Abstract

Objective

The current report provides the result of a Phase II clinical trial regarding the effectiveness and feasibility of problem-solving therapy for psychological distress experienced by Japanese early-stage breast cancer patients.

Methods

Participants were 36 post-surgery Japanese breast cancer patients in a university hospital located in Osaka Prefecture, Japan. After screening for psychological distress using the Distress and Impact Thermometer and the Hospital Anxiety and Depression Scale, highly distressed patients were exposed to 5 weekly sessions of the problem-solving therapy program.

Results

Nineteen patients completed the intervention and follow-up. There was a significant difference between the pre-intervention and the 3-month follow-up in the total Hospital Anxiety and Depression Scale score (P = 0.02), and the mean change score from the pre-intervention to the follow-up was 6.05 (SD = 1.94). The intervention had a large effect size (d = 0.82). There were also significant changes in worry, self-efficacy and quality of life measures.

Conclusions

The findings of our study suggest that the problem-solving therapy program has potential to be effective for alleviating psychological distress experienced by Japanese early-stage breast cancer patients. The true effectiveness of the program should be confirmed by a future randomized control trial.

INTRODUCTION

The experience of cancer causes considerable stress to patients. Previous studies investigating the prevalence of psychological distress in cancer patients have revealed rates of 15–40% (1). In addition, some patients seek psychological help even though their psychological status does not reach a formal psychiatric diagnosis (2). In particular, psychological distress is a significant problem for breast cancer patients. Approximately 20–40% of women with breast cancer reported clinically significant levels of depression during or after treatment (3–5). Protracted breast cancer treatment and inadequate psychological adjustment after breast surgery, adjuvant chemotherapy or radiation therapy may cause patients to face difficulties in daily life, work, human relationships and adherence to hormone therapy. Therefore, psychological support at this phase is important for patients' quality of life (QOL).

Two therapies for psychological distress considered to be potentially effective are psychotherapy and pharmacotherapy. Regarding patient preference, a Japanese study indicated that psychotherapy is more acceptable than pharmacotherapy among cancer patients (6). Although previous reviews highlight the general efficacy of various psychosocial interventions, very few studies addressed what kind of psychotherapy is feasible or effective for Japanese cancer patients in actual breast cancer treatment settings.

Therefore, we have been interested in the effectiveness and feasibility of problem-solving therapy (PST) as a brief, structured psychological intervention. PST is one form of cognitive-behavioral therapy based on social problem-solving theory (7) and includes five components: (i) problem definition, (ii) goal setting, (iii) solution generation, (iv) decision-making, (v) implementation. In the Western literature, PST for depression (8) or other mental and physical health problems (9) has been demonstrated to be effective via meta-analysis. Especially in the realm of oncology, PST programs for cancer patients with their significant others (10) and including mothers for pediatric cancer patients (11) have been developed and validated as useful strategies.

We have previously reported clinical findings using our early version of PST programs for Japanese cancer patients in which the feasibility and effectiveness of PST have been suggested (12). The current report introduces a Phase II clinical trial demonstrating the feasibility and effectiveness of PST for psychological distress experienced by Japanese breast cancer patients after surgery.

PATIENTS AND METHODS

Participants

We conveniently enrolled 36 post-surgery Japanese breast cancer patients from seven physicians of a university hospital located in Osaka Prefecture, Japan in our study from November 2008 to August 2010. The inclusion criteria were (i) patients who were diagnosed as having breast cancer either clinically, histologically or pathologically; (ii) patients who had received adjuvant chemotherapy 6 months after surgery or who had received only hormone therapy after surgery; (iii) patients who had been told their diagnosis; (iv) patients aged older than 20 years and younger than 70 years; (v) patients with Eastern Cooperative Oncology Group (ECOG) PS being 0 or 1, and having the ability to go to the hospital and to work with light physical activity; (vi) patients who had met the criteria for one of their scores on the Distress and Impact Thermometer (DIT) or the Hospital Anxiety and Depression Scale (HADS) (see measures, P.7). To ensure a sufficient sensitivity for patients who experienced psychological distress, we adopted the sixth condition.

The exclusion criteria were (i) patients who were diagnosed by a physician as requiring psychiatric treatment, such as patients suffering from depressive disorder with suicidal thoughts or wishes; (ii) patients with the evidence of cognitive impairment such as dementia and delirium or mental illness such as schizophrenia; (iii) patients taking antipsychotics; (iv) patients with the evidence of cognitive function impairment; (v) patients with difficulties in Japanese language literacy.

