VOLUME 23 䡠 NUMBER 6 䡠 FEBRUARY 20 2005

JOURNAL OF CLINICAL ONCOLOGY O R I G I N A L R E P O R T

Psychoeducational Intervention for Patients With

From the Institute of Cancer
Epidemiology, Danish Cancer Society;
Department of Plastic Surgery and Burn
Unit, Rigshospitalet, University of
Copenhagen, Copenhagen; Department
of Plastic Surgery, Herlev Hospital,
University of Copenhagen, Herlev
Ringvej, Copenhagen County; and
Department of Plastic and Reconstruc-
tive Surgery, Roskilde University
Hospital, Roskilde, Denmark.
Submitted May 29, 2003; accepted
November 3, 2004.
Supported by the Psychosocial Research
Committee, The Danish Cancer Society
(9722559 and PP01016), and the IMK
Foundation (5322569).
Authors’ disclosures of potential con-
flicts of interest are found at the end of
this article.
Address reprint requests to Ellen H.
Boesen, MSc, PhD, Institute of Cancer
Epidemiology, Danish Cancer Society,
Strandboulevarden 49, DK-2100
Copenhagen, Denmark; e-mail:
ellen@cancer.dk.
© 2005 by American Society of Clinical
Oncology
0732-183X/05/2306-1270/$20.00
DOI: 10.1200/JCO.2005.05.193
Cutaneous Malignant Melanoma: A Replication Study
Ellen H. Boesen, Lone Ross, Kirsten Frederiksen, Birthe L. Thomsen, Karin Dahlstrøm, Grethe Schmidt,
Jesper Næsted, Christen Krag, and Christoffer Johansen
A B S T R A C T
Purpose
In 1993, a randomized intervention study among patients with malignant melanoma showed
a significant decrease in psychological distress and increased coping capacity 6 months after
the intervention and enhanced survival 6 years later. We applied a similar intervention with
a few modifications in a randomized controlled trial among Danish patients with malignant
melanoma and evaluated results on immediate and long-term effects on psychological
distress and coping capacity.
Patients and Methods
A total of 262 patients with primary cutaneous malignant melanoma were randomly
assigned to the control or intervention group. Patients in the intervention group were
offered six weekly sessions of 2 hours of psychoeducation, consisting of health
education, enhancement of problem-solving skills, stress management, and psycholog-
ical support. The participants were assessed at baseline before random assignment and
6 and 12 months after surgery. The analyses of the main effects of the intervention were
based on analyses of covariance.
Results
The patients in the intervention group showed significantly less fatigue, greater vigor, and
lower total mood disturbance compared with the controls, and they used significantly more
active-behavioral and active-cognitive coping than the patients in the control group. The
improvements were only significant at first follow-up.
Conclusion
The findings of this study support the results of an earlier intervention study among patients
with malignant melanoma and indicate that a psychoeducational group intervention for such
patients can decrease psychological distress and enhance effective coping. However, this
effect is short term and the clinical relevance is not obvious.

J Clin Oncol 23:1270-1277. © 2005 by American Society of Clinical Oncology

additional area for clinical intervention

INTRODUCTION
During the last 20 years, more than 40 ran-
domized studies of various psychosocial in-
tervention strategies for cancer patients have
been conducted to improve the emotional
adjustment and prevent negative psycho-
social effects after a cancer diagnosis.1 The
promising results of several randomized
psychosocial intervention studies showing
improved survival highlight a potential
and research.2-5,6
A large replication study by Spiegel
et al2 on long-term supportive-expressive
group therapy among women with meta-
static breast cancer did not find increased
survival but showed improved mood, pri-
marily in women who were initially more
distressed.7 Similar results regarding re-
duced traumatic stress symptoms were re-
ported in another replication study from the

