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Journal of Clinical Oncology, Vol 23, No 22 (August 1), 2005: pp. 5263 © 2005 American Society of Clinical Oncology. DOI: 10.1200/JCO.2004.01.0199
Possible Effects of Psychological Therapy on Survival Duration in Cancer PatientsDivision of Epidemiology, Statistics and Behavioral Research, University Health Network/Princess Margaret Hospital, Toronto, Ontario, Canada To the Editor: Whether or not psychological therapies can prolong the life span of cancer patients has been hotly debated during the last 15 years. Two recent articles in this Journal contribute substantially to the debate: an original study by Kissane et al,1 which concluded that "cognitive-existential group therapy does not prolong survival in women with early stage breast cancer," and an Editorial by Dr Goodwin commenting on the study.2 There are now approximately equal numbers of published clinical trials reporting that psychological therapies of various kinds do or do not prolong median life span in patients with metastatic cancers, with later and better-designed studies favoring the negative conclusion. Goodwin proposes that, "for many, the report by Kissane et al will be viewed as the final nail in the coffin for potential survival benefits of psychological interventions in cancer."2 Such a generalization would, we believe, be unwarranted. What has been demonstrated is that certain kinds of short-term group psychological interventions fail to prolong the mean or median life span of groups of cancer patients. This is a useful finding that sets limits on what we can expect from such interventions, and one that may help to quell the more extreme claims for effects of mind on cancer that are common in the popular press. What should not be dismissed, however, is the possibility that some therapies may have the potential to extend life in certain patients under some conditions. To rule this out risks making a type II error that could inhibit further research on an issue that is of great importance to many cancer patients. We have examined the possible influence of mental variables on cancer progression by asking a different question than that addressed by trials methods—namely, what are the psychological characteristics of people with metastatic cancers who do survive long beyond their prognoses? We have presented prospective data showing a highly significant correlation between strong involvement in psychological and spiritual "self help" strategies and prolonged survival (possible confounding factors being controlled for).3,4 The data obtained in these exploratory studies (and a larger replication of our intervention study is in progress) not only point to a potentially important influence of psychological qualities on survival, but also suggest that we need to consider carefully what methods are best suited to this kind of study. It should not be assumed that hypothesis testing through randomized controlled trials is the approach of choice at this early stage of research in the subject. When the question at issue is potential effects of a psychological change on subjects adhering to a therapy, it is vital to document the response of each subject to therapy and to relate this to any effects on life span. Psychotherapy cannot readily be treated like a drug because what the patients do with it varies enormously and is much more relevant than what is offered to them. Where the proportion of subjects making substantial psychological change is low, comparing group means may result in losing any effects attained by a few dedicated participants. This is like using a trials design to test the effect of an oral medication that only a small percentage of the treated group actually ingests. We entirely agree with Goodwin,2 that future research is needed to "elucidat(e) which interventions, and delivered by whom are most beneficial for which individuals at differing stages of their illnesses." Benefits including, but not restricted to prolongation of life, that are currently experienced by only those few individuals who make substantial efforts to help themselves through psychological change, may become available to many more when the process is better understood through further exploratory research. Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest. REFERENCES
1. Kissane DW, Love A, Hatton A, et al: Effect of cognitive-existential group therapy on survival in early-stage breast cancer. J Clin Oncol 22:4255-4260, 2004
2. Goodwin PJ: Support groups in breast cancer: When a negative result is positive. J Clin Oncol 22:4244-4246, 2004 3. Cunningham AJ, Edmonds CVI, Phillips C, et al: A prospective, longitudinal study of the relationship of psychological work to duration of survival in patients with metastatic cancer. PsychoOncology 9:323-339, 2000[CrossRef][Medline]
4. Cunningham AJ, Watson K: How psychological therapy may prolong survival in cancer patients: New evidence and a simple theory. Integr Cancer Ther 3:214-229, 2004
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Copyright © 2005 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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