Psychologic intervention improves survival for breast cancer patients: a randomized clinical trial

Positive psychology in cancer care: bad science, exaggerated claims, and unproven medicine

Background

Claims of positive psychology about people with cancer enjoy great popularity because they seem to offer scientific confirmation of strongly held cultural beliefs and values.

Purpose

Our goal is to examine critically four widely accepted claims in the positive psychology literature regarding adaptational outcomes among individuals living with cancer.

Methods

We examine: (1) the role of positive factors, such as a “fighting spirit” in extending the life of persons with cancer; (2) effects of interventions cultivating positive psychological states on immune functioning and cancer progression and mortality; and evidence concerning (3) benefit finding and (4) post-traumatic growth following serious illness such as cancer and other highly threatening experiences.

Results

Claims about these areas of research routinely made in the positive psychology literature do not fit with available evidence. We note in particular the incoherence of claims about the adaptational value of benefit finding and post-traumatic growth among cancer patients, and the implausibility of claims that interventions that enhance benefit finding improve the prognosis of cancer patients by strengthening the immune system.

Conclusion

We urge positive psychologists to rededicate themselves to a positive psychology based on scientific evidence rather than wishful thinking.

Of babies and bathwater: a reply to Coyne and Tennen's views on positive psychology and health

PURPOSE

We disagree with several conclusions reached by Coyne and Tennen, as well as their interpretation of specific findings.

RESULTS

First, we dispute that researchers have advanced the claim that positive thinking can cure disease. Second, we question their exclusive focus on cancer-related mortality, when strong cumulative evidence suggests that optimism is related to positive health outcomes for other major diseases, and that psychosocial interventions may improve other important cancer outcomes, such as reduced pain and increased quality of life. Third, we disagree sharply with their assessment of the literature on posttraumatic growth and the implications of the research they cite.

CONCLUSION

It is premature to abandon efforts to understand and promote positive phenomena among people with various life-threatening illnesses. Instead, well-validated measures of positive phenomena should become routinely incorporated into a broader array of health psychology studies to provide a rigorous test of their role in human health and adaptation to disease.

Host factors and cancer progression: biobehavioral signaling pathways and interventions

Whereas evidence for the role of psychosocial factors in cancer initiation has been equivocal, support continues to grow for links between psychological factors such as stress, depression, and social isolation and progression of cancer. In vitro, in vivo, and clinical studies show that stress- related processes can impact pathways implicated in cancer progression, including immuno-regulation, angiogenesis, and invasion. Contributions of systemic factors, such as stress hormones to the crosstalk between tumor and stromal cells, appear to be critical in modulating downstream signaling pathways with important implications for disease progression. Inflammatory pathways may also be implicated in fatigue and other factors related to quality of life. Although substantial evidence supports a positive effect of psychosocial interventions on quality of life in cancer, the clinical evidence for efficacy of stress-modulating psychosocial interventions in slowing cancer progression remains inconclusive, and the biobehavioral mechanisms that might explain such effects are still being established. This article reviews research findings to date and outlines future avenues of research in this area.

Psychosomatic medicine

Psychosomatic medicine may be defined as a comprehensive, interdisciplinary framework for: assessment of psychological factors affecting individual vulnerability as well as course and outcome of illness; biopsychosocial consideration of patient care in clinical practice; specialist interventions to integrate psychological therapies in the prevention, treatment and rehabilitation of medical disease. The aim of this review was to provide an updated definition of psychosomatic medicine, to outline its boundaries with related disciplines and to illustrate its main contributions to clinical and preventive medicine. A review of the psychosomatic literature, using both Medline and manual searches, with particular reference to articles, which could be relevant to clinical practice, was performed. Current advances in the field have practical implications for medical research and practice, with particular reference to the role of lifestyle, the challenge of medically unexplained symptoms, the psychosocial needs entailed by chronic illness, the appraisal of therapy beyond pharmaceutical reductionism, the function of the patient actively contributing to his/her health. Today, the field of psychosomatic medicine is scientifically rigorous, more diversified and therapeutically relevant than ever before.

