Psychosocial Interventions for Patients With Head and Neck Cancer - Part 2
There are several distinct categories of interventions that have been employed for patients with cancer, namely, education, emotional support, and psychotherapy. Fawzy suggested that psychosocial interventions provide an overall positive effect on quality of life, although some interventions have failed to achieve the desired results.  For example, Pruitt et al undertook a prospective, randomized controlled trial to determine whether education would reduce psychological distress in newly diagnosed cancer patients.  Thirty-one patients who were assessed to be at high risk with high levels of distress were randomly assigned to three 1-hour information sessions about radiation therapy, cancer, coping strategies, and communication skills, or to a standard no intervention control group. Measures were taken at baseline and 1 and 3 months later. Depression decreased in the intervention group but there were no changes in affective state or knowledge levels.
Conversely, Greer et al. reported on a prospective, randomized controlled trial comparing the quality of life of 156 patients with cancer (various cancer sites except cerebral tumor and nonmelanoma skin tumors) receiving psychotherapy based on the premise of CBT to patients receiving no therapy.  This brief cognitive behavioral treatment program specially designed for individual patients with cancer demonstrated that patients receiving therapy had significantly lower scores on helplessness, anxious preoccupation, depression, and fatalism and significantly higher scores on fighting spirit at the end of 8 weeks of therapy. At 4 months, this improvement continued. Moorey et al. reported on the long-term effect of this intervention program on the same cohort.  At 1-year follow-up, 19% of patients receiving therapy were still clinically anxious compared to 44% of patients in the control group. A similar trend was noted concerning depression, 11% of patients receiving therapy were depressed as compared to 18% of patients in the control group. More recently, Davidson has suggested that CBT is emerging as the most therapeutic and cost-effective approach for adult patients with cancer with psychological morbidity. 
Fawzy alluded to the quest for interventions to help individual patients with cancer to cope with this life crisis. [17,18] Also, clinicians and researchers have highlighted the need for psychosocial intervention for patients with head and neck cancer. [73,74] However, when the body of literature is examined for effective intervention programs for these patients, there is a significant dearth of research and clinical work.
More than 20 years ago, Fiegenbaum developed a practical social skills training program for patients with facial disfigurement following treatment for head and neck cancer.  Although this was with a small sample ( N = 17), under experimental or control group conditions, data relating to pretraining and posttraining measures, including 2 years after therapy, were collected. Patients in the experimental group had 10 training sessions of 2 hours duration, which covered disfigurement-related issues and also problems with speech and eating. In the experimental group, data showed significant reduction in social anxiety and improvements in self-confidence, and these improvements were maintained over the 2-year follow-up period. Despite the methodological shortcomings from the small sample size, possibly accounting for an unrepresentative biased sample and thus limiting the generalizability of the findings, these data have been pivotal in influencing other research studies for patients with disfigurements.
Robinson et al designed a similar social interaction skills workshop for a heterogeneous sample of participants with acquired and congenital disfigurements ( N = 64).  Measures of psychological well-being using standardized scales were taken prior to a workshop and at 6 weeks and 6 months follow-up. Mean scores of social avoidance and distress were significantly lower than preworkshop levels and reduced slightly further at 6 months follow-up For example, on the Social Avoidance and Distress Scale,  the preworkshop mean score was 15.4, the 6 weeks postworkshop mean score was 13.5 ( P < .05), and the 6 months postworkshop mean score was 13.2 ( P < .01). However, with the lack of a control group measure, it is difficult to ascertain whether the affective changes were resulting from the opportunity of meeting other people with disfigurement rather than the practice and application of social skills explored within the workshop.
Clarke designed a social rehabilitation program to promote coping in patients with head and neck cancer.  Eight head and neck nurse specialists, following training in managing psychosocial issues for patients with head and neck cancer, delivered this program. Within this cohort, clear gains were measured in reducing social embarrassment and, subsequently, facilitating social functioning. This consequently had a positive impact on quality of life as measured by standardized global and disease-specific tools with good psychometric properties. Despite the small sample size, comparison of mean pretest and posttest scores using the Wilcoxon test demonstrated a trend toward significance for reduced anxiety and depression as measured by the HADS. However, this study had obvious limitations, notably the small sample size ( N = 16) and the lack of a control group.
