A hypothesis about Spiegel et al.'s 1989 paper on Psychosocial intervention and breast cancer survival

The flourishing scholarship of psychosocial oncology viewed across 30 years through the lens of this journal, Psycho-Oncology

OBJECTIVE

This issue celebrates the 30th anniversary of Psycho-Oncology as a journal, a home for scholarship integrating the psychological, social and behavioural dimensions of cancer. Psycho-oncology developed as an evidence-based discipline to offer an alternative to unproven therapies and to optimise coping and support for patients with cancer and their families.

METHODS

A review of key articles was undertaken for this editorial.

RESULTS

Empirical studies have defined the prevalence of morbidity arising from cancer and the acute, longer-term and late effects of its varied treatments. Interventions have been adapted to respond to existential challenges, death anxiety, fear of recurrence, disease progression, palliative care and have been continued into bereavement. Mixed modality treatments have combined psychotropic and psychotherapeutic interventions. Survivorship studies have examined rehabilitation, fertility, sexuality, body image and relational impacts of illness.

CONCLUSION

This journal has helped the discipline to flourish by publishing the innovative outputs of its community of researchers.

Effectiveness of palliative care interventions offering social support to people with life-limiting illness-A systematic review

Individuals managing the challenges of life-limiting illness require adequate social support to maintain quality of life. Qualitative research reports that patients value highly the social support obtained in palliative care interventions such as day care and group therapies. This systematic review aims to summarise existing quantitative evidence on palliative care interventions that facilitate social support. Research literature was systematically searched using electronic databases and key journals. Searches returned a total of 6,247 unique titles of which sixteen were eligible for inclusion. Interventions include group therapies, group practical interventions and palliative day care. Outcome measures and study designs were heterogeneous. Only one study used a validated outcome measure of social support. Benefits were influenced by participant characteristics such as baseline distress. Partial economic evaluation was attempted by two studies. Methodological challenges include attrition and use of outcome measures that were insensitive to change. Statistically significant results were reported in psychological and physical domains. Evidence is limited due to methodological issues and a scarcity of quantitative research, particularly regarding long-term benefits and cost-effectiveness. Interventions may be more beneficial to some groups than others.

Change Is Complex: Rethinking Research on Psychosocial Interventions and Cancer

The widely discussed 1989 study by Spiegel and colleagues, which suggested that a psychosocial group intervention affected survival in metastatic breast cancer, was not replicated by Goodwin and colleagues in 2001. We analyze methodological issues in both studies, including issues of sampling, randomization, interpretation, and the adequacy and validity of psychosocial constructs and measures to assess hypothesized ingredients of change. The notion of psychogenicityis introduced, conceived as the ability of psychosocial interventions to elicit changes hypothesized to be linked to desired medical outcomes. These considerations lead to the conclusion that there is insufficient evidence to be able to generalize from either study for or against the notion that psychosocial interventions can affect survival in breast cancer. The failure to incorporate into research designs a comprehensive understanding of how coping patterns and related factors may interact with psychosocial interventions to influence cancer progression, and to address hypothesized mediating mechanisms is discussed. Finally, strategies are proposed for future biopsychosocial and intervention research in the field of biopsychooncology.

The Value of Stress-Management Interventions in Life-Threatening Medical Conditions

Emotional stress has been associated with the development and progression of several chronic medical conditions. Recently, researchers have assessed the impact of stress-management interventions on patients' psychological functioning, quality of life, and various disease outcomes, including survival. This review summarizes the value of stress-management techniques in the treatment of two important, life-threatening conditions: coronary heart disease and cancer. Results from randomized clinical trials indicate that psychological interventions can improve patients' psychological functioning and quality of life. However, there is limited evidence to suggest that these interventions significantly reduce morbidity and mortality.

Targeted drugs and Psycho-oncological intervention for breast cancer patients

Personalized medicine is a new field based on molecular biology and genomics in which targeted tumor therapies are administered to patients. Psycho-oncology is a complementary approach that considers social and psychological aspects of patients as part of the treatments for cancer patients.

The aim of this mini-review is to weigh clinical benefits for breast cancer patients of both treatments and possibily enhance benefits by modulating the use of both interventions. We have compared and evaluated on the one hand the use of anti Vascular Endothelial Growth Factor and, on the other hand, psycho-oncological interventions in metastatic and non-metastatic breast cancer patients.

