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Effects of Psychological Treatment on Cancer Patients: A Critical

Review

R. W. TRIJSBURG, F. C. E. VAN KNIPPENBERG, S. E. RIJPMA

Twenty-two studies on the effects of psychological treatment on cancer patients are reviewed.
Only studies that compared one or more experimental conditions with at least one control
group have been considered. The studies were evaluated with respect to a) research methods,
b) psychological interventions, and c) results. Tailored counseling has been shown to be
effective with respect to distress, self-concept, (health) locus of control, fatigue, and sexual
problems. Structured counseling showed positive effects with respect to depression and distress.
Behavioral interventions and hypnosis were effective with respect to specific symptoms such
as anxiety, pain, nausea, and vomiting. The research methods, interventions and results of the
studies are reviewed critically. Several recommendations for future research are made.
Key words: psychotherapy; psychological intervention; cancer; quality of life.

INTRODUCTION loss of weight (8, 10), and dispnoeic at-


tacks (10).
Over the past 20 years, the number of As the interventions described in these
studies on the somatic, psychic, and social and other case studies were beneficial,
problems of cancer patients and their the question arose as to whether these
need for psychological help has been in- effects could also be shown in controlled
creasing (1-4). Several case reports on studies. In a review by Watson (11), some
psychotherapy for cancer patients have methodological shortcomings of empirical
also been published (5-10). The effects of studies were pointed out, such as the ab-
relaxation, modeling, and hypnosis on sence of control groups and the incom-
nausea and vomiting, resulting from pleteness of data on crucial aspects, e.g.,
chemotherapy, have been described by characteristics of interventions, refusals,
Bos-Branolte (6). Kaye (8), and Dempster attrition, and statistical techniques. After
et al. (9). Other case reports have ad- reviewing 12 controlled studies, Watson
dressed such subjects as the effects of (11) concluded: "To the question of
hypnosis on anxiety and pain during med- whether specialist support programs ben-
ical examinations (9), depression (8, 10), efit patients, the answer is a qualified
yes." (p. 843).
This article supplements and extends
the scope of Watson's review in two as-
From the Department of Medical Psychology and pects. First, 22 controlled studies on the
Psychotherapy, Erasmus University, Rotterdam, The effects of psychological interventions on
Netherlands. cancer patients were screened. Second,
Address reprint requests to: Dr. R.W. Trijsburg, the current study highlights the method-
Department of Medical Psychology and Psychother- ological aspects and results of the studies
apy, Medical Faculty, Erasmus University, P.O. Box
1738, 3000 DR Rotterdam, The Netherlands. in greater detail. The studies were re-
Received for publication January 31, 1991; revi- viewed on three aspects: methods, psy-
sion received January 9, 1992 chological intervention, and results.

Psychosomatic Medicine 54:489-517 (1992) 489

0033-3174/92/5404-0489S03.00/0
Copyright 1992 by the American Psychosomatic Society
R. W. TRIJSBURG et al.

Selection of the Studies received normal care. In one study (17), two forms
of psychological intervention were compared, one
The studies were selected from those serving as a control for the other. Five studies com-
published between 1976 and September pared different forms of psychological intervention
1990. As the scope of this review limits in addition to a control condition (6, 18-21). In four
of these studies (18-21). the experimental groups
itself to the effects of psychological inter- were comparable in terms of duration and number
ventions, studies on the effects of educa- of meetings.
tional programs or information per se, or Comparability with Respect to Crucial Variables.
self-help groups were not included. The In order to be able to compare treatment effects
review was limited to studies in which between groups, the groups need to be comparable
as far as crucial variables are concerned. These
the intervention group was compared variables are. medical and psychological status and
with one or more control groups.1 Table 1 sociodemographic characteristics. To check for un-
presents an overview of the 22 studies equal distributions of both conditions, statistical cor-
selected. The first aspect to be reviewed rections should be applied. Finally, measurements
is research methods. need to take place at approximately the same time
in both the experimental and control groups.
Sociodemographic Variables. With respect to so-
ciodemographic variables, the random assignment
RESEARCH METHODS of patients to ensure comparability of the research
groups was applied in 14 studies (Table 3, column
1). In 15 studies differences between the groups were
Three questions were of relevance when review- checked retrospectively (Table 3. column 4).
ing the research methods. First, the question of
whether the studies were designed in a way that Medical Variables. Random assignment was ap-
permitted conclusions concerning the interventions. plied in 14 studies (Table 3, column 1). In 14 studies,
Second, whether the instruments used for outcome comparability regarding medical variables was
variables were valid and reliable, and finally, checked retrospectively (Table 3, column 3). In sev-
whether the patient selection procedure was ade- eral studies, variability of medical factors was min-
quate. Hence, the three topics to be reviewed were: imized by the formation of homogeneous groups,
1. design (experimental conditions, comparability e.g., with respect to the type of medical treatment,
with respect to crucial variables, use of pretesting the time interval between medical treatment and
and post-testing); 2. instrumentation (psychometric psychological treatment, previous medical treat-
aspects); and 3. patient selection. ment, time period between diagnosis and the start
of the study, the stage of the illness and the prog-
nosis. However, data on medical variables often
could not be traced (see Table 1). In 7 studies, it was
stated that patients were treated medically during
1. Design the period of the study, but the treatment was not
Experimental Conditions (see Table 1, Coiumns 5- specified. In four studies, no data were supplied (see
8j. In 11 studies, in addition to the experimental Table 1, column 3). In two studies (18, 22), the
group (psychological intervention), there was one prognosis of the illness was specified (see Table 2).
control group that received normal care. In three Psychological interventions took place over the
studies (12-14), one extra control group was used to same period of time as the medical treatment, or
control for nonspecific attention. In two studies (15, subsequently. The timing of the psychological inter-
16) two control groups were formed, which both vention appeared to be evenly spread across the
conditions.
In some studies medical variables were used as
independent variables. For example, Lyles et al. (13)
1
compared two types of drug administration that
The studies by Golonka (16) and by Farash (19) were being applied, and Gordon et al. (15) studied
were abstracts. Therefore, some of the aspects, the interaction between psychological interventions
which were relevant in the present review, could and the type of cancer.
not be evaluated. Psychological Variables. Psychological trait vari-

