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Introduction

For most individuals diagnosed with cancer, their psychological adjustment depends strongly on their interpersonal relationships. Cancer patients identify their spouses or intimate partners as their most important sources of practical and emotional support; spouses or partners are also the first persons from whom support is often sought after patients receive a cancer diagnosis [1]. However, the diagnosis and treatment of cancer can affect every aspect of both the patients’ and their partners’ quality of life (QOL). Patients must cope with the role changes and distress brought about by the physical side effects and increased functional disability associated with their disease and treatment. Their partners must not only confront the potential loss of a life partner (the patient), but also must become adept at providing instrumental and emotional support to the patient during a time when they themselves are under extreme stress. Coping with cancer treatment can also challenge a couple’s established communication patterns, roles, and responsibilities [2, 3]. Thus, it is not surprising that some couples report that the cancer experience brought them closer together, whereas other couples experience significant adjustment and communication difficulties that result in feelings of decreased intimacy and greater interpersonal conflict over time [4, 5].

Traditional approaches for addressing psychosocial adaptation after a cancer diagnosis have focused on either the patient or the patient’s partner. However, a burgeoning literature involving couple-based interventions has emerged over the past two decades and there have been a number of notable reviews in this area. For example, Manne and Badr [6] conducted a thematic review of descriptive and intervention studies that focused on couples coping with cancer, although their review was not exhaustive. Both Scott and Kayser [7] and Baik and Adams [8] each conducted systematic reviews of psychosocial interventions that included randomized controlled trials (RCTs) as well as quasi-experimental studies (in which patients were not randomized or in which there was no control group). Scott and Kayser’s [7] review was also narrowly focused on sexual interventions. Finally, Martire and colleagues [9] conducted a meta-analysis of interventions for couples coping with chronic illness. Although many of the studies focused on cancer patients and their partners, the review was broad and encompassed interventions geared toward couples with a variety of illnesses. Given the aforementioned issues, the conclusions that can be drawn from existing reviews regarding the efficacy of psychosocial interventions in couples coping with cancer are limited.

The primary goal of this chapter is to systematically review the efficacy of existing psychosocial interventions in cancer involving couples on patients’ and their partners’ quality of life (QOL). The secondary goal is to provide direction for future research based on identified gaps in the literature. Toward this end, we sought to identify all published reports of randomized controlled trials (RCTs) of psychosocial interventions conducted with cancer patients and their partners that were aimed at improving the patient’s and/or the partner’s QOL. Given that QOL is a multidimensional construct that includes physical, psychological, and social well-being [10, 11], studies that included health, psychological, or relationship outcomes were included in our review.

Systematic Review

Identification of appropriate RCTs began with electronic searches to identify English language journal articles published from January, 1980 to February, 2011 in the PubMed, Embase, PsychInfo, Web of Science, and LISTA (EBSCO) databases. The search terms, based on the interventions and outcomes of interest, were “intervention,” “cancer,” “couple,” “dyad,” “spouse,” “symptom management,” “behavioral,” “therapy,” and “psychosocial.” Our strategy in selecting search terms was to balance sensitivity with specificity [12] and to verify and augment the search results by reviewing reference lists from publications retrieved, which included relevant systematic reviews and meta-analyses.

Figure 11.1 shows a flow chart depicting the process we used to identify and select journal articles that were relevant to our study. We identified 744 articles and used bibliographic software (Endnote X2), EPPI-Reviewer 4.0 software, and manual review to remove duplicate publications, resulting in 275 articles. Identified articles were then screened for inclusion using the EPPI-Reviewer 4.0 software followed by manual review. The criteria for article inclusion were article was peer reviewed, study was cancer based, study participants were randomized, study was couple based, study was a psychosocial intervention, and article was available in English. Of these 275 articles, 249 did not meet these criteria and were excluded—most because they were not peer-reviewed articles (e.g., conference abstracts). We then further refined our search by manually examining the abstracts, titles, and full texts of the 26 remaining articles. An article was excluded if the article did not report original trial outcomes (i.e., it was a secondary analysis), if the article did not report on a psychological, health, or relationship outcome, or if the study reported did not include a control group. Studies that compared two interventions but did not include a control group were excluded because our goal was to examine intervention efficacy relative to either standard care (i.e., usual medical care or standard psychosocial services) or a time or attention control (i.e., standard medical education was provided). Using these criteria, seven articles were excluded; thus, 19 studies were included in our review (see Fig. 11.1). After finalizing the list of studies to be included in the review, two independent raters (HB and MT) abstracted data on intervention design, participant characteristics, theoretical basis, and key findings. Discrepancies between raters were resolved through review and discussion.

Fig. 11.1
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Flow diagram depicting the systematic review process

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Intervention Design and Participant Characteristics

Intervention Design

As Table 11.1 shows, the vast majority of studies involved interventions conducted directly with individual couples; only one study involved a group intervention [13]. Four studies had attention control groups where educational information was provided [14–17]. The remaining studies had standard care control groups where the patient received either standard psychosocial services [18, 19] or usual medical care [13, 20–31]. In two of the usual care control groups [21, 25], participants were part of a wait-list control and eventually were offered the intervention.