PST Program

The intervention program was an individual psychological treatment based on PST. According to the principles behind PST (13,14), psychosocial problems influence psychological distress (e.g. depression, anxiety). Therefore, it is useful to teach structured problem-solving strategies to patients. We developed a PST program for Japanese cancer patients, modeling the concepts and techniques of PST used in previous western studies (10,14). This program included a therapist manual and a worksheet for patients (all materials are available from the authors). Our PST program consisted of 5 weekly sessions (1 h/session) and was conducted according to a worksheet developed using five steps for problem solving: Step 1: assessing their problems; Step 2: setting an achievable goal related to one of their problems; Step 3: generating a solution; Step 4: choosing the solution; Step 5: implementing the solution and evaluating the outcome.

Procedure

This study utilized a before and after design. The study protocol was approved by the institutional review boards of the Osaka University Hospital and was registered in the clinical trials registry by the University Hospital Medical Information Network (UMIN-CTR). First, physicians of the eligible patients informed the patients about the aim of the study during an outpatient adjuvant chemotherapy or hormone therapy session. Then, research staff conducted a psychological screening of patients using DIT and HADS. If patients met the inclusion criteria and consented to enroll in this study via written consent, the PST program was started. Self-reported questionnaires were conducted before the first session (pre-intervention), after the final session (post-intervention) and 3 months after the final session (3-month follow-up). To confirm the feasibility of the intervention, telephone interviews were also conducted on the follow-up or when the participants turned down the continuation of the intervention (dropout) to explore the qualitative aspects of the intervention.

Measures

Demographic data such as sex, age and educational level were obtained by self-report. Medical information was obtained from patients' doctors. Five psychological and QOL measures were utilized as follows:

  • The DIT (15) is a two-item self-reported questionnaire for assessing patients' psychological distress on an 11-point Likert-type scale, ranging from 0 (not at all) to 10 (extremely). Although the standard cut-off score for screening for adjustment disorder and major depression is 3/4 on the ‘distress’ score and 2/3 on the ‘impact’ score, in this study, we employed an inclusion criterion of a distress score cut-off of 2/3 and an impact score cut-off of 0/1 in order to ensure a sufficient sensitivity to psychological distress.

  • The Japanese version of the HADS (16) was used for evaluating depression and anxiety. It consisted of 14 items (7 items each for anxiety and depression), and participants rated how they felt during the previous week on a 4-point scale. Total scores ranged from 0 to 42. The cut-off score for screening for adjustment disorder and major depressive disorder among the Japanese cancer patients was 10/11 (17). Thus, in this study, we used this score (10/11) as the inclusion criterion.

  • The Self-Efficacy for Advanced Cancer (SEAC) (18) was used to assess the degree of self-efficacy in the patients. It is an 18-item scale on an 11-point Likert-type scale, ranging from 0 (not at all confident) to 100 (extremely confident). The SEAC consisted of the following three subscales: symptom coping efficacy (SCE); activities of daily living (ADL) efficacy (ADE) and affect regulation efficacy. Higher aggregate scores on each subscale indicate a greater level of self-efficacy for symptom coping, ADL and affect regulation.

  • The Brief Cancer-related Worry Inventory (BCWI) (19) was used to measure the contents and intensity of patients' worry. Participants were asked to rate their degree of worry across 15 items on an 11-point scale, ranging from 0 (not at all worried) to 100 (extremely worried). The BCWI consisted of subscales concerning future prospects (6 items), physical problems (4 items) and interpersonal problems (5 items). Higher aggregate scores indicated worrying about a greater variety of issues.

  • The Japanese version of the European Organization for Research and Treatment of Cancer 30-item Core Quality of Life Questionnaire (EORTC QLQ-C30) (20) was used to measure QOL. In this study, we measured the global health status score in addition to physical, role, cognitive, emotional and social function.

Sample Size Calculation and Data Analysis

We first calculated the natural change in HADS score in the Japanese breast cancer patients after surgery using data from a previous observational study (21). Patients with a high HADS score (11) 3 months after surgery and without adjuvant chemotherapy displayed a gradual increase in HADS score from 3 months (15.81 ± 4.21) to 6 months (17.55 ± 5.66), and the mean change in HADS score was 1.74 ± 6.82. The mean minus 1 SD (|1.74 – 6.82| = 5.08) could possibly represent a clinically significant change by the intervention. That is, we assume that this mean HADS change score represents a natural change and that a 5-point decrease in HADS score over 3 months could represent a clinically significant improvement by the intervention.