Similar methodological weakness, of a small sample size, were noted within 2 pilot studies designed to explore both the feasibility and efficiency of 2 psychosocial intervention approaches for patients with head and neck cancer at different stages of their disease trajectory.  The first study evaluated the effect of group psychological therapy, using a combination of cognitive and behavioral techniques, including relaxation, led by a psychologist for newly diagnosed patients. Quality of life, including psychiatric morbidity, was measured longitudinally for 1 year and compared with that of a control group. Thirteen patients started the group psychotherapy intervention, and 8 participants completed both the intervention and evaluation process. At 1-year follow-up, the intervention group had improved in most areas as compared to the control group ( N = 34). Significance testing was not performed because of the small sample size in this pilot study; however, the improvement noted on the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-head and neck cancer module 35 (EORTC QLQ-H&N35) of more than 10 points was evident in 10 of the 20 domains. In contrast, the control group findings revealed that only one domain improved more than l0 points. In addition, psychiatric morbidity as measured by the HADS was studied in both groups. At 1-year follow-up, the therapy group had improved markedly compared to the control group, with fewer patients considered as probable or possible cases of psychiatric morbidity.
The second pilot study investigated the effect of a 1-week psychoeducational program, for patients 1 year after diagnosis at a rehabilitation center for patients with cancer. Participants' quality-of-life scores were measured longitudinally from the time of diagnosis until 4 weeks after the intervention. According to the HADS scale, results demonstrated that the number of probable or possible cases for anxiety and depression was almost constant throughout the study, whereas the EORTC QLQ C30  and H&N35 depicted a pattern of improvement in the majority of functions and symptoms after the intensive short-term psychoeducational program, with the most evident changes in the eating domain. When considering the timeliness of an intervention, it is important to note that participants would have preferred the intervention at an earlier stage of their disease. However, these 2 pilot studies suggest that patients with head and neck cancer can benefit from psychosocial intervention.
The only larger, longitudinal, case-control study published that evaluated the effect of a psychosocial support program on HRQoL in patients with head and neck cancer was undertaken by Petruson et al.  One hundred forty-two newly diagnosed patients with head and neck cancer in Sweden were included in this study. Fifty-two participants in the study group were given additional emotional support and information on head and neck cancer, its treatment, and side effects repeatedly throughout the first year after diagnosis. Results highlighted that both the study and control groups did not differ at diagnosis and during treatment regarding HRQoL scores as measured by the EORTC QLQ H&N35 and HADS. At 1-year follow-up, the control group had a clinically and statistically better global quality-of-life score. However, at 3-year follow-up, participants of both groups had high levels of depression and treatment-related side effects were also prevalent in both groups.
It must be noted that the aim of the support team (consisting of a ward nurse from a head and neck unit and a dietitian) was to provide information and give emotional support. It has been suggested that the lower quality-of-life scores could possibly be explained by regular follow-up, causing some patients to develop a dependency.  Moreover, the team did not have any training in diagnosing or treating depression or other related psychological problems. Therefore, a time-limited intervention, using cognitive and behavioral techniques, delivered by professionals trained in detecting affective disorders may prove more beneficial in reducing psychosocial dysfunction and enhancing quality of life for patients with head and neck cancer. Nevertheless, the findings obtained provide a basis for further research and intervention development.
The design of a psychosocial intervention program to effectively meet the magnitude of needs for patients with head and neck cancer is clearly warranted and a major challenge. Today, many global and disease-specific research instruments have already been developed and validated for use with patients diagnosed with head and neck cancer, and these provide a timely opportunity for further research. Using these standardized tools, researchers can find out more about the difficulties experienced by patients with head and neck cancer and how they relate to their quality of life. With such knowledge, an appropriate intervention program can be developed and evaluated. The intervention program could be best evaluated using a randomized controlled trial. To this end, the first author (C.J.S.), under the supervision of the coauthors, has commenced work in this area.
This article was originally presented in Cancer Nurs. 2004;27(6):p434-441.
1. Sawyer H. Meeting the information needs of cancer patients. Prof Nurse . 2000;15(4):244-247.
2. Mills ME, Sullivan K. The importance of information giving for patients newly diagnosed with cancer: a review of the literature. J Clin Nurs . 1999;8:631-642.
