|Year : 2016 | Volume
| Issue : 2 | Page : 157-169
The effectiveness of support groups in Asian breast cancer patients: An integrative review
Fang-Yu Chou PhD, RN 1, Frances Lee-Lin2, Lily Y Kuang1
1 School of Nursing, San Francisco State University, San Francisco, CA, USA
2 Oregon Health Science University, Portland, OR, USA
|Date of Submission||09-Jun-2015|
|Date of Acceptance||06-Jul-2015|
|Date of Web Publication||25-May-2016|
Associate Professor, School of Nursing BH358, San Francisco State University
Source of Support: None, Conflict of Interest: None
Cancer support group has been studied as an intervention to improve patient psychosocial well-being. The effectiveness of support groups among Asian breast cancer (BC) patients has been unclear and received limited attention to the evidence of its effectiveness. The social-cognitive processing theory underlies the principles of support groups and advocates that a positive, supportive social environment can improve cognitive processing. The purpose of this paper is to present an integrative review of research evidence on the effectiveness of cancer support groups with Asian BC patients. Empirical studies related to support group among Asian and Asian American BC patients published between 1982 and April 2014 are reviewed. There are 15 studies selected (12 from the Asian-Pacific region and 3 from Western countries). The review includes 1 qualitative study, 3 descriptive studies, 1 mixed method design, and 10 experimental or quasi-experimental studies. The support group intervention activities include psycho-educational program such as health education, problem-solving, and stress management. These studies support the effectiveness of support group in alleviating psychological distress and supporting quality of life of Asian BC women. Overall, there is limited research on the use and effectiveness of support groups with Asians cancer patients in Asia and in Western countries. Without accounting for Asian immigrants overseas, the Asian population is expected to grow from 4.3 to 5.3 billion by 2050. As cancer patients become more diverse due to global emigration, more rigorous studies examining the effectiveness of psychosocial intervention among transcultural cancer patients are needed.
Keywords: Support group, Asians with cancer, review
|How to cite this article:|
Chou FY, Lee-Lin F, Kuang LY. The effectiveness of support groups in Asian breast cancer patients: An integrative review. Asia Pac J Oncol Nurs 2016;3:157-69
|How to cite this URL:|
Chou FY, Lee-Lin F, Kuang LY. The effectiveness of support groups in Asian breast cancer patients: An integrative review. Asia Pac J Oncol Nurs [serial online] 2016 [cited 2019 Jan 19];3:157-69. Available from: http://www.apjon.org/text.asp?2016/3/2/157/162826
| Introduction|| |
Breast cancer (BC) survivors are the most prevalent cancer survivors with 4.4 million survivors living up to 5 years postdiagnosis.  Due to improvements in early detection and treatment, the population of BC patient is expected to increase, and research has focused on BC patients' experience and needs. The need for psychosocial support among cancer patients is well-established in Western countries. Numerous studies have reported on the emotional distress experienced by BC patients. BC patients reported experiencing high levels of psychological distress and depression, particularly after diagnosis and treatment, and need psychosocial support. ,,,, One study found that 41% of recently diagnosed BC patients experience high levels of distress and 11% had clinically significant levels of depression.  As a result, numerous studies have explored the role of cancer groups in improving cancer patients' well-being.
The social-cognitive processing theory (SCPT) is consistent with the use of cancer support groups. This theory explicates how the social context influences emotional adjustment to cancer. It advocates that a positive and supportive social environment improves cognitive processing by allowing cancer patients to reflect and discuss thoughts and feelings caused by cancer. , A cancer support group can provide an exchange of social and emotional support and educational information for cancer patients in a comfortable social environment; thus, it helps patients to cope with cancer by adjusting their attitudes, knowledge, and expectation about the disease. ,,,,,, According to SCPT, two critical processes lead to optimal health and adjustment following a stressful event:
- Emotional expression
- Social support (SS)
Both of these processes are inherent to most support groups. The majority of support group interventions studies were conducted in Western countries and used Caucasian and/or African American cancer participants. Due to communication style and culture differences, it is questionable whether the Western intervention of cancer support group is applicable and effective with Asians BC patients. Early cross-cultural research suggested that the common communication style for Asian Americans was an indirect mode with minimal expression of emotion. , Asians are reported as less likely to express their emotions freely in public. Seeking help for emotional support outside of the immediate family is commonly perceived by family and others as inadequate family training and can result in loss of face for one's family.  Additionally, the Asian culture promotes homogeneity among its members and perceives deviants as shameful and embarrassing. In fear of being stigmatized by their illness, most Asians refrain from openly discussing their sickness with others. 
