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Interventions 1. Primary prevention The most useful prevention strategy is reduction in tobacco consumption (all forms).

. Currently about 50% of cancers in men and 20% of cancers in women are related to tobacco use. These cancers can be prevented to a large extent through a comprehensive tobacco control programme which will include awareness, education, legislation, community participation and tobacco cessation services. A healthy lifestyle, which includes eating plenty of fruits and vegetables, avoidance of alcohol and adequate physical activity, is protective for many of the non communicable diseases including cardiovascular disease and diabetes, and can be considered as part of the overall health promotion programmers. Cancers related to infectious agents such as human papillomavirus and hepatitis B virus can be prevented through vaccination strategies. Screening Screening is the application of a relatively simple and inexpensive test to asymptomatic subjects to classify them as being likely or unlikely to have cancer. A screening test in itself will not prevent cancer; it needs to be followed up through a systematic approach. Opportunistic screening or case finding can be attempted, but may not result in significant reduction in the incidence of cancer in a population as the coverage will be poor. However, it might help to increase the awareness and produce the human resources needed for future programmes, which include populationbased screening in an organized manner with proper mechanisms for call recall and quality control. At present, cytology-based Papanicolaou smear screening is the only proven strategy for cervical cancer and this can be undertaken in areas which are covered by cancer registries. Alternative strategies are being researched and might prove beneficial in certain settings. At present, mammography as a screening tool is not applicable to India. Breast cancer awareness can be propagated along with provision for fine-needle aspiration cytology, pathology services and surgical interventions. Once-a-year clinical breast examination can be made feasible for women above the age of 40 years, which can be carried out by general practitioners or trained health workers.

Cancers in accessible parts of the body like the oral cavity may be detected at an early stage or even in a precancerous stage through simple inspection and examination, which can be practised by a trained health care worker. Self-examination of the oral cavity (MSE) and breast (BSE) can be useful methods and each can be propagated widely as a strategy. Early detection, diagnosis and treatment/referral chain Cancer detection and diagnostic facilities have to be made available at medical colleges and district-level hospitals if they are to be accessible, and a clear referral chain should be established to ensure that those who require further treatment are referred to higher-care centres such as RCCs. Medical colleges should have provision for the management of all early common cancers. Dedicated centres need to be established for the management of paediatric cancers. RCCs should be equipped for comprehensive cancer control, treatment and research. Palliative care Oral morphine has to be made available at the district level throughout the country. Various categories of health professionals need to be trained in the WHO step-ladder approach to pain management. Palliative care should be treated as an integral part of cancer management. Figure 2 depicts the appropriate course and mix of curative and palliative care services and the relative positions of the two approaches. Surveillance and monitoring The cancer registry programme has to be expanded and be made the monitoring component of the cancer control programme. At least 50% of the population has to be made aware NCMH Background PapersBurden of Disease in India Cancer: Current scenario, intervention strategies and projections for 2015 of the disease, its risk factors, prevention potential and curability. Paramedical personnel and field-level health workers have to be trained for providing awareness, documentation and ensuring compliance to referral and treatment. A comprehensive tobacco control programme must be implemented to reduce the prevalence of tobacco use by 10% from the current levels. 2.BEHAVIORAL MEDICINE

One of the most important contributions of the behavioral sciences during the last 40 years has been the development of effective intervention methods to facilitate positive psychosocial adjustment in adults and children. Most of the advances in behavioral theory and research have come from the disciplines of psychology and education. The focus of the work has been broad, from remedial education/training of the mentally retarded and rehabilitation of institutionalized psychiatric patients to behavioral coping strategies to control nausea in cancer chemotherapy patients and biofeedback training for stroke victims. The theoretical foundation for the work is found in the behavioral conditioning studies of Pavlov (6), Skinner (7,8), and Thorndike (9) as well as in the child development research of Bijou and Baer (1012). The early behaviorists did not propose elaborate models that specified particular psychologic needs; rather, they stressed the role of immediate environmental factors on behavior. In contrast to Sigmund Freud, Carl Jung, and other intrapsychic