (safe doses of radiation which are skin sparing in comparison to old techniques), the treatment causes some common physical side effects, for example: fatigue, nausea, di-arrhoea, gastrointestinal symptoms and skin irritation. Some of them can persist even after the treatment. Studies revealed that cancer patients may also face some psychological problems during the treatment with RT.11,15 A wide range of different aspects of psychologi-cal functioning and well-being can be im-paired in cancer patients prior to, during, and after RT.16,17 Therefore a better insight into the psychosocial functioning of patients un-dergoing RT could facilitate the identification of those who are at higher risk of developing mood disturbances. These patients should re-ceive a full psychosocial support to manage the coping process with cancer and adopt ap-propriate coping strategies.18,19
There are many methods and techniques of psychosocial interventions that are com-
monly used in psycho-oncological practices. Most of them are useful in treating cancer pa-tients undergoing RT as well.20,21 A variety of psychosocial approaches (education in group, education on pain management, meditation training, biofeedback, relaxation training, vi-sualization, creative therapies such as music, art or role play, peer supportive group thera-py, family counselling, etc.) have been stud-ied and approved to significantly contribute to patient’s QoL. Nevertheless, many of them are ineffective if medical staff is not ac-quainted with the dynamic of psychological functioning of cancer patients undergoing RT and well trained for recognizing the patient’s crisis. In the following review some aspects of psychosocial functioning and distress in can-cer patients treated with RT will be discussed. In addition some psychosocial interventions will be described.
Distress induced by experience with cancer
Several studies clearly demonstrate that psy-chosocial distress occurs in one-third to one-half of all cancer patients.3,10,11 There are some groups of cancer patients that are espe-cially vulnerable to psychosocial distress. Particularly patients with history of chronic depression, patients with breast and genitalia cancer, patients using specific coping strate-gy (hopelessness/helplessness), patients without social support, children and elderly patients should be recognized at earlier stages of cancer diagnosis and treatment.3,5,22 Although severity of emotional distress is more closely related to a patient’s pre-exist-ing vulnerability than to the characteristics of the cancer, it is more likely to occur at the fol-lowing stages of patient’s experience with
cancer:23-25
Diagnosis
Investigation and diagnosis can induce anger,
shock, disbelief and emotional distress in
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cancer patients. Whereas these can be re-solved without interventions in the most cas-es, especially high levels of distress at this time are predictive for onset of later emotional problems.
During treatment
Side-effects of hospital attendance, unpleas-ant surgery, RT and/or chemotherapy are pre-vailing reasons for the distress. Patients might become particularly distressed during apparent treatment failure.
End of treatment
Some patients can experience "rebound" dis-tress associated with the fear that cancer could spread or occur again. The sense of loss and vulnerability may also appear at this point as outcome of ending the prolonged re-lationship with the cancer service staff.
After treatment
Many patients who survive cancer may reorder their life priorities. On the other hand others need help to overcome worries, preoc-cupation with loss and illness, a tendency to avoid reminders of cancer, difficulties coping with intimacy and return to work. A form of health anxiety with misinterpretation of physiological sensations and anxious seeking of reassurance may develop as a form of fears of cancer recurrence.
Recurrence
Patients who believe that they have been cured are at greater risk of severe distress if recurrence occurs. For some of them recur-rence of cancer may be more distressing than receiving the initial diagnosis.
Terminal disease
Depression is common in the terminal phase, particularly in cancer patients with poorly controlled physical symptoms. Majority of cancer patients experience fear of uncon-trolled pain and the process of dying. They
worry what happens after death and are con-cerned about loved ones.
