Lung cancer

What is the role of psychological support and interventions in the treatment of lung cancer?

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Guideline contents > What is the role of psychological support and interventions in the treatment of lung cancer?
Clinical practice guidelines for the treatment of lung cancer
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Ftanou, M, Michael, N, Pollard, A, Clayton, J, Cancer Council Australia Lung Cancer Guidelines Working Party. Clinical question:What is the role of psychological support and interventions in the treatment of lung cancer? . In: Clinical practice guidelines for the treatment of lung cancer. Sydney: Australian Government / Cancer Australia. [Version URL: https://wiki.cancer.org.au/australiawiki/index.php?oldid=203172, cited 2023 May 28]. Available from: https://wiki.cancer.org.au/australia/Guidelines:Lung_cancer.


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20 May 2019 08:36:09

What is the role of psychological support and interventions in the treatment of lung cancer?

Introduction

Palliative care is appropriate for all people facing life threatening disease, though in practice in Australia, most services are directed toward people with life limiting/terminal disease. While most studies reviewed to create the palliative care section are derived from studies relating to patients with NSCLC, it is likely that the themes and concepts are broadly applicable to those with SCLC.

Lung cancer patients’ have been found to have a significantly higher burden of unmet psychological need compared to other cancer patients,[1] with studies quoting up to 43% of lung cancer patients experiencing psychological distress compared with approximately 35% of patients with other cancer diagnoses.[2] The psychological distress of lung cancer patients has been found to persist throughout the clinical course of illness[3] as poor prognosis, symptom severity and treatment side-effects of lung cancer adversely affects psychological wellbeing.[4] Early identification, treatment, screening and timely referrals are important first steps in the management of psychological distress and optimising quality of life (QoL) in these patients.[5][6]

These guidelines will provide direction for non-pharmacological evidence-based management of common psychological problems seen in the NSCLC population, including depression, anxiety, fatigue, pain and disruption to QoL. These guidelines have been developed following review of current literature, taking into account the limited number of randomised control trials, small sample sizes, heterogenous samples and high attrition rates in this population.

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Psychosocial treatment of depression

There have been five recent systematic reviews[7][8][9][10][11] and one meta-analysis[12] evaluating the efficacy of psychological interventions for the treatment of depression in samples of mixed cancer patients.

Barsevic et al[7] in a systematic review of 36 studies, including two well conducted meta-analyses (N= 22,319), concluded that psycho-educational interventions benefited cancer patients with depressive symptomatology. In regard to content of these studies the authors concluded that 70% of behaviour therapy studies, 66% of counseling studies and 58% of studies that tested behaviour and counseling in combination with cancer education were effective. Uitterhoeve et al[10] conducted a systematic review of psychosocial interventions specifically for patients with advanced cancer. The review included 10 RCTs (N=862) involving 13 trials, and reported that behaviour therapy improved mood in advanced cancer patients in 12 out of 13 trials.

A systematic review by Newell et al[8] and a meta-analysis by Osborne et al[12] suggested that that Cognitive Behaviour Therapy (CBT) was effective in the management of depression particularly in the short-term.

In a recent RCT utilizing a collaborative and integrated approach that involved a multidisciplinary team (e.g.: nursing, psychiatry, oncology) and a combination of CBT strategies (such as problem-solving, psychoeducation, and behavioural activation), rapport building, counselling techniques and anti-depressant medication, it was found that depression severity was significantly lower in patients allocated to the collaborative depression care group (mean score on the SCL-20 1.24 [SD 0.64]) than in those allocated to a treatment as usual group (mean score 1.61 [SD 0.58]); difference −0.38 (95% CI −0.58 to −0.18). These improvements were also maintained at 12 weeks.[13]

The literature provides moderate support for the use of psychotherapy interventions in group settings for reducing the impact of depression in cancer patients. Newell et al, in a systematic review of 15 trials of psychological interventions, concluded that a variety of psychotherapeutic interventions including group therapy, education, structured counseling, and CBT, warrant further investigation to justify their use, but that tentative recommendations could be made for the use of group psychotherapy, education and structured counseling for depressed patients with cancer.[8] A further systematic review by Williams et al concluded that CBT, counselling and psychotherapy and group social support were all effective in reducing symptoms of depression in patients with cancer, including lung cancer.[9] Also, Uitterhoeve et al found that patient self-esteem and mood improved with a combination of behavioural therapy and group support. In contrast, Osborne et al found that individual interventions were more effective than group interventions for treatment of depression, anxiety and quality of life in cancer survivors.[12] This inconsistency in the literature may reflect different sample characteristics, for example Osborne et al’s meta-analysis focused on cancer survivors, whereas the two reviews[8],[9] involved either a mixed sample of cancer survivors or focused on patients with advanced cancer. All three reviews commented on inconsistencies in the methodoclogical quality of studies examined, whilst Newell et al provided a summary of quality indicators to ensure methodological rigour of future studies could be improved.[8]