Table 11.1 Randomized psychosocial intervention studies of couples coping with cancer
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In terms of delivery, ten interventions involved in-person sessions (individual or group) [13, 14, 18–20, 24–27], three were exclusively over the telephone [23, 29, 32], and five involved a combination of telephone and in-person sessions [16, 17, 21, 22, 28–30, 32]. Interventions were primarily conducted in a hospital; however, a few were conducted in the patient’s home [17, 20]. The interventions were administered by psychologists or therapists with masters or doctoral degrees (number [N]  =  11), nurses (N  =  7), or licensed clinical social workers (N  =  1) who used a variety of techniques, including cognitive behavior therapy (e.g., relaxation or cognitive restructuring), education, interpersonal counseling, and behavioral marital therapy.

One of the most frequently used treatments in the couples therapy literature is behavioral marital therapy [33]. The goal or behavioral marital therapy is to increase the ratio of positive to negative behaviors exchanged between partners [34]. Thus, behavioral exchange, improving adaptive communication, conflict resolution, and problem-solving skills are targeted [35, 36], and patients and partners are taught to be more aware of how they influence and are influenced by their interactions with one another [37].

Interventions included partners in one of two ways. The first method, used in 11 studies, treated the partner as an assistant or “coach” to facilitate learning and coping skills in the patient [14, 16, 17, 20, 23, 27–32]. In most of the interventions that used this method, the partner was present with the patient during all sessions; however, in three studies, the patient and partner each received separate instruction [15, 16, 23]. The second method, used by the remaining eight studies, treated the couple as a unit (i.e., both patient and partner were present in the room and treated together at all times during the intervention). Interventions using this method focus on improving the spousal relationship and interaction patterns by teaching skills that build teamwork, improve communication, and encourage the couple to view cancer in relational terms [6].

In terms of dosage, most interventions involved 6 weekly or biweekly sessions; however the number of sessions ranged from 1 to 16, and session-length varied from 20 to 120 min. For the most part, the number of couples who dropped out of the study before completing all of the intervention sessions was minimal. Only Manne and colleagues [13, 19] conducted questionnaire follow-ups and analyses of couples who were randomized to the intervention group but did not attend any sessions.

Participant Characteristics

As Table 11.1 shows, the mean age of participants ranged from 40 to 64 years (mean age was not specified in one study [26]), and the number enrolled varied considerably, from 14 to 252. Only eight studies had sample sizes of 100 or more [13, 14, 16, 17, 22, 23, 27, 28]. Of the 14 studies that provided descriptive data on their recruitment efforts, participation refusal rates varied widely from 3 [25] to 82 % [18]. Nine of the 14 studies had refusal rates of 50 % or more [13, 14, 16, 18–20, 28, 30], The time of follow-up ranged from postintervention to 1 year later and the number of follow-ups ranged from one to four. Regarding participant attrition at final follow-up, attrition rates for the studies that reported this information ranged from 5 [23] to 34 % [25].

Seven studies focused exclusively on couples coping with breast cancer [13, 15, 16, 18, 24, 26, 31], six studies focused exclusively on couples coping with prostate cancer [19, 21–23, 29, 30], five studies involved couples coping with different types of cancer [17, 20, 25, 27, 28], and one study focused exclusively on couples coping with gastrointestinal cancer [14]. With the exception of one study that focused exclusively on pain management at the end of life [20], all studies involved patients who had either early-stage or nonmetastatic disease. In most studies, participants were predominately white, with the exception of one study that focused exclusively on African American prostate cancer patients and their partners [29], and one study that included approximately an equal number of white and African American prostate cancer patients [23].

Even though both patients and partners participated, seven studies reported no outcomes whatsoever for partners [14, 21, 27, 28, 30, 31, 38]. However, a diverse set of patient outcomes were reported, including psychological functioning/distress, uncertainty, general QOL, relationship satisfaction, disease-specific QOL domains (e.g., pain and urinary and bowel function), sexual functioning, medication use (e.g., for erectile dysfunction), and attitudes about analgesic use.

Theoretical Bases and Description of Key Findings

Even though a variety of theoretical frameworks were used in the studies we reviewed (see Table 11.1), we classified them into three main categories based on previous reviews of the literature on couples coping with cancer [6]. First, individual stress and coping models focus on the role of stress appraisals in individual adjustment and emphasize the importance of social support provided by the partner to the patient. Second, resource theories view the marital relationship as a resource for couples to draw upon in times of stress. Third, dyadic-level theories focus on interaction patterns between patients and their partners and approaching cancer together as a team. The individual theories falling under each category are described below followed by brief descriptions and key findings of the interventions that utilized them.

Individual Stress and Coping Models

Two studies explicitly mentioned individual stress and coping models as their theoretical basis [16, 21]. These models posit that person-, social-, and illness-related factors influence how people appraise and cope with an illness, which in turn affects their QOL. They also view social support as a form of coping assistance [39]. Given this, interventions that utilize individual stress and coping models often conceptualize the healthy partner as the support provider and the patient as the support recipient [40].

Northouse and colleagues’ [21] examined the efficacy of a couple-focused counseling intervention for 235 men diagnosed with prostate cancer and their spouses. The five-session intervention targeted communication skills, maintaining a positive attitude, managing stress and adopting a healthy lifestyle, obtaining information and managing uncertainty, and managing symptoms. No significant differences between the intervention arm and the control group were noted for patients’ QOL, but patients enrolled in the intervention arm reported significantly less illness uncertainty and more communication with their partners about the illness than reported by patients in the control group. Compared with spouses in the control group, spouses in the intervention group reported better QOL, more positive appraisal of care giving, less hopelessness, less illness uncertainty, more self-efficacy, better communication with the patient, fewer concerns about the patient’s urinary incontinence, and less symptom distress. Some of these effects were sustained at the 8- and 12-month follow-ups.