Negative or positive psychological states Studies engaged with adjustment to cancer focused primarily on negative psychological states like depression, anxiety and general distress.26-28 Many of them concluded that cancer could be understood as an event and an ongoing process that may physically and emotionally weaken the individual. On the other hand, the number of studies on positive consequences of the cancer experience is growing. These studies suggested that experi-ence with cancer may result also in some positive outcomes, for example: increased self–esteem and more optimistic look, im-proved interpersonal relationships, re-evalua-tion of prior goals, altered priorities in life and new pursuits.29-33
Radiotherapy and psychosocial functioning in cancer patients
The results of studies comparing RT to other cancer treatments revealed few differences in psychological functioning among different treatment modalities.11,34 The patients under-going RT experienced a common distress –similar to patients without RT. Some studies indicated a great variability in reported re-sults, but the global trends in psychological responses to RT prevailed. The most common reactions reported by patients before starting a course of RT, were feelings of anxiety rather than depressive symptoms. During the course of treatment, most studies indicated a decline in feelings of anxiety. An increase of depressive symptoms and negative mood was found during and after RT. It was also em-phasized that the field lacks a systematic overview of the empirical data regarding psy-chological functioning prior to, during and after RT. 11,16,35
Although RT is not painful it induces
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many side effects, which can continue long after completion of treatment. Nevertheless, the non-invasive nature of RT can make it easier for patients to adapt, which could ex-plain why in spite of anxiety, patients often experience RT much more positive than ini-tially expected.11,36 Some studies aimed to en-lighten the psychosocial functioning in can-cer patients undergoing RT since some un-pleasant side-effects could interfere with their quality of life, namely: fatigue, skin irritation, nausea, diarrhoea, genitourinary and gastrointestinal symptoms, long-term cogni-tive disability in patients undergoing RT of brain, eating problems and oral complica-tions in patients undergoing RT of head and neck, etc.37-44
Some recent studies reviewed the impact of RT on neuropsychological functioning in cancer patients.38,45-48 Neuropsychological side-effects of different cancer treatments may include difficulty concentrating, im-paired verbal and visual memory, difficulty organizing information, decreased motor skills, and language problems. It remains un-clear to which extent intellectual and cogni-tive impairment in cancer patients could be linked with RT, since some patients could have already been experiencing some cogni-tive decline due to the effects of stress, fa-tigue or the sometimes toxic by-products of the cancer process itself.
It has been emphasized, that the assess-ment of RT side-effects either by the doctor or the patient remains subjective and often leads to different results.49 This implied a need for establishing reliable screening system with objective parameters in assessment of psychophysical and social distress of ra-diooncological patients.50-54 To provide effec-tive psychosocial support for cancer patients undergoing RT, the screening for psychoso-cial status of patients should be performed during diagnostic and therapeutic proce-dures. A distress inventory composed of interviews;   checklists   and   questionnaires
should be applied before, during and after the course of RT.
First intervention step: screening for cancer patients in distress
Depressive and anxiety disorders often remain unrecognised. In this regard an active screening by simply asking patients about symptoms of anxiety and depression may be helpful. How can an oncologist screen for pa-tients in distress? One research group report-ed that single-item screening was sensitive and specific for depression – an oncologist must simply ask a question: "Are you depressed most of the time?"3 Usually the questionnaire for assessing patients' anxiety and depression includes questions like: "How are you feeling in yourself?"; "Have you felt low or worried?"; "Have you ever been troubled by feeling anxious, ner-vous, or depressed?"; "What are your main con-cerns or worries at the moment?"; "What have you been doing to cope with these?"; "What effects do you feel cancer and its treatment will have on your life?"; "Is there anything that would help you cope with this?"; "Who do you feel is helping you at the moment?" Doctors should also be aware that patients might be distressed because of fac-tors unrelated to cancer.23,55,56
Additional check-up for some risk factors that underlie psychiatric disorders is also re-quired in cancer patients. Risk factors associated with patient (history of psychiatric disorder, social isolation, dissatisfaction with medical care, poor coping), cancer (limitation of activities, disfiguring, poor prognosis) and treatment (disfiguring, side-effects) should be taken into consideration.8,57
It is common to use diagnostic tools or (computerized) screening programs to pro-vide a better insight into patient’s crisis. Several agencies developed screening guidelines or books of standards in order to pro-vide distress screening for each patient. Most widely used tools are: Brief Symptom Inven-
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tory (BSI), Hospital Anxiety and Depression Scale (HADS), General Health Question-naire, QoL Questionnaires and distress ther-mometer.9 A large amount of studies on psy-chometrical characteristics of these screening tools is available on-line.
Review of literature showed that more than 45 tools/instruments have been used to measure psychological distress.58 Unfortu-nately none of them is able to identify pa-tients who are highly distressed without clin-ical symptoms of anxiety and depression. Therefore, the development of a reliable screening mechanism seems appropriate and may help in identifying patients who specifi-cally warrant the intervention. Distress-screening tool may also assist health professionals to provide patient-specific-interven-tion processes if the distress level and cause could be identified.
