Yonago Acta medica 2011;54:65–74

Psychological Factors and Characteristics of Recurrent
Breast Cancer Patients with or without Psychosocial
Group Therapy Intervention
Masami Chujo, Junzo Kigawa and Hitoshi Okamura*
Tottori University Hospital Cancer Center, Yonago 683-8504 and *Hiroshima University Graduate
School of Medicine, Department of Public Health, Hiroshima 834-8551, JapanTo clarify psychological factors of patients with recurrent breast cancer, we examined
their interest in group intervention and studied the characteristics of participants andnon-participants in an intervention program. Using several self-administered assessment
scales to evaluate the quality of life (QOL) of cancer patients and the symptoms specific tobreast cancer patients, we compared sociomedical variables and QOL scores between participants and non-participants. Inter-group differences were significant in the scores forconstipation, body image and future perspectives, suggesting the QOL to be higher among
participants than non-participants. Interest in group intervention was identified as a major
reason for participation in this type of program. Not only physical but also psychologicalfactors were shown to be the reasons for deciding not to participate in group intervention.
It is now desirable that efforts be made to stimulate greater understanding of group intervention as a means of psychosocial support for patients with recurrent breast cancer andthat social environments be arranged so that these patients are supported by an approach
tailored to individual cases, involving both group and individual intervention.
Key words: participant and non-participant; psychological factor; psychosocial group intervention;
recurrent breast cancer patient

It is essential to nurse individual cancer patients interms of not only their physical problems but also
in terms of psychological factors. For patients withcancer, we have aimed at psychosocial intervention
for reducing psychological stress and raising the
Quality of Life (QOL), and performed studies totest the effectiveness of psychosocial group intervention (Goodwin et al., 2001; Fukui et al., 2001).
In studies on breast cancer patients, 40% to 80% of
eligible patients were enrolled (Spiegel et al., 1981;
Edmonds et al., 1999; Goodwin et al., 2001). Several previous studies compared the characteristics
of patients participating in the studies to those notparticipating in an attempt to examine the clinicalapplicability of psychosocial group intervention.
In Western countries, cancer patients who
gave consent to group intervention were sufferingfrom some psychosocial problems other than depression (Taylor et al., 1986; Berglund et al., 1997),
desired to explore or experience support services(Taylor et al., 1986; Bauman et al., 1992), wereencouraged by medical staff (Taylor et al., 1986),
expected mutual support (Thiel de Bocanegra,1992), and had the following characteristics: below
the age of 50, unmarried (Bauman et al., 1992),
middle class, predominantly female (Taylor et al.,1986) and recently diagnosed with cancer (Thiel de
Bocanegra, 1992).

Abbreviations: EORTC, European Organization for Research and Treatment of Cancer; QLQ-Br23, QOL questionnairebreast cancer module 23; QLQ-C30, QOL questionnaire-cancer 30; QOL, quality of life65

M. Chujo et al.

As to the characteristics of Japanese patientswith breast cancer who participated in group intervention, some investigators reported that many had
surgery within the previous 12 months, had strong
anxiety and were between 50 and 65 years of age(Fukui et al., 2000). However, no such survey has
been conducted on patients with recurrent or metastatic cancer, which has a particularly strong impact and causes patients considerable psychologicalstress (Okamura et al., 2000).
The present study was undertaken to analyze
the interest of patients with recurrent breast cancerin psychosocial group intervention and to analyze
the characteristics of these patients. They weredivided into 2 groups, intervention participant andnon-participant. We anticipate that the results ofthis study will contribute to raising the QOL ofpatients with recurrent breast cancer and promoting group intervention for patients with this type ofcancer.

of individual privacy, each patient was asked in theabsence of other patients to participate in the study
after having been informed of the design of thestudy.
After access to the medical records of patientswas approved by the National Hospital Organization Shikoku Cancer Center, we selected patientssatisfying the inclusion criteria. Of the patients
rated as eligible to participate in the study, those
who were interested in group intervention and gave
written consent to participate in all 6 sessions ofintervention (once a week for 6 weeks) were assigned to the intervention group. Of the patients
who decided not to participate in group intervention, those who had an interest in intervention andgave consent to answering the questionnaire wereassigned to the non-intervention group, and those
who agreed to an interview but did not consent toanswering the questionnaire survey were assigned
to the refusal group.
In the present study, group intervention was
carried out by 2 group leaders (a nurse and a psychiatrist both experienced in group therapy). One
group was composed of 4 to 8 patients. Six groupintervention sessions, each lasting 90 min, were
held (1 session/week). Each session included 20
min of teaching about how to cope with stressrelated to psychosocial problems of individual
patients with recurrent breast cancer and how toresolve these problems, 50 min of discussion about
coping and 20 min of learning about progressive
muscle relaxation.