3. Semple CJ. The role of the CNS in head and neck oncology. Nurs Stand . 2001;15(31):39-42.
4. Koster META, Bergsma J. Problems and coping behaviours of facial cancer patients. Soc Sci Med. 1990;30(5):569-578.
5. Wadsworth JT, Somers KD, Stack BC, et al. Identification of patients with head and neck cancer using serum protein profiles. Arch Otolaryngol Head Neck Surg. 2004;130:98-104.
6. Otto, S. Oncology Nursing . 4th ed. London: Mosby; 2001.
7. Gritz ER, Carmack CL, de Moor C. Cossarelli A, Schacherer CW, Meyers EG. First year after head and neck cancer: quality of Life. J Clin Oncol. 1999;17(1):352-362.
8. Argerakis GP. Psychosocial considerations of the post-treatment of head and neck cancer patients. Dent Clin North Am. 1990;34(2):285-305.
9. Herzon F, Boshier M. Head and neck cancer-emotional management. Head Neck Surgery . 1990;2:112-118.
10. D'Antonio lL, Zimmermen GJ, Cella DF, Long SA. Quality of life and functional status measures in patients with head and neck cancer. Arch Otolaryngol Head Neck Surg. 1996;122:482-487.
11. Devins GM, Stam HJ, Koopmans JP. Psychosocial impact of laryngectomy mediated by perceived stigma and illness intrusiveness. Can J Psychiatry . 1994;39:608-616.
12. Hammerlid E, Persson L, Sullivan M, Westin T. Quality-of-life effects of psychosocial intervention in patients with head and neck cancer. Otolaryngol Head Neck Surg. 1999;120:507-516.
13. Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand. 1983;63:361-370.
14. Morton RP, Davies ADM, Baker J, Baker GA, Stell PM. Quality of life in treated head and neck cancer patients: a preliminary report. Clin Otolaryngol. 1984;9:181-185.
15. Boulnd G. Suicide and cancer, II: medical factors in suicide by cancer patients in Sweden, 1973-1976. J Psychosoc Oncol. 1985;3:31-35.
16. Farberow NL, Ganzler S, Cutter F, Reynolds D. An eight-year survey of hospital suicides. Life Threat Behav. 1971;1(3):184-202.
17. Edgar LN, Rosberger Z, Nowlis D. Coping with cancer during the first year after diagnosis. Cancer . 1992;69:817-828.
18. Fawzy FI. Psychosocial interventions for patients with cancer: what works and what doesn't. Eur J Cancer . 1999;35(11):1559-1564.
19. Marks IM. Forty years of psychosocial treatments. Behav Cogn Psychother. 2000;28:323-334.
20. Moorey S, Greer S, Watson M. Adjuvant psychological therapy for patients with cancer. Psycho-Oncology . 1994;7:218-228.
21. Cunningham AJ, Toccom EK. A randomized trial of group psychoeducational therapy for cancer patients. Patient Educ Couns. 1989;14: 101-114.
22. Edelman S, Bell DR, Kidman AD. A group-cognitive behaviour therapy programme with metastatic breast cancer patients. Psycho-Oncology . 1999;8:295-305.
23. Newell R, Clarke M. Evaluation of a self-help leaflet in treatment of social difficulties following facial disfigurements. Int J Nurs Stud. 2000;37: 381-388.
24. Yeole BB, Sankaranarayanan R, Sunny L, Swaminathan R, Parkin DM. Survival from head and neck cancer in Mumbai (Bombay), India. Am Cancer Soc. 2000;89:437-444.
25. Spence RAJ, Johnston PG. Oncology . Oxford: Oxford University Press; 2001.
26. Schantz SP, Yu G. Head and neck cancer incidence trends in Young Americans, 1973-1997, with a special analysis for tongue cancer. Arch Otolaryngol Head Neck Surg. 2002;128:268-274.
27. Brown AE, Langdon JD. Management of oral cancer. Ann R Coll Surg Engl. 1995;77:404-408.
28. Department of Health, Social Services and Public Health (DHSSPS). A Five-year Tobacco Action Plan 2003-2008. Belfast, Northern, Ireland: DHSSPS;2003.
29. Eakin R. Head and neck cancer. In: Spence RAJ, Johnston PG, eds. Oncology . Oxford: Oxford University Press: 2001:191-208.