We calculated the sample size using this decreased HADS score (5.0) as the estimated effect size of the intervention and 6.0 as the standard deviation in HADS score among distressed patients (HADS score 11 and without chemotherapy). In the end, we found that the required sample size for this study was 17 (α = 0.05, β = 0.10). However, in order to obtain the needed number of patients for the analysis, we had decided that 30 patients should be enrolled in this study, due to the potential elimination or dropout of patients during the trial.

We conducted all statistical analyses using the SPSS software package (version 19.0). Descriptive statistics were calculated as an average of all measures at each time point (pre-, post- and follow-up tests). In order to investigate the effectiveness of the intervention, we conducted three separate repeated-measures ANOVAs for HADS, BCWI, SEAC and EORTC-QLQ scores.

RESULTS

Of the 36 participants targeted, 26 individuals agreed to enroll in this study. Of the 26 patients, 3 were not eligible under our inclusion criteria, 3 dropped out after starting treatment (they also did not respond to the final questionnaires) and 1 did not respond to questionnaires at the 3-month follow-up (see Fig. 1). The reasons for patients dropping out (n = 3) was that it was difficult for 2 of them to participate in weekly sessions and it was a burden for 1 patient to think about her own problems. Therefore, in the end we analyzed 19 patients. Their mean age was 50.21 (SD = 11.09) years. The majority of the participants were married (n = 15, 78.95%) and diagnosed with stage II cancer (n = 18, 94.74%). Patients' characteristics are shown in Table 1.

Table 1.

Patients’ characteristics

Variable n % of sample 
Education 
 Junior high school 5.26 
 High school 47.37 
 Junior/vocational college 26.32 
 College 21.05 
Marital status 
 Married 15 78.95 
 Single 10.53 
 Divorced 10.53 
 Separated 0.00 
Occupational status 
 Full time work 36.84 
 Part time work 5.26 
 Not working 42.11 
Breast cancer stage 
 I 5.26 
 II 18 94.74 
Treatment 
 Surgery   
  Mastectomy 21.05 
  Lumpectomy 15 78.95 
 Chemotherapy 19 100.00 
  Neo-adjuvant 12 63.16 
 Radiotherapy 31.58 
 Hormone therapy 17 89.47 
Variable n % of sample 
Education 
 Junior high school 5.26 
 High school 47.37 
 Junior/vocational college 26.32 
 College 21.05 
Marital status 
 Married 15 78.95 
 Single 10.53 
 Divorced 10.53 
 Separated 0.00 
Occupational status 
 Full time work 36.84 
 Part time work 5.26 
 Not working 42.11 
Breast cancer stage 
 I 5.26 
 II 18 94.74 
Treatment 
 Surgery   
  Mastectomy 21.05 
  Lumpectomy 15 78.95 
 Chemotherapy 19 100.00 
  Neo-adjuvant 12 63.16 
 Radiotherapy 31.58 
 Hormone therapy 17 89.47 

Note: n = 19, mean age = 50.21 (SD = 11.09) years.

Figure 1.

Trial profile in this study.

Figure 1.

Trial profile in this study.

Primary Outcome Measure

The completion rate of the intervention was 82.6% (19/23). Table 2 presents the mean HADS scores and the other self-reported measures at the pre- and post-intervention and the 3-month follow-up stages. The mean change score from the pre-intervention to the follow-up was 6.05 (SD = 1.94), which was above the previously assumed significant decrease (5.0). Repeated-measures ANOVA revealed a significant effect of time on total [F(2, 36) = 6.45, P < 0.01], anxiety [F(2, 36) = 5.56, P < 0.01], and depression scores [F(2, 36) = 5.55, P < 0.01]. A post hoc analysis with the Bonferroni method showed a marginally significant difference between the pre- and post-intervention in the total HADS score (P = 0.07, d = 0.47) and depression score (P = 0.07, d = 0.46) and a significant difference between the pre-intervention and the 3-month follow-up in the total HADS score (P = 0.02, d = 0.82), depression score (P = 0.03, d = 0.90) and anxiety score (P = 0.02, d = 0.86).

Table 2.