Both treatments did not increase survival of metastatic breast cancer patients, while in a selected study psycho-oncological interventions extended lifespan of non-metastatic breast cancer patients and ameliorate psychological and social factors of metastatic breast cancer patients. Because the two approaches address completely different aspects of cancer patients, if the comparison is limited to the extension of survival, the value of these two treatments cannot be assessed and compared.

It is likely that by comparing patients reported outcomes, possibly by using standardized Quality of Life questionnaires, both patients and health care providers can weigh the benefits of the two treatments. It is therefore important to evaluate the use of cancer patients’ quality of life measures as a mean to improve their experiences about life and treatment, and possibly to extend their survival.

Can We Improve Our Physical Health by Altering Our Social Networks?

Persons with more types of social relationships live longer and have less cognitive decline with aging, greater resistance to infectious disease, and better prognoses when facing chronic life-threatening illnesses. We have known about the importance of social integration (engaging in diverse types of relationships) for health and longevity for 30 years. Yet, we still do not know why having a more diverse social network would have a positive influence on our health, and we have yet to design effective interventions that influence key components of the network and in turn physical health. Better understanding of the role of social integration in health will require research on how integrated social networks influence health relevant behaviors, regulate emotions and biological responses, and contribute to our expectations and worldviews.

Psychological interventions for women with metastatic breast cancer

BACKGROUND

Psychological symptoms are associated with metastatic breast cancer. This is the basis for exploring the impact of psychological interventions on psychosocial and survival outcomes. One early study appeared to show significant survival and psychological benefits from psychological support while subsequent studies have revealed conflicting results. This review is an update of a Cochrane review first published in 2004 and previously updated in 2007.

OBJECTIVES

To assess the effects of psychological interventions on psychosocial and survival outcomes for women with metastatic breast cancer.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group Specialised Register, MEDLINE (OvidSP), EMBASE (OvidSP), PsycINFO (OvidSP), CINAHL (EBSCO), online trials and research registers in June/July 2011. Further potentially relevant studies were identified from handsearching references of previous trials, systematic reviews and meta-analyses. 

SELECTION CRITERIA

Randomised controlled trials (RCTs) and cluster RCTs of psychological interventions, which recruited women with metastatic breast cancer. Outcomes selected for analyses were overall survival, psychological outcomes, pain, quality of life, condition-specific outcome measures, relationship and social support measures, and sleep quality. Studies were excluded if no discrete data were available on women with metastatic breast cancer. 

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data and assessed the quality of the studies using the Cochrane Collaboration risk of bias tool. Where possible, authors were contacted for missing information. Data on the nature and setting of the intervention, relevant outcome data, and items relating to methodological quality were extracted. Meta-analyses was performed using a random-effects or fixed-effect Mantel-Haenszel model, depending on expected levels of heterogeneity.

MAIN RESULTS

Ten RCTs with 1378 women were identified. Of the seven RCTs on group psychological interventions, three were on cognitive behavioural therapy and four were on supportive-expressive group therapy. The remaining three studies were individual based and the types of psychological interventions were not common to either cognitive behavioural or supportive-expressive therapy. A clear pattern of psychological outcomes could not be discerned as a wide variety of outcome measures and durations of follow-up were used in the included studies. The overall effect of the psychological interventions across six studies, on one-year survival, favoured the psychological intervention group with an odds ratio (OR) of 1.46 (95% confidence interval (CI) 1.07 to 1.99). Pooled data from four studies did not show any survival benefit at five-years follow-up (OR 1.03, 95% CI 0.42 to 2.52). There was evidence of a short-term benefit for some psychological outcomes and improvement in pain scores.

AUTHORS' CONCLUSIONS

Psychological interventions appear to be effective in improving survival at 12 months but not at longer-term follow-up, and they are effective in reducing psychological symptoms only in some of the outcomes assessed in women with metastatic breast cancer. However, findings of the review should be interpreted with caution as there is a relative lack of data in this field, and the included trials had reporting or methodological weaknesses and were heterogeneous in terms of interventions and outcome measures.  