theorists who sought to determine the long-term effects of unresolved childhood issues and used lengthy psychoanalytic exploration, the early behaviorists focused on the here and now. Their behavioral interventions could best be described as practical, seeking to modify those conditions (environmental and social) and coping skill deficits that adversely affect daily functioning. With greater acceptance of behavioral intervention strategies within the medical health and education communities, this approach has been adopted in the treatment of increasingly complex issues. There is almost no aspect of our lives that has not been the focus of behavioral intervention. An important result of the broad application of the approach is an increased appreciation for the role of cognitive factors in behavior. Now, in addition to changing the patient's environment and coping skills, many clinicians focus on how to change beliefs, feelings, and attitudes that a substantial proportion of the behavioral camp believes affect people's behavior. The widening conceptual base of behavioral intervention is reflected in the terms frequently used to describe the approach; these terms include cognitive-behavior therapy, cognitive-behavioral approach, and behavioral medicine intervention. For the purpose of this review, we will use the term behavioral intervention. The application of the behavioral approach to the treatment and prevention of disease began in the early 1970s. The impetus was research on biofeedback in the treatment of headache, asthma, and epilepsy. Biofeedback provides the individual with a moment-tomoment feedback regarding normally nonvolitional functions, such as heart rate, body temperature, and electromyographic feedback. Biofeedback is typically provided as the individual sits quietly and attempts to control those vital functions. The dramatic success of such training for patients with asthma, epilepsy, and migraine headache drew considerable attention among both academic and lay groups (13). Those studying biofeedback immediately saw its potential importance in the treatment of a variety of medical disorders; in 1977, they held the Yale Conference on Behavioral Medicine (14). At that meeting, the following two issues were addressed: 1) the potential scope of the field (from prevention to rehabilitation) and 2) its break from psychosomatic medicine. Psychosomatic medicine evolved from the biomedical sciences with a focus on disease etiology and pathogenesis, whereas behavioral medicine evolved from the behavioral sciences with a focus on prevention and treatment of physical disease. In the early 1980s, investigators began to explore the application of behavioral medicine to cancer and its treatment. That early

work (1517) focused on the control of aversive side effects of cancer chemotherapy through the use of relaxation, hypnosis, and distraction. Behavioral medicine is now a major area of scientific research, with its own professional society, at least five professional journals, and two National Institutes of Health study sections for peer review of investigator-initiated research proposals. Behavioral medicine has also achieved considerable prominence among cancer-focused professional groups and funding agencies. The American Cancer Society supports both intramural and extramural behavioral research, and one of the major thrusts of the National Cancer Institute's effort in prevention and control is behavioral. Moreover, a number of federal and private agencies support graduate and postgraduate training programs for those interested in the psychologic and sociologic factors in cancer. There clearly appears to be broad professional recognition of behavioral factors as they contribute to cancer treatment. As discussed above, behavioral interventions are concrete in their focus and application. The clinician is interested in what can be done to alter those coping skills and environmental, physical, social, and cognitive factors that affect the person's behavior in specific situations. However, in the case of cancer, the physical factors that affect behavior are often difficult to change. For example, although specific factors that contribute to the occurrence of treatment side effects (e.g., the emetic potential of chemotherapeutic agents) have been identified, it would be medically ill advised to change them (e.g., reduce the intensity of treatment) as a way to reduce aversive side effects. For this reason, clinicians have focused on teaching patients behavioral coping skills. Training is directed toward teaching specific behaviors that reduce anxiety, nausea, pain, and related distress. The clinician and the patient usually work as a team, and much of the intervention is carried out by the patient. For example, the patient who becomes highly anxious during venipuncture might be taught paced breathing and self-hypnosis and then instructed how to use the newly found skills during aversive medical procedures. Previous SectionNext Section SPECIFIC BEHAVIORAL TREATMENT METHODS Before the specific methods used to reduce aversive side effects of cancer treatment are outlined, it is important to point out the critical role of assessment in behavioral intervention. The emphasis on ongoing assessment is an important factor that distinguishes behavioral intervention from more traditional psychodynamic approaches. Such assessment is critical at every point in the