Subjects and Methods
Of the patients with recurrent breast cancer followed-up at the Department of Surgery of the National Hospital Organization Shikoku Cancer Center who were diagnosed 3 to 12 months previously,
those who satisfied the following requirements
were rated as eligible for this study: i) adult womenover 20 years of age, ii) patients with histologicallyestablished breast cancer which showed histological and/or clinical recurrence, iii) women who had
not developed recurrence before, iv) women forwhom information on recurrence had been disclosed, v) patients whose general condition was notsevere, vi) patients without active double cancer,vii) patients not requiring psychiatric treatment ofdepression, adjustment disorder, etc. and viii) patients able to understand the purpose of the study
without difficulty.
A request to participate in the study was
made to each candidate between 2002 and 2003
at the National Hospital Organization Shikoku
Cancer Center. In a room that allowed protection

Variables evaluatedSociomedical variables
Information about age, performance states(criteria determined by the Eastern Cooperative
Oncology Group), date of diagnosis of recurrence,disease-free period and history of cancer treatment
was collected from medical records combined withthe responses to the questionnaire. The following
information was entered by each patient into theself-administered questionnaire: educational history, disease history, occupation, marital status,
66

Characteristics about group participants

psychological status, occupational status and thedate they went to the hospital.

logical and social QOL of patients with breast cancer, composed of a combination of EORTC QLQC30 (a 30-item scale for evaluation of the QOL ofcancer patients) and EORTC QLQ-Br23 (a 23-item
scale for evaluation of symptoms specific to breast
cancer patients).
EORTC QLQ-C30 (Aaronson et al., 1993) is aself-administered assessment scale. It is composedof 30 items, i.e., subscales of function of cancer
patients (physical function, role-playing function,
emotional function, social function and cognitive
function), symptom scales, comprehensive health/
QOL, economic impulses and symptoms (difficulty breathing, sleep disorder, appetite, diarrhea
and constipation). The reliability and validity of its
Japanese version have been analyzed (Kobayashi
et al., 1998), and the reliability and validity of the
English version in patients with metastatic breast
cancer have been tested (Kobayashi et al., 1998).
EORTC QLQ-Br23 (Sprangers et al., 1996)
is a 23-item self-administered scale for assessmentof patients with breast cancer. The EORTC has authorized the use of its Japanese version (EORTIC
Group for research into Quality of Life, http://groups.
eortc.be/qol/questionnaires_downloads.htm).

QOL
Profile of mood states: The profile of moodstates is a self-administered assessment scale fortemporary emotional states composed of 65 items(McNair, 1971). It allows evaluation of 6 emotional
states (tension-anxiety, depression-dejection, angerhostility, vitality, exhaustion and confusion) and thetotal mood disturbance. The reliability and validityof its Japanese version have also been verified (Yokoyama et al., 1990).
Impact of event scale-revised: Impact of
event scale-revised (Weiss and Marmer, 1997) is aself- administered scale for assessment of the influence of mental trauma. It is composed of 22 items.
This scale was a modification of the impact of event
scale (Horowitz, 1979). It allows evaluation of thesubscales of the 2 conventional categories (symptoms
of intrusion and avoidance) plus a new category(over-arousal), and the reliability and validity of its
Japanese version have been verified (Asukai et al.,2002).
Mental adjustment to cancer scale: The
mental adjustment to cancer scale (Watson et al.,1988) is a self-administered scale for assessment of
the psychological attitudes of individuals to cancer,
composed of 40 items. It is composed of 5 items(fighting spirit, hopelessness, anxious preoccupation, fatalism and avoidance). It evaluates individual
patients from 2 aspects: i) evaluation of psychological responses to the diagnosis of recurrent cancer,
and ii) patient’s recognition of the cancer and actions she took to alleviate the threat. The reliability
and validity of its Japanese versions have been verified (Akechi et al., 2000).