Biobehavioral influences on cancer progression

This review focuses on the contributions of stress-related behavioral factors to cancer growth and metastasis and the biobehavioral mechanisms underlying these relationships. Behavioral factors that are important in modulation of the stress response and the pivotal role of neuroendocrine regulation in the downstream alteration of physiologic pathways relevant to cancer control, including the cellular immune response, inflammation, and tumor angiogenesis, invasion, and cell signaling pathways are described. Consequences for cancer progression and metastasis, as well as quality of life, are delineated. Behavioral and pharmacologic interventions with the potential to alter these biobehavioral pathways for patients with cancer are discussed.

Improving the health and well-being of cancer survivors: past as prologue

During the past two decades, there have been a number of unsuccessful replication attempts of our finding that group psychotherapy improves cancer survival. One explanation for this failure is that the wrong phenomenon has been studied. Rather than focusing on the effects of the psychotherapeutic relationship, perhaps, the focus should have been on the social support provided and networks developed by these groups. Since the late 1970s, a growing body of research indicates the importance of social networks and social support on reductions in not only all cause mortality, but also disease specific mortality including cancer. We have learned about how the health, well-being, and ultimate survival of cancer patients is improved by social support and social networks. The social milieu within which we live can provide resources that facilitate reintegration into society. These resources at the individual level, such as one's perception of social and emotional support, at the level of one's social ties with family and friends, and at the community level appear to improve survival across disease conditions including cancer. Even though, the mechanisms by which these endpoints are achieved remain elusive, there is much that can be done. The challenge of our time is to translate what we already know into programs to improve quality of life and to focus research toward increasing our understanding the mechanisms.

Impact of psychotherapy on cancer survival: time to move on?

PURPOSE OF REVIEW

The effect of psychotherapy on the survival of cancer patients has been debated for the past 20 years, mainly due to contradictory findings in the studies published so far. Several reviews have been published, almost all of which criticize the methods used in the studies. In 2007, three replication studies were published, which indicate that the hypothesis that psychotherapy prolongs life should be abandoned. The purpose of the present review of randomized studies of psychosocial intervention is to determine the strength of the evidence for enhanced survival after participation in psychosocial interventions.

RECENT FINDINGS

Three recently published replication studies, which addressed a number of the methodological flaws of earlier studies, did not report better survival among the patients receiving the intervention than among those in the control group.

SUMMARY

The hypothesis that psychotherapy enhances survival should be abandoned in the light of the latest replication studies, which show null results for improved survival after psychotherapy. The evidence to date points to a need for investigating the interactions between the medical, psychological, social and health behaviour components of intervention programmes, as recently published studies indicate reduced mortality among patients who engage in physical activity and change to a healthier diet.

Psychological interventions for women with metastatic breast cancer

BACKGROUND

Systematic reviews of psychological interventions for patients with cancer are conflicting, some showing benefits for patients and others not. One early study appeared to show significant survival and psychological benefits from a psychological intervention given to women with metastatic breast cancer. Subsequent studies have however demonstrated conflicting results.

OBJECTIVES

To assess the effects of psychological interventions (educational, individual cognitive behavioural or psychotherapeutic, or group support) on psychological and survival outcomes for women with metastatic breast cancer.

SEARCH STRATEGY

For this update, the Cochrane Breast Cancer Group Specialised Register was searched (September 2007). Also searched were MEDLINE (1966-September 2006), CINAHL (1982-September 2006), PsycInfo (1974-September 2006), and SIGLE (1980-September 2006).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of psychological interventions for women with metastatic breast cancer. Studies which were not t 'intention to treat' were included owing to the nature of the patient group under study and the likely high loss of follow-up data.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two reviewers. Data about the nature and setting of the intervention, relevant outcome data and items relating to methodological quality were extracted.

MAIN RESULTS

Five primary studies (511 women) were identified all group psychological interventions. Two of these were cognitive behavioural interventions and three evaluated support-expressive group therapy. The five studies of group psychological therapies showed very limited evidence of benefit arising from these interventions. Although there was evidence of short-term benefit for some psychological outcomes, in general these were not sustained at follow-up. A clearer pattern of psychological outcomes could not be discerned as a wide variety of outcome measures and durations of follow-up were used in the included studies. The possible longer survival times in women allocated to receive psychological intervention in the early study have not been replicated in the subsequent four studies (including one by members of the first study group), and overall the effects of these interventions on survival are not statistically significant (for example, odds ratio for 5 year survival 0.83 (95% confidence interval [CI] 0.53 - 1.28).

