problem solving therapy and cancer

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Problem-Solving Therapy for Cancer Caregivers in Outpatient Palliative Care

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• DOI: 10.5209/REV_PSIC.2013.V10.N2-3.43445
• Corpus ID: 54951094

Problem-solving therapy for cancer patients

• A. Nezu , C. Nezu , K. E. Salber
• Published 23 January 2014
• Psychology, Medicine

8 Citations

Problem-solving skills training in adult cancer survivors: bright ideas-ac pilot study., enabling patients in effective self-management of breathlessness in lung cancer: the neglected pillar of personalized medicine, rehabilitation and pediatric oncology: supporting patients and families during and after treatment, role of religiosity, optimism, demographic characteristics and mental health problems among cancer patients., background factors associated with problem avoidance behavior in healthy partners of breast cancer patients, la prevención de recaídas desde el modelo de marlatt. aportaciones desde el trabajo social [the prevention of relapses in the marlatt model. contributions from the field of social work ], propiedades psicométricas del inventario de depresión de beck ii en pacientes con cáncer, stomiecare : un programme d’intervention psycho-éducationnelle individuelle à composantes cognitivo-comportementales pour des patients opérés d’un cancer du rectum avec stomie temporaire, 40 references, relevance of problem-solving therapy to psychosocial oncology, project genesis: assessing the efficacy of problem-solving therapy for distressed adult cancer patients., psychological approaches for enhancing coping among cancer patients: a review, cancer and psychological distress : two investigations regarding the role of social problem-solving, a problem‐solving approach to stress reduction among younger women with breast carcinoma, helping cancer patients cope: a problem-solving approach.

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A problem solving intervention for caregivers of cancer patients.

Biobehavioral outcomes following psychological interventions for cancer patients., brief behavioral activation and problem-solving therapy for depressed breast cancer patients: randomized trial., problem-solving skills training for mothers of children with newly diagnosed cancer: a randomized trial, related papers.

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JOHN T. MILLIKEN DEPARTMENT OF MEDICINE

Division of Palliative Medicine

Problem-Solving Therapy for Cancer Caregivers: A Randomized Clinical Trial in Outpatient Palliative Care

Principal Investigator: Dr. Karla Washington - Washington University in St. Louis

In response to the pressing need for an evidence base to support psychosocial services in the ambulatory palliative care setting, this multi-site clinical trial tests the efficacy of a problem-solving therapy intervention designed to reduce psychological distress and improve positive aspects of caregiving among cancer family caregivers.

Contact: Joanna Helmkamp, BSW Project Administrator Washington University in St. Louis [email protected]

Funding and Study Information: National Cancer Institute Grant Number R01CA258311 ClinicalTrials.gov Identifier NCT04867122

Social Support Lead Investigator: Keisha White Makinde, MD Washington University in St. Louis

Interventionists: Diane Huneke, RN Washington University in St. Louis Cathryn Koplitz, MSEd, MPhilEd University of Pennsylvania Rachael Paulbeck, MA University of Pennsylvania

University of Missouri Lead Investigator: Shannon Canfield, PhD

University of Pennsylvania Lead Investigator: George Demiris, PhD

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• Problem solving therapy improved quality of life and reduced pyschological distress in adults with cancer
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• cognitive therapy
• problem solving


 
 Q In patients 18–65 years of age with cancer and psychological distress, is problem solving therapy (PST) effective for improving quality of life and reducing measures of pyschological stress.

randomised controlled trial.

Allocation:

Unclear allocation concealment. *

blinded (outcome assessors). *

Follow up period:

2 hospitals in Pennsylvania, USA.

150 patients 18–65 years of age with cancer and psychological distress who were able to identify a significant other (SO) person willing to participate in the study. Exclusion criteria included a known psychiatric disturbance before a diagnosis of cancer and mental retardation.

Intervention:

50 patients each were allocated to PST for the patient alone (PSTA), PST for the patient and a SO person (PSTSO), or waiting list control (WLC). …

↵ * See glossary.

For correspondence: Dr A M Nezu, Drexel University, Philadelphia, PA, USA. art.nezuverizon.net

Source of funding: National Cancer Institute.

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What Is Problem-Solving Therapy?

Verywell / Madelyn Goodnight

Problem-Solving Therapy Techniques

How effective is problem-solving therapy, things to consider, how to get started.

Problem-solving therapy is a brief intervention that provides people with the tools they need to identify and solve problems that arise from big and small life stressors. It aims to improve your overall quality of life and reduce the negative impact of psychological and physical illness.

Problem-solving therapy can be used to treat depression , among other conditions. It can be administered by a doctor or mental health professional and may be combined with other treatment approaches.

At a Glance

Problem-solving therapy is a short-term treatment used to help people who are experiencing depression, stress, PTSD, self-harm, suicidal ideation, and other mental health problems develop the tools they need to deal with challenges. This approach teaches people to identify problems, generate solutions, and implement those solutions. Let's take a closer look at how problem-solving therapy can help people be more resilient and adaptive in the face of stress.

Problem-solving therapy is based on a model that takes into account the importance of real-life problem-solving. In other words, the key to managing the impact of stressful life events is to know how to address issues as they arise. Problem-solving therapy is very practical in its approach and is only concerned with the present, rather than delving into your past.

This form of therapy can take place one-on-one or in a group format and may be offered in person or online via telehealth . Sessions can be anywhere from 30 minutes to two hours long. 

