6/26/2007 The new issue of the American Psychological Association’s *Psychological
Bulletin* (vol. 133, @3) includes an article: “Psychotherapy and
survival in cancer: The conflict between hope and evidence” by James
Coyne, Michael Stefanek, & Steven Palmer.”

Here’s how the article begins:

[begin excerpt]

The belief that psychological factors affect the progression of cancer
has become prevalent among the lay public and some oncology
professionals (Doan, Gray, & Davis, 1993; Lemon & Edelman, 2003). An
extension of this belief is that improvement in psychological
functioning can prolong the survival after a diagnosis of cancer. Were
this true, psychotherapy could not only benefit mood and quality of life
but increase life expectancy as well. Indeed, there is some lay
acceptance of this notion, as a substantial proportion of women with
breast cancer attending support groups do so believing they may be
extending their lives (Miller et al., 1998).

Two studies (Fawzy et al., 1993; Spiegel et al., 1989) have been widely
interpreted as providing early support for the contention that
psychotherapy promotes survival. Neither study, however, was designed to
test this hypothesis. Provocative claims have been made that women with
metastatic breast cancer who received supportive-expressive group
psychotherapy survived almost twice as long as women in the control
group (Spiegel et al., 1989). Claims have also been made that group
cognitive-behavioral therapy provided persons with malignant melanoma
with a sevenfold decrease in risk of death at 6-year follow-up and a
threefold decrease in risk of death at 10 years (Fawzy, Canada, & Fawzy,
2003; Fawzy et al., 1993).

Yet studies yielding null findings include a large-scale, adequately
powered clinical trial attempting to replicate the Spiegel et al. (1989)
intervention, on which Dr. Spiegel served as a consultant (Goodwin et
al., 2001). Three meta-analyses have also failed to find an overall
effect of psychotherapy on survival (Chow, Tsao, & Harth, 2004; Edwards,
Hailey, & Maxwell, 2004; Smedslund & Ringdal, 2004). More positive
assessments of the literature have been made on the basis of box scores
derived from diverse studies of interventions with people with cancer
(Sephton & Spiegel, 2003; Spiegel & Giese-Davis, 2004). Before the
publication of an additional null trial (Kissane et al., 2004), Spiegel
and Giese-Davis (2004) concluded that “5 of 10 randomized clinical
trials demonstrate an effect of psychosocial intervention on survival
time” (p. 275). They proposed a variety of mechanisms by which
psychological factors might affect disease progression. Similarly,
Sephton and Spiegel (2003) declared, “If nothing else, these studies
challenge us to systematically examine the interaction of mind and body,
to determine the aspects of therapeutic intervention that are most
effective and the populations that are most likely to benefit” (p. 322).

Enumerating the mechanisms by which a phenomenon might occur increases
confidence that there is actually a phenomenon to explain (Anderson,
Lepper, & Ross, 1980), and repeating claims that psychotherapy promotes
survival may lend more credibility than is warranted by the evidence.
Consensus appears to be growing that the evidence for a benefit to
survival attributable to psychotherapy is, at best, “mixed” (Lillquist &
Abramson, 2002, p. 65), “controversial” (Schattner, 2003, p. 618), or
“contradictory” (Greer, 2002, p. 238). However, ambiguity as to the
implications of such assessments remains (Blake-Mortimer, Gore-Felton,
Kimerling, Turner-Cobb, & Spiegel, 1999; Palmer & Coyne, 2004; Ross,
Boesen, Dalton, & Johansen, 2002), and it is unclear what would be
required to revise a claim, based on a recent meta-analysis that found
no effect of psychotherapy on survival, that “a definite conclusion
about whether psychosocial interventions prolong cancer survival seems
premature” (Smedslund & Ringdal, 2004, p. 123).

[end excerpt]

Here’s another excerpt: “The studies that are now the primary sources
for evaluating whether psychotherapy improves survival in cancer
patients have been termed “apples and oranges” (Smedslund & Ringdal,
2004, p. 123; Spiegel, 2004, p. 133). Even this analogy, however, fails
to fully capture the range of differences among these studies and the
methodological shortcomings from which they suffer. Kraemer, Gardner,
Brooks, and Yesavage (1998) cautioned against optimism that combining
flawed studies, particularly small studies (of 20-100 patients), can
inform the literature, noting that such underpowered studies are likely
to be at increased risk of producing false-positive results and thus
more likely to be the source of inflated estimates of treatment effects
when their end results are statistically significant.”

