Effects of Psychological Treatment on Cancer Patients: A Critical

Review

R. W. TRIJSBURG, F. C. E. VAN KNIPPENBERG, S. E. RIJPMA

Twenty-two studies on the effects of psychological treatment on cancer patients are reviewed.
Only studies that compared one or more experimental conditions with at least one control
group have been considered. The studies were evaluated with respect to a) research methods,
b) psychological interventions, and c) results. Tailored counseling has been shown to be
effective with respect to distress, self-concept, (health) locus of control, fatigue, and sexual
problems. Structured counseling showed positive effects with respect to depression and distress.
Behavioral interventions and hypnosis were effective with respect to specific symptoms such
as anxiety, pain, nausea, and vomiting. The research methods, interventions and results of the
studies are reviewed critically. Several recommendations for future research are made.
Key words: psychotherapy; psychological intervention; cancer; quality of life.

INTRODUCTION loss of weight (8, 10), and dispnoeic at-

Over the past 20 years, the number of
studies on the somatic, psychic, and social
problems of cancer patients and their
need for psychological help has been in-
creasing (1-4). Several case reports on
psychotherapy for cancer patients have
also been published (5-10). The effects of
relaxation, modeling, and hypnosis on
nausea and vomiting, resulting from
chemotherapy, have been described by
Bos-Branolte (6). Kaye (8), and Dempster
et al. (9). Other case reports have ad-
dressed such subjects as the effects of
hypnosis on anxiety and pain during med-
ical examinations (9), depression (8, 10),
From the Department of Medical Psychology and
Psychotherapy, Erasmus University, Rotterdam, The
Netherlands.
Address reprint requests to: Dr. R.W. Trijsburg,
Department of Medical Psychology and Psychother-
apy, Medical Faculty, Erasmus University, P.O. Box
1738, 3000 DR Rotterdam, The Netherlands.
Received for publication January 31, 1991; revi-
sion received January 9, 1992
tacks (10).
As the interventions described in these
and other case studies were beneficial,
the question arose as to whether these
effects could also be shown in controlled
studies. In a review by Watson (11), some
methodological shortcomings of empirical
studies were pointed out, such as the ab-
sence of control groups and the incom-
pleteness of data on crucial aspects, e.g.,
characteristics of interventions, refusals,
attrition, and statistical techniques. After
reviewing 12 controlled studies, Watson
(11) concluded: "To the question of
whether specialist support programs ben-
efit patients, the answer is a qualified
yes." (p. 843).
This article supplements and extends
the scope of Watson's review in two as-
pects. First, 22 controlled studies on the
effects of psychological interventions on
cancer patients were screened. Second,
the current study highlights the method-
ological aspects and results of the studies
in greater detail. The studies were re-
viewed on three aspects: methods, psy-
chological intervention, and results.

Psychosomatic Medicine 54:489-517 (1992) 489

0033-3174/92/5404-0489S03.00/0
Copyright 1992 by the American Psychosomatic Society

