Biobehavioral Study Finds Clues To Improve Quality of Life in Cervical Cancer Survivors

Lari Wenzel, PhD

A new study has found that a psychosocial telephone counseling intervention helps improve mood and quality of life in cervical cancer survivors.

The results, published in the Journal of Clinical Oncology, show that a psychosocial telephone counseling intervention benefits mood and quality of life, including cancer-specific and gynecologic concerns for this population of patients.

“What our work has determined over the years preceding this trial was that women with cervical cancer in particular are one of the most distressed group of cancer survivors, if not the most in the United States,” lead author Lari Wenzel, PhD, Associate Director for Population Science and Cancer Control at the University of California, Irvine Chao Family Comprehensive Cancer Center, said in a recent phone interview with Oncology Nursing News. “Also, this is a group who may not get the amount or type of supportive care services that could be beneficial.”

Many cervical cancer patients are often young and underserved minorities, said Wenzel, who is also a professor of Medicine and Public Health at the UCI School of Medicine. Survivors of the disease often face quality of life disruptions that can linger for long periods of time after treatment has ended, such as sexual and childbearing functioning concerns.

Wenzel said the idea of testing a telephone counseling intervention made sense in this situation because these patients are “a group that don’t avail themselves of typical services such as a support group at a hospital or elsewhere.”

For the study, 204 patients who were ≥9 months and <30 months from diagnosis were randomized to receive the telephone counseling service or usual care.

The psychological telephone counseling intervention included five weekly sessions and a 1-month booster. Patients reported outcomes at baseline and 4 and 9 months after enrollment.

The participants in the telephone-counseling group received a 5-minute pre-call to schedule the first session, which took up to 60 minutes. The rest of the sessions ranged from 20 to 60 minutes and included topics on managing stress and emotions, health and wellness, managing relationships and sexuality concerns, and communicating with the health care team.

After each session, the counselor would prepare a summary letter of the session along with “homework” assignments to help the patient overcome stresses or concerns that they had talked with the counselor about.

Wenzel said one of the benefits of this strategy was that even though the counselors talked about general themes around areas that cancer survivors find important, the homework assignments allowed the treatment to be tailored for each individual.

A Potential Biobehavioral Pathway

The study also looked to see if there was an association between quality of life and biomarkers.

Interestingly, the study found a correlation between the improvement in patient-reported outcomes and a decrease in both T-helper type 2 (TH-2) and counter-regulatory cytokines.

Edward L. Nelson, MD, FACP

“We know that in individuals that experience chronic psychological stress, their immune system tends to shift a bit, its “immunological stance”, to try to make more antibodies to keep the body from getting an infection rather than having an immune system that is ready and primed to fight the infection once it arrives. We call that a T-helper type 2 or TH-2, response,” study author Edward L. Nelson, MD, FACP, Chief of the Hematology/Oncology Division and Associate Professor of Medicine, Molecular Biology & Biochemistry, at the University of California, Irvine said in an interview.

“So under chronic psychological stress, the amount of TH-2 is much higher than it is when you don’t have that chronic psychological stress. TH-1 and TH-2 can be thought of as being on opposite sides of a seesaw. TH-1 responses are thought to be best for fighting cancers and virus infections. If you have a whole bunch of TH-2, you have less TH-1.”

The study found that women who had improvement in the quality of life and a decrease in their stress level also saw a decrease in TH-2.

“This study reinforces a paradigm that connects the psychological state to downstream effects on the neuroendocrine and immune systems, the immune system in particular,” he said. “If you’re going to ask the immune system to behave in the way that you would like it to behave, to fight off cancer, especially with some of our other now novel immunotherapeutic strategies, you would like it to be tuned up in a way that makes it most likely that it is going to be effective.“

Even though the study didn’t explore whether a decrease in TH-2 resulted in either longer control of a tumor or improved survival, stress raises TH-2, which is associated with decreased magnitude of TH-1.

“Under situations of chronic psychological stress, the immune system is…not tuned up for fighting off tumors,” Nelson continued. “And so, as we start to think about ways to tap into the immune system for fighting off cancer, we would do well to think about how we can address the psychological state to help our immune system be tuned up to do the best job that it can.”

Using the Results to Move Forward

The study found that survivors receiving the psychosocial telephone counseling intervention had significantly improved depression and gynecologic and cancer-specific concerns at 4 months compared with those who only received usual care (P < .05) and the significant differences in gynecologic and cancer-specific concerns were sustained at 9 months.

Based on these data, Wenzel said there’s plenty that oncology nurses can take away and even use in practice.

“I know that [oncology nurses] are already sensitive to the psychosocial issues of cancer patients,” she said. “But I think that they can look at this cancer population and if they start out by saying ‘Well, this is a population that is particularly in need of supportive care efforts,’ and it’s not one-size-fits-all, but [nurses] might be able to have a conversation to be able to understand the issues that these women are facing in such a way that this conversation and a follow-up care plan could be very helpful for the patient.”

“I think the other thing that oncology nurses can take away is the understanding that these women are going to have some rather profound stressors and disruption of their quality of life,” Nelson said. “So lots of times, having our patients know what’s coming and knowing that there are other resources that are available to help them is a way, in and of itself, to decrease the distress.”

Looking forward, Wenzel said she believes that these patients would benefit from booster or maintenance sessions, to help the patients continue their progress.

“This could be extremely cost effective if we’re helping people long-term,” she said. “But this is something we need to test to see if we can help people long term.”

Some changes might need to be made to the counseling service, too, Wenzel said.

Data showed that those with higher depression in the telephone intervention arm were significantly more likely to drop out of the study. In order to combat this in the future, Wenzel said she plans to make the first session more interactive.

“Some of the questions that we were asking were quite probing in terms of level of depression, sexual dysfunction, relationships, interactions with the healthcare team, and you can imagine if you’re already experiencing a level of depression that’s rather profound, sometimes actually people just want to turn inward and don’t want to talk about it,” she said. “So I think what I would do differently in our session 1 is to be sensitive to those presumed issues and allow the counselor and the patient to develop a relationship at a pace that the patient is optimally comfortable with.”

The intervention also has the potential to be brought into the clinic, Wenzel said. And implementing the intervention closer to the time of diagnosis may help improve stress and quality of life earlier, with potential long term benefits as well.

“Since this [study] has been published, we’ve heard from many physicians who have said they would appreciate help with this population,” she said.

The intervention also has the potential to be tested as a web-based intervention or more closely integrate technology, such as email or text messaging. This intervention can also be tested among other cancer survivors, Nelson said.

“There are other patient populations besides women with cervical cancer and cervical cancer survivors who also have fairly profound disruptions in their quality of life,” he said. “So we’d like to be able to know if this same strategy can be applied to those patient populations.”