1270
 Psychoeducational Intervention for Melanoma
United States.8 It seems that strategies that focus solely
on emotional support through peer discussion may be less
helpful for patients with primary cancer.9,10 An intervention
combining cognitive therapy with supportive-expressive ther-
apy for women with primary breast cancer found only small
improvements in mood and mental adjustment.11
Fawzy et al12 used structured psychoeducational group
interventions for patients with primary malignant mela-
noma; in combination with cognitive behavioral therapy,
these interventions have been shown to decrease anxiety
and/or depression.13-18 The results of studies that involved
only information strategies or behavioral approaches (re-
laxation or meditation training) showed that just one of the
two types of interventions may suffice.19-24
Research has shown that patients with poor problem-
solving abilities and feelings of lack of control also report
higher levels of depressive symptoms and anxiety, indicat-
ing that interventions aimed at improving coping skills may
thereby reduce depression and anxiety.25-27 Interventions
that aim to increase self-efficacy seem to promote better
adjustment to cancer.28 In a meta-analysis of psychosocial
intervention components, interventions with a greater
number of components related to social cognitive theory
gave better quality-of-life outcomes than interventions with
fewer or no such components.29 In the study by Fawzy et
al,30 a positive correlation was found between use of active
coping and decreased distress, which supports the sug-
gested association between coping and psychological well-
being. Fawzy et al30 suggested that the enhanced survival found
among the patients in the intervention group is linked to
improved compliance with follow-up routines and preventive
health behavior, which may reflect increased self-efficacy.
Components closely related to social cognitive theory are cop-
ing abilities, problem solving, and stress management, which is
the focus of the intervention by Fawzy et al.12
Psychosocial intervention studies that show psycho-
logical benefits for cancer patients must be replicated, pref-
erably in large-scale studies, to validate their results. We
conducted a randomized, controlled intervention trial of
241 patients with primary cutaneous malignant melanoma.
The intervention was based on the structured psychoedu-
cational group model of Fawzy et al12 for United States
cancer patients; however, it was slightly modified to fit
Danish cancer patients. Our hypotheses were that psycho-
education among a group of Danish patients with malig-
nant melanoma would decrease psychological distress and
improve active coping methods and health behavior. We
report the effect of the intervention on psychological dis-
tress measured by Profile of Mood States (POMS) scale and
coping measured by the Dealing With Illness Inventory–
Revised (DWI-R),31 which was a revised version of the
Dealing With Illness Inventory (DWI), developed by Fawzy
et al. Results on survival will be reported when 3-year
follow-up data are obtained in 2005.
www.jco.org
PATIENTS AND METHODS
Selection Criteria
Eligible patients were 18 to 70 years of age with cutaneous
malignant melanoma of T1-4, N1a-2a, M032 diagnosed and
treated in eastern Denmark. Patients were contacted by a project
nurse in the outpatient clinics between 3 and 12 weeks after sur-
gery. Patients who gave oral and written consent completed a
baseline questionnaire and were then immediately randomly as-
signed to the intervention or the control group. Randomization
was performed with a computer program, which generated a
balanced number of random assignments to the two groups in
blocks of randomly varying sizes of six, eight, or 10 patients. This
ensured equal distribution of patients in the two groups and
reduced possible confounding from season or calendar time. Be-
tween February 1, 1999, and June 15, 2001, the physicians reported
420 eligible patients for the project. Of these, 21 patients (5%)
were excluded before random assignment because of the informa-
tion obtained at the recruitment interview. These comprised three
patients with dementia, one with cognitive deficits after brain
damage, two with a diagnosis of a second primary melanoma, four
with an unclear pathologic diagnosis, two in whom cancer had
been diagnosed before the cutaneous malignant melanoma, one
with in situ melanoma, and one with a serious but nonmalignant
chronic blood disease. An additional five patients had exceeded
the time span for inclusion, and two patients did not attend the
medical check-ups.
Of the 399 patients who met the inclusion criteria, 262 (66%)
agreed to participate and 137 (34%) refused to participate because
of the distance involved or lack of time, or because they felt no
need for support.
Of the 131 patients originally assigned to the intervention
group, three (2%) were excluded from the questionnaire analyses;
one patient had a cancer diagnosis before inclusion, one received
immunotherapy, and one patient died before the start of the
intervention. Another 16 patients (12%) dropped out of the inter-
vention group before it started (nine patients) or after one session
(seven patients). All patients who dropped out cited the time or
the distance involved, or they felt no need for support. Because of
ethical concerns, the 16 patients who dropped out were not asked
to continue in the study with follow-up questionnaires. These
exclusions left 112 patients in the intervention group.
Of the 131 patients originally assigned to the control group,
two dropped out shortly after random assignment (one due to
disappointment because of control status and the other for an
unknown reason), leaving 129 patients in the control group.
Baseline Clinical Measures
Information about the prior and current health status of
patients in both arms was obtained from medical records at the
hospitals where they had been treated, and included informa-
tion on sentinel node dissection and lymph node status. Clini-
cal information on the malignant melanoma included tumor
thickness; histologic level of invasion; location and type of
melanoma; surgical treatment; and presence of ulceration, sat-
ellites, and regression.
Outcome Measures
Patients in both groups were asked to complete a question-
naire identical to the baseline questionnaire 6 and 12 months after
surgery. For patients in the intervention group, the time between
the end of the intervention and completion of the first follow-up
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 Boesen et al
questionnaire varied from 1 to 60 days. For 46 patients, the inter-
vention started late and therefore ended more than 6 months after
surgery. For these patients, the first follow-up questionnaire was
administered 1 day after the end of the intervention.
The questionnaire covered sociodemographic information.
The POMS scale33 was used to measure psychological distress.
This instrument contains 65 items to measure six mood or affec-
tive states: tension-anxiety, depression-dejection, anger-hostility,
vigor-activity, fatigue-inertia, and confusion-bewilderment. The
results are summed to a total mood disturbance (TMD) score for
affective state. Numerous studies have used the scale and demon-
strated that it is valid and reliable.2,8,20,34-36 Coping styles were
elicited from the DWI-R,31 a revised questionnaire originally de-
veloped to measure the ability of patients to cope with newly
diagnosed AIDS, for which it showed internal consistency. Fawzy
et al30,37 also used the scale to measure the coping methods of
cancer patients in two studies, and he revised the scale on the basis
of these results because some questions regarding sexual behavior
were ill suited for cancer patients. The revised questionnaire
(DWI-R) comprises 50 items to assess cognitive and behavioral
means of dealing with serious illness (see Appendix). The re-
sponses are categorized into three general coping methods: the
active-behavioral method, the active-cognitive method, and
avoidance. High scores indicate greater use of a particular coping
method. The revised scale was used for this study. Scales included
in this study to measure alcohol, smoking, and exercise habits have
been used in large-scale population-based Danish cross-sectional
surveys.38 However, follow-up data revealed that the question-
naires were not suited for a small cohort like ours because the
questionnaire could not measure small changes (eg, the major-
ity of the patients in our study accumulated in the middle
category of five possible answers to exercise habits). The ques-
tions used to measure sun behavior were derived by the exper-
imenter and not validated, which limits the value of this scale.
For these reasons, results on health behavior are not published.
Group Intervention
The psychoeducational intervention was offered between 3
weeks and 4 months after surgery to groups of eight to 10 patients.
This intervention was organized into six sessions lasting approxi-
mately 2.5 hours each and conducted over a 6-week period, based on
the manual developed by Fawzy et al.12 Two physicians provided a
health education component consisting of information about malig-
nant melanoma and proper follow-up routines. Two nurses provided
patients with information on cancer-preventive behavior, particu-
larly regarding the hazards of exposure to the sun. This health educa-
tion component differed from the original intervention manual12 in
that specialized health staff and not the group therapist provided the
information. The group therapist (psychologist) provided a method
for stress management and a coping method. The stress management
component was divided into two sections: stress awareness, during
which the participants were provided with stress monitor question-
naires to increase their awareness about stress, and actual manage-
ment of stress, during which patients were taught simple relaxation
exercises (relaxation followed by guided imagery) and encouraged to
use this technique daily by using a complementary compact disk with
relaxation and imagery exercises. In the coping method component,
the participants were introduced to the concepts of active and avoid-
ance coping and effective problem solving, and asked to apply these
methods in specific situations. According to the original intervention
manual, the patients should discuss the different coping methods
based on illustrations of coping scenarios.12 However, we changed
1272
this approach to discussions of the patients’ own experiences and
problems on the basis of questions about various topics (eg, “How did
you react when you discovered the mole?”) because the patients in the
first intervention group raised objections to the scenarios in their
evaluation of the intervention. Psychological support was available
from two perspectives: the supportive climate provided by discus-
sions among patients, and the presence of a group therapist through-
out all sessions.
Statistical Analysis
Baseline characteristics were compared using ␹2 test for cate-
goric variables. The continuous variables (age and tumor thickness)
were tested using the Mann-Whitney U test. Baseline values for
POMS and DWI-R were tested using the Mann-Whitney U test.
The analyses of the main effect of the intervention were based
on analyses of covariance of the difference between the score at
follow-up and the baseline score. The two follow-up times were
analyzed separately and the analyses were adjusted for the baseline
value. We evaluated sex, age, marital status, tumor thickness, and
the baseline value of TMD and DWI-R as possible effect modifiers.
These evaluations were performed in larger models including the
baseline value interacting with intervention and the specific po-
tential effect modifier interacting with intervention. We also eval-
uated the effect in models including all main effects of the
covariates and all first-order interactions between intervention
and the covariates with similar results.
RESULTS
Baseline Characteristics
Baseline characteristics are listed in Table 1. No significant
differences were observed between the two treatment groups
on any variables (all P ⬎ .31). Comparison of participants and
dropouts showed that relatively more women dropped out
(P ⫽ .02) of the study. Baseline data for the POMS and the
DWI-R are listed in Table 2. No significant differences between
the two treatment groups were found on these variables (all
P ⬎ .25). Comparison of participants and dropouts showed no
differences except on the subscale anxiety, for which the drop-
outs were more anxious than participants (P ⫽ .04).
Effects of Psychoeducation on
Mood Disturbance
The main effect of the intervention on distress is sum-
marized in Table 3. A significantly larger average decrease in
the TMD score was observed in the intervention group
compared with the control group at first follow-up
(P ⫽ .04). The difference between the groups was mainly
caused by differences on the subscales for vigor (P ⫽ .003)
and fatigue (P ⫽ .04), respectively. No differences in TMD
were observed at 12-month follow-up.
We found a significant interaction with the baseline
value for TMD at first follow-up (P ⫽ .001), indicating that
the beneficial effect of the intervention was larger for pa-
tients with higher baseline values. The interaction was
mainly seen on the depression (P ⫽ .001), anger (P ⫽ .008),
and fatigue (P ⫽ .01) subscales. For patients with baseline
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 Psychoeducational Intervention for Melanoma