Globally, the implementation of both clinical and lay cancer support groups is increasing. Yet, it is unclear if a support group intervention is effective for Asian BC patients. The purpose of this paper is to review research on cancer support group interventions among Asians BC patients and to examine whether groups consistent with SCPT is a cultural fit with them.
| Methods|| |
A literature search for research studies related to emotion expression and receipt of emotional support in a social-cognitive supportive group environment among Asians. According to the US Census, "Asian" is defined as an individual with origins from the Far East, South-East Asia, or the Indian Subcontinent.  The computerized databases MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, and PsycINFO were searched for research studies written in English from 1982 to April 2014 that addressed support groups among Asian populations. The key words used in the search were: "Psychosocial support," "emotional expression," "support groups," "health," "BC," and "Asians." The reference lists from these studies were also carefully reviewed. Articles that did not involve:
- Cancer support group interventions
- Discussion sessions
- Quantitative or qualitative psychosocial evaluation of the intervention were excluded from the review
| Results|| |
Of the 27 studies identified and reviewed by all authors, 12 were excluded because they did not meet inclusion criteria. A total of 15 articles related to group interventions for Asian cancer patients were identified. Most of the studies were reported a decade ago 73% and used female subjects only 60%. Three studies used male subjects in addition to female subjects ,, and 3 studies did not disclose the gender of their subjects. ,,, One dissertation study  was included in this review. All types of studies were included; study designs included 1 qualitative studies,  3 descriptive studies, ,, 1 mixed qualitative and quantitative design,  and 10 random-control trial or quasi-experimental studies. ,,,,,,,,, Twelve out of 15 studies were from Asian Countries. Two were from Hong Kong, , 1 from China,  1 from Malaysia,  1 from Indonesia,  and the majority (n = 7) was focused on Japanese BC patients in Japan. ,,,,, Only 3 articles about cancer-related support groups were conducted in Western countries; 2 studies originated from United States, , and 1 was from Australia  [Table 1].
|Table 1: Summary of cancer support group studies in Asian cancer patients|
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Support groups among breast cancer patients in Japan
A pilot study  was one of the first studies conducted in Japan to compare group support counseling with individual counseling among 20 Japanese BC women with a random assignment study design. Both individual and group supportive interventions were based on a series of once a week, five 1-h sessions, which included psycho-education, problem-solving, psychological support, relaxation training, and guided imagery (SCPT concepts). The study results concluded that the intervention was not effective in changing coping styles. While, there were significant decreases in the reports of depression, fatigue, anxiety, and mood disturbances. The results indicated that both interventions were positively effective in decreasing psychological distress. Despite the hesitation to talk to each other in earlier sessions, the author was surprised to find that all women were able to discuss their disease directly using words, which are often considered culturally "taboo" such as "BC" and "metastasis." In addition, participants that received the individual therapy expressed interest in the group support intervention method; however, the reverse was not true.
Following the pilot study,  the research team ,, published a series of articles from studying the effects of a structured psychiatric group intervention on 57 Japanese BC patients' emotions. The study demonstrated the effectiveness of the intervention in alleviating some psychological distress.  When evaluating its effectiveness after 6 months, the investigators found individual differences for maintaining positive adjustment. Patients with lymph node metastasis and/or those with a psychiatric diagnosis at entry did not show persistent effects in psychological adjustment.  After adding 3 more group meetings, the intervention then showed effectiveness in patients with lymph node metastasis and/or with adjustment disorders.  Based on findings, the authors recommended that a structured psychiatric group intervention as theorized by SCPT has prolonged effects in decreasing psychological distress, even with patients with metastases and/or adjustment disorders.
In another series of studies from Japan, ,, the cultural applicability of a structured psychosocial group intervention among Japanese women with BC was examined in a randomized clinical trial. The group intervention involved a series of six 1.5-h sessions that included health education, coping-skills training, relaxation training, and psychological support was provided to participants (SCPT). The study participants reported three aspects of the Western-based group intervention were inappropriate and required significant changes that were, the discussion of sexuality, provision of medical statistical information, and communication sessions with husband and doctors. The authors concluded that it might be too distressing to face the news and that women were concerned that hearing the information might diminish their hope and desire to fight their cancer.  On the other hand, most participants desired more psychological information (i.e., information on stress and how to cope) and wanted to discuss their own cancer experiences. Regarding family support, female family members, and friends were the main sources of support for Japanese women diagnosed with cancer, not their husbands. The authors further modified the intervention model and received positive responses from the participants. The authors suggested that psychosocial group support intervention was relevant for Japanese women diagnosed with BC when the model was adapted in the consideration for cultural differences.