course of the intervention: 1) before the actual intervention is initiated to determine what environmental factors should be targeted for change and what resources the patient has to facilitate the intervention, 2) during the period when the intervention is being implemented to provide feedback so that the methods can be refined to meet the patient's particular needs, and 3) after the intervention is completed to guide follow-up care. In each instance, assessment involves monitoring the patient's behavior in terms of its frequency, intensity, and the circumstances under which it occurs. The following eight specific methods have been used in behavioral intervention to reduce aversive side effects of cancer treatment: 1) contingency management, 2) cognitive/attentional distraction, 3) hypnosis/distracting imagery, 4) systematic desensitization, 5) emotive imagery, 6) relaxation training, 7) cognitive restructuring, and 8) modeling. Each method is briefly reviewed below. The application of these behavioral methods to specific problems associated with the treatment of cancer has been guided by

practical concerns and by clinical judgment as well as by behavioral research in education and psychology. References for each procedure are provided so that the reader can obtain fuller descriptions of methods and their clinical application. 1) Contingency management. Based on Thorndike's Law of Effect (9), contingency management involves the use of rewards (prizes, treats, and/or special events) to increase the patient's adherence to the treatment regimen. It has been used most frequently on pediatric cancer patients to encourage their cooperation. For example, parents might implement a program in which their child receives stars toward the acquisition of a special toy or treat contingent on his/her lying still during painful diagnostic and treatment procedures (18,19). Contingency management is typically used in the context of a larger intervention program incorporating a number of behavioral methods. 2) Cognitive/attentional distraction. This distraction method is used to control nausea and acute pain/distress. It involves engaging the patient in highly interesting (i.e., absorbing) activities during invasive procedures. Although the mechanism underlying the role of attentional distraction in symptom control has not been identified formally, it is presumed that the patient's attention to (i.e., awareness of) aversive stimuli is blocked by his/her involvement in the task. Activities used to effectively block the occurrence of aversive side effects through distraction include the following: guided imagery (20), storytelling (21), video game playing (22), and playing with a party blower (a simple paper noise maker) (20,21). Guided imagery training (primarily used with adults) and storytelling (used with children) are quite similar and involve the clinician's presenting imagery suggestions like those used in hypnosis (e.g., floating on a raft on a quiet lake and sitting by the ocean as the waves ebb and flow). The positive effects of distraction usually last only as long as the patient is actively engaged in the distraction task. That is, symptoms are controlled while the patient's attention is focused on the distraction task, but they return immediately if the patient's focus is lost. This limitation does not usually present a clinical problem because many aversive treatment procedures, like venipuncture, can be completed relatively quickly. For procedures that are prolonged, patients can be taught to maintain focused attention for extended periods of time. If symptoms break through, the patient can return to the distraction task and regain symptom control. 3) Hypnosis/distracting imagery. There are theoretical controversies regarding what constitutes hypnosis, and interventions employing hypnosis vary in the treatment strategies used (2326).Although hypnosis has historically been considered at times to be a psychoanalytic approach in psychotherapy [e.g., see (27)], more recent conceptualizations of hypnosis have clearly placed it within the behavioral realm [see Kirsch (28)]. Such conceptualizations argue that hypnosis employs what are now considered to be classic behavioral intervention approaches (e.g., distraction and relaxation). Although the use of hypnosis predates behavioral medicine, contemporary hypnosis researchers recognize that hypnosis is not a therapeutic treatment modality per se, but rather it is one technique under the behavioral umbrella [see (29)]. Classifying hypnosis as a behavioral technique emphasizes its operational components and avoids

perpetuation of the myth that hypnosis is a magical experience (17,30). In this review, hypnosis is defined as a relatively simple process in which the patient learns to focus attention on thoughts or images unrelated to the source of distress. While the patient is relaxed through meditation-like excursions to pleasant locations/activities, the clinician introduces suggestions of calm and well-being. With children, such imaginative involvement is often gained through storytelling. Hypnosis and attentional/cognitive distraction appear to rely on similar skills. Nevertheless, a meta-analysis (29) has revealed that using the term hypnosis can increase the beneficial impact of the behavioral intervention in a variety of circumstances. Although some patients may not be comfortable with hypnosis (31), for those who are, hypnosis may enhance clinical outcomes (e.g., improved pain control)(32). With cancer patients, hypnosis is used most frequently to control nausea, pain, and anxiety. 