30. Feber T. Head and Neck Oncology Nursing . London: Whurr Publishers Ltd; 2000.
31. Craddock C. Head and neck cancer prevention: the new challenge. Semin Oncol Nurs. 1993;9(3):169-173.
32. Vokes EE. Head and neck cancer. N Engl J Med. 1993;328(3):184-194.
33. Andre E, Schraub S, Mercier M, Bontemps P. Role of tobacco and alcohol in the aetiology of head and neck cancer: a case control study in the Doubs region of France. Eur J Cancer Oral Oncol. 1999;31(B):301-309.
34. Davis R. Nursing management of head and neck cancer. Macmillan Nurse. 1998;7:7-14.
35. Kurtulmaz SY, Erkal HS, Serin M, Elhan AH, Cakmak A. Squamous cell carcinoma of the head and neck: descriptive analysis of 1293 cases. J Laryngol Otol. 1997;111(6):531-535.
36. Edwards D. Face to Face . London: King's Fund; 1997.
37. Breitbart W, Holland J. Psychosocial aspects of head and neck cancer. Semin Oncol. 1988;15(1):61-69.
38. Cash TF, Pruzinsky T. Body Images: Development, Deviances and Change . New York: Guildford Press; 1990.
39. Beeken L, Calman F. A return to normal eating after curative treatment for oral cancer. What are the long-term prospects? Eur J Cancer Oral Oncol. 1994;30(B):387-392.
40. List MA, D'Antonio LL, Cella DF, et al. The performance status scale for head and neck cancer patients and the functional assessment of cancer therapy-head and neck scale. A study of utility and validity. Cancer . 1996;77:2294-2301.
41. Clarke A. Psychosocial aspects of facial disfigurement: problems, management and the role of a lay-led organization. Psychol Health Med. 1999; 4(2):127-142.
42. Mc Grouther DA. Facial disfigurement: the last bastion of discrimination. Br Med J. 1997;314:991.
43. Partridge J. Changing faces: taking up Macgregor's challenge. J Burn Care Rehabil. 1998;19:174-180.
44. Kent G. Understanding the experience of people with disfigurements: an integration of four models of social and psychological functioning. Psychol Health Med. 2000;5(2):117-129.
45. Kish V, Lansdown R. Meeting the psychosocial impact of facial disfigurement: developing a clinical service for children and families. Clin Child Psychol Psychiatry . 2000;504:497-512.
46. Saunders C. The Management of Terminal Malignant Disease. 2nd Ed. London: Edward Arnold, 1989.
47. Mc Guire DB, Sheidler VR. Pain. In: Groenwald SL, Hansen FM, Goodman M, Henke YC, eds. Cancer Nursing: Principles and Practice . 4th ed. Boston: Jones & Bartlett; 1997.
48. Chaplin JM, Morton RP. A prospective, longitudinal study of pain in head and neck cancer patients. Head Neck . 1999;21(6):531-537.
49. Bowling A. Measuring Disease . 2nd ed. Buckingham, England: Open University Press; 2001.
50. Morton RP. Laryngeal cancer: quality-of-life and cost-effectiveness. Head Neck . 1997;19(4):243-250.
51. Fallowfield L. The Quality of Life: The Missing Measurement in Health Care . London: Souvenir Press; 1990.
52. Spielberger CD, Sarason IG. Stress and Emotion . Vol 15. Washington, DC: Taylor & Francis; 1995.
53. The WHOQOL Group. Development of the WHOQOL-BREF quality of life assessment. Psychol Med. 1998;28:551-558.
54. Calman KC. Quality of life in cancer patients: a hypothesis. J Med Ethics . 1984;10:124-127.
55. Dolbeault S, Szporn A, Holland JC. Psycho-oncology: Where have we been? where are we going? Eur J Cancer . 1999;35(11):1554-1558.
56. Gamba A, Romano M, Grosso IM, et al. Psychosocial adjustment of patients surgically treated for head and neck cancer. Head Neck . 1992;14:218-213.
57. Mc Donough EM, Boyd JH, Varvores MA, Maves MD. Relationship between psychological status and compliance in a sample of patients treated for cancer of the head and neck. Head Neck . 1996;3(2):269-276.