Several groups of scientists are dealing with development of screening mechanism for distress induced by RT. A group of German scientists (Klinikum Grosshadern, Munchen) developed questionnaire SIRO (The Stress Index RadioOncology).50 A group in Canada has been developing a computer-ized QoL program for clinical use in palliative RT.5,59 In recent studies two instruments were tested for benefits in screening process: a short and structured interview procedure PRIME-MD (Primary Care Evaluation of Mental Disorders) and BCD (Brief Case-Find for Depression).10,60 Both instruments were found to quickly and reliably identify the prevalence and types of mood disorders (depressive disorders: major depression, minor -subsyndromal depression/adjustment disorder, dysthymia, bipolar disorder; anxiety disorders: panic disorder, generalized anxiety disorder). When compared to the PRIME-MD diagnosis of depression the BCD had greater sensitivity. No specific training is needed to administer PRIME-MD and BCD; their application is quick and therefore convenient for screening by oncologist.
Second intervention step: post-screening intervention strategies
Interventions usually assume the following common strategies: psycho-education, cogni-tive-behavioural training (group or individ-ual), supportive therapy (group or individ-ual).5 They target different points on the ill-ness trajectory: diagnosis/pre-treatment, im-mediately post-treatment or during extended treatment (such as RT or chemotherapy) and disseminated disease or death. Certain moda-lities of intervention strategies have been proven to be more efficacious at one or more of these time periods. For example, psycho-education may be most effective during the diagnosis/pre-treatment period, when patient searches for information. Group support may be more effective at later stages to cope with more advanced disease.61,62 Cognitive-behav-ioural techniques such as relaxation, stress management and cognitive coping could be most useful during extended treatments.63,64 Relaxation and imagery have been shown to be effective in controlling nausea and vomit-ing associated with chemotherapy treat-ment,65 and furthermore, these techniques can also help patient to decrease the usage of
pain medications.66
Many studies have focused on the efficacy of group interventions. It seems that group therapies have repeatedly been shown to be as effective as individual treatment.63,67 Because of the reduced cost of group thera-pies (the greater number of patients who can be treated at the same time) many researchers identify group therapy as the preferred route for treating distress in cancer patients. Several specific group therapy interventions have been standardized and proven effica-cious, for example: supportive expressive therapy for metastatic early stage breast can-cer,68,69 mindfulness-meditation based stress reduction70,71 and standardized group psy-cho-education for patients with different types of cancer diagnoses.72
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On the other hand recent surveys confirm the popularity of non-traditional therapies among cancer patients. 23% – 81 % of U.S. and Canadian, 22% – 52% of Australian, 16% – 32% of British and 10% – 61% of mainland European cancer patients used at least one such thera-py.20,73,74 Psychological therapies (e.g., relaxation, meditation, visual imagery, and hyp-notherapy) are among most popular non-tradi-tional therapies. More than 50% of Australian and up to 29% of U.S. and 10% of European and Canadian cancer patients have reported the use of at least one type of psychological therapy.75,76 Patients have high expectations of these therapies: in one study, up to 25% of par-ticipants expected the psychological therapy to cure their cancer and 75% – 100% expected it to assist their traditional therapies.76
Moreover, alternative/complementary thera-pies are increasingly used to reduce side ef-fects of cancer treatment, without convincing evidence of their effectiveness.77 Some stud-ies are in favor of using complementary ther-apy in order to reduce the stress and anxiety in cancer patient.78,79 A study of patient’s per-ceptions of the benefits of reflexology on their QoL revealed that reflexology interventions were perceived to impact positively on psychophysical functioning.80,81
Further indications for effective acupunc-ture treatment of patients with radiation-in-duced xerostomia came from study with pa-tients undergoing RT for head and neck can-cer.82,83 Some national institutes of health support the use of acupuncture for chemo-therapy-induced nausea and vomiting.84 The nurse practitioners are obligated to be knowl-edgeable about the use of these and other ef-fective complementary treatments in order to provide the best care. Used in conjunction with current antiemetic drugs, acupuncture and acupressure have been shown to be safe and effective for relief of the nausea and vom-iting resulting from chemotherapy.
