Cognitive Behavioral Interventions/Approach

Cognitive Behavioral Interventions/Approach

PEP Topic 
Hot Flashes
Description 

Cognitive behavioral interventions are designed to reflect concepts from cognitive behavioral therapy, which examines the association among thoughts, feelings, and behaviors.  Cognitive behavioral (CB) interventions do not involve full CBT psychotherapy. However, they do assist patients to identify negative or unhelpful thoughts and beliefs in order to change them.  CB interventions also help individuals to identify helpful and unhelpful behaviors, to establish goals, and to develop skills to solve problems and implement new behaviors to facilitate effective coping.  Structured programs based on cognitive behavioral interventions may include activities such as education or relaxation training, may be provided in individual or group settings, and may be delivered in person, telephonically, or by other methods.

Effectiveness Not Established

Research Evidence Summaries

Ganz, P. A., Greendale, G. A., Petersen, L., Zibecchi, L., Kahn, B., & Belin, T. R. (2000). Managing menopausal symptoms in breast cancer survivors: results of a randomized controlled trial. Journal of the National Cancer Institute, 92, 1054-1064.

doi:10.1093/jnci/92.13.1054
Print

Study Purpose:

This study intended to test the effectiveness of a comprehensive menopausal assessment (CMA) on symptom relief, quality of life, and sexual functioning.

Intervention Characteristics/Basic Study Process:

Participants were randomized by age (≤55 and >55) and tamoxifen use (current vs. not used). The CMA was delivered by a trained nurse practitioner with a specialty in family and women’s health over a 4-month period and focused on structured symptom assessment of hot flashes, vaginal dryness, and stress urinary incontinence. After assessment, patients were provided with individualized education and counseling, psychosocial support, referrals, and individualized follow-up. Specific pharmacologic and behavioral interventions for the target symptoms were implemented to control symptoms based on treatment protocols developed by the NP and the study physician. The intervention group returned for a 2-month follow-up visit. The usual care group received a telephone call 2 months after baseline to ask about therapies used to manage their symptoms. Data was collected at baseline and 4 months. The usual care group was then able to take part in the CMA but no further data was collected.

Sample Characteristics:

  • The study enrolled 42 women with breast cancer.

Setting:

  • SITE:  Single site    
  • SETTING TYPE : Outpatient    
  • LOCATION: California/community recruitment

Phase of Care and Clinical Applications:

PHASE OF CARE: Late effects and survivorship

Study Design:

This was a randomized, controlled trial.

Measurement Instruments/Methods:

  • Menopausal Symptom Scale Score (adapted from the Breast Cancer Prevention Trial Symptom Checklist)
  • Vitality Scale from the RAND 36-item Health Survey (aka Medical Outcomes Study SF-36)
  • Sexual Summary Scale from the Cancer Rehabilitation Evaluation (CARES)

Results:

97% of women in the study reported hot flashes at baseline, with no difference between groups. There was a significant difference in the menopause symptom scale (p=.0004), with women in the intervention group showing the most improvement in symptoms. There was no difference between groups in QOL (p=.77). The CMA group had significantly better sexual functioning at follow-up compared to the usual care group (p=.02). No specific data on improvement in hot flashes was provided. Only the overall symptom scale was reported.

Conclusions:

CMA is an effective intervention to improve/reduce the number of menopausal symptoms in breast cancer survivors and to improve sexual function for these women.

Limitations:

Limitations of the study included:

  • Small sample (< 100)
  • Risk of bias (no blinding)
  • Intervention expensive, impractical, or training needs
  • Requires a specially trained nurse practitioner for the intervention

Nursing Implications:

A nurse-led intervention to target menopausal symptoms is an effective way to reduce these symptoms in women who are survivors of breast cancer. However, the intervention may be too expensive or impractical given the training requirements of the intervention nurse and institutional guidelines on billable appointments.