Selection of the Studies
The studies were selected from those
published between 1976 and September
1990. As the scope of this review limits
itself to the effects of psychological inter-
ventions, studies on the effects of educa-
tional programs or information per se, or
self-help groups were not included. The
review was limited to studies in which
the intervention group was compared
with one or more control groups.1 Table 1
presents an overview of the 22 studies
selected. The first aspect to be reviewed
is research methods.
RESEARCH METHODS
Three questions were of relevance when review-
ing the research methods. First, the question of
whether the studies were designed in a way that
permitted conclusions concerning the interventions.
Second, whether the instruments used for outcome
variables were valid and reliable, and finally,
whether the patient selection procedure was ade-
quate. Hence, the three topics to be reviewed were:
1. design (experimental conditions, comparability
with respect to crucial variables, use of pretesting
and post-testing); 2. instrumentation (psychometric
aspects); and 3. patient selection.
1. Design
Experimental Conditions (see Table 1, Coiumns 5-
8j. In 11 studies, in addition to the experimental
group (psychological intervention), there was one
control group that received normal care. In three
studies (12-14), one extra control group was used to
control for nonspecific attention. In two studies (15,
16) two control groups were formed, which both
1
The studies by Golonka (16) and by Farash (19)
were abstracts. Therefore, some of the aspects,
which were relevant in the present review, could
not be evaluated.
490
R. W. TRIJSBURG et al.
received normal care. In one study (17), two forms
of psychological intervention were compared, one
serving as a control for the other. Five studies com-
pared different forms of psychological intervention
in addition to a control condition (6, 18-21). In four
of these studies (18-21). the experimental groups
were comparable in terms of duration and number
of meetings.
Comparability with Respect to Crucial Variables.
In order to be able to compare treatment effects
between groups, the groups need to be comparable
as far as crucial variables are concerned. These
variables are. medical and psychological status and
sociodemographic characteristics. To check for un-
equal distributions of both conditions, statistical cor-
rections should be applied. Finally, measurements
need to take place at approximately the same time
in both the experimental and control groups.
Sociodemographic Variables. With respect to so-
ciodemographic variables, the random assignment
of patients to ensure comparability of the research
groups was applied in 14 studies (Table 3, column
1). In 15 studies differences between the groups were
checked retrospectively (Table 3. column 4).
Medical Variables. Random assignment was ap-
plied in 14 studies (Table 3, column 1). In 14 studies,
comparability regarding medical variables was
checked retrospectively (Table 3, column 3). In sev-
eral studies, variability of medical factors was min-
imized by the formation of homogeneous groups,
e.g., with respect to the type of medical treatment,
the time interval between medical treatment and
psychological treatment, previous medical treat-
ment, time period between diagnosis and the start
of the study, the stage of the illness and the prog-
nosis. However, data on medical variables often
could not be traced (see Table 1). In 7 studies, it was
stated that patients were treated medically during
the period of the study, but the treatment was not
specified. In four studies, no data were supplied (see
Table 1, column 3). In two studies (18, 22), the
prognosis of the illness was specified (see Table 2).
Psychological interventions took place over the
same period of time as the medical treatment, or
subsequently. The timing of the psychological inter-
vention appeared to be evenly spread across the
conditions.
In some studies medical variables were used as
independent variables. For example, Lyles et al. (13)
compared two types of drug administration that
were being applied, and Gordon et al. (15) studied
the interaction between psychological interventions
and the type of cancer.
Psychological Variables. Psychological trait vari-
Psychosomatic Medicine 54:489-517 (1992)
 TABLE 1. Data on Patients and Groups
Tim~ngof Groups and Number of Pat~ents
Type of
T ~ m eSmce Intervention
Reference Cancer S~te and Medlcjl Experimental Control
Diagnos~s Med~cal
Treatment
Treatment Group(s) Group(s)
60s-Branolte (6) Gynecology Surgery After
Kad~otherapy
Chenlotherapy
Bur~shand Lyles (32) >Three cancer sites Chemotherapy Dur~ng
Cam et al. (18) Gynecology Newly d~agnosed Unspec~t~ed Dur~ng
Capone et al. (27) Gynecology Newly d~agnosed Unspec~f~ed Durmg
Chr~stensen(35) Breast ? Surgery After
Farash (19) Breasl ? Surgery After
Ferl~cet al. (24) >Three cancer sltes Newly diagnosed ? During
Forester et al. (23) >Three cancer sltes ? D u r ~ n g& after
Goldberg and Wool (33) Lung Newly d~agnosed During
Golonka (16) Breast i' Chemotherapy Dur~ng
Gordon et al. (15) Breast, melanoma, Newly d~agnosed Unspeched Durmg & after
lung
H e ~ n r ~ cand
h Schag (25) >Three cancer sltes 2 years ? 7
Houts et al. (34) Gynecology Newly d~agnosed Unspec~f~ed Dur~ng
Kuttner (14) Leukernla 7 BMAs, LPs Dur~ng
Linn et al. (22) >Three cancer srtes 0.8 years Unspecified During
Lyles et al. (13) >Three cancer sites ? Chemotherapy Durmg
Magu~reet al. (28) Uterus ? Surgery Durmg
Morrow and Morrell (12) >Three cancer sites ? Chenlotherapy Durmg
Sp~egelet al. (26) Breast 4-5 years Unspec~f~ed During
Spiegel and Bloom (20) Breast 2 years Unspecif~ed Dur~ng
Worden and We~sman(21) >Three cancer sltes Newly diagnosed ? ?
Zeltzer and LeBaron (17) Leukemia, neural 2 years BMAs, LPs
tumors, non-
Hodgk~n
Explanat~ons:
Type of medical treatment:
BMAs. LPs = Bone marrow aspirat~ons,lumbar punctures
Timing of intervention and m e d d treatment:
After = psychological treatment was gwen after medical treatment.
During = psycholog~callntervention was gwen during med~caltreatment.
During & after = psychological treatment was grven during and after medical treatment.
Groups:
- - there was no such group
= intervention control group.
? = data on this aspect were not available.