Application of psychological interventions has been found in many studies to improve the
QoL in cancer patients. These is hypothesized to be mainly due to reducing their psychologi-cal symptoms and distress, enhancing psycho-logical and functional adjustment and rehabilitation as well.85 However, the relevance of psy-chosocial interventions on survival from cancer has been widely criticized. In the recent review all identifiable publications about psychologi-cal therapies used by cancer patients have been critically and systematically analysed.20 Despite of extensive body of literature authors could not make strong recommendations about the effectiveness of psychological intervention strategies at improving cancer patient’s out-comes. The results of this review were consid-erably less enthusiastic about the likely bene-fits of psychological therapies for cancer pa-tients compared to the results of other recent reviews. While many studies recommended widespread and routine use of psychological therapies to improve patient’s psychosocial, side effect, survival and immune outcomes, this study emphasized that the most beneficial are group therapy, education, structured and unstructured counselling and cognitive behav-ioural therapy. Furthermore, some long-term cost studies have proven that psychosocial intervention programs have also beneficial eco-nomical value.5,86
Cancer patients undergoing RT can engage in all above described intervention programs. Some findings about psychosocial side ef-fects of RT, discussed in previous section have also got practical implications for med-ical staff in oncology practice.87 Namely, it is very important that patient is well informed what to expect during the treatment period. The aim of the RT should be explained and misperceptions eliminated (role models that underwent the RT could be used for educa-tion of patients). This is not important only because of the cooperation between the patient and medical staff, but also because talking often reduces the anxiety that ascends from specific, unknown and uncontrollable situation. In addition, after completed treat-
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ment with RT patients show high need for information – particularly about the psy-chophysical changes they could experience after completing RT. They are also interested how they could best ask their physicians questions, which agencies they could call when they need help and how they could cope with painful emotions. Therefore pro-viding an information booklet in form of a self-management package seems to be an ef-fective intervention.88
Conclusions
Although recent studies comparing different cancer treatments suggested that the psycho-logical impact of RT is not superimposed to other treatments, some measures have to be taken to avoid further psychiatric complica-tions (anxiety, depression, adjustment disorders and suicide) in cancer patients undergo-ing RT. 3,10,11,34 The first step is to effectively screen for patients in distress throughout the treatment process (patients should be screened at the initial visit and at appropriate intervals).10-14 A multidisciplinary approach that includes psychological as well as medical assessment and intervention should be car-ried out. Otherwise psychological care might be neglected by the medical focus on cancer treatment. Consequently screening program-mes for those patients who are likely to show psychological dysfunction and helping them to cope with treatment and cancer related problems should be the constituent part of
cancer managment.5,36,86
The knowledge of the coping process with cancer and some fundamental strategies in screening for distress is substantial for medi-cal staff working with patients undergoing RT.86 What is expected before starting a course of RT? The majority of patients will experience anxiety (which will probably de-cline during the treatment).11,16,35 They will be distressed mostly by fears of possible side-
effects and by the fact of being irradiated. An effective intervention strategy at this stage is psycho-education (providing information about RT and its side effects). The visualiza-tion and the relaxation training are also use-ful for reducing the anxiety. In contrast to the anxiety an increase of depressive symptoms is expected during and after RT. At this point the group-supportive therapy might be ap-propriate.61-69 To conclude: different psycho-logical interventions evoke different effects according to the specific stages of the cancer treatment.
In general, five types of therapies were es-tablished due to increasingly active participa-tion by the recipient: providing information, emotional support, behavioral training in coping skills, psychotherapy and spiritual/ex-istential therapy.72 The widespread usage of nontraditional psychological and comple-mentary therapies20,73-84 is a big challenge to the traditional medical and psychological ap-proaches to cancer experience. The field lacks a systematic overview of different approach-es and their contributions to the QoL as well as to the cancer prognosis.
Patients are most often willing to partici-pate in the therapeutic process of cancer, yet the psychological aspect of medication might be underestimated by the patient. Therefore oncologist should also notice if a patient needs some further psychological or psychi-atric consultations. Quick and reliable screening tools could be useful for this purpose. Although there are some available instruments for such purposes (BSI, HADS, PRIME-MD, etc.),9,10,58 many findings suggest that the screening process for cancer patients experiencing distress while undergoing RT requires additional empirical analysis.
References
1. Sivesind D, Baile WF. The psychologic distress in patients with cancer. Nurs Clin North Am 2001; 36: 809-25.
Radiol Oncol 2004; 38(3): 193-203.
200
Šoštarič M et al. / Psychological distress and radiotherapy
2.   Parker PA, Baile WF, de Moor C, Cohen L. Psychosocial and demographic predictors of qual-ity of life in a large sample of cancer patients. Psychooncology 2003; 12: 183-93.
3.   Chochinov HM. Depression in cancer patients. Lancet Oncol 2001; 2: 599-606.
4.   Filiberti A, Ripamonti C. Suicide and suicidal thoughts in cancer patients. Tumori 2002; 88: 193-9.
5.   Carlson LE, Bultz BD. Benefits of psychosocial on-cology care: improved quality of life and medical cost offset. Health Qual Life Outcomes 2003; 1: 8.
6.   Fawzy FI. Psychosocial interventions for patients with cancer: what works and what doesn't. Eur J Cancer 1999; 35: 1559-64.