Biobehavioral, immune, and health benefits following recurrence for psychological intervention participants

PURPOSE

A clinical trial was designed to test the hypothesis that a psychological intervention could reduce the risk of cancer recurrence. Newly diagnosed regional breast cancer patients (n = 227) were randomized to the intervention-with-assessment or the assessment-only arm. The intervention had positive psychological, social, immune, and health benefits, and after a median of 11 years the intervention arm was found to have reduced the risk of recurrence (hazard ratio, 0.55; P = 0.034). In follow-up, we hypothesized that the intervention arm might also show longer survival after recurrence. If observed, we then would examine potential biobehavioral mechanisms.

EXPERIMENTAL DESIGN

All patients were followed; 62 recurred. Survival analyses included all 62. Upon recurrence diagnosis, those available for further biobehavioral study were accrued (n = 41, 23 intervention and 18 assessment). For those 41, psychological, social, adherence, health, and immune (natural killer cell cytotoxicity, T-cell proliferation) data were collected at recurrence diagnosis and 4, 8, and 12 months later.

RESULTS

Intent-to-treat analysis revealed reduced risk of death following recurrence for the intervention arm (hazard ratio, 0.41; P = 0.014). Mixed-effects follow-up analyses with biobehavioral data showed that all patients responded with significant psychological distress at recurrence diagnosis, but thereafter only the intervention arm improved (P values < 0.023). Immune indices were significantly higher for the intervention arm at 12 months (P values < 0.017).

CONCLUSIONS

Hazards analyses augment previous findings in showing improved survival for the intervention arm after recurrence. Follow-up analyses showing biobehavioral advantages for the intervention arm contribute to our understanding of how improved survival was achieved.

Stress generation over the course of breast cancer survivorship

Depressive symptoms are frequently elevated following breast cancer diagnosis. The stress generation hypothesis states that people with depression generate stressful events and these stressors lead to subsequent depression. This study tested the stress generation hypothesis over the first 5 years of cancer survivorship. Women with stage II or III breast cancer (N = 113) were accrued. Five mediation models were constructed, one for each year. Each model tested whether stressful events in each year mediated the relationship between depression at the beginning and end of that year. Stress generation was observed in the first 2 years following cancer diagnosis but not from 2 to 5 years after diagnosis. The relationship of depression to future stress in breast cancer patients may be moderated by phase of survivorship. Screening and treatment of depressive symptoms in cancer survivors may need to consider the generation of stressful events.

[Long-term survival of adult cancer patients from a psychosomatic perspective - literature review and consequences for future research]

OBJECTIVES

The increasing survival of cancer patients is the result of early detection, improved treatment, and demographic change. This poses urgent questions regarding the stresses and needs for care long-term survivors face.

METHODS

A literature survey (PubMed, Scopus) was conducted based on all publications with a psychooncological background from 2004 to 2008 concerning long-term survivors.

RESULTS

Of the 164 publications found, 74 referred to breast cancer; 62 % came from the United States and only 4 % from Germany. Although overall quality of life among long-term survivors appears to be good, considerable adverse somatic effects (long-term effects, late consequences, recidivism, second tumors) and mental effects (e.g., fear of recurrence) persist. Somatic and psychosocial determinants of long-term adjustment, health behaviour, health care needs and utilization, and the quality of life of next-to-kin have hardly been studied. The effects of psychotherapy on survival remain controversial.

CONCLUSIONS

In light of the growing number of long-term surviving cancer patients, it is necessary to study their strains and needs for care under a lifespan perspective.

Finding what is not there: unwarranted claims of an effect of psychosocial intervention on recurrence and survival

In a recently published randomized trial, Andersen et al. claimed to observe a reduced risk of recurrence and improved survival among women with early stage breast cancer who were assigned to a psychological intervention versus an assessment-only group. Anderson et al. concluded that "psychological intervention, as delivered and studied here, can improve survival." The current commentary challenges that conclusion on methodological and statistical grounds, noting that the study by Andersen et al. was not designed to assess survival and used methods that capitalized on chance, making it highly unlikely that their claims could be replicated. No other study designed to assess whether psychosocial intervention provides a survival benefit for cancer patients has ever demonstrated such an effect; and, currently, there is no support for the hypothesis that survival benefits can be attributed to psychosocial intervention. The authors of this commentary argue that much needs to be learned at the more basic biobehavioral level about the impact of stress or psychological factors on tumor biology before even considering whether large clinical trials are warranted. In addition, making the claim that psychological interventions improve survival is not evidence-based, is potentially harmful, and detracts from the potential significant benefits of psychological interventions related to quality of life.