Key Components

There are two major components that make up the problem-solving therapy framework:

• Applying a positive problem-solving orientation to your life
• Using problem-solving skills

A positive problem-solving orientation means viewing things in an optimistic light, embracing self-efficacy , and accepting the idea that problems are a normal part of life. Problem-solving skills are behaviors that you can rely on to help you navigate conflict, even during times of stress. This includes skills like:

• Knowing how to identify a problem
• Defining the problem in a helpful way
• Trying to understand the problem more deeply
• Setting goals related to the problem
• Generating alternative, creative solutions to the problem
• Choosing the best course of action
• Implementing the choice you have made
• Evaluating the outcome to determine next steps

Problem-solving therapy is all about training you to become adaptive in your life so that you will start to see problems as challenges to be solved instead of insurmountable obstacles. It also means that you will recognize the action that is required to engage in effective problem-solving techniques.

Planful Problem-Solving

One problem-solving technique, called planful problem-solving, involves following a series of steps to fix issues in a healthy, constructive way:

• Problem definition and formulation : This step involves identifying the real-life problem that needs to be solved and formulating it in a way that allows you to generate potential solutions.
• Generation of alternative solutions : This stage involves coming up with various potential solutions to the problem at hand. The goal in this step is to brainstorm options to creatively address the life stressor in ways that you may not have previously considered.
• Decision-making strategies : This stage involves discussing different strategies for making decisions as well as identifying obstacles that may get in the way of solving the problem at hand.
• Solution implementation and verification : This stage involves implementing a chosen solution and then verifying whether it was effective in addressing the problem.

Other Techniques

Other techniques your therapist may go over include:

• Problem-solving multitasking , which helps you learn to think clearly and solve problems effectively even during times of stress
• Stop, slow down, think, and act (SSTA) , which is meant to encourage you to become more emotionally mindful when faced with conflict
• Healthy thinking and imagery , which teaches you how to embrace more positive self-talk while problem-solving

What Problem-Solving Therapy Can Help With

Problem-solving therapy addresses life stress issues and focuses on helping you find solutions to concrete issues. This approach can be applied to problems associated with various psychological and physiological symptoms.

Mental Health Issues

Problem-solving therapy may help address mental health issues, like:

• Chronic stress due to accumulating minor issues
• Complications associated with traumatic brain injury (TBI)
• Emotional distress
• Post-traumatic stress disorder (PTSD)
• Problems associated with a chronic disease like cancer, heart disease, or diabetes
• Self-harm and feelings of hopelessness
• Substance use
• Suicidal ideation

Specific Life Challenges

This form of therapy is also helpful for dealing with specific life problems, such as:

• Death of a loved one
• Dissatisfaction at work
• Everyday life stressors
• Family problems
• Financial difficulties
• Relationship conflicts

Your doctor or mental healthcare professional will be able to advise whether problem-solving therapy could be helpful for your particular issue. In general, if you are struggling with specific, concrete problems that you are having trouble finding solutions for, problem-solving therapy could be helpful for you.

Benefits of Problem-Solving Therapy

The skills learned in problem-solving therapy can be helpful for managing all areas of your life. These can include:

• Being able to identify which stressors trigger your negative emotions (e.g., sadness, anger)
• Confidence that you can handle problems that you face
• Having a systematic approach on how to deal with life's problems
• Having a toolbox of strategies to solve the issues you face
• Increased confidence to find creative solutions
• Knowing how to identify which barriers will impede your progress
• Knowing how to manage emotions when they arise
• Reduced avoidance and increased action-taking
• The ability to accept life problems that can't be solved
• The ability to make effective decisions
• The development of patience (realizing that not all problems have a "quick fix")

Problem-solving therapy can help people feel more empowered to deal with the problems they face in their lives. Rather than feeling overwhelmed when stressors begin to take a toll, this therapy introduces new coping skills that can boost self-efficacy and resilience .

Other Types of Therapy

Other similar types of therapy include cognitive-behavioral therapy (CBT) and solution-focused brief therapy (SFBT) . While these therapies work to change thinking and behaviors, they work a bit differently. Both CBT and SFBT are less structured than problem-solving therapy and may focus on broader issues. CBT focuses on identifying and changing maladaptive thoughts, and SFBT works to help people look for solutions and build self-efficacy based on strengths.

This form of therapy was initially developed to help people combat stress through effective problem-solving, and it was later adapted to address clinical depression specifically. Today, much of the research on problem-solving therapy deals with its effectiveness in treating depression.

Problem-solving therapy has been shown to help depression in: 

• Older adults
• People coping with serious illnesses like cancer

Problem-solving therapy also appears to be effective as a brief treatment for depression, offering benefits in as little as six to eight sessions with a therapist or another healthcare professional. This may make it a good option for someone unable to commit to a lengthier treatment for depression.

Problem-solving therapy is not a good fit for everyone. It may not be effective at addressing issues that don't have clear solutions, like seeking meaning or purpose in life. Problem-solving therapy is also intended to treat specific problems, not general habits or thought patterns .

In general, it's also important to remember that problem-solving therapy is not a primary treatment for mental disorders. If you are living with the symptoms of a serious mental illness such as bipolar disorder or schizophrenia , you may need additional treatment with evidence-based approaches for your particular concern.

Problem-solving therapy is best aimed at someone who has a mental or physical issue that is being treated separately, but who also has life issues that go along with that problem that has yet to be addressed.

For example, it could help if you can't clean your house or pay your bills because of your depression, or if a cancer diagnosis is interfering with your quality of life.

Your doctor may be able to recommend therapists in your area who utilize this approach, or they may offer it themselves as part of their practice. You can also search for a problem-solving therapist with help from the American Psychological Association’s (APA) Society of Clinical Psychology .

If receiving problem-solving therapy from a doctor or mental healthcare professional is not an option for you, you could also consider implementing it as a self-help strategy using a workbook designed to help you learn problem-solving skills on your own.