Budin and colleagues [16] targeted both patient and partner, but intervened separately with each individual. These researchers assigned patients and partners to one of four study arms: (1) an attention control group that received education about disease management; (2) a group that watched four educational videotapes focusing on effective coping with a cancer diagnosis; recovery from surgery, adjuvant therapy, and ongoing recovery; (3) a group that received four telephone counseling sessions focusing on stress management, effective coping, and facilitating communication; or (4) a group that watched four educational videotapes and received four telephone counseling sessions. None of the patients or partners showed evidence of improvement in psychosocial functioning; however, partners in the control group reported greater distress compared with partners in the other three groups.

Resource Theories

Resource theories such as the social cognitive processing models (SCPMs) and equity theories adopt the view that the marital relationship is a resource for individuals to draw upon for assistance during difficult life events. These theories and their representative interventions are described below.

Social-Cognitive Processing Model. The SCPM posits that the social context in which recovery from cancer takes place influences emotional adjustment [41]. For many patients, cancer is experienced as a traumatic event eliciting symptoms such as intrusive thoughts and cognitive and behavioral avoidance [42, 43]. While some intrusive thoughts are an adaptive part of the cognitive processing and integration of traumatic events, these thoughts often elicit negative emotional responses. To manage emotions associated with a trauma, a person may actively avoid thinking or talking about the traumatic event. According to conditioning theories, avoidance may persist because it temporarily relieves anxiety. If avoidance continues in the long run, however, it hinders the cognitive and emotional processing of the event, causing both intrusive thoughts and psychological distress to increase [44]. Intrusive thoughts and avoidance are indicators that further cognitive processing may be needed.

According to the SCPM, a supportive spouse can serve as a resource for the patient in terms of providing assistance in cognitive processing. The spouse can also serve as a barrier to effective processing if he or she is either unavailable or unsupportive, which may be particularly problematic because of the level of importance the spouse has as both a confidante and a primary source of support [45]. Qualitative [46] and quantitative studies with cancer patients support this model [47–49]. Despite the fact that the SCPM was not explicitly mentioned as the theoretical basis for intervention, the four articles described below clearly utilized elements of this model and emphasized the role of disclosure and communication skills training as a means of reducing distress for both patients and/or their partners.

Badger and colleagues [15] conducted an RCT to examine whether telephone-delivered interventions decreased depression and anxiety in women with breast cancer and their partners. Couples participated in one of three different 6-week programs: (1) telephone interpersonal counseling, (2) self-managed physical activity, or (3) an attention control group where patients and partners received educational pamphlets and separate phone calls. Patients’ and partners’ symptoms of anxiety decreased over time in the telephone interpersonal counseling and exercise groups over time but not in the attention control group.

Manne and colleagues [13] conducted the only couples’ group intervention study included in this review. A total of 238 women with early-stage breast cancer were randomly assigned to either a six-session couple-focused group intervention or usual care control condition. The intervention focused on support and encouragement of effective coping by facilitating communication and expression of emotions. Compared with patients receiving usual care, patients receiving the intervention reported greater reductions in symptoms of depression and these reductions persisted over the 6-month follow-up period. Subgroup analyses showed that patients who rated their partners as unsupportive benefited more from the intervention than patients with supportive partners. In addition, patients who had higher levels of physical impairment before the intervention benefited more from the intervention than did patients with lower preintervention levels of physical impairment.

Scott and colleagues [17] conducted an RCT examining the effectiveness of a six-session couple-based cognitive behavioral therapy program called Cancer Coping for Couples (CanCOPE) among 94 patients recently diagnosed with early-stage breast or gynecological cancer and their partners. Patients were randomly assigned to one of three study arms: (1) a medical information attention control group, where patients received booklets that explained their cancer and its treatment and brief telephone calls; (2) a patient-only counseling group, which involved the provision of medical information, coping education, and supportive counseling; or (3) the CanCOPE couple-based intervention group. The goal of the intervention was to enhance couples’ ability to cope, reduce psychological distress, and promote better female body image and sexual adjustment. To accomplish this, CanCOPE focused largely on teaching individual coping skills and cognitive restructuring, but patients and partners were encouraged to support each other in applying these strategies. Compared with the medical information and patient-only study arms, CanCOPE produced a large increase in couples’ supportive communication, a decrease in patients’ psychological distress, and improvements in patients’ sexual self-schema and intimacy with their partners. No differences between conditions were found with regarding couples’ expression of warmth, validation, or negativity or in patients’ levels of sexual responsiveness.

Porter and colleagues [14] randomly assigned 130 patients with gastrointestinal cancer and their partners to either four sessions of a partner-assisted emotional disclosure intervention or a couples’ attention control group involving cancer education. The intervention was designed to systematically train patients and partners in strategies to facilitate the patients’ disclosure of their cancer-related concerns and give patients the opportunity to talk with their partners about their concerns. The intervention was found to be effective for a subset of couples. Compared with couples enrolled in the attention control group, improvements in relationship quality and intimacy were found for couples in the intervention group in which the patients initially reported higher levels of holding back discussing cancer-related concerns.