Decreased cancer survival in individuals separated at time of diagnosis: critical period for cancer pathophysiology?

BACKGROUND

: It long has been recognized that married patients have improved cancer survival when compared with unmarried patients. This has been postulated as being due to increased support, potentially leading to better compliance with therapy. Conversely, some data exist pointing to a relationship between marital discord and decreased immunity. We examined whether unmarried patients have a different prognosis by whether they are 1) never married, 2) divorced, 3) widowed, or 4) separated at time of diagnosis.

METHODS

: The public access data of the Surveillance, Epidemiology and End Results (SEER) registry were queried for cancer survival across all 17 registries between 1973 and 2004. SEER last updated data in April 2007. Records of 3.79 million patients were included in the analysis. We specifically analyzed 5-year and 10-year relative survival (RS; 5yRS, 10yRS), defined as observed survival divided by observed survival of an age-matched, race-matched, and gender-matched population without disease, for all cancer patients by marital status, with specific subset analyses as indicated.

RESULTS

: Among unmarried patients, those separated at time of diagnosis had the lowest survival, followed by widowed, divorced, and never married patients. 5-year and 10-year RS of separated patients was 72% and 64% than that of married patients, respectively. This relationship persists when data are analyzed by gender.

CONCLUSIONS

: Separated marital status is associated with a significant decrement in cancer survival, even in comparison with other unmarried groups. While other socioeconomic variables could contribute to this phenomenon, further research into the immunologic correlates of the acutely stressful condition of marital separation should be conducted. Cancer 2009. (c) 2009 American Cancer Society.

Cancer-specific beliefs and survival in nonmetastatic colorectal cancer patients

BACKGROUND

Colorectal cancer (CRC) is the third leading cause of cancer mortality in the United States. Associations between cancer-specific beliefs (beliefs) and survival have been observed among other cancer populations, but similar research in CRC patients is virtually nonexistent, especially in racially diverse populations. The relationship between beliefs and survival was investigated in a cohort of African Americans and non-Hispanic whites with newly diagnosed nonmetastatic CRC, followed for up to 15 years.

METHODS

The authors analyzed data from a population-based cohort of 286 individuals (115 African Americans and 171 whites, approximately 52% women) diagnosed with nonmetastatic CRC in Connecticut, 1987 to 1991. Cox proportional hazards models were adjusted for sociodemographic (age, sex, race, education, income, occupational status, marital status) and biomedical (stage at diagnosis, histological grade, treatment) variables.

RESULTS

Not believing in the curability of cancer increased the risk of all-cause mortality (hazard ratio [HR], 1.59; 95% confidence interval [CI], 1.06-2.39) and CRC-specific mortality (HR, 1.65; 95% CI, 0.90-3.03; P=.10). These multivariate estimates were not altered by additional adjustment for insurance coverage, obesity, smoking, alcohol consumption, or comorbidity. Furthermore, the association between perceived curability and survival did not vary significantly by key sociodemographic or biomedical factors. Other beliefs were not associated with survival.

CONCLUSIONS

Among a racially diverse cohort of men and women with CRC, believing in the curability of cancer was independently associated with survival over a 15-year period. Confirmation of the role of cancer-specific beliefs on survival and study of the potential biobehavioral mechanisms is needed. Findings may inform the design of interventions for cancer survivors.

A model of gene-environment interaction reveals altered mammary gland gene expression and increased tumor growth following social isolation

