Journal of Psychosomatic Research, Vol. 45, No. 3, pp.
191–200, 1998
Copyright 1998 Elsevier Science Inc.
All rights reserved.
0022-3999/98 $–see front matter
S0022-3999(98)00015-4
REVIEW
GROUP THERAPY IN THE CANCER SETTING
FAWZY I. FAWZY* and NANCY W. FAWZY†
INTRODUCTION
The importance of psychiatric interventions designed to assist cancer patients in
dealing with diagnosis and treatment has increased dramatically as survival rates
have improved along with advances in medical care [1–3]. According to Holland [4],
the goals of these interventions are to decrease feelings of alienation, isolation,
helplessness, and being neglected; to reduce anxiety about the treatments; and to
assist in clarifying misperception and misinformation. Such interventions, designed
to help individuals to feel less helpless and hopeless have the additional benefit of
encouraging more responsibility to get well and compliance with medical regimens.
Today’s patients, aware of the benefits of these psychosocial therapeutic interven-
tions, often specifically request such services.
One intervention category that has received major attention is that of group ther-
apy. The purpose of this article is to review those group therapy studies that have
been designed specifically for cancer populations. It will describe these interven-
tions addressing the type of patient population, research design, treatments, and
outcomes. Outcome measures include changes in coping, affective state, quality of
life (QOL), knowledge regarding disease and treatment, compliance, changes in
physical status, and recurrence and survival. The value of group versus individual
interventions will be discussed and a model of group intervention will be explored.
GROUP INTERVENTIONS
In the late 1970s, reports began appearing in the literature of group interventions
for cancer patients. In 1978, Wood et al. [5] reported the findings of a pilot study
with 15 cancer patients receiving various diagnoses. Eight weekly 90-minute ses-
sions were held. The groups were co-led by a psychiatrist, a registered nurse, and
a social worker. The discussions were designed to focus on issues of living and cop-
ing with cancer. A survey using a Likert scale and covering 20 areas of changed ex-
perience was used to evaluate effectiveness. The investigators reported difficulty in
keeping the group focused on the intended content. However, patients reported
*Department of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine, Los Angeles, Cal-
ifornia, USA.
†John Wayne Cancer Institute, Saint John’s Hospital and Health Center, Santa Monica, California,
USA.
Address correspondence to: Fawzy I. Fawzy, UCLA Neuropsychiatric Institute, 760 Westwood Plaza,
Los Angeles, CA 90024-1759. Tel: (310)-825-0249; Fax: 310-825-0323.
191
192 Review
that the intervention was useful in helping them to get information, to talk about
and face fears and anxieties, to feel less isolated, and to feel supported in general.
Ferlic et al. [6] provided 30 newly diagnosed cancer patients with six group coun-
seling sessions (each 90 minutes) over 2 weeks. The content consisted of: (1) patient
education; (2) team presentations (nursing perspectives, medical and psychological
aspects, religion, sexuality, and nutrition); and (3) group support. A social worker
(MSW) co-led the session each week with the help of one team member (i.e., one
of three nurses, two physicians, two chaplains, an occupational therapist, and a di-
etitian). Group members were compared with patients in a control group who did
not attend the sessions. The method of assignment to groups was unclear. The Self-
Concept Questionnaire and Patient Perception Test were administered pre- and
postintervention and then 6 months later by mail. Unfortunately, the 6-month re-
sponse was too small to provide adequate data. The postintervention data indicated
that the intervention proved at least short-term usefulness in improving patients’
scores in group attitude, hospital adjustment, relationship strength, cancer knowl-
edge, and perceptions about death. It also served to enhance self-concept.
The Omega Project [7] employed a structured intervention addressing the usual
questions and concerns of cancer patients, providing education and teaching relax-
ation techniques. The program employed four audio-tapes and ten sets of illustrated
‘‘problem” cards to guide discussions. Patients met four times over a 6-week period.