In summary, “whilst it may be reasonable to treat depression in individuals with lung cancer with standard treatments until more specific evidence is available, clinicians should be aware that the effectiveness and potential adverse effects of these treatments remain unknown in this patient group.”[11]

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Psychosocial treatment of anxiety

CBT remains the recommended first line treatment for anxiety in non-cancer populations, few studies have evaluated its efficacy in patients with lung cancer

The evidence supporting the use of CBT as a treatment for anxiety in advanced cancer remains inconclusive. Moorey et al. conducted a small randomized control trial (RCT) of 80 participants with advanced cancer comparing a control group (usual care) with CBT. Results suggested that participants receiving CBT had consistently lower anxiety over time.[14]. Newell et al in a systematic review did not find consistent evidence for the use of CBT to treat anxiety,[8] however Osborne et al’s meta-analysis found that CBT for anxiety had a large effect in a sample of cancer survivors (g=1.99 p<0.01; 95% CI 0.69- 3.31).[12]

The benefits of group interventions for cancer patients with anxiety remain unclear. A systematic review involving 13 trials found only one trial, involving a Supportive Group Psychotherapy intervention, had a positive impact on anxiety. This trial involved women with metastatic breast cancer only, therefore the results cannot be generalize to NSCLC population.[10] In a recent pilot RCT, 90 patients with stage III or stage IV advanced cancer were randomly assigned to Meaning Centered Group Psychotherapy (MCGP) or Supportive Group Psychotherapy (SGP) with results suggesting that participants in the MCGP group, in addition to showing greater improvements in spiritual well-being and sense of meaning also showed improvement in anxiety, whereas participants in the SGP did not show any improvements in these areas.[15] Some evidence is also starting to emerge that individual narrative meaning making interventions (e.g: where patients are promoted to discuss their sense of ‘‘meaning’’, psychological, physical, social and spiritual wellbeing and sense of suffering) may have a role in improving anxiety and depression, however, larger powered trials are required to draw any conclusions.[16]

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Psychosocial treatment of fatigue

The numbers of psychological interventions that specifically target fatigue are limited as fatigue is typically measured as a secondary outcome to depression or QoL. The available literature suggests that psychological interventions may assist in the treatment of fatigue.[17][18][19]

A Cochrane systematic review of “psychosocial interventions for reducing fatigue during cancer treatment in adults” identified 27 studies involving 3324 participants that specifically targeted fatigue as an outcome. Only five of these studies utilised psychological interventions to specifically treat fatigue.[20] Of these latter studies, four studies indicated that that they were effective in treating fatigue and two of these studies indicated that the effects were maintained at follow-up whilst small sample size may have reduced the effectiveness of one study. The Cochrane review found that the fatigue specific programs had three main components:

1) fatigue education;
2) self-care and coping techniques; and
3) activity management learning to balance activity and rest.

These interventions were also short interventions consisting of three sessions and varying durations from 10 to 60 minutes per session. Researchers also found three interventions that were not targeting fatigue as their primary outcome to have a significant effect on fatigue. The content of these three interventions included both supportive and unstructured therapy approaches or CBT.[20] Overall the Cochrane review concluded that evidence for fatigue management was weak to moderate with fatigue specific interventions having better outcomes.

Kangas et al[21] conducted a systematic review and meta-analysis of 57 RCTs of non-pharmacological studies that had fatigue or tiredness as an outcome, and concluded that both exercise and psychological interventions reduced cancer-related fatigue with no significant differences between these two interventions whilst psychological interventions that used supportive expressive and CBT modalities were also found to have a moderate effect in reducing fatigue.[21] Similarly to the Cochrane review,[20] Kangas et al concluded that these studies, which specifically targeted fatigue in their hypothesis, yielded larger effect sizes.

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Psychosocial treatment of pain

RCTs evaluating the efficacy of psychological support in reducing pain specifically in NSCLC cancer patients are not available.