490 Psychosomatic Medicine 54:489-517 (1992)


TABLE 1. Data on Patients and Groups
Tim~ngof Groups and Number of Pat~ents
Type of
T ~ m eSmce Intervention
Reference Cancer S~te and Medlcjl Experimental Control
Diagnos~s Med~cal
Treatment
Treatment Group(s) Group(s)
60s-Branolte (6) Gynecology Surgery After
Kad~otherapy
Chenlotherapy
Bur~shand Lyles (32) >Three cancer sites Chemotherapy Dur~ng
Cam et al. (18) Gynecology Newly d~agnosed Unspec~t~ed Dur~ng
Capone et al. (27) Gynecology Newly d~agnosed Unspec~f~ed Durmg
Chr~stensen(35) Breast ? Surgery After
Farash (19) Breasl ? Surgery After
Ferl~cet al. (24) >Three cancer sltes Newly diagnosed ? During
Forester et al. (23) >Three cancer sltes ? D u r ~ n g& after
Goldberg and Wool (33) Lung Newly d~agnosed During
Golonka (16) Breast i' Chemotherapy Dur~ng
Gordon et al. (15) Breast, melanoma, Newly d~agnosed Unspeched Durmg & after
lung
H e ~ n r ~ cand
h Schag (25) >Three cancer sltes 2 years ? 7
Houts et al. (34) Gynecology Newly d~agnosed Unspec~f~ed Dur~ng
Kuttner (14) Leukernla 7 BMAs, LPs Dur~ng
Linn et al. (22) >Three cancer srtes 0.8 years Unspecified During
Lyles et al. (13) >Three cancer sites ? Chemotherapy Durmg
Magu~reet al. (28) Uterus ? Surgery Durmg
Morrow and Morrell (12) >Three cancer sites ? Chenlotherapy Durmg
Sp~egelet al. (26) Breast 4-5 years Unspec~f~ed During
Spiegel and Bloom (20) Breast 2 years Unspecif~ed Dur~ng
Worden and We~sman(21) >Three cancer sltes Newly diagnosed ? ?
Zeltzer and LeBaron (17) Leukemia, neural 2 years BMAs, LPs
tumors, non-
Hodgk~n
Explanat~ons:
Type of medical treatment:
BMAs. LPs = Bone marrow aspirat~ons,lumbar punctures
Timing of intervention and m e d d treatment:
After = psychological treatment was gwen after medical treatment.
During = psycholog~callntervention was gwen during med~caltreatment.
During & after = psychological treatment was grven during and after medical treatment.
Groups:
- - there was no such group
= intervention control group.
? = data on this aspect were not available.
R. W. TRIJSBURG et al.
TABLE 2. Data on Patients and Groups: Remaining Characteristics and Screening Criteria
Bos-Branolte (6) M: Patients had to be in complete remission for at least 6 months after
medical treatment; without any other type of cancer
P: Informed about the cancer diagnosis; free from manifest psychiatric
pathology
D: Not older than 70
Burish and Lyles (32) M: Patients had exhibited anticipatory anxiety, nausea, and/or vomit-
ing to chemotherapy treatments
Cain et al. (18) M: Expected survival of at least 1 year
P: No previous history of severe psychiatric problems or exhibiting
symptoms requiring referral to a psychiatrist
D: Age between 18 and 75 years
Christensen (35) M: Patients' cancer was arrested and nonmetastatic; surgery had been
completed 2 to 3 months prior to the study
P: Absence of a crisis, such as divorce or unemployment; absence of a
major emotional disturbance that would require prompt specialized
attention
D. The patient had a husband, who was also willing to participate
Farash (19) M: Patients entered the study approximately 2 months following mas-
tectomy
Ferhc et al (24) M: Advanced cancer; no prior chemotherapy; not moribund; patients
with primary or metastatic cancer of the brain were excluded
Forester et al. (23) M: Patients with abdominal cancer were excluded
Goldberg and Wool (33) D: A significant key other was willing to participate
Cordon et al. (15) M: No prior medical treatment for their present condition; no brain
damage
P: No previous psychiatric history or diagnosis of mental retardation
D: Age between 18 and 75
Heinnch and Shag (25) M: Karnofsky performance status equal to 70 or higher; no brain
disease
P: No major psychiatric illness; no major cognitive deficits; no alcohol
or drug abuse
D: Age between 25 and 70
Kuttner (14) M: Patients had pain, distress, or anxiety during bone marrow aspira-
tion or lumbar punctures
D: Aged 3 to 7
Linn et al. (22) M: End-stage cancer, at least three but no more than 12 months of
survival
Lyles et al. (13) M: Patients had received a minimum of two chemotherapy treatments
and were scheduled for at least six additional treatments; they had
exhibited anticipatory anxiety, nausea, and/or vomiting in response
to chemotherapy treatments
Morrow and Morell (12) M: Patients had had anticipatory nausea and vomiting before their
fourth chemotherapy treatment; patients with metastatic disease of
the brain or obstruction of the alimentary canal were excluded
Spiegel et al. (26) M: Only patients with documented metastases were included
Spiegel and Bloom (20) M: Only patients with documented metastases were included
Worden and Weisman (21) M: Prognosis of at least 4 months
P: At risk for high levels of emotional distress and poor coping
D: Over 18 years of age
Zeltzer and LeBaron (17) M: Patients had pain and anxiety during bone marrow aspiration or
lumbar punctures
D: Aged 6 to 17
M, medical; P, psychological; D, demographic.

492 Psychosomatic Medicine 54:489-517 (1992)


PSYCHOLOGICAL TREATMENT OF CANCER PATIENTS

ables should be comparable across the conditions, in psychological problems and related the results to the
the same way that medical variables should. Scores effects of psychological intervention. It is generally
on outcome measures have been adjusted for the assumed that the psychological status of the groups
level of pretreatment scores in many studies (see under study are comparable at the first measure-
Table 3, column 5). However, trait variables (e.g., ment when randomization procedures are applied.
neuroticism or trait anxiety) were not controlled for
in the studies. Comparability was also controlled for by comparing
the mean group scores at pretest (F test, or chi-
The fact that psychological factors are important
was shown in several studies. For example, Bos- square). Statistical corrections were made by means
Branolte (6) showed that the patients who refused of change scores (24), the analysis of co-variance (14,
psychotherapy were suffering less from psychologi- 22, 25) or slope analysis (20. 26). VVorden and Weis-
cal problems than those who received psychological man (21) corrected for distress scores, but were un-
treatment. Forester et al. (23) and Gordon et al. (15) clear about the procedure used. In two studies (27,
made an explicit distinction between the number of 28), post-treatment scores were not adjusted for pre-

TABLE 3. Assignment to Groups and Baseline Comparison


Assignment Baseline comparison of crucial variables
Reference
Random Stratificatior i Medical 1Demographic Psychological
Bos-Branolte (6) No No Yes Yes Yes
Burish and Lyles (32) Yes Yes No No Yes
Cain et al. (18) Yes Yes Yes Yes Yes
Capone et al. (27) ? ? Yes Yes Yes
Chnstensen (35) Yes No No No Yes
Farash (19) Yes No ? ? ?

Ferlic et al. (24) No Yes No Yes Yes


Forester et al. (23) Yes No Yes Yes Yes
Goldberg and Wool (33) Yes No Yes Yes Yes
Colonka (16) ? ? ? ? ?
Gordon et al. (15) Other Yes Yes Yes Yes
Hemrich and Schag (25) Other Yes Yes Yes Yes
Houts et al. (34) Other No No Yes Yes
Kuttner (14) Yes No No No Yes
Linn et al (22) Yes No Yes Yes Yes
Lyles et al. (13) Yes Yes Yes No Yes
Maguire et al. (28) Yes No Yes Yes No
Morrow and Morrell (12) Yes No Yes Yes Yes
Spiegel et al. (26) Yes No Yes Yes Yes
Spiegel and Bloom (20) Yes No Yes Yes Yes
Worden and Weisman (21) No No Yes Yes Yes
Zeltzer and LeBaron (17) Yes Yes No No Yes
Explanations:
Assignment:
Other = other design, e.g., nonequivalent control group design with time-:
Demographic:
Demographical factors, mostly age, sex, race, and marital status.
Psychological:
Dependent variables, mostly psychological factors.
No, no random assignment/no stratification/no control afterwards.
Yes, random assignment/stratification/control afterwards.
?, data on this subject were not available.

Psychosomatic Medicine 54:489-517 (1992) 493


R. W. TRIJSBURG et al.

treatment scores. No data were available for two pects were: type of cancer, time elapsed since diag-
other studies (16, 19). nosis, drop-out rate and refusals, and seriousness of
Use of Pretesl and Posl-Test. In 19 studies, the the psychological problems.
times of testing were the same for both the interven- Type of Cancer. In 10 studies, patients were se-
tion and control groups. In Farash's (19) and Capone lected on the basis of having different types of cancer
et al.'s (27) study, there were no pretreatment meas- (eight studies covered more than three types, two
urements of dependent variables, so the effects could covered three types). In one of these studies (15)
not be adjusted for scores at pretest. However, Ca- statistical analyses were carried out on a subsample
pone et al. were able to compare the results of the of patients with lung cancer: this sample contained
intervention group with those from a normal group. the largest number of patients in the study. The
In the study by Maguire et al. (28), which addressed stage of illness, the prognosis and the general phys-
the development of psychiatric complaints during ical condition of the patients were rarely given. The
and after medical treatment, no pretests were used remaining 12 studies each addressed one type of
for the self-rating of anxiety and depression. There- cancer (Table 1, column 1).
fore, the post-test scores of patient-rated anxiety or Time Elapsed Since Diagnosis (Table 1, coiumn 2).
depression could not be controlled for. On the other In five studies, the patients had known their diag-
hand, pre-existing psychiatric problems were as- nosis for 8 months or longer. In seven studies, newly
sessed shortly after surgery, thus making the effects diagnosed patients were selected. In 10 studies, the
of the intervention to some extent comparable at the time elapsed since the diagnosis was not given.
level of psychiatric morbidity. In Warden and Weis-
Type and Timing of Medical Treatment (see Table
man's (21) study the intervention and control groups
1, columns 3 and 4). Eight out of the 22 studies were
were tested several times, but the intervals between
concerned with psychological interventions during
measurements differed from one group to the next.
medical treatment (chemotherapy, radiotherapy,
bone marrow aspiration, lumbar punctures, surgical
intervention). In five of these studies the psycholog-
ical intervention was aimed specifically at amelio-
2. Instrumentation (see Table 4A rating the effects of the medical interventions, e.g.,
and B) nausea and vomiting in reaction to the chemother-
apy (12,13, 32); reduction of pain and distress during
The instruments used for measuring personality lumbar punctures and/or bone marrow aspirations
characteristics or psychological state should be reli- (14, 17) (see Table 1, column 4). In one study the
able and valid (29-31). In 21 out of the 22 studies, at intervention started 3 months after the medical
least some of the instruments used are known to be treatment had ended. In two studies the intervention
reliable and valid (e.g., POMS, PAIS, and STAI), or started after surgery, although the time elapsed since
their psychometric qualities could be validated with surgery was not specified. In seven studies, the psy-
the aid of literature references indicated in the text. chological intervention was also given during med-
Relevant information was unavailable in the case of ical treatment, but the medical treatments were not
the Patient Perception Test (24), the Cancer Infor- specified. In four studies, there were no data con-
mation and QL tests (25), and the BDRI (19). cerning medical treatment.
In 11 (6, 13-15, 17, 20, 21, 28, 32-34) out of the 22
studies, the measurement instruments were spe- Seriousness of the Psychological Problems (TabJe
cially designed for specific purposes. In five out of 2J. In five studies, any patients with psychiatric
these studies (6,14,15, 21, 33), references were given problems were excluded from the study. Christen-
for the relevant psychometric data. In some cases, sen (35) not only excluded patients with psychiatric
existing instruments had been adapted for use in the problems, but also patients who were in a state of
study (22, 24, 35). In these studies, no relevant psy- emotional crisis, e.g., marital. Worden and Weisman
chometric data were presented. (21) included only patients that were at risk for high
levels of emotional distress and low ability to cope.
Drop-Out Rate and Re/usaJs (see Table 5j. Most
studies gave due consideration to the percentage of
refusals and drop-outs. Reasons frequently given
3. Selection of Patients were: death, too ill, and moving from one house to
The basis for patient selection was rather variable another. The percentage of patients who refused or
across the studies. The most commonly chosen as- dropped out varied across the studies.