AUTHORS' CONCLUSIONS

There is insufficient evidence to advocate that group psychological therapies (either cognitive behavioural or supportive-expressive) should be made available to all women diagnosed with metastatic breast cancer. Any benefits of the interventions are only evident for some of the psychological outcomes and in the short term. The possibility of the interventions causing harm is not ruled out by the available data.

Effects of supportive-expressive group therapy on survival of patients with metastatic breast cancer: a randomized prospective trial

BACKGROUND

This study was designed to replicate our earlier finding that intensive group therapy extended survival time of women with metastatic breast cancer. Subsequent findings concerning the question of whether such psychosocial support affects survival have been mixed.

METHODS

One hundred twenty-five women with confirmed metastatic (n = 122) or locally recurrent (n = 3) breast cancer were randomly assigned either to the supportive-expressive group therapy condition (n = 64), where they received educational materials plus weekly supportive-expressive group therapy, or to the control condition (n = 61), where they received only educational materials for a minimum of 1 year. The treatment, 90 minutes once a week, was designed to build new bonds of social support, encourage expression of emotion, deal with fears of dying and death, help restructure life priorities, improve communication with family members and healthcare professionals, and enhance control of pain and anxiety.

RESULTS

Overall mortality after 14 years was 86%; median survival time was 32.8 months. No overall statistically significant effect of treatment on survival was found for treatment (median, 30.7 months) compared with control (median, 33.3 months) patients, but there was a statistically significant intervention site-by-condition interaction. Exploratory moderator analysis to explain that interaction revealed a significant overall interaction between estrogen-receptor (ER) status and treatment condition (P = .002) such that among the 25 ER-negative participants, those randomized to treatment survived longer (median, 29.8 months) than ER-negative controls (median, 9.3 months), whereas the ER-positive participants showed no treatment effect.

CONCLUSIONS

The earlier finding that longer survival was associated with supportive-expressive group therapy was not replicated. Although it is possible that psychosocial effects on survival are relevant to a small subsample of women who are more refractory to current hormonal treatments, further research is required to investigate subgroup differences.

What is the state of the evidence on the mind–cancer survival question, and where do we go from here? A point of view

GOALS OF WORK

There is long history of anecdote and surmise linking psychosocial factors to cancer incidence and survival. However, over the past three decades, an increasing number of rigorous studies have investigated the possibility of a mind-cancer survival connection. The objective of this paper is (1) to review the past 30 years of psycho-oncology research on the mind-cancer survival question, (2) to review the methodological debate and interpretations of the research findings, and (3) to consider future research directions.

MAIN RESULTS

Over the past three decades, a small number of studies have been published. Some observational and quasi-experimental studies suggest the possibility that coping and psychological factors may influence disease outcomes, but clinical trials suggest that psychosocial interventions do not prolong survival. Methodological comment and interpretation about the significance of these trials vary. Some researchers view the mind-cancer survival question as resolved and negative, whereas others identify conceptual and methodological challenges and view the possible impact of psychosocial factors on survival as simply unproven. We take the position that the question is unanswered.

CONCLUSION

Recommended future research directions include: (1) more trials based on testable theories, targeted interventions, and greater specificity in the measurement model and (2) new research questions and more rigorous observational, prospective, and longitudinal studies, case studies, mixed methods, and innovative design approaches being developed by complementary and alternative medicine researchers. Further research is warranted on the mind-cancer survival question.

Support groups in advanced breast cancer

Considerable research has been conducted into the potential benefits of support groups for patients with metastatic breast cancer. An early report by Spiegel et al. suggested that participation in these groups not only had psychologic benefits but also resulted in prolongation of survival. A review of the published literature was undertaken. Five randomized trials of support groups in metastatic breast cancer have been published. Four of those five trials have reported survival results: Survival outcomes from the fifth study are pending. A variety of group interventions were investigated. All of the studies reported beneficial psychosocial effects of the intervention, although the effects, at times, were transient and were not always present for all study outcomes. Only the original publication by Spiegel's group identified a survival benefit. No survival benefit was seen for participation in support groups for the other three studies that reported survival effects. Mixed survival effects were reported for other psychologic interventions in other cancers. There was good evidence that support groups in metastatic breast cancer lead to improved psychologic outcomes. Evidence of beneficial survival effects was not convincing.

