Psychological interventions to improve the quality of life in Indian lung cancer patients: A neglected area

Abstract

The incidence of lung cancer is very high and evidence suggests that patients experience imbalanced emotional capabilities due to less survival rate compared to other cancers. Direct and indirect psychological interventions are mandatory to improve the outcome of lung cancer treatment. Although such interventions are being practiced in developed nations, the effects of psychological interventions on the treatment outcome in the Indian context are lacking. Since there is a definite correlation between treatment outcome and psychological issues, it is high time that clinicians in developing countries including India adopt practices to enhance the quality of life of lung cancer patients.

Keywords

anxiety distress lung cancer performance status psychological intervention quality of life

Introduction

Patients with chronic illness including lung cancer need to make behavioral, social, and emotional adjustments. The emotional capabilities of any person are seriously affected by chronic illness and it varies widely among the population. The ability of a person to cope with chronic illness depends on several factors such as illness, physical, social, environmental, and personal factors. However, coping with the situation is a must, which starts with understanding the nature of illness and its significant effect on life followed by adaptations to the realities. Better the coping to the illness, better will be the quality of life (QOL). In a broader term, QOL is defined as the effect of an illness on the physical, emotional, and social well-being as perceived by the patient (Roila and Cortesi, 2001). For any chronic illness, there are two outcomes, namely, disease outcome and the patient-reported outcome (PRO) that can be assessed by specific instruments. Physicians are more interested in the former and the latter remained a neglected area.

Because of the growing importance of PRO and its relation with QOL and treatment outcome, an understanding on the basic concepts of PRO, its design, usage, and limitations is required. The same are detailed in document titled “Patient-Reported Outcome Measures: Use in Medical Product Development to Support Labeling Claims” released by the US Food and Drug Administration agency (FDA) in 2009. PRO instrument is a questionnaire used to record patient-reported data for measuring benefits of treatment or risks associated with a specific medical treatment or product or trial (FDA report). Furthermore, the findings obtained using this instrument will be credible only if evidence of its usefulness in its target population is available. Development of standard PRO instruments should be based on adequate literature review and expert opinion to ensure a strong conceptual background confirmed by observation among items and domains. The PRO instrument format should be consistent with the format used during the design process that can encompass different factors that can contribute to the respondent burden. The discriminant and convergent validity of the instrument should be ensured. PRO instruments should be used carefully since a simple model cannot substantiate a complex and multi-domain concept. Measurement of a general concept of interest can be achieved by designing multi-domain PRO instruments in such a way that the interpretation and reporting of results is not misleading. The use of PRO instruments to collect data from someone who is on behalf of the patient (proxy) and from patients who are cognitively impaired is highly discouraged. However, PRO instruments can be modified to suit specific clinical conditions, nature of clinical trials being conducted, and the way the patients would like to respond to the questions.

In majority of the clinical trials, when the efficacy of the new drug or a modified drug is being assessed, health-related quality of life (HRQOL) is measured using standard PRO instruments. Recommendations for the use of such PROs in the drug evaluation processes are detailed in the “reflection paper on the regulatory guidance for the use of HRQOL measures in the evaluation of medicinal products” by the Committee for Medicinal Products for human use (CHMP) of European Medicines Agency in 2005. It emphasizes on the multidimensionality of HRQOL and that it should be distinct from the core symptoms of the disease. The improvement in the efficacy of the drug being developed should be backed by the clinically meaningful improvement in HRQOL (change in the pre-defined HRQOL domains of interest) using both generic and disease-specific questionnaires. In general, the validation of HRQOL instrument should be evaluated well before its use in the confirmatory trials and the assessment may be done either before or after obtaining market authorization for the drug of interest. HRQOL assessment involves multiple items and domains assessed repeatedly over a period of time, thereby increasing multiplicity and the same should be addressed by taking care of statistical manipulations. Reporting global scores across domains to reduce the multiplicity should be avoided since it may mask or overestimate HRQOL differences. HRQOL measurement plays a significant role in deciding the choice of drug in non-life-threatening diseases. Among two or more drugs that may show similar efficacy, the one with better HRQOL measurements is recommended. In the case of life-threatening diseases such as cancer, the drug with HRQOL benefit achieved without a loss of efficacy is preferred, although other drugs may have better efficacy but not HRQOL benefit.

