CRITICALLY APPRAISED PAPER (CAP) Loh, S. Y., Packer, T., Passmore, A., Yip C. H., Tan, F. L., & Xavier, M. (2010). Psychological distress of women newly diagnosed with breast cancer: Relationship with a self management intervention program. Asian Journal of Occupational Therapy, 8, 5 11. https://doi.org/10.11596/asiajot.8.5 CLINICAL BOTTOM LINE A diagnosis of breast cancer can severely affect a woman s psychological well-being. This study examined the effectiveness of an occupation-focused 4-week self-management group, Staying Abreast, Moving Ahead (SAMA), with an embedded two-tier peer buddy system to reduce levels of stress, anxiety, and depression for women newly diagnosed with breast cancer. The occupational therapy group intervention used group work, mini-lectures, and occupationbased homework (e.g., visiting a wig shop, planning meals, going on community outings with an assigned peer buddy, engaging in social participation occupations, visiting breast cancer resource centers). The occupational therapy group was provided in addition to usual care. The results suggest statistically significant reductions in levels of stress, anxiety, and depression for individuals who completed the occupational therapy SAMA group, compared with participants in the control group. The findings also suggest that women who reported moderate to high physical activity levels experienced significantly lower levels of stress than participants who reported sedentary to low physical activity levels. This study provides additional positive evidence for group interventions over individual treatments for reducing psychosocial distress. The authors suggested that the two-tiered peer buddy system, which embedded social participation occupation in the intervention design, likely led to positive outcomes for those in the intervention group. One buddy was assigned by the researchers, and participants were able to select a second buddy. It is important for occupational therapy practitioners to test and identify certain interventions for improving mental health in practice areas that are prone to high psychological stress, such as oncology and cancer survivorship. The authors recommended incorporating the SAMA intervention into occupational therapy practice guidelines during the early stages of a breast cancer diagnosis to reduce psychosocial distress. Introduced early in the process, SAMA also supports women in developing self-management skills and effective lifestyle strategies to maintain satisfactory levels of engagement in valued occupations. 1
RESEARCH OBJECTIVE(S) To determine the effectiveness of an occupation-focused, 4-week occupational therapy selfmanagement group intervention in reducing symptoms of depression, anxiety, and stress for women who were recently (past 12 months) diagnosed with breast cancer DESIGN TYPE AND LEVEL OF EVIDENCE Level II; two groups, nonrandomized, repeated measures PARTICIPANT SELECTION How were participants recruited and selected to participate? Participants were recruited through the University Malaya Medical Center in Kuala Lumpur, Malaysia. The researchers used a convenience sampling technique to recruit patients who had been diagnosed with breast cancer between December 2006 and February 2008. Inclusion criteria: Participants Were older than 18 years, Had been diagnosed with Stage I III breast cancer (within 1 year of diagnosis), Completed surgery (might be undergoing chemotherapy or radiation), Might be receiving Tamoxifen or other endocrine or adjuvant therapy, Had basic English literacy, and Were able to give informed consent. Exclusion criteria: Individuals were excluded if they had Significant cognitive impairments or learning disabilities, or Other reported medical conditions that might negatively affect their ability to participate in and attend group sessions. PARTICIPANT CHARACTERISTICS N= 147 #/ % Male: 0/(0%) #/ % Female: 147/(100%) 2
Ethnicity: Multiethnic sample: Chinese: 95 (65%) Indian: 21 (14%) Malay: 22 (15%) Other: 9 (6%) Disease/disability diagnosis: Breast cancer (Stages I III and diagnosed within the past 12 months): 147 (100%) INTERVENTION AND CONTROL GROUPS Group 1: Intervention group Brief description of the intervention How many participants in the group? Where did the intervention take place? Who delivered? How often? For how long? Participants in this group experienced usual care as well as the occupation-focused SAMA self-management group intervention. The self-management program consisted of different themes for each week of the group. The topics were medical management tasks, emotional management tasks, health management tasks, and role management tasks. The program used group work, mini-lectures, and homework in each of the sessions. A two-tier buddy system was also added to the program to provide embedded support to patients and encourage them to communicate with their group members about their homework. 69 (all women), groups of 8 15 women University Malaya Medical Center, Kuala Lumpur, Malaysia Health professionals at the University Malaya Medical Center. Primary author confirmed in personal communication that group facilitators were senior occupational therapists. Once weekly for 2.5-hour sessions 4 consecutive weeks, with measures taken at baseline, conclusion of the intervention (Week 4), and again 4 weeks later (Week 8) Group 2: Control group 3