During your first session, your therapist may spend some time explaining their process and approach. They may ask you to identify the problem you’re currently facing, and they’ll likely discuss your goals for therapy .

Keep In Mind

Problem-solving therapy may be a short-term intervention that's focused on solving a specific issue in your life. If you need further help with something more pervasive, it can also become a longer-term treatment option.

Get Help Now

We've tried, tested, and written unbiased reviews of the best online therapy programs including Talkspace, BetterHelp, and ReGain. Find out which option is the best for you.

Shang P, Cao X, You S, Feng X, Li N, Jia Y. Problem-solving therapy for major depressive disorders in older adults: an updated systematic review and meta-analysis of randomized controlled trials .  Aging Clin Exp Res . 2021;33(6):1465-1475. doi:10.1007/s40520-020-01672-3

Cuijpers P, Wit L de, Kleiboer A, Karyotaki E, Ebert DD. Problem-solving therapy for adult depression: An updated meta-analysis . Eur Psychiatry . 2018;48(1):27-37. doi:10.1016/j.eurpsy.2017.11.006

Nezu AM, Nezu CM, D'Zurilla TJ. Problem-Solving Therapy: A Treatment Manual . New York; 2013. doi:10.1891/9780826109415.0001

Owens D, Wright-Hughes A, Graham L, et al. Problem-solving therapy rather than treatment as usual for adults after self-harm: a pragmatic, feasibility, randomised controlled trial (the MIDSHIPS trial) .  Pilot Feasibility Stud . 2020;6:119. doi:10.1186/s40814-020-00668-0

Sorsdahl K, Stein DJ, Corrigall J, et al. The efficacy of a blended motivational interviewing and problem solving therapy intervention to reduce substance use among patients presenting for emergency services in South Africa: A randomized controlled trial . Subst Abuse Treat Prev Policy . 2015;10(1):46. doi:doi.org/10.1186/s13011-015-0042-1

Margolis SA, Osborne P, Gonzalez JS. Problem solving . In: Gellman MD, ed. Encyclopedia of Behavioral Medicine . Springer International Publishing; 2020:1745-1747. doi:10.1007/978-3-030-39903-0_208

Kirkham JG, Choi N, Seitz DP. Meta-analysis of problem solving therapy for the treatment of major depressive disorder in older adults . Int J Geriatr Psychiatry . 2016;31(5):526-535. doi:10.1002/gps.4358

Garand L, Rinaldo DE, Alberth MM, et al. Effects of problem solving therapy on mental health outcomes in family caregivers of persons with a new diagnosis of mild cognitive impairment or early dementia: A randomized controlled trial . Am J Geriatr Psychiatry . 2014;22(8):771-781. doi:10.1016/j.jagp.2013.07.007

Noyes K, Zapf AL, Depner RM, et al. Problem-solving skills training in adult cancer survivors: Bright IDEAS-AC pilot study .  Cancer Treat Res Commun . 2022;31:100552. doi:10.1016/j.ctarc.2022.100552

Albert SM, King J, Anderson S, et al. Depression agency-based collaborative: effect of problem-solving therapy on risk of common mental disorders in older adults with home care needs . The American Journal of Geriatric Psychiatry . 2019;27(6):619-624. doi:10.1016/j.jagp.2019.01.002

By Arlin Cuncic, MA Arlin Cuncic, MA, is the author of The Anxiety Workbook and founder of the website About Social Anxiety. She has a Master's degree in clinical psychology.

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Efficacy of problem-solving therapy for spouses of men with prostate cancer: A randomized controlled trial

Affiliations.

• 1 Department of Psychology, San Diego State University, San Diego, CA, USA.
• 2 San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology, San Diego State University and University of California, San Diego, CA, USA.
• 3 San Diego Moores Cancer Center, University of California, San Diego, CA, USA.
• 4 Department of Psychology, University of Redlands, Redlands, CA, USA.
• 5 Department of Surgery, University of California, San Diego, CA, USA.
• PMID: 30548230
• DOI: 10.1002/pon.4964

Objective: Prostate cancer can have a significant negative impact on patients and their spouses. Problem-solving therapy (PST) has been shown to help reduce distress and improve quality of life among cancer and caregiver populations. This study tested the efficacy of PST for spouses of men with prostate cancer.

Methods: Spouses of men diagnosed with prostate cancer within the past 18 months (N = 164) were randomly assigned to PST (n = 78) or usual psychosocial care (UPC; n = 86). Spouses completed measures of constructive and dysfunctional problem solving, cancer-related distress, mood, physical and mental health, and dyadic adjustment at preintervention and post-intervention and 3-month post-intervention follow-up.

Results: Constructive problem solving increased from pre-intervention to post-intervention among spouses receiving PST but not for spouses receiving UPC; this was maintained at follow-up. There was no decrease in dysfunctional problem solving. Spouses receiving PST versus UPC reported less cancer-related distress post-intervention and at follow-up. There were no significant changes in mood or physical and mental health. Dyadic adjustment was significantly better for spouses receiving PST versus UPC at post-intervention but not at follow-up. Improvements in constructive problem solving mediated better mood and dyadic adjustment post-intervention.

Conclusions: Results support the efficacy of PST for improving spouses' constructive problem solving. There was evidence of both direct and mediated positive effects of PST for both individual and dyadic adjustment. PST may be useful for improving individual and dyadic outcomes for spouses of men with prostate cancer.

Keywords: dyadic adjustment; health-related quality of life; problem-solving therapy; prostate cancer; psychosocial oncology; spousal caregivers.

© 2018 John Wiley & Sons, Ltd.

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Problem-Solving Skills Training in Adult Cancer Survivors: Bright IDEAS-AC Pilot Study

Katia noyes.