7.   Zabora J, BrintzenhofeSzoc K, Jacobsen P, Curbow B, Piantadosi S, Hooker C, et al. A new psychoso-cial screening instrument for use with cancer pa-tients. Psychosomatics 2001; 42: 241-6.
8.   Keller M, Sommerfeldt S, Fischer C, Knight L, Riesbeck M, Lowe B, et al. Recognition of distress and psychiatric morbidity in cancer patients: a multi-method approach. Ann Oncol 2004; 15: 1243-9.
9.   Carlson LE, Bultz BD. Cancer distress screening. Needs, models, and methods. J Psychosom Res 2003; 55: 403-9.
10. Leopold KA, Ahles TA, Walch S, Amdur RJ, Mott LA, Wiegand-Packard L, et al. Prevalence of mood disorders and utility of the PRIME-MD in patients undergoing radiation therapy. Int J Radiat Oncol Biol Phys 1998; 5: 1105-12.
11. Stiegelis HE, Ranchor AV, Sanderman R. Psychological functioning in cancer patients treat-ed with radiotherapy. Patient Educ Couns 2004, 52: 131-41.
12. Roth AJ, Modi R. Psychiatric issues in older cancer patients. Crit Rev Oncol Hematol 2003, 48: 185-97.
13. Zabora JR, Loscalzo MJ, Weber J. Managing com-plications in cancer: identifying and responding to the patient's perspective. Semin Oncol Nurs 2003; 19: 1-9.
14. Chow E, Tsao MN, Harth T. Does psychosocial intervention improve survival in cancer? A meta-analysis. Palliat Med 2004; 18: 25-31.
15. Janda M, Newman B, Obermair A, Woelfl H, Trimmel M, Schroeckmayr H, et al. Impaired qual-ity of life in patients commencing radiotherapy for cancer. Strahlenther Onkol 2004; 180: 78-83.
16. Sehlen S, Hollenhorst H, Schymura B, Herschbach P, Aydemir U, Firsching M, et al. Psychosocial stress in cancer patients during and after radio-therapy. Strahlenther Onkol 2003; 179: 175-80.
17. Sehlen S, Song R, Fahmuller H, Herschbach P, Lenk M, Hollenhorst H, et al. Coping of cancer pa-tients during and after radiotherapy--a follow-up of 2 years. Onkologie 2003; 26: 557-63.
18. de Vries A, Sollner W, Steixner E, Auer V, Schiessling G, Stzankay A, et al. Subjective psy-chological stress and need for psychosocial support in cancer patients during radiotherapy treat-ment. Strahlenther Onkol 1998; 174: 408-14.
19. Fritzsche K, Liptai C, Henke M. Psychosocial dis-tress and need for psychotherapeutic treatment in cancer patients undergoing radiotherapy. Radiother Oncol 2004; 72: 183-9.
20. Newell SA, Sanson-Fisher RW, Savolainen NJ. Systematic review of psychological therapies for cancer patients: overview and recommendations for future research. J Natl Cancer Inst 2002; 94: 58-84.
21. Herschbach P, Keller M, Knight L, Brandl T, Huber B, Henrich G, et al. Psychological problems of cancer patients: a cancer distress screening with a cancer-specific questionnaire. Br J Cancer 2004; 91: 504-11.
22. Kusch M, Labouvie H, Ladisch V, Fleischhack G, Bode U. Structuring psychosocial care in pediatric oncology. Patient Educ Couns 2000, 40: 231-45.
23. White C, Macleod U. Cancer. ABC of psychologi-cal medicine. BMJ 2002; 325: 377–80.
24. Strittmatter G, Tilkorn M, Mawick R. How to iden-tify patients in need of psychological intervention. Recent Results Cancer Res 2002; 160: 353-61.
25. Cordova MJ, Andrykowski MA. Responses to can-cer diagnosis and treatment: posttraumatic stress and posttraumatic growth. Semin Clin Neuropsy-chiatry 2003; 8: 286-96.
26. Epping-Jordan J, Compas B, Osowiecki D, Oppedisano G, Gerhardt C, Primo K, et al. Psychological adjustment in breast cancer: Processes of emotional distress. Health Psychol 1999; 18: 315-26.
27. Kugaya A, Akechi T, Okuyama T, Nakano T, Mikami I, Okamura H, et al. Prevalence, predic-tive factors, and screening for psychologic distress in patients with newly diagnosed head and neck cancer. Cancer 2000; 88: 2817-23.