Table 1. Sociodemographic and Biological Characteristics of 259 Patients With Malignant Melanoma Included in a Randomized Intervention
Study of Psychoeducational Group Therapy, Copenhagen, Denmark, 1999-2001
IG CG Dropout IG
(n ⫽ 112) (n ⫽ 129) (n ⫽ 16) No. of
CG Participants
No. of No. of IG v CG No. of Dropouts v Dropouts
Characteristic Patients % Patients % Pⴱ Patients % (n ⫽ 2) Pⴱ
Sex .56 .02
Male 44 39 46 36 2 12 2
Female 68 61 83 64 14 88 0
Age at inclusion, years .51 .27
⬍ 30 11 10 6 5 1 6 0
30-39 24 21 24 19 3 19 0
40-49 22 20 37 29 2 13 1
50-59 37 33 39 30 6 37 1
60-70 18 16 23 18 4 25 0
Marital status .57 .83
Married or cohabiting 84 75 104 81 14 87 1
Single† 27 24 24 18 2 13 1
Unknown 1 1 1 1 0 0 0
Family social class .78 .80
I 25 22 28 22 3 19 0
II 43 38 43 33 5 31 1
III 14 13 22 17 4 25 0
IV 26 23 29 22 4 25 0
V 4 4 7 5 0 0 0
Outside social class system 0 0 0 0 0 0 1
Tumor thickness, mm .31 .53
0.1-0.75 52 46 49 38 6 38 1
0.76-1.5 28 25 36 28 4 25 0
1.6-4.0 18 16 21 16 2 12 0
⬎ 4.0 3 3 5 4 2 12 0
Not measurable 11 10 18 14 2 12 1
Ulceration .76 .11
Yes 12 11 15 12 5 31 0
No 98 87 113 87 11 69 2
Unclassified 2 2 1 1 0 0 0
Level of invasion .66 .29
II 45 40 49 38 5 31 1
III 35 31 38 29 6 38 0
IV 23 21 26 20 2 12 0
V 0 0 2 2 1 6 0
Unclassified 9 8 14 11 2 12 1
Location .44 .46
Head and neck 3 3 7 5 0 0 0
Trunk 62 55 65 50 6 38 1
Upper extremities 11 10 19 15 3 19 0
Lower extremities 36 32 38 29 7 44 1