494 Psychosomatic Medicine 54:489-517 (1992)


PSYCHOLOGICAL TREATMENT OF CANCER PATIENTS

TABLE 4A. Instruments (Psychological Variables)


(Health)
Anger, Hostility, _ .
Instruments Anxiety Depression % ' . Distress Selfconcept Locus of
Confusion
Control
POMS 26, 33, 34 22, 26, 33, 34 20,21,33,34 21,26,27,34
MAACL 13, 15,22 13, 15,32
HAS 18 15, 32
EO 13, 14, 17, 28 21, 28
28, 32
PSE 28 28
STAI 12, 16, 35
SCL90 25 25
BOS 6 6 6 6
ARS/DAL 16
VUL 21 21 21
HDRS 18
SRSS 27 27
BDI 19, 35
BDRI 19
SADS 23
PAIS 18, 25
LS 15
QL 25
PSI 35
PBRS-R 14
CANTRIL 22
24
SCQ 22
SHS 26
JFS 27
TSCS 35
RSE
22, 35
LC 12, 15, 26
HLC
The numbers in the cells represent references.
For full descriptions: see references.

PSYCHOLOGICAL INTERVENTIONS ('tailored counseling,' See Table 6A).


Counseling and support were the main
Psychological interventions differ in ingredients here. In some cases the inter-
goals and treatment techniques, depend-
ing on the particular problems confront- vention may also contain educational ele-
ing the patients, which in turn are asso- ments. The majority of these studies pre-
ciated with the sort of disease, its stage, sent an outline of the main objectives and
and whether or not medical treatments techniques. These studies do not offer a
are given. Many studies offer counseling definite, structured program, although
as treatment of choice. Most of these were the studies by Bos-Branolte (6-group
tailored to the needs of the patients therapy), Capone et al. (27) and Houts et

Psychosomatic Medicine 54:489-517 (1992) 495


R. W. TRIJSBURC et al.

Psychosomatic Medicine 54:489-517 (1992)


PSYCHOLOGICAL TREATMENT OF CANCER PATIENTS

TABLE 5. Refusals and Drop-Outs


Number of Refusals Drop-Outs Drop-Outs E(xperimental)
Reference
Patients (%) (%) and C(ontrol) Group(s)
Bos-Branolte (6) 119 24% T3: 8% (E4%C 10%)
Burish and Lyles (32) 18 11% T5:?
Cain et al (18) 94 15% T3- 20%
Capone et al. (27) 111 13% T4:?
Christensen (35) ? ? T2: 0%
Farash(19) ? ? T2:? ?
Ferhc et al. (24) 70 15% T3: 55% (E 40% C 70%)
Forester et al. (23) i ? T5:? ?

Goldberg and Wool (33) i 23% T3: 62% (E6r.CC 64%)


Golonka (16) ? ? T2:? ?
Gordon et al. (15) ? 23% T4: 36% (E35%C41%C32%)
Heinnch and Schag (25) 81 14% T3: 8% ?
T2:27%
Houts et al. (34) 41 2% T3: 20% ?

Kuttner(14) ? ? T3: 28% ?


Linn et al. (22) 141 15% T6:? (E 85% C 76%)
Lyles etal. (13) 57 12% T5 > 40% ?

T4: 8%
Maguire et al. (28) 172 3% T3 9% ?
Morrow and Morrell (12) 87 11% T?: 22% ?

Spiegel et al. (26) 109 17% T4: 65% (E68%C61%)


Spiegel and Bloom (20) 109 17% T4: 63% (E 63% C 64%)
Worden and Weisman (21) 125" 22% T5: 39% ?

Zeltzerand LeBaron (17) 45 27% T?:? ?


Explanations:
Number of patients:
Number of patients asked to cooperate.
Refusals:
Percentages refer to the number of patients who refused to cooperate.
Drop-outs:
Percentages refer to the number of patients who dropped out after initial participation; T1 is first assessment,
T2 second assessment, etc.
Drop-outs experimental and control group(s):
Percentages are mentioned separately for the intervention (E) and control (C) group.
? = data were not available.
" In the study of Worden and Weisman, only data about the experimental group are given.

al. (34) contain some fixed elements. Next plicitly at overcoming anxiety or pain due
to these studies there were studies that to medical procedures by employing be-
offer an explicitly formulated structured havioral techniques or hypnosis (12-14,
counseling program (18, 24, 25, 35) ('struc- 17, 32) ('behavioral/hypnosis,' see Table
tured counseling,' see Table 6B). They 6C). The study by Spiegel and Bloom (20)
may contain educational aspects and be- combines supportive group therapy with
havioral instructions, and exercise may self-hypnosis (pain-control) in the exper-
also be given. Apart from the counseling imental condition.
studies, there were studies that aim ex- Given these different approaches to

Psychosomatic Medicine 54:489-517 (1992) 497


TABLE 6A. Interventions and Outcome in Studies Using Tailored Counseling ?
Reference Intervention Outcome 3
60s-Branolte (6) Group therapy (progressive muscle relaxa- (At 9 months) Improvement In self-esteem, well-being, 4
tion, role-play~ng,learn~ngby im~tation); body image, partner relationship. The latter two im- -
=
lndiv~dualtherapy (same format) proved more In indiv~dualthan in group therapy V)
Capone et al. (27) lndiv~dualcounseling (reality-oriented, fac~li- (At 12 months) Less confusion and contradiction in
rn
tatrng attainment, adaptrve behavior self-perception, positive effects in return to voca- s
change) tional and sexual funct~ons C,
Farash (19) Self-help counselmg group; No differences In effectweness between self-help and
lndwidual cris~s~nterventlon indiv~dualcounselrng; in mastectomy patients coun-
2
seling assists wlth the resolut~onof body image dis- k
turbance
Forester et al. (23) lndividual supportive psychotherapy (educa- Emotional (depression, pessimism, anxiety) and physi-
tional, interpretive, cathartic) cal (anorexia, fatigue, nausea and vomrting) symp-
toms Improved
Goldberg and Wool (33) Psychosocial intervent~onw ~ t hsignrf~cantkey (At 6 months) No different~alchange over trme for
other (maintam soc~alsupport system, pro- significant key other or pat~entsin emotional, soclal,
mote autonomy of patient, advocate for and physical functronlng
patlent, encourage communication, facili-
tate mutual expression of emotion)
Golonka ( 1 6) Supportive group counseling (exam~ning No differences in anx~ety
problems, verbahzing emotions)
Cordon et al. (15) lndividual psychosocial rehabilltation (educa- (At 6 months) Less psychosocial problems, more rapid
tional, counseling, env~ronmentalmanipu- decl~neof anxiety, host~l~ty, depression, more realls-
lat~on) t~c outlook on life, greater proport~onreturning to
former vocatronal status, more actlve usage of tlme
Houts et al. (34) lndividual counselmg (telephone) by former (At 3 months) No d~fferencesin emotional status, one
cancer patients aspect of coplng differing in d~rect~onopposite to
prediction
L~nnet al. (22) lndiv~dualcounsellng concerning death and (At 12 months) Improvement in quality of life (depres-
dying sion, self-esteem, Ilfe-sat~sfact~on,
alienation, locus
of control); no differences in functional status or
survival
Magulre et a!. (28) Individual counselrng by speclallzed nurse (12 to 18 months after mastectomy) Much less psychi-
(prevent~onof psychiatric morbidity) atric morbid~tyIn counseled than In control group
Sp~egelet al. (26) Supportive group meetmgs focusing on prob- (At 12 months) Decrease in mood-d~sturbance,fewer
lems of terminal ~llness,improving relatron- maladaptwe coping responses, less phobic com-
ships, "livlng as fully as possible in the face plaints
of death")
Worden and Weisman (21) Problem oriknted indiv~dualcounseling; (At 6 months) S~gnif~cantlylower levels of distress, de-
lndividual training of problem solving skills n~al,and higher rates of ~ r o b l e mresolution
PSYCHOLOGICAL TREATMENT OF CANCER PATIENTS