28. Akechi T, Okuyama T, Sugawara Y, Nakano T, Shima Y, Uchitomi Y. Major depression, adjust-
Radiol Oncol 2004; 38(3): 193-203.
Šoštarič M et al. / Psychological distress and radiotherapy
201
ment disorders, and post-traumatic stress disorder in terminally ill cancer patients: associated and predictive factors. J Clin Oncol 2004; 22: 1957-65.
29. Ferrell BR, Grant M, Funk B, Otis GS, Garcia N. Quality of life in breast cancer. Part II: Psychological and spiritual well-being. Cancer Nurs 1997; 21: 1-9.
30. Sodergren S, Hyland M. What are the positive consequences of illness? Psychol Health 2000; 15: 85-97.
31. Andrykowski MA, Brady MJ, Hunt JW. Positive psychosocial adjustment in potential bone mar-row transplant recipients: cancer as a psychosocial transition. Psychooncology 1993; 2: 261-76.
32. Stiegelis HE, Hagedoorn M, Sanderman R, van der Zee KI, Buunk BP, van den Bergh AC. Cognitive adaptation: a comparison of cancer patients and healthy references. Br J Health Psychol 2003; 8: 303-18.
33. Petrie K, Buick D, Weinman J, Booth R. Positive ef-fects of illness reported by myocardial infarction and breast cancer patients. J Pychosom Res 1999; 47: 537-43.
34. De Leeuw JR, De Graeff A, Ros WJ, Hordijk GJ, Blijham GH, Winnubst JA. Negative and positive influences of social support on depression in pa-tients with head and neck cancer: a prospective study. Psychooncology 2000; 9: 20-8.
35. Lamszus K, Verres R, Hubener KH. How do pa-tients experience radiotherapy? Strahlenther Onkol 1994; 170: 162-8.
36. Mose S, Budischewski KM, Rahn AN, ZanderHeinz AC, Bormeth S, Boettcher HD. Influence of irradiation on therapy-associated psychological distress in breast carcinoma patients. Int J Radiat Oncol Biol Phys 2001; 51: 1328-35.
37. Oehrn K. Oral Health and Experience of Oral Care among Cancer Patients during Radio- or Chemo-therapy. Uppsala: Acta Universitatis Upsaliensis, Comprehensive Dissertations from the Faculty of Medicine 1998; 2001. p. 7-10.
38. Klein M, Heimans JJ Aaronson NK, van der Ploeg HM, Grit J, Muller M, et al. Effect of radiotherapy and other treatment-related factors on mid-term to long-term cognitive sequelae in low-grade gliomas: a comparative study. Lancet 2002; 360: 1361-8.
39. Caffo O, Amichetti M, Mussari S, Romano M, Maluta S, Tomio L, et al. Physical side effects and quality of life during postoperative radiotherapy for uterine cancer, prospective evaluation by a di-ary card. Gynecol Oncol 2003; 88: 270-6.
40. Larsson M, Hedelin B, Athlin E. Lived experiences of eating problems for patients with head and neck cancer during radiotherapy. J Clin Nurs 2003; 12: 562-70.
41. Sehlen S, Hollenhorst H, Lenk M, Schymura B, Herschbach P, Aydemir U, et al. Only sociodemo-graphic variables predict quality of life after radi-ography in patients with head-and-neck cancer. Int J Radiat Oncol Biol Phys 2002; 52: 779-83.
42. Chandra PS, Chaturvedi SK, Channabasavanna SM, Anantha N, Reddy BK, Sharma S, et al. Psychological well-being among cancer patients receiving radiotherapy--a prospective study. Qual Life Res 1998; 7: 495-500.
43. Jacobsen PB, Thors CL. Fatigue in the radiation therapy patient: current management and investi-gations. Semin Radiat Oncol 2003; 13: 372-80.
44. Montgomery C, Lydon A, Lloyd K. Psychological distress among cancer patients and informed con-sent. J Psychosom Res 1999; 46: 241-5.
45. Anderson-Hanley C, Sherman ML, Riggs R, Agocha VB, Compas BE. Neuropsychological ef-fects of treatments for adults with cancer: a meta-analysis and review of the literature. J Int Neuropsychol Soc 2003; 9: 967-82.
46. Syrjala KL. The neuropsychology of cancer treat-ment. Introduction. Semin Clin Neuropsychiatry 2003; 8: 197-200.
47. Wefel JS, Kayl AE, Meyers CA. Neuropsycho-logical dysfunction associated with cancer and cancer therapies: a conceptual review of an emerg-ing target. Br J Cancer 2004; 90: 1691-6.
