Editorials

Psychosocial interventions in cancer

Growing awareness of the many psychosocial problems associated with malignant disease and its treatment has led to the development of a myriad of supportive interventions for patients and their families. These interventions range from traditional approaches such as psychotherapy to the less orthodox music therapy and aromatherapy. They may be offered formally or informally by health care professionals or by lay volunteers, including patients themselves. Some psychosocial interventions, such as counselling by specialist nurses in breast cancer units, have been incorporated into the routine care of patients with cancer. Other interventions may be provided outside hospitals by a wide variety of self help groups or national and local cancer support organisations. In addition, private practitioners offer everything from psychotherapy to therapeutic massage on a fee paying basis.

The mere existence of so many different approaches shows that the demand for this form of support is considerable. The question for patients and purchasing authorities is: what impact do these forms of psychosocial intervention have on the wellbeing of patients with cancer? Despite considerable anecdotal evidence attesting to their benefits, objective evidence of efficacy has not been compelling.^{1 2 3} Significant and non-significant results from methodologically inadequate studies purporting to evaluate psychosocial interventions have, if anything, hampered their integration into the formal care and management of patients with cancer.⁴ The dearth of good empirical data can be partly explained by the fact that the activities covered by the term psychosocial intervention vary widely with regard to the training and ability of therapists, their relationship with the patient, the nature and content of the intervention, the primary goals, and the predicted outcomes.⁵ However, a review of the literature that focuses on the four mainstream psychosocial interventions--behavioural therapy (including relaxation, biofeedback, and hypnosis); educational therapy (including training in coping skills and providing information to enhance a patient's sense of control); psychotherapy (including counselling); and support groups (which help patients to express their emotions)--shows that there is increasing evidence of efficacy.^{6 7 8 9}

Published controlled studies have shown positive benefits. Examples include a reduction in the side effects of chemotherapy after biofeedback and relaxation therapy¹⁰; a significant reduction in psychological morbidity after cognitive and behavioural therapy⁸; improved coping skills after psychoeducational approaches⁷; and a reduction in pain, less mood disturbance, and fewer maladaptive coping responses after supportive group therapy.¹¹ More contentiously and provocatively, some researchers have suggested that psychosocial interventions not only improve the quality of patients' lives but also extend their survival.^{7 11} The fact that controlled studies of psychosocial interventions show beneficial effects is remarkable, given the small numbers of patients in such studies and innumerable confounding factors influencing the outcomes. But modest positive effects, albeit with low statistical power, are clearly observable.

More convincing evidence for efficacy was provided recently by a meta-analysis of the effects of psychosocial interventions in adults with cancer.¹² Meyer and Mark retrieved 62 studies comparing treatment and control groups for various psychosocial, behavioural, and psychoeducational interventions. They classified the outcomes of each study into five summary categories: (1) emotional adjustment, which included outcomes such as mood state, self esteem, locus of control, denial, and repression; (2) functional adjustment, which consisted of outcomes such as socialising and returning to work; (3) symptoms related to the disease or treatment, including nausea, vomiting, and pain; (4) medical outcomes, such as leucocyte activity, the response of the tumour, and the progression of disease; and a final category, (5) global outcomes, in which several areas from the four other categories were combined. The results of the meta-analysis were expressed as a unit free effect size ranging from 0 to 1, calculated by dividing the difference in the means of the control and treatment groups by the pooled standard deviation. They showed significant beneficial effect sizes of from 0.19 to 0.28 for all the summary categories except the medical outcomes category, which at 0.17 was not significant. These positive effects are within the range expected for psychological procedures that "work"; they are, however, small, and consequently some people might question their clinical importance. Meyer and Mark point out that within medicine in general even quite modest effects can have an important impact on the outcome of treatment.

Although type II statistical errors are possible because of small effect sizes and relatively few treatment-control comparisons, no significant differences in effect size were found between the different summary categories for different types of psychosocial interventions. This is worthy of further research. We need more information about the most effective types of interventions, as well as some innovative work on different combinations that might produce even greater benefits to patients.

Meta-analysis has become an increasingly important and established method of determining benefit from medical procedures. The analysis conducted by Meyer and Mark is the first that explicitly examines the putative benefits of psychosocial interventions for patients with cancer. The results, together with the data now accumulating from larger, more methodologically sound evaluations, begin to place psychological interventions firmly on the list of requirements for good cancer care. Such interventions should no longer be seen as an optional extra but as an integral part of every patient's management plan. The delivery of medical care is becoming increasingly evidenced based; for the non-believers in psychosocial care here is that evidence.

Reader in psycho-oncology CRC Communication and Counselling Research Centre, Department of Oncology, University College London Medical School, Bland Sutton Institute, London W1P 7PL

Lesley Fallowfield 

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