In the consequent randomized controlled trial (RCT) study,  a 6-week structured, psychosocial group intervention; participants were assessed in 46 Japanese women with BC. The experimental group had significantly lower scores than the control group (CG) for total mood disturbance and significantly higher scores for vigor on the Profile of Mood States and for fighting spirit on the Mental Adjustment to Cancer scale. These positive results continue at the 6-month follow-up. The reasons of refusal to participate in the support group included work, childcare, and geographic distance.  It was also found that those who wished to participate were significantly older, with a high level of anxiety, and had surgery within the last 12 months. On the other hand, nonparticipants without any interest had significantly higher anxiety levels than those with interest but unable to participate. The authors suggested that other support such as medication or individual psychotherapy might be needed to help alleviate the psychological distress among those that expressed no interest in support groups.
Support groups among Chinese cancer patients in Hong Kong and China
A qualitative study  explored the benefits of SCPT self-help peer-facilitated cancer groups from the perspective of 12 Hong Kong Chinese patients with cancer. The reported benefits included feeling connected by mutual cancer experience and being able to share openly about their difficulties. Most participants also reported improved self-care, a sense of empowerment, role modeling and positive outlook. The reported negative experience is the sad feeling when the condition of a close group member deteriorates.
Another randomized trial study conducted in Hong Kong  examined the psycho-physiological outcomes of different psychosocial group interventions for 87 BC patients in Hong Kong. Participants were randomly assigned to a no-intervention CG or three intervention groups: Body-mind-spirit (BMS) (a culturally-sensitive approach), supportive-expressive (SE) (a Western-style intervention approach), or a SS self-help group. The intervention course was over 5-8 weeks depending on support group. Psychiatric morbidity, distress level, mental adjustment, emotional control, and SS were measured and salivary cortisol was used as the physiological stress marker. The study results indicated that BMS intervention, a culturally-sensitive approach, produced the greatest and the most persistent effects. Most participants in SE groups reported the treatment was helpful, but changes in total salivary cortisol were not statistically significant from baseline for this group. Participants in SS group had adverse effect on negative emotions in members after 4-8 months. The nonintervention CG reported a decline in SS. The authors suggested that an active professional intervention which address of patient's spiritual needs and is culturally-sensitive is likely to generate therapeutic effects for Chinese BC patients.
Another study was conducted in mainland China  to evaluate the benefits of a psychosocial interventions among 178 BC and various cancer patients who receive radiation therapy (RT) in a RCT. The intervention includes: Psycho-education, cognitive behavioral therapy, and SE therapy. The levels of anxiety, depression, and quality of life (QOL) were evaluated during the study period and poststudy 2 years follow-up on the overall and disease-free survival (DFS) were also examined. The results showed that the intervention group had significantly improved depression, anxiety, and health-related QOL in the posttreatment stage. However, at 2 years post-follow-up, there was no improvement in the overall and DFS rate in the intervention group compared to the CG. The authors concluded that the psychosocial intervention is effective in reducing levels of anxiety and depression of Chinese cancer patients receiving RT.
Support groups among Asian cancer patients in Indonesia and Malaysia
The effect of participation in a support group on body image, intimacy, and self-efficacy for 87 Indonesian women with BC was explored in a quasi-experimental study.  The intervention group received the intervention in semi-structured meetings from a female nurse facilitator over the course of 6 weeks. Information related to BC, its treatment, problem-solving, stress reduction strategies were provided to the participants in the intervention group. The findings from this study did not support the hypotheses that Indonesian women with BC who participated in informational support group would experience positive responses on body image, intimacy, and self-efficacy. However, findings from author's field notes indicated that women found participation in the support group can improve their self-confidence, coping (by using learned disease information and coping methods), and communication with husbands and other family members.
A more recent study completed in Malaysia,  the effectiveness of a group psycho-education on well-being and depression was examined among a convenient sample of 34 Malaysian BC survivors. The group psycho-education included the presentation of medical information and discussion of cancer causes, prognosis, and treatment strategies. The results reflect that group psycho-education played a significant role in improving the well-being status and reducing depression of BC survivors.