Equity Theory. Some researchers have argued that for support to be beneficial, it must be reciprocal [50]. However, in the context of cancer, relationships may be affected by changes in the balance of give and take between partners [6]. Whereas support may have flowed back and forth between partners before the onset of illness, the exchange may become more one-sided with the healthy spouse’s contributions to the relationship far exceeding those of the patient. According to equity theory, when the ratio of contributions to rewards for one partner differs from that of the other, the relationship is out of balance and those who are in inequitable relationships are more likely to become distressed [51], regardless of whether they are receiving more or less from their partners than what they are providing [52].

Kuijer and colleagues’ [25] conducted a randomized trial with 59 couples. The intervention focused primarily on reducing feelings of inequity and restoring equity between the partners. Findings showed that the intervention significantly affected participants’ perceptions of the give-and-take balance and relationship quality. However, because the perceptions of inequity between the intervention and wait-list control groups were significantly different at baseline, the authors could not conclude that the intervention was successful in reducing perceptions of inequity. Patients also reported lower levels of psychological distress after the intervention, but the intervention effects were not maintained at the 3-month follow-up.

Dyadic-Level Theories

Dyadic-level theories focus on the couple as the unit of study and examine the ongoing contributions that both partners make to preserve or improve the quality of their relationship as they strive to cope together with the cancer experience [6].

Relationship Intimacy Model. The relationship intimacy model of couples’ psychosocial adaptation to cancer developed by Manne and Badr [6] posits that intimacy is a key mechanism by which relationship communication and interaction behaviors influence patient and partner adjustment. Specifically, the model proposes that relationship-enhancing and compromising behaviors can influence perceptions of relationship intimacy and that intimacy mediates the associations between these component processes and couples’ psychosocial adaptation to cancer. Relationship-enhancing behaviors include the disclosure of concerns and feelings about the cancer experience, the sense that one is understood, cared for, and accepted by one’s partner, and the view that cancer has implications for the relationship, whereas relationship-compromising behaviors include avoidance, criticism, and pressure-withdraw (e.g., when one partner pressures the other to discuss a cancer-related problem and the other partner withdraws).

Using this model, Manne and colleagues [19] compared a five-session intervention for men who had undergone prostatectomy and/or radiation therapy for prostate cancer and their wives to a usual care control group where patients received standard psychosocial care. The goals of the intervention were to assist couples to (1) learn ways to share their concerns about prostate cancer; (2) improve mutual understanding and support regarding one another’s cancer experience; (3) engage in constructive and empathic communication regarding concerns about the loss of sexual functioning; (4) find ways to talk about feelings of shame, embarrassment, and any perceived loss of masculinity in a sensitive manner; and (5) maintain emotional and sexual intimacy despite restrictions in sexuality. The intervention was only found to be effective for a subset of patients and partners. Specifically, patients who had higher levels of cancer concerns at pretreatment reported significant reductions in concerns posttreatment. Similarly, partners who began the intervention with higher cancer-specific distress, lower marital satisfaction, less marital intimacy, and poorer communication reported significant improvements in these outcomes after treatment.

Dyadic/Communal Coping. Broadly viewed, dyadic or communal coping recognizes mutuality and interdependence in coping responses to a specific shared stressor, indicating that couples respond to stressors as interpersonal units rather than as individuals in isolation. The construct of dyadic coping goes beyond the exchange of social support, although that is a central component in most definitions [53]. In dyadic coping, the members of the couple negotiate the emotional aspects of their shared experience [54] or engage in collaborative coping, such as joint problem solving [55], coordinating everyday demands, and relaxing together, as well as mutual calming, sharing, and expressions of solidarity. From this perspective, individual and relational well-being are believed to be affected by the couple’s ability to work as a team to manage aspects of the stressor that affects both of them [56, 57]. Despite the fact that a dyadic or communal coping theory was not explicitly mentioned as the theoretical basis for intervention, three articles utilized elements of this model and are described below.

Baucom and colleagues’ [26] relationship-enhancement intervention used cognitive behavioral techniques to teach couples to communicate effectively, share feelings and thoughts, and reach important decisions together as a team. The intervention also focused on both partners needs and emphasized addressing cancer-related problems as well as building positives in the couples’ relationship. Results showed that both women and men in the relationship-enhancement intervention arm experienced improved psychological and relationship functioning at the postintervention and 1-year follow-ups compared to those in the control group arm where the patient received usual care. Women in the relationship-enhancement group also reported fewer medical symptoms at both follow-up time points.

Christensen [24] conducted an RCT with 20 patients with breast cancer and their partners. The therapy included educational component and a couples counseling component that was focused on communication, problem solving, and body image/sexuality. Compared with the control group who received standard care, the treatment resulted in modest decreases in emotional discomfort for both partners and patients, reduced depression in patients, and increased sexual satisfaction for both partners and patients. This study contained a number of elements common to behavioral marital therapy and dyadic-level theories; however, an explicit theoretical approach was not specified. This is likely due to the fact that this is the oldest couple-based intervention in cancer and was conducted prior to the publication of the dyadic-level theoretical models that are discussed in this chapter.