Here’s another excerpt:

[begin excerpt]

As an overview, the idea that psychotherapy prolongs the survival of
people with cancer remains “inherently improbable” (Spiegel, 2004, p.
133), despite an accumulation of more than 15 years of research. As we
have shown, empirical support for the hypothesis that psychotherapy
promotes survival depends on attaching considerable weight to two trials
with modest samples sizes, no a priori hypotheses concerning survival,
and less appropriate strategies for reducing, analyzing, and
interpreting the resulting data. In each study, the investigators
claimed a strong effect on survival. In support of this claim, the first
trial (Spiegel et al., 1989) focused on mean survival times, rather than
the more appropriate median, and had to accommodate evidence that the
intervention affected survival because it warded off an anomalous
increase in mortality among control patients 2 years after
randomization. Making a strong claim on the basis of the second study
(Fawzy et al., 1993) involves ignoring a host of problems: analyses that
did not use an intent-to-treat method; selective exclusion of
intervention patients who were unlikely to show a benefit from
treatment; an anomalous level of death among controls; and a
statistically significant effect that would be undone by
reclassification of a single patient (in comparison to the multiple
patients lost to follow-up in both groups). Results of these trials thus
do not provide a basis for revising the assessment that survival effects
for psychotherapy are inherently improbable. If the results of Spiegel
et al. and Fawzy et al. are not sufficient to revise a negative
appraisal of the evidence, we are not given further encouragement from
recent null trials. Our conclusion is that given the limitations, there
is not reason to assume that psychotherapy promotes survival. The lack
of evidence for a mechanism by which psychotherapy should influence
survival serves to strengthen this skepticism.

Much importance has been attached to the claim that psychotherapy
promotes the survival of people with cancer, and abandoning this claim
may have negative consequences for this field. It would be useful for
the field’s development to consider why it may have taken so long to
recognize the lack of support for this claim. First, it appears that the
field was excited by the positive interpretations given to the results
of Spiegel et al. (1989) and Fawzy et al. (1993); if psychotherapy were
to improve survival, a great deal of pain and suffering could be
ameliorated and avoided. Second, interventions with little
psychotherapeutic content or with substantial cointervention confound
were presented as relevant by the leading researchers. Inclusion of
these studies in box scores misspecified the constructs under
investigation in the design of the interventions and created “bracket
creep” (McNally, 2003) that allowed survival effects that might have
been related to improved medical monitoring or more intensive medical
care to be attributed to psychotherapy.

The problems with many studies cited as evidence of an effect of
psychotherapy on survival are evident from a careful reading. However,
we believe that a third factor in the persistent advocacy for a survival
effect relates to differences in the training of behavioral scientists
and medical trialists. The superiority of medians over means for
summarizing survival data, given the characteristic distribution of
length of patient survival, is well recognized in clinical epidemiology
but seldom noted in behavioral medicine. Yet this recognition is crucial
for critically appraising Spiegel et al. (1989). Similarly, the
importance of intent-to-treat-analysis has not been appreciated in
behavioral medicine until very recently, and the requisite acquisition
of data from patients who do not complete treatment could even be seen
as counterintuitive. Our discussion of the pitfalls of accepting
unexpected strong results from trials with modest sample sizes also
clashes with the common wisdom that significant results obtained with a
small sample are more rather than less impressive. Additionally, the
failure to appreciate the importance of cointervention confounds has
hampered the ability of the field to interpret the relevance of other
studies to the survival hypothesis. An evaluation of the available
evidence for the effects of psychotherapy on survival (or any other
effect based on data from randomized clinical trials) requires knowledge
and skills that have been in short supply. Recognition of the inadequate
response of the field to the quality of these data should serve as a
call for higher standards and better education concerning the conduct,
reporting, and interpretation of clinical trials. This effort has begun,
as evidenced by the randomized clinical trial training sessions now
offered by the National Institutes of Health Office of Behavioral and
Social Science Research, but there remains much to do early in training
as well.

We believe that claims that psychotherapy promotes survival have gone
beyond the data that have been mustered in their support. Indeed, the
reception of claims that psychotherapy promotes survival of persons who
have been diagnosed with cancer is a striking instance of how social
factors determine how empirical data are filtered, interpreted, and
accepted (Dopson & Fitzgerald, 2005). Initially, the claims that caught
the attention of the media and a broad lay audience were that a
psychotherapeutic intervention study demonstrated that women with cancer
received a substantial survival benefit from intervention, and that this
result was surprising even to the research team that carried out the
study. This claim appears to have caused excitement in both professional
and lay communities eager for an indication that patients could exert
some direct control over their illness. Next, a study team that had
completed an examination of the effects of group cognitive-behavioral
therapy on psychosocial outcomes among melanoma patients produced a post
hoc examination of their survival data, reporting an effect on survival
and offering explanations of the mechanisms by which such an effect
might have been obtained.

[end excerpt]

Here’s how the article ends: “There is no good a priori reason to reject
the assumption that with appropriate tailoring to the demands of cancer
and its treatment, interventions that reduce prolonged or functionally
impairing distress in other contexts will benefit persons with cancer.
However, we are concerned that the necessary retreat from the claim that
all persons with cancer need or will benefit from formal psychosocial
interventions becomes more awkward and embarrassing when it is
accompanied by a delayed concession that such interventions do not
extend survival.”

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