Rosenberg self-esteem scale: This is a 10item self-administered scale for assessment ofself-esteem (Rosenberg, 1965) designed to allow
subjects to evaluate their own degree of self-esteem
and self-value. Differences in scores are considered
to reflect differences in cognition and behaviors.
The reliability and validity of its Japanese version
have been verified (Suga, 1984).
General self-efficacy scale: This is a 16-item
self-administered scale for assessment of generalself-efficacy during one’s daily life (Sakano andTojo, 1986). They subsequently tested its reliability
and validity. This scale is designed to evaluate theconfidence of individuals in the extent to which
they can appropriately take an action needed toachieve a given goal.

EORTC QLQ-C30/Br23: European Organization for Research and Treatment of Cancer QOL
Questionnaire-Cancer 30/Breast cancer module 23(EORTC QLQ-C30/Br23) is a 53-item self-administered scale for evaluation of the physical, psycho67

M. Chujo et al.

Degree of satisfaction with social support anddegree of information provided: The degree of satisfaction with social support and the degree of information provided were measured by the Likert scalefrom 1 to 4.

Ethical considerations
This study was performed in accordance with its
protocol after approval was obtained from the Ethics Committee of the National Hospital Organization Shikoku Cancer Center, enrolling only thosepatients who gave informed consent in writing.
Each candidate was well informed as to the study
design and purpose through a pamphlet containing the following information: i) the patient canconsent or refuse participation in the study at her
own discretion; ii) the patient will suffer no disadvantage related to her care even if she does not participate in the study; iii) the personal informationof the patient will not be disclosed when the resultsof the study are published; iv) the patient’s visits tothe clinic for the purpose of this study may place
physical stress on the patient and v) discussions
during group intervention or surveys using scales
for psychological aspects may cause discomfort orstress to the patient. Efforts were thus made to obtain consent from patients after providing adequate
explanatory information.

Interest and reasons for participation/non-participation in group intervention
When being asked to participate in this study,
patients were interviewed on why they wanted toparticipate or not participate, what knowledge they
had about group intervention and their awarenessof their stress level at that time, and what their interest and reasons were for their participating or
not participating in group intervention.
AnalysesComparison of baseline data among the intervention, non-intervention and refusal groups
For sociomedical variables that allowed comparison among the 3 groups, one-way analysis ofvariance was conducted after confirming data distribution. In comparison of sociomedical variables
and scores on each scale between the intervention
and the non-intervention groups, we used either thechi-square test or the t-test (after checking for regularity of data).
In all tests, P < 0.05 (both sides) was regarded
as statistically significant. The Statistical Package
for the Social Sciences, version 11.5J (SPSS Japan,
Tokyo, Japan) was used for all statistical analyses.

Results
Participation in the study
During the enrollment period, there were 80 patients who had developed recurrence of breast cancer for the first time 3 to 12 months previously. Of
these patients, 58 eligible subjects referred by theirattending physicians were well informed about
the study. Twenty-eight patients (48%) gave written consent to participate in group intervention. Of
the 30 patients (52%) who refused to participate
in group intervention, 11 had an interest in groupintervention and gave written consent to cooperatewith the self-administered questionnaire survey to
be conducted at 3 time points.

Analysis of interest in the intervention and psychological factors in determining the intervention
In the interviews with patients, they variously
expressed their motives for intervention. First, wearranged their self-expressions into several groups
by similarity. Next, we analyzed the self-expressions by groups to designate categories with more
popular sounding names. Whole responses wereclassified into several categories. Then, the percentage of a category was calculated by dividing thenumber of entry subjects allocated to the given category by the whole number of subjects.