Support groups among Asian cancer patients in the Western countries
There are 3 studies conducted in the Western countries that included Asian cancer patients and evaluated the effectiveness of cancer support groups. Through the conduction of interviews,  the preference for psychosocial support among a diverse sample of 194 newly diagnosed cancer patients were evaluated. The study sample (n = 194) consisted of Americans of European descent (35%), Filipino Americans (17%), Native Hawaiians (18%), and Japanese Americans (30%). The cancer sites included breast (34%), prostate (26%), uterus (10%), and other (30%). The majority of participants (84%) in the study reported experiencing cancer-related distress. The results indicated that women and younger patients reported more stress. In addition, Filipino cancer patients reported more distress or a lower QOL when compared with the other three ethnic groups. Contrary to the investigators' expectations, both Japanese and Filipino American patients (64%) believed that a support group would have helped them, while only 38% of Hawaiians and 32% of European Americans responded that a support group would be helpful.
Another study reviewed the 10-year experiences of using support groups with Chinese women with cancer from San Francisco's Chinatown area.  The Chinese women in the study may be less acculturated in the Western society than those women who live outside of Chinatown. The Chinese women's cancer support group was initiated in 1994 as a 6-week education and support program for 22 Chinese women with cancer. The main purpose was to meet the emotional needs of Chinese women coping with cancer. Each session consisted of a 1-h educational lecture and a 1-h facilitated discussion. The meeting was conducted in Cantonese Chinese. In a survey evaluation at the end of 2002, most participants reported that the program helped them with coping with cancer by feeling more supported, less isolated, more hopeful, more knowledgeable about resources, and were now able to help others. A majority stated that they had applied skills they learned (i.e., Tai Chi, meditation, communication, coping with stress, centering, anger management, sharing, etc.) to their lives. Additionally, the women in the study also expressed difficulties in sharing their cancer experience with their young children. The study reported that in response to women's concerns, the "Dr. Play" children's support group for children age 4-14 was established in 1999. The women reported that the children's support group helped their children to feel more secure and self-assured, and more able to face the reality of their mothers having cancer. The authors suggested having a group conducted in their own language and having committed bilingual and bicultural group facilitators has been integral to the effectiveness of this support group. It is likely that the trust and support from facilitators and among support group members facilitated cognitive processing and psychological recovery for these Chinese women with cancer and their children in Chinatown.
In a similar study conducted in Australia,  a culturally and linguistically sensitive Chinese women BC support group was developed and evaluated. This study was based on a prior pilot study  and found that Chinese-Australian BC women with unmet information needs and frustration regarding the lack of culturally appropriate cancer support resources in their Chinese language. This support group was facilitated in Cantonese for a total of 8 weeks for 29 women. The group meeting involves educating patients on BC management and remission prevention by using culturally relevant examples (i.e., using Chinese food remedies to control cancer treatment side effects) and promoting patients sharing their information. The evaluation showed that the program was helpful in instilling a sense of interconnectedness among its users and minimized their feelings of alienation and helplessness. It helped these women connect with others with the same language and who are in similar situations. A majority of participants provided positive evaluations on the program and they strongly agree or agree that the program improved their understanding of BC management, increased their confidence in ability to cope, provided opportunities to share their questions or anxiety, and suited their needs.
There are immense opportunities for providing emotional group support to Asian cancer patients. As evidenced by the above review, there has been limited research investigating Asian cancer patients' perception and acceptance of support group intervention. However, the above studies suggest that Asian patients expressed interest in and benefited from cancer support groups similar to findings for Western patients.
Despite stereotypical assumptions that Asian culture devalues the public expressions of emotions, the principles associated SCPT as applied in cancer support group showed some promising benefits in Asian populations if the process integrates Asian cultural values and languages. Many Asians in Japan, China, Australia, Canada, and the US showed interest in the support group approach and believed a support group would help them in coping with cancer. ,,,,,,,,,,
The 7 articles completed in Japan provided some pioneer groundwork for studying support group intervention in Asian countries. The results indicated that support groups were relevant for Asian cancer patients when the intervention accounted for cultural differences. The participation rates in the Japanese studies were lower than those achieved in previous studies conducted in Western countries, which have ranged from 60% to 87%.  Cultural differences may explain the lower participation rate in these studies. Further research is needed to explore concerns of nonparticipants with and without interests in a support group. Possible barriers may include lack of time, transportation and childcare issues, and stigma of having cancer. The stigma and negative beliefs about cancer could make it very difficult for Asian cancer patients. Some believed that it might have been caused by some crime the person committed in their previous life.  Additional psychosocial support interventions should also be explored to help ease cancer-related emotional distress for those Asian cancer patients who may not find a support group beneficial. Other types of cancer patients, Asian men with cancer, and other Asian subgroups can also be investigated with randomly controlled intervention studies in the future.