problems, there still were substantial dif-


ferences within a subgroup of studies with
o> A
respect to the setting, the number and
duration of sessions, the duration of the
O J2 T3 intervention period, the aims of the treat-
c -D~ ra
= ^ S ment, treatment techniques, and the type
" j i
C 11 />o 0.0= -
D. ? >S
r Q. C
of therapist. These aspects are discussed
01
o> ~ O r-~ below. However, in some cases, relevant
c -c
DO
O DO information was either not given, or
rather difficult to reconstruct (see Table
0)-DS5>E"ra"D
"""111 S
a.
5- c
7).
-J-5ij5'5:5<u3lS - ^ o5 .y
-= o ^ ^ o S
E
- a i 5sI
1X5 +_, ZZ 7~\ U fO
E "5
<
0) S a g- JJ
" u E a Z 'o 1. Treatment Setting
Tailored counseling was given individ-
bi <u ually in seven studies (Table 6A). In two
~ -S M studies, treatment was restricted to group
2 3 2z
sessions. In one study group therapy was
compared with individual treatment. In
o. g J the study by Farash (19), individual ther-
nl Oi
apy was compared with self-help groups.
Another study addressed itself to the "sig-
9- a. nificant key other" (33). Worden and
^ S' Weisman (21) offered two forms of coun-
seling, one being more didactic than the
other. Structured counseling programs
I gill were given in various ways (see Table 6B).
3 --T P <U 3
Group therapy was applied in one study.
One study compared group with individ-
ual treatment. The other two studies con-
sidered patients and partners either indi-
vidually (35) or in a group (25).
Behavioral interventions and hypnosis
were applied individually in all cases (see
Table 6C). with the exception of Spiegel
and Bloom (20). In this study, training in
self-hypnosis was given during the last 5
to 10 minutes of supportive group
sessions.

Psychosomatic Medicine 54:489-517 (1992) 499


TABLE 6C, Interventions and Outcome i n Studies Using Behavioral Interventions or Hypnosis
Reference Intervention Outcome
Bur~shand Lyles (32) lnd~vidualprogressive muscle relaxation traln- During and after tra~ningsessions, less emo-
Ing; guided relaxation imagery during tlonal distress, nausea, and phys~ological
chemotherapy arousal
Kuttner (14) Individual hypnotic trance induction (favorite Reduction of distress, pain, and anxiety d u r ~ n g
story telling technique) BMA, sustained at subsequent medical pro-
Distractions with physical objects cedures (only behavioral checklist and self-
report NS)
Lyles et al. (13) lndiv~dualprogressive muscle relaxation train- Considerable reduction in many of the s ~ d e
ing plus gu~dedrelaxation imagery effects (systolic blood pressure, patlent-
Individual support and encouragement rated nausea, nurse-rated anx~ety)
Morrow and Morell lndiv~dualsystemat~cdesensitization More SD patients reported no antlclpatory
(12) Individual counsel~ng nausea than patlents glven counselmg; less
severe antlc~patorynausea and vornitlng,
w shorter durat~onof ant~c~patorynausea ~n
.(" SD group
r Splegel and Bloom (20) Supportwe group therapy wlth self-hypnosis (At 12 months) Both groups less self-rated
i (concerning pain) pain sensation and suffer~ng,self-hypnos~s
Croup therapy w~thoutself-hypnosis group best in controlling pain sensation;
changes correlate w ~ t hself-rated mood d ~ s -
2.
3 turbance (total, anxiety, depression, and fa-
t~gue) ?
E Zeltzer and LeBaron lndiv~dualhypnosis (a~dedby Imagery, fan- Less pain and anx~etyw ~ t hhypnos~s(BMA and
2. r
tasy, story tell~ng) lumbar punctures); nonhypnotic techniques
(D (17)
lndiv~dualnonhypnotic techn~ques(deep only effectwe with pain in BMA and anxiety -I
~n

z breathing, d~straction) ~nlumbar punctures -w


V,
0) m
'a C
wl
-L
4' R
A
A
bo z
N
bo
- L
TABLE 7. Formal Characteristics of Psychological Interventions

Reference weeks= EEZ;! Counselor/Therapist


Type' Mlnutesb
A. Individual and group counselrng
Bos-Branolte (6) G Psychologist
I Psychologist
Capone et al. (27) I ?
Farash (19) G
I
Forester et al. (23) I 7
Goldberg and Wool (33) 0 Social worker or psycholog~st
Golonka (16) G ?
Gordon et al. (15) I Psychologist, soclal worker or nurse
Houts et al. (34) I Social worker (ex-patient)
Linn et al. (22) I Trained counselor
Maguire et al. (28) I Tralned nurse
Spiegel et al. (26) G Psychiatrist or social worker with patient
Worden and Weisman (21) I Psychologist
I Psychologist
B: Structured counseling programs
Cain et al. (18) G Social worker and other experts
I
Chrlstensen (35) 0 ?
Ferllc et al. (24) G Social worker and other experts
Heinrich and Schag (25) 0 ?
C: Behavioral interventions or hypnosis
Burish and Lyles (32) I 4-5/var. ?
Kuttner (14) I 3/? ?
Lyles et al. (13) I 5/var. Psychologist or nurse
I 5/var
Morrow and Morrell (12) I 2/60" ?
I 2/60" ?
Spiegel and Bloom (20) G 40/90" (e) Psychiatrist, social worker, or patient
(hypnosis by psychiatrist)
G
Zeltzer and LeBaron (17) I Pedlatrlcian, pediatric psychologist
I
"Types are: Individual, Group, or Other (e.g., patient and partner) treatment.
" Sessions/rninutes: number of sessions and duratlon of a session in minutes.
Weeks: number of weeks of treatment or of the study.
" OpenIFixed: Open-ended treatment or number of sesslons or treatment period fixed in advance.
'Supportive group sessions, including 5-10 minutes self-hypnosis training versus supportive group sesslons only.
?: Data are unavailable.
R. W. TRIJSBURG et al.

2. Number of Sessions and Period of specifications. Frequently stated objec-


Time tives were: enhancing adequate coping
In tailored counseling therapies the strategies, e.g., adequate contact with the
number of sessions varies from three to medical staff (11 studies), expressing feel-
40, and from 20 to 90 minutes per session ings and concerns (10 studies), preserving
(see Table 7). Likewise treatments last the social support system of the patient
from 4 to in excess of 52 weeks. They may and improving communication within the
be open-ended (6-individual therapy, 22, system (nine studies), increasing knowl-
26-28), or have a fixed number of sessions edge, removing misunderstandings and
(6-group therapy, 15,16, 19, 21, 23, 33, 34) myths, e.g., about the illness, the care
(See Table 7). Structured counseling pro- system, dieting (eight studies), promoting
grammes took four to eight sessions of hope, a positive self-image and adequate
different duration (90 or 120 minutes). sexual relationships (five studies), en-
The treatment period was 2 to 8 weeks. couraging relaxation (nonspecific) (five
All are for a fixed number of sessions. studies), and increasing insight by means
In the majority of cases of behavioral of clarification and interpretation (four
interventions or hypnosis, two to five ses- studies).
sions of variable duration were given. The
time period is between 2 and 8 weeks. Objectives incidentally referred to,
Given the fact that Spiegel and Bloom's were, among others, promoting the auton-
study (20) took 1 year, hypnosis training omy of the patient, enhancing a realistic
may have been given on up to 52 attitude, accepting the finite nature of life,
occasions. finding solutions with respect to religious
problems, and enhancing the subject's
perspective on the future, his activity
level, his compliance, and his insight into
3. Goals of Treatment the past. In some cases goals were derived
In many of the (tailored and structured) from a specific problem, e.g., sexual and
counseling studies, the objectives of psy- self-image problems in reaction to mastec-
chological treatment were defined glob- tomy (6,19) and problems related to death
ally. In studies using a tailored approach and dying in terminal patients (20, 22).
(see Table 6A) global objectives were, for In behavioral or hypnosis studies (see
instance, enhancing the quality of life (6, Table 6C) the objectives of the psycholog-
22. 26, 33), diminishing distress and other
adverse effects of medical treatment (21, ical treatment were specifically derived
23), reducing psychosocial problems and from the type of problem. For example, in
discomfort, enhancing social adjustment cases of distress such as anxiety, nausea,
(15, 27), and increasing effective coping and vomiting caused by chemotherapy,
strategies (21, 34). Structured treatment specific interventions were applied,
studies (see Table 6B) focused in particu- which aimed at reducing these (condi-
lar on reducing stress and increasing ef- tioned) reactions (12, 13, 32). The same
fective coping strategies (18, 24, 25, 35). applies to specific forms of pain, e.g., in
However, most of the studies which reaction to bone marrow aspiration (14,
referred to global objectives, gave detailed 17, 20).