Brief description of the intervention How many participants in the group? Where did the intervention take place? Who delivered? How often? For how long? Participants in this group experienced usual care, which consisted of surgery as well as a mixture of chemotherapy, radiotherapy, and targeted therapy as prescribed. 78 (all women) University Malaya Medical Center, Kuala Lumpur, Malaysia Health professionals at the University Malaya Medical Center Information about the length and occurrence of the control group interventions was not provided in this article but is available in a previously published article. Treatment length was not specified. Participants in the control group completed measures at baseline, 4 weeks after baseline (Week 4), and 8 weeks after baseline (Week 8) to mirror the protocol for the experimental group. INTERVENTION BIASES Contamination: NO The intervention was performed in a closed group, which prevented the members of the control group from participating in the intervention. Co-intervention: NR Participants in both groups received treatment as usual. Treatment as usual included surgery and a combination of chemotherapy, radiotherapy, and targeted therapy. Timing of intervention: It is worth noting that newly diagnosed was defined as within the past 12 months. As such, some participants in the experimental group might have had more familiarity with self-management information and time to practice self-managing medical, emotional, and role tasks than those participants who had been more recently diagnosed. Site of intervention: 4
NO The study took place at the medical center where the participants were used to receiving care. Use of different therapists to provide intervention: NO Specific health care providers who delivered interventions were not named explicitly in the article. Personal communication with the primary author confirmed that all group interventions were run by senior occupational therapists trained in self-management. Baseline equality: The authors performed t tests, and no significant differences were shown between the two groups except two minor demographic differences (ethnicity and insurance status). MEASURES AND OUTCOMES (Only on measures relevant to occupational therapy practice) Measure 1: Depression, Anxiety, and Stress Scales (DASS) Name/type of measure used: What outcome is measured? DASS Self-reported questionnaire used to measure psychological distress 21 items related to symptoms experienced in the past week Three scales (Depression, Anxiety, and Stress) Item responses range from 0 (not at all) to 3 (most of the time) Total subscores range from 0 to 21 (a higher score indicates more symptoms) Is the measure reliable (as reported in the article)? Is the measure valid (as reported in the article)? When is the measure used? Not Reported Cronbach s α =.73.81 (.73 anxiety,.81 depression,.81 stress) Not Reported The authors reported satisfactory convergent and discriminate validity. Additionally, they noted that the DASS is a valid outcome measure in clinical and nonclinical groups. The measurement was used before treatment began to establish a baseline value for each participant as well as at 4 weeks postbaseline and 8 weeks postbaseline. MEASUREMENT BIASES 5
Were the evaluators blind to treatment status? NR The authors did not report whether evaluators were blind to treatment status. Was there recall or memory bias? NR Because the DASS is a self-report questionnaire, there is the possibility of recall or memory bias, given the repeated-measures design. Additionally, it is worth noting that the measure was completed three times in an 8-week period. Other measurement biases: Although it was not reported by the authors of the study, volunteer bias might have influenced outcomes, because participation in the self-management group interventions was voluntary. RESULTS Before beginning statistical analysis of postintervention DASS questionnaire data, the researchers performed a t test to ensure that there were no differences between groups during the baseline. They determined that there were no statistically significant differences in mean baseline scores between the experimental and control groups in anxiety (p =.299), depression (p =.44), and stress (p =.08). Descriptive statistics reported show a number of decreases for all measures in the experimental group and increases for the control group. According to the authors, there was a decrease of 19.8% in stress and 33.3% in depression in the experimental group from baseline to Week 4. Additionally, there were decreases in anxiety (13.7%) and stress (17.1%) from Week 4 to Week 8. In the control group, increases were