Correspondence
Group Psychosocial Support in Metastatic Breast Cancer
N Engl J Med 2002; 346:1247-1248April 18, 2002
- Article
To the Editor:
Goodwin et al. (Dec. 13 issue)1 report that support groups do not improve survival among women with metastatic breast cancer. We applaud this work but would like to raise several issues regarding its goals and conclusions. The investigators' main objective was to replicate a previous study, by Spiegel et al.2 This is not possible. As Spiegel's accompanying editorial3 suggests, breast cancer was a silent disease during the period in which the earlier study was conducted; women who received the diagnosis often felt isolated and without resources.4 This is no longer true. Support groups are now one of many tools available to women (as evidenced by the additional interventions offered to participants in the current study). Thus, since we cannot replicate the findings of Spiegel et al., we also cannot rule them out. (It might be interesting to conduct their study now in an environment similar to the one existing during their study, in which information and emotional support were scarce.)
The study reported by Goodwin et al. focuses on prolonging survival. But is that why women join support groups? According to the literature4 and our experience, women join in order to feel less isolated, to learn coping skills, and to obtain information. Whether women's expectations are met in these areas needs further study.
Finally, the findings reported by Goodwin et al. make it clear that support groups for patients with metastatic cancer now join the ranks of the more toxic treatments that fail to prolong survival.5 In clinical settings, palliation is often the real and only goal.
We have growing evidence that support groups improve women's psychological well-being. Perhaps we need to accept this as the primary clinical and study objective. We look forward to future reports from Goodwin and colleagues on the effect of support groups on the quality of life and other psychosocial outcomes.
5 ReferencesLarissa Nekhlyudov, M.D., M.P.H.
Harvard Medical School, Boston, MA 02115
larissa_nekhlyudov@harvardpilgrim.org Alice Yaker, J.D.
Connections Health Consulting, New York, NY 100241
Goodwin PJ ,Leszcz M ,Ennis M , et al. The effect of group psychosocial support on survival in metastatic breast cancer. N Engl J Med 2001;345:1719-1726
Full Text | Web of Science | Medline2
Spiegel D ,Bloom JR ,Kraemer HC ,Gottheil E . Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet 1989;2:888-891
CrossRef | Web of Science | Medline3
Spiegel D . Mind matters -- group therapy and survival in breast cancer. N Engl J Med 2001;345:1767-1768
Full Text | Web of Science | Medline4
Kasper AS, Ferguson SJ. Breast cancer: society shapes an epidemic. New York: St. Martin's Press, 2000.
5
Ellis MJ, Hayes DF, Lippman ME. Treatment of metastatic breast cancer. In: Harris JR, Lippman ME, Morrow M, Osborne CK, eds. Diseases of the breast. 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2000:749-97.
To the Editor:
The results reported by Goodwin et al. are in agreement with those of an earlier study that we conducted,1 but we are concerned that these results may be generalized to support a conclusion that the mind can have no influence on cancer and survival.
These trials have at least two important limitations. The first is that in both studies, the intervention was supportive and was not designed to induce psychological change. The second limitation is that these randomized trials compared the mean or median survival of groups of patients. The lack of a mean difference between groups does not preclude the possibility that individual patients, who may become very involved with psychological self-help or self-healing work, may live longer, a possibility we recently suggested.2 Further work, initially with nonexperimental designs, is needed to address the possibility that more intensive therapies may increase the life span of some patients with cancer and to clarify the conditions under which such a benefit may occur.3
3 ReferencesAlastair J. Cunningham, Ph.D., Ph.D.C.Psych.
Claire Edmonds, Ph.D.
Ontario Cancer Institute, Toronto, ON M5G 2M9, Canada
acunningham@uhnres.utoronto. ca 1
Cunningham AJ ,Edmonds CV ,Jenkins GP ,Pollack H ,Lockwood GA ,Warr DA . A randomized controlled trial of the effects of group psychological therapy on the survival of women with metastatic breast cancer. Psychooncology 1998;7:508-517
CrossRef | Web of Science | Medline2
Cunningham AJ ,Edmonds CV ,Phillips C ,Soots K ,Hedley D ,Lockwood GA . A prospective, longitudinal study of the relationship of psychological work to duration of survival in patients with metastatic cancer. Psychooncology 2000;9:323-339
CrossRef | Web of Science | Medline3
Cunningham AJ . Healing through the mind: extending our theories, research, and clinical practice. Adv Mind Body Med 2001;17:214-227
Medline
Author/Editor Response
The authors reply:
To the Editor: Nekhlyudov and Yaker state that we were not able to replicate the study by Spiegel et al. because of changes in the societal response to breast cancer. We agree that there is increased openness regarding breast cancer; our goal was to replicate the results (not the study itself) in the current atmosphere of increased openness, and our primary objective was to examine survival effects. We found psychological benefits associated with the intervention. We agree that future studies should focus on psychological effects.
Cunningham and Edmonds are concerned that our results may be generalized to support the conclusion that the mind has no influence on cancer and survival. Although we share this concern, we note that three psychosocial-intervention trials of patients with metastatic breast cancer1,2 (including our own trial and the trial by Cunningham and colleagues) have failed to identify a survival benefit. We disagree that our intervention was supportive only; it promoted emotional expressiveness, a realignment of social support, and efforts to confront existential issues, all of which led to psychological change.
Randomized trials in which group outcomes are compared are the gold standard for assessing survival benefits. The suggestion that certain interventions could cause individual patients to live longer is fraught with scientific ambiguity. Individual prognoses cannot be accurately predicted. Furthermore, nonrandomized comparisons are susceptible to confounding. For example, the degree of participation in psychosocial interventions may appear to predict survival, when in reality good health is the underlying reason both for more extensive participation and for longer survival. Only with randomized comparisons can it be determined whether an intervention improves survival.
2 ReferencesPamela J. Goodwin, M.D.
Marguerite Ennis, Ph.D.
Molyn Leszcz, M.D.
Mount Sinai Hospital, Toronto, ON M5G 1X5, Canada
pgoodwin@mtsinai.on. ca 1
Cunningham AJ ,Edmonds CV ,Jenkins GP ,Pollack H ,Lockwood GA ,Warr DA . A randomized controlled trial of the effects of group psychological therapy on the survival of women with metastatic breast cancer. Psychooncology 1998;7:508-517
CrossRef | Web of Science | Medline2
Edelman S ,Lemon J ,Bell DR ,Kidman AD . Effects of group CBT on the survival time of patients with metastatic breast cancer. Psychooncology 1999;8:474-481
CrossRef | Web of Science | Medline
