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Does Psychotherapy Affect the Survival of Cancer Patients? More Questions Than Answers

Department of Hematology, Oncology and Transfusion Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany

To the Editor:

We read with great interest the article by Küchler et al¹ about the impact of psychotherapy on survival of cancer patients undergoing GI surgery. This report, which was broadly discussed in the German press, suggests that psychotherapeutic support may lead to a long-term improved outcome of patients with GI cancer undergoing surgery. However, we believed that the results of the trial might have been affected by a randomization bias. Although the statistical analysis did not show differences in the composition of the experimental and control groups with respect to site of tumor, TNM staging, or residual tumor classification (RTC), there was a substantial difference between both groups regarding the result of surgical treatment. RTC is a basic predictor of survival rate, with 95% of patients after a N0 resection having a relapse rate of less than 5% after 5 years.² In the report by Küchler et al, 39.5% of patients (17 of 136) in the intervention arm were alive after 10 years, compared with 18.8% of patients (six of 135) in the control arm. However, the postoperative evaluation showed an in sano resection in 44 patients in the experimental group and 29 patients in the control group, making an absolute difference of 15 patients between groups. This figure could explain the higher number of survivors in the intervention group (17 v six). Furthermore, it is likely that the statistical analysis failed to detect a significant difference in the composition of the intervention and the control groups, given that the absolute number of patients who were potentially healed by surgery represents a small percentage of the participants at the trial (26%). Moreover, the proportion of patients with R0 resection was diluted further by the inclusion of patients with benign tumors. Finally, as the authors state in their report, the difference between groups regarding survival was limited to patients with local or regional involvement, which might be healed after surgery.

The authors mention some possible mechanisms (improved coping, greater awareness of health behaviors, enhanced social support, and more efficient immune function due to fear reduction) that hypothetically may account for a survival benefit in cancer patients. However, we are worried by the fact that death causes were not evaluated. The authors state that the results of the study in terms of survival benefits for the experimental patients were surprising and had not been hypothesized. We believe that the evaluation of outcomes that were not end points of a trial requires extraordinary caution, especially if these outcomes are critical (ie, survival rates). Given that causes of death were not evaluated, it is not clear if psychotherapy had a specific impact on cancer survival or if it affected other factors related to life expectation (nutrition, exercise habits, or participation at prevention programs).

As mentioned in the editorial about the report, scientifically rigorous implementation of psychological intervention outcome trials is extraordinarily difficult. Although the results of the trial are intriguing and stimulating, we believe that the above-mentioned methodologic problems yield a source of concern.

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: 10-year survival results of a randomized trial. J Clin Oncol 25:2702-2708, 2007[Abstract/Free Full Text]

2. DeVita VT, Hellmann S, Rosenberg SA: Cancer: Principles and Practice of Oncology (ed 7). Philadelphia, PA, JB Lippincott, 2005

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