48. Costello A, Shallice T, Gullan R, Beaney R. The early effects of radiotherapy on intellectual and cognitive functioning in patients with frontal brain tumours: the use of a new neuropsychologi-cal methodology. J Neurooncol 2004; 67: 351-9.
49. Goldner G, Wachter-Gerstner N, Wachter S, Dieckmann K, Janda M, Poetter R. Acute Side Effects during 3-D-Planned Conformal Radio-therapy of Prostate Cancer. Strahlenther Onkol 2003; 5: 320-7.
50. Sehlen S, Fahmuller H, Herschbach P, Aydemir U, Lenk M, Duhmke E. Psychometric properties of the Stress Index RadioOncology (SIRO)--a new questionnaire measuring quality of life of cancer patients during radiotherapy. Strahlenther Onkol 2003; 179: 261-9.
51. Thomas BC, Mohan VN, Thomas I, Pandey M. Development of a distress inventory for cancer: preliminary results. J Postgrad Med 2002; 48: 16-20.
Radiol Oncol 2004; 38(3): 193-203.
202
Šoštarič M et al. / Psychological distress and radiotherapy
52. Katz MR, Kopek N, Waldron J, Devins GM, Tomlinson G. Screening for depression in head and neck cancer. Psychooncology 2004; 13: 269-80.
53. Lee-Preston V, Steen IN, Dear A, Kelly CG, Welch AR, Meikle D, et al. Optimizing the assessment of quality of life after laryngeal cancer treatment. J Laryngol Otol 2004; 118: 432-8.
54. Monfardini S, Ferrucci L, Fratino L, del Lungo I, Serraino D, Zagonel V. Validation of a multidi-mensional evaluation scale for use in elderly can-cer patients. Cancer 1996; 77: 395-401.
55. McDaniel JS, Musselman DL, Porter MR, Reed DA, Nemeroff CB. Depression in patients with cancer. Diagnosis, biology, and treatment. Arch Gen Psychiatry 1995; 52: 89–99.
56. Sheard T, Maguire P. The effect of psychological interventions on anxiety and depression in cancer patients: results of two meta–analyses. Br J Cancer 1999; 80: 1770–80.
57. Forester BM, Kornfeld DS, Fleiss J. Psychiatric as-pects ofradiotherapy. Am J Psychiatry 1978; 135: 960-3.
58. Thomas BC, Mohan VN, Thomas I, Pandey M. Development of a distress inventory for cancer: preliminary results. J Postgrad Med 2002; 48: 16-20.
59. Bezjak A, Skeel R, Depetrillo AD, Comis R, Taylor KM. Oncologist’s use of quality of life information: results of a survey of castem cooperative on-cology group physicians. Qual Life Res 2001; 10: 1-13.
60. Jefford M, Mileshkin L, Richards K, Thomson J, Matthews JP, Zalcberg J, et al. Rapid screening for depression - validation of the Brief Case-Find for Depression (BCD) in medical oncology and palliative care patients. Br J Cancer 2004 [in print].
61. Blake-Mortimer J, Gore-Felton C, Kimerling R, Turner-Cobb JM, Spiegel D. Improving the quality and quantity of life among patients with cancer: a review of the effectiveness of group psychothera-py. Eur J Cancer 1999, 35: 1581-6.
62. Clark MM, Bostwick JM, Rummans TA. Group and individual treatment strategies for distress in cancer patients. Mayo Clin Proc 2003; 78: 1538-43.
63. Bottomley A. Where are we now? Evaluating two decades of group interventions with adult cancer patients. J Psychiatr Ment Health Nurs 1997; 4: 251-65.
64. Fawzy FI. A short-term psychoeducational intervention for patients newly diagnosed with cancer. Support Care Cancer 1995; 3: 235-8.
65. Fawzy FI, Fawzy NW, Arndt LA, Pasnau RO. Critical review of psychosocial interventions in cancer care. Arch Gen Psychiatry 1995; 52: 100-13.
66. Sloman R, Brown P, Aldama E, Chu E. The use of relaxation for the promotion of comfort and pain relief in persons with advanced cancer. Contemp Nurse 1994; 3: 6-12.
67. Fobair P. Cancer support groups and group thera-pies: Part I. Historical and theoretical background and research on effectiveness. Journal of Psycho-social Oncology 1997; 15: 63-81.
