Claire V.I. Edmonds

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.

Psychological response to long term group therapy: a randomized trial with metastatic breast cancer patients

Research has demonstrated that short term psychological interventions improve the quality of life of cancer patients. However, there is much less evidence for the efficacy of longer term interventions. We report the psychometric results from a randomized clinical trial (n=66) assessing the effects of an 8 month, weekly psychological intervention on 30 metastatic breast cancer patients. Subjects were assessed at baseline, 4, 8 and 14 months for mood, quality of life and adjustment to cancer. Results demonstrated little psychometric difference between the control (n=36) and intervention groups over this length of time, in spite of the fact that when the intervention subjects attended a weekend of support and training in coping skills, the usual significant, short term changes were observed. In the long term intervention, subjects did experience more anxious preoccupation and less helplessness than the controls but no recorded improvements in mood or quality of life. However, profound clinical changes were observed by the therapists, similar to those noted by Spiegel et al. (1981) . We conclude that many of the psychological changes made by subjects in longer term interventions may elude conventional psychometric assessment. Further research, of a rigorous qualitative nature, is required to develop a clearer understanding of the experience of living and eventually dying of cancer within the context of a long term intervention. Copyright

Group Psychological Therapy for Cancer Patients: A Point of View, and Discussion of the Hierarchy of Options

Objective: We present here a point of view about the logical role of group psychological therapies in the care of cancer patients, and propose a comprehensive, four-stage program that could be implemented at any large cancer treatment center. Method: Our proposals rest on a review of the literature, and on our own experience with various kinds of psychological help for cancer patients, some of which is described. Results: It is clear that group psychological therapies improve the quality of life of many participating cancer patients, and there is preliminary evidence that it may prolong life in some cases. We describe five main kinds of adjuvant psychological therapy, arranging them on a hierarchy of increasingly active participation by the recipient, and noting the status of evidence for their efficacy. They are: providing information, emotional support, behavioral training in coping skills, psychotherapy (of various kinds), and, more speculatively, spiritual/existential therapy. Conclusions: We propose that it is time to consider psychological therapy as an adjuvant in cancer management, analogous to adjuvant chemotherapy. The main indication for advocating group psychological therapy to patients should, we argue, be an expert assessment that the patient is likely to benefit, and should not (as is usual at present) be restricted to either 1) those patients with overt psychopathology, or 2) those few who specifically request it.

Which Cancer Patients Benefit Most from a Brief, Group, Coping Skills Program?

Objective: The purpose of this study was to explore the influence of a number of variables on the improvements in quality of life of some 400 cancer patients who completed a brief, group program providing psychosocial support and training in coping skills. Method: The factors tested were: patient gender, age, marital status, religion, education level, diagnostic site, recurrence status, expectations of the course, previous experience in self-help techniques, and different group leaders. Three assessment instruments were used, the Profile of Mood States (POMS), the Functional Living Index for Cancer (FLIC), and the Stanford Inventory of Cancer Patient Adjustment (SICPA). Assessments were made at three time points. Results: The overall finding was that the program improved mood and enhanced quality of life for most cancer patients: there was no evidence that it was more or less effective for subgroups based on gender, marital status, religious orientation, education level, and previous experience with mental self-help techniques. It was also found that several different group leaders with widely varying experience facilitated similar improvements. However, there was a significant tendency for patients under fifty to improve more by the end of the program, than older patients, although this difference disappeared at the three month follow-up. In addition, patients with recurrent disease showed less improvement in quality of life than those with primary cancer. Conclusions: The beneficial effects on quality of life of a seven-session group psychoeducational program were seen across a wide range of categories of cancer patients. The generalizability and implications of these findings are briefly discussed.

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.