Comparison of characteristics between participants and non-participants
Among the intervention, non-intervention andrefusal groups, we compared sociomedical vari68

Characteristics about group participants
Table 1. Characteristics of group participants and non-participants				Intervention
group [n = 28]

Non-intervention
group [n = 11]

Refusalgroup [n = 19]

Age (yr)		
Post-recurrence period (mo)		
Disease-free period≤ 24 mo> 24 mo
Chemotherapy ongoing treatment Present
AbsentPerformance status†
0≥1
Marital status
MarriedSingle/divorced/widowed
Educational history≤ 12 yr> 12 yr
History of psychiatric treatment
Present
AbsentTime needed to get to hospital≤ 30 min> 30 minOccupation status
Present
AbsentProfile of mood states
Tension-anxiety
Depression-dejection
Anger-hostility
Vitality
Exhaustion
Confusion
Total mood disturbance
Impact of event scale-revised		
Mental adjustment to cancer
Fighting spirit
Hopelessness
Anxious preoccupation
Fatalism
Avoidance
QLQ-C30/Br23‡
Comprehensive health/QOL
Physical function
Role-playing function
Emotional function
Cognitive function
Social function
Fatigue
Vomiting
Pain
Difficulty breathing
Sleep disorder
Appetite
Diarrhea
Constipation
Economic impulses
QLQ-C30/Br23‡
Body images
Sexual function
Sexual pleasure
Future perspectives
Reactions to treatment
Breast symptom
Arm symptom
Confusion of hair loss
Rosenberg self-esteem scale		
General self-efficacy scale		
Satisfaction with social support		
Degree of information provided		

53.57 ± 12.91		 57.18 ± 10.20
55.58 ± 10.00 0.65
7.14 ± 3.30		 6.09 ± 3.30
7.84 ± 3.39 0.38
12 			
4 			
4
16 			
7 			15				
0.30
16 			
6 			912 			
5 			10				
0.80
19 			
8 			
11
9 			
3 			
8				
0.66
18 			
98 			2 							0.6816 			
410 			
7 							
0.27
3 			
0
23 			
11 							
0.5413 			
213 			
9 							
0.14
8 			
4
18 			
7 							1.0010.85 ± 5.84		 13.91 ± 8.35					
0.2013.73 ± 9.89		 17.73 ± 16.64					
0.479.08 ± 7.28		 10.91 ± 13.51					
0.6711.58 ± 5.58		 11.00 ± 7.84					
0.809.00 ± 6.59		 10.82 ± 8.68					
0.499.24 ± 5.41		11.82 ± 6.97					 0.31
40.73 ± 34.77		 54.18 ± 57.89					
0.4818.65 ± 13.76		 25.91 ± 12.81					
0.1446.50 ± 6.91		 48.09 ± 6.66					
0.5210.08 ± 3.59		 12.45 ± 5.43					
0.2023.12 ± 4.62		 25.36 ± 2.87					
0.1419.96 ± 4.94		23.00 ± 4.12					
0.081.77 ± 0.77		 1.82 ± 1.40					
0.9165.69 ± 21.43		 60.09 ± 17.87					
0.4577.96 ± 14.92		 69.64 ± 22.61					
0.0976.35 ± 23.59		 78.73 ± 22.49					
0.9078.27 ± 18.31		 75.09 ± 20.06					
0.5670.5 ± 25.07		 65.27 ± 18.73					
0.0777.62 ± 16.19		 69.73 ± 29.60					
0.8838.73 ± 25.08		 49.45 ± 21.54					
0.863.38 ± 11.82		 6.00 ± 13.35					
0.3723.08 ± 22.59		 22.73 ± 25.05					
0.9624.27 ± 27.60		 21.27 ± 30.95					
0.3816.54 ± 19.35		 12.09 ± 22.49					
0.9424.23 ± 25.91		 27.18 ± 32.74					
0.4917.85 ± 25.31		 15.00 ± 17.23					
0.333.85 ± 14.41		 15.09 ± 22.92					 < 0.01**
30.73 ± 29.79		 30.27 ± 40.73					
0.1736.54 ± 23.36		 62.82 ± 28.90					 < 0.01**
9.62 ± 17.10		 6.09 ± 11.22					
0.5333.14 ± 19.34		 33.00 ± 0.00 						–51.31 ± 21.81		 72.73 ± 29.24					0.01*21.08 ± 17.53		 28.45 ± 16.81					
0.2416.65 ± 16.21		 21.91 ± 23.77					
0.4422.12 ± 24.16		 22.09 ± 19.85					
0.9951.78 ± 33.92 		 73.20 ± 36.70						–27.96 ± 4.36		 29.27 ± 6.99					
0.579.23 ± 2.58		 8.45 ± 3.64					
0.464.77 ± 0.43		 4.82 ± 0.41					
0.742.69 ± 0.61		 2.64 ± 0.67					0.80Shown are mean ± SD.
QOL, quality of life.
Statistical significance was examined with one-way analysis of variance, t-test or chi-square test. *P < 0.05; **P < 0.01.
† Performance status by the Eastern Cooperative Oncology Group.
‡ European Organization for Research and Treatment of Cancer QOL questionnaire-cancer 30/breast cancer module 23.