1 University at Buffalo, Buffalo, NY

Alaina L Zapf

2 University of Rochester Medical Center, Rochester, NY

Rachel M. Depner

3 Alpert Medical School of Brown University, Providence, RI

Tessa Flores

4 Roswell Park Comprehensive Cancer Center, Buffalo, NY

Alissa Huston

Hani h. rashid, demetria mcneal.

5 University of Colorado Anschutz Medical Campus, Aurora, CO

Louis S. Constine

Fergal j. fleming, gregory e. wilding, olle jane z. sahler.

Authors’ individual contributions:

Alaina L. Zapf: Data curation; Project administration.

Rachel M. Depner: Data curation; Project administration.

Tessa Flores: Data curation; Resources.

Alissa Huston: Data curation; Resources; Writing – review & editing.

Hani H. Rashid: Data curation; Resources.

Demetria McNeal: Data curation; Formal analysis; Investigation; Writing – review & editing.

Louis S. Constine: Data curation; Resources.

Fergal J. Fleming: Data curation; Resources.

Gregory E. Wilding: Formal analysis; Software; Writing – review & editing.

Olle Jane Z. Sahler: Conceptualization; Funding acquisition; Methodology; Investigation; Supervision; Validation; Writing – review & editing.

Associated Data

Cancer patients experience significant distress and burden of decision-making throughout treatment and beyond. These stressors can interfere with their ability to make reasoned and timely decisions about their care and lead to low physical and social functioning and poor survival. This pilot study examined the impact of offering Problem-Solving Skills Training (PSST) to adult cancer survivors to help them and their caregivers cope more successfully with post-treatment decision-making burden and distress.

Patients and Methods

Fifty patients who completed their definitive treatment for colorectal, breast or prostate cancer within the last 6 months and reported distress (level > 2 on the National Comprehensive Cancer Network distress thermometer) were randomly assigned to either care as usual (CAU) or 8 weekly PSST sessions. Patients were invited to include a supportive other (n=17). Patient and caregiver assessments at baseline (T1), end of intervention or 3 months (T2), and at 6 months (T3) focused on problem-solving skills, anxiety/depression, quality of life and healthcare utilization. We compared outcomes by study arm and interviewed participants about PSST burden and skill maintenance.

Trial participation rate was 60%; 76% of the participants successfully completed PSST training. PSST patients reported reduction in anxiety/depression, improvement in QoL (p<0.05) and lower use of hospital and emergency department services compared to CAU patients (p=0.04).

Conclusions

The evidence from this pilot study indicates that a remotely delivered PSST is a feasible and potentially effective strategy to improve mood and self-management in cancer survivors in community oncology settings.

1. INTRODUCTION

Recent advances in cancer treatment and gains in life expectancy mean that close to 40% of Americans will be diagnosed with cancer at least once in their lifetime. 1 Despite significant breakthroughs in management, cancer patients and survivors experience significant stress throughout the entire continuum of treatment, including the transition to post-treatment survivorship. A large body of literature shows that negative affectivity and poor problem-solving skills are associated with poor treatment adherence and prognosis. 2 – 4 Recent evidence demonstrates 3 , 5 – 9 that cancer survivors are often distressed and overwhelmed by the burden of decision making and prioritizing among family obligations and self-care, employment and disability-related issues, coordination of primary care and specialist services, insurance coverage and other costs.

Prior research has demonstrated that problem-solving skills training (PSST) offered to both cancer patients and their caregivers/supportive others (SO) can significantly improve problem-solving abilities and reduce negative affectivity. 10 – 12 However, to date, there have been no studies examining whether improvement in problem-solving skills translates into better patient self-management, quicker return to regular activities, and lower utilization of emergency and inpatient services.

We examined the feasibility and preliminary impact of offering the Bright IDEAS system of PSST to adult cancer survivors, Bright IDEAS-AC (BI-AC), to help them and their caregivers improve long-term quality of life and self-management skills. The study tested the following hypotheses: (1) At least 70% of contacted patients will enroll in the study; (2) At least 80% of patients randomized to PSST will complete 80% of PSST sessions; (3) At least 50% of patients will identify a supportive other to join them in learning about problem solving PSST; and (4) At least 50% of patients will identify usefulness of the PSST training as > 3 on a 5-point Likert scale (useful or very useful).

To maximize potential future implementation and dissemination of BI-AC, this pilot study was guided by the Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. 15 In addition to Effectiveness, our study assessed the potential of BI-AC for Implementation and Maintenance. Implementation was defined as the extent to which participants in the intervention arm adhered to the intervention protocol. Problem-solving skills maintenance was assessed post-study as the degree to which initial changes in participant behavior were sustained post-intervention.

2. PATIENTS AND METHODS

2.1. recruitment and study population.

Adult cancer patients who had completed treatment for stage I-III colorectal, breast or prostate cancer within the previous 6 months were recruited from clinics at Roswell Park Comprehensive Cancer Center (Roswell), Buffalo, NY and Wilmot Cancer Institute (WCI), Rochester, NY. Patients who lived >40 miles from the cancer center were specifically targeted as this population is known to have poorer access to care. 16

Eligibility criteria included: (a) English speaker; (b) a 5-year survival rate of ≥50% deemed by their physician; and (c) a distress level > 2 on the National Comprehensive Cancer Network (NCCN) distress thermometer. The NCCN thermometer is a commonly used tool to assess patient distress during the previous week on a 0 to 10 scale, with any patient reporting distress ≥ 8 being referred for further psychological evaluation and treatment. For this study we included patients who reported distress greater than 2 and less than 8 to capture patients at risk. 17 – 19 Exclusion criteria included (a) diagnosis of intellectual disability and/or (b) acute suicidal behavior.