Kayser [58] examined the effects of the Partners in Coping Program (PICP) in a study of 63 patients with nonmetastatic breast cancer and their partners. The PICP consisted of nine 1-h sessions that patients and their partners attended together over the course of the first year following breast cancer diagnosis. The strategies utilized in the PICP were educational with some skills training in relaxation, communication, coping with changes in sexuality, and alternative ways of expressing intimacy. Compared to those in the control group who were offered standard social services, including the option to consult with a social worker at the hospital, patients in the PICP reported an increase in dyadic coping 6 months postbaseline, suggesting that the intervention may have facilitated a sense of “we-ness” in coping with the illness. However, these gains in patient-reported dyadic coping were not maintained at the 12-month follow-up. In contrast, partners in the PICP reported increases in their willingness to communicate their own stress to the patient over the 12-month period relative to those in the control group, and both patients and partners in the PICP reported improvements in psychosocial adjustment over time.

Interventions with No Explicit or Implied Theory

The seven intervention studies that did not have an explicit or implied theoretical framework are described in greater detail below. Most assessed general or cancer-specific mental health outcomes and sought to ameliorate the couple’s distress. One study focused specifically on addressing attitudes about pain and analgesic use [59], and two studies included components to address cancer-specific symptoms (pain and bowel/urinary functioning) [28, 30]. Four interventions included components to address or to enhance sexual rehabilitation and body image [17, 18, 22, 31]; only two of these interventions included a component that focused explicitly on addressing changes in the couples’ relationship and improving the marital relationship [22, 29].

Campbell and colleagues’ [29] partner-assisted coping skills training (CST) telephone-based intervention was developed for prostate cancer survivors and their intimate partners. The goal of the six-session program was to assist couples in learning to manage symptoms by providing information about prostate cancer and possible long-term side effects, teaching problem-solving and coping skills, and improving relationship communication. Compared with the control group who received usual care, the CST intervention produced moderate to large treatment effects for disease-specific QOL, such as bowel function, and urinary, sexual, and hormonal function domains. For partners, no significant differences were found between the treatment and control groups on the general health QOL and self-efficacy scores; however partners in the intervention arm reported modest improvements in depressive symptoms and fatigue.

Giesler and colleagues [30] conducted an intervention aimed at improving QOL for prostate cancer patients and their partners. Participants in the intervention arm met once a month for 6 months with an oncology nurse who helped them identify their QOL needs using an interactive computer program. The nurse then provided education and support tailored to the individual needs of the patient. Results showed that patients in the intervention condition experienced long-term improvements in QOL outcomes related to sexual functioning and cancer worry compared with the control group who received usual care.

Keefe and colleagues [20] conducted a partner-guided pain management training intervention for patients who were facing the end of life. The three-session intervention conducted in patients’ homes integrated educational information about cancer pain with systematic training of patients and partners in cognitive and behavioral pain coping skills. When compared with usual care, the intervention did not have a significant impact on patients’ QOL; however, it did produce significant increases in partners’ ratings of their self-efficacy for helping the patient control pain and self-efficacy for controlling other symptoms. Partners enrolled in the intervention also reported modest improvements in their levels of caregiver strain compared with partners in the control group.

McCorkle and colleagues [22] conducted an RCT to examine the effects of a standardized nursing intervention protocol designed to improve patients’ and their spouses’ depressive symptoms, sexual function, and marital interaction after prostate cancer. A total of 16 contacts (home visits and telephone calls) were made with patients and their spouses over 8 weeks; each intervention session had content that was specifically relevant to the patient, the spouse, and the patient and spouse as a couple. Results showed that compared to usual care, the intervention had a modest positive effect on patients’ sexual function and marital interaction over time; however, patients in the intervention group reported greater distress over time. Similar outcomes were found for spouses.

Kalaitzi and colleagues [31] conducted a study on a structured combination of brief couples therapy and sex therapy for breast cancer patients and their partners. Session content included education, communication training, and sensate focus exercises and addressed body image concerns. Compared with patients in the control group who received usual medical care, patients who received the intervention experienced less depression and anxiety at follow-up; patients in the intervention arm also experienced improved body image, expressed greater satisfaction with their relationship, and reported greater orgasm frequency.

The three remaining studies that did not have an explicit or implied theoretical basis compared the efficacy of a couples’ intervention condition to both a usual care control group and a patient-only intervention [23, 27, 28]. Mishel and colleagues [23] conducted an uncertainty management intervention that was delivered over the telephone to couples coping with localized prostate cancer. Patients who received the intervention—either alone (second intervention arm) or supplemented with a family member, the majority of whom were spouses (couples intervention arm)—participated in a weekly telephone call for 8 consecutive weeks with a nurse. Patients and their family members (in the couples intervention arm) received separate phone calls; nurses were matched with the patient and family member by ethnicity and gender. The nurse assessed the patient’s concerns, perceived level of threat, and uncertainty related to the prostate cancer. The intervention consisted of cognitive reframing exercises, problem solving, and techniques for improving patient–provider communication. Both individual and couple interventions were effective in reducing uncertainty than was usual care; however, partners in the couples group did not fare any better than those in the individual group on the primary outcome of uncertainty.

Nezu and colleagues [27] examined the efficacy of problem-solving therapy among people diagnosed with different types of cancer. These researchers incorporated a significant other (95 % of whom were spouses) as a “coach” to assist the patient in learning coping skills. Distressed patients were randomly assigned to receive ten sessions of individual problem-solving skills training, ten sessions of problems-solving skills training with a significant other present to provide support and coaching, or a wait-list control group. Although there were no significant differences between the two problem-solving skills training groups, participants in both problem-solving skills training groups reported lower distress and better clinician ratings of functioning than did participants in the wait-list control group.