Similarly, the 5 studies conducted in Indonesia, Malaysia, Hong Kong, and Mainland China found support groups to be effective with Asian BC patients. Future studies should replicate findings using a larger sample size to clarify whether peer-led self-help supports benefits cancer participants and compare peer-facilitated groups with professional facilitated groups to examine whether there are differences in outcomes.  In addition, negative emotional effects of support groups, like grief of other members and feeling overwhelmed, were noted in some studies. , The support group interventions can take into consideration that group members bond through their mutual suffering, feel depressive over another group member's suffering, and need support on how to cope with depression and possibly, grief of a fellow member's death. ,
While it was found that the support group has no effect on the body image, intimacy, and self-efficacy,  the possible effects of lack of culturally-sensitive measures and confounding effects from treatments can also be further explored. The adjuvant therapies, along with lymphedema complications, change the physical appearance of the breast and adversely affect women's psychosocial. Furthermore, women with limited functional status related to treatment and mastectomy are associated with low self-esteem, poor body image, and depressive symptoms.  However, other studies suggest that Asian women are less concerned with their body image and more concern on whether they are still able to perform their roles as a wife and mother. ,
There were limited studies conducted in the Western countries regarding cancer support group among Asian ethnic groups and most of them were descriptive studies. Further studies with interventional designs are needed to evaluate the effectiveness of social-cognitive processing support group among Asian cancer patients in Western countries. Furthermore, from the above review, Japanese Americans, Filipino Americans, Native Hawaiian, Chinese Americans, and Chinese-Australian were the only Asians/Pacific Islanders studied to date in the Western countries. There are over 25 Asian ethnicities; each group is unique and differs in language, culture, and beliefs. Other Asian subgroups (i.e., Korean, Vietnamese Americans, etc.) should also be studied to detect the within-group differences. Asian subgroup differences between Filipino and Japanese Americans were noted in the study.  Moreover, new immigrants, affected by communication barriers and unfamiliarity with the Western health care system and values, are likely to have different preferences of support.  The style of the facilitator is also likely to be important. For example, the bilingual and bicultural group facilitators was reported having was an important factor in making their support group program a success in Chinatown. , For example, it was reported that Japanese patients preferred an authoritative therapist style. 
Research findings suggest that individual difference factors may explain the variability in comfort levels of Asian with emotional expression and SS. It was found  that highly acculturated Asian Americans were very similar to European Americans in emotional expressions. However, age differences were more significant than either ethnic or acculturation differences. A higher distress level in younger women was consistent with the study of ethnic differences in emotional responses in both Chinese and European Americans. , Similarly, it was reported that younger cancer patients reported more psychosocial stress.  It is likely that age and acculturation differences are more significant than ethnicity alone in explaining the needs for psychological support. Furthermore, cancer patients of different stages have different needs; patients who are newly diagnosed and going under treatment seek related information. Some studies reported that Asian BC patients of different stages of illness have different motivation for attending support groups. ,, It was recommended that newly diagnosed patients be provided a structured group course until they have come to terms with their illness and decided on their treatment options. Then, the patients can focus on their emotions, become receptive to support, and develop coping methods. Further studies may also focus on the differences between support groups for early BC patients and those for patients straggling with metastatic disease to identify any different needs.
Finally, descriptive data suggest that health care providers and cancer patients may be poorly informed about the availability or potential values of support groups for Asians.  It is likely that many providers hold a stereotypical basis and believe Asians do not openly express emotions; therefore they may be hesitant to refer Asian patients to support groups. Proper education on the availability and values of a cancer support group should be provided to cancer health care providers and Asians cancer patients.
Without accounting for Asian immigrants overseas, the Asian population is expected to grow from 4.3 to 5.3 billion by 2050.  Their rapidly increasing numbers suggest the need for rigorous study of this population. Also, given that Western countries are increasing in diversity due to transglobal travels, there is a demand for studies to examine how Western support groups met the needs of ethnic cancer patients. To improve the QOL of Asian cancer patients, psychosocial interventions should be further developed and evaluated. A theoretical framework provided by the SCPT has applicability to this group of cancer patients. Considering cultural differences when implementing psychosocial interventions based on SCPT, which have primarily been developed in Western culture, may help to achieve maximum psychosocial benefits in Asian populations.
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Conflicts of interest
There are no conflicts of interest.
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