Fifty-nine subjects participated in the intervention, whereas 58 were in the control
condition. Cancer diagnoses were mixed. Patients were screened for variables such
as religion, socioeconomic status, race, and demographics. The assessment instru-
ments included the Profile of Mood States (POMS), Index of Vulnerability, Thera-
pist Rating Form, Patient Evaluation of Psychosocial Intervention, and Inventory of
Current Concerns. Results showed that this intervention increased communication
and coping skills in subjects when compared with controls after 6 months. In 1982, So-
bel and Worden published the practitioner’s manual to guide other professionals in
implementing their intervention program for cancer patients [8].
Spiegel et al. [9, 10] performed a prospective intervention study of patients with
metastatic breast cancer. Patients were randomly assigned to a control group that
received only standard treatment or to an experimental group in which patients also
met weekly in psychological support groups for a year. Meetings were informal and
consisted of interpersonal exploration, as well as discussions of death and dying,
family problems, communication problems, and living as richly as possible with a
terminal illness. Emphasis was placed on group cohesion, emotional support, shar-
ing of mutual fears, and self-disclosure. Interaction between patients outside of the
weekly meeting was encouraged. At 12 months, experimental patients showed sig-
nificantly less tension, less fatigue, less confusion, and more vigor than those in the
control group. Interestingly, there was also a significant reduction in levels of pain
for experimental patients. Trends toward lower depression and fewer maladjusted
coping responses and phobias were also apparent. Ten years later, 83 of the original
86 patients had died. Death records were obtained of those who had died. Although
not a goal of the original intervention, survival time was significantly different. The
intervention group had a mean survival of 36.3 months compared with 18.9 months
in the control group. Lower mood disturbance and higher ratings of vigor on the
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Profile of Mood States (POMS) at the end of the 1-year intervention period were
significantly associated with greater survival time.
Johnson [11] then randomized 52 newly diagnosed or recurrent cancer patients
to either a 4-week, eight-session structured psychoeducational intervention, titled
I Can Cope, or to a control group. Pre- and postintervention measures of anxiety,
knowledge about cancer, and perceived purpose and meaningfulness in life were
performed. As intended, the structured intervention positively affected all three
outcome measures.
Vachon et al. [12] compared 64 women with breast cancer who resided at a hospi-
tal lodge while going through approximately 3 weeks of radiation therapy to 104
women who went through their therapy while living at home. Patients stayed in the
lodge because they lived too far from the hospital to commute for their radiation
therapy treatments. The lodge provided Coping with Cancer support groups. In
these groups, patients were given information about their disease and treatment,
opportunities to express emotions, and coping skills. They were also able to meet
with patients who had completed therapy and were doing well. The actual number
of group sessions held during the 3 weeks or the length of each session was not spec-
ified. Affective state was measured by the General Health Questionnaire. Resi-
dence in the lodge with attendance in the groups was associated with a decreased
chance of change for the worse in affective state and an increased chance of change
for the better.
Henreich and Schag [13] studied 25 patients who were in a current available care
(CAC) control group to 26 patients with various cancer diagnoses who participated
in a stress and activity management group (SAM). Patients were recruited in se-
quential groups of about 10 to whatever condition was open at the time they were
recruited. Twelve spouses in the treatment group and 13 in the control group also
participated. SAM was a comprehensive, structured 6-week-long group consisting
of education, exercise, coping including problem solving, and stress management
techniques such as relaxation exercises. Patients were assessed pretreatment, post-
treatment, and 2 and 4 months later using the Karnofsky Performance Status Scale;
the Cancer Information Test; the Psychosocial Adjustment to Illness Scale (PAIS);
and the Depression, Anxiety, and Global Severity Index from the SCL-90-R, Qual-
ity of Life, and Daily Activity Diary. Surprisingly, both patients and spouses in the
SAM group all showed an increase in knowledge even though most of the patients
had been dealing with their cancer for over 2 years. SAM patients and spouses re-
ported being able to cope better and had a more positive attitude toward treatment.
