Multiple Psychological Approaches Detailed Scientific Review

Overview

Background

Studies in animals have confirmed the deleterious effects of stress upon the immune system. These effects have been associated with both the incidence and metastasis of tumors in mice and rats^1-5 with interactions reported with sex⁴ and age⁵. Early studies in animals used highly artificial stressors such as electroshock, but recent studies have used more natural stressors such as introduction of dominant males into the cages of stable pairs of animals².

Evaluating the effects of stress upon the immune system in humans is far more challenging and complex because of the limits of what can be done experimentally to people². Investigators in this field, known as "psychoneuroimmunology", however, do continue to find other ways to explore interrelationships between psychological states and the neurological, endocrine, and immune systems of humans. Extensive research has clearly show that both acute and chronic stressors cause dysregulation of the immune system⁶. In recognition of the major role that psychological issues and coping assume in the lives of patients with cancer, the field of psychosocial oncology or "psychooncology" developed in the 1970s¹.

In the early 1980s, Dr. O. Carl Simonton, a radiotherapist and Stephanie Mathews-Simonton, a motivational counselor, used meditation and visual imaging techniques for patients with cancer. Their book, "Getting Well Again", provided case reports of unexpectedly long survival time following the use of visual imaging⁷.

Dr. Bernie Siegel, a surgical oncologist who attended one of the Simontons’ seminars on meditation and visualization, subsequently developed a therapy group, Exceptional Cancer Patients. This group used dreams, drawings and images to help bring about personal changes and healing with or without actual observed effects upon their cancers. His book, Love, Medicine & Miracles, describes case reports in which drawing and painting helped patients to identify and overcome psychological obstacles in their strivings for health⁸.

In 1989, a major work, the Handbook of Psychooncology, by Holland and Rowland, described research based findings concerning potential psychotherapeutic interventions for psychosocial challenges faced by cancer patients⁹. (An updated version was published in 1998 by Holland and colleagues¹⁰.) History and major issues concerning the possible relationships between psychological factors and cancer have been summarized in Michael Lerner’s book, Choices in Healing¹.

An unintended consequence of these explorations of mind-body interactions with cancer has been a belief by some that controlling cancer requires a simple exertion of mind over matter or that people get cancer because of some deep emotional need for it. Such thoughts have lead many patients with cancer to have needless feelings of guilt¹¹.

A review that was published in 2002 of randomized clinical trials of multiple psychological therapies is summarized in the Summary of Research.

Summary of Research

In 2002, Newell and colleagues published a systematic review¹² of "fair" or "good" randomized controlled trials that evaluated various psychological therapies for cancer patients. Their review process included searches of Medline, the Cochrane Review database, various psychological databases, and individual bibliographies. They identified 627 papers published or in manuscript form between 1954 and the end of 1998. Classification of these articles yielded 271 studies involving 329 separate intervention trials of which 155 were randomized controlled trials (RCTs).

Newell’s group then ranked all 329 intervention trials by a 30-point scale of methodological quality that included items such as description of selection strategy: randomization, consecutive series, or all patients selected, treatment group blinded to patients, care providers blinded to treatment, control patients receiving equivalent other treatments, etc. Scores of greater than 20 points were considered "good", those of 11-20 points "fair", and those less than 11 points "poor". Trials with poor scores or other problems were excluded yielding a total of 53 intervention trials of fair or good quality.

Interventions studied included both group and individual therapy, therapist and non-therapist delivery, audiotapes, involvement of the patient’s significant other, information and education, structured and unstructured counseling, relaxation training, cognitive behavioral therapy, communication and expression training, guided imagery and visualization, and self-practice of techniques taught.

Outcomes assessed by these 53 intervention trials included psychosocial effects (anxiety, depression, hostility, stress/distress, coping control, vocational/domestic adjustment, interpersonal /social adjustment, sexual/marital adjustment, and general overall), relief of physical and conditioned side effects (nausea, vomiting, pain, fatigue, and overall) and survival or immune outcomes.

Because of wide variations in the nature of these interventions, outcome measures, length of follow-up and presentation of trial results; the reviewers were not able to use meta-analysis to evaluate the effectiveness of these interventions. Accordingly, they used a previously published decision process^13,14 that resulted in one of five outcomes:

1. Strong recommendation for the intervention strategy
2. Tentative recommendation
3. Tentative recommendation against
4. Strong recommendation against
5. No recommendation for or against (needs further exploration)

Conclusions of the reviewers concerning psychosocial outcomes were that they could not strongly recommend any of the psychological therapies in the trials reviewed. However, they could tentatively recommend music therapy, counseling, guided imagery, education, cognitive behavioral therapy, communication skills training, therapist delivered group therapy, self practice and non-therapist delivered structured counseling for certain outcomes. For these and other outcomes they also recommended further exploration for therapist delivered individual therapy, cognitive behavioral therapy, communication skills training, relaxation training, guided imagery, self practice, group therapy, education, structured counseling, self-esteem building and interventions involving patients’ significant others. A table summarizes their conclusions concerning psychosocial outcomes.