502 Psychosomatic Medicine 54:489-517 (1992)


PSYCHOLOGICAL TREATMENT OF CANCER PATIENTS

5. Treatment Techniques RESULTS


In order to replicate a study, it is nec- Nineteen of the 22 studies report posi-
essary to know how a specific psycholog- tive effects of psychological interventions
ical treatment was carried out (11). In in at least some aspects of the psycholog-
three out of 11 tailored (15, 26, 33) and ical and somatic functioning of patients
three out of four structured counseling (see Table 6A-C). Since all studies de-
therapies (18, 24, 35), technical proce- scribed used at least one control group,
dures were described in reasonable detail. the conclusion is warranted that psycho-
The other studies on counseling gave am- logical treatment of cancer patients is
biguous (6, 21, 23, 27, 34) or incomplete beneficial to at least some extent. With
(16, 19, 22, 28) information. However, the exception of studies using survival
seven studies referred to relevant publi- analysis, positive effects were found up to
cations or treatment manuals (15, 21, 26- about 1 year after the intervention.
28, 33, 35). Three studies referred to the After giving this overall and encourag-
use of aids, such as video and audiotapes, ing representation of the effectiveness of
notebooks, reading material, and home- psychological interventions, we will now
work assignments (6, 34, 35). In eight stud- turn to a more critical analysis of the
ies, there were no references that would effects, which were specifically tested
aid future investigators to replicate the (See Table 8A, Psychological effects, and
study (6, 16, 18, 19, 22-24, 34). Clinical 8B, Somatic and other). The studies are
case material was presented in two stud- grouped by type of intervention: tailored
ies (23, 26). counseling, structured counseling, and
In behavioral or hypnosis studies stand- behavioral/hypnosis. Only those vari-
ardized treatments, such as systematic de- ables that were used in more than one
sensitisation (12), relaxation with guided study are discussed. Outcome measures
imagery (13, 32) and hypnosis (14, 20) which were used only incidentally (in-
were described in a way that enables rep- cluding attitudes towards the hospital
lication without much difficulty. Kuttner staff, expression of emotions, denial, abil-
(14) and Zeltzer and LeBaron (17) also ity to cope, loneliness, life-events, evalu-
present case material. Some studies re- ation of care, partner relationships, and
ferred to relevant technical specifications psychiatric referrals) are not presented
in other publications or treatment man- here. Measurement instruments are rep-
resented in Table 4A (Psychological vari-
uals (14, 17, 20). ables) and 4B (Somatic and other). No
distinction is made as to whether instru-
ments are self- or observer-rated.
6. Qualifications of Therapists The effects described refer to compari-
sons between one or more intervention
In 13 cases the professional status of the groups and one or more control groups.
therapists was stated (see Table 7). This Positive effects are defined as those which
occurs .in eight out of 12 tailored counsel- were evaluated as positive changes in the
ing studies, in two out of four structured intervention (psychological treatment)
counseling studies, and in three out of six groups, and which significantly exceeded
behavioral/hypnosis studies. the same changes in the control groups.

Psychosomatic Medicine 54:489-517 (1992) 503


R. W. TRIJSBURG et al.

TABLE 8A. Outcome (Psychological Variables)


Ang/Hos . Self
Reference E/FUa Anxb Deprc Distr"e , HLC8
Confd cone
A: Tailored counseling
Bos-Branolte (6) FU (9 m) 0 0 - + +/0 -
Capone et al. (27) FU(3, 6, 12 m) 0 0 0 0 + (3 m) -
Farash (19) E - 0 - - + -
Forester et al. (23) E - - - + -
FU (4 w) +
Goldberg and Wool (33) E 0 0 0 - - -
Golonka(16) E 0 - - - - -
Gordon etal. (150 E 0 0 0 0 0
+ (3m) + (3m)
Houts et al. (34) E 0 0 0 0 -
Linn et al. (22) E - 0 - + + +
+ (3m)
Maguire et al. (28)'' FU(18m) + + - + - -
Spiegel et al. (26)' E + 0 - + 0 0
Worden and Weisman (21) FU (2, 4, 6 m) ? ? + + - -
B: Structured counseling
Cain etal. (18y E +/0 0/0 - 0/0 -
FU (6 m) +/+ +/+ +/+
Christensen (35) E 0 + - + 0 0
Ferlic et al. (24) E - - - - + -
Heinrich and Schag (25) FU (2 m) 0 0 - 0 -
C: Behavioral interventions or hypnosis
Burish and Lyles (32) FU + + + - - -
Kuttner (14)fc E +/0 - - + - -
Lyles etal. (13) FU +/0/0 0 - - - -
Morrow and Morrell (12) FU 0 - - - - 0
Spiegel and Bloom (20) E - - - - - -
Zeltzerand LeBaron (17)k E + - - - -
+: significant effect in the expected direction.
0: no significant effect.
: this variable not measured.
" E, measurement at the end of psychological intervention; FU, at follow-up (m, months; w, weeks).
6
Anxiety.
c
Depression.
d
Anger/hostility, confusion.
" Distress.
'Self-concept.
B
Health locus of control.
h
Psychiatric morbidity interpreted as distress.
1
Slopes analysis.
' Individual/group intervention.
k
Measurement(s) during medical procedures.

504 Psychosomatic Medicine 54:489-517 (1992)


PSYCHOLOGICAL TREATMENT OF CANCER PATIENTS

TABLE 8B. Outcome (Somatic and Other Variables)


Reference E/FU FA N/V PA ST AC FS LA WK LW P/B SR
A: Tailored counseling
Bos-8ranolte (6) FU _ _ _ _ _ _ _ _ _ _ +/Q
Caponeetal. (27) FU _ _ _ _ _ _ _ n _ _ +
Farash(19) E _ _ _ _ _ _ _ _ _ _ _
Forester et al. (23) E + + _ _ _ _ _ _ + _ _
FU 0 0 0
Goldberg and Wool (33) E 0 - - - - 0 0 - - - -
Golonka(16) E _ _ _ _ _ _ _ _ _ _ _
Gordon etal. (15) E - - - - + - 0 0 - - -
Houts et al. (34) E n - - - - - - - - - -
Linnetal. (22) E _ _ _ 0 - 0 - - - - -
Maguire et al. (28) FU _ _ _ _ _ _ _ _ _ _ +
Spiegel et al. (26)J E + _ _ _ _ _ _ _ _ _ _
Spiegel et al. (36) +
Worden and Weisman (21) FU 2,4, 6 m + - _ _ _ _ _ _ _ _ _
B: Structured counseling
Cain etal. (18)" E - - - - - - 0/0 0/0 - - 0/0
FU +/+ +/+ +/+
Christensen (35) E _ _ _ _ _ _ _ _ _ _ +
Ferhc et al. (24) E _ _ _ _ _ _ _ _ _ _ _
Heinrich and Schag (25) FU _ _ _ _ n - 0 - - - -
C1 Behavioral interventions or hypnosis
Burish and Lyles (32) FU _ + _ _ _ _ _ _ _ +PR
Kuttner(14) c E - - +/0 - - - - - - - -
Lyles etal. (13) FU - +/0 - - - - - - - +BP -
+PR
Morrow and Morrell (12) E _ + _ _ _ _ _ _ _ _ _
Spiegel and Bloom (20)'1 E _ _ + _ _ _ _ _ _ _ _
Zeltzer and LeBaron (17)c E _ _ + _ _ _ _ _ _ _ _
+: Significant effect in the expected direction.
0: No significant effect.
: This variable not measured.
E/FU: End of treatment/Follow-up (for specifications see Table 8A).
FA: Fatigue.
N/V: Nausea and vomiting.
PA: Pain.
ST: Survival time.
AC: Activities.
FS: Functional status.
LA- Leisure activities.
WK: Work.
LW: Loss of weight.
P/B- Pulse rate (PR)/blood pressure (BP = systolic).
SR: Sexual relationship.
a
Slopes analysis.
6
Individual/group intervention.
c
Measurement(s) during medical procedures.