There was no difference between groups in psychosocial adjustment to illness. This
may have been a function of the instrument used (PAIS), which may not have been
sensitive enough to pick up differences in this population even though it is very use-
ful in extremely ill patients.
Cain et al. [14] randomly assigned 80 women with gynecological cancer to a con-
trol group or to either an individual or group thematic counseling intervention.
Coping and adjustment was measured by the PAIS and affective state via the Ham-
ilton Depression Rating Scale. The eight weekly sessions of thematic counseling (in-
dividual or group) were provided by social workers along with an oncology nurse
and fellow, a radiologist, and a dietitian. Themes included the nature of cancer,
194 Review
causes, impact of treatment particularly on body image and sexuality, relaxation,
diet and exercise, relating to caregivers, talking with family and friends, and goal
setting. The investigators concluded that the individual and group counseling were
equally effective in decreasing anxiety and depression and increasing adjustment to
the illness up to 6 months later. Although no objective measurement of knowledge
was reported, the investigators also claimed that the intervention patients were sig-
nificantly more knowledgeable about their illness and treatment.
Forty-one cancer patients with different diagnoses and stages of disease who were
exhibiting marked levels of psychosocial distress were randomized by Telch and
Telch [15] to: (1) a coping skills instruction group; (2) an emotional support group;
or (3) a no-treatment control group. The two intervention groups met once a week
for 6 weeks (90 minutes each session). The emotional support group was unstruc-
tured and geared toward encouraging patients to express feelings and emotions.
The coping skills groups had a specific agenda including the teaching and rehearsal
of cognitive, behavioral, and affective coping strategies. Patients were assessed
prior to and immediately after the 6-week groups. The primary instruments were
the Profile of Mood States (POMS) and the Cancer Inventory of Problem Situations
(CIPS). The coping skills group showed consistent improvement in affective state,
satisfaction related to work, social activities, physical appearance, sexual intimacy,
physical and social activities, cognitive distress, communications, and coping with
medical procedures. Patients in the emotional support group showed little or no im-
provement, whereas the control patients actually deteriorated in their psychologi-
cal functioning.
Cunningham and Tocco [16] randomly assigned 60 patients with mixed cancer di-
agnoses to either: (1) a supportive discussion group with education in coping skills;
or (2) a supportive discussion group alone. The psychoeducational intervention
consisted of supportive discussion; ventilation of feelings; general problem solving
and information sharing; progressive muscle relaxation (PMR); self-hypnosis;
guided imagery (GI); and goal setting and general lifestyle management, which in-
cluded diet, exercise, work, recreation, and discussion of spiritual issues. The inves-
tigators referred to the second group as the “control” intervention, which consisted
of just the supportive discussion, ventilation of feelings, general problem solving,
and information sharing. Another group of 18 patients who delayed starting the in-
tervention for 6 weeks were also tested and served as a nonrandomized control
group. These three groups were all tested pregroup, immediately postgroup, and
2–3 weeks later. Additionally, a fourth group of 39 patients, who were also nonran-
domized, participated in the psychoeducational intervention and were followed for
3 months. Affective state assessments were done with the POMS and the SCL-90-R.
Both intervention groups showed a significant improvement in affective state com-
pared with the no-treatment “control” group. The psychoeducational group showed
a greater gain. The 39 patients in the fourth group demonstrated a sustained im-
provement in the 3-month follow-up period.
Cunningham et al. [17] used the Profile of Mood States (POMS), the Functional
Living Index for Cancer, and the Stanford Inventory of Cancer Patient Adjustment
to assess improvements in the quality of life among 400 cancer patients who com-
pleted a brief support group program intended to train patients in coping skills. Re-
Review 195
sults showed that subgroups based on religious status, gender, education level, mari-
tal status, and previous experience with mental self-help techniques did not vary
significantly, but the overall program increased coping skills and enhanced mood
states for most subjects involved. The seven-session intervention appeared to bene-
fit younger patients somewhat more than older ones and, at the 3-month follow-up,
positive improvements remained. There was no random selection or control group
used in this study.
