Introduction to the JPO special issue: Innovations and real world applications of relationship research in cancer

Thanks to an aging population and improvements in cancer screening, early detection, and treatment, there are now more than 15.5 million people living in the United States who either have or have had a diagnosis of cancer.^1–3 These individuals have complex health care needs including the management of side effects, support for rehabilitation and recommended lifestyle behavioral changes, and interventions to improve coping and adjustment.² Yet, living with and beyond cancer does not occur in a vacuum, and it has long been recognized that the diagnosis of cancer in one family member has significant repercussions for the entire family.⁴ Among these relationships, the relationship between the patient and his/her partner/spouse is considered a key coping resource.⁵ For example, studies have demonstrated that patients who are married or in a partnered relationship experience better cancer outcomes than those who are not married including stronger performance status, better symptom management, and even longer survival.^6–10 One explanation is that spouses/partners provide critical care and support throughout the cancer trajectory.

As the primary setting for cancer care has shifted from hospital to home, the role of spouses/partners and other informal caregivers has changed dramatically from providing convalescence and emotional support to assisting with complex care tasks (e.g., hygiene care, symptom management, medication administration) and coordinating with the health care team.¹¹ Most caregivers assume this role with little to no formal training, so it is not surprising that they experience distress, fatigue, weight loss, burn out, social isolation, and deterioration in health as a result of their caregiving role.^12,13 Moreover, even though marital/family relationships can be a tremendous resource, they can be challenged and tested by the cancer experience. For example, cancer can induce changes in couples’ established communication patterns, roles, and responsibilities.¹⁴ Some couples report that the cancer experience brought them closer together, whereas others experience significant adjustment and communication difficulties that lead to feelings of decreased intimacy or greater interpersonal conflict.¹⁴ Given the growing acknowledgement that patients, caregivers, and their relationships are profoundly affected by the cancer experience, a burgeoning literature involving descriptive and intervention research has evolved focusing on dyadic relationships (e.g., couples, patient–caregiver, parent–child) in cancer.^15–17 However, gaps remain in our understanding of how patients and partners/caregivers affect one another’s psychosocial adaptation to cancer, how they successfully negotiate the cancer experience together, and how to design more effective and disseminable dyadic interventions.

This special issue of the Journal of Psychosocial Oncology showcases nine empirical articles and a book review that seek to address these knowledge gaps. Four articles highlight the dyadic nature of the cancer experience and interdependence between relational partners. In a daily diary study of couples facing the first follow-up mammogram after cancer treatment, Soriano et al. found that both partners experienced the mammogram as a stressful event, but that when spouses were more threat sensitive, both patients and spouses took longer to recover in terms of their fear of cancer recurrence. In a cross-sectional study of heterosexual couples coping with early stage cancers, Karademas et al. found that spouse illness representations were associated with patient coping – both directly and indirectly through patient illness representations. Using a novel methodological approach – the Electronically Activated Recorder (EAR) – Robbins et al. examined naturally occurring word use in the conversations of couples’ coping with breast cancer. They found that patients’ and spouses’ use of positive emotion and cognitive processing words was associated with their own and their partner’s reported positive reframing and lower levels of stress. Finally, Young et al. used qualitative interviews to shed light on the complex couple context of coping with an inherited cancer syndrome, Li-Fraumeni Syndrome, which has a lifetime cancer risk approaching 100%. Together, these studies demonstrate the role of the spouse in affecting patient coping and adjustment and highlight the importance of considering the couple context in which coping with cancer occurs. They also showcase novel methodologies for measuring and assessing couple interdependence and chart new ground by examining how couples cope across the cancer trajectory, including how they deal with pre-neoplastic conditions and post-treatment survivorship issues – both of which have been understudied areas in dyadic cancer research.

