Applying Cognitive Behavior Therapy to Patients with Lung Cancer

Xiao-Feng Su,Ji-Ming Han＊

1Medical College,Yan’an University,Yan’an,Shanxi,China.

Abstract

Keywords:Cognitive behavioral therapy,Cancer,Quality of life,Pain,Cancer-related fatigue,Fear of cancer recurrence,Anxiety,Depression,Psychosocial support,Psycho-oncology

Introduction

The American Cancer Society(ACS)[1]estimates approximately 1.9 million new cancer cases and 600,000 deaths in the United States by 2021.However,the global overall cancer mortality rate decreased by 31%[2].With the national tobacco prevention and control policies and substantial progress in diagnosis and treatment,the mortality rate for lung cancer has declined rapidly[1].However,the overall quality of life of survivors remains unoptimistic,which is closely linked to the disease,adverse physical symptoms associated with treatment,and negative emotions that influence mental health.Therefore,simple drug treatments cannot address the overall quality of life in patients with lung cancer.Cognitive behavior therapy(CBT)is one of the most evidence-based psychological intervention methods [3].Characterized by high feasibility and few side effects,CBT has been widely examined and used in the intervention treatments for many mental(i.e.,depression and anxiety)and non-mental(i.e.,irritable bowel syndrome,insomnia of chronic fatigue syndrome,and migraine)health issues.The paper presents a review of the intervention status of CBT in patients with lung cancer to lay the foundation for the promotion of CBT in the treatment of the physical and mental symptoms of patients with lung cancer in China.

Origin of cognitive behavior therapy

CBT refers to the integration of cognitive therapy(CT)into behavioral therapy(BT).The CT treatment posits that the cognitive process and its resulting misconceptions are the intermediary between behavior and emotion.Individuals can rectify misconceptions by modifying the cognitive process,thereby adjusting negative emotions and behaviors.The inspiration for BT stems from behaviorists,such as Watson and Skinner,who argued that the formation of individual behaviors occurs through learning while avoiding unobservable mental states[4].In practical work,however,medical staff with behavioral orientation will naturally find ways to deal with cognition and emotion.However,communicating with patients only through BT may be difficult and less effective.Thus far,the development process led to the generation of CBT.A feasible scheme for psychological intervention therapy,CBT is a convenient product formed by the combination of BT and CT to a certain extent under the influence of humanistic psychology and cognitive psychology in the field of psychological therapy.The psychological intervention method has undergone multiple stages of development since the initial formation of the feasible promotion of clinical practice[5-6].The CBT cooperative group of the Chinese Medical Association,CBT Committee of the Chinese Mental Health Association,CBT academic group of the Chinese Psychological Association,and CBT working group of the Chinese Physician Association have been established to form the“China CBT professional organization”to promote the application and development of CBT in clinical medical practice in China.

Connotation of cognitive behavior therapy

CBT pertains to a group of problem-oriented short-term psychotherapy methods that alleviate negative cognition by changing the thought processes,beliefs,or behaviors of individuals to eliminate unpleasant emotions and behaviors [7-8].It emphasizes attention to goals,the present,and things that affect life and pays less attention to motivation behind events and unconscious psychological conflicts[9].The study aims to utilize CBT by recording physiological responses to events and emotions to reduce negative emotions and behaviors.

Cognitive behavior therapy technology

CT frequently uses cognitive reconstruction,psychological coping,and problem-solving techniques during psychological counseling and treatment.Out of these methods,cognitive reconstruction is the most frequently employed[10].Conversely,BT mainly includes relaxation therapy,desensitization therapy,shock therapy,and aversion therapy,among others.CBT formed by the integration of CT and BT leads to a structured short-term psychotherapy method that aims to eliminate adverse emotions and behaviors by modifying the views and attitudes of clients about themselves,others,or events.CBT mainly targets depression,anxiety,obsessive-compulsive disorder,and other psychological issues as well as psychological problems caused by non-rational cognition.The proponents of CBT believe that emotions are deduced from belief,evaluation,or interpretation of an event instead of the event itself.Its main representative,Beck AT,postulated that maladjustments in behavior and emotion originate from the cognition of deviationt.Moreover,CBT is a form of “problem-centered”and“action-centered”conversational therapy.In addition to the traditional one-to-one CBT,other forms include short-term,group,and network-based CBTs.Mindfulness cognition,acceptance commitment,and dialectical BT compose the third generation of CBT,which led to a new zenith in CBT treatment[11].