Additionally, Cunningham et al. [18] compared two different formats of a brief,
group psychoeducational program for cancer patients. Patients were randomly as-
signed to either a standard (six weekly 2-hour sessions) intervention or a “weekend
intensive” intervention group. At 19 weeks following intervention, the two formats
were found to have comparable effects on mood and quality of life. Quality-of-life
improvement appeared to be somewhat greater for the standard 6-week interven-
tion group.
Cella et al. [19] reported on an 8-week support group for 77 cancer patients in a
local community. There was no random selection or a control group in this study.
As expected, self-reported quality of life improved significantly by the final session.
Community and peer support was noted by participants as the most helpful aspect
of the program and the group evaluations showed high satisfaction levels in all ar-
eas. In discussing the issue of a lack of randomization or a control group, the investi-
gators focused on the need to assess patients in the “real world” where self-selection
of groups is, in fact, the norm.
Berglund et al. [20] established a prospective, randomized study with 98 cancer
patients who took part in a rehabilitation program and 101 patients who served as
controls. The intervention, which focused on “Starting Again,” consisted of 11
structured, 2-hour sessions led by an oncology nurse during a period of 7 weeks.
Physical exercise, coping skills, and information were the primary goals of the pro-
gram, while assessments were made using the Cancer Inventory of Problem Situa-
tions, the Quality of Life (two global items) Scale, and the Mental Adjustment to
Cancer Scale. Subjects in the experimental condition improved significantly in phys-
ical training, physical strength, fighting spirit, body image, sufficient information,
and decreased sleeping problems, when compared with the control patients.
Fawzy et al. [21] developed a 6-week structured group intervention tailored to en-
compass health education, stress management, coping skills, and supportive group
psychotherapy for newly diagnosed malignant melanoma patients who had under-
gone standard surgical treatment.
Health care information specific to the particular type of cancer was provided.
The stress management component was divided into two main sections. First, the
patients were taught about stress awareness, which was defined as identifying
the sources of stress and their personal reactions to it. The second component
was the actual management of stress. Patients were taught simple relaxation exer-
cises, including progressive muscle relaxation followed by guided imagery or self-
hypnosis. In the coping skills component of the intervention, patients were first
taught the components of problem-solving and were then introduced to the concept
of coping methods. The final part of the coping skills component involved integ-
rating the stress management and problem-solving techniques with the information
196 Review
on coping methods and applying these to specific situations. The method used was
modeled after Project Omega [7, 8]. New pictures illustrating ten common prob-
lems/situations encountered by cancer patients were developed [21]. The illustrated
situations include: prediagnosis (worries and concerns about the possible implica-
tions of the condition); diagnosis (accepting the diagnosis and informing family and
friends); doctor–patient relationship (developing a collaborative partnership and
opening up clear lines of communication); treatment issues (feelings of fear, isola-
tion, and dealing with the overwhelming technological environment); body image
(dealing with surgical scars, loss of body parts, hair loss, weight loss, etc.); depres-
sion (coping with varying degrees of depression that can occur immediately after
the diagnosis to years later); interpersonal relationships (communicating feelings
and perceptions with significant others); dealing with coworkers (communicating
with one’s extended social network); returning to “normal” (re-entering life and
participating in previously enjoyed activities); and planning for a future (celebrating
birthdays, buying houses and/or cars). Each situation is represented by two different
pictures. A short scenario below the first picture describes the particular situation
and how the person in the picture is coping. The coping behavior described is gener-
ally ineffective. The second picture is the same situation as the first but with the per-
son using more effective coping methods/strategies. The patients are encouraged to
apply these pictured situations to their own real-life situations.
Psychological support was inherent throughout the intervention. The interaction
of patients within the group provided a significant source of emotional support.
