Psychooncology

Psycho-oncology
Abstract
Oncologic disease is now more prevalent overall thanks to advancements in medicine, better
living circumstances overall, and longer life expectancies. More importantly, a growing
number of patients are surviving cancer or dealing with it for an extended length of time.
While the fight for survival is ongoing, enhancing the quality of life for patients has taken
centre stage. While psychosocial factors may alter the course of the illness, they primarily
have a significant effect on patients' physical and mental health. A relatively new
interdisciplinary discipline called psycho-oncology has emerged with the goal of addressing
these problems and offering assistance to patients who are dealing with a variety of
difficulties throughout the various stages of their illness.
Rationale and Objectives
In this article, we provide an overview of the current knowledge of body-mind interactions in

cancer and an outline of the broad spectrum of psycho-oncologic care, with a special focus on
the treatment of pain, fatigue, sexual issues, and fear of progression.
The objectives of psycho-oncology, identified by individuals from the major oncologic

specialties and disciplines, are listed below: to foster the education and training of a group of
clinicians and investigators whose special expertise is identified as psychooncology, and
whose special training identifies them as psycho-oncologists; to foster concern for integration
of psychological care into the total care of all patients with cancer, at all levels of illness, and
of their families, by all health professionals in oncology; to develop training curricula in
psychooncology which contain a common core of information relevant to all professionals,
and specific components to address the particular educational needs of specific oncologic
disciplines (oncologist, nurse, social worker) to assure psychological principles of good care
are incorporated into total care;
Method
A systematic review of psycho-oncological literature and a meta-analysis of the predominant

finding in the field.
Study identification
Studies included in the larger review (Moyer et al., in press) examined psychosocial
interventions for adult cancer patients that (1) reported outcomes on psychological,
emotional, behavioral, physiological, functional, or medical status; (2) were first reported as a
published article or dissertation between January 1980 and December 2005; and (3) included
10 or more individuals per group. Electronic databases (PsycINFO, which indexes
dissertations; PubMed; and Dissertation Abstracts Online, which indexes doctoral theses
from 1861 to the present from US, Canadian, British, and European universities [10] were
searched using key terms (e.g. cancer, neoplasms, tumor, and psychosocial intervention,
psychotherapy, psychological treatment, education, cognitive behavioral, relaxation, stress
management, support group, selfhelp group, nursing intervention, biofeedback). The
reference lists of included reports and of 94 prior reviews and meta-analyses were also
examined. Searches for articles citing prior reviews and the tables of contents of several
journals (PsychoOncology, Journal of Clinical Oncology, Cancer, Journal of Psychosocial
Oncology, European Journal of Cancer, and Cancer Nursing) were conducted. Separate
reports based on the same sample (e.g. separate articles reporting outcomes at 3-month and
12-month follow-ups) were consolidated as being from the same project. The larger sample
included 673 reports comprising 488 projects, 107 of which included dissertations. As some
projects yielded multiple dissertations tions reported on more than one project), there were
112 dissertations conducted across the 107 projects. However, our analyses were at the
project level. A follow-up search of the PubMed and PsycINFO bibliographic databases
determined if unpublished dissertations had been published by November 2008. For projects
that yielded more than one dissertation, if at least one was published, we coded the project as
published. In all, 42 projects comprised (at least one) dissertation that had been published and
65 projects comprised (at least one) dissertation that had not been published; for simplicity,
we refer to these as published dissertations and unpublished dissertations, respectively.
Study coding
Coding of descriptive project characteristics involved the types of interventions that had been
investigated and whether the project had received research funding. Because some authors
have noted difficulties in tracking dissertations when female investigators have married and
changed their names [6], we also examined whether our coding of publication status was
linked to the gender of the principal investigator. Coding items assessing the quality of study
methodology and reporting were adapted from prior work [11]. Although consensus on
essential areas of methodological quality has yet to be reached, and no one scale is considered
appropriate for all research topic areas [12] we included aspects of quality conventionally
considered important. These involved aspects of the sample description; the research design,
including the quality of randomization, where applicable; intervention specification and
provision; and data analyses, such as whether intent-to-treat analyses were conducted. Owing
to the low feasibility of keeping participants and interventionists blind to treatment groups for
psychosocial interventions, items assessing this were not included. Similarly, because
outcomes in this area are predominantly based on self-report, assessments of blinding of
outcome assessors were also not included. Aspects of reporting from the CONSORT [13],
such as noting the number dropping out of treatment, were also evaluated. Combining
elements related to different dimensions of methodological quality is not advised because
they are theoretically independent and may be negatively related [2]. Therefore, we report
these elements of methodological quality separately. Because prior research has shown that
studies in the published literature have more participants than studies in the gray literature
[5], we also examined sample size. Finally, to address the question of publication bias, we
coded whether or not a project reported at least one significant intervention effect.
Results
Statistical analyses
For continuous outcome variables, we used t-tests to compare published and unpublished
dissertations. For categorical outcome variables, we used w2 tests and Fisher’s exact test
when cells had an expected count of less than 5. A Bonferronicorrected a level of 0.002
(0.05/26) was adopted to account for the multiple tests of significance conducted. Results
Investigator, report, and intervention characteristics Published dissertations were significantly
more likely to have had some form of research funding (73.7%) than unpublished
dissertations (26.3%, w2 [1, N 5 107] 5 29.30, p 5 0.000). The proportion of female principal
investigators was somewhat greater (85.7%) for published dissertations than for unpublished
dissertations (67.2%, w2 [1, N 5 106] 5 4.59, p 5 0.032), but this difference was not
significant at the corrected a level. There were no significant differences in the likelihood of
published versus unpublished dissertations’ examining cognitive, behavioral, or cognitive–
behavioral.
Quality of study methodology and reporting
Comparison of the methodological and reporting quality of published versus unpublished