Among the chronic illnesses predominant in the world, lung cancer stands out because of its high incidence and mortality. Due to phenomenal developments in the detection and treatment of lung cancer in the recent years, it is estimated that a large number of lung cancer survivors will be registered throughout the world. For example, an estimated 18 million people will live with cancer in the United States by the end of the next decade (DeSantis et al., 2014; Siegel et al., 2012). Among all cancers, the diagnosis of lung cancer is generally delayed since the disease is often asymptomatic. Thus, the number of long-term survivors of lung cancer is significantly lower when compared to other cancers (Sugimura and Yang, 2006; Wang et al., 2010). Although the numbers are smaller, the burden is quite heavy and the survivorship issues of these patients is an area of investigation in the recent years. Because of delayed diagnosis and less survival time, lung cancer patients suffer a huge psychological trauma (Nweze and Maureen, 2014). Furthermore, cancer not only causes trauma to the individual, but also to the whole family. It is generally understood that the survival rate and response to treatment depends on the psychological status in cancer patients including those with lung cancer. During our sample collection for the analyses of genetic polymorphisms in lung cancer patients (Peddireddy et al., 2014, 2016a, 2016b), an informal enquiry revealed that they do not undergo psychological counseling during medical treatment. Literature search reveals a very low number of studies that briefly mention about the QOL in Indian cancer patients. In the recent years, along with the existing conventional treatment protocols, psychological interventions have gained prominence, especially measuring the QOL. Hence, in this review, the recent developments that encompass the psychological status of lung cancer patients and the influence of these factors in the enhanced survival are discussed.

QOL—how important it is in lung cancer patients?

Because of the importance of QOL associated with treatment outcomes, a variety of instruments such as questionnaires and telephonic and personal interviews are used to assess the same. The essential features of the instrument used for QOL are reproducibility, validity, responsiveness, and interpretability. Assessment of QOL is very useful in phase III clinical trials since it gives definite conclusions about the treatment efficiency and strategy. Priority for QOL lies when (1) different treatment modalities are being considered, (2) even one factor of a treatment can alter QOL, (3) overall survivorship can be predicted by a particular treatment modality, (4) treatment outcome is considered as unsatisfactory due to decrease in QOL, and (5) survivorship may not increase but QOL is better.

In lung cancer, besides coughing and dyspnea, the most useful symptoms are pain and malaise and these are commonly considered for the estimation of QOL. The reluctance of clinicians to consider QOL as a prognostic factor is evident from the fact that 14 out of 39 randomized clinical phase III trials for lung cancer had information about QOL and ironically only five of these considered QOL as the end points (Sarna and Riedinger, 2004). However, including assessment of QOL is slowly becoming a practice even in the developing countries. About 50 varieties of instruments with specific outcomes were developed that addressed the QOL of lung cancer patients. FACT-L, EORTC QLQ C30, and LCSS are the widely used instruments and the variables assessed are given in Table 1. Besides these, the Sloan-Kettering Cancer Centre developed a “lung cancer symptom scale” containing nine items to calculate the “average symptom burden.” During the treatment period, a change of 10 mm on the patient’s scale is taken as a significant change in the QOL, which correlated with the symptomatic changes (Frasci et al., 2000). Existing data obtained from these instruments allows a patient to opt for treatment strategy that may either give a high quality of QOL or the one that has long survivorship but with less QOL. On the other hand, assessment of QOL has drawbacks that depends on the intra and inter errors in observation and perception. Linguistic, religious, and cultural barriers; age of the patient; comorbidities; quality of palliative care; timing of assessment; treatment modalities; length of follow-up; patient’s cooperation; and dropout rate are some of the difficulties in assessing the QOL in lung cancer patients. Hence, analysis of QOL is not valid when less than 30 percent of the data are available (Ranson et al., 2000). A surrogate marker for QOL, that is, the performance status (PS), is also a prognostic and predicting factor for lung cancer patients (Buccheri and Ferrigno, 1994) and correlates well with the severity of the disease (Hopwood and Stephens, 1995).