69

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M. Chujo et al.

Table 2. Psychological factors of group participants and non-participants
Intervention
group[n = 28]
Reasons for participation
Group intervention is attractive
11 (39.3)
Want to try relaxation
5 (17.9)
Want to talk with someone who has the same disease
17 (60.7)
Need information
7 (25.0)
Wish to cooperate with the survey
6 (21.4)
Need mental support
8 (28.6)
Recommendation by other participants
1 ( 3.6)
Recommendation by her family members
1 ( 3.6)
Reasons for non-participation
The hospital is too far away
1 ( 3.6)
Work			Caring for children			
Caring for family members			
No interest in group therapy 			No need for mental support			Poor physical condition			Don’t like to talk with other patients suffering from the same disease			
OthersHave knowledge of group therapy
6 (21.4)
Feel stress at present
9 (32.1)

Non-intervention
group[n = 11]

Refusalgroup[n = 19]

5 (45.5)
2 (18.2)
3 (27.3)0 ( 0.0)
8 (72.7)
1 ( 9.1)0 ( 0.0)0 ( 0.0)

1 ( 5.3)
4 (21.1)
1 ( 5.3)

6 (54.5)
2 (18.2)
1 ( 9.1)0 ( 0.0)0 ( 0.0)0 ( 0.0)
4 (36.4)
3 (27.3)

9 (47.4)
4 (21.1)
1 ( 5.3)
1 ( 5.3)
1 ( 5.3)
9 (47.4)
3 (15.8)
1 ( 5.3)

2 (18.2)
4 (33.3)

1 ( 5.3)
7 (38.9)

1 ( 5.3)( ), percentage.

ables, scores of profile of mood states, impact of
event scale-revised, mental adjustment to cancer,
QLQ-C30/Br23, Rosenberg self-esteem scale andgeneral self-efficacy scale, degree of satisfaction
with social support and degree of satisfaction withinformation provided at the baseline. This analysis
revealed significant inter-group differences in the
QLQ-C30/Br23 scores for constipation (P < 0.01),
body image (P < 0.01) and future perspectives (P =0.01), as shown in Table 1.

group, 2 patients (18.2%) from the non-intervention
group and 1 patient (5.3%) from the refusal group.
Among all patients, 20 patients (34.4%) were awareof some stress, including 9 patients (32.1%) fromthe intervention group, 4 patients (33.3%) from thenon-intervention group and 7 patients (38.9%) fromthe refusal group.
Major reasons for participation in group intervention were “I want to talk with someone who has
the same disease” in 17 patients (60.7%), “Group
intervention is attractive” in 11 patients (39.3%) and“Need mental support” in 8 patients (28.6%) (Table2). In the non-intervention group, major reasonsfor non-participation were “The hospital is too far
away” in 6 patients (54.5%) and “Don’t like talking
with anyone suffering from the same disease” in 3
patients (27.3%). In the refusal group, major reasonsfor non-participation were “No need for mental
support” in 9 patients (47.4%) and “The hospital is
too far away” in 9 patients (47.4%). Among the patients who did not participate in group intervention,

Analysis of interest and reasons for participation/non-participation in group intervention
Table 2 shows the results of analyzing interest ingroup intervention and the reasons for participation/
non-participation in such intervention, conductedat the time of enrollment. Knowledge about groupintervention was self-reported by 9 patients (15.5%),
including 6 patients (21.4%) from the intervention
70