Ward and colleagues [28] attempted to ­overcome patient and partner attitudinal barriers to reporting cancer pain and using analgesics through education. One hundred sixty-one patients with different types of cancer were randomized to a couples intervention (patient and significant other received the intervention), solo intervention (only the patient received the intervention), or usual care. Although the intervention content was not theory-based, the authors did note that the process by which they delivered intervention materials to participants was based on a representational approach to patient education [60]. Participants received education about managing cancer pain and overcoming misconceptions and barriers. In the last session, they created a plan for changing the way they managed cancer pain. Results showed that the intervention was no more efficacious when it was presented to dyads than to patients alone. However, participants in the two intervention groups reported significant decreases in attitudinal barriers compared to those in the control group.

The conclusions that can be drawn from these three studies regarding the efficacy of couple-based interventions compared with patient-only interventions are limited because the role of the partner was primarily supportive (in terms of what he/she could do to help the patient), and the studies did not focus on addressing couples’ interaction patterns or the impact of cancer on the couple’s relationship. These factors would appear to be important components of a couples’ intervention approach given that Scott and colleagues’ [17] CanCOPE intervention had an implied theoretical basis, focused on couples’ relationship and interaction patterns, and was found to be effective relative to a patient-only intervention and an attention control group. More research is thus needed to determine the circumstances under which partners should be included in interventions, the optimal degree of the partner’s involvement, and whether couple-based interventions that focus on the needs of both patients and partners and their relationship interaction patterns are more effective than those targeting the patient alone.

Summary and Directions for Future Research

As our review suggests, there is a growing literature on psychological interventions for couples coping with cancer. Owing to the varied or sometimes absent theoretical basis, the varied intervention approaches used, and the diversity in outcomes reported, it is difficult to discern a clear pattern. Overall, most studies had at least some positive results. Those that were aimed at improving communication, reciprocal understanding, and intimacy appeared to be effective in reducing distress and improving relationship functioning in one or both partners. However, three studies [14, 19, 38] found that such interventions seemed to benefit only a subset of couples—particularly those who have poorer functioning relationships, greater cancer-related distress or concerns, or poor communication skills at the outset. More research is needed to determine whether there are certain profiles of at-risk couples who may benefit from such interventions.

This review highlights a number of clear limitations in the couples’ intervention literature. Most studies had small sample sizes and thus were largely underpowered to examine changes in multiple outcomes over time. Several did not report on outcomes for the patient’s partner; those that did often demonstrated unequal effectiveness for patients and their partners and/or a limited maintenance of improvements over time. Whereas the standard dose of cognitive behavior therapy is 8–12 sessions, the majority of interventions were comparatively brief, comprising six sessions or less. This is no doubt reflective of the difficulty of recruiting and retaining cancer patients who are often undergoing active treatment. It remains unclear how the length of treatment, number of treatments, or timing of intervention may have affected study outcomes. In addition, several studies did not include important information related to their refusal or attrition rates, suggesting that reporting standards need to improve.

Almost half of the interventions reviewed seemed to be based on theory, though several researchers did not explicitly acknowledge a theoretical basis for their interventions. Few studies examined the mechanisms by which interventions impacted psychosocial outcomes; thus, there are limitations as to whether the theoretical basis of the intervention was as hypothesized. In the studies without a theoretical basis, intervention elements were largely dependent on cognitive behavioral techniques. Most included an educational component, and communication and symptom management training. It is interesting to note that while some interventions addressed cancer-specific issues (e.g., uncertainty, need for medical information, and problems communicating with providers or partners about cancer-related concerns), the vast majority of intervention content was similar to either couples therapy interventions developed for healthy populations or cognitive behavior interventions geared toward individuals coping with cancer. In addition, the vast majority of studies were geared toward couples where the patient was newly diagnosed and had early-stage cancer. The longest follow-up was 12-month postintervention. Given that the demands couples face change as cancer progresses [61] and long-term cancer survivors may experience different stressors than couples coping with the acute stages of the disease, it is important to assess the ongoing adaptation of couples to cancer over longer periods and to determine whether booster sessions are needed to maintain the impact of intervention.

Cognitive behavior therapy and behavioral marital therapy were the most commonly used therapeutic techniques in the studies we reviewed. It is noteworthy that none of the studies used emotion-focused therapy (which focuses on restructuring interpersonal patterns to incorporate each partner’s needs for experiencing secure attachment) [62], despite it being the second most common therapeutic technique used in couples therapy [8]. Perhaps one reason for this is that the majority of studies focused on improving individual psychological outcomes; few studies examined the impact of the intervention on dyadic-level or relationship outcomes, even though most interventions included components to improve couples’ interaction patterns, joint problem solving, and dyadic coping. Likewise, disease-specific QOL outcomes were rarely the primary focus of the couples’ interventions.

A significant number of interventions were either offered exclusively via telephone or in combination with in-person sessions. Telephone interventions may allow therapists to reach couples who do not have local resources, who live in rural areas, or who are immobile. Additionally, couples who are not comfortable with traditional face-to-face interventions may prefer the anonymity offered through telephone counseling [63]. More research is needed to determine whether telephone interventions conducted with couples are as effective or are more effective than in-person interventions and whether telephone interventions with couples are logistically practical and cost-effective.