Patients were randomly assigned to either a control group receiving routine medi-
cal care or to an experimental group receiving the same kind of routine medical care
plus the intervention just described.
All patients reported moderate to high levels of psychological distress at baseline
comparable to other cancer patients. However, at the end of the 6-week structured
group intervention, the experimental subjects exhibited significantly lower levels of
distress than the control subjects. Six months following the intervention, the group
differences were even more pronounced. The experimental group reported signifi-
cantly lower levels of confusion, depression, fatigue, and total mood disturbance,
and higher levels of vigor on the Profile of Mood States (POMS).
Immediately following the 6-week structured intervention, the experimental sub-
jects showed significantly greater use of active–behavioral coping methods than the
control subjects. In addition, the experimental subjects used significantly more ac-
tive–positive, active–expressive, active–reliance, cognitive–positive, and distraction
coping strategies. Six months following the intervention, the experimental patients
continued to use significantly more active–behavioral coping methods as well as
more active–cognitive coping methods than the controls.
At the end of the 6-week intervention, there was a significant increase in the per-
centage of large granular lymphocytes (LGLs) (defined as CD57 with Leu-7). Six
months following the intervention, there continued to be an increase in the percent-
age of LGLs (defined as CD57 with Leu-7) as well as increases in natural killer
(NK) cells (defined as CD16 with Leu-11 and CD56 with Leu-19) and interferon-
alpha-augmented NK cell cytotoxicity [22].
In both experimental and control subjects combined, quality of life was strongly
Review 197
negatively correlated with anxiety (p⫽0.0001), depression (p⫽0.0001), anger
(p⫽0.007), confusion (p⫽0.0001), and total mood disturbance (p⫽0.0001) at
6-month follow-up. As negative affective state decreased through lower levels of
anxiety, depression, anger, confusion, and total mood disturbance, the quality of life
of these patients increased.
At the 6-year follow-up period recurrence and survival were assessed. For the
control group, there was a trend for recurrence (13 of 34) and statistically significant
greater rate of death (10 of 34) than for the experimental patients (7 of 34 and 3 of
34, respectively) [1].
This study [21] was compared with another study [23] in which the same content
(i.e., health education, stress management, coping skills) was provided on an indi-
vidual basis versus in a group setting [24]. As stated earlier, the group study helped
to improve coping over time for the intervention subjects. No significant between-
group differences were seen in coping at any time point for the individual study
subjects. Within-group changes in the individual study were conflicting with the
intervention patients using both more effective active–positive and ineffective cog-
nitive–passive coping. The control patients were using more distraction, which is
considered effective, but were also using less of the effective active–expressive strat-
egies and more of the ineffective cognitive–passive strategies.
Over time, the only significant affective state change occurring in either study for
the control patients was a small, within-group improvement in vigor for the control
group patients. However, there was a consistent pattern of clinical improvement in
affective state seen in the intervention patients of both studies with the magnitude
of improvement being clearly greater for the group than for the individual patients.
It would seem that, without some kind of intervention, very little, if any, positive
change took place in the control subjects in either of these studies. The individual
intervention [23] did seem to help but the improvement was not as dramatic or sus-
tained as for the group intervention [21]. Although lower than baseline, the individ-
ual study intervention patients’ 1-year scores indicated that they were still suffering
from a fair amount of psychological distress. On the other hand, the intervention
subjects in the group study improved substantially.
The difference could be explained by “dose” response. The patients in the group
intervention received 9 hours of attention versus only 3 hours in the individual
study. However, each patient in the individual study had the undivided attention of
the therapist and did not have to “wait a turn” to ask questions and express feelings
and emotions. The patients in the group study had to share the time with 8–10 other
patients. In addition, the individual study patients were given detailed and compre-
hensive written information on the content of the intervention that they could take
home and review on their own. Still, the 3 hours of therapist attention may not have
been sufficient to provide patients with the education and support they needed.