68. Classen C, Butler LD, Koopman C, Miller E, DiMiceli S, Giese- Davis J. Supportive-expressive group therapy and distress in patients with metastatic breast cancer: a randomized clinical intervention trial. Arch Gen Psychiatry 2001; 58: 494-501.
69. Spiegel D, Morrow GR, Classen C, Raubertas R, Stott PB, Mudaliar N. Group psychotherapy for re-cently diagnosed breast cancer patients: a multicenter feasibility study. Psychooncology 1999; 8: 482-93.
70. Carlson LE, Ursuliak Z, Goodey E, Angen M, Speca M. The effects of a mindfulness meditation based stress reduction program on mood and symptoms of Stress in cancer outpatients: six month follow-up. Support Care Cancer 2001; 9: 112-23.
71. Speca M, Carlson LE, Goodey E, Angen M A. Randomized, waitlist controlled clinical trial: the effect of a mindfulness meditation-based stress re-duction program on mood and symptoms of stress in cancer outpatients. Psychosom Med 2000; 62: 613-62.
72. Cunningham AJ, Edmonds VI, Hampson AW, Hanson H, Hovenac M, Jenkins G. A group psy-choeducational program to help cancer patients cope with and combat their disease. Advances 1991; 7: 41-56.
73. Begbie SD, Kerestes ZL, Bell DR. Patterns of alternative medicine use by cancer patients. Med J Aust 1996; 165: 545–8.
74. Miller M, Boyer MJ, Butow PN, Gattellari M, Dunn SM, Childs A. The use of unproven methods of treatment by cancer patients. Frequency, expecta-tions and cost. Supp Care Cancer 1998; 6: 337–47.
75. Maher EJ, Young T, Feigel I. Complementary ther-apies used by patients with cancer. BMJ 1994; 309: 671–2.
76. Sollner W, Zingg-Schir M, Rumpold G, Fritsch P. Attitude toward alternative therapy, compliance
Radiol Oncol 2004; 38(3): 193-203.
Šoštarič M et al. / Psychological distress and radiotherapy
203
with standard treatment, and need for emotional support in patients with melanoma. Arch Dermatol 1997; 133: 316–21.
77. Post-White J, Kinney ME, Savik K, Gau JB, Wilcox C, Lerner I. Therapeutic massage and healing touch improve symptoms in cancer. Integr Cancer Ther 2003; 2: 332-44.
78. Keegan L. Therapies to reduce stress and anxiety. Crit Care Nurs Clin North Am 2003; 15: 321-7.
79. Fellowes D, Barnes K, Wilkinson S. Aromatherapy and massage for symptom relief in patients with cancer. Cochrane Database Syst Rev 2004; 2: CD002287.
80. Wright S, Courtney M, Donnely C, Kenny T, Lavin C. Client’s perceptions of the benefits of reflexol-ogy on their quality of life. Complement Therap Nurs Midwifery 2002; 8: 69-76.
81. Luebbert K, Dahme B, Hasenbring M. The effec-tiveness of relaxation training in reducing treat-ment-related symptoms and improving emotional adjustment in acute non-surgical cancer treat-ment: a meta-analytical review. Psychooncology 2001; 10: 490-502.
82. Blom M, Dawidson I, Fernberg JO, Johnson G, Angmar-Mansson B. Acupuncture treatment of patients with radiation-induced xerostomia. Eur J Cancer B Oral Oncol 1996; 32B: 182-90.
83. Blom M, Lundeberg T. Long-term follow-up of pa-tients treated with acupuncture for xerostomia and the influence of additional treatment. Oral Dis 2000; 6: 15-24.
84. Collins KB, Thomas DJ. Acupuncture and acupres-sure for the management of chemotherapy-in-duced nausea and vomiting. J Am Acad Nurse Pract 2004; 16: 76-80.
85. Ross L, Boesen E H, Dalton SO, Johansen C. Mind and cancer: does psychosocial intervention im-prove survival and psychological well-being? Eur J Cancer 2002, 38: 1447-57.
86. Šprah L, Šoštarič M. Psychosocial coping strate-gies in cancer patients. Radiol Oncol 2004; 38: 35-42.
87. Fritzsche K, Liptai C, Henke M. Psychosocial dis-tress and need for psychotherapeutic treatment in cancer patients undergoing radiotherapy. Radiother Oncol 2004; 72: 183-9.
88. Jenkins V, Fallowfield L, Saul J. Information needs of patients with cancer: results from a large study in UK cancer centres. B J Cancer 2000; 84: 48-51.
Radiol Oncol 2004; 38(3): 193-203.