Devine et al performed a meta-analysis of 25 psychological intervention studies, published from 1978 -2001, which included data from 1723 adults with cancer. The authors found that relaxation-based interventions, relaxation and cognitive behavioural interventions, educational and supportive counseling interventions resulted in generally beneficial effects on pain outcomes, and when the analysis was limited to the three studies employing group randomization the effect on pain was statistically significant (d+ = 0.33, 95%CI=0.07-0.59).[22] Relaxation and cognitive-based interventions were effective in reducing pain shortly after treatment and were acceptable to patients, however the authors concluded that the long-term effects of these interventions are unknown in this population.

The results of one RCT, utilising psycho-education strategies versus standard care, found that psycho-educational strategies resulted in statistically and clinically significant reductions in pain.[23] An innovative intervention study,[23] conducted with patients with advanced colorectal, lung, prostate and gynecological cancer, received education and training to use an MP3 player loaded with 12 cognitive behavioural strategies (e.g.: relaxation, guided imagery). These patients demonstrated a significant reduction in pain both immediately before and after the use of CBT strategies.[24] In a more recent RCT, Carlson et al (2013)[25] found that pain was also significantly reduced in patients with lung cancer who received a thorough triage (e.g: Distress Thermometer, Canadian Problem Checklist (CPC), Pain Thermometer, Fatigue Thermometer, and the Psychological Screen plus the option of a phone call) versus minimal screening (e.g: Distress Thermometer).

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Quality of life

Uttierhoeve et al[10] conducted a systematic review of literature published between 1990 and 2002 regarding psychological interventions for people with advanced cancer. They concluded that behavioural therapy had positive effects on QoL domains, including improvements in mood, coping and functional living . Graves[26] in a meta-analysis found that interventions that were based in social cognitive therapy including self -efficacy and self-regulation lead to global improvement in QoL. Furthermore meta-analysis involving the impact of CBT on QoL in cancer survivors found that CBT had large positive long-term effect on QoL (g = 0.91, p<0.01;95% CI-0.38-1.44).[12]

A Cochrane review of non-invasive intervention aimed at improving QoL of lung cancer patients found that two nursing interventions aimed at managing breathlessness and three structured programs improved patients mood symptoms and performance status.[27] A recent study, however, found no evidence that a nurse navigation intervention was more effective in improving quality of life than treatment as usual.[28]

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Dyadic Interventions

There is a small body of research emerging that is examining the role that dyadic intervention may have in improving the psychosocial impacts of lung cancer. For instance, Badr, Smith, Goldstein, Gomez, Redd (2015)[29] conducted a pilot study examining the feasibility, acceptability, of a 6-session telephone-based dyadic psychosocial intervention. The intervention was grounded in Self-determination Theory and covered the following topics: self-care, stress and coping, symptom management, effective communication, problem-solving, and maintaining and enhancing relationships for both patients and carers. The intervention was found to led to significant improvements in depression, anxiety, and caregiver burden. Similarly Northouse, Mood Schafenacker, Kalemkerian , Zalupski, & LoRusso (2013)[30] found positive effects from that dyadic intervention. They found that dyadic interventions led to improvements in dyads' coping (p<.05), self-efficacy (p<.05), and social QOL (p<.01), and in caregivers' emotional QOL (p<.05). These studies although promising have a number of limitations including the involvement of a small number of lung cancer patients and inconsistent methodology and outcome measures. More RCTs are needed before we can conclude whether Dyadic interventions are beneficial for lung cancer patients.

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Conclusion

The diagnosis of stage IV NSCLC impacts on physical, psychological well-being and QoL of patients. The Psychosocial Guidelines for Adults with Cancer[6] identifies disease factors such as stage of disease, and poor prognosis as risk factors for increased distress. These factors, together with other patient characteristics including psychiatric history, drug and alcohol use, age, social support, co-morbid medical conditions and socio-economic status, are predictors of psychological distress and will affect individual capacity to adjust to incurable disease. Research demonstrates that psychological interventions can assist in improving psychological well-being and coping with physical symptoms of disease and treatment. Combinations of CBT, psycho-education, relaxation, supportive and unstructured therapies appear to be the most beneficial in this group of patients.

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Evidence summary and recommendations

Depression

Evidence summary Level References
Psycho-educational interventions assist in treating depressive symptomatology in patient with cancer (in group or individual format).

Last reviewed December 2015

I [7], [10]
Cognitive Behaviour Therapy (CBT) is effective in the management of depression, particularly in the short-term (in group or individual format).

