Group Psychosocial Therapy Improves Mood And Pain in Metastatic Breast Cancer Patients

SAN FRANCISCO—For patients with metastatic breast cancer, adding weekly group therapy to standard care does not appear to improve survival, although psychological and other benefits are seen in certain patients, according to results of a multicenter, randomized, controlled Canadian trial.

"The addition of supportive-expressive group therapy to standard care in women with metastatic breast cancer does not result in prolonged survival," said Pamela J. Goodwin, MD, associate professor of medicine, University of Toronto. "But it does result in modestly improved mood in women who are experiencing psychological distress, and modestly improved pain control in women who are experiencing pain."

Dr. Goodwin reported results of the Breast Expressive-Supportive Therapy (BEST) study, funded by the Medical Research Council of Canada and the Canadian Breast Cancer Research Initiative, at the 37th Annual Meeting of the American Society of Clinical Oncology (ASCO abstract 79) (The article has since been published: N Engl J Med 345:1719-1726, 2001.)

Suspicion that group psychosocial support might actually prolong survival in metastatic breast cancer arose following an unexpected observation in a previous trial. Spiegel et al (Lancet 2:888-889, 1989) reported that women who received supportive-expressive group therapy lived, on average, twice as long as those who did not. Since then, other studies have examined survival effects of psychosocial interventions in cancer, and results have been inconsistent.

To determine the effects of weekly expressive-supportive therapy on survival, Canadian investigators at seven centers randomized 235 metastatic breast cancer patients (mean age, 50.2 years; mean of 20.4 months since first metastasis) in a 2:1 fashion to weekly 90-minute support group sessions led by a therapist or to a control arm. All women received standard medical or psychosocial care as needed.

Sessions were designed to foster social integration, encourage emotional expressiveness, enhance coping strategies, and promote self-hypnosis and relaxation skills. Two trained and experienced leaders coordinated each session.

With median follow-up of about 4 years, median survival in the two arms was similar (17.9 months for the intervention group vs 17.6 months for controls, P = .72), with no evidence that the result was influenced by variables including study center, baseline psychological stress, or marital status.

Mood states were evaluated using a validated, self-administered questionnaire. Total mood disturbance, as well as subscales of depression, anxiety, anger, and confusion, all improved to a significantly greater extent in the intervention group than in controls within the year after randomization.

The effect of intervention was less for patients with low levels of baseline mood disturbance. But within 6 months of therapy, for women with higher-than-normal levels of baseline distress, a 13.5% improvement was noted in overall mood, which is "a magnitude that is probably clinically significant," Dr. Goodwin said. Similar improvements were noted for depression, anxiety, anger, and confusion among patients with baseline disturbances.

Interestingly, women who received group therapy also reported significant improvement in self-reported scales of pain but, again, only among those reporting high baseline levels. As with mood, the magnitude was 15% of the range of the scale.

Investigators believe pain may have improved because women discussed pain management frequently in the groups and were encouraged to use narcotic analgesics appropriately and without fear of addiction.

The investigator would not rule out offering group therapy to metastatic breast cancer patients who had no evidence of mood or pain disturbances. "Women can make decisions on their own as to whether they would like to participate or not," Dr. Goodwin said. "There may be other benefits we haven’t measured that they feel would be important to them."

David Spiegel, MD, of Stanford University School of Medicine, lead author in the 1989 study suggesting survival benefit to group therapy, called the Canadian investigation an "excellent trial" in the growing field of psycho-oncology.

"Dickens started A Tale of Two Cities: ‘It was the best of times, it was the worst of times.’ This is the best of studies, and it clearly does not replicate our original finding of a survival effect," he said. "I hope future studies will provide a definitive answer."