A life threatening illness such as breast cancer can lead to a secondary diagnosis of PTSD (post traumatic stress disorder) [1
]. The reported frequency of PTSD for breast cancer patients varies between 2–22%, depending on methods of measurement. At present it is therefore difficult to draw any conclusions about the actual prevalence of PTSD. Intrusive thoughts, avoidance behavior and worry are all common symptoms. Nordin and Glimelius [2
] reported that clinical levels of worry or depression in combination with intrusive thoughts in individuals with breast cancer make it possible to identify women who will need psychological support at a later stage of treatment. In a study [3
] it was found that measures of avoidance behavior could predict the effects of treatment on an individual’s quality of life. Extensive avoidance behavior at the start of treatment is correlated with deterioration in physical and social functioning as well as impaired general health. Half of the women diagnosed with breast cancer in Sweden are under the age of 65 and at least theoretically gainfully employed [4
]. To juggle the demands of work and a family, especially when there are children living at home, is a demanding task [5
]. To be diagnosed with breast cancer on top of these demands can be the straw that breaks the camel’s back. At present there is very little research that has examined this combination of stress factors in women diagnosed with breast cancer.
In an international perspective there is a fair amount of evidence which indicates that methods which are based on cognitive behavior therapy can improve health-related quality of life (HRQoL), reduce psychosocial stress and increase perceived Personal control of treatment side-effects and disease symptoms for cancer patients [6
]. According to SBU (The Swedish Council on Technology Assessment in Health Care) providing cognitive behavior therapy 1–3 months after a traumatic event reduces the occurrence of PTSD in states of intensive stress [8
]. At present there is a lack of solid research findings for comparisons of cost-effectiveness and outcome [8
The research group “Support project” has studied the effect of individual counselling conducted by a specially trained nurse [9
]. This intervention was compared to the results of therapy conducted by a psychologist and to a group that received treatment as usual. The project started in 1997 with special training for nurses [10
]. The project continued during for the next 5 years and data collection was concluded in January 2002. Patients in this study had been diagnosed with breast cancer and were offered adjuvant treatment. A total of 179 patients were consecutively included. The results showed that both active treatments had a positive effect, measured in terms of increased HRQoL and decreased symptoms of stress (e.g. intrusive thoughts) in comparison to the control group who received treatment as usual [9
]. More patients in the control group took advantage of the psychosocial support that was available for all patients in standard care as compared to both intervention groups. The level of satisfaction was generally high in both intervention groups [11
]. However patients in the nurse-counselor groups reported that greater satisfaction with interventions for worry, information about their illness, prognosis, tests, treatment as well as general contact with health care facilities than patients in the psychologist groups. Utilization of health care and number of days on sick leave can be attributed to the adjuvant treatment [12
]. Both the intervention groups had lower total costs for medical care than the control group who required more days for in-patient care. The conclusions that can be drawn from this study are that the psychosocial interventions were useful for breast cancer patients, that they were relatively inexpensive and that interventions offered by nurses were as effective as those given by psychologists. The results of the “Support Project” described above generated additional questions. Most patients reported relatively high levels of HRQoL as well as relatively low levels of symptoms and side-effects of their illness and treatment. Despite these findings 75% of the patients reported that they had problems for which the psychosocial interventions provided help. A more detailed analysis of the data showed that 80% of the patients in the study reported a high level of stress symptoms initially, such as intrusive thoughts and avoidance behavior. These symptoms remained high throughout the study. Other symptoms such as worry and depression were also reported at high levels initially but these symptoms had decreased to normal levels after 3 months. This indicates that here is a need for closer examination of other factors for breast cancer patients, such as stress-related symptoms and behavior, predictors for stress, effects on role and social functions as well as utilization of heath care, sick leave and return to work settings. In addition there is a need to study how psychosocial interventions with a focus on stress management can influence the above-mentioned factors.
This paper presents the design of a randomized multi-centre trial to evaluate the effectiveness and cost-effectiveness of a stress management intervention using a stepped- care approach. The first step is a low intensity intervention that is given to all patients. Patients who do not respond to this level are thereafter given more intensive treatment at step 2 in the program. They will in step 2 be randomised to more intensive stress-management intervention in a group setting or individual. The hypothesis is that half of the individuals assigned to a low intensity intervention will be significantly improved after treatment. For individuals who continue to have symptoms after low intensity treatment it is hypothesized that continued treatment in a group setting with high intensity interventions will be more cost-effective. In addition the assumption is that reduction of stress symptoms in women with breast cancer will lead to a reduction in socio-economic costs.