Characteristics about group participants

there were some who gave the following answers:“Group intervention appears to be attractive” in
5 patients (45.5%) of the non-intervention groupand 1 (5.6%) of the refusal group; “Want to talkwith someone with the same disease” in 3 patients(27.3%) of the non-intervention group and 1 (5.6%)of the refusal group; “Need mental supports” in 1
patient (9.1%) of the non-intervention group and 1
patient (5.6%) of the refusal group.
Of the patients who participated in group intervention, 7 patients (25.0%) answered that theyneeded information, while none of the non-participants gave such an answer.

of the group intervention participants in the present study wanted to have discussions with other
patients suffering from the same disease. This suggests that the Japanese also have a desire to shareexperiences with other patients suffering from thesame disease, as is the case with cancer patients in
Western countries (Cope, 1995).
The percentage of breast cancer patients who
participated in group intervention in the present
study was higher than the previously reported inJapan (35%) (Fukui et al., 2000). In considerationof the report that patients who wanted to participate in group intervention were often facing strong
mental stress (Thiel de Bocanegra, 1992), the highpercentage of the present participants indicated that
there were many patients who wanted psychosocial
intervention. In the literature, the psychologicalstress associated with recurrence of cancer was
higher than that associated with the initial cancer(Okamura et al., 2000).

Discussion
Interest in group intervention and percentagesof participants: When the subjects of this study
were assessed for knowledge of group intervention,
only 15% were found to have such knowledge. In
Western countries, studies on group intervention
have been conducted since 1970s, and knowledgeof this intervention has spread considerably among
the general public. In Japan, on the other hand, thetherapeutic efficacy of group intervention with cancer patients has begun to be evaluated just recently.
The low percentage of patients who had knowledgeof group intervention in the present study seems toreflect the current status in Japan, i.e., group intervention has not yet become widespread.
However, of all patients eligible to participate
in this study, 67% had an interest in group intervention and 48% actually participated in the intervention. Thus, a relatively high percentage of patients
had an interest and participated in group intervention. In Western countries, the percentage of patients with metastatic breast cancer who participate
in group intervention is reportedly 50% to 78%(Spiegel et al., 1981; Fukui et al., 2001; Goodwin
et al., 2001). The percentage in the present study
was close to that in Western countries. Despite theprevious report that the Japanese tended to dislike
talking about personal matters in the presence ofother people (Spiegel and Classen, 2000), mostCharacteristics of participants in group intervention: In the analysis of QOL, significant intergroup differences were noted in the scores forconstipation, body image and future perspectives
rated according to the QLQ-C30/Br23, suggestingthat QOL was higher for participants than for nonparticipants. During group intervention, education on cancer and talks among participants werecarried out, requiring the participants to confront
certain aspects of their situation which they foundstressful. Breast cancer is a disease which causes
the patient to perceive changes in her body anddeterioration of femininity and physical function,and group intervention for patients with this disease often adopts body image as a topic (Classen
et al., 1993; Fawzy and Fawzy 1994). Therefore,
what is required for breast cancer patients in theparticipation seems that body image- and future
perspective-related QOL scores are not very low.
On the other hand, the score for psychologicalstress showed no significant inter-group differencein the present study, despite significant differences
reported between participants and non-participants(Berglund et al., 1997; Fukui, 2001). When asked
71

M. Chujo et al.

about the reasons for the participation, our patients
often gave reasons associated with the desire todeal with psychological stress, e.g., “I want to talkwith someone suffering from the same disease”, “I
need mental support”, and so on. It was written thatpatients often came to have an interest in group intervention while they were aware of or were exploring the usefulness of groups (Thiel de Bocanegra,1992). In view of these findings, in recurrent breast
cancer patients, the participation might be stimulated by their awareness of the necessity of copingwith psychological stress and of the usefulness ofgroup intervention. Such awareness was acquired
through their previous experience with coping withand overcoming the difficulties associated withcancer.
In the present study, the time needed for patients to attend the intervention meeting did notserve as an obstacle to the participation. The lackof influence of geographical distance in the participation is probably because many patients are skillfully utilizing potentially beneficial services (Bauman et al., 1992). Like their patients, our subjects
had received follow-ups at a cancer center, and it
is reasonable to assume that many of them more
willingly accepted services which they felt to bebeneficial than patients with other cancer did.