This review highlights a number of gaps in the literature on couples’ interventions in cancer. First, there were no interventions focusing on health or lifestyle behavior changes following a cancer diagnosis. Even though the second intervention arm in the study by Badger and colleagues [15] involved an exercise component, exercise was not a component of their intervention content for couples. Second, none of the studies focused exclusively on sexual functioning issues, even though this was a component in a few studies. It is noteworthy that such studies do not examine sexual functioning from a dyadic perspective. Third, all of the studies used similar modes of intervention delivery (i.e., in-person visits or telephone calls), which might not be desirable or feasible for all couples facing cancer. We now turn our discussion to each of these issues as potential avenues for future research.

The Need for Couples’ Interventions Targeting Lifestyle Behavioral Change

The social cognitive theory [64], one of the most robust models of behavior change, posits that individuals acquire behavioral routines by performing them, being reinforced for performance, and observing others. In the behavior change process, we are more likely to change when (1) we receive support from others who make us feel capable, express confidence in us, and provide specific feedback on our performance; (2) we see others modeling desired behaviors; and (3) we successfully perform the behaviors ourselves [17, 64]. Thus, interventions that include the patient’s spouse, the patient’s most important source of support [65], may be more powerful in promoting the cancer patient’s long-term behavior change.

However, if not carefully designed and implemented, such interventions may seek to enlist the spouse to “help” the cancer patient make behavior changes but instead may leave the patient feeling controlled or overprotected. This may explain why behavior change studies enlisting spouses only as supporters have reported limited success [66]. Consideration of social support within the context of theories such as Self-Determination Theory [67] may enhance the understanding that how support is provided is important. Specifically, this theory emphasizes the provision of autonomous support such that the receiver of support actually feels a sense of volition, choice, and control. Exerting social control tactics (e.g., demanding, threatening, criticizing, or using guilt) can actually have a negative effect on health behavior change. For example, Helgeson and colleagues [68] found from interviews of men with prostate cancer that if their wives used social control over health-comprising behaviors like smoking, it was associated with poor health behavior. It also was associated with greater psychological distress.

Recently, it has been suggested that behavior change interventions may be most effective if they consider the interdependence of the couple—how one partner’s attitude and behavior supports his/her own behavior change as well as that of the other partner. Thus, motivation for behavior change requires both members to engage in behaviors that serve the best interest of the relationship (relationship-centered) rather than the best interest of oneself (person-centered) [69]. When motivation is transformed from being self-centered to relationship-centered, it increases the couple’s confidence that they can successfully cope together. For this communal coping to be effective, partners must develop a sense of confidence that together, they can plan, coordinate, and execute their strategies and that their joint behaviors will increase their mutual benefit and lessen their individual risk. Encouraging both partners to adopt and maintain healthy behaviors is particularly important since there is a strong concordance between spousal health behaviors [70] and spousal health behavior change [71].

Couple-based interventions are consistent with theories of behavior change such as Social Cognitive Theory, which emphasize the importance of social influence on the process of behavior change [64], and Self-Determination Theory [67]. The format encourages couples to model healthy behaviors for each other; observing one another’s success can increase each partner’s confidence. In the process, couples learn to provide one another with support and feedback regarding goal setting and to work together to solve problems and overcome barriers. They also develop skills in working together to enlist support from their environments. Finally, this process of making behavioral changes together (e.g., taking walks or preparing meals) can help couples create positive memories that make them more likely to want to continue behavior change efforts. Couples working together as they set individual and couple-focused goals will likely increase their success in changing their behaviors. Indeed, couples report that having their partner perform and model goal behaviors, join in discussions of health issues, and provide emotional support encourages their own behavior change [72].

Currently, support for such a model has shown promise for increased screening for colorectal cancer, with higher attendance rates for those invited to attend screening with their partner, compared with those who were invited to attend alone [73]. A recent review of the role of social support in smoking cessation points to the mixed results for social networks, including spouses, to enhance intervention efficacy. However, the review highlights that findings may possibly be a function of how support was provided [74]. Thus, studies examining the efficacy of support in improving behavior change outcomes must be based on a guiding conceptual framework in which possible theoretical mediators for behavior change are studied. By using this approach, we may learn why, when, and for whom partner support promotes behavior change [9, 74].

The Need for Sexual Functioning Interventions to Take a Dyadic Perspective

Physical intimacy is vital to maintaining satisfying relationships and may reduce emotional distress [75]. Virtually all cancers and their treatments (i.e., surgery, radiation therapy, chemotherapy, and hormone therapy) either directly or indirectly affect patients’ sexual function [76]. Despite this, the vast majority of studies addressing sexual problems in cancer patients have been confined to problems that directly affect the reproductive and sexual organs. This finding is surprising because cancers that do not directly involve a sexual organ (e.g., hematopoietic cancers) may also indirectly affects sexual function via treatment side effects such as fatigue, pain, nausea, decreased sexual desire, and vaginal dryness and dyspareunia in women and erectile dysfunction in men.