Table 1.

Common instruments used in measuring QOL in lung cancer.

	QOL domains	Symptom domains
LCSS	Overall, physical and functional	Breathing, site of pain, cough, consciousness, weight loss, nausea, sexuality, energy levels, insomnia, general effects of treatment
FACT-L	Physical, social, family, emotional, functional	Pain, appetite, cough, dyspnea, fatigue, and general symptoms
EORTC-QLQ-LC13	Economic implications, patients role, cognitive, social, emotional and physical symptoms	Cough, dysphagia, dyspnea, fatigue, hemoptysis, pain, ulcers, diarrhea, constipation, weight loss, appetite loss, nausea, insomnia, neuropathy and alopecia

QOL: quality of life.

In addition to a variety of instruments used for QOL, the World Health Organization Quality of Life—Brief (WHOQOL-BREF) questionnaire is a generic tool developed about 15 years ago and still recommended for clinical use in many diseased conditions including lung cancer (Lin et al., 2016; WHOQOL, 1993, 1998). This tool defines QOL in terms of how the individuals perceive their living standards in relation to their goals, expectations, and concerns as well as to the value systems and culture they are exposed. In the recent years, WHOQOL-BREF was used for analyzing the psychometric properties of cancer patients (Den Oudsten et al., 2009; Paredes et al., 2010). Lin et al. first reported the use of this instrument in lung cancer (Lin et al., 2016) by applying the Rasch models instead of the conventional classical test theory model and results indicate that this generic tool is one of the best tools to provide improved healthcare to lung cancer patients.

The initial QOL is a definitive prognostic marker for survival in lung cancer. The quality of supportive care given during chemotherapy enhanced QOL which then reflected the survival rate (Helsing et al., 1998). On the other hand, despite increase in survival rate during paclitaxel or cisplatin chemotherapy, the QOL was found to be decreased (Bonomi et al., 2000). Thus, the treatment strategy to be adopted is not only at the discretion of the clinician, but with the consultation of the patient also. The benefit of chemotherapy versus best palliative care on the lines of QOL should be addressed both by the patient and the clinician. However, the primary goal of the clinician should be to enhance the QOL of the patient. Such practices have made significant difference on the hope of lung cancer patients.

Is lung cancer behaviorally associated?

With the changing lifestyle, there had been a major shift in the general behavioral pattern throughout the world. Smoking, alcoholism, and drug abuse, besides unconventional food habits, are on the rise. Such behavioral changes resulted in the incidence of a variety of diseases including lung cancer. The major contributory factor for lung cancer is smoking (CDC, 2015). The reasons to resort for smoking are varied such as peer pressure, replicating the style of iconic personalities, and work pressure. In the recent years, a new concept that lung cancer is no more a disease of smokers has emerged for the fact that the incidence of this disease is on the rise in never smokers also (Samet et al., 2009). In this subset of population, other behavioral issues such as alcoholism and chewing of tobacco have been the major contributing factors (Peddireddy et al., 2014). Behavioral aspects exhibited by lung cancer patients when they are diagnosed with the disease include denying or taking easy or misinterpreting the symptoms and the tendency to argue that they are healthy since they have not experienced any unconventional bodily changes. This behavior is the main cause of delayed medical care in majority of the lung cancer patients (Sullivan et al., 2010; Vos et al., 2011). Following diagnosis of lung cancer, the QOL depends on the way the patients behave immediately. Some tend to enter depression whereas others resort to active engagement with the existing scenario (Lowe and Molassiotis, 2011). During the treatment period, the psychological characteristics of the lung cancer patients are about the diagnostic and therapeutic procedures and the effect of these procedures on their well-being (Boucher et al., 2015; Fujisawa et al., 2015; Islam et al., 2016; Kaptein et al., 2011). Thus, the behavior of individuals changes with the progress of the illness and a number of models have been proposed. For example, the self-regulation model, considered to be the latest, included the sociodemographic, clinical (type and stage of illness), and psychological and treatment outcome factors to determine the QOL (Brandes and Mullan, 2014). It is very important to note that addressing the behavioral aspects of individuals during the progress of lung cancer had a significant beneficial effect on the patients (Temel et al., 2011). Overall, it appears that the behavior and perceptions of individuals about lung cancer, the consequences, and the ability to live with it is shaped based on the information provided by parents, relatives, friends, healthcare providers, and importantly the media (Kaptein et al., 2015)