Eligible patients were provided further information about the study and those willing to participate were asked to give written informed consent and to agree to audiotaping training sessions. Eligible patients were identified by chart review and mailed an invitation letter followed by a phone call to present study details. Patients expressing a willingness to participate met with the trainer to review the study consent document. Patients who consented were invited to identify a Supportive Other (SO) willing to participate in the study with them. All study procedures and materials were reviewed and approved by Roswell and WCI Institutional Review Boards.

2.2. Study Arms:

2.2.1. intervention.

BI-AC is an evidence-based PSST 10 , 11 intervention for adult cancer survivors and their caregivers. 20 BI-AC is an adaptation of the previously validated Bright IDEAS intervention designed to improve problem-solving skills and negative affectivity of mothers of children newly diagnosed with cancer. 12 , 21 – 23 BI-AC is different from Bright IDEAS in two critical ways: (i) BI-AC primarily focuses on adult cancer survivors (instead of mothers of children with cancer) and (ii) in addition to addressing problem-solving skills and mood, BI-AC aims to improve cancer survivors’ ability to make rational decisions and benefit from available medical, social, and supportive services. “Bright” represents the sense of optimism (positive orientation) necessary for successful problem solving. The letters in “IDEAS” signify the five major steps of problem solving: I= identify the problem, D= define your options, E= evaluate your options, A= act, S= see if it worked. 21 , 22

The intervention consists of eight one-hour individual weekly virtual (phone or video) counseling sessions conducted according to the previously published comprehensive protocol as summarized below. 12 Problem solving is presented as a general coping skill applicable to a range of challenging circumstances commonly encountered by cancer survivors. Patients randomized to the treatment arm are instructed to identify specific problems relevant to them and to their family’s situation to be discussed and then “solved” during PSST sessions and afterwards as “homework”. Session 1 is devoted to rapport building and understanding relevant social and medical information. The trainer introduces PSST and the Bright IDEAS paradigm, presents worksheets to guide PSST homework assignments, and gives an overview of subsequent sessions. In sessions 2–7, the trainer and patient, with a SO if available, review the patient’s identified problems and practice applying problem-solving strategies. Session 8 is focused on a review of PSST and long-term skills use that emphasizes persistence and learned optimism. To assure treatment integrity, every session was audiotaped, de-identified and stored securely; 20% of sessions chosen at random were scored by the treatment integrity monitor (OJS) according to a checklist that was shared with the trainers.

The two trainers employed for this project were psycho-oncology graduate students trained together by one of the study PIs (OJS). The team had weekly debriefings and monthly audits of the recorded sessions to insure fidelity and consistency between the trainers.

2.2.2. Care as Usual Group (CAU)

CAU participants, as well as intervention subjects, used any clinically appropriate medical and behavioral care without restriction as recommended by their healthcare providers. After study completion, CAU participants were offered the PSST training manual and brief counseling about the BI-AC intervention.

2.3. Randomization

After consent was obtained and the baseline assessment (T1) was completed by both the subject and the SO, if any, patients were randomized 1:1 to BI-AC or Care as Usual (CAU) using a permuted block randomization scheme with stratification by sex and study site.

2.4. Measures

In addition to the baseline T1 assessment, study participants completed a self-assessment (T2) immediately following the intervention (PSST arm) or 3 months after enrollment (CAU arm) and at 6 months after enrollment (T3, both arms). All assessment materials were mailed to patients and SOs ahead of their assessment dates. Participants could also complete the assessment over the phone with the research assistant. Participants (both patients and SOs) received stipends after each returned assessment to compensate for their time.

Demographic data were collected at baseline and included age, gender, race/ethnicity, health insurance, place of residence, and living arrangements as well as SO gender and relationship to the patient. Treatment information (diagnosis, treatment history, survivorship care plan, and time since diagnosis and since the end of treatment) was obtained from clinic records.

The Social Problem-Solving Inventory-Revised-short form (SPSI-R:S) 24 is a 25-item self-report tool linked to a multidimensional model of problem-solving skills. SPSI-R:S has been demonstrated to have strong reliability and validity estimates. 25 The scale includes 5 sub-scales grouped into two decision-making styles: constructive (Positive Problem Orientation and Rational Problem Solving) and dysfunctional (Negative Problem Orientation, Impulsivity/ Carelessness, and Avoidance). Each subscale and the total SPSI-R:S scores are expressed on a 0–20 scale; higher scores indicate better skills.

Hospital Anxiety and Depression Scale (HADS) assesses symptoms of depression (7 questions) and anxiety (7 questions) over the previous week, each question on the scale 0 (most of the time) to 3 (not at all); scores >8 are considered abnormal.

The Functional Assessment of Cancer Therapy - General (FACT-G) is a 27-item questionnaire designed to measure four domains of health-related quality of life in cancer patients based on the past 7 days: physical, social, emotional, and functional well-being (score range is 1–108; higher scores indicate better quality of life). The scale’s ability to discriminate patients on the basis of performance status and hospitalization status supports its sensitivity. It has also demonstrated sensitivity to change over time. Differences of 5–7 points are considered clinically significant.

Supportive Other’s Problem Inventory (SOPI) was used to assess the caregiving burden of the SO. We adapted a previously validated tool developed for mothers of children with cancer, Pediatric Parenting Stress Inventory (PPSI). 31 The tool includes a 45-item listing of potential problems experienced by SOs caring for a cancer survivor during the previous week. SOs were asked to complete the SOPI tool and rank each problem as 0 to 4 (none to overwhelming) at T1, T2, and T3.