Psychosomatic Medicine 54:489-517 (1992) 505


R. W. TRIJSBURG et al.

Effects are specified according to the time out of three studies for each), anxiety (one
of measurement as end-of-treatment (E), out of three studies) and self-concept (one
or as follow-up after treatment (F), where out of two studies). In Cain et al.'s study
the latter included those where no end- (18) both types of counseling used (indi-
of-treatment measurement had been vidual and group) were effective at fol-
made. low-up after 6 months. All in all, struc-
tured types of intervention yielded posi-
tive results in 50% of the variables
measured.
Psychological Effects Behavioral interventions and hypnosis
Positive results were found with respect were effective with respect to anxiety
to all variables measured (see Table 8A- (four out of five studies), depression (one
C). out of two), anger, hostility, or confusion
Tailored counseling interventions were (one study) and distress (one study). In
effective with respect to distress (six out one study (12) health locus of control was
of nine studies), to self-concept (four out measured, but no effect found. In Kutt-
of five studies), and to (health) locus of ner's study (14) observer-rated anxiety
control (two positive out of three studies). yielded significant effects, but patient-
These interventions were the least effec- rated anxiety did not. Although hypnosis
tive with respect to anxiety (two out of was more effective, there were also some
eight studies yield positive results), positive results using a distraction tech-
depression (two positive out of nine stud- nique. In Lyles' study (13) one out of three
ies), anger, hostility or confusion (two pos- anxiety measures yielded significant re-
itive out of five studies). Results with re- sults. In Zeltzer and LeBaron's study (17)
spect to anxiety and depression could not hypnosis was more effective with respect
be interpreted for the Worden and Weis- to bone marrow aspiration than to lumbar
man (21) study. Two studies yield some- punctures. In summary, positive effects
what ambiguous results (15, 22). Both were found with respect to seven out of
were significantly effective in some re- 10 variables measured.
spects during the period of intervention,
but not at the end of the intervention
period. The intervention in Bos-Branolte's
study (6) was effective in patients having Somatic and Other Effects
moderate problems, but less so in patients Many symptoms related to somatic
with severe problems. One positive effect treatment were studied, e.g., fatigue, nau-
found at follow-up (3 months) in Capone's sea and vomiting, loss of hair, tremor,
study (27) was not substantiated at follow- problems with hearing (deafness), dry
up after 6 and 12 months. In summary, mouth, loss of taste, coughing, diarrhea,
46% of the variables measured showed itching, pain, weight loss, inflammations,
positive results, whereas 54% were and irritations. The somatic effects of the
negative. psychological treatment most frequently
In structured counseling interventions measured were fatigue, (anticipatory)
positive results were found in three stud- nausea and vomiting, and pain. Fatigue
ies. Positive effects were shown with re- (or malaise) and notably nausea and vom-
spect to depression and distress (in two iting are well-known reactions to cyto-

506 Psychosomatic Medicine 54:489-517 (1992)


PSYCHOLOGICAL TREATMENT OF CANCER PATIENTS

toxic chemotherapy. Apart from assessing months) than patients in the control
the level of adaptation to the (changed) group.
situation, other variables are also indica- Survival was measured in two studies
tive of somatic functioning, e.g., func- (22, 36). Linn et al. (22) did not find any
tional status, activity level, leisure time differences between the intervention and
activities, work, and sexual relationship. control groups. Spiegel et al. (36) showed
Work resumption, often irrelevant to the a substantial difference in the survival
patient group under study, was rarely ex- time in favor of the intervention group.
amined. Apart from this, two studies (This study is a correlation of the 1981
measuring survival time (22, 36) are in- study by the same group, see reference
cluded in this review. (Two further stud- 26.)
ies measuring survival time (37, 38) were Structured counseling studies were
not included in this review. The study by concerned with activity level (25), leisure
Morgenstern et al. (37) was not included activities (18, 25), work (18), and sexual
since the control group was not ade- relations (18, 35). Of the six variables
quately selected, and the study by Rich- measured, four yielded positive effects.
ardson et al. (38) used an educational Cain et al. (18) showed positive effects
program.) concerning leisure activities, work and
Tailored Counseling.. Ten out of 19 sexual relations, both for individual and
variables measured (53%) yielded positive for group counseling, at follow-up. The
effects. These effects concerned fatigue study by Christensen (35) yielded positive
(21, 23, 26), nausea and vomiting (23), effects with respect to sexual relations.
weight loss (23), activity level (15), sexual The findings of Heinrich and Schag (25)
relations (6, 27, 28), and survival (36). were not significant, but differences were
Functional status (22, 33) work (15, 27), in the direction predicted.
and leisure activities (15, 33), yielded no As behavioral interventions aim at re-
significant effects compared with a con- lieving (anticipatory) nausea and vomit-
trol group in all studies concerned. ing, it is evident that they measure so-
In Forester's study (23) the positive matic variables concerning these symp-
findings concerning fatigue, nausea and toms. In the same vein the variables
vomiting, and work were not substanti- measured in studies using hypnosis are
ated at follow-up (4 weeks). They also concerned with anxiety and pain, since
showed positive effects on weight loss in hypnosis is used during medical proce-
patients receiving radiotherapy, which dures which are particularly frightening
did not persist at follow-up. Concerning and/or painful. It can be concluded that
sexual or intimate relationships, Bos- all variables measured yield positive
Branolte's study (6) was effective with results.
patients having moderate problems, but Morrow and Morell (12) showed a re-
not with patients having severe problems. duction in the seriousness and duration
In Capone et al.'s study the effects on the of anticipatory nausea as well as a reduc-
sexual relationship were positive at all tion in the seriousness of anticipatory
follow-up measurements (3, 6 and 12 vomiting in patients receiving systematic
months). In Maguire et al.'s study (28) desensitisation. Burish and Lyles (32) and
fewer patients in the intervention group Lyles et al. (13) showed a positive effect
had sexual problems at follow-up (18 on nausea during and after chemother-

Psychosomatic Medicine 54:489-517 (1992) 507


R. W. TRIJSBURG et al.

apy, due to muscle relaxation combined DISCUSSION


with guided imagery. In Lyles et al.'s
study [13) the effects at follow-up were In the preceding sections, 22 studies
positive for home-recorded severity of were described with respect to research
nausea, approaching significance for pa- methods, psychological interventions,
tient-recorded nausea during chemother- and results. The discussion is divided up
apy, and negative for nurse-rated nausea in the same way. The last section contains
during chemotherapy. several recommendations.
In relation to nausea and vomiting,
Burish and Lyles (32) and Lyles et al. (13)
found a positive effect on systolic blood
pressure (13) and on pulse rate (13, 32) Research Methods
immediately after chemotherapy. In the Comparability of Groups. All the stud-
study by Burish and Lyles (32), the effects ies reviewed compared one or more ex-
were again found at follow-up (14 days). perimental groups receiving psychologi-
Spiegel and Bloom (20) found that hyp- cal intervention with one or more control
nosis had a beneficial effect on pain sen- groups. It was stressed that groups should
sation. No differences in the duration and be comparable in particular aspects. Com-
frequency of pain were found between parability, however, may have been influ-
the intervention and control groups. In enced by several factors, thus leading to
the study by Zeltzer and LeBaron (17) difficulties in interpretating the effects of
hypnosis was particularly effective in the intervention. First, comparability may
group undergoing lumbar punctures. In have been influenced by the design of the
the group receiving bone marrow aspira- study.
tions, hypnosis and distraction were 1. Patients in control groups who are
equally effective. In the study by Kuttner not given psychological help may come to
(14), hypnosis was more effective in re- the conclusion that taking part in the
ducing pain in patients undergoing bone study is not beneficial in the light of their
marrow aspiration than distraction or no own psychosocial problems. This could
special intervention at all (pain judged by lead to a higher drop-out rate in the con-
independent observers). Differences were trol groups. Any effects found in the ex-
not found when the patients rated the perimental group may then be significant
pain themselves. due to distorted control groups. In fact,
It is concluded that tailored counseling the studies which did report drop-out
has been shown to be most effective with rates, showed no tendency for control
respect to distress, self-concept, (health) groups to have higher percentages of
locus of control, fatigue, and sexual prob- drop-out. Thus, there is no justification
lems. Studies applying structured coun- for the suggestion that control groups
seling have shown positive effects mainly might have been biased.
with respect to depression and distress. 2. All studies assume that the experi-
When behavioral interventions or hyp- mental groups would experience positive
nosis were applied, positive effects were effects due to the specific psychological
found with respect to specific symptoms intervention. However, only studies that
such as anxiety, pain, nausea and apply behavioral interventions or hypno-
vomiting. sis (12-14, 17) controlled for nonspecific