Hunter, M. S., Coventry, S., Hamed, H., Fentiman, I., & Grunfeld, E. A. (2009). Evaluation of a group cognitive behavioural intervention for women suffering from menopausal symptoms following breast cancer treatment. Psycho-Oncology, 18, 560–563.

doi: 10.1002/pon.1414
Print

Study Purpose:

To evaluate a group cognitive-behavioral intervention to alleviate menopausal symptoms (hot flushes [HF] and/or night sweats [NS]) in women who have had treatment for breast cancer.

Intervention Characteristics/Basic Study Process:

Following a two-week daily diary assessment, patients were offered six 90-minute weekly sessions of group cognitive-behavioral therapy (CBT). CBT included:  information and discussion about menopausal symptoms; monitoring and modifying stimulants that precipitate symptoms; relaxation and paced breathing; and techniques to reduce stress and manage HF, NS, and sleep. The primary outcome measures were HF frequency and HF problem rating. Secondary outcomes included scores on the Women’s Health Questionnaire (WHQ) and scores pertaining to health-related quality of life (HRQOL) as measured by the SF-36®. Beliefs about HF were monitored to examine the effects of CBT. 

Sample Characteristics:

  • The study was comprised of 17 women receiving group CBT.
  • Mean age was 53.7 years (range 46–65).
  • Of the patients, 12 (71%) had undergone breast-conserving surgery; 3 (18%), modified radical mastectomy; 9 (53%), chemotherapy; 14 (82%), radiotherapy; and 12 (71%) were taking adjuvant hormonal therapies (11 were taking tamoxifen; 1 was taking anastrozole).
  • At diagnosis, seven patients (41%) were premenopausal, six (35%) were in the early or late transition stage of menopause, and four (24%) were in the early or late postmenopausal stage.
  • Average time since diagnosis was 23.2 months.
  • Average duration of HF and NS was 2.1 years.
  • Patients were treated in groups (of six, six, and five members); 12 women (59%) attended all six sessions, three women attended five sessions, and two attended three sessions. The majority (83%) completed all assessments.

Setting:

  • Multisite
  • Outpatient
  • Clinic staff recruited patients by using a database at two breast units in London, England.

Phase of Care and Clinical Applications:

  • Patients were undergoing the transition phase of care:  after initial treatment and completion of chemotherapy and/or radiotherapy and with or without hormone replacement therapy.
  • The study has clinical applicability for late effects and survivorship.

Study Design:

The study was a single-group, exploratory trial with pre- and posttreatment assessment after six weeks and three months.

Measurement Instruments/Methods:

  • Hot Flush Frequency and Problem Rating Scale (HFRS) 
  • WHQ
  • Hot Flush Beliefs Scale (HFBS)
  • SF-36® HRQOL ratings
  • Daily diaries
     

Results:

  • Weekly frequency of HF and NS was reduced from 75.7 to 46.9 (p < 0.03) at the posttreatment measure to 38.3 (p < 0.02) at the three-month follow-up. This change represents a 38% reduction at posttreatment and a 49% reduction at the three-month follow-up.
  • Problem rating was reduced from 6.3 to 3.4 at posttreatment (p < 0.0001) and to 2.6 at follow-up (p < 0.0001).
  • Depressed mood and anxiety significantly decreased from assessment to posttreatment (p < 0.02), and reductions were maintained at the three-month follow-up (p < 0.03).
  • Sleep improved significantly (p < 0.003).
  • Subscales of the SF-36® showed other significant improvements:  emotional role limitation (p < 0.0001), mental health (p < 0.01), energy/vitality (p < 0.0001), and general health (p < 0.003).
  • Total scores on the HFBS decreased significantly, from 28.2 to 22.4 at posttreatment (t = 3.77; df = 16; p < 0.002), and were maintained at 22.7 at follow-up (t = 4.34; df = 16; p < 0.001). These reductions reflected a significant change in beliefs.

Conclusions:

  • Results suggest that CBT delivered in groups might offer a viable option for women with troublesome, undertreated, menopausal symptoms following breast cancer treatment, but further controlled trials are needed.
  • CBT is consistent with the preferred treatment of women surveyed.
  • Improvements continued after treatment, which may reflect the skills-learning aspect of CBT. HF and NS decreased, as did depressed mood and anxiety.
  • Sleep improved, as reported by changes in WHQ ratings.
  • Results showed no signficant improvement in specific dimensions of HRQOL, particularly emotional role limitation, energy/vitality, or mental health.

