Education and Peer Discussion Group Interventionsand Adjustment to Breast CancerVicki S. Helgeson, PhD; Sheldon Cohen, PhD; Richard Schulz, PhD; Joyce Yasko, PhD, FAANBackground: We report a clinical trial comparing theeffectiveness of education-based and peer discussion–basedgroup interventions on adjustment to breast cancer.Methods: Women with stage I, II, or III breast cancer(n = 312) were randomly assigned to 1 of 4 group con-ditions: control, education, peer discussion, or educa-tion plus peer discussion (combination). Seven groups(each comprising 8-12 women) were conducted in eachof the 4 conditions (28 groups total). Adjustment wasmeasured before the intervention, immediately after theintervention, and 6 months after the intervention.Results: Consistently positive effects on adjustment wereseen in the education groups both immediately follow-ing and 6 months after the intervention. There were nobenefits of participation in peer discussion groups, andsome indications of adverse effects on adjustment at bothfollow-up examinations. The effects could be explainedby changes in self-esteem, body image, and intrusivethoughts about the illness.Conclusions: Education-based group interventions fa-cilitated the initial adjustment of women diagnosed withearly stage breast cancer. There was no evidence of ben-efits from peer discussion group interventions.Arch Gen Psychiatry. 1999;56:340-347EVIDENCE EXISTS that psycho-therapeutic group interven-tions conducted by profes-sional therapists facilitateadjustment to disease amongpeople with cancer.1,2However, the costsassociated with formal psychotherapygroups preclude communities from usingthem. Instead, community support groupsborrow some of the cognitive and behav-ioral principles of psychotherapy, often fo-cusing on providing emotional supportthrough peer discussion and informa-tional support through education. Educa-tion-based group interventions seem to pro-duce more consistent, positive effects onadjustment than peer discussion group in-terventions.3However, most interven-tions include components of both educa-tion and peer discussion, making it difficultto determine which is responsible for posi-tive effects on adjustment.4,5We compared the effects of educa-tion-based and peer discussion–basedgroup interventions among women withstage I, II, and III breast cancer. An edu-cational intervention was developed to pro-vide patients with informational sup-port, which we expected would enhancetheir sense of control over the illness andreduce feelings of uncertainty and confu-sion associated with the illness. A peer dis-cussion group intervention was devel-oped to provide patients with emotionalsupport, which we expected would en-hance self-image and promote positivedownward comparisons (ie, feeling luckyin comparison with others who were worseoff), both of which have been shown toenhance self-esteem.6Both interventionswere expected to reduce intrusive thoughtsabout the illness.We recruited a sample of 312 womenand randomly assigned them to 1 of 4group categories: control, education, peerdiscussion, or education plus peer discus-sion (combination). Seven groups in eachof the 4 conditions were conducted.Previous research suggests thatwomen with breast cancer want emo-tional and informational support. Thus, weexpected combination groups to be the bestadjusted. We predicted that both educa-tion-based and peer discussion interven-tions would enhance adjustment to dis-ease, but did not predict that one wouldbe more effective than the other.RESULTSRANDOMIZATION,PARTICIPATION, ANDTREATMENT FIDELITYIntervention condition was not associatedwith medical variables, demographic vari-From the PsychologyDepartment, Carnegie MellonUniversity (Drs Helgeson andCohen); Department ofPsychiatry, University ofPittsburgh (Dr Schulz); and theUniversity of Pittsburgh Schoolof Nursing and University ofPittsburgh Cancer Institute(Dr Yasko), Pittsburgh, Pa.ORIGINAL ARTICLEARCH GEN PSYCHIATRY/ VOL 56, APR 1999340©1999 American Medical Association. All rights reserved.ables, or use of other support services (all P..10).There was a single intervention effect on one t1 out-come, t1 negative effect, and it was an interactionbetween peer discussion and education, F1,308= 8.14,P,.01. Higher initial negative affect was observedin education-only (mean, 2.17; SD, 0.80) and peerPARTICIPANTS AND METHODSPARTICIPANTSWomen who had stage I or II breast cancer, were beingtreated with surgery and adjuvant chemotherapy, and livedwithin a 1-hour radius of Pittsburgh, Pa, were eligible forthe study. We contacted 445 patients from more than 40medical oncologists’ offices, and 364 (82%) agreed to par-ticipate. Of those, 312 agreed to randomization and pro-vided informed consent. Thus, our effective recruitmentrate was 70%.The age of the participants ranged from 27 to 75 years(mean, 48.25 years; SD, 9.64 years). Although physicians’offices were supposed to refer women with stage I and IIdisease only, our examination of medical records using theNational Cancer Institute criteria for staging revealed that25% had stage I disease, 69% had stage II disease, and 6%had stage III disease. Most women underwent lumpecto-mies (68%) rather than mastectomies (32%), which is con-sistent with the norms for the Pittsburgh area. Other de-mographic information is given inTable 1.RANDOM ASSIGNMENTGroup meetings were held in 1 of 3 sites in the Pittsburgharea. When 10 to 12 women had been recruited for a site,we randomized the group to 1 of 4 conditions (control, peerdiscussion, education, or combination). Women were nottold the condition to which they would be assigned dur-ing recruitment or during the baseline (time 1 [t1]) inter-view conducted prior to the intervention. Equal numbersof groups from each condition were conducted at each ofthe 3 sites. There were 28 groups consisting of 7 controlgroups (n = 77), 7 education groups (n = 79), 7 peer dis-cussion groups (n = 74), and 7 combination groups (n = 82).PROCEDUREGroups met weekly for 8 consecutive weeks. The peer dis-cussion and education groups met for 60 and 45 minutes,respectively. The combination group included 45 minutesof education followed by 60 minutes of peer discussion. Thetime 2 (t2) interview, conducted by telephone and mailedquestionnaire, took place 1 to 2 weeks after the interven-tion ended. Time 3 (t3) data were collected from a mailedquestionnaire sent 6 months after the intervention.GROUP INTERVENTIONSAn oncology nurse and an