Meta-analysis of the effects of psychosocial interventions on survival time in cancer patients

OBJECTIVE

To provide a quantitative summary of effects of psychosocial interventions on cancer survival, and to present an overview of methodological and reporting aspects of the studies.

METHOD

Electronic searches and manual searches of reference lists from review articles and retrieved papers. Two coders independently coded study, participant, treatment, and outcome characteristics of the studies meeting selection criteria.

RESULTS

Thirteen journal articles published between 1989 and 2003 reporting results from 14 controlled intervention studies were included. Results are based on data obtained from 2626 subjects. Effect sizes [hazard ratios (HR)] were heterogeneous and random effects models were used in the analyses. The total mean inverse-variance-weighted HR was 0.85 (95% CI: 0.65-1.11). Randomized studies (n=8) showed no overall treatment effect (HR: 0.77, 95% CI: 0.56-1.06), neither did the nonrandomized studies (HR: 1.00, 95% CI: 0.61-1.62). Interventions using individual treatment (n=3) were, however, found to be effective (HR: 0.55, 95% CI: 0.43-0.70) but interventions using group treatment (n=9) were ineffective (HR: 0.97, 95% CI: 0.73-1.27). Group treatments of breast cancer (n=6) were ineffective (HR: 0.95, 95% CI: 0.69-1.31).

CONCLUSION

A definite conclusion about whether psychosocial interventions prolong cancer survival seems premature. Future studies should use randomization to avoid self-selection of patients with poor prognosis. Interventions should focus on a single diagnosis, take into account known risk factors, and describe their interventions thoroughly.

Help me help you: support groups in cancer therapy

Shortly before his death in 1995, Kenneth B. Schwartz, a cancer patient at Massachusetts General Hospital (MGH), founded The Kenneth B. Schwartz Center at MGH. The Schwartz Center is a non-profit organization dedicated to supporting and advancing compassionate health care delivery that provides hope to the patient, support to caregivers, and encourages the healing process. The Center sponsors the Schwartz Center Rounds, a monthly multidisciplinary forum where caregivers reflect on important psychosocial issues faced by patients, their families, and their caregivers, and gain insight and support from fellow staff members. Three invited patients attended rounds and told their compelling stories; these each effectively demonstrated their fight as cancer survivors. Much of the strength that they displayed came from the different types of support they each received, and the invaluable role of the medical team. Each shared a very positive experience with 'The Wellness Community,' in Boston. The article discusses issues of support and the role of formal support groups. Types of support intervention, the impact they have on quality of life and survival are reviewed.

Psychological interventions for women with metastatic breast cancer

BACKGROUND

There have been conflicting results from systematic reviews of psychological interventions for patients with cancer, some showing benefits for patients and others not. One early study appeared to show significant survival benefits as well as psychological benefits from a psychological intervention given to women with metastatic breast cancer. Some further studies have been undertaken, again with conflicting results.

OBJECTIVES

To assess the effects of psychological interventions (educational, individual cognitive behavioural or psychotherapeutic, or group support) on psychological and survival outcomes for women with metastatic breast cancer.

SEARCH STRATEGY

We searched the Cochrane Breast Cancer Group Trials Register (September 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2003), MEDLINE (1966-October 2003), CancerLit (1983-2000), CINAHL (1982-October 2003), PsycInfo (1974-November 2003), and SIGLE (1980-November 2003).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of psychological interventions for women with metastatic breast cancer. Studies were included even if they were not 'intention to treat', owing to the nature of the patient group under study and the likely high loss of follow-up data.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two reviewers. Data about the nature and setting of the intervention, and the relevant outcome data were extracted, along with items relating to methodological quality.

MAIN RESULTS

Five primary studies were identified, all group psychological interventions. Two of these were cognitive behavioural interventions and three evaluated support-expressive group therapy. The five studies of group psychological therapies for women with metastatic breast cancer showed very limited evidence of benefit arising from these interventions. Although there was evidence of short-term benefit for some psychological outcomes, in general these were not sustained at follow-up. A clearer pattern of psychological outcomes could not be discerned as a wide variety of outcome measures and durations of follow-up were used in the included studies. The possible longer survival times in women allocated to receive psychological intervention in the early study have not been replicated in the subsequent four studies (including one by members of the first study group), and overall the effects of these interventions on survival are not statistically significant (for example, odds ratio for 5 year survival 0.83 (95% confidence interval [CI] 0.53 - 1.28).