Healthcare Utilization was assessed at T2 and T3 by asking the patients about their healthcare utilization since the last study assessment including primary care, specialist and ED visits, use of supportive services and any hospital stays.

2.5. Data Analysis

Data analyses were generated using the SAS System for Windows v.9.3 (2013; SAS Institute, Cary, NC). Data from all participants were analyzed using an intent-to-treat approach. Power calculations show that the proposed sample size n=50 would allow us to detect differences as small as 0.8 standard deviations with at least 80% power for the key parameters (Primary outcome SPSI-R (range 0–20), secondary outcomes HADS (0–21) anxiety and depression). We compared patient demographics and health outcome changes T1-T2 and T1-T3, by study arm, using t -tests and chi-square tests as appropriate. We used multivariate regression analysis, Generalized Estimating Equation (GEE), to identify subgroups of patients with positive and negative responses to problem-solving skills training and to control for multiple observations per patient. Healthcare utilization at 3 and 6 months was compared between the study arms using count data models. Imputation of individual missing values (single or multiple imputation approach, <10% of all assessments) had no effect on the study results. 34

2.6. Implementation and Maintenance Assessments

An investigator who was not involved with patient recruitment, intervention or assessment conducted phone semi-structured interviews of a sample of cancer patients and SOs who completed the study. The purpose of the qualitative analysis was two-fold: to learn how the intervention had been implemented and maintained among patients and their SOs and to understand participant experiences and perceptions of the intervention. Participants were mailed invitation letters followed by a phone call inviting them to share their thoughts with the independent investigator confidentially. Fourteen subjects and 5 SOs were contacted; 12 subjects and 3 SOs participated.

3.1. Patient characteristics and study feasibility

Our hypothesis one was that at least 70% of contacted patients will enroll in the study. Of 84 eligible patients, 50 (60%) consented to participate. Thus, H1 was not supported. However, we discovered that when recruited at the recommendation of the treating physician, the response rate was 80%; in contrast, 25% responded to recruitment by letter only. Average age of the participants was 63 years (range 45–87); racial and ethnic distributions were representative of the local population (88% white) ( Table 1 ). Two thirds of the participants were women (n=32). and non-participants did not differ in age or cancer type but non-participants were more likely to be men.

Comparisons of Patient Characteristics by Arms, Bright IDEAS-AC

Half of the participants preferred receiving study materials via regular mail, with only 18% opting for electronic communication. One third of the patients were recruited and received training fully remotely due to COVID-19 pandemic restrictions. Participants and non-participants did not differ in age or cancer type but non-participants were more likely to be men.

3.2. Intervention adherence

Our second hypothesis was that at least 80% of patients randomized to PSST will complete 80% of PSST sessions. Seventy-six percent (n=19) of the PSST patients completed the PSST (defined as sufficient mastery of problem-solving skills as verified by the therapist after at least 6 sessions). The primary reason for not completing eight sessions was inability to schedule sessions within the 16-week window allowed. None of the CAU participants requested PSST training at the end of the 6-month follow-up.

3.3. Assessment of problem-solving skills, negative affectivity and QoL

Five PSST patients (20%) and one CAU patient (4%) did not complete at least one of the three study assessments and 3 PSST patients missed two assessments. The reasons for missing assessments were active or passive refusal (4 of 6), cancer recurrence (1 of 6) and family emergency (1 of 6). Five of the six patients with missed assessments were women.

Patients in the treatment arm reported a trend towards reduced dysfunctional problem-solving style (Impulsivity/Carelessness Style, p=0.06) and improved constructive style (Rational Problem Solving, p=0.09) while problem-solving skills of CAU patients remained unchanged ( Figure 1 ). Lower problem-solving skills at baseline was associated with greater improvement in skills at 6 months (p=0.03).

Mean + SE. Individual components of SPSI-R:S: Rational Problem Solving (RPS), Impulsivity/Carelessness Style (ICS); Hospital Anxiety and Depression Scale (HADS), and Functional Assessment of Cancer Therapy- General (FACT-G). Bars represent 95% confidence intervals.

Patients in the PSST arm reported significant reductions in anxiety and depression (Δ=−1.5 at T2 and −2.6 at T3 for anxiety, and −1.0 (T2) and −1.4 (T3) for depression, p<0.05) and improvement in cancer-specific quality of life (Δ=3.2 at T2 and 8.0 at T3, p<0.05) that were sustained at 6 months ( Figure 1 , Table 2 ). Anxiety and QoL in CAU patients remained unchanged (p>0.05) and depression worsened (p<0.05).

Within-Group Changes in Outcome Measures, by Intervention Arms

3.4. Impact of PSST on care utilization

The overall use of hospital and ED services was very low among the survivors in both groups although no subjects in the intervention group were admitted to the hospital or visited the ED: hospital (0.0 vs 0.4 visits, p=0.04); ED services (0.0 vs 0.3 visits, p=0.09). The use of ambulatory services (e.g., outpatient PCP and specialist visits, therapy, yoga, acupuncture and others) was not statistically different between the treatment arms (6.5 vs 5.7 visits, p=0.55).

3.6. Participation of supportive others

Our third hypothesis was that at least 50% of patients will identify a supportive other to join them in learning about problem solving. This hypothesis was not supported. Seventeen patients (34%) were accompanied by a SO who agreed to participate prior to randomization. By chance, SO participation was significantly higher among patients in the control arm (48% vs 20%, p=0.04). Despite low participation, recruitment of SOs revealed that male participants were significantly more likely to be accompanied by a SO compared to female participants (56% vs 22%, p<0.05). For men, all SOs were spouses or intimate partners. For women, SOs consisted of intimate partners (84%) and adult female children (14%). Participation of a SO did not have a significant effect on patient outcomes or intervention adherence. Self-reported SO burden as measured by the SO PI was not significantly different between the treatment groups and did not change over time (p>0.5).