Abbreviations: IG, intervention group; CG, control group.

ⴱ
The categorical variables are tested using ␹2 and U test. The continuous variables (age, tumor thickness) are tested using Mann-Whitney U test.
†Unmarried, divorced, or widowed.

TMD scores ⱖ 30, the mean change (standard error of the
mean [SEM]) at first follow-up was ⫺35.88 (SEM, 7.19) in
the intervention group (n ⫽ 16), compared with ⫺14.48
(SEM, 7.68) in the control group (n ⫽ 23; data not shown).
The only statistically significant interaction between
intervention and the background variables was an interac-
tion with marital status at the first follow-up, for which a
significantly stronger effect of the intervention was seen for
married patients (TMD, P ⫽ .03). No other significant inter-
actions with treatment group were seen (TMD, all P ⬎ .11).
Effects of Psychoeducation on Coping Methods
The main effect of the intervention on coping capac-
ity is listed in Table 3. The intervention group used
significantly more active-behavioral coping and active-
cognitive coping than the control group at 6-months

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 Boesen et al

Table 2. POMS and DWI-R Baseline Data of 259 Patients With Malignant Melanoma Included in a Randomized Intervention Study of
Psychoeducational Group Therapy, Copenhagen, Denmark, 1999-2001
IG CG Dropout IG Dropout CG
Participants
IG v CG Observed v Dropouts
Measure Mean SEM STD Mean SEM STD Pⴱ Mean SEM STD Values Pⴱ
POMS
TMD 6.1 2.31 24.7 6.1 2.31 24.5 .67 13.33 6.66 25.8 ⫺7 14 .44
Depression 5.2 0.65 6.9 5.9 0.69 7.8 .43 7.9 1.95 7.5 1 15 .21
Anger 5.6 0.57 5.9 6.6 0.69 7.7 .25 4.9 1.01 3.9 3 11 .54
Vigor 15.9 0.56 5.8 16.5 0.54 6.1 .41 16.4 1.30 5.2 13 23 .80
Fatigue 5.1 0.38 3.9 5.2 0.43 4.8 .92 6.0 1.18 4.6 1 1 .79
Confusion 1.8 0.40 4.2 1.9 0.37 4.1 .84 2.2 1.05 4.07 0 2 .79
Anxiety 4.2 0.54 5.8 4.9 0.59 6.59 .42 8.2 1.84 7.1 1 8 .04
DWI-R
Behavioral coping 45.9 1.04 11.1 45.9 1.05 11.1 .49 42.5 2.21 8.9 34 54 .29
Cognitive coping 51.7 0.84 8.9 51.7 0.84 8.9 .56 50.5 1.65 6.6 53 60 .65
Avoidance 28.8 0.60 6.3 28.8 0.59 6.3 .62 30.6 1.88 7.5 25 25 .55