dissertations. Of 16 statistical comparisons, there were no significant differences between
published and unpublished dissertations. Although published dissertations were somewhat
more likely to use randomized as opposed to other types of designs (83.3 versus 61.5%, w2
[1, N 5 107] 5 5.78, p 5 0.016), this trend was not significant. In addition, published
dissertations did not have significantly larger numbers of initial participants per group (M 5
37.70, SD 5 42.46) than unpublished dissertations (M 5 29.39, SD 5 23.94, t[105] 5 1.29, p 5
0.199). Finally, there was a trend for a larger proportion of published dissertations to report
significant findings than unpublished dissertations, (100.0 versus 84.6%, Fisher’s Exact [N 5
107] 5 0.006), although it did not reach significance at the corrected a level.
Discussion
We examined 107 projects comprising 42 published and 65 unpublished dissertations

examining psychosocial interventions for cancer patients, comparing their characteristics and
methodological quality. Published versus unpublished dissertations were not more likely to
examine different types of interventions, but were more likely to be supported by research
funding. On several indices of methodological quality, differences were minimal. However,
there was a trend for dissertations in this area to exhibit publication bias, whereas every
published dissertation reported a significant finding, only a proportion of unpublished
dissertations reported one. Thus, excluding unpublished dissertations from systematic
reviews may ignore null results from methodologically sound research. It was not clear
whether having research support for the study was linked to the likelihood of using a rigorous
randomized design, which may lead to a more publishable study, or if having funding is
linked to publication status independently, perhaps by producing an imperative to persevere
in publishing a study. We found no association between having funding and using
randomized designs (w2 [1, N 5 107] 5 0.36, p 5 0.55), suggesting that being awarded
funding may encourage authors to pursue publication, perhaps through pressure from funding
agencies that expect timely publication of projects and use this in decisions for future
funding. Limitations of this analysis include the fact that our search strategy involved only
three bibliographic databases, although additional channels of study identification were
pursued. Although Dissertation Abstract Online indexes dissertations conducted at most
North American, UK, and many European universities, coverage of other countries is limited.
Consequently, some existing dissertations likely remained unidentified. Findings support the
notion that unpublished doctoral dissertations, at least in this area of research, are not
necessarily of vastly inferior quality. Because doctoral dissertations are easy to identify in
bibliographic databases, are not subject to publication-review bias and the file-drawer effect
due to automatic entry into the Dissertation Abstracts International database, can often be
obtained via institutions’ interlibrary loan services (or purchased commercially), and have
thorough reporting, we concur with other authors [4,6] that they merit inclusion in
comprehensive literature reviews.
References
1. McAuley L, Pham B, Tugwell P, Moher D. Does the inclusion of grey literature influence
estimates of intervention effectiveness reported in meta-analyses? Lancet 2000;356:1228–
1231.
2. Conn VS, Valentine JC, Cooper HM, Rantz MJ. Grey literature in meta-analyses. NursRes
2003;52:256–261.
3. Conn VS. The light under the bushel basket: unpublished dissertations. West J Nurs Res
2008;30:537–538.
4. McLeod BD, Weisz JR. Using dissertations to examine potential bias in child and
adolescent clinical trials. J Consult Clin Psychol 2004;72:235–251.
5. Hopewell S, McDonald S, Clarke M, Egger M. Grey literature in meta-analyses of

randomized trials of health care interventions. Cochrane Database Syst Rev 2007;MR000010.
6. Vickers AJ, Smith C. Incorporating data from dissertations in systematic reviews. Int J
Technol Assess Health Care 2000;16:711–713.
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Psycho-oncology

Rationale and Objectives

In this article, we provide an overview of the current knowledge of body-mind interactions in

The objectives of psycho-oncology, identified by individuals from the major oncologic

A systematic review of psycho-oncological literature and a meta-analysis of the predominant

Quality of study methodology and reporting

Comparison of the methodological and reporting quality of published versus unpublished

We examined 107 projects comprising 42 published and 65 unpublished dissertations

5. Hopewell S, McDonald S, Clarke M, Egger M. Grey literature in meta-analyses of

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