Mean scores of pre- and post-intervention and the 3-month follow-up tests for all measures

  Pre-intervention
 
Post-intervention
 
3-month FU
 
F s Effect size (d)
 
SD SD SD Pre − Post Pre − FU 
HADS 
 Total 14.42 8.02 10.95 6.60 8.37 6.77 6.45 <0.01 0.47 0.82 
 Anxiety 6.74 3.48 5.32 3.16 3.89 3.16 5.56 <0.01 0.43 0.86 
 Depression 7.68 5.04 5.63 3.80 4.47 4.01 5.55 <0.01 0.46 0.90 
BCWI 
 Future 62.28 26.08 51.23 26.94 48.86 32.01 4.30 0.02 0.42 0.46 
 Physical 63.42 29.32 53.03 31.53 44.74 33.91 4.93 0.01 0.34 0.59 
 Interpersonal 55.16 25.40 47.21 27.11 39.47 31.87 8.47 <0.01 0.30 0.35 
SEAC 
 Symptom coping 55.26 20.92 62.59 22.29 62.11 23.27 2.90 0.07 0.34 0.31 
 Affect regulation 56.45 20.26 67.72 19.82 69.47 20.61 8.38 <0.01 0.56 0.64 
 Activity of daily living 72.25 20.78 79.30 17.37 81.84 17.06 2.81 0.07 0.37 0.51 
EORTC QLQ-C30 
 Global health status 53.95 16.52 67.98 17.62 72.37 27.08 4.87 0.01 0.82 0.82 
 Physical function 74.74 18.00 82.11 12.58 80.70 15.22 3.23 0.05 0.48 0.36 
 Role function 69.30 23.74 78.95 19.12 81.58 23.50 2.56 0.09 0.45 0.52 
 Cognitive function 67.54 25.74 77.19 18.60 78.07 22.26 1.75 n.s. 0.43 0.44 
 Emotional function 64.91 20.52 76.75 13.20 76.32 18.27 4.33 0.02 0.69 0.67 
 Social function 57.89 31.12 80.70 20.98 79.82 23.95 8.48 <0.01 0.86 0.79 
  Pre-intervention
 
Post-intervention
 
3-month FU
 
F s Effect size (d)
 
SD SD SD Pre − Post Pre − FU 
HADS 
 Total 14.42 8.02 10.95 6.60 8.37 6.77 6.45 <0.01 0.47 0.82 
 Anxiety 6.74 3.48 5.32 3.16 3.89 3.16 5.56 <0.01 0.43 0.86 
 Depression 7.68 5.04 5.63 3.80 4.47 4.01 5.55 <0.01 0.46 0.90 
BCWI 
 Future 62.28 26.08 51.23 26.94 48.86 32.01 4.30 0.02 0.42 0.46 
 Physical 63.42 29.32 53.03 31.53 44.74 33.91 4.93 0.01 0.34 0.59 
 Interpersonal 55.16 25.40 47.21 27.11 39.47 31.87 8.47 <0.01 0.30 0.35 
SEAC 
 Symptom coping 55.26 20.92 62.59 22.29 62.11 23.27 2.90 0.07 0.34 0.31 
 Affect regulation 56.45 20.26 67.72 19.82 69.47 20.61 8.38 <0.01 0.56 0.64 
 Activity of daily living 72.25 20.78 79.30 17.37 81.84 17.06 2.81 0.07 0.37 0.51 
EORTC QLQ-C30 
 Global health status 53.95 16.52 67.98 17.62 72.37 27.08 4.87 0.01 0.82 0.82 
 Physical function 74.74 18.00 82.11 12.58 80.70 15.22 3.23 0.05 0.48 0.36 
 Role function 69.30 23.74 78.95 19.12 81.58 23.50 2.56 0.09 0.45 0.52 
 Cognitive function 67.54 25.74 77.19 18.60 78.07 22.26 1.75 n.s. 0.43 0.44 
 Emotional function 64.91 20.52 76.75 13.20 76.32 18.27 4.33 0.02 0.69 0.67 
 Social function 57.89 31.12 80.70 20.98 79.82 23.95 8.48 <0.01 0.86 0.79 

Note. n = 19; M, mean; SD, standard deviation; FU, follow-up; HADS, the Hospital Anxiety and Depression Scale; BCWI, Brief Cancer-related Worry Inventory; SEAC, the Self-efficacy for Advanced Cancer; EORTC-QLQ-C30, European Organization for Research and Treatment of Cancer 30-item Core Quality of Life Questionnaire, effect size (d) = (meanpre − meanpost or FU)/SDpooled.