TABLE 2. Data on Patients and Groups: Remaining Characteristics and Screening Criteria
Bos-Branolte (6)
Burish and Lyles (32)
Cain et al. (18)
Christensen (35)
Farash (19)
Ferhc et al (24)
Forester et al. (23)
Goldberg and Wool (33)
Cordon et al. (15)
Heinnch and Shag (25)
Kuttner (14)
Linn et al. (22)
Lyles et al. (13)
Morrow and Morell (12)
Spiegel et al. (26)
Spiegel and Bloom (20)
Worden and Weisman (21)
Zeltzer and LeBaron (17)
M, medical; P, psychological; D, demographic.
492
R. W. TRIJSBURG et al.
M: Patients had to be in complete remission for at least 6 months after
medical treatment; without any other type of cancer
P: Informed about the cancer diagnosis; free from manifest psychiatric
pathology
D: Not older than 70
M: Patients had exhibited anticipatory anxiety, nausea, and/or vomit-
ing to chemotherapy treatments
M: Expected survival of at least 1 year
P: No previous history of severe psychiatric problems or exhibiting
symptoms requiring referral to a psychiatrist
D: Age between 18 and 75 years
M: Patients' cancer was arrested and nonmetastatic; surgery had been
completed 2 to 3 months prior to the study
P: Absence of a crisis, such as divorce or unemployment; absence of a
major emotional disturbance that would require prompt specialized
attention
D. The patient had a husband, who was also willing to participate
M: Patients entered the study approximately 2 months following mas-
tectomy
M: Advanced cancer; no prior chemotherapy; not moribund; patients
with primary or metastatic cancer of the brain were excluded
M: Patients with abdominal cancer were excluded
D: A significant key other was willing to participate
M: No prior medical treatment for their present condition; no brain
damage
P: No previous psychiatric history or diagnosis of mental retardation
D: Age between 18 and 75
M: Karnofsky performance status equal to 70 or higher; no brain
disease
P: No major psychiatric illness; no major cognitive deficits; no alcohol
or drug abuse
D: Age between 25 and 70
M: Patients had pain, distress, or anxiety during bone marrow aspira-
tion or lumbar punctures
D: Aged 3 to 7
M: End-stage cancer, at least three but no more than 12 months of
survival
M: Patients had received a minimum of two chemotherapy treatments
and were scheduled for at least six additional treatments; they had
exhibited anticipatory anxiety, nausea, and/or vomiting in response
to chemotherapy treatments
M: Patients had had anticipatory nausea and vomiting before their
fourth chemotherapy treatment; patients with metastatic disease of
the brain or obstruction of the alimentary canal were excluded
M: Only patients with documented metastases were included
M: Only patients with documented metastases were included
M: Prognosis of at least 4 months
P: At risk for high levels of emotional distress and poor coping
D: Over 18 years of age
M: Patients had pain and anxiety during bone marrow aspiration or
lumbar punctures
D: Aged 6 to 17
Psychosomatic Medicine 54:489-517 (1992)
PSYCHOLOGICAL TREATMENT OF CANCER PATIENTS

ables should be comparable across the conditions, in
the same way that medical variables should. Scores
on outcome measures have been adjusted for the
level of pretreatment scores in many studies (see
Table 3, column 5). However, trait variables (e.g.,
neuroticism or trait anxiety) were not controlled for
in the studies.
The fact that psychological factors are important
was shown in several studies. For example, Bos-
Branolte (6) showed that the patients who refused
psychotherapy were suffering less from psychologi-
cal problems than those who received psychological
treatment. Forester et al. (23) and Gordon et al. (15)
made an explicit distinction between the number of
psychological problems and related the results to the
effects of psychological intervention. It is generally
assumed that the psychological status of the groups
under study are comparable at the first measure-
ment when randomization procedures are applied.
Comparability was also controlled for by comparing
the mean group scores at pretest (F test, or chi-
square). Statistical corrections were made by means
of change scores (24), the analysis of co-variance (14,
22, 25) or slope analysis (20. 26). VVorden and Weis-
man (21) corrected for distress scores, but were un-
clear about the procedure used. In two studies (27,
28), post-treatment scores were not adjusted for pre-

TABLE 3. Assignment to Groups and Baseline Comparison

Assignment Baseline comparison of crucial variables
Reference
Random Stratificatior i Medical 1Demographic Psychological
Bos-Branolte (6) No No Yes Yes Yes
Burish and Lyles (32) Yes Yes No No Yes
Cain et al. (18) Yes Yes Yes Yes Yes
Capone et al. (27) ? ? Yes Yes Yes
Chnstensen (35) Yes No No No Yes
Farash (19) Yes No ? ? ?