Lung cancer survivorship—direct psychological interventions

The definition of “cancer survivor” is about an individual who has experienced cancer diagnosis and lived to the end of life (Alfano and Rowland, 2006; Hewitt et al., 2006; Miller, 2008). In a broader sense, this term also includes the family members, friends, and caregivers of the patient, although they don’t experience the biological trauma, but the psychological trauma. Beyond therapeutic interventions, providing psychological care and enhancing the QOL is crucial for cancer survivors (Alfano and Rowland, 2006). During the survivorship, the status of the patient may change from a hopeless phase to a life of renewed happiness (Evans et al., 2004). Such phases are nomenclatured as acute (diagnosis and treatment), extended survivorship (reminiscence of the disease or cured or maintenance therapy), and permanent survivorship (presumed cured) (Mullan, 1985). A recent report includes the “transition” phase (adjusting to the new normal life) after diagnosis and treatment and three tangents of the extended survivor phase, namely, remission, cancer free, and living with cancer (Miller et al., 2008; O’Brien et al., 2014).

In the case of lung cancer, a traditional definition for “survivor,” that is, life from day of diagnosis to 5 years, seems to hold good because of lower extended survival rates (Miller, 2008). Lung cancer patients have a higher risk of developing a second type of cancer of head or neck or urinary tract (Bellury et al., 2011). Because of the smoking habit prevalent in lung cancer patients, the chances of developing pulmonary and cardiac diseases are high (Hill-Kayser et al., 2009). Furthermore, lung cancer patients are known to have high chances of comorbidities compared to other forms of cancer. Thus, the psychological characteristics of lung cancer patients are quite different from those of other cancers. Survivorship programs and models are developed to enhance the QOL of lung cancer patients. Care plans and treatment summaries for lung cancer patients are developed by American Society of Clinical Oncology (ASCO, 2016) and National Comprehensive Cancer Network (NCCN, 2015). The Commission on Cancer included the assessment of psychological distress at multiple stages of survivorship program (COC, 2016). “Journey Forward” is a downloadable survivorship program that provides a plan for lung cancer patients and their healthcare providers (Mayer et al., 2012). During lung cancer survivorship, QOL is used as a strong prognostic factor (Gilbert et al., 2008; Sarna et al., 2002). Treatment modalities (surgery, radiation, and chemotherapy), patient age, physical impact, fatigue, dyspnea, and psychological impact are the main factors that play a role in determining the QOL of lung cancer survivors (Pozo et al., 2014).