Secondary Outcome Measure

For worry measured by BCWI, repeated-measures ANOVA revealed a significant effect of time on all subscales of BCWI [future: F(2, 36) = 4.30, P = 0.02; physical: F(2, 36) = 4.93, P = 0.01; interpersonal: F(2, 36) = 8.47, P < 0.01]. A post hoc analysis showed a significant difference between the pre- and post-intervention in future prospect (P < 0.05, d = 0.42) and between the pre-intervention and the 3-month follow-up in future prospect (P = 0.04, d = 0.46) and in physical (P < 0.01, d = 0.59) and interpersonal problems (P < 0.01, d = 0.35).

Regarding self-efficacy measured by SEAC, repeated-measures ANOVA showed a significant effect of time on affect regulation [F(2, 36) = 8.38, P < 0.01]. A post hoc analysis revealed, in terms of affect regulation efficacy, a significant difference between the pre- and post-intervention (P < 0.01, d = 0.56) and between the pre-intervention and the 3-month follow-up (P = 0.02, d = 64).

Finally, repeated-measures ANOVA for EORTC QLQ-C30 revealed a significant effect of time on global health status [F(2, 36) = 4.87, P = 0.01], emotional function[(F(2, 36) = 4.33, P = 0.02] and social function [F(2, 36) = 8.48, P < 0.01]. A post hoc analysis showed a significant difference between the pre- and post-intervention in social function (P = 0.01, d = 0.86) and between the pre-intervention and the 3-month follow-up in global health status (P = 0.04, d = 0.82) and in social function (P = 0.01, d = 0.79).

DISCUSSION

The findings of our study suggest that the PST program is feasible and have potential to be effective for alleviating psychological distress experienced by Japanese early-stage breast cancer patients. The completion rate of the intervention was high (82.6%) and only one patient dissatisfied or felt burden of the intervention and the mean HADS change score from the pre-intervention to the 3-month follow-up (6.05) is larger than the expected mean change score (5.0) estimated from a previous observational study. Further, the effect size (d = 0.82) of our PST program is large and considered clinically meaningful. Therefore, although our study design is one arm without a control group, the feasibility and effectiveness of our PST program seem to be adequate for clinical application.

The most important finding is that a minimal intervention (namely, a short-term psychological intervention with only five sessions) seems to be helpful for breast cancer patients who experience psychological distress after surgery and adjuvant chemotherapy. Prior to this study, we had identified the timing at which the intervention would have the most significant impact on the alleviation of psychological distress (21). We consider that our moderate, clinically meaningful effect size is due to the appropriateness of the timing of the intervention just after adjuvant chemotherapy, in addition to the inclusion criteria being set at the adequate level of psychological distress (a total HADS score >11).

A number of studies have investigated the effects of psychological intervention for cancer patients. A systematic western review of the effectiveness of psychosocial interventions for cancer patients recommended cognitive behavioral therapy (CBT) (22). In Japan, the effect of group psychosocial interventions (23,24) and progressive muscle relaxation has also been investigated (25). However, conducting group psychosocial interventions in an actual clinical setting is often difficult. Our intervention had a considerable effect in an extremely realistic clinical setting, and was made with careful consideration of specific points of its implementation for individual patients. Although PST is one form of CBT, our PST seems to have a more moderate structure, flexibility and simplicity compared with traditional and comprehensive CBT. These features of our PST were suited to Japanese breast cancer patients since most cancer patients do not have an extreme distortion of cognition and traditional CBT interventions are often not appropriate for cancer patients (12).

Therefore, our results may provide several suggestions for the clinical implementation of psychological interventions for breast cancer patients. This therapy will work for treating the fear of recurrence and/or metastasis of the disease, which is the most common distress experienced by Japanese cancer patients (26), and unfortunately there are no standard interventions for alleviating this distress (27). In addition, one previous study indicated the usefulness of PST in distress among palliative care patients (28). These findings suggest that PST can be used for a broad range of psychological distress situations in clinical settings. At the present time, we are conducting group PST intervention programs for mixed-stage cancer patients, in which patients with advanced cancer and metastasis or end-stage cancer patients are included. We have not observed any difficulties utilizing this PST intervention for such patients.