REVIEWERS' CONCLUSIONS

There is insufficient evidence to advocate that group psychological therapies (either cognitive behavioural or supportive-expressive) should be made available to all women diagnosed with metastatic breast cancer. Any benefits of the interventions are only evident for some of the psychological outcomes and in the short term. The possibility of the interventions causing harm is not ruled out by the available data.

Supportive-expressive group therapy: The transformation of existential ambivalence into creative living while enhancing adherence to anti-cancer therapies

Supportive-Expressive Group Therapy (SEGT) has been developed and manualised in the research setting, but there have been few clinical accounts of its utility. In this qualitative review of its application in the Melbourne-based randomised control trial (RCT) for women with advanced breast cancer, SEGT is considered from the perspective of the structure and framework of therapy, its therapists, the issues that develop in exploring its common themes and what constitutes a well functioning group. Groups move through identifiable developmental phases. The mature group process transforms existential ambivalence into creative living, evidenced by humour, celebration, assertiveness, altruism, new creative pursuits and eventually courageous acceptance of dying. Challenges and pitfalls include avoidance, non-containment of ambivalence, intolerance of difference, anti-group phenomena and splitting. A key element is the medicalization of the group culture whereby members and co-therapists explore health beliefs and attitudes about care. This promotes compliance with anti-cancer treatments, including both the initiation of and perseverance with chemotherapy. This mechanism could prove to be a potentially important pathway in promoting longer survival.

Hypnotherapy and cognitive-behaviour therapy in cancer care: the patients' view

Psychological intervention is not widely available for emotionally distressed patients with cancer. The purpose of this study is to investigate and report on the experiences of eight patients who participated in a programme consisting of hypnotherapy and cognitive-behaviour therapy. Following the 12-session intervention, qualitative analysis of interview data demonstrated that patients had acquired the skills to enable them to cope, both with invasive medical procedures and the psychological traumas they faced. The findings also indicated some initial misconceptions about hypnotherapy and the need to provide a therapy setting sensitive to the needs of cancer patients undergoing active medical treatment.

Psycho-oncology in a united Europe--changes and challenges

The paper provides an overview on the 11th scientific conference of the European Society for Psycho-Oncology (ESPO), which took place in June 2001, at Heidelberg, Germany. The main topics discussed during the conference were: (1) the state of the art of research on the effects of psychological interventions in cancer patients; (2) psychosocial aspects in the new field of cancer genetics; (3) recent developments in Quality of Life research; (4) Psycho-Oncology from an European perspective; and (5) children and cancer. The conference gave an impressive picture of the many achievements Psycho-Oncology in Europe has accomplished during the last years, in the clinical and scientific domain. With recent biomedical innovations Psycho-Oncology is facing new challenges. Despite these achievements limitations have become apparent. Identifying these limitations, future aims can be outlined. Among these, there is the need for methodological refinement, as well as for proof of clinical relevance of research results, in order to narrow the gap between research and practice.

Controversies in cancer and the mind: effects of psychosocial support

In the last decades of the twentieth century, interest in effects of consciousness on health and illness generated several lines of investigation into effects on cancer. Animal studies showed sensitivity of some cancers to hormonal and stressful influences. However, those findings did not translate into effects on humans, nor did they lead to advances in understanding of human cancer. The proposal that emotional state or stress, mediated through psycho-neuro-immunologic mechanisms would affect cancer generation or growth, resulted in conflicting information. Major surveys found no relationship. The proposal of a cancer personality (Type C) also was not confirmed. Initial observations that depression and stress affected human cancer seem to have best been explained by misinterpretations of cause and effect. By the mid 1990s, a remaining thesis--effect of psychosocial support on longevity and the course of cancer--was yet to be resolved. Initial positive results, especially findings in two popularly quoted studies, were not confirmed; they seem to have been due to inadequate numbers (chance) or to artifacts in study design or implementation. Psychosocial support may result in better adjustment and quality of life, but it does not directly affect the evolution of human cancer.

