A Four-Step Approach to Psychosocial Care in Head and Neck Cancer


For the distress and depression that patients with head and neck cancer can experience, a gradual or "stepped" approach can help to improve quality of life and reduce costs.

A Four Step Approach to Psychosocial Care in Head and Neck Cancer

A Four Step Approach to Psychosocial Care in Head and Neck Cancer

Patients diagnosed with head and neck or lung cancer are especially prone to feelings of distress, especially depression, and researchers in the Netherlands have found that using a gradual or “stepped” approach to providing psychosocial support not only improves their quality of life but is also cost-effective.

A team of investigators at the Vu Medical Center in Amsterdam sought to determine the cost-utility of a psychosocial intervention based on a stepped care (SC) model, whereby patients proceed to the next level of care only when their symptoms don’t resolve.

The approach involves 4 steps: (1) watchful waiting; (2) guided self-help via the Internet or a booklet; (3) face-to-face problem-solving therapy; and (4) specialized psychological interventions and/or psychotropic medication.

Prior cost-effectiveness studies of SC programs have shown that they improve quality-adjusted life years (QALYs) or the number of days without depression when compared with care as usual (CAU) controls, but these have been limited to primary care and older patients, as well as those with diabetes. The cost utility of the SC model has not yet been examined in patients with cancer, the researchers noted in their cost analysis, published online in the Journal of Clinical Oncology.1

To determine eligibility for the randomized controlled trial upon which this cost utility analysis was based, patients with head and neck or lung cancer were screened for symptoms of distress, anxiety, or depression, using the Hospital Anxiety and Depression Scale (HADS). A total of 265 eligible patients with elevated HADS scores were identified; after excluding those who didn’t want to participate or were unable to be reached, 156 patients were randomized to either SC (n = 75) or CAU (n = 81).

The efficacy of the SC model in this trial was analyzed and reported in the Annals of Oncology.2 Overall, investigators reported that patients with untreated distress in the SC group scored better than controls on the HADS, with recovery rates of 55% versus 29%, respectively, posttreatment (P = .002), and 46% versus 37%, at the 12-month follow-up (P = .35). Over the course of the 4 steps, 28% of those in the SC group improved after watchful waiting, 34% following the guided self-help, 9% after step 3 (problem-solving), and 17% after receiving psychotherapy and/or psychotropic medication.

For the study reported here, investigators evaluated the intervention’s economic value by calculating the mean cumulative costs and mean number of patient QALYs. The mean cumulative cost figure is based on several variables, including the cost of healthcare use and medication (direct medical costs), cost of psychological help, direct nonmedical costs (eg, support groups, transportation, and parking), and indirect nonmedical costs such as loss of productivity from employment due to absenteeism or working while in poor health.

Five follow-up assessments were conducted in each arm: Patients in the SC group were evaluated after completing stepped care, and 3, 6, 9, and 12 months later. Usual care participants were assessed at 4 months, and then at the same 4 follow-up time points as the intervention arm.

The researchers reported that the number of QALYs was higher in the SC group and cumulative costs were lower when compared with patients in the control group. Specifically, mean cumulative costs were —€3950 (~–$4196) lower (95% CI, –€8158 to –€190) using SC. Overall, they found that the mean number of QALYs was 0.116 higher in the SC arm versus controls (95% CI, 0.005 to 0.227).

These findings, they reported, translate into a 96% probability that cumulative costs were lower and QALYs higher with SC—a finding which held up after 4 additional data analyses, including 1 that excluded the effect of productivity losses.

“Our efficacy study showed that SC was beneficial in improving level of distress,” the authors wrote, “which may have had a beneficial effect on productivity losses in the intervention group compared with the control group … However, even without productivity losses, SC had a probability of being 97% more effective and less costly.”

Although study authors recommended further research to learn how stepped care can best be integrated into clinical practice, they expressed confidence about its cost-utility:

“Stepped care is highly likely to be effective,” they concluded. “In combination with findings on the efficacy of SC, it is expected to be beneficial in routine head and neck cancer and lung cancer care practice.”


  • Jansen F, Krebber AM, Coupé VM, et al. Cost-utility of stepped care targeting psychological distress in patients with head and neck or lung cancer [published online ahead of print December 5, 2016]. J Clin Oncol.
  • Krebber AM, Jansen F, Witte BI, et al. Stepped care targeting psychological distress in head and neck cancer and lung cancer patients: a randomized, controlled trial. Ann Oncol. 2016;27(9):1754-1760.

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