Psychological impact in lung cancer survivors is well documented (Gao et al., 2010; Maliski et al., 2003; Stein et al., 2008). Although some lung cancer survivors feel that it is a new lease of life, the trauma they undergo during the diagnosis, treatment, and follow-up causes negative effects on their QOL, which slowly leads to psychological problems (Morgan, 2009; Sarna and Riedinger, 2004). Up to 80 percent of lung cancer patients experience psychological distress, anxiety, and depression (Sarna et al., 2002). Surprisingly, lung cancer patients experience thrice the amount of distress than that experienced by other cancer patients (Gao et al., 2010). This could be due to perception by the patient that the survival rate in lung cancer is very low when compared to other cancers. Furthermore, distress among lung cancer patients is under reported (ranging from 11% to 44%) and under treated (Gilbert et al., 2008). Concrete evidence exists that correlates the levels of psychological distress and the decline in quality of living (Boucher et al., 2015; Maliski et al., 2003). A decline in cognition and social functioning is also reported in lung cancer patients experiencing distress (Fox and Lyon, 2006; Giacalone et al., 2012). Factors that contribute to the distress included access to treatment, comorbid conditions, external stress, economic status, history of depression, and the ability to adjust to new situations (Wang et al., 2010; Weisman and Worden, 1976). Loss of sleep, sadness, fear, and uncertainty are some of the symptoms of distress and they generally are associated with diagnosis (Pearman, 2008; Stein et al., 2008). It is observed that distress levels can change in either direction based on the prognosis and the treatment outcome (Henoch et al., 2007; Maliski et al., 2003). Patient’s self-coping capacity and social support are the key factors that enable the patient to adapt to distress (Alfano and Rowland, 2006; Weisman and Worden, 1976).

Another important psychological aspect of lung cancer is the anxiety. It is known to have negative effects on the quality of living, although it is perceived to be a normal response in any patient. Immediate interventions are required to deal with anxiety since its persistence leads to decrease in physical and cognitive functions of lung cancer patients (Buchanan et al., 2010; Roulston et al., 2012). The main causes of anxiety in survivors is the fear of recurrence of lung cancer (since the risk remains up to 10 years) and secondary cancers, whereas it is the treatment outcome and the result of diagnostic tests in the case of lung cancer patient and suspected lung cancer patient, respectively (Sarna et al., 2002). Depending on the psychological intervention, the degree of anxiety generally decreases over a period of time, but spikes are often observed also due to any other clinical symptoms and during follow-up (Roulston et al., 2012).

Social stigma though not only has serious consequences on the well-being of the lung cancer patients, its effects are also translated to an extent that funding allocations are reduced for research, since it is believed that the survival rate is anyway poor (Moran Mendoza, 2011). Social stigma causes depressive symptoms and psychological morbidity, thus leading to significantly decreased QOL (Conlon et al., 2010; Gonzalez and Jacobsen, 2012). Stigmatized patients show a reluctance to seek social and medical support (Conlon et al., 2010). Compared to other types of cancer, funding for lung cancer seems to be on the lower side due to the impression that these patients have a poor prognosis and survival rate (Conlon et al., 2010). Developing of survivorship programs and plans should ensure the confidentiality of the patient and include psychological interventions that can address the stigma associated with lung cancer.

Psychological interventions are recommended by the commission on cancer psychosocial distress screening standards and it insists that distress, anxiety, and stigma be addressed during crucial visits of the patient. A distress thermometer is designed to serve as a screening instrument and be applied to the patient frequently (Goldstein et al., 1976). The treatment outcome and quality of living of lung cancer patients have been positively correlated with the robustness with which the psychosocial concerns are addressed (Cooper et al., 2010; Ferrell et al., 1995).