Applying cognitive behavior therapy to patients with lung cancer

Except for the impact of sensible physical symptoms on the overall quality of life of survivor of lung cancer,medically unexplainable symptoms are more devastating to health.The patient presents with extensive and persistent physical discomfort.However,the affected physical components or other pathological and diagnostic indicators remain unclear even after sufficient examination[12].Previous research[13-14]provided evidence on the beneficial effects of CBT on the treatment of psychosomatic diseases.Therefore,under the premise that symptomatic treatment counters the intervention bottleneck,introducing CBT intervention based on the patient’s perspective of life support treatment for pulmonary carcinoma may point to immeasurable potential benefits to various physical aspects,such as pain related to cancer.Psychological symptoms are mainly caused by cancer-related fatigue(CRF)and negative emotional distress,such as fear of cancer recurrence(FCR)and anxiety.Different CBT operating procedures(i.e.,short-term single CBT,group single CBT,and combination with other psychological intervention methods)and operating methods(i.e.,acceptance of commitment therapy and mindfulness-based CT)exert varied effects on patients’adverse physical and mental symptoms.

Physical symptoms

Pain

Symptom management for patients with cancer focuses on cancer pain.In addition to the agitating outcomes of the disease itself,such as cancer cell infiltration,tumor compression,or metastasis,the cause of pain is one of the reasons for the patient’s subjective and non-rational perception of pain.Emotional distress,depression,anxiety,disease uncertainty,and feelings of hopelessness interact with pain and aggravate the pain perception of patients[15].Su et al.[13]demonstrated that CBT can improve the quality of life of patients and alleviate negative emotions.Through emotional grooming,patients’attention to the disease can be redirected,such that relaxing the nerves and muscles can increase one’s pain threshold to a certain extent,thus reducing pain.Although clinical trials illustrated that CBT is effective,previous studies confirmed that it does not display a consistent advantage over other types of psychosocial interventions[16].The Adult Cancer Pain Guidelines issued by the National Comprehensive Cancer Network[17]recommend that CBT is a viable method for improving self-control among patients with cancer,thereby alleviating cancer pain to a certain extent.Systematic group cognitive behavioral therapy aims to enhance patients’scientific understanding of cancer pain to establish awareness that it can be prevented and addressed.Furthermore,this form of CBT emphasizes that the emergence of cancer pain does not necessarily indicate the end of life.Zhang et al.[18]combined group CBT and wrist-ankle acupuncture as an intervention for patients experiencing cancer pain for four weeks.The results revealed that combination therapy can reduce the symptoms of cancer pain.Moreover,Kwekkebloom et al.[19]found that CBT cloud reduce the daily severity of pain in patients with lung cancer.However,CBT lacks supporting evidence for the duration of pain control in patients with lung cancer[20].

Cancer-related fatigue

CRF is the most common and most severe symptom in patients with lung tumors throughout the course of the disease[21].However,no gold standard for treatment exists[22],whereas effective drug interventions have not been established[23].Currently,CBT is one of the most feasible and easy-to-implement non-pharmaceutical therapies that can improve a patient’s ability to cope with fatigue by modifying the false perception about fatigue-related symptoms.Mendoza et al.[24]conducted a randomized,controlled cross-over clinical trial on 44 cancer survivors by combining CBT and hypnotherapy.The results demonstrated that 89% of subjects reported a significant improvement in fatigue compared with other outcome indicators and control conditions after receiving active treatment.However,other mental or physical symptoms(i.e.,pain,anxiety,nausea,and fatigue)as a result of cancer or treatment in patients with lung cancer are notexist alone.Fatigue,restless sleep,and pain in patients with lung cancer during chemotherapy are grouped as fatigue-related symptoms[25].Moreover,interactions among symptoms add complexity to the implementation of psychological intervention.Many studies[26-27]confirmed CBT as an effective intervention for cancer-induced fatigue.However,Van’s[28]findings suggest that although CBT can reduce CRF in cancer survivors within a short period of time,the Change is short-lived.In other words,the level of fatigue deteriorates over time.At present,a few intervention studies continue to target patients with lung cancer;however,high-quality clinical research on the application of CBT treatment to CRF remains lacking.In the future,multi-center and methodologically rigorous clinical trials with large sample sizes are required to verify the applicability and effectiveness of CBT in alleviating fatigue symptoms among patients with lung cancer in China.

