Group Therapy and Cancer Survival-- Where Does the Evidence Lie in 2007?

One of the most hotly debated questions within oncology over the past decade has been whether the promotion of psychological wellness can extend survival for patients with advanced cancer.^1,2 The converse-that psychiatric disorder shortens survival-seems true, with mechanisms of poor self-care and reduced adherence to anticancer treatments resultant from depressive or psychotic disorders explaining this outcome.³

But can group therapy for patients with advanced cancer help to extend survival? Three carefully conducted and methodologically sound replication studies of supportive expressive group therapy (SEGT) for women with advanced breast cancer have been completed recently without evidence of extended survival.^4-6 Just as better studies examining whether stress is a cause of cancer suggest that it is not,⁷ so, too, it seems unlikely that promoting psychological wellness will extend survival. In reviewing these studies, let us take stock of the current status of the field of psycho-oncology and what the benefits of group therapy are in this setting.

SEGT for women with advanced breast cancer

Adjusting to a diagnosis of advanced breast cancer can be one of the most challenging and overwhelming tasks of a woman's life. SEGT, a professionally led psychosocial group intervention, provides a safe and supportive environment in which women can express their cancer-related concerns and overcome any feelings of isolation and stigma that so often accompany a cancer diagnosis.

The main goals of SEGT are summarized as building bonds, expressing emotions, "detoxifying" death and dying, redefining life's priorities, fortifying families and friends, enhancing doctor-patient relationships, and improving coping.⁸ In so doing, major emphasis is placed on the role of relationships in facilitating patients' adjustment to illness, including relationships within the group itself, with family and friends, and with treating clinicians.⁹

SEGT was initially developed by Yalom's group in the 1970s for women with metastatic breast cancer. Early reports were promising and indicated an effect on psychological distress and quality of life, including reducing symp- toms of depression and self-reported pain among women with metastatic cancer.^10,11

It was not until 1989, however, that interest in and research on SEGT began to truly flourish, spurred almost entirely by the publication of a 10-year follow-up of a randomized controlled trial (RCT) of women with advanced breast cancer. In this seminal paper, Spiegel and colleagues¹² reported that women who received SEGT survived an average of 18 months longer than controls, who received only routine care. This unexpected survival benefit generated widespread interest in the intervention and stimulated investigations aimed at replicating and extending these findings.

Illustrative of the scientific interest in SEGT and the ongoing debate that it inspires, Fox demonstrated that the survival of the control patients in the original cohort was markedly poorer than a San Francisco Surveillance, Epidemiology and End Results (SEER) program sample and argued that selection biases were the explanation for the 1989 Stanford findings.¹³

In response, Goodwin and colleagues argued that while results from the original trial may have indeed lacked external validity (ie, the ability to be generalized to other groups given the nonrepresentativeness of the sample), the study itself nevertheless possessed internal validity, the hallmark and goal of randomization and randomized clinical trials, and that as a result the impact of the intervention within the study population cannot be discounted.¹⁴

Although Fox has further countered some of Goodwin and colleagues' arguments, including questioning whether the original study was indeed internally valid,¹⁵ both sides agreed that additional studies are needed to cross-validate and replicate the earlier findings.

Recent studies and survival

In the Canadian Breast Expressive-Supportive Therapy (BEST) multisite study of 235 women with advanced breast cancer, survival was unaltered for those receiving SEGT compared with controls (17.9 months and 17.6 months, respectively).⁴ In California, Spiegel's group enrolled 125 women in their replication study and also failed to identify a survival benefit (SEGT, 30.7 months; controls, 33.3 months).⁶ Finally, in Melbourne, survival was not significantly prolonged in an RCT of 227 women with advanced breast cancer (SEGT, 24.0 months; controls, 18.3 months).⁵ Taken together, these 3 studies provide strong, mounting evidence that SEGT does not extend patient survival.

Quality of life benefits and prevention of depression

While the failure to affect survival is disappointing, the results of these studies have been largely consistent in finding a treatment effect on 1 or more indices of psychological distress. Moreover, each study has shown that women with higher levels of initial distress are especially likely to benefit. For example, in the California study, participants in the SEGT group experienced a significant decline in symptoms of traumatic stress as assessed by the Impact of Events Scale compared with controls-with the greatest decline found in women with the highest baseline traumatic stress levels.¹⁶

The findings for mood disturbance, which was assessed using the Profile of Mood States (POMS), revealed a treatment effect only when the final assessment within a year of death was removed; however, as with traumatic stress symptoms, women with higher baseline mood disturbance evidenced the most improvement during the first 12 months. Similar results were reported in the Canadian study, where women randomized to SEGT evidenced significantly lower scores on the POMS at 1-year postrandomization than their counterparts in the control group, who received only educational material as part of their participation.⁴

