Heinrichs, N., Zimmermann, T., Huber, B., Herschbach, P., Russell, D.W., & Baucom, D.H. (2012). Cancer distress reduction with a couple-based skills training: A randomized controlled trial. Annals of Behavioral Medicine, 43, 239–252.

To investigate the short- and long-term effects of a psychosocial side-by-side couple's intervention on disease distress, post-traumatic growth, communication, and dyadic coping among women with breast and gynecologic cancers and their partners

The side-by-side intervention consisted of four meeting sessions between a participating couple and a therapist on a biweekly, face-to-face basis at the couple’s home. Each meeting session lasted two hours. Each of the four sessions focused on a certain theme and had specific objectives.

The Couples Control Program was the control group. Control group couples received only one two-hour session where they were given written educational materials about breast and gynecological cancers. The therapist used a structured protocol when interacting with participants.

• The sample included 72 participants.
• Age range of participants was 25–80 years, with a median age of 52 for the combined sample of women and their partners.
• Males (partners) represented 50% of the sample; mean age of partners (all men) was 52.2 years (SD = 11.3).
• The study involved women with breast or gynecologic cancers and their partners. Patients’ treatments for their disease included surgery (90%), radiation therapy (72%), chemotherapy (69%), and hormone therapy (60%).
• There were significant differences between groups for cancer-specific distress (F (1,71) = 6.2, p = 0.02) and fear of progression (F (1,71) = 8.6, p = 0.005) at pretesting.

• Multisite
• Outpatient setting
• Couples were recruited in three regional hospitals in Germany.

Active antitumor treatment phase

 A two-site, controlled, parallel-group study with random assignment (balanced randomization [1:1]) was used.

Psychosocial distress:

• Questionnaire on Stress in Cancer Patients (QSC-R23) was used to assess cancer-specific distress. This questionnaire was given to the women only (patients). Internal reliability was good (alpha 0.87).
• Fear of Progression Questionnaire (FoP-Q) was used to assess fear of cancer progression in both the women and their partners. Internal reliability was good (alpha 0.87).
• Avoidance-Defense Scale, which is a subscale of the Dealing With Illness Inventory–Revised, assessed how much women and their partners used avoidant behaviors in dealing with the disease. Internal consistency was alpha 0.54 and 0.51 for women and men, respectively.

Benefit finding:

• Post-Traumatic Growth Inventory was used to assess an individual finding meaning and benefit from the experience of severe life events; this inventory was done for women and their partners.  Reliability was good (alpha 0.92 and 0.91 for women and men, respectively).

Relationship satisfaction:

• Quality of Marriage Index (QMI) was used to assess marital satisfaction for women and their partners. Reliability was good (alpha 0.95).

Communication:

• Communication subscale of the Partnership Questionnaire was used to assess communication quality for both women and their partners. Reliability was good (alpha 0.86 and 0.82 for women and men, respectively).

Dyadic coping:

• Dyadic Coping Inventory was used to assess how partners cope with stress in their relationship; they report on their own behavior, their perceived partner’s behaviors, and their perceived behavior on themselves as a couple. This was measured for women and their partners. Reliability was not reported.

Sample description and differences:

• Baseline data showed that women in both groups (intervention and control) were somewhat distressed and that both men and women showed high average dyadic coping at baseline in both groups. Furthermore, participants in the intervention group showed significantly higher levels of fear of disease progression than their control group counterparts (M = 39 [SD = 9.2] versus M = 32.8 [SD = 8.6], F (1, 71) = 8.6, p =0.005).
• The only significant difference between groups was in their continuation with the long-term assessments at 12-month assessment: More couples dropped from the control group (45%) compared with the intervention group (17%) X² (df) = 1) = 6.7, p < 0.001. In addition, women who dropped in the control group after the post-treatment had lower communication quality (M = 16 [SD = 3.6]) at baseline than those who continued in the study (M = 19.9 [SD = 4.9], F (1, 25) = 4.6, p = 0.04.  

The following changes were observed in the outcome variables:

• Women in the intervention group showed less avoidant behavior over time compared to women in the control group who showed an increase in avoidant behavior. The interaction between intervention, time, and gender was a significant predictor t (395) = 2.56, p = 0.011 (β = 0.31 [SD=0.12]). Males in the intervention group had an increase in avoidance from pre to first follow-up (third assessment ), whereas males in the control group maintained a high level of avoidance across time.
• Couples in the intervention group showed a higher level of dyadic coping at all assessments (pre, post, follow-up 1, and follow-up 2), whereas couples in the control group showed decline across post through follow-up 1, with an increase in dyadic coping at follow-up 2.

Side-by-side intervention showed clear benefit compared to the control group in fear of disease progression and avoidant behavior. This benefit was short-term and did not carry through to long-term assessments. There was also clear benefit in dyadic coping and communication, but both were also short-term. 

Side-by-side intervention has shown potential benefit in faster post-traumatic growth compared to control group.

• The sample was small, with less than 100 participants.
• There were baseline sample/group differences of import.
• The study had risk of bias due to no blinding and no random assignment, as well as the sample characteristics.*
• The intervention was expensive, impractical, and/or required training needs.*
• Subject withdrawals were 10% or higher.
• Other limitations/*explanation: The study was too complex to be readily comprehensible. Based on the descriptions in the study, it is not clear when the different sessions of intervention occurred, and the timeline was confusing. The reporting was too detailed and presented in a way that loses the reader in the detail. The study design required assessments over time (about 16 months), which leads to attrition challenges. The attrition affected, and possibly contributed to, some bias in the results. The study was thorough but also a case where too much was done. In short, the study was far from parsimony.

The findings indirectly indicate that the interdisciplinary team caring for women with cancer should involve the services of psychologists, family therapists, or advanced practice nurses with specialized training in mental and relationship wellness for patients and their partners.

Nursing care should include an assessment of a couple's distress level and communication patterns over the trajectory of a breast or gynecologic cancer illness.  

Attrition and recruitment in long-term studies involving caregivers remain serious threats, and future research designs and methodologies should include clear plans to manage these challenging aspects.