508 Psychosomatic Medicine 54:489-517 (1992)


PSYCHOLOGICAL TREATMENT OF CANCER PATIENTS

effects which, among others, could have help groups. It is also possible that these
resulted from extra attention being given patients receive extra help from their own
to the experimental groups. In other cases social environment. This could lead to a
positive results could be explained as ef- decrease in the problems in the control
fects of attention, rather than the specific group. Although this does not reduce the
psychological intervention. Further study value of any conclusions from controlled
is needed to find out whether nonspecific studies (in fact it would make it more
factors account for the effects in studies difficult to show any intervention effect),
applying counseling and supportive it would be of interest to study (levels of)
therapies. social support as an independent variable
Second, medical factors, e.g., type of in intervention studies, or to control for
cancer, stage of the disease, the intensity any effects engendered by this variable.
and duration of medical treatment and This is of special importance since social
practical conditions of treatment, may in- support has a documented effect on the
fluence the effects of psychological inter- quality of life in cancer patients (45-47).
ventions by contributing to the amount of The current situation is that social sup-
distress during and after medical treat- port was not introduced into any study as
ment (39-43). Also the interaction be- an independent variable, nor was this
tween medical variables and psychosocial variable controlled for.
variables is still unclear (44). It is, there- With respect to personality character-
fore, necessary to control for the compa- istics, variables known to have an influ-
rability of groups with respect to medical ence on adaptation, such as ego strength
variables. Many studies did in fact either (48), the habitual style of coping with and
control for these effects, or selected ho- defending against stress (49-54), neuroti-
mogeneous groups. However, in the cur- cism (55), and trait anxiety (56), were not
rent review, only two studies used medi- studied as independent variables, nor
cal variables as independent variables in were the effects of these characteristics
their design (13, 15). In addition, many controlled for. Differences regarding these
studies gave no information on medical aspects both between the patient groups
variables, thus making interpretation of and within a group may, however, ac-
the results problematic. count for the differences in results (44,
Third, although intervention and con- 55). Only Forester et al. (23) introduced
trol groups were comparable in many an independent psychological variable
studies with respect to sociodemographic into the design, namely knowledge of the
variables, other relevant psychosocial diagnosis. This variable contributed to the
variables, such as the type of social sup- amount of distress experienced by the
port and premorbid personality character- patient, thus emphasizing the importance
istics, were not controlled for. of this type of variable.
The factor social support is of special Instrumentation. In the majority of
interest in this respect. The possibility studies, at least one validated instrument
exists that control group patients (suffer- was used for measuring effects. However,
ing from psychosocial problems and not it is difficult to compare the results be-
receiving psychological treatment in the tween one study and another, due to the
study) seek support from other care-pro- heterogeneity of the variables measured
viders, e.g., clergy, herb doctors, or self- and due to the lack of information on the

Psychosomatic Medicine 54:489-517 (1992) 509


R. W. TRIJSBURG et al.

relationships between the instruments. logical treatment in groups with individ-


The comparability of the results could ual counseling (6, 18, 19). Of these, two
have been enhanced if standardized in- showed no differences in effect (18, 19).
struments had been applied in a more The study by Bos-Branolte (6) showed that
uniform way. In addition, statistical pa- patients receiving individual treatment
rameters should be more accessible, thus generally responded more positively in
enabling meta-analysis of effects, e.g., some respects. However, treatment con-
using methods for comparing standard- ditions in this study were not comparable
ized effect size, such as Cohen's d. At due to selection bias and a different num-
present meta-analysis can be carried out ber of sessions. In view of this, the ques-
with 12 out of the 22 studies. This is tion of whether or not group therapy is
currently being prepared by the authors. more effective than individual therapy
Selection of Patients. The studies dif- cannot be answered as yet (11, 26). This
fered strongly with respect to variables applies equally to any comparison be-
used for patient selection. tween the treatment of individuals and
1. The type of cancer differed not only that of (married) couples.
from one study to another, but also within Format of the Intervention. Some stud-
the studies. Differences between the type ies presented a time-limited, structured
of cancer yielded prognostic differences, treatment program, whereas others were
which roughly correlated with the differ- more tailored to the patients' needs. The
ences between the type and seriousness studies reported did not allow definite
of the psychological problems. conclusions to be drawn concerning the
2. Medical treatments differed with re- relative effects of structured versus tai-
gard to the amount and seriousness of the lored psychological treatments, since no
side-effects. Some more than others inter- intercomparison of treatment types was
fered significantly with adaptation. made during any of the studies.
3. The time interval since medical treat- Furthermore, the frequency and dura-
ment differed from one study to another, tion of psychological interventions were
thus making the results difficult to com- also rather variable across the studies. A
pare. For one given type of cancer, e.g, premature suggestion was drawn in three
gynaecological, the patients in one study studies (18, 23, 25) concerning the advan-
may be initially more distressed than tages of time-limited, structured psycho-
those in another and may benefit more, therapy on the basis of cost-efficiency
or less, from the intervention than those considerations. There were no studies
in any other study, depending on the time which compared the effects of time-lim-
of intervention. ited treatment to prolonged (spaced-out)
treatment. On the contrary, with the ex-
ception of two (6-individual-, 26), many
studies stayed below 12 sessions. After 1
Interventions year of group sessions, Spiegel and Bloom
The setting (individual, group, partner (20) and Spiegel et al. (26, 36) produced
relationship]. The present level of knowl- some excellent results. The patients in
edge is insufficient for definite conclu- this study were allowed to stay on in their
sions to be drawn with respect to the group for as long as they wished, which
setting. Three studies compared psycho- may account for the unique findings con-

510 Psychosomatic Medicine 54:489-517 (1992)


PSYCHOLOGICAL TREATMENT OF CANCER PATIENTS

cerning survival (36). It may be that, as was the main treatment goal with newly
Watson stated in 1983 (11), "some psycho- diagnosed patients and with patients in
logical responses to the stress of cancer remission, whereas support and emo-
can only be changed through protracted tional adaptation were the main issues in
therapeutic intervention." (p. 842). A pref- terminal cancer cases.
erence for structured and time-limited Qualifications of Therapists. Some au-
forms of psychological treatment can only thors imply that psychological treatment
be justified if it would be shown that could be applied by different types of
prolonged (spaced-out) treatment is less professionals, irrespective of supplemen-
or equally effective. tary training or supervision. However,
Moreover, the studies reviewed did not there were no studies that support such a
show that psychological treatment was view. In the study by Houts et al. (34), the
cost-effective. Our present knowledge on results of counseling by former cancer
the structure of interventions precludes patients did not exceed those of the con-
straightforward conclusions over what trol condition. However, the authors re-
should be done, or, for that matter, should ported that psychological support, which
not be done in order to alleviate distress was routinely given to patients in the con-
(11). It is significant in this respect that no trol condition, was excellent in its own
study reported on the adverse effects of right. Furthermore, both therapists in the
psychological treatment. experimental group were social workers
Techniques and Goals. Comparisons be- by profession. Because of the possible
tween studies with respect to psychologi- cost-effectiveness, it would be of interest
cal techniques are hindered by the sub- in future research to compare the relative
stantial differences across studies regard- effects of psychosocial interventions from
ing the combination of specific treatment different types of professionals.
goals and specific treatment techniques
(11). Apart from this, counseling treat-
ments tended to take the form of a "pack-
age deal," which leads to difficulties in Results
specifying the essential elements account- In 19 out of 22 studies at least some
ing for the success in achieving specific positive effects of psychological interven-
treatment objectives. tions were found. For the three studies
The studies were generally in agree- (16, 33, 34) that did not find differences
ment with each other as to the relevance between intervention and control-groups,
of specific therapeutic techniques in spe- the reasons may be self-explanatory in
cific situations, e.g., behavioural inter- two cases due to the treatment conditions.
ventions in the case of nausea and vom- The study by Goldberg and Wool (33) was
iting; counseling and support in dying pa- directed at the spouses of patients with
tients. However, the amount and clarity lung carcinoma. The effects thus had to
of information concerning treatment be gained indirectly which could have
techniques differed greatly from one been too complex an approach. The study
study to the next. by Houts et al. (34) added a minimum of
There was no controversy over the gen- individual counseling (three telephone
eral treatment goal for different patient calls) to an already extensive supportive
groups. For example, ego-strengthening program given to intervention and control

