Review
Mind and cancer: does psychosocial intervention improve survival and psychological well-being?

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Abstract

The aim of this review was to evaluate the scientific evidence for an effect of psychosocial intervention on survival from cancer and well-being and in particular on anxiety and depression. A literature search yielded 43 randomised studies of psychosocial intervention. Four of the eight studies in which survival was assessed showed a significant effect, and the effect on anxiety and depression was also inconsistent, indicating three possible explanations: (i) only some of the intervention strategies affect prognosis and/or well-being and in only certain patient groups; (ii) the effect was weak, so that inconsistent results were found in the generally small study populations; or (iii) the effect was diluted by the inclusion of unselected patient groups rather than being restricted to patients in need of psychosocial support. Thus, large-scale studies with sound methods are needed in which eligible patients are screened for distress. Meanwhile, the question of whether psychosocial intervention among cancer patients has a beneficial effect remains unresolved.

Introduction

Cancer is a potentially life-threatening disease and is often accompanied by major psychological distress. In a review of studies of cancer patients at various times during their disease, the prevalence of depression ranged from 4.5% up to 50% [1]. Additionally, the patients reported distress in other family members [2], adverse neuropsychological reactions to chemotherapy [3], sexual problems [4] and disruption of daily social, physical and cognitive functioning [5]. The diagnosis and treatment of cancer therefore have long-lasting, pervasive psychosocial effects on the lives of many patients. In an attempt to improve emotional adjustment and to prevent negative psychosocial effects, several intervention strategies have been used over the past 30–40 years. Furthermore, the results of two randomised studies of psychosocial intervention, by Spiegel and colleagues in 1989 [6] and Fawzy and colleagues in 1993 [7], which showed remarkable increases in the length of survival of breast cancer patients and of patients with malignant melanoma, respectively, led the public to believe that psychosocial support for cancer patients can affect their prognosis.

Even if reliable, valid associations can be established between psychosocial intervention and subsequent improvement in the length of survival, the mechanisms underlying this effect have yet to be determined. Several explanations have been proposed. Kiecolt-Glaser in 1999 [8] suggested that psychological stress is directly linked to immune downregulation, and that distress or depression is associated with a poorer repair of damaged DNA and alterations in apoptosis. These adverse effects are hypothesised to be amenable to psychosocial intervention. An indirect biological effect could be mediated by healthier behaviour after psychosocial intervention, i.e. reductions in smoking, alcohol abuse and sleep disturbances and improved nutrition, physical activity and compliance with medical regimens [9].

The purpose of this comprehensive review of randomised studies of psychosocial intervention is to elucidate the degree of evidence for enhanced survival and psychological well-being after participation in such intervention. In another paper, we review the role of psychosocial factors in the causation of cancer [10].

Section snippets

Material and methods

The Medline (1966–June 2001) and Psych-INFO (1974–June 2001) databases were searched with the keywords psychotherapy or social or psychosocial combined with intervention and cancer. Citations were also sought manually in the papers and reviews that were identified. We included only randomised studies of psychosocial interventions among cancer patients aged 18 years or more, which included an untreated control group and in which effects on prognosis and/or psychological well-being were reported.

Effect of psychosocial intervention on prognosis

The effect of psychosocial intervention on the length of survival of cancer patients has been assessed in eight randomised studies (Table 1). In four studies, the intervention was found to be positively correlated with survival from cancer, whereas four studies failed to find this association.

In a study from the USA in 1982 by Linn and colleagues [14], 120 men with advanced cancer were included. After randomisation, the intervention group received individual counselling when needed, often

Survival

The eight studies of the effect of interventions on survival were generally well conducted, but three had a sample size of fewer than 90 persons 6, 7, 20, which would have increased the possibility that a positive or detrimental effect would be observed on the basis of a few atypical patients. The two studies with a sample size greater than 250 both showed improved survival 24, 25, but the follow-up in these two studies was less than 4 years, which reduces the conclusiveness of the results. Two

Conclusion

The results of a large number of studies fail to demonstrate a conclusive effect of psychosocial intervention on survival and psychological well-being. Several explanations are possible. First, different intervention strategies were used in different studies, and perhaps only some of them affect prognosis and/or well-being and in only certain patient groups. Secondly, the effect may be weak, accounting for the inconsistent results found for the generally small study populations. Thirdly, the

Acknowledgements

The study was financially supported by The Danish Cancer Society, Psychosocial Research Foundation (Grant 97 225 58), The Health Insurance Fund (Grant 11/047-97), Mogens and Else Wedell-Wedellsborg's Fund (Grant 579), and The IMK General Fund (Grant 30206-081).

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