Further, a "randomization group by baseline score" interaction was found-women with greater mood disturbance at baseline benefited more than those who were initially less distressed, with the same being true for their experience of pain. Specifically, while women in the intervention group reported less pain during the course of a year than did controls, they only benefited if their baseline scores were high.⁴ These mood findings were again replicated in the Melbourne trial, where SEGT not only effectively treated DSM-IV depressive disorders but significantly prevented new cases of depression, reduced a hopeless-helpless attitude, improved social functioning, and assuaged traumatic stress symptoms.¹⁷

Whereas results related to traumatic stress symptoms and pain have been fairly consistent in finding an ameliorating effect of SEGT, results for emotion regulation and mood disturbance have been notably less stable. In a study assessing the impact of 1 year of SEGT on emotion regulation in women with metastatic breast cancer, significant treatment effects were found in reducing suppression of negative affect (as assessed by the Courtauld Emotional Control Scale) and increasing restraint of aggressive behavior (as assessed by the Restraint subscale of the Weinberger Adjustment Inventory), both of which have been associated with better overall positive affect and psychosocial adjustment in cancer patients.¹⁸ The intervention did not, however, increase emotional self-efficacy or reduce repressive defensiveness.

Studies using the POMS to assess mood disturbance have alternately reported an effect of SEGT on mood,⁴ or an effect only after secondary analyses with a subset of study participants.¹⁶ Classen and colleagues¹⁶ failed to find the main effects of treatment using the Center for Epidemiological Studies Depression Scale.¹⁹ Several factors might explain these apparently negative findings. To begin with, as suggested by several investigators,^1,19,20 conventional methods of assessment may miss changes in psychological distress that have been observed clinically, thus risking a type II error (ie, failure to detect a treatment effect when an effect is present).

More qualitative methods of assessment may be needed to truly understand the impact of SEGT on patients' mood or other indices of psychosocial functioning and adjustment, including existential distress, which has rarely been explicitly assessed in SEGT studies. That a more in-depth assessment using tools other than self-report measures might yield more compelling results is suggested by the findings of the Melbourne study,¹⁷ where both a treatment and prophylactic effect of SEGT on diagnosable DSM-IV depressive disorders was found. More rigorous and/or qualitative assessment may also point to a more lasting effect of treatment, because some longer-term evaluations of SEGT have indicated that treatment effects may be transient.¹

Who should be helped by group therapy?

As previously discussed, current evidence suggests that SEGT may be of more benefit to women with higher levels of psychological distress or physical pain. Should group therapy be offered only to highly distressed women, rather than to all women with advanced breast cancer?^21,22 The evidence from the Melbourne study that group therapy prevented depression suggests that a more general application is justified. Moreover, women typically report receiving at least some benefit from participation in supportive interventions, even if this benefit has eluded traditional psychometric assessment.

Future directions

Might specific subgroups of women be more likely to benefit from SEGT, such as women with specific personality characteristics or interpersonal styles?¹ To date, there have been no studies of SEGT that have attempted to identify how personality and attachment styles might interact with group treatment in order to predict outcomes.

Another notable gap in the current literature has been the lack of representation of women from racial and ethnic minority backgrounds. This is particularly unfortunate given the well-documented disparity in breast cancer death rates between whites and racial and ethnic minorities, such as African Americans, and the differential rates of decline in breast cancer mortality (2.4% per year in whites, 1.8% in Latino women, and 1.0% in African Americans).^23,24 The shortage of minority women might result from a lack of concerted effort or ingenuity during recruitment or the unwillingness of women to participate because of skepticism or fatalism. While the reason is most likely multifactorial, an effort should be made to address the issues that have prevented inclusion of more minority women.

In a cross-sectional study conducted by Bickell and colleagues,²⁵ despite similar rates of oncological consultation, minority women with early-stage breast cancer had double the risk of white women of not receiving adjuvant treatment. Given that SEGT did enhance adherence to chemotherapy and hormone therapy in the Melbourne trial,¹⁷ could the intervention be adapted to respond sensitively to culturally based beliefs about illness and health, the doctor-patient relationship, and treatment preferences? Might the induction of some shift in these beliefs lead to improved adherence? Our research group is currently exploring this possibility. Measures of health beliefs are included in assessing the outcome of SEGT and serve as more proximal indicators of adherence to anticancer treatments. More research is needed to test this hypothesis and to elucidate the mediators of this effect.

Conclusion

The issues that women with advanced breast cancer face on a daily basis are taxing on both a physical and emotional level. SEGT can provide these women with the support needed to successfully adjust to the diagnosis and to find comfort in facing the illness head on. Although it remains to be determined whether SEGT can indeed improve treatment adherence and outcome for underserved populations, strong evidence supports SEGT as an effective intervention in reducing traumatic stress symptoms and, in most cases, improving mood symptoms. Future research is still needed, however, to address the points raised herein, including the personality and attachment styles that may respond well and the impact of culturally determined health beliefs on minority women.

References:

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