Abbreviations: POMS, Profile of Mood States; DWI-R, Dealing With Illness Inventory–Revised; IG, intervention group; CG, control group; SEM, standard error
of the mean; STD, standard deviation; TMD, Total Mood Disturbance.
ⴱ
The variables were tested using Mann-Whitney U test.

follow-up. No differences were seen at 12-month follow- DISCUSSION

up. No significant differences between the two groups were
observed for avoidance coping.
There were no significant interactions between inter-
vention and baseline values (all P ⬎ .11), but there was a
significant interaction between intervention and marital
status, with a significantly stronger effect of the intervention
for married patients (behavioral coping, P ⫽ .05; cognitive
coping, P ⫽ .01), limited to the first follow-up time. No
other significant interactions with treatment group were
seen (all P ⬎ .13).
We found an effect of a psychoeducational intervention for
patients with malignant melanoma on the TMD of the
POMS scale and on the coping capacity (DWI-R) at the first
follow-up. The effect on TMD was most pronounced for
the patients who were most distressed at baseline. The
beneficial effect of the intervention was clearest for the
married patients, which is in contrast to previous research
indicating that social support might moderate the effective-
ness of psychosocial intervention.9 However, this was not

Table 3. Means of Changes From Baseline in POMS Scores and DWI-R Scores at 6 and 12 Months After Surgery, in the Randomized
Intervention Study of Psychoeducational Group Therapy for Patients With Cutaneous Malignant Melanoma, Copenhagen, Denmark, 1999-2001
6 Months Follow-Up 12 Months Follow-Up
IG CG IG CG
Mean Mean Mean Mean
Scale Change SEM STD Change SEM STD Pⴱ Change SEM STD Change SEM STD Pⴱ
POMS
TMD ⫺8.43 2.47 24.3 ⫺2.64 2.10 22.1 .04 ⫺5.01 2.14 21.5 ⫺4.67 2.29 24.1 .89
Anxiety ⫺1.78 0.54 5.3 ⫺1.66 0.51 5.4 .71 ⫺1.57 0.50 5.0 ⫺1.64 0.56 5.9 .90
Depression ⫺1.45 0.73 7.2 ⫺0.57 0.65 6.8 .16 ⫺0.52 0.68 6.8 ⫺1.15 0.64 6.9 .63
Anger ⫺1.20 0.60 5.9 ⫺0.88 0.55 5.9 .31 0.14 0.59 5.9 ⫺0.63 0.62 6.6 .53
Vigor 2.36 0.67 6.6 ⫺0.22 0.51 4.5 .003 1.38 0.50 5.0 0.49 0.51 5.5 .38
Fatigue ⫺0.80 0.43 4.3 0.46 0.43 4.6 .04 ⫺0.80 0.41 4.0 ⫺0.35 0.39 4.1 .56
Confusion ⫺1.09 0.40 3.9 ⫺0.53 0.36 3.9 .28 ⫺0.87 0.37 3.7 ⫺0.69 0.39 4.1 .72
Coping method
Behavioral 1.81 0.66 6.5 ⫺1.33 0.59 6.4 .0007 ⫺0.17 0.67 6.74 ⫺0.87 0.66 7.1 .33
Cognitive ⫺0.01 0.70 6.9 ⫺3.40 0.80 8.6 .0002 ⫺2.74 0.81 8.1 ⫺3.74 0.89 9.5 .34
Avoidance ⫺1.59 0.48 4.8 ⫺2.27 0.49 5.2 .32 ⫺2.04 0.58 5.9 ⫺2.48 0.50 5.4 .62

Abbreviations: POMS, Profile of Mood States; DWI-R, Dealing With Illness–Revised; IG, intervention group; CG, control group; SEM, standard error of the
mean; STD, standard deviation; TMD, Total Mood Disturbance.
ⴱ
Analysis of covariance adjusted for baseline score.