Although there have been no couple-based interventions meeting our search criteria that strictly target sexual concerns from a dyadic perspective, couples’ interventions such as CanCOPE [17], relationship enhancement [26], and Kalaitzi’s [31] sexual counseling program have included body image and sexual components and have shown to be effective. However, all of these studies were in female cancers (e.g., breast and gynecological cancer). Canada and colleagues [77] conducted a counseling intervention aimed at improving levels of sexual satisfaction for prostate cancer survivors who had been treated with radical prostatectomy or radiation therapy and their partners. Couples were randomized to attend four sessions of counseling together or to have the man attend alone. Because the study did not include a usual care control group, it did not meet our inclusion criteria and was not included in our review. Session content included education about prostate cancer, sexual function, erectile dysfunction treatment options, and sexual communication and stimulation skills. Compared with patients in the patient-only intervention arm, patients in the couples’ intervention arm reported improvement in psychological distress, and patients and their partners reported improvement in sexual function at the 3-month follow-up; however, these treatment gains were not sustained at the 6-month follow-up.

Because patients and partners are likely to be of a similar age and experiencing the physical consequences of the aging process [78, 79], examining sexual concerns from a dyadic perspective is important. Indeed, it is well documented that within couples, sexual dysfunctions coexist [80, 81], and in cancer, research has shown that patient and partner sexual function is moderately to highly correlated (r  =  0.30 to 0.74) [82]. Even in cases where the partner is not experiencing sexual problems, he or she may experience increased distress and decreased marital satisfaction as a function of the loss in sexual and nonsexual intimacy with the patient [83]. Patients and partners may avoid discussing sexual concerns because they feel that the changes in sexual and nonsexual intimacy are time limited and that they will return back to normal after treatment. However, for many, these changes are long-lasting [84], and research has shown that open discussions about sexual concerns may help to alleviate the negative impact that sexual problems have on both partners’ adjustment [82]. Given this, interventions that address both partners’ sexual function concerns, facilitate healthy spousal communication, and help couples to set realistic goals and manage sexual expectations after cancer treatment may prove beneficial for both partners’ adjustment. Further research is needed to determine whether taking a dyadic approach is useful in both male and female cancers that affect sexual organs as well as in cancers affecting both genders that do not affect a sexual organ but still affect sexual functioning (e.g., head and neck or blood cancers).

The Need for New Intervention Modalities

While research supports the efficacy of in-person couples-based interventions for cancer patients and their partners, questions arise about generalizability, as most studies include primarily white, educated patients. Such demographics likely reflect who has access and ability to attend these programs, excluding patients residing in rural areas or areas distant from their care center, patients with limited resources and/or transportation problems, and patients with physical limitations that make travel difficult. Thus, employing interventions that can be widely disseminated is critical to advancing science and providing equal access for disparate populations. Emerging technologies—including the Internet, the telephone, and videoconferencing via the Internet or the telephone—allow for more widespread dissemination of psychosocial interventions through “remote counseling” [85].

Public Internet use continues to expand. According to the 2010 PEW Internet Report [86], Internet use was reported by 79 % of the adult population, and 66 % of adults have broadband access in their homes. The digital divide is closing in minority groups as 71 % of non-Hispanic blacks and 82 % of English-speaking Hispanics use the Internet. The multiple advantages of using the Internet for intervention delivery include reduced costs, increased convenience for users, improved access to isolated or stigmatized groups, and timeliness of access to the Internet [87]. In online support groups, participants share a high level of personal disclosure and openness, which is likely secondary to anonymity. The social equality that comes from this anonymity, the increased access to other survivors, and the potentially greater opportunity for self-expression are all features that may make the Internet a viable modality for delivering future couple-based interventions [88].

Videoconferencing is another means by which couple-based interventions could be delivered. The benefit of this modality is that communication would occur in real time with the added benefit of verbal and nonverbal cues. A counselor can moderate the discussion and ensure participants the opportunity to participate in the discussion. Such interventions could occur by Internet or telephone [85]. Internet-based videoconferencing could occur through the use of a computer with a webcam and an appropriate videoconferencing platform. Couples could access the Internet from home, work or even during travel. Another alternative is to provide the videoconferencing system through the telephone, which couples could access at a location of their choice. Existing studies with cancer patients have examined the use of videophones to deliver psychosocial interventions in an individual format [89, 90]. Studies consistently show the feasibility of using the videophone technology even with very ill patients, including terminally ill cancer patients diagnosed with adjustment disorder or major depression [89] and dying patients [90]. More research is needed to determine the intervention preferences of couples coping with cancer and whether factors such as patient advanced disease status, age, or comfort with technology affect receptivity to such interventions.

Conclusion

Cancer takes a toll on both patients and their partners, and targeting the couple in psychosocial interventions is an approach that merits further investigation. Two areas that appear to be fruitful for future intervention include expanding choice of outcomes to include health behaviors and designing sexual interventions that include both patients and their partners and that address both of their sexual functioning concerns. At the same time, efforts are needed to strengthen future studies both conceptually and methodologically. For example, few RCTs have been designed to compare couple- and patient-oriented approaches, making it difficult to evaluate the relative efficacy of a couples approach. The majority of studies reviewed did not specify how theory was used in the development of intervention materials, did not examine mediators of intervention efficacy, and did not report on outcomes for partners; thus, existing research provides an incomplete picture regarding efficacy. More research is needed to determine whether intervention modality affects intervention efficacy and whether technologically based interventions are easier to disseminate and are cost-effective. Finally, questions remain regarding at what point in the illness and treatment trajectory couples’ interventions should be delivered, and how long the interventions should continue. Despite these issues, this review indicates that couples interventions appear to have beneficial effects in terms of improving psychosocial outcomes such as distress or couples functioning.