2006 presentation at The European Health Psychology Conference in Bath: Can We Bury the Idea That Psychotherapy Extends the survival of Cancer Patients?

1. Can We Bury The Idea That
Psychotherapy Increases The
Survival Of Cancer Patients?
James C. Coyne, Ph.D., Michael Stefanek, Ph.D.,
Steven C. Palmer, Ph.D.
jcoyne@ mail.med.upenn.edu

2. A significant proportion of
breast cancer patients
attending support groups
do so with the belief that
they may be extending
their lives (Miller et al.,
1998).

3. Can We Move Beyond the Impasse?
Claimed that 5 of 11 randomized trials demonstrate
an effect of psychosocial intervention on survival
time.
Evidence for a benefit to survival attributable to
psychotherapy is, at best, “mixed”, (Lillquist &
Abramson, 2002, p. 65), “controversial” (Schattner,
2003, p. 618) and “contradictory” (Greer, 2002, p.
238).
“A definite conclusion about whether psychosocial
interventions prolong cancer survival seems
premature” (Smedslund & Ringdal, 2004, p 123).

4. It is with a heavy heart that I have concluded that Dr. Coyne
suffers from an incurable illness: narcissistic myopia. He is a
depression researcher, so successful treatment of mere
anxiety symptoms appears meaningless to his limited vision. It
… seems to permit him to dismiss the results of 25 years of my
and many other colleagues' research demonstrating positive
effects of group support for cancer patients. I can live with his
distortion of the published data…But when he insults my
colleague Dr. Catherine Classen by referring to her as "Cathy,"
and worse insults my patients by informing us that our
supportive/expressive groups are a "waste of seriously ill
patients' potentially short remaining lives," my tolerance for
his obvious impairment vanishes. One of my patients who
attended our supportive/expressive group for six years said:
"This group is the least superficial thing I do in my life." She
and her family thanked me for it when I visited her home
shortly before she died.
David Spiegel, M.D., Stanford University

5. Re-Evaluating the
“Positive Studies”…

6. Three of the “positive trials” can be
eliminated because in each case,
patients in the intervention got
substantially better medical surveillance
and care.
Two of the investigator groups for these
trials deny that they were even studying
psychotherapy!

7. McCorkle R, Strumpf NE, Nuamah
IF, Adler DC, Cooley ME, Jepson C,
Lusk EJ, Torosian M (2000): A
specialized home care intervention
improves survival among older
post-surgical cancer patients. J
Am Geriatr Soc, 48: 1707-1713

8. McCorkle et al (2000)
Authors distinguish their intervention
from studies examining psychosocial
variables, stating, “…this is the first
[study] to examine the impact of…
nursing interventions on survival in
cancer patients. Other studies have
focused have focused on…patient’s
psychosocial status, including
depressive symptoms, function, and the
effects of support groups” (pp. 1708).

9. McCorkle et al (2000)
“We did what we did really because of
the physical care. The deaths were
related to major complications, sepsis,
pulmonary embolus, etc. The nurses
picked these things up and prevented
the crisis” (McCorkle, personal email
communication, August 3, 2004).

10. Kuchler T, Henne-Burns D,
Rappat S, Holst K, Williams JI,
Wood-Dauphinee (1999):
Impact of psychotherapeutic
support on gastrointestinal
cancer patients undergoing
surgery: Survival results of a
trial. Hepato-Gastroenrerol
46:322-335

11. Kuchler et al (1999)
Although the length of hospital stay was
approximately the same in the two
groups, the intervention group received
almost twice as much intensive care.
Post-treatment, patients in the
intervention group reported twice as much
chemotherapy and three times as much
“alternative treatment.”

12. Richardson JL, Shelton DR,
Krailo M, Levine AM (1990):
The effect of compliance
with treatment on survival
among patients with
hematologic malignancies. J
Clin Oncol, 8: 356-364.

13. Richardson et al
I would agree that our study was not
psychotherapy. Our study was very
behavioral in concept and delivery -
teaching people how to manage the disease,
the treatment and the health care system. I
think you can go a long way with basic
patient education, family education, and
health care system manipulation strategies.
Richardson (Personal communication, Jan 3, 2005)

14. Spiegel D, Bloom JR, Kraemer
HC, Gottheil E (1989): Effect of
treatment on the survival of
patients with metastasic breast
cancer. Lancet 2:888-891.
Cited 900 Times

16. Something Odd Occurred in the
Control Group.
Of the 12 patients assigned to the control group who were still alive at 2 years,
all died by one day after the four year anniversary of randomization.
inconsistent with typical survival curves for people with cancer, which are
generally skewed due to a few people surviving markedly longer than the rest.
Patients were on average already two years past diagnosis at randomization,
so this increased rate of death occurred relatively late.
32% of locale-matched women with metastatic breast cancer would be
expected to be alive between 5 and 10 years after diagnosis.
Spiegel et al.’s control patients experienced a four-year survival rate of only
2.8%.
In contrast, the four-year survival of patients randomized to intervention was
24%, substantially closer to expected value in the absence of an effective
intervention and suggesting bias in the initial sampling.