A Randomised Comparison of Two Forms of a Brief, Group, Psychoeducational Program for Cancer Patients: Weekly Sessions versus a “Weekend Intensive”:

There is considerable evidence that brief group psychoeducational programs for cancer patients, offering support and some training in coping skills, may have lasting beneficial effects on mood and quality of life. Objective: to compare two different formats of a brief, group psychoeducational program for cancer patients; a standard format of six weekly two-hour sessions or a “weekend intensive,” involving the same content and contact time compressed into two days. Method: Cancer patients were randomly assigned to either the standard weekly intervention (n = 77) or the weekend program (n = 79). Two assessment measures were used: Profile of Mood States (POMS) and Functional Living Index for Cancer (FLIC). Assessments were made before and after each intervention and at a nineteen-week follow-up. Results: While the two formats were found to be equivalent in their overall effects on mood and quality of life, there were some differences. There was a sudden, large improvement in mood by the end of the weekend version of the course (2-day time point) but this did not persist, and by the six-week point and again at nineteen-weeks, mood improvement was the same for both groups. Quality of life improvement seemed to be marginally greater with the six-weekly sessions (reaching statistical significance at the 6-week point). Conclusions: The two formats produced similar improvements in both mood and quality of life. We discuss the need for further studies to find optimal ways of presenting such help for different patient groups.

Delivering a very brief psychoeducational program to cancer patients and family members in a large group format

It is well established that brief psychoeducational programs for cancer patients will significantly improve mean quality of life. As this kind of adjunctive treatment becomes integrated into general cancer management, it will be necessary to devise cost‐effective and efficacious programs that can be offered to relatively large numbers of patients. We have developed a very brief 4‐session program that provides this service to 40–80 patients and family members per month (and seems capable of serving much larger numbers, depending on the capacity of the facility in which they assemble). Patients meet in a hospital auditorium for a large group, lecture‐style program that offers training in basic coping skills: stress management, relaxation training, thought monitoring and changing, mental imagery and goal setting. Over the first year we have treated 363 patients and 150 family members. Improvements were assessed by changes in the POMS‐Short Form, and both patients and family members were found to improve significantly over the course of the program. While this is not a randomized comparison, it suggests that the benefits gained from a large group in a classroom are not substantially less than the improvements that have been documented in the usual small group format, where more interactive discussions are possible. Copyright

Fighting for Life: A Qualitative Analysis of the Process of Psychotherapy-Assisted Self- Help in Patients With Metastatic Cancer

This exploratory study is an attempt to define psychological attributes related to longer survival in patients with meta-static cancers. Previous published analyses have been limited in two ways. First, they have almost always been carried out on patients not receiving therapy; we have followed people receiving a year of group therapy, on the assumption that if mental qualities are to affect cancer progression, substantial mental change would be needed to alter the established balance between the cancer cells and host regulatory mechanisms. Second, the methods typically used to characterize patients’ psychology have been self-report inventories, and many decades of research with such methods have largely failed to produce a consensus on what mental qualities, if any, promote survival. By contrast, we have used qualitative methods, allowing a much more in-depth analysis of the patients, without preliminary assumptions as to what would be important. The present report describes the results of a detailed qualitative analysis of data collected from 22 participants over a year of weekly group therapy. Using grounded methods, categories were derived from the extensive verbal data (comprising patients’ written homework and therapists’ notes), and linked in a model of change. By applying ratings to some of these categories, and combining these ratings, we derived a quantitative estimate of patients’“involvement in self-help.” Rankings on degree of involvement corresponded quite closely with the quality of patients’ experience and with their survival duration. There was a great range in degree of involvement, and various subgroupings could be discerned. Nine of the participants were classed as “highly involved,” meaning that they devoted regular daily time, often several hours, to such self-help strategies as relaxation, mental imaging, meditation, cognitive monitoring and journalling. All but 1 of these patients enjoyed a good quality of life and lived at least 2 years. Two of them have remained in complete remission for 7 years. At the other end of the scale, 8 patients showed little application to the work, being either unconvinced that it would help them or hampered by psychological problems such as low self-esteem. None of these was rated as having a good quality of life, and only 1 lived more than 2 years, although, as a group, their medicalprognoses were no more unfavorable at the onset of therapy than for the “high in volvement” group. The different subgroups and aspects of the model are illustrated by representative quotations.