Budin, W.C., Hoskins, C.N., Haber, J., Sherman, D.W., Maislin, G., Cater, J.R., . . . Shukla, S. (2008). Breast cancer: Education, counseling, and adjustment among patients and partners: A randomized clinical trial. Nursing Research, 57(3), 199–213.

To determine the effects of care phase-specific psychoeducation and telephone counseling on emotional, physical, and social adjustment of patients and partners, compared to standard treatment of disease management

Patients and partners were randomly assigned to one of four groups in dyads.

• The control group (group 1) received standard disease management (DM), which consisted of stated adherence of providers to evidence-based treatment protocols.
• Group 2 received psychoeducation (SE) consisting of four phase-specific videos involving coping, recovering from surgery, and understanding adjuvant therapy.
• Group 3 received DM plus telephone counseling (TC) using treatment phase-specific scripted telephone counseling interventions.
• Group 4 consisted of combined SE and TC interventions.

The partner involved was the person the patient identified as most intimately involved in the breast cancer experience. Care phases were defined as Time 0 (T0) (upon study entry), T1 (diagnostic—when the diagnosis of breast cancer was determined), T2 (postsurgical phase—two days after surgery), T3 (adjuvant therapy phase—when making decisions about therapy), and T4 (ongoing recovery—two weeks after completion of chemotherapy or radiation, or six months after surgery if no adjuvant therapy was done).

• The sample consisted of 126 patients and 126 partners.
• The average patient age was 53.8 ± 11.7. The average partner age was 51.6 ± 12.0.
• Gender: (only reporting on partners; all patients were female.)
  • Females: 41.6%
  • Males: 58.4%
• All patients had breast cancer.
  • Had a family history of breast cancer: 49.8%
  • Had lumpectomy or wide excision: 53.4%
  • Had radical mastectomy: 8.7%
  • Had stage 0 disease: 22.9%
  • Had stage 3 disease: 5.9%
• Sixty percent of partners were spouses or live-in partners, 12% were daughters, 13% were sisters, 11% were friends, and 4% were mothers.
• Seventy percent of partners were Caucasian, and 12.8% were African American.
• Approximately 85% of partners had at least some college education.
• Sixty percent of partners and 52.8% of patients were employed full time. 71.3% of partners reported a combined income greater than $50,000.
• Seventy-seven percent of partners reported having children.

• Multi-site
• Outpatient
• Medical centers in the New York metropolitan area

• Profile of adaptation to life clinical scale (PAL-C)
• Breast cancer treatment response inventory (BCTRI)
• Self-rated health subscale (SRHS)
• Psychosocial adjustment to illness scale (PAIS)

Patients' psychological well-being (p = 0.033) improved over time in all groups. There was also a significant difference in improvement over time depending on the study group assigned (group plus time effect) (p = 0.004). The TC group had the highest psychological well-being at the adjuvant therapy stage.

No significant effects were noted among partners. No significant effects related to distress from side effects among patients were noted in any group. For patients in the DM control group (group 1), significantly greater side-effect distress was noted compared to all treatment groups combined (p = 0.02). The side-effect severity for patients had a significant effect over time, and mean severity of side effects was significantly higher from baseline to T4 in the DM control group (p = 0.016). Partners in the SE and TC group (group 4) reported significantly fewer side effects than those in the TC-only group (group 3) (p = 0.017), and a significant overall effect of the intervention (p = 0.024) on physical symptoms was reported. Physical symptoms reported by partners did not demonstrate an effect from time. Partners' overall health scores were not affected, and patients' overall health improved over time for all groups (p < 0.0001). The intervention had no significant effect on vocational adjustment for patients, and in partners, both group assignment and time demonstrated significant main effects in analysis (p </= 0.05). Only time appeared to affect social adjustment.

Most outcomes for patients and partners improved over time, regardless of group assignment. The combination of standardized SE and TC as provided in the study was associated with improved psychological well-being across the timeframe of the study.

• No appropriate control group or attentional control was used.
• It is not clear what patient education and counseling and amount of patient contact and attention was provided in the DM control group to differentiate fully between interventions. Standard or usual care was not clearly defined or applied.
• Group assignment was not blinded.
• The sample tended to be well-educated and of relatively high income levels, so findings may not be applicable to other socioeconomic and cultural groups.
• All patients were women, and as other studies have shown, differences in variables associated with patient and caregiver gender may influence these outcomes producing findings that may not be applicable to other types of patient-partner groups.
• Although some improvements were seen over time for both patients and partners, authors point out that higher than normal levels of adjustment problems were evident at the time of final data collection. The findings may have been biased by lack of blinding and the sample who chose to participate, as these patients may have been more motivated or more distressed than others in the total population.
• It is not clear how outcomes actually changed over time in all groups. The authors provide graphic representation of predicted outcomes over time rather than actual mean results.
• The time frame of interventions carried out might have influenced the findings. Specifically, the adjuvant therapy group was collected prior to adjuvant therapy, which may be misleading.

Both patient and partner reactions to breast cancer vary over time and tend to improve over time, and findings suggest that patient needs and issues vary at different phases in care, suggesting the need for different strategies and interventions according to the phase of care. SE and supportive counseling activities can be helpful to patients and caregivers in management of physical symptoms and side effects. TC intervention in combination with SE activities as provided by video, as in this study, may provide a practical alternative method to provide this type of intervention.