Last reviewed December 2015

I [8], [9], [10], [12]
Evidence-based recommendationQuestion mark transparent.png Grade
Psycho-educational interventions including: counseling, behaviour therapy, education/information giving, and social support will assist in ameliorating the impact of depression.

Last reviewed December 2015

B
Evidence-based recommendationQuestion mark transparent.png Grade
There is reasonable evidence from systematic reviews to support the use of Cognitive Behaviour Therapy (CBT) in the management of depression particularly in the short-term (in group or individual format). Further randomised controlled trials involving adequately powered studies and consistent methodology should be conducted.

Last reviewed December 2015

B


Anxiety

Evidence summary Level References
Cognitive Behaviour Therapy (CBT) may have an effective role as a treatment of anxiety in NSCLC cancer population.

Last reviewed December 2015

I, II [12], [14], [31], [32]
Supportive and Meaning-based Group Psychotherapies have a positive impact on anxiety.

Last reviewed December 2015

I, II [10], [15]
Evidence-based recommendationQuestion mark transparent.png Grade
Cognitive Behaviour Therapy (CBT) is recommended for the treatment of anxiety in NSCLC. Further randomised controlled trials involving adequately powered studies and consistent methodology should be conducted.

Last reviewed December 2015

B
Evidence-based recommendationQuestion mark transparent.png Grade
Supportive and Meaning based group psychotherapies, may be helpful in reducing anxiety in NSCLC patients. Further randomised controlled trials involving adequately powered studies and consistent methodology should be conducted.

Last reviewed December 2015

B


Fatigue

Evidence summary Level References
Psychotherapeutic intervention including Cognitive Behaviour Therapy (CBT), education, self-care strategies, behavioural interventions, activity management, supportive psychotherapy have all been found to ameliorate fatigue. Psychological interventions that specifically target fatigue are the most beneficial.

Last reviewed December 2015

I, II [17], [18], [20], [21], [19]
Evidence-based recommendationQuestion mark transparent.png Grade
Psychological interventions including Cognitive Behaviour Therapy (CBT), education, self-care strategies, behavioural interventions, activity management, supportive psychotherapy have all been found to ameliorate fatigue.

Further randomised controlled trials involving adequately powered studies and consistent methodology can be conducted to ascertain unmet needs in advanced cancer.
Last reviewed December 2015

C


Pain

Evidence summary Level References
Evidence suggests that Cognitive Behaviour Therapy (CBT), relaxation-based interventions (eg: guided imagery, progressive muscle relaxation) supportive psychotherapies and psycho-educational strategies have role in pain management.


Last reviewed December 2015

I, II [22], [23], [24]
Evidence-based recommendationQuestion mark transparent.png Grade
Psychological interventions have an important role in the management of cancer related pain.
Last reviewed December 2015 		B


Quality of life

Evidence summary Level References
Evidence suggests that behavioural, cognitive and social cognitive therapies may be useful in improving coping, adjustment, functional ability and quality of life.


Last reviewed December 2015

I [10], [12], [26], [27]
Non- invasive nurse-led programs aimed to target symptom management lead to improvement in wellbeing and quality of life.


Last reviewed December 2015

I [27]
Evidence-based recommendationQuestion mark transparent.png Grade
Quality of life of lung patients may improve with behavioural, cognitive or social cognitive therapies.


Last reviewed December 2015

C
Evidence-based recommendationQuestion mark transparent.png Grade
Non-invasive nurse-led programs with a focus on managing physical symptoms and treatment related toxicities may be used to optimise quality of life.


