Psychosomatic, or mind-body, medicine consists of a loose collection of ideas, data and notions that often exist on the borderlands of medicine, beyond the reach of current medical therapies or where people struggle to make sense of their illness-related suffering. One lasting theme that’s acquired quite a bit of supporting data is the notion that there’s a relationship between the degree of social/emotional support a person has and their resistance to disease. Early workers in the field of psycho-oncology were careful to insist that their psychological work with cancer patients wasn’t a mind-body intervention to treat the cancer but rather an attempt to help improve the quality of life of their patients. There was no data to support the idea that emotional states had any impact on the biology of cancer. In fact, the idea could be harmful — some patients reported feeling that they were emotionally defective or inferior when their cancer did not respond to medical treatment.
Enhanced quality of life
Then, in 1989 a surprising incidental finding reported by David Spiegel, a psychiatrist at Stanford University, seemed to support the idea of direct mind-body interaction in cancer. He’d conducted a randomized, controlled study of an existential-cognitive group therapy treatment aimed at helping women with metastatic breast cancer deal with issues of illness and death. As hoped, this study showed that women who received the treatment had better quality of life, improved mood stability, less maladaptive coping, and less phobic avoidance. The researchers also found that women in the treatment group lived, on average, twice as long as those in the control group (36.6 vs 18.9 months) (The Lancet 1989;889-91). Spiegel’s groups weren’t focused on feeling good or on positive thinking; rather, they focused on allowing the participants to voice and explore their deepest fears about death and dying. The implications of this finding were profound and have had a great influence on the treatment of cancer patients in North America.
Longer survival rates?
Attempts to replicate this finding have been disappointing, however. Although three randomized trials between 1990 and 2003 showed psychosocial treatments had survival and psychological benefits, six other studies found no survival benefit and three of those found only transient psychological benefit. Spiegel began a carefully designed replication study in 1991, gathering 125 women with metastatic or locally recurrent breast cancer and randomizing them to receive supportive-expressive group therapy and access to educational materials about coping with cancer, and a control group receiving only the educational materials. He extended the study five more years in 2000, but the final results did not show that the group therapy was associated with longer survival time (Cancer 2007;110:1130-8).
Therapy’s common today
Spiegel noted that the concept of social support is now widespread in cancer treatment and 42% of the control patients were in groups outside the study; as well, 21.9% of treatment patients were also in other groups. Spiegel’s whole sample had a longer overall survival time compared to some other studies, which he suggested reflected sample differences and improvements in treatment of breast cancer. The group therapy reduced distress and improved emotional functioning in the women who had it. In a further analysis, Spiegel found that participation in the group intervention did have an association with significantly longer survival in women with estrogen receptor (ER)-negative tumours. Hormonal treatments have been shown to be very effective for ER-positive tumours, perhaps obscuring any effect of the group intervention.
Spiegel’s careful study replicated the inconsistent and even contradictory results of other studies. It confirmed that group psychotherapy is clearly emotionally beneficial to women with metastatic breast cancer. But answers to the deeper question of the mind-body interface in cancer are unclear. This story is not yet finished.
Barry L. Gilbert, MD, CCFP, FRCPC is a psychiatrist, psychoanalyst and Assistant Professor of Psychiatry at the University of Toronto.