1274 JOURNAL OF CLINICAL ONCOLOGY

 Psychoeducational Intervention for Melanoma
anticipated, and we attribute the result to a type I error until
the association is found by other studies.
The methodological advantages of our study are the
substantial number of participants and the population-
based recruitment of patients (the project nurse ap-
proached approximately 80% of the total eligible patients in
eastern Denmark). A limitation, however, is that 16 patients
in the intervention group and two in the control group
dropped out, and for ethical reasons no follow-up data were
obtained. There were no significant differences between
dropouts and participants on the TMD score, but the drop-
outs from the intervention group seemed more anxious
than participants, which could bias the results. If the effect
of the intervention is strongest among the most distressed
patients, the results might have been more pronounced if
the 16 patients had not dropped out. Conversely, if dropping
out were due to the kind of intervention offered and the 16
dropouts would not have decreased their level of distress dur-
ing follow-up, the results might be biased toward overestima-
tion of the effect. Given that half of the participants who
dropped out did so before the intervention started, and the
reasons for dropping out most often were time or distance
involved, the participants in the two randomization groups
appeared to be comparable on all variables including anxiety.
Therefore, we still believe that the results are valid.
Another limitation to this study was the use of an
unvalidated version of the coping questionnaire derived by
Namir et al31 for a study among AIDS patients and later
revised by Fawzy et al30,37 for studies among cancer patients.
The revised questionnaire needs to be validated for a Danish
population of cancer patients. The results of this study on
coping methods should therefore be interpreted with cau-
tion. However, for reasons of comparison, it seems reason-
able to include this questionnaire.
The beneficial psychosocial effects observed in this in-
tervention study are consistent with previous reports of the
benefits of psychoeducational or cognitive behavioral
group therapy among patients with malignant melano-
ma30,37 and other cancer diagnoses.13-16 The psychobehav-
ioral factors reflected in the vigor and fatigue subscales
(functional ability) were affected most by the intervention.
This result was in accordance with the findings of Fawzy et
al,30 who found improvements in these subscales.
In contrast to the results of our study, four trials
showed that the level of anxiety decreased significantly in
the intervention group compared with the control
group.13-15,36 Five studies reported a decrease in the level
of depression.16-18,30,36 In our study, the intervention did
not affect the level of anxiety or depression, possibly
because of low levels of anxiety and depression at base-
line that were difficult to reduce further.
Belief in one’s own coping abilities has been shown to
predict more adaptive psychological and physiological
functioning,39 which is associated with higher quality of
www.jco.org
life.29 The patients in the intervention group used more of
the active-behavioral and active-cognitive coping methods
than controls; this result was also found by Fawzy et al.30
Improving the use of adaptive coping by providing infor-
mation and teaching problem solving and stress manage-
ment may be the pathway to the improved mood found in
this study, which is also supported by the positive correla-
tion between adaptive coping and decreased distress found
by Fawzy et al.30
The revision of the intervention used for the Danish
patients might be necessary to meet cultural differences
between the United States and Denmark. A Japanese study also
used a revised version of the intervention strategy by Fawzy et
al40 and found an effect on coping methods and psychological
distress.36 These results indicate that the psychoeducational
intervention developed by Fawzy et al12 can be applied with
relevant modifications to patients from a wide cultural range
with a beneficial effect on coping methods.
However, the average beneficial effects of the interven-
tion were modest. This might be due to the low baseline
TMD scores on the POMS scale for both treatment groups,
which indicate that most participants in this study had
accepted their diagnosis better than the patients in other
studies of melanoma patients,30,41,42 and much better than
other groups of cancer patients.7,8,43,44 This finding obvi-
ously calls into question the need for psychosocial support
at all, and the modest average effect of our study on psycho-
logical distress also calls into question the clinical relevance
of the results. Goodwin et al7 showed an effect of a psycho-
social intervention only for women who were initially more
distressed; our study also found a stronger effect among the
more distressed patients. The intervention should perhaps
be limited to these more distressed patients, given that they
seemed to benefit the most from the intervention; further-
more, previous studies have shown an effect on those who
on a screening test were suffering from psychological
distress.14,16,44-46
There are reasons to believe that the overall improve-
ment of the TMD score as well as the changes in the use of
behavioral and cognitive coping capacities reflect true pat-
terns because the results are in line with those of Fawzy et
al.30,37 With necessary modifications of the original inter-
vention model developed by Fawzy et al30 to meet cultural
differences between countries, it was possible to find bene-
ficial effect of psychoeducation for Danish patients with
malignant melanoma, especially among those who were
most distressed at baseline. However, the average effect was
modest and an evaluation of the clinical relevance of the
intervention awaits the future study of survival.
■ ■ ■
Acknowledgment
We thank the Plastic Surgery Departments of
Rigshospitalet, Herlev, and Roskilde Hospital for excellent
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 Boesen et al