Last reviewed December 2015

C


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References

  1. ↑ Li J, Girgis A. Supportive care needs: are patients with lung cancer a neglected population? Psychooncology 2006 Jun;15(6):509-16 Available from: http://www.ncbi.nlm.nih.gov/pubmed/16292789.
  2. ↑ Zabora J, BrintzenhofeSzoc K, Curbow B, Hooker C, Piantadosi S. The prevalence of psychological distress by cancer site. Psychooncology 2001;10(1):19-28 Available from: http://www.ncbi.nlm.nih.gov/pubmed/11180574.
  3. ↑ Akechi T, Okuyama T, Akizuki N, Azuma H, Sagawa R, Furukawa TA, et al. Course of psychological distress and its predictors in advanced non-small cell lung cancer patients. Psychooncology 2006 Jun;15(6):463-73 Available from: http://www.ncbi.nlm.nih.gov/pubmed/16173112.
  4. ↑ Kurtz ME, Kurtz JC, Stommel M, Given CW, Given B. Predictors of depressive symptomatology of geriatric patients with lung cancer-a longitudinal analysis. Psychooncology 2002;11(1):12-22 Available from: http://www.ncbi.nlm.nih.gov/pubmed/11835589.
  5. ↑ Néron S, Correa JA, Dajczman E, Kasymjanova G, Kreisman H, Small D. Screening for depressive symptoms in patients with unresectable lung cancer. Support Care Cancer 2007 Oct;15(10):1207-12 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17879108.
  6. ↑ 6.0 6.1 National Breast Cancer Centre and National Cancer Control Initiative. Clinical practice guidelines for the psychosocial care of adults with cancer. National Breast Cancer Centre, Camperdown, NSW 2003 Available from: http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp90.pdf.
  7. ↑ 7.0 7.1 7.2 Barsevick AM, Sweeney C, Haney E, Chung E. A systematic qualitative analysis of psychoeducational interventions for depression in patients with cancer. Oncol Nurs Forum 2002;29(1):73-84; quiz 85-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/11817494.
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 8.6 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 Apr 17;94(8):558-84 Available from: http://www.ncbi.nlm.nih.gov/pubmed/11959890.
  9. ↑ 9.0 9.1 9.2 9.3 Williams S, Dale J. The effectiveness of treatment for depression/depressive symptoms in adults with cancer: a systematic review. Br J Cancer 2006 Feb 13;94(3):372-90 Available from: http://www.ncbi.nlm.nih.gov/pubmed/16465173.
  10. ↑ 10.0 10.1 10.2 10.3 10.4 10.5 10.6 10.7 Uitterhoeve RJ, Vernooy M, Litjens M, Potting K, Bensing J, De Mulder P, et al. Psychosocial interventions for patients with advanced cancer - a systematic review of the literature. Br J Cancer 2004 Sep 13;91(6):1050-62 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15316564.
  11. ↑ 11.0 11.1 Walker J, Sawhney A, Hansen CH, Symeonides S, Martin P, Murray G, et al. Treatment of depression in people with lung cancer: a systematic review. Lung Cancer 2013 Jan;79(1):46-53 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23102652.
  12. ↑ 12.0 12.1 12.2 12.3 12.4 12.5 12.6 12.7 Osborn RL, Demoncada AC, Feuerstein M. Psychosocial interventions for depression, anxiety, and quality of life in cancer survivors: meta-analyses. Int J Psychiatry Med 2006;36(1):13-34 Available from: http://www.ncbi.nlm.nih.gov/pubmed/16927576.
  13. ↑ Walker J, Hansen CH, Martin P, Symeonides S, Gourley C, Wall L, et al. Integrated collaborative care for major depression comorbid with a poor prognosis cancer (SMaRT Oncology-3): a multicentre randomised controlled trial in patients with lung cancer. Lancet Oncol 2014 Sep;15(10):1168-76 Available from: http://www.ncbi.nlm.nih.gov/pubmed/25175097.
  14. ↑ 14.0 14.1 Moorey S, Cort E, Kapari M, Monroe B, Hansford P, Mannix K, et al. A cluster randomized controlled trial of cognitive behaviour therapy for common mental disorders in patients with advanced cancer. Psychol Med 2009 May;39(5):713-23 Available from: http://www.ncbi.nlm.nih.gov/pubmed/18761755.
  15. ↑ 15.0 15.1 Breitbart W, Rosenfeld B, Gibson C, Pessin H, Poppito S, Nelson C, et al. Meaning-centered group psychotherapy for patients with advanced cancer: a pilot randomized controlled trial. Psychooncology 2010 Jan;19(1):21-8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19274623.
  16. ↑ Lloyd-Williams M, Cobb M, O'Connor C, Dunn L, Shiels C. A pilot randomised controlled trial to reduce suffering and emotional distress in patients with advanced cancer. J Affect Disord 2013 May 15;148(1):141-5 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23219061.