4) Systematic desensitization. This method is used to alter patients' aversive reactions to stimuli associated with treatment (e.g., anxiety and nausea upon seeing a chemotherapy nurse). It involves gradually introducing feared stimuli/events in a hierarchical manner, beginning with the least feared stimuli and progressing to the most feared. This exposure is carried out across individual sessions with the patient calm and relaxed. Exposure to feared stimuli/events can be in vivo (actual re-exposure to the feared stimuli while the patient is in a state of relaxation) or imaginal (exposure to verbal descriptions of the feared stimuli or situations). Fears gradually diminish with repeated exposure in this carefully programmed manner. A particularly dramatic example of in vivo systematic desensitization in the context of cancer treatment is its application to control a life-threatening eating disorder following successful gastrointestinal surgery in a female patient (33).Despite reassurances from her doctors that surgery had removed all of the cancer, the patient insisted that it was coming back. This belief was related to the fact that after surgery she would vomit and become upset whenever she tried to eat solid foods (as she did when her disease was first discovered). At the time that the psychiatric consultation was called, the only medical option was a feeding tube. Systematic desensitization involved a careful assessment of medical and psychosocial factors and then the gradual introduction of solid foods while the patient was relaxed. During twice-daily sessions, the patient was first relaxed and then gradually given solid foods. After 14 such desensitization sessions, the patient was then able to retain solid foods and go home. A 9-month follow-up evaluation revealed that the patient had returned to her normal weight and displayed no behavioral symptoms. In addition to presenting the application of systematic desensitization, this case demonstrates the critical role that behavioral factors can have in recovery after cancer surgery. 5) Emotive imagery. This method is similar to desensitization, distraction, and hypnosis and is used most frequently with children. It differs from those procedures because it incorporates personalized storytelling and takes advantage of the child's openness to fantasy. After establishing rapport with the child, the clinician determines the child's favorite storybook hero and then tells the child a series of stories involving the child and his/her hero. The child is encouraged to become engaged in imagining himself/herself being helped by the hero. Each subsequent story brings the child closer to the feared setting/procedure, while

the hero and the child master the situation. The rationale is that the elicitation of strong anxiety-inhibiting emotive images in the context of the feared stimuli/procedures will reduce anxiety reactions (1921). Parents are frequently involved in the intervention and retell the stories during invasive diagnostic and treatment procedures. 6) Relaxation training. The goal of relaxation training is to teach the patient how to establish a state of deep relaxation, which has been shown to reduce pain (34) and anxiety (35) and to facilitate distraction (3638). During training with a clinician or via an audio-tape recording, the patient learns to focus on soothing images, to tense and release muscles, and/or to breath deeply. With practice, the patient is able to control his/her level of relaxation and to go quickly into a state of deep relaxation. The patient then uses this skill during aversive procedures and when he/she feels tense and anxious. A variety of related techniques have been developed to increase relaxation and to reduce anxiety and distress. They differ primarily in terms of the techniques used to induce relaxation. Patients are instructed either to focus on tranquil imagery (focused imagery), to tense and release muscle groups, or to deepen and slow the pace of breathing. Hypnosis has also been used as a method for relaxation training (17), since deep breathing and focused imagery are common components of hypnotic inductions (39). For this reason, in clinical practice, it is often difficult to distinguish between relaxation and hypnosis. 7) Cognitive restructuring. Cognitive restructuring interventions are used to alter beliefs and attitudes that may contribute to the patient's distress. This technique is similar to that used by many modern psychotherapists who often encourage the patient to reframe stressful life events as less threatening and under his/her control. In this way, the patient is encouraged to restructure his/her thoughts and beliefs. This method involves the patient and clinician reviewing thoughts, feelings, and beliefs about medical treatment/procedures in order to identify those that elicit fear and distress. The patient is then encouraged to consider other ways of viewing the fearful event(s) that might help reduce feelings of distress and anxiety. An interesting example of the use of cognitive restructuring is reported by Chen et al. (40), who studied children undergoing lumbar puncture in the treatment of leukemia. To reduce the children's distress, Chen et al. had them recall and then more realistically appraise their responses to their most recent lumbar puncture. The aim was to enhance the children's confidence and beliefs regarding their ability to cope effectively with the pain and distress of lumbar punctures. The intervention was successful, resulting in reductions in both pain and distress. 