cooperation; Nancy Fawzy, RN, DNSc, the John Wayne Cancer
Institute, for kindly letting the author (E.H.B.) watch a group
intervention; and all of the patients participating in the study.
Appendix
Revision of the Dealing With Illness Inventory (DWI-R)
The questionnaire was developed with AIDS in mind
(Namir et al31); several of the questions are inappropriate
for cancer and therefore have been dropped. Other items
were being interpreted in different ways by cancer patients
and have been reworded. The changes are outlined in the
following lists.
Items deleted from the questionnaire:
32. Got involved in political activities
33. Increased sex with others
44. Increased sex with self
Items reworded:
6. Accepted the reality of my diagnosis but not that I
had to automatically accept a poor prognosis
32. Accepted the situation and got on with doing what
needed to be done
33. Felt that it was my doctor’s responsibility to make
treatment decisions for me
36. I was assertive (with medical staff, family, friends)
about what I thought was best for me
38. Released my feelings somehow (eg, cried, yelled,
laughed) instead of holding them in
40. Believed that there was nothing I could do but wait
since only time would make a difference
44. Resigned myself to the situation since nothing
could be done
45. I have trust (respect, faith, belief) in my doctor’s
medical knowledge and technical skills
49. Tried to work together with my doctor to decide
what is best for me (ie, established a collaborative relation-
ship with my doctor)
50. Thought about how much better off I am than some
other people with my illness
Authors’ Disclosures of Potential
Conflicts of Interest
The authors indicated no potential conflicts of interest.

REFERENCES
1. Ross L, Boesen EH, Dalton SO, et al: Mind
and cancer: Does psychosocial intervention im-
prove survival and psychological well-being? Eur
J Cancer 38:1447-1457, 2002
2. Spiegel D, Bloom JR, Kraemer HC, et al:
Effect of psychosocial treatment on survival of
patients with metastatic breast cancer. Lancet
2:888-891, 1989
3. Fawzy FI, Fawzy NW, Hyun CS, et al:
Malignant melanoma: Effects of an early struc-
tured psychiatric intervention, coping, and affec-
tive state on recurrence and survival 6 years
later. Arch Gen Psychiatry 50:681-689, 1993
4. Kuchler T, Henne-Bruns D, Rappat S, et al:
Impact of psychotherapeutic support on gastro-
intestinal cancer patients undergoing surgery:
Survival results of a trial. Hepatogastroenterol-
ogy 46:322-335, 1999
5. McCorkle R, Strumpf NE, Nuamah IF, et
al: A specialized home care intervention im-
proves survival among older post-surgical cancer
patients. J Am Geriatr Soc 48:1707-1713, 2000
6. Fawzy FI, Canada AL, Fawzy NW: Malig-
nant melanoma: Effects of a brief, structured
psychiatric intervention on survival and recur-
rence at 10-year follow-up. Arch Gen Psychiatry
60:100-103, 2003
7. Goodwin PJ, Leszcz M, Ennis M, et al: The
effect of group psychosocial support on survival
in metastatic breast cancer. N Engl J Med 345:
1719-1726, 2001
8. Classen C, Butler LD, Koopman C, et al:
Supportive-expressive group therapy and dis-
tress in patients with metastatic breast cancer: A
randomized clinical intervention trial. Arch Gen
Psychiatry 58:494-501, 2001
9. Helgeson VS, Cohen S, Schulz R, et al:
Group support interventions for women with
breast cancer: Who benefits from what? Health
Psychol 19:107-114, 2000
10. Andersen BL: Psychological interventions
for cancer patients to enhance the quality of life.
J Consult Clin Psychol 60:552-568, 1992
11. Kissane DW, Bloch S, Smith GC, et al:
Cognitive-existential group psychotherapy for
women with primary breast cancer: A random-
ised controlled trial. Psychooncology 12:532-
546, 2003
12. Fawzy FI, Fawzy NW: A structured psy-
choeducational intervention for cancer patients.
Gen Hosp Psychiatry 16:149-192, 1994
13. Johnson J: The effects of a patient educa-
tion course on persons with a chronic illness.
Cancer Nurs 2:117-123, 1982
14. Greer S, Moorey S, Baruch JD, et al:
Adjuvant psychological therapy for patients with
cancer: A prospective randomised trial. BMJ
304:675-680, 1992
15. Cain EN, Kohorn EI, Quinlan DM, et al:
Psychosocial benefits of a cancer support group.
Cancer 57:183-189, 1986
16. Pruitt BT, Valigora-Serafin B, McMahon T,
et al: An educational intervention for newly-
diagnosed cancer patients undergoing radiother-
apy. Psychooncology 2:55-62, 1993
17. Marchioro G, Azzarello G, Checchin F, et
al: The impact of a psychological intervention on
quality of life in non-metastatic breast cancer.
Eur J Cancer 32A:1612-1615, 1996
18. Edelman S, Bell DR, Kidman AD: A group
cognitive behaviour therapy programme with
metastatic breast cancer patients. Psychooncol-
ogy 8:295-305, 1999
19. Burish TG, Snyder SL, Jenkins RA: Prepar-
ing patients for cancer chemotherapy: Effect of
coping preparation and relaxation interventions.
J Consult Clin Psychol 59:518-525, 1991
20. McQuellon RP, Wells M, Hoffman S, et al:
Reducing distress in cancer patients with an
orientation program. Psychooncology 7:207-217,
1998
21. Ali NS, Khalil HZ: Effect of psychoeduca-
tional intervention on anxiety among Egyptian
bladder cancer patients. Cancer Nurs 12:236-
242, 1989
22. Davis H: Effects of biofeedback and cog-
nitive therapy on stress in patients with breast
cancer. Psychol Rep 59:967-974, 1986
23. Bindemann S, Soukop M, Kaye SB: Ran-
domised controlled study of relaxation training.
Eur J Cancer 27:170-174, 1991
24. Speca M, Carlson LE, Goodey E, et al: A
randomized, wait-list controlled clinical trial: The
effect of a mindfulness meditation-based stress
reduction program on mood and symptoms of
stress in cancer outpatients. Psychosom Med
62:613-622, 2000
25. Nezu AM, Nezu CM, Houtset al: Rele-
vance of problem-solving therapy to psychoso-
cial oncology. J Psychosoc Oncol 16:5-26, 1999
26. Brennan J: Adjustment to cancer-coping
or personal transition? Psychooncology 10:1-18,
2001
27. Taylor SE, Helgeson VS, Reed GM, et al:
Self-generated feelings of control and adjust-
ment to physical illness. J Soc Issues 47:91-109,
1991
28. Lev EL: Bandura’s theory of self-efficacy:
Applications to oncology. Sch Inq Nurs Pract
11:21-37, 1997
29. Graves KD: Social cognitive theory and
cancer patients’ quality of life: A meta-analysis of
psychosocial intervention components. Health
Psychol 22:210-219, 2003
30. Fawzy FI, Cousins N, Fawzy NW, et al: A
structured psychiatric intervention for cancer pa-
tients. I: Changes over time in methods of cop-
ing and affective disturbance Arch Gen
Psychiatry 47:720-725, 1990
31. Namir S, Wolcott D, Fawzy FI, et al: Cop-
ing with AIDS: Psychological and health implica-
tions. J Appl Soc Psychol 17:309-328, 1987
32. Balch CM, Buzaid AC, Soong SJ, et al:
Final version of the American Joint Committee
on Cancer staging system for cutaneous mela-
noma. J Clin Oncol 19:3635-3648, 2001

