Lost in translation: the need for clinically relevant research on psychological interventions for distress in cancer patients.

The two sides in the current debate have engaged in a spirited and illuminating discussion of the current status of research on psychological interventions for distress in cancer patients. As would be expected, each side makes compelling arguments in favor of its position and identifies key weaknesses in the other side’s position. More important, the audience benefits from the insightful comments about this field of research contained in the debaters’ remarks. I believe the success of this debate will best be measured in terms of its impact on the direction and conduct of future research on psychosocial interventions for distress in cancer patients. Accordingly, I view my contribution as discussant to be that of providing an initial perspective on the ways in which the issues raised should inform this line of research. The manner in which these articles are cited in future publications will be the ultimate indicator of how the issues raised in this debate influence the field. My perspective on these proceedings reflects my professional roles as both an investigator engaged in research on psychological interventions and a clinician and administrator charged with organizing the delivery of psychological services at a comprehensive cancer center. As a researcher, I find the debate underscores the importance of quality considerations in designing, reporting, and evaluating studies of psychological interventions with cancer patients. Although they disagree about many issues, both sides agree on several features that characterize the design of higher quality studies, such as the use of randomized clinical trial designs and the performance of intention-to-treat analyses (1,2). Both sides also emphasize quality considerations in the reporting of research (1,2), citing the Consolidated Standards of Reporting Trials (CONSORT) criteria (3) to illustrate how study methodology and results should be reported. In addition to facilitating the scientific community’s ability to judge the quality of the research performed, the widespread adoption of standardized reporting methods by leading journals should have a positive influence on the design and execution of future studies. Finally, both sides agree on the importance of taking quality into account in attempting to aggregate findings across studies (4,5). Systematic literature reviews that include a consideration of study quality are seen as providing the most credible and unbiased summaries of the available evidence. The various ways in which the debaters have emphasized quality are likely to accelerate trends already noted for the growing improvement in the quality of both individual studies (1) and reviews of the literature (2). These improvements should, in turn, provide more useful information with which to judge the efficacy of psychological interventions for distress in cancer patients. This issue is critical because the quality of much of the research conducted to date can be judged as suboptimal based on how the findings have been reported (6). From my perspective as a clinician and administrator, the debate highlights the need to improve the translation of research on this topic into clinical practice. The use of research to guide practice is at the core of evidence-based medicine, a movement that seeks to integrate individual clinical care with the best available evidence from systematic research (7). Unfortunately, many studies of psychological interventions for distress in cancer patients possess characteristics that limit their ability to inform patient care. For example, relatively few studies in the literature have restricted eligibility to patients experiencing heightened levels of distress (2). Consequently, the information obtained from these studies is relevant only to management of low to moderate levels of distress or the prevention of future distress in patients not currently distressed. This situation is problematic because much of the provision of clinical care to cancer patients is for heightened distress. A related concern is that many of the interventions evaluated require commitments of patient and professional time so considerable that they possess limited potential for dissemination even if found to be efficacious (2). Designing and evaluating interventions with regard to how well they can be disseminated is one means of improving the translation of research into practice, and one that is receiving increasing attention in behavioral medicine literature (8). The current debate is framed in terms of whether psychological interventions for distress in cancer patients are effective and acceptable. This yes/no dichotomy provides an effective and dramatic backdrop for the exchange of ideas but does not directly address the clinical imperative of identifying and implementing methods effective in relieving the distress that so many patients experience. Viewed from this clinical perspective, the goal is to evaluate whether the extant research is sufficient to develop evidence-based clinical practice guidelines for the management of distress in cancer patients. Such guidelines should be able to identify not only whether an intervention is efficacious but for what indications (mild, moderate, or severe distress), for what stage of disease (early or late), for when in the treatment process (during active treatment or beyond), and for what types of cancer. My own view is that a number of randomized clinical trials of varying quality have demonstrated the efficacy of psychological interventions for distress in cancer patients (9). However, the current body of evidence consists of too few replicated findings and too little information about when, for what, and for whom these interventions are beneficial to