8) Modeling. This method involves the use of in vivo or videotape demonstrations of successful coping during invasive diagnostic/treatment procedures to teach behavioral coping skills. It is most commonly used with children. One example of this method is the use of a film in which a child scheduled for repeated bone marrow aspirations describes thoughts and feelings that he/she often experiences and then demonstrates behavioral coping skills to manage his/her fear and distress (19). Previous SectionNext Section

3. Accomplishments in Pediatric Oncology Research Related to Psychological Intervention A strong foundation for psychological intervention research in pediatric oncology has developed over the past two to three decades. Work contributing to this empirical foundation may be classified into four general areas of accomplishment: understanding and reducing procedural pain; realizing long-term consequences; appreciating distress at diagnosis and over time; and knowing the importance of social relationships. For each of these areas, I present major and consistent findings and their applicability toward intervention, as well as summaries of pertinent empirical intervention research. Understanding Procedural Pain Applications of behavioral models and treatments to help children undergoing invasive and painful procedures as part of their cancer care are exemplars of research that informs clinical practice in pediatric oncology. A range of cognitive and behavioral approaches have been utilized and investigated, including preparation, desensitization, imagery, relaxation, modelling, distraction, and positive reinforcement. Approaches that use a combination of cognitivebehavioral approaches are among the most commonly studied (Kazak & Kunin-Batson, 2001) and are regarded as well-established treatments (Powers, 1999). The procedural pain literature provides information potentially generalizable to other types of intervention. First, interventions in this field have developed systematically from wellestablished learning principles. Second, procedural pain interventions have been tested in carefully controlled studies and have used multiple outcome measures, such as child, parent, and staff report; observational techniques; and physiological measurements (e.g., heart rate) or neuroendocrine measurements (e.g., cortisol; Chen, Joseph, & Zeltzer, 2000; Jay, Elliott, Fitzgibbons, Woody, & Siegel, 1995). Furthermore, child factors such as temperament have been shown to affect intervention efficacy (Chen, Craske, Katz, Schwartz, & Zeltzer, 2000). Third, research has shown that parents and staff can learn and implement these interventions (Barrera, 2000; Blount et al., 1992; Kazak, Penati, et al., 1998). Fourth, application of these interventions has remained flexible to accommodate change. The availability, refined delivery, and positive outcomes of pharmacological treatments to prevent and reduce pain and distress during procedures have made use of cognitivebehavioral treatments less common in practice. Such shifts in treatment require flexibility in applying psychological knowledge to pediatric problems. For example, the integration of cognitivebehavioral therapy with other intervention approachesin this case, pharmacologichas proven highly effective (Jay et al., 1991; Kazak, Penati, et al., 1998) and can help identify new opportunities for intervention. Realizing Long-Term Consequences With increasing rates of successful pediatric cancer treatment, there has been a parallel increase in our appreciation for the medical and psychological sequelae of cancers and their treatments. In their review of late effects of cancer therapy,Friedman and Meadows (2002) highlight not only the growing body of research on adverse consequences of treatment but also the difficulties of conducting research in this area. Specifically, they emphasize the importance of integrating research and clinical care to identify and treat medical and psychological aftereffects effectively. The threatened or actual development of

late effects from pediatric cancer therapy provide important opportunities for psychosocial intervention, particularly for subgroups of patients at high risk for persistent difficulties. Indeed, data from the first major cohort of childhood cancer survivors indicate that psychological adjustment was in general quite good. Across studies from the late 1970s through the 1990s, a minority of survivors (10%20%) were reported to have ongoing distress; for most, adjustment was within normal limits as measured using standardized questionnaires (Kazak, 1994). The most consistent finding, in terms of factors associated with less positive adjustment, was disease and treatment that affected the central nervous system (Kazak, 1994). However, psychological late effects, neurocognitive and psychosocial, continue to be prevalent and concerning (Friedman & Meadows, 2002). Current thinking suggests that traditional or general measures of psychopathology and well-being may not have captured the specific and persistent experiences of childhood cancer survivors and their families. Empirical