The final remarkable result is the improvement observed in the index indicating patients' social relationships, such as EORTC's social function and interpersonal problems of BCWI. This indicates that our PST program facilitated patients' daily, family or work-related behavior and activities, which may have led to decreased symptoms of depression and anxiety in the patients. This could suggest that the intervention's effect may possibly vitalize patient behavior in a social context, thus initiating a cognitive change. Future studies on mechanisms of how the PST program works for social aspects in the process of a patient's adjustment to cancer are needed.

This study has several limitations. The study design utilized a before and after study design without a control group. However, if a control group would be set in this study, two types of control groups should be included: one being a no-intervention group and the other being an intentional-control group using traditional counseling. In the current Japanese medical health system, there are seldom any tools available for the psychological care for breast cancer patients. It is thus almost impossible to provide an intentional control represented by patients receiving traditional psychological care in our study. Therefore, we employed data related to our primary endpoint from a previous observational study (21) for sample size calculation and to set to the strictest standard the estimated significant decrease in HADS score following intervention. We believe that these procedures have contributed to the validity of our study, although the results will need to be interpreted in a certain limited way. The second limitation of our study is the sampling method. We used convenient sampling and could not use consecutive sampling because the initial recruitment for this study relied entirely on physicians in a very busy outpatient service. This may have resulted in systematic and random errors in the study. However, our strict inclusion criteria and selection process using psychological screening tools should have reduced systematic errors. The true effectiveness of the program should be confirmed by a future randomized control trial.

Funding

This study was supported in part by a Grant-in-Aid for Cancer Research Grant from the Japanese Ministry of Labor, Health and Welfare.

Conflict of interest statement

None declared.

Acknowledgements

The authors wish to thank Shinzaburo Noguchi, Tetsuya Taguchi, Satsuki Ueda, Naomi Maruyama, Fumine Tsukamoto, Kenji Akazawa, Akiyuki Ohi, Kaori, Masuda, Toshinori Ito, Toru Kitagawa, Hitoshi Tanimukai, Kyoko Kaji, Naoko Kanai, Masako Shokoji, and Tomoko Fujioka for their research assistance.