Limitations:

  • The study had a small sample size, with less than 30 patients.
  • The study is of limited generalizability.
  • The main limitations of the study were lack of controls for placebo effects, attention, and spontaneous remission.
     

Nursing Implications:

Nurses could be trained to conduct structured, interactive, group CBT with individual treatment goals. A randomized, controlled trial is recommended for further investigation.

Mann, E., Smith, M. J., Hellier, J., Balabanovic, J. A., Hamed, H., Grunfeld, E. A., & Hunter, M. S. (2012). Cognitive behavioural treatment for women who have menopausal symptoms after breast cancer treatment (MENOS 1): a randomised controlled trial. Lancet Oncology, 13, 309–318.

doi: 10.1016/S1470-2045(11)70364-3
Print

Study Purpose:

To investigate whether cognitive-behavioral therapy (CBT) can help survivors of breast cancer in effectively managing menopausal symptoms.

Intervention Characteristics/Basic Study Process:

The intervention consisted of six 90-minute weekly sessions with group discussions, handouts, weekly homework, and paced breathing and relaxation practice—along with an audio CD to practice paced breathing and relaxation at home daily—in addition to usual care. The control group received usual care and follow-up by an oncologist or clinical nurse specialist every six months. Assessments took place at baseline, nine weeks after randomization (typically two weeks after treatment), and 26 weeks after randomization. All sessions were audio recorded, and a 10% random sample of the tapes was reviewed to evaluate the intervention.

Sample Characteristics:

  • The study enrolled 88 English-speaking women with breast cancer who were randomized into blocks, stratified by age (younger than 50 years and 50 years or older).
  • Patients reported a minimum of 10 problematic episodes of hot flashes per week for a duration of two months or more.

Setting:

  • Mutlisite
  • Outpatient
  • Breast clinics in London, England

Phase of Care and Clinical Applications:

  • Patients were undergoing the transition phase of care after initial treatment.
  • The study has clinical applicability for palliative and end-of-life care.

Study Design:

This was a triple-blinded, randomized, controlled trial.

Measurement Instruments/Methods:

  • Sternal Skin Conductance (SSC) for physiological symptoms from hot flashes  
  • SF-36® health-related quality-of-life ratings
  • Women’s Health Questionnaire (WHQ)
  • Adherence was measured by the number of sessions attended and the number of times that a patient practiced relaxation or paced breathing each week.

Results:

Night sweats problem rating scores at 9 and 26 weeks were lower in the CBT group than they were in the usual care group, with a mean difference between groups of –1.67 (95% confidence interval [CI] [–2.43, –0.91]; p < .0001). These scores also declined over time in the control group. There were no differences between groups in hot flush frequency, night sweats frequency, or SSC measures. Those receiving the CBT intervention reported less sleep problems (adjusted mean difference (AMD) = –0.16; 95% CI [–0.29, –0.02]), anxiety (AMD = –0.16; 95% CI [–0.29, –0.02]), and better memory and concentration (AMD = –0.14; 95% CI [–0.26, –0.02]).

Conclusions:

The findings suggest that group CBT improved patients’ perceptions of the degree to which hot flashes were a problem but did not appear to affect the actual frequency or objective measures of hot flashes. Group CBT appeared to have a small size of effect on sleep problems, anxiety, and other self-reported outcomes.

Limitations:

  • The study had a small sample size, with less than 100 patients.
  • No attentional control was used.
  • Specific AMD calculation was not described, so it is not clear how well this represents an effect size. 
  • Measures for anxiety and other outcomes were limited.

Nursing Implications:

This study provides some supportive evidence for the benefit of cognitive-behavioral approaches. Group CBT may have a benefit in managing hot flashes and other symptoms through altered perceptions of the degree to which these symptoms are seen as problematic. Health professionals, such as breast cancer nurses or clinical nurse specialists trained in CBT, can improve long-term health outcomes for patients with breast cancer, and CBT could be incorporated into breast cancer survivorship programs. 


Menu