by Don Benjamin
CISS – The Cancer Information and Support Society, 13/1A Berry Road St Leonards NSW 2065 AUSTRALIA. Phone: +61-2+9906 2189 Website: www.ciss.org.au Email: email@example.com
Randomised trials show the dramatic effect of a particular form of psychotherapy, viz behaviour therapy, on survival and mortality with cancer. The three major papers demonstrating the efficacy of group or individual behaviour therapy in the treatment of cancer are those by David Spiegel et al from Stanford University School of Medicine (Calif)1; Hans J Eysenck and R Grossarth-Maticek from the University of London2; and Fawzy I Fawzy from the Department of Psychiatry and Biobehavioural Sciences, UCLA School of Medicine1.
1. In David Spiegel’s paper results were from randomising 86 women with metastatic breast cancer, 50 into the treatment group and 36 into the control group. The treatment group met weekly for ninety minutes for one year and received group therapy. This involved expressing their feelings, learning to cope with their cancer and its effect on their lives, learning to grieve and become more assertive. Self-hypnosis was taught for pain control. This approach indirectly helped the patients counter social isolation and put them back into control of their lives.
Results: After 10 years follow up three were still alive, all from the treatment group. None of those in the untreated (control) group lasted more than four years. Mean survival time from randomisation was 36.6 months for the therapy group and 18.9 for the control group, a difference of nearly 18 months. From initial diagnosis mean survival time was 94.6 months for the treated group and 81.2 months for the control group, a difference of more than 12 months. Quality of life was also improved in the therapy group. An unusual phenomenon observed was that the increased survival did not become apparent until six months after therapy had finished. The authors attributed this to a mild cumulative effect.
Two possible shortcomings of this trial were not knowing how representative the patients were of the wider community; and the limitation of matching in small groups. For example the intervention group had a slight advantage over the control group in relation to the interval between initial diagnosis and entry into the trial, viz, 58.0 months vs 62.3 months. However the large differences in survival could not be explained by these small differences.
2. In the Eysenck and Grossarth-Maticek paper, published two years after Spiegel’s, there was improved randomisation. Patients suffering stress were first matched into pairs based on sex, age, smoking, cholesterol level, blood pressure and personality type. Only after both members of a matched pair had agreed to participate in the trial were they randomised into therapy and control groups. This guaranteed that the therapy and control groups were accurately matched despite their small sizes. Cancer prone (Type 1 or “Type C”) and coronary heart disease (CHD) prone (Type 2 or “Type A”) patients were treated separately in some of the studies.
They carried out five studies related to cancer to test various hypotheses –
two treatment studies:
- the effect of behaviour therapy on survival of terminal cancer patients
- a comparison of the effects of behaviour therapy and chemotherapy on the survival of cancer patients
three prevention studies:
- the effect of individual therapy on the prevention of cancer
- the effect of group therapy on the prevention of cancer
- the effect of bibliotherapy (learning the therapy from a text) on the prevention of cancer
The results of the treatment studies were as follows:
Study 1 – Therapy on Terminal Cancer Patients: This study involved 24 pairs of cancer patients with six different types of inoperable cancer, including scrotal (1), stomach (2), bronchiolar (7), corpus uteri (4), cervical (5) and colorectal (5).
Survival times of the treated group averaged 5.07 years (ranging from 1.7 yrs for bronchiolar to 9.5 yrs for colorectal). For the control group survival averaged 3.09 years (ranging from 1.0 yrs for bronchiolar to 4.9 yrs for colorectal) – Increased survival 64%
Study 2 – Behaviour therapy and Chemotherapy: 129 women with metastasised breast cancer for whom chemotherapy had been proposed were asked to participate. 17 refused psychotherapy and 56 refused chemotherapy. 50 of those who accepted chemotherapy were divided into pairs matched for age, social background, extent of cancer and medical treatment. One of each pair was then randomised to receive psychotherapy. Similarly 50 of those who refused chemotherapy were matched then one of each pair was randomised to receive psychotherapy.
This study therefore involved 100 women with metastasised breast cancer, in four similar groups of 25 who received chemotherapy + psychotherapy, chemotherapy alone, psychotherapy alone and no therapy. Of the 50 who received psychotherapy 24 received creative novation behaviour therapy (as in studies 3 and 4 described below), 12 received depth psychotherapy and 14 received orthodox behaviour therapy (relaxation training and desensitisation). 30 hrs of psychotherapy was given.
Results: Mean survival times for the 100 patients was 15.7 months, ranging from 11.28 for those who received no therapy (having refused chemotherapy), to 14.08 for chemotherapy alone, to 14.9 for psychotherapy alone to 22.4 months for chemotherapy + psychotherapy.
The authors state that chemotherapy alone increased mean survival by 2.80 (14.08-11.28) and psychotherapy alone increased it by 3.64 (14.9-11.28). Theoretically by adding these two effects, chemotherapy + psychotherapy should have increased survival by only 6.44 months to 17.72 months. In fact it increased it to 22.4 months exceeding the additive value by 4.68 months, suggesting a synergistic interaction between these two therapies.
It was also observed that the lymphocyte count of those receiving psychotherapy continued to rise over time whereas those not receiving psychotherapy fell, suggesting that the psychotherapeutic intervention may have had its effect through the involvement of the immune system.