Psychopsychiatric symptoms

Diseases exacerbate psychological stress and negative emotions.On the contrary,emotional distress aggravates the progression of the disease,which forms a vicious circle.Moreover,anxiety and depression are common psychosomatic symptoms of patients with various forms of cancer.Initial diagnosis of the disease,cancer screening,and traditional medical treatment,as well as in-depth tumor innovative treatments(i.e.,targeted therapy and immunotherapy)also lead to varying levels of psychological distress to patients.Several scholars[29]compared the effects of CBT and integrative body-mind-spirit intervention(I-BMS)on the psychological and mental symptoms of patients with lung cancer.The study found that CBT renders patients emotionally vulnerable with obvious improvements compared with I-BMS.Both interventions are beneficial to the adjustment of the emotional and mental state of patients;however,I-BMS is more effective in relieve symptoms of depression among patients with lung cancer.Moreover,both methods are suitable for alleviating negative emotions among the carers of patients with lung cancer.However,sample size restricted the study,and CBT failed to display obvious advantages over I-BMS.In addition,patients are vulnerable to medical treatment information and understand the latest progress of the disease in terms of research.Thus,negative emotions induced by lung cancer can lead patients to unconsciously compare with surrounding failure cases,which may induce the assumption that the condition is uncontrollable.This cognition renders patients prone to fear,specifically,FCR or the persistent fear experienced by patients with cancer about the recurrence,progression,or metastasis of the cancer at the primary site[30].The daily recording method is embedded in the application of cognitive psychology to monitor patients’daily thoughts.This method can help eliminate negative emotions and change one’s perspective of the situation.For example,Jiao et al.[31]conducted an intervention using a three-month daily recording method on 92 patients with lung cancer and found that the observation group displayed a decline in fear based on helplessness and anxiety scores obtained via a disease progression scale.Such scores were significantly lower than those in the control group,whereas attitude scores were significantly higher than the control group.This finding indicates that the daily record method can reduce psychological fear among patients with lung cancer and can facilitate patients in opting for active coping styles in the face of cancer at the same time.Zhao et al.[32]combined CBT with active coping strategies to guide patients in transforming negative cognition and eliminating harmful emotions and behaviors.The results illustrated that the FCR of patients with lung cancer undergoing chemotherapy reached a moderate level.After receiving six cognitive-existence group interventions,FCR levels decreased dramatically,which suggested that reducing FCR levels can promote the formation of healthy behaviors in patients.At present,no unified clinical practice plan exists for intervention using CBT to address the psychological and mental symptoms of patients with lung cancer.However,the positive effect of this treatment on the balanced development of the mental and physical health of patients with lung cancer is undeniable and can transmit positive beliefs to other patients in terms of rehabilitation.

Diagnosis and treatment using modern and novel medical methods aim to promote the simultaneous treatment of the body and mind.Multiple factors are attributed to the occurrence and development of diseases.In particular,physical discomfort induced by a disease is a visible risk factor that interferes with the mental health of patients.In fact,75% of the occurrence,deterioration,and prolonged healing of diseases are related to psychological factors[33].However,patients with lung cancer carry a heavy burden of symptoms and psychological pressure,which becomes more obvious than patients with other forms of cancer due to multiple interference from the disease itself,life support treatment,and social and psychological factors[34].

Conclusion

CBT is beneficial for the intervention on psychosomatic symptoms among patients with lung cancer.However,it remains only one of the potential adjuvant treatments and cannot completely replace other non-drug therapies or clinical symptomatic drug treatments.For patients unwilling to change their original beliefs or continue to experience difficulty in understanding at an older age,the smooth implementation of CBT may be limited.In addition,CBT intervention cycles,methods,and locations of various studies lack consensus.Therefore,making full use of the psychological theory of CBT and developing unified,flawless,and suitable CBT intervention programs for patients with lung cancer in China is an interesting avenue for future research.