In Cancer Survival, 'Mind Matters,' Says Expert

End of life is most relevant

Nick Mulcahy

February 02, 2011

February 2, 2011 — Social support and psychologic/psychiatric interventions can improve survival in cancer but are "overlooked" in the treatment of the disease, argues a psychiatrist in an essay published in the February 2 issue of the Journal of the American Medical Association.

Dr. David Spiegel

"A patient's personal mental management of the stresses associated with cancer" is a "natural ally" in the battle with this disease, writes David Spiegel, MD, from the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine in Palo Alto, California.

"It is plausible that interventions providing emotional and social support at the end of life have a positive influence on physiological stress-response systems that affect survival," he writes, suggesting a mechanism of action.

But another expert in the field of behavioral medicine noted that there is very little evidence of such survival benefit.

"Social support almost certainly makes people feel better, which is hugely important, and I wouldn't be surprised if it did improve survival," said Richard Sloan, PhD, from the Division of Behavioral Medicine at the Columbia University Medical Center in New York City. But, he added, there is no strong body of evidence that treatments and services addressing social or emotional issues improve survival in the field of cancer.

For instance, "I know of no study in cancer patients that shows that reducing depression improves survival," he said. "We should treat depression because it makes patients miserable, not because we think it may improve survival," he added.

Dr. Sloan's great concern about the discussion of the evidence regarding psychosocial support and cancer survival is how the information is received by the public, most importantly cancer patients.

"We have to be really careful not to oversell the interventions we have," he told Medscape Medical News. The reason? "People can feel at fault if they don't respond to a program," he said. In a recent editorial in the New York Times, Dr. Sloan discusses some of the history of "mind cure" movements in the United States. The editorial touches on the lack of scientific validity in the belief that personality or "a way of thinking" can influence disease outcomes. As he notes, a recent large study dismissed the idea that any personality type is associated with the risk of getting or surviving cancer.

Dr. Spiegel does not say that cancer can be cured by psychosocial interventions and makes no claims about the power of positive thinking. Instead, he argues that psychosocial support, which includes the discussion of death and learning how to manage pain and anxiety, might extend survival, particularly at the end of life. He summarizes: "It is not simply mind over matter — but mind matters."

Follows Palliative Care Study

Dr. Spiegel's essay comes about 6 months after a study on palliative care in cancer was published in the New England Journal of Medicine (2010;363:733-742). In that study, the introduction of palliative care — a program designed to minimize pain and improve quality of life — at diagnosis, in parallel with standard oncologic care, was associated with a significant improvement in survival in patients with metastatic nonsmall-cell lung cancer (NSCLS).

After discussing the palliative care study in his essay, Dr. Spiegel states that "there is increasing evidence that social support affects survival [in cancer]." He cites 2 studies in particular: a study in women with early-stage breast cancer, which was led by Barbara Andersen, PhD, from Ohio State University in Columbus (Cancer. 2008;113:3450-3458); and a study by Dr. Spiegel himself in women with metastatic breast cancer (Lancet. 1989;2:888-891).

To Medscape Medical News, he mentioned 3 other randomized trials and 1 matched-cohort trial that "have found that psychosocial treatment for patients with a variety of cancers produced both psychological and survival benefits." The cancers in these types of studies tend to be those with the poorest prognosis, including malignant melanoma, NSCLC, leukemia, and gastrointestinal tract cancers, Dr. Spiegel points out in his essay.

"For breast and other cancers, when aggressive antitumor treatments are less effective, supportive approaches appear to become more useful," observed Dr. Spiegel.

Dr. Andersen said that the quantity of cancer research that indicates a survival benefit of psychosocial interventions is not abundant. "There is not all that much data on social support in particular," she told Medscape Medical News.

Nonetheless, Dr. Andersen suggested that the palliative care study represents a pivotal moment in this area of research. The fact that the New England Journal of Medicine published it was "quite amazing," she said. The journal has a "history of considerable skepticism with regard to the importance of psychological and behavioral factors in cancer," she explained.

Dr. Andersen also pointed out that "there's a whole lot more going on in psychosocial interventions than just social support." For instance, in her breast cancer study, she and her colleagues note that the intervention was psychologist led, conducted in small groups, and included strategies to reduce stress, improve mood, alter health behaviors, and maintain adherence to cancer treatment and care.

Therein lies a problem, said Dr. Sloan. "It's hard to know which is the active agent" in such multifactorial studies. For instance, he wondered whether treatment adherence was the element of the Ohio State program that tipped the scale toward a survival benefit.

Dr. Andersen responded that adherence was not a factor in the differential survival.

Dr. Andersen would like the discussion about the benefits of psychosocial interventions and drug therapies and other treatments to not be a matter of "either/or." The various interventions should work together, she said.

The authors have disclosed no relevant financial relationships.

JAMA. 2011;305:502-503.

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