Clinical studies have revealed that social support improves the outcome of cancer patients, whereas epidemiologic studies suggest that social isolation increases the risk of death associated with several chronic diseases. However, the precise molecular consequences of an unfavorable social environment have not been defined. To do so, robust, reproducible preclinical models are needed to study the mechanisms whereby an adverse environment affects gene expression and cancer biology. Because random assignment of inbred laboratory mice to well-defined social environments allows accurate and repeated measurements of behavioral and endocrine parameters, transgenic mice provide a preclinical framework with which to begin to determine gene-environment mechanisms. In this study, we found that female C3(1)/SV40 T-antigen mice deprived of social interaction from weaning exhibited increased expression of genes encoding key metabolic pathway enzymes in the premalignant mammary gland. Chronic social isolation was associated with up-regulated lipid synthesis and glycolytic pathway gene expression-both pathways are known to contribute to increased breast cancer growth. Consistent with the expression of metabolic genes in premalignant mammary tissue, isolated mice subsequently developed a significantly larger mammary gland tumors burden compared with group-housed mice. Endocrine evaluation confirmed that isolated mice developed a heightened corticosterone stress response compared with group-housed mice. Together, these transdisciplinary studies show for the first time that an adverse social environment is associated with altered mammary gland gene expression and tumor growth. Moreover, the identification of specific alterations in metabolic pathways gene expression favoring tumor growth suggests potential molecular biomarkers and/or targets (e.g., fatty acid synthesis) for preventive intervention in breast cancer.

Effect of adenosine 5'-triphosphate infusions on the nutritional status and survival of preterminal cancer patients

The aim of the study was to investigate the effect of intravenous infusions of adenosine 5'-triphosphate (ATP) on nutritional status and survival in preterminal cancer patients. Ninety-nine preterminal cancer patients (estimated life expectancy 1-6 months) with mixed tumor types were randomly allocated to receive either intravenous ATP weekly (8-10 h/week, maximum 50 microg/kg/min) for 8 weeks, or no ATP (control group). Nutritional status parameters were assessed until 8 weeks, and analyzed by repeated-measures analysis of covariance. Cox proportional hazards models were fitted to assess the effect of ATP on short-term (0-8 weeks) and long-term (0-6 months) survival. Fifty-one patients were randomized to ATP and 48 to the control group. Results showed a significant favorable effect of ATP on triceps skin fold thickness [between-group difference per 8 weeks 1.76 mm, 95% confidence interval (CI): 0.48-3.12 mm; P = 0.009] and on short-term survival [0-8 weeks hazard ratio (HR): 0.40, 95% CI: 0.17-0.95; P = 0.037]. In weight-stable patients and in lung cancer patients, long-term survival (0-6 months) was also significantly better in ATP-treated patients (weight-stable patients HR: 0.40, 95% CI: 0.19-0.83; P = 0.014; patients with lung cancer: HR: 0.35, 95% CI: 0.14-0.88; P = 0.025). In conclusion, in this population of preterminal cancer patients, ATP infusions, at the dose and schedule studied, had a favorable effect on triceps skin fold thickness and survival, especially in weight-stable patients and patients with lung cancer. Larger studies are warranted to confirm these findings and to further define the effect of ATP on tumor growth and survival.

A psychological intervention reduces inflammatory markers by alleviating depressive symptoms: secondary analysis of a randomized controlled trial

OBJECTIVES

To test experimentally whether a psychological intervention reduces depression-related symptoms and markers of inflammation among cancer patients and to test one mechanism for the intervention effects. Depression and inflammation are common among cancer patients. Data suggest that inflammation can contribute to depressive symptoms, although the converse remains untested.

METHODS

As part of a randomized clinical trial, newly diagnosed breast cancer patients (n = 45) with clinically significant depressive symptoms were evaluated and randomized to psychological intervention with assessment or assessment only study arms. The intervention spanned 12 months, with assessments at baseline, 4, 8, and 12 months. Mixed-effects modeling tested the hypothesis that the intervention reduced self-reported depressive symptoms (Center for Epidemiological Studies Depression scale, Profile of Mood States Depression and Fatigue subscales, and Medical Outcomes Study-Short Form 36 Bodily Pain subscale) and immune cell numbers that are elevated in the presence of inflammation (white blood cell count, neutrophil count, and helper/suppressor ratio). Mediation analyses tested whether change in depressive symptoms, pain, or fatigue predicted change in white blood cell count, neutrophil count, or the helper/suppressor ratio.

RESULTS

The intervention reduced significantly depressive symptoms, pain, fatigue, and inflammation markers. Moreover, the intervention effect on inflammation was mediated by its effect on depressive symptoms.