Conclusions of the Newell review concerning relief of side effects of conventional treatment were that they could not strongly recommend or be against any of the psychological therapies in the trials reviewed. However, they tentatively recommended relaxation, guided imagery, group therapy, cognitive behavioral therapy, self-practice and hypnosis for certain conditions. For these and other conditions, they recommended further exploration for therapist delivered interventions involving individual therapy, unstructured counseling, relaxation, audiotapes, cognitive behavioral therapy, self-practice and guided imagery. A table summarizes their conclusions concerning relief of side effects.

Conclusions of the Newell review concerning survival were that none of the psychological therapies in the trials reviewed could be either strongly recommended for or against, but that group therapy, education, and relaxation warranted further exploration. Their review was completed before the publication of a major multi-center cooperative trial evaluating survival outcomes for patients with and without support groups; however, that trial also reported no effects upon survival¹⁵. A recent review of survival outcomes limited to support groups that includes that study may be accessed on this Web site at Support Groups & Survival.

Conclusions of the Newell review concerning immune system effects were that none of the psychological therapies in the trials reviewed could be either strongly recommended for or against, but that therapist delivered individual therapy, education, relaxation training, cognitive behavioral therapy, guided imagery and electromyography feedback warranted further exploration.

The complete article (Newell, SA, Sanson-Fisher RW, Savolainen NJ. Systematic Review of Psychological Therpies for Cancer Patients: Overview and Recommendations for Future Research. JNCI, 94, 8, April 17, 2001, 558-584) may be accessed through the Journal of the National Cancer Institute.

Reference List

1. Lerner M. Psychological Approaches to Cancer. Lerner M. Choices in Healing: Integrating the best of conventional and complementary approaches to cancer. 1st ed. Cambridge, MA: The MIT Press, 1994:137-94.
2. Stefanski V. Social stress in laboratory rats: Behavior, immune function, and tumor metastasis. Physiology & Behavior 2001;73:385-91.
3. Wu W, Yamaura T, Murakami K, Murata J, Matsumoto K, Watanabe H, et al. Social isolation stress enhanced liver metastasis of murine colon 26-L5 carcinoma cells by suppressing immune responses in mice. Life Sciences 2000;66(19):1827-38.
4. Kerr LR, Wilkinson jDA, Emerman JT, Weinberg J. Interactive effects of psychosocial stressors and gender on mouse mammary tumor growth. Physiology & Behavior 1999;66(2):277-84.
5. Kanno J, Wakikawa A, Utsuyama M, Hirokawa K. Effect of restraint stress on immune system and experimental B16 melanoma metastasis in aged mice. Mechanisms of Ageing and Development 1997;93:107-17.
6. Ader R, Felten DL, Cohen N, (eds). Psychoneuroimmunology. San Diego, CA, USA: Academic Press, 2001.
7. Simonton CO, Matthews-Simonton S, Creighton J. Getting well again. New York: J.P. Tarcher, Inc., 1978.
8. Siegel BS. Love, Medicine & Miracles. New York, NY: Harper & Row, 1990.
9. Holland JC, Rowland JH, Chief, Psychiatry Service Memorial Sloan-Kettering. Handbook of Psychooncology: Psychological care of the patient with cancer. New York: Oxford University Press, 1989.
10. Holland JC, Breitbart W et al., editors. Psycho-oncology. New York: Oxford University Press, 1998.
11. Spiegel D. Mind Matters: Group therapy and survival in breast cancer. New England Journal of Medicine 2001; 345(December):1767-8 .
12. Newell SA, Sanson-Fisher RW, Savolainen NJ. Systematic Review of Psychological Therapies for cancer patients: overview and recommendations for future research. J of the National Cancer Institute 2002 Apr;94(8):558-84.
13. Petitti DB. Meta-analysis, decision analysis, and cost-effectiveness analysis: methods for quantitative synthesis in medicine. 2nd ed. New York: Oxford University Press, 2000.
14. Ernst E. Informed consent in complementary and alternative medicine. Arch Intern Med 2001;161:2288.
15. Goodwin PA, Leszcz M, Ennis M, Koopmans J, Vincent L, Guthr H, et al. The effect of group psychosocial support on survival in metastatic breast cancer. The New England Journal of Medicine 2001 Dec;345(24):1719-26.