Psychosomatic Medicine 54:489-517 (1992) 511


R. W. TRIJSBURG et al.

group patients. This could have given rise (20, 26, 36). Structured counseling yielded
to a minimal residual gain. The report by the best results with respect to depression
Golonka (16) (which is a summary) did and distress. Specific symptoms such as
not give any indications as to why the anxiety, pain, nausea and vomiting were
results were negative. shown to benefit from interventions
Five studies (6, 19, 21, 27, 28) have aimed directly at relieving them, e.g., be-
methodological shortcomings, so that cau- havioral therapy or specific instructions.
tion needs to be exercised when inter- After excluding the studies by Caine et
preting the effects. Treatment conditions al. (18), Maguire et al. (28), and Spiegel et
were not comparable in Bos-Branolte's (6) al. (26), the four remaining studies (13, 14,
study. In Worden and Weisman's (21) 17, 32) used specific anxiety-reducing
study, the control group differed in cer- techniques to relieve anxiety.
tain respects from the treatment groups. In three studies positive effects were
In the Farash (19), Capone et al. (27), and found for fatigue. As these studies did not
Maguire et al. studies (28), there were no select patients who particularly com-
pretreatment measurements of dependent plained of fatigue, further study on se-
variables, so that the effects could not be lected patients is needed to demonstrate
adjusted for scores at pretest. Since the the positive effects of behavioral interven-
study by Maguire et al. (28) was con- tions. It would also be pertinent to study
cerned with psychiatric morbidity in the the role of depression in the genesis and
long run (at 12 to 18 months after mastec- continuation of fatigue and malaise, thus
tomy), the self-reported anxiety and contributing to the differential diagnosis
depression at 12 to 18 months could be and selection of therapy in these
relatively unimportant compared with conditions.
the recognition of psychiatric problems. Positive effects were found in all four
The psychological treatment of cancer studies which aimed at the reduction of
patients has been shown to be beneficial nausea and vomiting. Behavioral thera-
in at least some respects. With the excep- peutic interventions to reduce anticipa-
tion of studies using survival analysis, tory nausea and vomiting are acceptable
positive effects were found up to 1 year intervention strategies (57). Another pos-
after the psychological intervention. itive finding was that hypnosis, or a story-
When studied in detail, the results are telling technique (guided imagery), gave
somewhat less conclusive. The overall rise to a reduction in pain resulting from
picture is that positive psychological ef- medical intervention. The value of behav-
fects were achieved for 31 out of 61 vari- ioral therapeutic techniques, such as de-
ables (51%). With respect to somatic and sensitization, in this respect, has not been
other variables, positive effects were studied yet.
found for 22 out of 33 variables (67%). The role of variables that mediate pain
A tailored counseling approach has perception, such as emotional support and
been shown to be particularly effective depression, is still unclear. Spiegel and
for distress, self-concept, (health) locus of Bloom (20) showed that changes in pain
control, fatigue, and sexual problems. sensation and suffering correlated with
Open-ended counseling could be effective changes in mood disturbance. Apart from
for (future) psychiatric problems (28) and the interwoven and reinforcing character
problems associated with death and dying of changes in mood disturbance and pain,

512 Psychosomatic Medicine 54:489-517 (1992)


PSYCHOLOGICAL TREATMENT OF CANCER PATIENTS

and the direct alteration of the patients' tually impossible (if not unethical) to use
perception of pain due to hypnosis, they (levels of) attention and social support as
postulate that pain may serve to signal independent variables. It is therefore rec-
emotional problems. When these prob- ommended that these variables are con-
lems are discussed, pain could diminish trolled for in future studies in order to
or disappear. Further study of the effects gain more understanding of the specific
of variables that mediate pain perception role of the various interventions.
would clarify this issue. 3. Some studies aim at strengthening
Several variables yield inconsistent social support within the treatment group,
findings. Anxiety, depression, distress, thus leading to changes in attitude to-
sexual problems, and somatic symptoms, wards medical treatment and the medical
e.g., fatigue, nausea and vomiting, and profession (36, 58). This change may have
pain would be the most promising vari- led to a more effective adaptation to the
ables for future research. illness and this may have contributed to
prolonging survival. It is therefore rec-
ommended that the effects are studied of
(group and individual) counseling aimed
CONCLUSIONS AND particularly at strengthening the social
RECOMMENDATIONS support system and assertiveness during
contact with the medical profession. This
1. There were rather great differences could be compared with the effects of
between studies with respect to design counseling aimed, for instance, at reduc-
(experimental conditions, and group com- ing the emotional distress caused by the
parability in the area of sociodemo- illness itself. Naturally, the use of medical
graphic, medical and psychological vari- services should be measured in order to
ables), instruments, patient selection, psy- find out whether qualitative and quanti-
chological interventions (the setting, tative changes take place.
structure, goals, treatment techniques), 4. Most studies controlled for sociode-
and outcome variables. Due to these dif- mographic and medical variables. How-
ferences, it is difficult to draw general ever, psychological variables (e.g., trait
conclusions regarding the effects of psy- anxiety, neuroticism, level of premorbid
chological interventions in cancer pa- functioning) were not taken into account.
tients. It is therefore recommended that As the effects of psychological interven-
future studies use more precise designs tions may be influenced by the level of
and more restrictive criteria in the selec- functioning before the onset of the disease
tion of patients, treatment targets, psycho- (coping and defending), it is recom-
logical interventions and outcome mended that psychological variables are
measures. controlled for in future studies.
2. Studies that introduce behavioral 5. With the exception of the studies by
therapy or hypnosis tend to introduce at- Spiegel and Bloom (20) and Spiegel et al.
tention and support as independent vari- (26, 36), Linn et al. (22, Maguire et al. (28),
ables. In order to demonstrate the effec- and Capone et al. (27), all other counseling
tiveness of a specific technique, this is a studies either did not study the effects at
necessary procedure. Depending on the follow-up, or the follow-up period stayed
sort of intervention it may often be vir- significantly less than 1 year. In addition,

Psychosomatic Medicine 54:489-517 (1992) 513


R. W. TRIJSBURG et al.

many studies appear to have consciously comparisons between self-help groups


kept the number of sessions to a mini- and psychological interventions.
mum. Although the development of cost-
effective and less time-consuming inter-
ventions may appear attractive in a num-
ber of respects, intensive and long-term SUMMARY
counseling yields significant changes in
several essential functional areas (20, 26, Twenty-two studies on the effects of
36). Therefore, it would be appropriate to psychological treatment on cancer pa-
study the differential effects of (spaced- tients were reviewed. The studies were
out) long-term counseling and short-term evaluated with respect to a) research
interventions. Longer follow-up periods, methods, b) psychological interventions,
extending over several years, could yield and c) results. Research methods are de-
important findings concerning adaptation scribed in terms of design, instrumenta-
and survival. tion and patient selection. Psychological
6. Depending on the sort of cancer, the interventions were evaluated with re-
stage, medical treatments, the time at spect to the setting, goals, techniques and
which emotional problems were assessed qualifications of the therapists. The out-
and the criteria used, the percentage of come is separately described in terms of
patients who develop serious emotional psychological and physical effects. Psy-
problems ranges from 25% to 70% of the chological interventions have been shown
sample being studied (28, 39, 41, 43, 47, to be effective in at least some aspects.
55, 59-69). Control group designs consist- When studied in detail, the effects are
ing of patients selected at random yield somewhat less conclusive. Tailored coun-
results that do not differentiate between seling was effective with respect to dis-
patients who are most in need of help and tress, self-concept, (health) locus of con-
patients who could have done well with- trol, fatigue and sexual problems. Struc-
out it (11). Therefore, it would be inter- tured counseling showed positive results
esting to develop instruments to identify with respect to depression and distress.
patients at risk and to study the effects of Behavioral interventions and hypnosis
psychological treatment on these partic- were effective with respect to anxiety,
ular patients (11, 70). pain, nausea and vomiting. The studies
7. Since studies on the effects of edu- did not control for nonspecific attention
cational programs or of information per se (except for some behavioral and hypnosis
were not sighted in this review, we did studies), nor for personality characteris-
not compare their effectiveness with that tics or social support. The variables meas-
of psychological interventions. Naturally, ured and patient selection were rather
such intervention programs, for instance variable across the studies. The replica-
one aiming directly at improving compli- tion of studies could be difficult at times
ance to the medical treatment (38), could due to vague descriptions of the psycho-
result in improvements comparable to or logical intervention. Several recommen-
excelling those engendered by psycholog- dations for future research are made.
ical interventions. It is therefore recom-
mended that the effects of such programs
are compared with those of psychological This project was supported by a grant
interventions. This applies equally to from the Dutch Cancer Society {1KR 88-04).

514 Psychosomatic Medicine 54:489-517 (1992)


PSYCHOLOGICAL TREATMENT OF CANCER PATIENTS

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