CONCLUSIONS

This is the first experiment to test whether psychological treatment effective in reducing depressive symptoms would also reduce indicators of inflammation. Data show that the intervention reduced directly depressive symptoms and reduced indirectly inflammation. Psychological treatment may treat effectively depressive symptoms, pain, and fatigue among cancer patients.

What is an exceptional cancer trajectory?: Multiple stakeholder perspectives on cancer trajectories in relation to complementary and alternative medicine use

BACKGROUND

Although links between exceptional cancer trajectories (ECTs) and complementary and alternative medicines (CAMs) have been suggested, most research on ECT uses predefined criteria for ECTs without necessarily including CAM use. Little knowledge can be found about subjective perspectives of ECTs in relation to CAM.

OBJECTIVES

This Swedish study explores how patients, significant others, and CAM and biomedical health care (BHC) providers reason about ECT, including the role of CAM.

METHODS

Using a case study approach, open interviews were conducted with multiple stakeholders about cancer trajectories reported as exceptional.

RESULTS

In-depth analysis of 5 cases indicated that although all stakeholders agreed that the reported cases were positive, in no case was the same trajectory considered exceptional by all stakeholders. Different stakeholders shared neither conceptualizations of what constituted an ECT nor attributions for positive trajectories. Patients, significant others, and CAM providers emphasized unexpectedly long survival and well-being in ECTs, whereas BHC providers only referred to survival. CAM and BHC providers normalized reported trajectories, although the forms for this differed between provider groups. CONCLUDING DISCUSSION: Stakeholders' accounts are discussed relative to different health care domains, legitimization processes, and legal constraints, which have led to the lack of a public sphere for CAM use in cancer.

The role of integrative oncology in a tertiary prevention survivorship program

OBJECTIVE

Since 64% of cancer patients survive more than 5 years beyond diagnosis, oncologists are challenged to expand their focus from acute care to managing the long-term health consequences of cancer treatment and ensuring the integration of cancer prevention into their practices. This review defines the cancer prevention role of integrative oncology as a key component in survivorship programs.

METHODS

A narrative review consisting of the results of preclinical studies, randomized controlled trials and systematic reviews that may contribute to cancer prevention.

RESULTS

Integrative oncology focuses on the complexities of health and proposes a multitude of approaches. Its categories are mind-body techniques, physical therapies, nutrition plus supplements, and botanicals or natural health products. Behavioral modification, through selected integrative oncology interventions may enhance cancer prevention.

CONCLUSION

Opportunities exist for oncologists to promote lifestyle changes that improve patients' length and quality of life. Integrative oncology utilizes techniques for self-empowerment, individual responsibility, and lifestyle changes that could potentially reduce both cancer recurrence and second primary tumors. Education in the principles of integrative oncology and evidence-based complementary therapies is lacking. There is a need for studies on cost-utility and effectiveness of whole systems programs of integrative oncology for the tertiary prevention of cancer.

Lifestyle Interventions in the Prevention and Treatment of Cancer

Despite evidence that cancer death rates in the United States are declining, the absolute number of new cancers and cancer deaths continues to increase, and there is clear evidence that certain human behaviors are influencing these increases. The 4 major factors of lifestyle that continue to be causally related to certain cancers—tobacco use, an unhealthy diet, inadequate exercise, and excessive exposure to ultraviolet radiation—are each independently important in their effects on the genetic and molecular processes that result in the malignant transformation of human cells. There is both irrefutable and otherwise strong evidence that 4 common cancers that occur in the United States—lung cancer, colon/rectal cancer, breast cancer, and prostate cancer—and a less common cancer, malignant melanoma, have etiologic factors that are lifestyle based and therefore controllable through alterations in human behavior. These cancers and the evidence that lifestyle is important in the causation and/or prevention of the disease are the subjects of this review.

In sickness and in health: maintaining intimacy after breast cancer recurrence

Sexual well-being after breast cancer recurrence has received little clinical attention. In discussing the sexual difficulties after recurrence we draw upon our longitudinal studies of newly diagnosed patients. It is noted that sexuality declines after a patient's initial diagnosis and treatment, with further decline after recurrence. However, data suggest that couples strive to maintain intimacy as the health of the patient falters, providing further evidence of the resilience of patients coping with a worsened prognosis.