CALM Intervention May Reduce Distress in Patients With Advanced Cancer

Many patients with advanced cancer experience physical discomfort and declining ability to perform activities of daily living. In addition, they may experience depression and other types of emotional distress. While palliative care has shown positive outcomes among patients with advanced disease, palliative care programs often are focused on symptom control and advanced care planning.

Canadian researchers recently highlighted the need for supportive psychotherapy interventions that are individualized to the patient, brief, and easy to implement. They created the Managing Cancer and Living Meaningfully (CALM) intervention for patients with advanced cancer who had a life expectancy of at least 1 year. The researchers conducted a randomized-controlled trial to compare CALM with usual care (UC) for patients with advanced cancer. Results of the study were published in the Journal of Clinical Oncology.

The basic tenets of CALM are:

• distress screening
• use of specially trained clinicians to implement the CALM program
• structured psychotherapy (3-6 sessions over 3-6 months)
• referral to other providers when indicated (e.g., psychiatrist, palliative care).

Clinician training consisted of a 2-day intensive CALM training workshop followed by successful completion of at least 2 clinical cases under the supervision of one of the main researchers, along with ongoing case supervision by the researchers. Psychotherapy sessions were either individualized or included a spouse or family member as deemed appropriate by the patient and therapist. The sessions focused on symptom management and communication with healthcare providers, changes in self and relations with close others, spiritual well-being and the sense of meaning and purpose, and mortality and future-oriented concerns.

Assessments of depressive symptoms (primary outcome), death-related distress, and other secondary outcomes were conducted at baseline, 3 months (primary end point), and 6 months (trial end point). Patients were randomly assigned to CALM (151 patients) or UC (154 patients).

CALM participants reported less-severe depressive symptoms than UC participants at 3 months and at 6 months. CALM participants also more frequently made end-of-life preparation at 6 months than those receiving usual care.

Among participants who were not depressed at baseline, those who received CALM were less likely to report threshold symptoms at the primary endpoint, which suggests that CALM may help to prevent the onset of depressive symptoms that may otherwise grow over time in patients with advanced disease. No adverse events from the CALM intervention were identified.

The researchers concluded that CALM has the potential to provide a systematic approach for reducing or alleviating concerns about end-of-life issues for patients with advanced cancer.

The researchers plan to discuss the mechanisms by which CALM exerts its effects in a separate publication, but theorize that CALM may be effective because patients with advanced disease have an increased opportunity to discuss issues and concerns with healthcare providers, are offered guidance on addressing the impact of advanced disease on their self-concept and family relationships, and may be able to find or strengthen a sense of meaning and purpose in life. They also have a safe place to express and manage fears and wishes about end-of-life care.

Nurses can use this information to consider collaborating with the oncology care team to explore initiating the CALM intervention or a similar supportive care program.