seen in both anxiety and depression, with percentages ranging from 8.9% to 14.9% between baseline and Week 4. In stress measurements, there was an initial increase, but from Week 4 to Week 8, there was a 2.5% mean score decrease in stress. Overall, however, the trend was for increased stress in the control group, as per the authors. To further explore differences between treatment groups, the authors performed analyses of variance (ANOVAs) for change between the baseline and Week 4 measures (referred to as change scores). These ANOVAs showed significant differences between groups in all three measures: stress, F(1, 140) = 13.68, p <.0001; depression, F(1, 140) = 11.57, p <.0001; and anxiety, F(1, 140) = 8.44, p <.004. The intervention group showed significant decreases across all subscales compared with the control group. Significant differences in stress were also seen, on the basis of reported levels of physical activity obtained from the initial demographic questionnaire (one question about physical activity level). Participants who reported having a moderate high level of physical activity had a significantly lower level of stress than those who reported a sedentary low level of activity (p =.031). No significant differences were seen for depression or anxiety levels on the basis of reported levels of physical activity. 6
Was this study adequately powered (large enough to show a difference)? NR Although the authors did not report information on power, they did conclude that future studies should consider larger cohorts. Were the analysis methods appropriate? ANOVA between groups was an appropriate method of analysis for this type of data. Were statistics appropriately reported (in written or table format)? Statistics were included in a table, and discussion of these values was included in a written Results section. Was participant dropout less than 20% in total sample and balanced between groups? YES NO NR What are the overall study limitations? Outcomes relied on self-report. Participants might have been receiving different treatment protocols; the article is unclear as to whether medical compliance was monitored. The small follow-up time limits the understanding of long-term effects of the intervention. The study design was unable to account for possible differences in psychosocial distress that might have been related to stage of cancer diagnosis, prognosis, or whether adjuvant interventions were required (e.g., chemotherapy, radiation, hormone therapy, targeted therapy). The demographic questionnaire did not inquire about previous issues with depression, anxiety, or stress; symptoms of psychosocial distress were wholly attributed to the new cancer diagnosis. Description of the SAMA group intervention was limited, which confounds opportunities for replication. The authors did not report the process for assigning peer buddies, although the two-tier 7
buddy arm of the intervention was considered to be clinically significant. Outcomes focused solely on symptomatology and did not address any changes in occupational performance or occupational engagement. CONCLUSION Emotional distress is a common downstream effect after a cancer diagnosis. Amelioration of this distress is important for increased quality of life for the recipients of a cancer diagnosis. The authors concluded that this distress was significantly decreased among women recently diagnosed with breast cancer as a result of an occupation-focused 4-week self-management group intervention. The results of the study show decreases in anxiety, depression, and stress among participants in the intervention group compared with those in the control group. Conversely, women who only received care as usual had increases in psychosocial distress over the observed 8-week period. Additionally, the authors found a statistically significant difference in reported stress among participants who reported higher levels of physical activity. As such, future studies are needed to further explore the role of physical activity in lowering stress for individuals with cancer. The authors concluded that women diagnosed with breast cancer should be offered information about exercise as a potential strategy for improved mental health. Finally, the authors concluded that SAMA may be most effective as an early intervention approach to addressing the psychosocial needs of women newly diagnosed with breast cancer. They recommended that occupational therapists consider interventions informed by selfmanagement principles, such as SAMA, as a vital component of clinical practice guidelines. This work is based on the evidence-based literature review completed by Ryan Dula; Mariam Kannan; Calliandra Lombard; Madison Morris; and Faculty Advisor Brad E. Egan, OTD, MA, CADC, OTR/L, Lenoir Rhyne University Columbia. CAP Worksheet adapted from Critical Review Form Quantitative Studies. Copyright 1998 by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, and M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: www.copyright.com 8