References

1
Akechi
T
Okuyama
T
Sugawara
Y
, et al.  . 
Major depression, adjustment disorders, and post-traumatic stress disorder in terminally ill cancer patients: associated and predictive factors
J Clin Oncol
 , 
2004
, vol. 
22
 (pg. 
1957
-
65
)
2
Akechi
T
Nakano
T
Okamura
H
, et al.  . 
Psychiatric disorders in cancer patients: descriptive analysis of 1721 psychiatric referrals at two Japanese cancer center hospitals
Jpn J Clin Oncol
 , 
2001
, vol. 
31
 (pg. 
188
-
94
)
3
Akechi
T
Okuyama
T
Imoto
S
, et al.  . 
Biomedical and psychosocial determinants of psychiatric morbidity among postoperative ambulatory breast cancer patients
Breast Cancer Res Treat
 , 
2001
, vol. 
65
 (pg. 
195
-
202
)
4
Ganz
PA
Coscarelli
A
Fred
C
, et al.  . 
Breast cancer survivors: psychosocial concerns and quality of life
Breast Cancer Res Treat
 , 
1996
, vol. 
38
 (pg. 
183
-
99
)
5
Maguire
GP
Lee
EG
Bevington
DJ
, et al.  . 
Psychiatric problems in the first year after mastectomy
Br Med J
 , 
1978
, vol. 
1
 (pg. 
963
-
5
)
6
Okuyama
T
Nakane
Y
Endo
C
, et al.  . 
Mental health literacy in Japanese cancer patients: ability to recognize depression and preferences of treatments—comparison with Japanese lay public
Psychooncology
 , 
2007
, vol. 
16
 (pg. 
834
-
42
)
7
D'Zurilla
TJ
Goldfried
MR
Problem solving and behavior modification
J Abnorm Psychol
 , 
1971
, vol. 
78
 (pg. 
107
-
26
)
8
Cuijpers
P
van Straten
A
Warmerdam
L
Problem solving therapies for depression: a meta-analysis
Eur Psychiatry
 , 
2007
, vol. 
22
 (pg. 
9
-
15
)
9
Malouff
JM
Thorsteinsson
EB
Schutte
NS
The efficacy of problem solving therapy in reducing mental and physical health problems: a meta-analysis
Clin Psychol Rev
 , 
2007
, vol. 
27
 (pg. 
46
-
57
)
10
Nezu
AM
Nezu
CM
Felgoise
SH
, et al.  . 
Project Genesis: assessing the efficacy of problem-solving therapy for distressed adult cancer patients
J Consult Clin Psychol
 , 
2003
, vol. 
71
 (pg. 
1036
-
48
)
11
Sahler
OJ
Fairclough
DL
Phipps
S
, et al.  . 
Using problem-solving skills training to reduce negative affectivity in mothers of children with newly diagnosed cancer: report of a multisite randomized trial
J Consult Clin Psychol
 , 
2005
, vol. 
73
 (pg. 
272
-
83
)
12
Akechi
T
Hirai
K
Motooka
H
, et al.  . 
Problem-solving therapy for psychological distress in Japanese cancer patients: preliminary clinical experience from psychiatric consultations
Jpn J Clin Oncol
 , 
2008
, vol. 
38
 (pg. 
867
-
70
)
13
D'Zurilla
TJ
Problem Solving Therapy: A Social Competence Approach to Clinical Intervention
 , 
1986
New York
Springer Publishing
14
Mynors-Wallis
L
Problem-solving Treatment for Anxiety and Depression: A Practical Guide
 , 
2005
Oxford
Oxford University Press
15
Akizuki
N
Yamawaki
S
Akechi
T
, et al.  . 
Development of an Impact Thermometer for use in combination with the Distress Thermometer as a brief screening tool for adjustment disorders and/or major depression in cancer patients
J Pain Symptom Manage
 , 
2005
, vol. 
29
 (pg. 
91
-
9
)
16
Zigmond
AS
Snaith
RP
Kitamura
T
The hospital anxiety and depression scale
Arch Psychiatr Diagnostics Clin Eva
 , 
1993
, vol. 
4
 (pg. 
371
-
2
(in Japanese)
17
Kugaya
A
Akechi
T
Okuyama
T
, et al.  . 
Screening for psychological distress in Japanese cancer patients
Jpn J Clin Oncol
 , 
1998
, vol. 
28
 (pg. 
333
-
8
)
18
Hirai
K
Suzuki
Y
Tsuneto
S
, et al.  . 
Self-efficacy scale for terminal cancer
Jpn Soc Psychosom Med
 , 
2001
, vol. 
41
 (pg. 
19
-
27
)
19
Hirai
K
Shiozaki
M
Motooka
H
, et al.  . 
Discrimination between worry and anxiety among cancer patients: development of a Brief Cancer-Related Worry Inventory
Psychooncology
 , 
2008
, vol. 
17
 (pg. 
1172
-
9
)
20
Kobayashi
K
Takeda
F
Teramukai
S
, et al.  . 
A cross-validation of the European Organization for Research and Treatment of Cancer QLQ-C30 (EORTC QLQ-C30) for Japanese with lung cancer
Eur J Cancer
 , 
1998
, vol. 
34
 (pg. 
810
-
5
)
21
Hirai
K
Shiozaki
M
Emotion and Adjustment in Breast Cancer Patients. In The 71st Annual Convention of the Japanese Psyhological Association
 , 
2007
Toyo University, Tokyo,
22
Williams
S
Dale
J
The effectiveness of treatment for depression/depressive symptoms in adults with cancer: a systematic review
Br J Cancer
 , 
2006
, vol. 
94
 (pg. 
372
-
90
)
23
Fukui
S
Kugaya
A
Okamura
H
, et al.  . 
A psychosocial group intervention for Japanese women with primary breast carcinoma
Cancer
 , 
2000
, vol. 
89
 (pg. 
1026
-
36
)
24
Miyashita
M
A randomized intervention study for breast cancer survivors in Japan: effects of short-term support group focused on possible breast cancer recurrence
Cancer Nurs
 , 
2005
, vol. 
28
 (pg. 
70
-
8
)
25
Arakawa
S
Relaxation to reduce nausea, vomiting, and anxiety induced by chemotherapy in Japanese patients
Cancer Nurs
 , 
1997
, vol. 
20
 (pg. 
342
-
9
)
26
Yamaguchi
K
Gan to mukiatta 7885 nin no koe
2006
27
Alfano
CM
Rowland
JH
Recovery issues in cancer survivorship: a new challenge for supportive care
Cancer J
 , 
2006
, vol. 
12
 (pg. 
432
-
43
)
28
Wood
BC
Mynors-Wallis
LM
Problem-solving therapy in palliative care
Palliat Med
 , 
1997
, vol. 
11
 (pg. 
49
-
54
)