studies of posttraumatic stress disorder (PTSD; American Psychiatric Association [APA], 1994) and posttraumatic stress symptoms (PTSS) in survivors and their families offer one alternative. The fourth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM IV; APA, 1994) added experiencing a life-threatening medical condition or observing it in a close affiliate (e.g., family member) as a qualifying event for PTSD. With regard to PTSD in childhood cancer survivors, rates are low (5%10%;Butler, Rizzi, & Handwerger, 1996; Erickson & Steiner, 2001; Kazak, Barakat et al., 2001); however, they are considerably higher when assessing symptom clusters (e.g., reexperiencing, arousal; Brown, Madan-Swain, & Lambert, 2003; Erickson & Steiner, 2001; Kazak, Barakat et al., 2001). High rates of PTSD and PTSS are reported for survivors of childhood cancer when they are young adults (1521%,Hobbie et al., 2000; Rourke, Hobbie, & Kazak, 2002). For parents of childhood cancer survivors, rates of PTSD or partial PTSD range from 5% to 25% (Brown et al., 2003; Kazak, Rourke et al., 2001; Kazak et al., 2004; Manne, DuHamel, Gallelli, Sorgen, & Redd, 1998; Manne et al., 2002) with subclinical PTSD being common as well. Mothers and fathers were found to have significantly higher levels of PTSS than were parents of never-ill children (Kazak et al., 1997). In a subsequent study, nearly all families (99%) had at least one parent meet criteria for Symptom Cluster B (reexperiencing), and 20% of the sample had at least one parent with current PTSD (Kazak, Alderfer et al., in press). Data also indicate PTSS in siblings of survivors (Alderfer, Labay, & Kazak, 2003). An intervention to reduce PTSS has been evaluated in a wait-list control randomized clinical trial of 150 families. The Surviving Cancer Competently Intervention Program (SCCIP; Kazak et al., 1999) integrates cognitive behavioral and family therapy in a foursession, 1-day program involving groups of adolescent cancer survivors and their mothers, fathers, and siblings. Using this treatment model, survivors and family members identify ongoing distressing beliefs about cancer and its treatment and utilize an interpersonal systems framework to identify the current and likely future impact of cancer on the family. The results of the randomized clinical trial indicate that families randomized to the SCCIP arm showed significant reductions in PTSS, particularly for survivors and fathers (Kazak, Alderfer et al., 2004). A two-session intervention based on the SCCIP model has also been developed and piloted among 21 young adult survivors (Rourke et al., 2002). Most recently, this treatment model has been revised and piloted for caregivers of children at the time of diagnosis (Kazak, Simms et al., in press).

Health-related problems that can develop secondary to cancer and its treatment provide opportunities for psychological intervention in cancer survivorship. For example, common late effects affecting the cardiopulmonary, endocrine, or musculoskeletal systems can each have psychological components and thus provide targets for treatment strategies. As an example, smoking prevention is important for everyone, but childhood cancer survivors with cardiopulmonary late effects and those who are at risk for secondary malignancies provide a particularly opportune group to target. In a randomized clinical trial of a brief (< 1 hr) educational intervention delivered by telephone, Tyc and colleagues (2003)provided evidence that at 1 year postintervention (but not at 6 months), adolescent survivors who received the intervention showed increased knowledge of smoking risks, reported more perceived vulnerability, and indicated less intent to smoke cigarettes than did control participants. Appreciating Distress at Diagnosis and Over Time The largest area of work in pediatric oncology has examined the psychological reactions of patients and parents during the course of active cancer treatment. This work provides ample evidence of challenges faced by children and families but has returned inconclusive data with regard to potential intervention targets. For example, survivors of childhood cancer do not evidence elevated levels of depression (Recklitis, OLeary, & Diller, 2003; Zebrack et al., 2002). The types of depressive symptoms seen in pediatric cancer patients during treatment are often indicators of an understandable and normal response to the distressing circumstances of diagnosis and treatment; they can be understood and treated contextually (Kazak, Simms, & Rourke, 2002; Mulhern, Fairclough, Smith, & Douglas, 1992). Parents similarly show elevations in scores on measures of psychological distress (HoekstraWeebers, Jaspers, Kamps, & Klip, 2001) but, again, not clearly of the magnitude generally associated with help seeking or psychotherapy. The few prospective studies of adjustment over time report similar findingsthat distress attenuates over time (irrespective of intervention) and that early adaptive adjustment is associated with comparable adjustment over time (Best, Streisand, Catania, & Kazak, 2002; Hoekstra-Weebers et al., 2001; Kazak & Barakat, 1997; Kazak, Penati, Brophy, & Himelstein, 1998; Kupst et al., 1995;Kupst & Schulman, 1988). That distress is high at diagnosis and naturally attentuates for most families poses particular challenges for interventions during treatment. For example, in a randomized study of an eight-session