1276 JOURNAL OF CLINICAL ONCOLOGY


33. McNair DM, Lorr M, Droppleman LF:
EdiTS manual for the Profile of Mood States.
Manual for the Profile of Mood States, 3-29. San
Diego, CA, Educational and Industrial Testing
Service, 1992
34. Cunningham AJ, Edmonds CV, Jenkins
GP, et al: A randomized controlled trial of the
effects of group psychological therapy on sur-
vival in women with metastatic breast cancer.
Psychooncology 7:508-517, 1998
35. Edelman S, Lemon J, Bell DR, et al: Ef-
fects of group CBT on the survival time of
patients with metastatic breast cancer. Psy-
chooncology 8:474-481, 1999
36. Fukui S, Kugaya A, Okamura H, et al: A
psychosocial group intervention for Japanese
women with primary breast carcinoma. Cancer
89:1026-1036, 2000
37. Fawzy NW: A psychoeducational nursing
intervention to enhance coping and affective
www.jco.org
Psychoeducational Intervention for Melanoma
state in newly diagnosed malignant melanoma
patients. Cancer Nurs 18:427-438, 1995
38. Kjoeller M, Rasmussen NK, Keiding L, et
al: Health and Morbidity in Denmark 1994.
Copenhagen, Denmark, Danish Institute for Clin-
ical Epidemiologi, 1995, pp 9-335
39. Bandura A: Self-Efficacy: The Exercise of
Control. New York, NY, W.H. Freeman, 1997
40. Fukui S, Kamiya M, Koike M, et al: Appli-
cability of a Western-developed psychosocial
group intervention for Japanese patients with
primary breast cancer. Psychooncology 9:169-
177, 2000
41. Baider L, Perry S, Sison A, et al: The role of
psychological variables in a group of melanoma
patients: An Israeli sample. Psychosomatics 38:
45-53, 1997
42. Fawzy FI, Fawzy NW, Arndt LA, et al:
Critical review of psychosocial interventions in
cancer care. Arch Gen Psychiatry 52:100-113,
1995
43. Cassileth BR, Lusk EJ, Brown L, et al:
Psychosocial status of cancer patients and
next of kin: Normative data from the Profile of
Mood States. J Psychosoc Oncol 3:99-105,
1985
44. Telch CF, Telch MJ: Group coping skills
instruction and supportive group therapy for can-
cer patients: A comparison of strategies. J Con-
sult Clin Psychol 54:802-808, 1986
45. Evans RL, Connis RT: Comparison of brief
group therapies for depressed cancer patients
receiving radiation treatment. Public Health Rep
110:306-311, 1995
46. Mantovani G, Astara G, Lampis N, et al:
Impact of psychosocial intervention on the qual-
ity of life of elderly cancer patients. Psychooncol-
ogy 5:127-135, 1996
1277