3.7. Bright IDEAS-AC Acceptance and Sustainability

Overall, all BI-AC patients were willing to recommend the intervention to other cancer survivors; 90% of PSST patients viewed the intervention as useful or very useful – much higher than 50% we hypothesized (H4) . Eighty five percent of participants were still using BI-AC at least once a week 3 months after completing the training.

During interviews, SOs commented positively on the benefits of using BI-AC ( Supplemental Table 1A ). Several patients pointed out that the skills they learned through BI-AC would also be very helpful to cancer patients who are still undergoing treatment, well before they reach the survivorship stage.

4. DISCUSSION

Our pilot study demonstrated that remote PSST delivery was acceptable and sustainable for a diverse range of cancer survivors. Patients who received PSST reported meaningful improvements in problem-solving skills, anxiety/depression and QoL after six to eight weekly remote training sessions. PSST patients also reported lower use of emergency services compared to CAU patients. Lastly, study participants indicated that PSST would be very helpful to patients undergoing active treatment.

According to the literature, 36 , 37 patient issues such as distress, depression, anxiety, body image, sexual dysfunction and intimacy concerns may vary depending on patient sex, as well as financial issues resulting from workforce displacement and/or costs of treatment but are similar across all cancer types. Indeed, in all Bright IDEAS studies including the one reported here, the problems were broadly logistical (how can I possibly get to appointments for treatment?) or emotion focused (how can I handle my anxiety about recurrence/hair loss/social isolation?) The specific issue or challenge provides the content for learning the steps of Bright IDEAS; successful resolution or, at least, a path to resolution, becomes the motivator for continued use.

Other evidence-based approaches to enable cancer patients to manage their care and control stress and symptoms of anxiety/depression include self-management (SM) 38 and cancer patient navigators (CPN) 39 . While these interventions have been shown to be effective in RCTs, implementation of self-management training and cancer care navigation programs has been slow and challenging. Expectations for patients and families to manage themselves have outpaced the development of effective SM interventions that impart the knowledge and skills and facilitate the social networking patients and families require for managing themselves. Patients and families also need to be assessed to determine their willingness to manage their health care themselves, including managing doctor appointments, long-term side-effects, emotional turmoil, and family dynamics. A CPN is an individual trained to help identify and resolve real and perceived barriers to care, enabling patients to adhere to care recommendations and thus improve their cancer outcomes CPN programs have generally been provided to patients actively undergoing treatments at a facility, thus limiting their usefulness for survivors who are receiving survivorship treatments in the community. The main challenge to broader dissemination of the CPN model is lack of funding for CPN training and reimbursement for CPN services by health insurance. Compared to SM and CPN, BI-AC provides an effective and potentially sustainable approach to delivery of supportive care to cancer patients and their supportive others.

Our study of PSST is unique in several important ways. Our inclusion criteria were less restrictive than previous trials of PSST, thus, allowing a wider range of oncology patients to participate (i.e., no requirement for a SO, broader range of distress and functional status at baseline). Similarly, virtual phone-based recruitment and the intervention itself allowed for greater patient accessibility and potential for BI-AC maintenance (e.g., centralized BI-AC administration, low patient and clinic burden). This remote, centralized delivery approach could help reduce disparities in access to cancer survivorship supportive services between academic and community oncology practices, as tele-counseling is quickly becoming a new norm and is reimbursed by most health insurance plans. Bright IDEAS provides an opportunity for experienced psycho-oncology providers at large cancer centers or private psychology clinics to provide BI-AC, a billable therapy service (CPT 90791,90832, 90834, 90837), to any cancer patient within the provider’s licensure. 40 Finally, by collecting data on different types of health services used by study subjects, we tested whether PSST could improve quality of care for cancer survivors by shifting their utilization away from emergency department visits. We were not powered to detect significant differences between groups, especially since the use of these services is low overall even among patients undergoing treatment. 41 However, this would be an excellent area of future investigation.

Despite its strengths and innovation, this study had several limitations. First, only 17 SOs were named by patients and of these, only 20% of PSST patients were accompanied by a SO, a rate significantly lower than among control patients. Since the choice of SO was made before randomization, the most likely explanation is chance alone. Second, identifying and recruiting patients from institutional electronic databases (e.g., tumor registry, scheduling system, EMR) is an attractive strategy to minimize the burden on treating physicians for their recommendation but resulted in a poor participation rate. We hypothesize that the main reason for this problem was outdated contact information for cancer survivors and missing data on cancer recurrence, survivorship status and distress that can misidentify many ineligible candidates. However, we should never underestimate the power of provider recommendation, which clearly was a major factor in our recruitment efforts. 42 , 43 Third, this pilot study was not powered to detect differences in our exploratory hypothesis that either hospital-based or ambulatory health services utilization would be different between groups. We also relied on patient recall over the past three months, which is known to result in underestimates of actual utilization and miscategorizations. 44 Fourth and finally, limited sample size did not allow us to control for differences in prior treatment or tumor site and stage which are independent predictors of health services utilization. 45 We would like to emphasize that this study was designed as effectiveness-implementation study and that the several hypotheses were formulated to explore HOW to best implement the intervention. Hence, rejecting these hypotheses does not de-value the effectiveness of BI-AC but rather provides empirical evidence to adjust recruitment process and eligibility requirements for the future studies as well as clinical practice.