In developing countries like India, access to tertiary healthcare involves financial implications. People diagnosed with chronic illness such as lung cancer should prepare mentally to take the social, psychological, emotional, and financial challenges. Although a number of government-funded hospitals cater to the treatment of various cancers, the costs are still high. Thus, the primary obstacle seeking medical treatment for cancer patients in developing countries like India start with financial burden. Taking it further, those with good financial background also find it difficult to cope with lung cancer because of the lack of emphasis by the healthcare providers on the QOL of the patient. Data on the QOL in Indian lung cancer patients and in all other cancers are meager. The concept of QOL in lung cancer patients in India is slowly emerging. It is reported that lung cancer patients in India have unsatisfactory quality of living (measured in terms of Karnofsky’s Performance Scale) (Mohan et al., 2006). In a study conducted in 1998 that focused on the psychiatric morbidity in South Indian population with different types of cancer revealed that a large number of patients were unaware of the diagnosis and these subsets were reluctant to undergo treatment for psychological distress (Chandra et al., 1998). There was no difference in the patterns and prevalence of morbidity between the aware and unaware groups of patients. The fact that the patients were unaware of the disease demonstrates the insensitivity or ignorance or suppression of facts by the healthcare providers and suppression of facts by relatives of the patients in conservative societies. Although counseling was offered, it was more to the oral cancer patients and those with cervical or other cancers were not counseled. The complexities encountered in assessing psychiatric requirements among South Indian cancer patients are highlighted (Chandra et al., 1998). Priyanka et al. in 2011 reported that cancer patients who visited a tertiary care hospital in Jaipur, a North Indian city, experienced fear of disease progression, tenseness, and impaired mental activity and emphasizes the need to offer psychological assistance along with medical care (Yadav and Jaroli, 2011). In another study conducted in 2014, the prevalence of anxiety and depression scores among Indian lung cancer patients were 7.73 and 6.63, which translated in a way that 47 percent had anxiety and 39 percent had depression (Santre et al., 2014). The main cause of distress and anxiety was due to the treatment options available (surgical or non-surgical), side effects, schedule of treatment, financial implications, and self-assessment of the chances of survival (Santre et al., 2014), thus emphasizing the fact that besides medical treatment, psychological measures to cope up emotional distress are also necessary. On the other hand, the QOL of Indian cancer patients were found to be improved due to medical interventions suggesting that psychological and medical interventions are inter-dependable (Barre et al., 2015). A closer look at these studies reveals that in the recent times, psychological interventions are being practiced in mainstream medicine to lung cancer patients, which is a positive development.

Lung cancer survivorship—indirect psychological interventions

Direct psychological interventions to lung cancer patients right from the day of diagnosis make a huge difference to the QOL. Besides these, there are some behavioral aspects of lung cancer patients that may not be directly influencing them during their survivorship. Because of the depression and associated factors, these patients lose interest on many routine activities such as regular physical activity and food intake (Nweze and Maureen, 2014). Another aspect is resorting to the luxuries and fantasies of life with the assumption that their fate is defined and would like to enjoy everything as soon as possible. These include alcoholism, smoking, indulging in extravagant food habits, and physical pleasures. It is important to address psychologically these “not so important” factors especially in lung cancer survivors. Timely interventions and the benefits of the same are described below.

Physical activity, in general, is known to prevent many diseases. Once a patient is diagnosed with life-threatening disease, this activity is not given importance. Studies have shown that physical activity coupled with treatment is a must in many cancers including lung cancer (Clark et al., 2008; Coups et al., 2009; Smith et al., 2011; Solberg Nes et al., 2012). Such a coupled program improved the QOL and survival rates in lung cancer (Jacobsen et al., 2013), and there was a direct relationship between the levels of physical activity and quality of living (Solberg Nes et al., 2012). Decreased pain, improvement in shortness of breath, decreased fatigue, and reduced distress were observed in lung cancer patients who engaged themselves in physical activity when compared to their sedentary counterparts (Solberg Nes et al., 2012). Because of associated comorbidities such as pulmonary function, compromised immunity, and loss of physical ability, individualized physical activity is recommended for lung cancer patients (Rock et al., 2012). A systematic review on Indian cancer patients, including lung cancer patients, indicated a positive correlation between QOL and exercise-based interventions (yoga, physiotherapy, and speech based) (Samuel et al., 2015). It is also suggested that exercise-based interventions to improve the QOL in Indian cancer patients is still limited. In light of these beneficial effects, especially in the Indian scenario, lung cancer patients should be psychologically motivated to include physical activity as a routine, which requires the coordinated efforts of healthcare professionals, family members, friends, and the patient.