psychoeducational intervention, both treatment and control groups improved over time (Hoekstra-Weebers, Heuvel, Jaspers, Kamps, & Klip, 1998). This highlights the potential importance for identifying specific targets of the intervention while being mindful of the fact that adaptation and coping over time will predict a natural decline in distress, regardless of intervention. The most promising interventions during cancer treatment appear to be those that are carefully timed and tailored to specific outcomes rather than those that rely on general outcomes. For example, problem-solving therapy has been shown to be more effective than treatment as usual in reducing negative affectivity and in increasing problem-solving skills for mothers of children currently in treatment (Sahler et al., 2002). These data have been replicated (Sahler et al., 2004) to show that a systematic, relatively easy-to-deliver intervention to address ways of solving problems may help mothers cope with the many stressful demands of cancer therapy and may provide benefits to their emotional well-

being. The data show the strongest support for short-term treatment effects, and the authors raise the possibility that problem solving may have an impact on other psychological outcomes over time (Sahler et al., 2002). In a pilot study with 22 mothers of children undergoing a bone marrow transplantation, Streisand, Rodrique, Houck, Graham-Pole, and Berlant (2000)demonstrated the feasibility of providing parents with stress reduction techniques in a one-session intervention. The data comparing the intervention to standard preparation suggest that the timing of intervention may be criticalin this case, before the admission for transplantation, when stress levels are elevated. Finally, building on a model that conceptualizes the diagnosis of cancer as a potentially traumatic event, a manualized intervention has been developed for parents and other immediate caregivers of newly diagnosed pediatric oncology patients (Kazak, 2002b). Using the SCCIP treatment model (Kazak et al., 1999), this three-session intervention helps caregivers link their cancer-related beliefs to their actions and emotions by identifying strategies to maximize adaptation in an interpersonal, family context. The goal of the intervention is to prevent PTSS and enhance family adjustment over the course of treatment (Kazak, Simms et al., in press). Knowing the Importance of Social Relationships Cancer affects families and other systems in addition to its obvious impact on patients (Kazak, Rourke, & Crump, 2003). This is particularly pertinent in pediatric oncology and explicit in the studies noted that include the family as well as the patient. Although this literature is less focused on treatment, research related to social relationships is critically important and relevant to intervention. The work of Noll and colleagues uses methodologically rigorous approaches to describe the peer relationships of children with cancer. In general, most children with cancer have been found to be quite resilient and have maintained good peer relationships over the course of treatment. Some consistent indications, however, suggest that children with cancer may be perceived as being socially withdrawn (Noll, Bukowski, Davies, Koontz, & Kulakrni, 1993; Noll, Bukowsky, Rogosch, LeRoy, & Kulkarni, 1990; Noll et al., 1999). Similar to other groups of children with chronic illness, children and adolescents at highest risk for peer difficulties are those whose treatment affects the central nervous system or who have obvious changes in physical appearance (Reiter-Purtill & Noll, 2003). An intervention with direct relevance to peer relationships is social skills training. A social skills intervention has been compared with a school reintegration approach, with data on the social skills package providing some evidence for its impact over a 9-month period, particularly for children at risk for behavioral concerns (Varni, Katz, Colegrove, & Dolgin, 1993). Social skills training has also been used with children with brain tumors in a pilot format (Barakat et al., 2003). Similar to the research guiding family intervention, the overall competence of children with cancer in their peer relationships necessitates carefully crafted interventions that target the most relevant subgroup of patients and provide a careful assessment of relevant outcome. By describing the social environment of the school and the patients interactions with other children, this work can inform the development and evaluation of school reintegration programs and other intervention approaches to help children with cancer reenter their schools and home communities (Prevatt, Heffer, & Lowe, 2000). Unfortunately, there are

no published studies of interventions with peers or other school-based interventions that focus on children with cancer. More generally, the amount and quality of support available to patients with cancer and their families form an important area of work. Social support is seen as protective against the development of distress and psychopathology and in adjustment to cancer (Helgeson & Cohen, 1996). Empirical studies of pediatric cancer show that parental social support is associated with adaptive functioning outcomes and that lack of social support for parents is related to greater risk for ongoing difficulties (Kazak, Stuber, et al., 1998; Sloper, 2000; Speechley & Noh, 1992).