their psychological stress was high.
None of the present participants answered theneed of information about intervention, and someof them explained as the reason of avoidance ofparticipation that they disliked talking with other
patients suffering from the same disease. Patientssometimes do not want information because theyfear receiving bad news (Meissner, 1990). Japanesecancer patients are often reluctant to talk with otherparticipants during group intervention (Hosaka,
1996). It is therefore possible that even when patients have an interest in group intervention and are
exposed to psychological stress, they decide not toparticipate in group intervention or do not admit
their interest in this form of intervention. We cannot ignore that adverse influence may possibly be
produced by providing information to patients who
do not want to receive bad news regarding their illness (Asai, 1995). Stress may be increased if suchinformation is provided to such patients (Mills,
1979). Patients who do not want to participate ingroup intervention despite facing psychologicalstress should be managed in a way tailored to theirindividual needs. For initial breast cancer patients
who are not yet classified for group therapy, a system of nursing combined with follow-up service
should be devised.

Characteristics of non-participants: More thanhalf of the patients studied refused to participate
in group intervention, and their QOL was lower
than that in the participants. For non-participants
as well, some psychosocial intervention are required, because more than 30% of participants andnon-participants felt stress and because some nonparticipants had interest in group intervention andwanted psychosocial support. On the other hand,about half of the patients who refused to cooperate in the survey answered that they had no needfor psychosocial support. In view of the previous
report that psychological stress was particularly
strong in patients who had no interest in group intervention (Fukui et al., 2001), it seems likely thatthese patients were coping with their problems bymeans of avoidance of facing the issue and that

Design and duration of group intervention:
The main reasons for deciding to participate ingroup intervention were psychological factors, i.e.,need for relaxation, transmission of informationand talks with other patients suffering from thesame disease. In this respect, the group intervention program we designed, composed of education, discussion and progressive muscle relaxation,satisfies the expectations of participants. Because
the efficacy of intervention is closely related to its
duration, long-term intervention has been justified (Spiegel and Classen, 2000) and implemented(Goodwin et al., 2001) for metastatic breast cancer
patients predicted to suffer from psychologicalstress for a prolonged period. However, short-term
intervention was reported more effective because
the enthusiasm of participants tends to subside and72

Characteristics about group participantsbecause they may be adversely affected by facing
the death of some participants during prolonged
intervention (Edmonds et al., 1999). We found that,
not a few participants quit the intervention program
midway because of inability to make arrangements
for continued participation although the intervention. On the other hand, some patients continued toparticipate in the intervention despite having a job
or living far away from the meeting place. They
could have arranged their personal schedules to allow continued participation because the duration ofintervention was short. The continued participation
by recurrent breast cancer patients had probably
been stimulated by the design of the intervention
program (short-term, structured intervention), as
well.

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Promotion of group intervention: Group intervention allows QOL to be improved to a degreecomparable to the improvement achieved by individual intervention (Sheard and Maguire, 1999), is
cost-effective (Goodwin et al., 2001) and it can deal
with many patients at one time. The participantsin our intervention program had knowledge aboutgroup intervention in a higher percentage than the
non-participants. So, to promote and deepen theknowledge about the presence of group intervention as a means of psychosocial support and about
the details of such intervention, opportunities are to
be provided for patients.
Social environments shoul be arranged so thatrecurrent breast cancer patients are supported by anapproach tailored to the individual, involving bothgroup and individual interventions.

Acknowledgments: This study was partially supported
by a Grant-in-Aid for Scientific Research from the Ministry of Education, Culture, Sports, Science and Technology within the framework of Grant-in-Aid for Scientific
Research (category C) “Structuralization of Facilitator
Intervention in Psychosocial Group Therapy for Breast
Cancer” (headed by MC).
We thank all staff of the Department of Surgery of
the National Hospital Organization Shikoku Cancer Center for their kind supporting study.

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Received September 13, 2011; accepted September 27, 2011
Corresponding author: Masami Chujo, RN, PhD

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