An alternative explanation may lie in the relationship between coping and dis-
tress. Adjustment and coping are factors that directly affect mood. When people
feel that they can cope with a new event or problem, then affective state is positively
impacted. Conversely, people feel bad when they believe they are helpless, out of
control, or powerless. The group intervention subjects had the opportunity to prac-
tice their coping skills in the group. Coping is greatly enhanced by sharing concerns
198 Review
with other group members. Patients receive first-hand information on how to deal
with the specific problems that each of them is facing. Furthermore, although it may
be helpful to receive coping information from an objective health care professional,
it is probably much more powerful coming subjectively from a fellow patient and
likely to have a more enduring effect. In summary, patients may have learned to
cope better in the group setting through interaction and practice. This enhancement
in coping may then have led to an improvement in affective state.
Another possible factor may be the emotional support that subjects received dur-
ing the group sessions. By about the third session, total strangers were able to form
a cohesive group. Everyone knew everyone else’s name, illness stories had been
shared, and people were getting to know about each other. With each group meet-
ing the feeling of camaraderie increased. Missing members were quickly identified
and asked about. A tremendous amount of emotional support was provided. Indi-
viduals were able to put aside their own issues for a time and reach out to others in
the group. Hand-holding, hugging, and verbal encouragement were common. This
emotional support continued outside the groups. Telephone numbers were ex-
changed so members could continue to talk with each other. A number of members
formed ongoing relationships, meeting for meals and social events. This social sup-
port was clearly an important component in decreasing emotional distress.
Our finding that group intervention patients demonstrated a greater magnitude
of improvement is unlike an earlier comparison of individual versus group counsel-
ing which found both formats equally effective [14]. The gender configurations of
the two studies (i.e., male and female vs. female only), time of follow-up (i.e., 1 year
vs. 6 months), and different instruments may be factors influencing these different
outcomes. The intervention content of the studies may also be important. With the-
matic counseling some situationally relevant problem solving occurred. Counseling
themes covered body image; relating to caregivers, family, and friends; and goal set-
tings in relation to the cancer. Expression of thoughts and feelings were encour-
aged. This emotion-focused coping appears to be much needed and very effective
in the initial stages of dealing with the diagnosis and treatment of cancer. However,
unless a theoretical framework of coping is presented and understood by the pa-
tients, they may not be able to continue using these effective coping techniques in
the future in relation to either their cancer or life in general. Such a theoretical
framework was not described in the Cain et al. study [14]. In the individual study,
the theoretical framework was presented, but time was limited to coping practice.
However, in the group study, there was ample opportunity for both the expression
of feelings and coping practice after the presentation of the theoretical framework.
CONCLUSION
The psychological and medical problems encountered by cancer patients are nu-
merous and unique. Patients with cancer clearly seem to benefit from a variety of
psychological intervention programs, in particular those employing a group format.
A structured intervention consisting of health education, stress management/behav-
ioral training, coping including problem-solving techniques, and psychosocial group
support seems to offer significant benefit for patients newly diagnosed or in the
early stages of their treatment. The focus is on learning how to live with cancer.
Review 199
Such an intervention offered early on during the course of cancer diagnosis and
treatment may be less stigmatizing and more readily accepted by both patients and
staff and easily integrated into the comprehensive medical care of cancer patients.
The advantages of such a program include easy implementation and replication,
promotion of important illness-related problem-solving skills, and increased partici-
pation in decisionmaking and active coping. We also encourage the development of
ongoing weekly group support programs for patients with advanced metastatic dis-
ease based on Spiegel’s work [9, 10]. The focus of these groups is on daily coping,
pain management, and dealing with both the practical and existential issues related
to death and dying. Group formats for psychoeducational interventions in the can-
cer setting are also probably the best means for providing effective interventions for
patients in the most cost-effective manner. Such group interventions should be used
as an integral adjunctive part of competent, comprehensive medical care and never
as an independent (i.e., solo alternative) treatment modality for cancer.
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