Two empirical articles in this special issue examined previously unexplored factors that may affect individual and dyadic resilience in the face of cancer. First, in a study of women being treated for non-metastatic breast cancer and their partners, Kayser and Acquati found that relational mutuality, which encompasses an individual’s capacity to express empathy, be authentic, and empower their partner, was positively associated with both partners’ reports of dyadic coping behaviors. Unlike the vast majority of dyadic studies that have investigated the effects of positive coping behaviors and couple communication processes on couple adjustment, Segrin et al. examined how loneliness affects health-related quality of life (HRQoL) in Latina breast cancer patients and their informal caregivers. They found that loneliness was negatively associated with HRQoL for both patients and caregivers and that patients’ baseline loneliness was associated with their own and their caregiver’s HRQoL at a 3-month follow-up. Taken together, these studies highlight the importance of social ties and relationship processes for cancer adjustment. They also suggest that research is needed to better understand the factors that contribute to relationship mutuality and loneliness so that interventions can be developed to enhance mutuality, mitigate loneliness, and improve patient and caregiver HRQoL. Karam’s book review of Helping Couples & Families Navigate Illness and Disability: An Integrated Approach extends the discussion by highlighting the need to focus more research attention onto the changing interactions between family members over different stages of cancer and the family life cycle.

The three final studies in the special issue focus on new directions for dyadic interventions. Most dyadic interventions in cancer have included a communication skills training component because communication is an important process through which couples make sense of cancer, engage in social support, negotiate role changes, and coordinate coping responses. However, scholars still know very little about what they should instruct couples to talk about, how often they should talk, and when talking (or not talking) is beneficial (and for whom – the patient, partner, or both).¹⁸ In a study of naturalistic communication in advanced cancer couples, Reblin et al. found that couples rarely engaged in communication about cancer or about their relationships and that the majority of observed communication was logistical or social small talk. The authors concluded that there appear to be few naturalistic cues encouraging couples to discuss potentially difficult topics and that more work is needed to determine the appropriate levels of communication. Couples’ need for talk may also change across the illness trajectory, so refining the prescription for spousal communication in dyadic interventions is an important area for future research.

Reese et al. conducted a randomized controlled trial of a couple-based intervention for post-treatment breast cancer survivors and found that the intervention was feasible, acceptable, and promising in addressing not only survivors’ sexual concerns, but also both partners’ intimate relationship and psychosocial well-being. In addition to being one of the few dyadic interventions to directly address couples’ sexual issues and concerns, the study highlights the importance of developing interventions to help couples return to a normal life after successful cancer treatment.¹⁹ It also prompts the question of the standard for efficacy for dyadic interventions. Reese et al.’s intervention demonstrated the benefits for both patients and spouses; however, other psychosocial interventions have demonstrated benefit for only one partner, and it is unclear whether benefit for one partner is sufficient to justify dyadic intervention.¹⁵ More work is therefore needed to compare the effects of individual and dyadic interventions on patient and partner outcomes.

Finally, in an effort to inform implementation of an efficacious family-based intervention for advanced cancer caregivers, Ratcliff et al. conducted interviews with individuals representing different oncology stakeholder groups. Questions focused on existing caregiver support services, barriers to integrating care for caregivers in routine patient care, and possible models for clinical uptake and dissemination. Findings suggest that dyadic and family-based researchers should evaluate intervention outcomes that are important to stakeholders, including cost, cost savings, and revenue generation potential in order to translate effective interventions from research to practice. They also suggest that more pragmatic trials are needed that allow for flexibility in the delivery of dyadic and family-based interventions.

In sum, the articles in this special issue reflect the wide-ranging stressors experienced by cancer patients and their caregivers across the cancer continuum. They investigate the core aspects or mechanisms of dyadic relationships that promote positive outcomes in cancer, showcase novel methods and intervention approaches, and highlight some of the challenges of conducting this kind of research. Overall, we believe they highlight several important and provocative questions that will stimulate new research to advance science of dyadic processes in cancer.

Hoda Badr
Department of Medicine, Baylor College of Medicine, Houston, TX, USA
[email protected]

Jennifer Barsky Reese
Cancer Prevention and Control Program, Fox Chase Cancer Center, Philadelphia, PA, USA
Department of Social and Behavioral Sciences, College of Public Health, Temple University, Philadelphia, PA, USA

Disclosure statement

No potential conflict of interest was reported by the authors.