Balanced nutrition rich in components that have beneficial effects on the overall health status is crucial in both lung cancer patients and survivors. They should be encouraged to take foods that are found to be having medicinal values. Colorful vegetables and fruits and whole grains are recommended (Rock et al., 2012). High-fat foods, red meat, and other processed food should be discouraged (Berdan et al., 2014; Rock et al., 2012). Although supplements are not recommended, many natural compounds that are known to have anti-cancer properties and immune boosting properties are to be consumed. All of this requires strong will power because cancer patients tend to relish themselves with a variety of cuisines, assuming that they may not survive for long. Nutrient interventions in the form of giving a cocktail of vitamins resulted in a risk refractory to carcinogens for oral cancer in Indian population (Krishnaswamy et al., 1995). It is also suggested that enteral nutrition support improved the QOL of head and neck cancer in Indian patients and that a follow-up by a nutritional expert will help to better manage the disease and treatment outcome (Namratha and Urooj, 2014). In Indian patients with chronic obstructive pulmonary disease (COPD), a risk factor for lung cancer, nutritional intervention improved the exercise capacity and in turn the QOL (Raizada et al., 2014). Constant psychological counseling about the beneficial aspects of healthy food on the treatment outcome and survivorship in the Indian clinical setting is necessary.

A well-established fact is that smoking is the primary cause of lung cancer. However, some lung cancer patients continue to smoke even after diagnosis because of addiction to it. Continued smoking in lung cancer patients result in less effective treatment outcomes and increase the risk of early death (Cataldo et al., 2010). Hence, smoking cessation is considered as an important component of treatment strategy for lung cancer. In patients who have quit smoking, the risk of relapse, survival time, better response to chemotherapy, and high QOL are observed (Tucker et al., 1997). Furthermore, quitting smoking improved sleep, mood, physical activity, and breathing in lung cancer patients (Tucker et al., 1997). Because of the beneficial effects of quitting smoking, healthcare providers and family members should counsel the patient in terms of hope to live longer despite a life-threatening disease. The patient should be desisted from the feeling that it is too late and self-blame. The bigger onus lies with the clinician since smoking status has to be monitored at every visit. Surprisingly, only 44 percent of lung cancer patients quit smoking after diagnosis and only 62 percent of the patients were counseled about smoking during their visit to clinics (Burke et al., 2009). Online resources such as “Rx for change” developed by University of California help clinicians and patients with various methods to psychologically counsel patients to quit smoking (Cataldo et al., 2010). On part of the family members, smoke-free homes should be provided to the lung cancer patients and counseling with compassion on how important the patient to the family is should be done on regular basis.

In the Indian context, smoking is prevalent in about 48 and 20 percent of men and women, respectively, and it also ranges widely across the geographical demography of this country (IIPS, 2001). In the rural areas, lack of risks and cultural habits are the prime cause for smoking in this country (Murthy and Saddichha, 2010). A recent study demonstrated that starting the use of any kind of tobacco product is prevalent in population with a mean of 15.6 ± 4.7 years and with average nicotine dependence for 20 ± 1.5 years. Interestingly, majority of these patients attempted to quit smoking due to psychological interventions by health practitioners and family members and were never self-motivated. However, peer pressure and withdrawal symptoms were the main causes of smoking resumption (Mandal et al., 2015). In such a scenario, smoking poses as the major risk factors for lung cancer in India. A common psychological intervention that appears to work in persuading to quit smoking in the Indian scenario seems to be the involvement and advice given by the family members and friends (Denny et al., 2014). Studies on the benefits of psychological intervention to desist from smoking and assessing the QOL in Indian lung cancer patients after this intervention are not yet reported.

In conclusion, it is clearly understood that implementation of psychosocial intervention programs for lung cancer patients defines the treatment outcome and this is being practiced in developed countries. In a developing country such as India, where lung cancer patients undergo severe emotional distress and experience low levels of quality of living and psychological counseling is rare, the use of generic and advanced instruments to measure the QOL by medical practitioners should be made mandatory. The effective outcomes due to use of QOL instruments should be demonstrated to the Indian medical practitioners during continuing medical educational (CME) programs. Course structure for medical graduates should invariably include topics on psychological interventions and measuring QOL using different instruments. On the other hand, governmental and non-governmental organizations should come forward to measure QOL in cancer patients and transmit it to the clinicians in addition to interacting with clinicians to convince them to practice and implement psychological interventions for a better survivorship.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Research involving human participants and/or animals

This article does not contain any studies with human participants or animals performed by any of the authors.

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