17. There is a lack of significant
differences when appropriate statistics
are used.
Spiegel et al. (1989) report that “the intervention
group lived on average twice as long as did
controls” (p. 889).
Given the skewness of most survival curves, median
survival time is generally considered the better
expression of central tendency because the median
reduces the possible excessive influence of outliers.
Median survival times for Spiegel et al.’s (1989)
intervention and control groups were not
significantly different.

18. Fawzy, F.I., Canada, A.L., & Fawzy, N.W.
(2003). Malignant melanoma: effects of a brief,
structured psychiatric intervention on survival
and recurrence at 10-year follow-up. Arch Gen
Psychiat 60, 100-103.*
Fawzy FI, Fawzy NW, Hyun CS, Elashoff R,
Guthrie, D, Fahey JL, M orton DL (1993):
Malignant melanoma. Effects of an early
structured psychiatric intervention, coping, and
affective state on recurrence and survival 6
years later. Arch Gen Psychiat, 50: 681-689.
*Cited Almost 500 Times

19. Fawzy et al. (1993) and Fawzy et al.
(2003)
Fawzy et al. (2003) provided a provocative and
seemingly compelling summary of the results for
the intervention prolonging survival as assessed at
six and ten year follow up:
When controlling for other risk factors, at 5-
to 6-year follow-up, participation in the
intervention lowered the risk of recurrence
by more than 2 1/2 fold (RR = 2.66), and
decreased the risk of death approximately
7-fold (RR = 6.89). At the 10-year follow-
up, a decrease in risk of recurrence was no
longer significant, and the risk of death was
3-fold lower (RR = 2.87) for those who
participated in the intervention.

20. Inappropriate Analysis and
Interpretation of Statistics
• Fawzy calculated an odds ratio, not a
relative risk, and it is an inappropriate
statistic for evaluating a clinical trial.
• Only 20 deaths in the entire retained
sample at 5-6 years, but Fawzy had
6 control variables in his regression
analysis, far below any
recommended minimum ratio of ten
to fifteen events per covariate The
risk of spurious findings is high.

21. Fawzy et al. (1993) and Fawzy et al.
(2003)
• Despite the dramatic way in which results for 10
year follow up were presented, a log rank test
revealed no significant difference between the
intervention and control group in overall survival
(Fawzy et al, 2003).
• Small magnitude of difference between
intervention and control group is highlighted by
noting that survival differences would become
non-significant with the reclassification of a single
patient (Fox, 1995; Palmer & Coyne, 2004).

22. Fawzy et al. (1993) and Fawzy
et al. (2003): A Critical Look
• Of 40 intervention patients, one was excluded
after randomization due to death during the
intervention, one due to incomplete baseline
data, and a third due to the presence of M ajor
Depressive Disorder.
• Of the 40 participants randomized to the
control condition, only 28 produced complete
baseline and 6-month data. Although lack of
complete data was a reason for excluding one
subject from the intervention condition,
survival data were included as much as
possible for those in the control condition,
regardless of the completeness of their data.

23. Neither the Spiegel nor the Fawzy
study were designed to test the
effects of psychotherapy on
survival.
Since then, there have been three
trials designed with this goal, and
none of them has yielded a positive
effect.

24. Cunningham, A. J., Edmonds, C. V. I., Jenkins, G. P., Pollack, H.,
Lockwood, G. A., & Warr, D.,(1998). A randomized controlled trial
of the effects of group psychological therapy on survival in
women with metastatic breast cancer. Psycho-Oncology, 7, 508-
517.
Goodwin, P. J., Leszcz, M., Ennis, M., Koopmans, J., Vincent, L.,
Guther, H., et al. (2001). The effect of group psychosocial support
on survival in metastatic breast cancer. New England Journal of
Medicine, 345, 1719-1726.
Kissane, D. W., Love A., Hatton, A., Smith, G., Clarke, D. M., Miach,
P., et al. (2004). Effect of cognitive-existential group therapy on
survival in early-stage breast cancer Journal of Clinical Oncology,
22, 4255-4260.

25. No study that was designed to test
whether psychotherapy improved
survival and in which the intervention
group did not get better medical care has
demonstrated an effect.
Claim that psychotherapy promotes
survival depend on the Spiegel and
Fawzy studies, which have serious
limitations.

26. Should We Attempt More Studies With
Metastatic Breast Cancer Patients?
We have no credible evidence that psychotherapy promotes
survival, and no compelling evidence for a mechanism that
might allow an effect.
There is evidence for some mechanisms by which biomedical
interventions might work, but not much success in producing
new, effective biomedical interventions.
“Despite more than 3 decades of research, metastatic breast
cancer (MBC) remains essentially incurable and, after
documentation of metastasis, the median survival time is
approximately 2 years” (Bernard-Marty, Fatima Cardoso, &
Piccart, 2004, p.617).

27. Should We Attempt More Studies With
Early Breast Cancer Patients?
In the U.S the 5-year survival rate for women with localized
breast cancer is now 98% (American Cancer Society, 2006).
This high rate of survival makes it difficult to demonstrate that
any additional treatment would yield a clinically significant
improvement.
An integration of 28 trials of with 16,513 women of whom 3782
had died concluded that both tamoxifen and cytotoxic
chemotherapy reduce five year mortality (Early Breast Cancer
Trialist’s Collaborative Group, 1988). Yet, when trials were
considered individually, only a single trial had an effect
significant at p <.01.

28. Inherently Implausible?