Separating the apples and oranges in the fruit cocktail: the mixed results of psychosocial interventions on cancer survival

In past reviews of the literature on psychosocial interventions for cancer patients, different reviewers have reached disparate conclusions about the ability of a psychosocial intervention to have an impact on cancer survival. This article highlights some of the basis for differences of opinion, including the range of psychosocial interventions provided to patients and the challenges inherent in conducting research studies of this type. Social workers who work with cancer patients at vulnerable times need to understand what the current evidence shows can be gained from participation in a psychosocial intervention. Several key questions have been identified that can provide the basis for future rigorous studies. The role of the social worker in participating and shaping research on the relationship of psychosocial intervention and cancer survival is also discussed.

Can psycotherapy increase the survival time of cancer patients?

OBJECTIVE

The aim of this paper was to review the evidence regarding the possibility of a relationship between psychological intervention and survival time of cancer patients.

METHOD

A literature search was conducted using CD ROM databases to identify studies which have evaluated the effects of psychological interventions on the survival time of cancer patients. The identified studies were critically reviewed.

RESULTS

Eight studies which used scientifically acceptable methodology to examine this question were identified. Three of these studies found evidence for a relationship between psychological intervention and patients' survival time, while five did not. Methodological issues and potentially confounding factors are discussed.

CONCLUSION

To date, a direct relationship between psychological intervention and patient survival time has not been conclusively demonstrated. Large-scale replication studies which are currently under way will provide more conclusive evidence on this question within the next few years.

A prospective, longitudinal study of the relationship of psychological work to duration of survival in patients with metastatic cancer

This study is a prospective, longitudinal investigation of the psychological factors associated with the duration of survival in patients with metastatic cancers of various kinds who were receiving group psychotherapy. A correlative approach rather than an experimental (trials) design was used in the study because our aim was to relate the psychological attributes of each individual to survival rather than to test the efficacy of the intervention. Twenty-two patients with medically incurable metastatic cancer of various kinds received weekly group psychotherapy for up to 1 year, the great majority remaining well enough to attend the group for at least 8 months. During this time, they provided extensive verbal data, through written homework, and from notes taken by the therapists at interviews and during group sessions. These data were subjected to detailed qualitative analysis, as a result of which a number of psychological themes were defined. A quantitative rating was assigned to the data for each theme in each individual patient through team discussions. The scores for the individual themes were summed to produce a 'total psychological score', representing the degree of each patient's involvement with psychological self-help work. The values for each patient were then related to his or her survival duration. Cox regression analyses showed that this composite score, and five of six major themes, were significantly related to survival duration. These themes were: ability to act and change; willingness to initiate change; application to self-help work; relationships with others; and quality of experience. In contrast, there was no relationship between survival and four standard psychometric measures taken at the onset of therapy. However, results on a 5-point scale measuring the subject's expectancy that psychological efforts would affect the disease showed a strong relationship to survival. To control for differences in severity of disease as a factor possibly influencing psychological work, the analyses were repeated, using the survival duration predicted for each patient by a panel of oncologists as a covariate. Closely similar results were obtained. Limitations on the interpretation of the results are discussed. Within these limits, it appears that there is a strong association between longer survival and psychological factors related to the involvement of cancer patients in psychological self-help activities. While causality cannot be inferred, reasons are given for believing that this is not a result of the disease influencing the patients' psychology, but rather the converse.

A randomized controlled trial of the effects of group psychological therapy on survival in women with metastatic breast cancer

In order to test the effect of a psychological intervention on survival from cancer, 66 women with metastatic breast cancer, all receiving standard medical care, were randomly assigned into two groups; one group (n = 30) attended the psychological intervention, consisting of 35 weekly, 2 h sessions of supportive plus cognitive behavioral therapy; the control group (n = 36) received only a home study cognitive behavioral package. No significant difference was found in survival post-randomization between the groups as assessed by a log rank test 5 years after the commencement of the study. As expected, several prognostic factors were significant predictors of survival: metastatic site, hormonal receptor status, and chemotherapy prior to randomization. While many personal and demographic variables did not influence survival, there was a significant effect of self-reported exercise (possibly due to better health). A small subgroup of intervention subjects who attended outside support groups also survived significantly longer than those who did not. The strengths and limitations of the present study are discussed, and the results contrasted with those of a well known study by Spiegel et al. (Spiegel, D., Bloom, J.R., Kraemer, H.C. and Gottheil, E. (1989) Lancet ii, 888-891). We propose that a different experimental design (correlative) may be needed to show any effect of self-help behaviors and psychological attributes in a small minority of patients.