  17. ↑ 17.0 17.1 Ream E, Richardson A, Alexander-Dann C. Supportive intervention for fatigue in patients undergoing chemotherapy: a randomized controlled trial. J Pain Symptom Manage 2006 Feb;31(2):148-61 Available from: http://www.ncbi.nlm.nih.gov/pubmed/16488348.
  18. ↑ 18.0 18.1 Armes J, Chalder T, Addington-Hall J, Richardson A, Hotopf M. A randomized controlled trial to evaluate the effectiveness of a brief, behaviorally oriented intervention for cancer-related fatigue. Cancer 2007 Sep 15;110(6):1385-95 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17661342.
  19. ↑ 19.0 19.1 Jacobsen PB, Donovan KA, Vadaparampil ST, Small BJ. Systematic review and meta-analysis of psychological and activity-based interventions for cancer-related fatigue. Health Psychol 2007 Nov;26(6):660-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/18020836.
  20. ↑ 20.0 20.1 20.2 20.3 Goedendorp MM, Gielissen MF, Verhagen CA, Bleijenberg G. Psychosocial interventions for reducing fatigue during cancer treatment in adults. Cochrane Database Syst Rev 2009 Jan 21;(1):CD006953 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19160308.
  21. ↑ 21.0 21.1 21.2 Kangas M, Bovbjerg DH, Montgomery GH. Cancer-related fatigue: a systematic and meta-analytic review of non-pharmacological therapies for cancer patients. Psychol Bull 2008 Sep;134(5):700-41 Available from: http://www.ncbi.nlm.nih.gov/pubmed/18729569.
  22. ↑ 22.0 22.1 Devine EC. Meta-analysis of the effect of psychoeducational interventions on pain in adults with cancer. Oncol Nurs Forum 2003;30(1):75-89 Available from: http://www.ncbi.nlm.nih.gov/pubmed/12515986.
  23. ↑ 23.0 23.1 23.2 Miaskowski C, Dodd M, West C, Paul SM, Schumacher K, Tripathy D, et al. The use of a responder analysis to identify differences in patient outcomes following a self-care intervention to improve cancer pain management. Pain 2007 May;129(1-2):55-63 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17257753.
  24. ↑ 24.0 24.1 Kwekkeboom KL, Abbott-Anderson K, Wanta B. Feasibility of a patient-controlled cognitive-behavioral intervention for pain, fatigue, and sleep disturbance in cancer. Oncol Nurs Forum 2010 May;37(3):E151-9 Available from: http://www.ncbi.nlm.nih.gov/pubmed/20439200.
  25. ↑ Carlson LE, Waller A, Groff SL, Bultz BD. Screening for distress, the sixth vital sign, in lung cancer patients: effects on pain, fatigue, and common problems--secondary outcomes of a randomized controlled trial. Psychooncology 2013 Aug;22(8):1880-8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23147718.
  26. ↑ 26.0 26.1 Graves KD. Social cognitive theory and cancer patients' quality of life: a meta-analysis of psychosocial intervention components. Health Psychol 2003 Mar;22(2):210-9 Available from: http://www.ncbi.nlm.nih.gov/pubmed/12683741.
  27. ↑ 27.0 27.1 27.2 Solà I, Thompson E, Subirana M, López C, Pascual A. Non-invasive interventions for improving well-being and quality of life in patients with lung cancer. Cochrane Database Syst Rev 2004 Oct 18;(4):CD004282 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15495096.
  28. ↑ Wagner EH, Ludman EJ, Aiello Bowles EJ, Penfold R, Reid RJ, Rutter CM, et al. Nurse Navigators in Early Cancer Care: A Randomized, Controlled Trial. J Clin Oncol 2013 Nov 25 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24276777.
  29. ↑ Badr H, Smith CB, Goldstein NE, Gomez JE, Redd WH. Dyadic psychosocial intervention for advanced lung cancer patients and their family caregivers: results of a randomized pilot trial. Cancer 2015 Jan 1;121(1):150-8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/25209975.
  30. ↑ Northouse LL, Mood DW, Schafenacker A, Kalemkerian G, Zalupski M, LoRusso P, et al. Randomized clinical trial of a brief and extensive dyadic intervention for advanced cancer patients and their family caregivers. Psychooncology 2013 Mar;22(3):555-63 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22290823.
  31. ↑ Greer JA, Park ER, Prigerson HG, Safren SA. Tailoring Cognitive-Behavioral Therapy to Treat Anxiety Comorbid with Advanced Cancer. J Cogn Psychother 2010 Jan 1;24(4):294-313 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21234281.
  32. ↑ Rolke HB, Bakke PS, Gallefoss F. Health related quality of life, mood disorders and coping abilities in an unselected sample of patients with primary lung cancer. Respir Med 2008 Oct;102(10):1460-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/18590954.

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