6. CONCLUSIONS

Our findings suggest that remotely delivered PSST is a feasible and potentially effective strategy to improve mood and self-management in cancer survivors. Given that many oncology patients have limited access to guideline-recommended care, our findings support the implementation of BI-AC as one potential solution to reduce disparities in cancer survivor outcomes. Paired with growing evidence of the feasibility, cost-effectiveness and acceptability of remote services for cancer patients across the continuum of the disease, the evidence from this pilot study could help guide development and implementation of a sustainable BI-AC intervention even for oncology patients receiving definitive care in community settings that lack the resources typically available at large centers.

Highlights:

• Remote problem-solving skills training is acceptable for cancer survivors.
• A third of patients in the study were accompanied by a supportive other.
• Three quarters of the survivors were able to complete the training.
• Patients who received PSST reported meaningful improvements in outcomes.
• The majority of PSST patients viewed the intervention as useful or very useful.

Supplementary Material

Supplemental Table 1A. Results of the BI-AC Implementation and Maintenance Assessments

Acknowledgments

Disclaimers: Clinical trial information NCT03567850 . Supported in part by NIH grant R21CA217382 (MPI: Noyes and Sahler).

Katia Noyes, PhD, MPH is professor of Public Health and Surgery at the University at Buffalo School of Public Health and Health Professions. She is also Director of Surgical Outcomes and Research (UB SOAR), for the UB Department of Surgery, and Adjunct Professor of Cancer Control at Roswell Park Comprehensive Cancer Center. She is a health services researcher with interest in cancer services delivery, dissemination and implementation research, cost-effectiveness evaluations and outcomes disparities.

Alaina L. Zapf, MA is a PsyD candidate in counseling and research assistant in the Department of Pediatrics and the James P. Wilmot Cancer Institute at the University of Rochester Medical Center.

Rachel M. Depner, PhD is a clinical psychologist and researcher at the Department of Psychiatry and Human Behavior at Alpert Medical School, Brown University. Her clinical and research interests focus on coping with difficult/traumatic life events and embodied self-regulation throughout the lifespan.

Tessa Flores, MD is Assistant Professor of Oncology at Roswell Park Comprehensive Cancer Center. She is Medical Director of Cancer Screening and Survivorship Program. She is a board certified internist and pediatrician. She is passionate about preventative care, wellness, cancer screening, and cancer survivorship.

Alissa Huston, MD is Assistant Professor of Medicine at the James P. Wilmot Cancer Institute at the University of Rochester, where her clinical efforts are focused on breast cancer. She is also the Director for Medical Student and Resident Education for the Hematology/Oncology Division. Her research efforts focus on understanding the effects of treatment for breast cancer upon bone health, the role of vitamin D in breast cancer and how improvements in education affect residents and medical students rotating on our inpatient oncology unit.

Hani H. Rashid, MD is a Professor of Urology. He joined the University of Rochester Medical Center in 2006 and has also served as Director of Robotics at Highland Hospital since 2011. Since 2019, he has been Program Directory for the Urology Resident Program. His areas of expertise include robotic and laparoscopic surgeries for prostate, kidney, bladder, adrenal and ureteral cancers.

Demetria McNeal, PhD, MBA is Assistant Professor of Medicine at the University of Colorado- Anschutz. Her focus is helping health care professionals and leadership teams develop and implement adaptive, sustainable strategies that produce results that address inequities in care delivery. These strategies oftentimes require creative, disruptive, innovative and unconventional approaches.

Louis S. Constine, MD, FASTRO, FACR is Professor of Radiation Oncology and Pediatrics and Vice Chair of the Department of Radiation Oncology. He is also the Director of the James P. Wilmot Cancer Institute Judy DiMarzo Survivorship Program. After graduating from Stanford University, and the Johns Hopkins University School of Medicine, he trained in pediatrics, pediatric oncology, and radiation oncology, and has board certification in these areas.

Fergal J. Fleming, MD is Associate Professor of Surgery and Oncology. He has been a Fellow in the URMC Division of Colorectal Surgery since 2009. Dr. Fleming was awarded his medical degree from the University College of Dublin, Ireland in 1998. He is also a Fellow of the Royal College of Surgeons in Ireland. Dr. Fleming’s surgical residency included extensive training in general, vascular and hepatobiliary surgery, as well as dedicated training in colorectal surgery. He was successfully awarded the Intercollegiate Specialist Examination (UK and Ireland) in general surgery with a sub-specialty interest in colorectal surgery in 2009. In addition to being licensed to practice medicine in the state of New York, Dr. Fleming is on the Specialist Register of the Irish Medical Council in recognition of his specialist training in the field of surgery.

Gregory E. Wilding, PhD is a Professor and Chair in the Department of Biostatistics at the University at Buffalo. He joined the Department of Biostatistics and Bioinformatics at Roswell Park Comprehensive Cancer Center as an Associate Biostatistics Consultant in 2004. He became an Assistant Professor of Biostatistics and Oncology in 2007 at Roswell Park. Then in 2009 he became an Associate Professor of Biostatistics and Oncology at Roswell Park and Professor in 2015.

Olle Jane Z. Sahler, MD is Professor of Pediatrics, Psychiatry, Health Humanities & Bioethics, and Oncology at the University of Rochester. She is a Behavioral Pediatrician and has specialized in the care of children and adolescents for 40 years. For the past 25 years, she has also been the Director of Pediatric Psychosocial Oncology Services and Research and for the past 15 years, she has served as Medical Director of the Long-Term Childhood Cancer Survivors Program at the Golisano Children’s Hospital in Rochester. She has published and presented widely on adaptation to chronic and terminal illness, in particular, to cancer. She has been the Principal Investigator on all foundation and NIH-funded projects to develop, evaluate, and disseminate Bright IDEAS awarded to the Psychosocial Adaptation to Childhood Cancer Research Consortium.

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