The mind matters when it comes to treating metastatic breast cancer. But better psychological health doesn’t necessarily translate into longer life.
Those were the findings from a multicenter trial of group psychosocial support for women with metastatic breast cancer published in the December 13, 2001, New England Journal of Medicine.
The study found that breast cancer patients who participated in weekly supportive-expressive group therapy did not live longer than women who received no such intervention.
Yet women who received the weekly psychosocial support reported less pain and greater improvement in psychological symptoms.
"We were not able to demonstrate a survival benefit for these women," said psychiatrist and lead author Molyn Leszcz, M.D., in an interview with Psychiatric News. "But what we did show is a significant psychological benefit, such that women who participated were psychologically much better than those who did not receive the intervention. That finding was especially true for women who started the study at a higher baseline of psychological distress.
"What I think we are showing is that the mind does matter," he said. "I would say this treatment has life-altering but not life-prolonging effects."
Leszcz is an associate professor and head of group therapy in the department of psychiatry at the University of Toronto. The study was led by oncologist Pamela Goodwin, M.D., also of the University of Toronto.
In the study, 235 women with metastatic breast cancer in seven Canadian cities were randomly assigned to receive weekly supportive-expressive group therapy or standard medical and psychosocial care. The average survival among the two groups was nearly identical: 17.9 months for women receiving the intervention, and 17.6 months for those who did not.
The study is the 10th randomized, control trial seeking to replicate findings from a landmark 1989 study published in the Lancet showing that supportive group psychotherapy improved survival for women with metastatic breast cancer. The results are now evenly divided—five trials have shown a survival benefit from psychosocial support, and five have not.
David Spiegel, M.D., lead researcher in the 1989 study and author of an editorial accompanying the report of the new study, acknowledged that the most recent study is a disappointment for those hoping to demonstrate that psychotherapy can extend the lives of patients with a life-threatening illness. But he emphasized that the study does corroborate the value of psychological interventions in the treatment of severe disease and in medical conditions generally.
"I would like to see psychiatrists pay more attention to the interface between psychiatric disorders and medical conditions and to the subthreshold depression and anxiety that accompany them," said Spiegel, who is associate chair of psychiatry and behavioral sciences and director of the psychosocial treatment laboratory at Stanford University School of Medicine. "We have left a lot of the territory of consultation and therapeutic support for people with medical illness to other disciplines."
Leszcz said that clarifying the benefits and limitations of psychosocial support—and the specific subgroup of patients whom it is most likely to help—is a significant advance.
"What this study teaches us is that if you are well-supported socially, and if you are coping well and don’t have a high degree of psychological stress, you don’t need to do this group," Leszcz said. "But if you are stressed, you can count on being significantly and meaningfully helped."
That’s crucial, Leszcz pointed out, because in the wake of studies suggesting that psychosocial support groups could extend life, some patients may have felt compelled to participate. "What it does is give choice back to people," he noted. "It removes the potential that people might feel a desperate need to get into this. Not everyone is interested in support groups."
The value of choice for women with breast cancer was also stressed by patient groups responding to news about the study.
"We believe that these findings are not surprising, and we will continue to reinforce psychosocial support as an option for improving a patient’s quality of life," said Rebecca Garcia, Ph.D., vice president of health sciences for the Susan G. Komen Breast Cancer Foundation, in response to the NEJM report. "The Komen Foundation feels that it is important for women to have a wide variety of support options when facing a breast cancer diagnosis and will continue to empower patients to make their own choices as to how to find the support they need during this time."
Spiegel told Psychiatric News that recent improvements in medical treatment of breast cancer may have raised the ceiling of survival, making it that much harder to demonstrate a survival benefit with psychotherapy. And some of those treatments, including new selective, estrogen-receptor modulators, appear also to affect the same stress-related hormone systems that psychosocial support may act on.
Spiegel stated that the entire arena of psychological treatment of breast cancer patients has improved markedly since his 1989 study. Then, it was difficult to recruit women to participate in psychosocial support groups; today, just the opposite is true, he said.
The "supportive-expressive" group therapy utilized in the new study is modeled on a protocol standardized by Spiegel for use with women having metastatic breast cancer—a disease with an average survival of two and a half years. Led by a professional therapist, the groups allow women to confront existential issues in a supportive atmosphere.
Spiegel said that the success of such groups at improving psychological health—if not always improving survival—has shattered the notion that life-threatening illness must be met with denial and a smile.
"When these groups were started in the 1970s, there was an assumption that we would make people worse by having them confront their own mortality," he observed. "It is extremely clear that that is not the case. Facing one’s own death and the death of another can be a growth experience, not a demoralizing one."
Leszcz agreed that the model of psychosocial support championed by Spiegel has sprung open the "prison of positive thinking" many patients with life-threatening illness feel confined by.
"Rather than facilitate denial, we wanted to create an environment in which women would be able to meaningfully confront their concerns, support each other, and develop coping strategies," he said. ▪