58. Gladis MM, Gosch EA, Dishuk NM, Critis-Christoph C. Quality of life: expanding the scope for clinical significance. J Consult Clin Psychol. 1999; 67(3):320-331.
59. Schwartz S, Patrick DL, Yeuh B. Quality-of-life outcomes in the evaluation of head and neck cancer treatments. Arch Otolaryngol Head Neck Surg. 2001;127:673-677.
60. Velikova G, Stark D, Selby P. Quality of life in oncology. Eur J Cancer . 1999;35(11):1571-1580.
61. Talmi YP. Review article: quality of life issues in cancer of the oral cavity. J Laryngol Otol. 2002:116;785-790.
62. Kaasa S. Measurement of quality of life in clinical trials. Oncology . 1992; 49;288-294.
63. Bjordal K, Ahlner-Elmqvist M, Tollesson E, et al. Development of a European Organisation for Research and Treatment of Cancer (EORTC) questionnaire module to be used in the quality of life assessment in head and neck cancer patients. Acta Oncol. 1994;33(8):879-885.
64. Baker CA. A functional status scale for measuring quality of life outcomes in head and neck cancer. Cancer Nurs. 1995;18:452-457.
65. Terrell JE, Nanavati K, Esclamado RM, Bishop JK, Bradford CR, Wolf GT. Head and neck cancer-specific quality of life: instrument validation. Arch Otolaryngol Head Neck Surg. 1997;123:1125-1132.
66. Gilikich RE, Goldsmith TA, Funk GF. Are head and neck specific quality of life measures necessary? Head Neck . 1997:19;474-480.
67. Young PE, Beasley NJ, Houghton DJ, et al. A new short practical quality of life questionnaire for the use in head and neck oncology outpatient clinics. Clin Otolaryngol. 1998;23:528-532.
68. Brownman GP, Levine MN, Hodson DI, et al. The head and neck radiotherapy questionnaire: a morbidity/quality of life instrument for clinical trials of radiation therapy in local advanced head and neck cancer. J Clin Oncol. 1993;11:863-872.
69. Rogers SN, Gwanne S, Lowe D, Humphris G, Yueh B, Weymuller EA. The addition of mood and anxiety domains to the University of Washington Quality of Life scale. Head Neck. 2002:24;521-529.
70. Pruitt BT, Waligora-Serafin B, McMahon T, et al. An educational intervention for newly-diagnosed cancer patients undergoing radiotherapy. Psycho-Oncology . 1993:2;55-62.
71. Greer S, Moorey S, Baruch JDR, et al. Adjuvant psychological therapy for patients with cancer: a prospective randomised trial. Br Med J. 1992:304; 675-680.
72. Davidson R. The psychology of cancer. In: Spence RAJ, Johnston PG, eds. Oncology . Oxford: Oxford University Press; 2001:93-104.
73. Baile WF, Gibertin M, Scott L, Endicott J. Prebiopsy assessment on patients with suspected head and neck cancer. J Psychosoc Oncol. 1993; 10(4):79-91.
74. Bjordal K, Freng A, Thorvik J, Kassa S. Patient self-reported and clinician rated quality of life in head and neck cancer: a cross-sectional study. Eur J Cancer Oral Oncol. 1995;31B(4):235-241.
75. Fiegenbaum W. A social training program for clients with facial disfigurements: a contribution to the rehabilitation of cancer patients. Int J Rehabil Res. 1981;4(4):501-509.
76. Robinson E, Rumsey N, Partridge J. An evaluation of the impact of social interaction skills training for facially disfigured people. Br J Plast Surg. 1996;49:281-289.
77. Watson D, Friend R. Management of social-evaluative anxiety. J Consult Clin Psychol. 1969;33:448-457.
78. Clarke A. Resourcing and Training Head and Neck Cancer Nurse Specialists to Deliver a Social Rehabilitation Programme to Patients . [doctoral thesis]. London: City University; 2001.
79. Aaronson NK, Ahmedzia S, Bergman B, et al. The European Organisation for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials. J Natl Cancer Inst. 1993; 85(5):365-376.
80. Petruson KM, Silander EM, Hammerlid EB. Effects of psychosocial intervention on quality of life in patients with head and neck cancer. Head Neck . 2003;25:576-584Part 1