The authors recognised that the trial was not one to test the effect of chemotherapy versus no chemotherapy, so there was no need to randomise patients into “chemotherapy” and “no chemotherapy” groups. This was done by self-selection: those refusing chemotherapy became the source for selecting and matching 50 women who would receive no chemotherapy but would be randomised to receive or not receive psychotherapy. This is in contrast to psychotherapy where in each case there was proper randomisation into the treatment and no treatment groups. Thus the only valid comparison of survival times is:
- between the psychotherapy alone (14.9 months) and no psychotherapy (11.28 months) group for those who had refused chemotherapy – increased survival 32%; and
- between the psychotherapy plus chemotherapy (22.4 months) and the chemotherapy alone (14.08 months) group for those who had accepted chemotherapy – increased survival 59%.
3. In Fawzy’s paper when psychotherapy was added to conventional treatment for melanoma there were only 3 deaths among the 34 in the treated group (9%) compared with 10 in the control group (29%), a 70% reduction in the number of deaths after 6 years.
The type of psychotherapy used by Spiegel, Eysenck and Fawzy incorporates a technique that enables cancer patients to break out of the hopeless/helpless situation and helps to put them back in control of their life and destiny. Hence the dramatic effect on survival and mortality.
Results of the Eysenck and Grossarth-Maticek prevention studies were as follows:
Study 3: Individual therapy: After 13 years of follow-up, none of the 50 treated in the cancer prone group had died compared with 16 of the 50 in the control group. 13 had cancer compared with 21 in the control group, 5 had died of other causes (cf 15) and 90% were still alive compare with 38% in the control group.
Personality retyping showed the therapy group’s cancer proneness scores had fallen from 9.8 to 5.7. As expected there was no change in score (9.8) for the untreated control group.
Study 4 – Group Therapy: (This was similar to Study 3 except that 245 patients received therapy in groups of 20-25 people; the untreated control group also contained 245 people; sessions lasted several hours depending on the wishes and progress of the participants; there were 6-15 sessions altogether.) After 7 years follow-up there were 18 cancer deaths in the 239 treated group(7.5%) compared with 111 of the 234 in the control group (47.4%) (A few could not be contacted). Cancer incidence was 75 in the treated group (31.9%) compared with 129 in the control group (55.8%). 191 were still alive (79.9%) – 57 with cancer – in the treatment group compared with 56 (23.9%) –18 with cancer – in the control group; 10 had died of CHD (4.2%) compared with 36 in the control group (15.4%), CHD incidence was 29 (12.3%) compared with 45 (19.5%); 20 had died of other causes (8.4%) compare with 33 (14.1%).
Study 5 – Bibliotherapy (therapy described in an article and explained in 3-5 hours of discussion): (There were 600 in the study group and 600 in the control group. (The latter were given an article that did not include any treatment techniques for them to use.) After 13 years follow-up there were 27 cancer deaths in the 600 treated group compared with 128 deaths in the 600 in the control group; 72 were alive with cancer compared with 71 in the control group; 47 had died of CHD compared with 176 in the control group, CHD incidence was 132 (cf 243); 115 had died of other causes (cf 192) and 409 (68.4%) of those treated were still alive compare with 97 (16.2%) in the control group.
This type of psychotherapy is therefore capable of a significant reduction in mortality for those who already have cancer and a dramatic reduction in the incidence and mortality of cancer among those classified as ‘cancer prone’.
1. Spiegel, D et al. The effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet, October 14 1989; ii: 888-891.
2. Eysenck, HJ & Grossarth-Maticek, R. Creative Novation Behaviour Therapy as a Prophylactic Treatment for Cancer and Coronary Heart Disease: Part II – Effects of Treatment. Behav Research and Therapy 1991; 29 (1): 17-31.
3. Fawzy FI et al. Malignant melanoma. Effects of an early structured psychiatric intervention, coping, and affective state on recurrence and survival 6 years later. Arch gen Psychiatry Sep 1993; 50 (9): 681-9.
Summary of Increased Survivals after Psychotherapy
Metastasised Breast Cancer (Spiegel, n=86)
36.6 vs 18.9 months = 94% – from start of treatment;
94.6 vs 81.2 months = 16% – from diagnosis.
Metastasised breast cancer (Eysenck)
14.9 vs 11.3 months = 32% – psychotherapy vs none
22.4 vs 14.1 months = 59% – Chemo + psycho vs chemo
Inoperable scrotal cancer (n=2)
5.8 vs 3.2 years = 81%
Inoperable stomach cancer (n=4)
3.6 vs 2.05 = 76%
Inoperable bronchiolar cancer (n=14)
3.7 vs1.5 = 148%
Inoperable corpus uteri cancer (n=8)
6.7 vs vs 3.9 = 71%
Inoperable cervical cancer (n=10)
4.4 vs 3.8 = 15%
Inoperable colorectal cancer (n=10)
6.8 vs 3.9 = 72%
Overall 5.07 vs 3.09 = 64% (n=48)
Melanoma (Fawzy, n=68)
3 deaths in 34 vs 10 deaths in 34 after 6 years
ie 9% vs 29% = 70% reduction in deaths