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Journal of Clinical Oncology, Vol 25, No 30 (October 20), 2007: pp. 4852-4853 © 2007 American Society of Clinical Oncology. DOI: 10.1200/JCO.2007.13.3967
Does Psychotherapy Extend Survival? Some Methodological Problems OverlookedUniversity of Pennsylvania School of Medicine, Philadeliphia, PA To the Editor: An article by Kuchler and colleagues1 and an accompanying editorial2 claim that an average of just 222 minutes of psychotherapy produced a 10-year survival benefit among a mixed group of patients with gastrointestinal cancer. Treatment was nonspecific, consisting of supportive psychotherapy, crisis intervention, and a small amount of relaxation training. About one third of the intervention focused on strategizing and rehearsing the patients' interactions with oncology physicians and nurses. Claims of such an effect on survival should arouse skepticism, but all the more so when details concerning the trial are gleaned from the recent report and an earlier report of survival at 2 years.3 As a starting point, survival does not appear to have been the primary end point of this study. The authors in passing note that such an effect "had not been hypothesized."1 The study was powered to examine quality of life as the primary end point. Survival was apparently specified as an outcome post hoc, perhaps inspired by the report of Spiegel and colleagues,4 with the rationale that it was a feature of the more reasonable outcome of improved quality of life. Moreover, it is unclear how psychotherapy might improve survival without improving quality of life, but outcome data for quality of life have not been provided. The 1999 article3 states that quality of life data would be presented in a later article, but a search of Medline and PsychInfo identifies no such report. Psychotherapy was provided almost entirely on the cancer ward, and it appears that key persons were not blinded to treatment assignment, including the oncology treatment team and the patients who crossed over into nonrandomized arms. Intervention was not limited to what is commonly considered psychotherapeutic, and study therapists spent as much time talking to the treatment team as to the patients, attending surgical and nursing rounds, reporting patients' symptoms of distress, and taking an active role advocating for the patient. These key interventions are ignored in the authors' speculation concerning the mechanism by which the effect they claim was obtained. What is telling is that despite an apparent lack of differences across basic clinical variables, there were substantial differences in the medical treatment received by the groups. Patients receiving the intervention received almost twice as many days of intensive care as the routine care group, they were also twice as likely to receive postoperative chemotherapy, five times as likely to receive radiotherapy, three times more likely to receive alternative treatments, and four times more likely to receive a combination of three treatments in the post-treatment period. Such specific treatment differences in the absence of clinical differences strongly suggest that medical surveillance and treatment were more generally superior for the intervention group, and this remains the most plausible explanation for any differences in survival.
An examination of the survival curves in the two reports of this study suggest group differences emerged almost immediately after treatment, were stable after a few months, and then did not differ greatly between the 2- and 10-year follow-up. Indeed, if one examines deaths between 2 and 10 years, there is no significant relationship between group status and survival ( There is no documented psychological mechanism by which a nonspecific supportive psychotherapy should have the effect claimed by Kuchler et al1 and the accompanying editorial.2 The authors note that the treatment targeted "fighting spirit," but that variable has not been shown to predict survival in a large observational study,5 and the evidence for psychological influences on survival is at best weak, inconsistent, and sometimes outright contradictory.6 However, there are good data that improving the care provided to cancer patients improves outcomes.7 While conceding a mixed picture of the evidence for an effect of psychotherapy on survival, Kuchler and colleagues1 and the accompanying editorial2 perpetuate overly positive assessments of two studies that have served as the main basis for the claim of an effect. No one has been able to replicate the odd pattern of survival in the control group in the original Spiegel study,4 whereas the survival curve for the intervention group resembles the survival curves for both control and intervention groups in the pattern of consistently null findings in subsequent studies.8 The claim of an effect for the Fawzy et al9 study is not based on intent-to-treat analyses; different rules were used to decide whether to include intervention and control patients in the final analyses; and reclassification of a single patient would eliminate any statistically significant group difference. A recent critical review concluded that no clinical trial has found that psychotherapy improved survival of cancer patients where survival was the a priori primary outcome and in which provision of psychotherapy was not confounded with enhancement of medical care.8 The original Kuchler et al study3 was included in this assessment, and for numerous reasons, the recent follow-up report does nothing to challenge it. The editorial accompanying the recent Kuchler report suggests that because psychotherapy is cheap, we should consider providing it to patients as a strategy for improving their survival. We disagree. Psychotherapy ought to be available to patients who desire it as a means of improving their adaptation and quality of life, but it is time that claims that psychotherapy also enhances survival meet the same methodological standards and be greeted with the same skepticism that would be accorded claims for other treatments that are aimed at altering biomedical outcomes. Encouraging cancer patients to seek psychotherapy to extend their lives is disrespectful of patients' autonomy, time, and resources. Encouraging patients to seek psychotherapy based on the available evidence of its effectiveness in improving quality of life among those experiencing decrements is respectful to patients and consistent with available science. Fostering improved care for all patients is an attainable goal, but requires that we face what we can and cannot achieve through psychological intervention. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author(s) indicated no potential conflicts of interest. REFERENCES
1. Küchler T, Bestmann B, Rappat S, et al: Impact of psychotherapeutic support for patients with gastrointestinal cancer undergoing surgery: Ten-year survival results of a randomized trial. J Clin Oncol 25:2702-2708, 2007 2. Andrykowski MA: Survival benefits associated with provision of psychotherapeutic support to patients with gastrointestinal cancer: Lots of bang for a few bucks? J Clin Oncol 25:2644-2645, 2007 3. Kuechler T, Henne-Bruns D, Rappat S, et al: Impact of psychotherapeutic support on gastrointestinal patients undergoing surgery. Hepatogastroenterology 46:322-335, 1999[Medline] 4. Spiegel D, Bloom JR, Kraemer HC, et al: Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet 2:888-891, 1989[CrossRef][Medline] 5. Greer S, Morris T, Pettingale KW, et al: Psychosocial response to breast cancer and 15-year outcome. Lancet 335:49-50, 1990[CrossRef][Medline] 6. Garssen B: Psychological factors and cancer development: Evidence after 30 years of research. Clin Psych Rev 24:315-338, 2004[CrossRef][Medline] 7. McCorkle R, Strumpf NE, Nuamah IF, et al: A specialized home care intervention improves survival among older post-surgical cancer patients. J Am Geriatrics Society 48:1707-1713, 2000 8. Coyne JC, Stefanek M, Palmer SC: Psychotherapy and survival in cancer: The conflict between hope and evidence. Psychol Bull 133:367-394, 2007[CrossRef][Medline] 9. Fawzy FI, Canada AL, Fawzy NW: Malignant melanoma: Effects of a brief, structured. Arch Gen Psychiatry 60:100-103, 2003 Related Reply
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Copyright © 2007 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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2 (1) = 2.03; P = .15). Thus, that the differences emerged early and were stable suggests the hypothesis that any differences in survival are due to differences in medical surveillance and treatment in the immediate acute care and post-treatment periods. 