Ferlic et al. (24) No Yes No Yes Yes

Forester et al. (23) Yes No Yes Yes Yes
Goldberg and Wool (33) Yes No Yes Yes Yes
Colonka (16) ? ? ? ? ?
Gordon et al. (15) Other Yes Yes Yes Yes
Hemrich and Schag (25) Other Yes Yes Yes Yes
Houts et al. (34) Other No No Yes Yes
Kuttner (14) Yes No No No Yes
Linn et al (22) Yes No Yes Yes Yes
Lyles et al. (13) Yes Yes Yes No Yes
Maguire et al. (28) Yes No Yes Yes No
Morrow and Morrell (12) Yes No Yes Yes Yes
Spiegel et al. (26) Yes No Yes Yes Yes
Spiegel and Bloom (20) Yes No Yes Yes Yes
Worden and Weisman (21) No No Yes Yes Yes
Zeltzer and LeBaron (17) Yes Yes No No Yes
Explanations:
Assignment:
Other = other design, e.g., nonequivalent control group design with time-:
Demographic:
Demographical factors, mostly age, sex, race, and marital status.
Psychological:
Dependent variables, mostly psychological factors.
No, no random assignment/no stratification/no control afterwards.
Yes, random assignment/stratification/control afterwards.
?, data on this subject were not available.

Psychosomatic Medicine 54:489-517 (1992) 493


treatment scores. No data were available for two
other studies (16, 19).
Use of Pretesl and Posl-Test. In 19 studies, the
times of testing were the same for both the interven-
tion and control groups. In Farash's (19) and Capone
et al.'s (27) study, there were no pretreatment meas-
urements of dependent variables, so the effects could
not be adjusted for scores at pretest. However, Ca-
pone et al. were able to compare the results of the
intervention group with those from a normal group.
In the study by Maguire et al. (28), which addressed
the development of psychiatric complaints during
and after medical treatment, no pretests were used
for the self-rating of anxiety and depression. There-
fore, the post-test scores of patient-rated anxiety or
depression could not be controlled for. On the other
hand, pre-existing psychiatric problems were as-
sessed shortly after surgery, thus making the effects
of the intervention to some extent comparable at the
level of psychiatric morbidity. In Warden and Weis-
man's (21) study the intervention and control groups
were tested several times, but the intervals between
measurements differed from one group to the next.
2. Instrumentation (see Table 4A
and B)
The instruments used for measuring personality
characteristics or psychological state should be reli-
able and valid (29-31). In 21 out of the 22 studies, at
least some of the instruments used are known to be
reliable and valid (e.g., POMS, PAIS, and STAI), or
their psychometric qualities could be validated with
the aid of literature references indicated in the text.
Relevant information was unavailable in the case of
the Patient Perception Test (24), the Cancer Infor-
mation and QL tests (25), and the BDRI (19).
In 11 (6, 13-15, 17, 20, 21, 28, 32-34) out of the 22
studies, the measurement instruments were spe-
cially designed for specific purposes. In five out of
these studies (6,14,15, 21, 33), references were given
for the relevant psychometric data. In some cases,
existing instruments had been adapted for use in the
study (22, 24, 35). In these studies, no relevant psy-
chometric data were presented.
3. Selection of Patients
The basis for patient selection was rather variable
across the studies. The most commonly chosen as-
494
R. W. TRIJSBURG et al.
pects were: type of cancer, time elapsed since diag-
nosis, drop-out rate and refusals, and seriousness of
the psychological problems.
Type of Cancer. In 10 studies, patients were se-
lected on the basis of having different types of cancer
(eight studies covered more than three types, two
covered three types). In one of these studies (15)
statistical analyses were carried out on a subsample
of patients with lung cancer: this sample contained
the largest number of patients in the study. The
stage of illness, the prognosis and the general phys-
ical condition of the patients were rarely given. The
remaining 12 studies each addressed one type of
cancer (Table 1, column 1).
Time Elapsed Since Diagnosis (Table 1, coiumn 2).
In five studies, the patients had known their diag-
nosis for 8 months or longer. In seven studies, newly
diagnosed patients were selected. In 10 studies, the
time elapsed since the diagnosis was not given.
Type and Timing of Medical Treatment (see Table
1, columns 3 and 4). Eight out of the 22 studies were
concerned with psychological interventions during
medical treatment (chemotherapy, radiotherapy,
bone marrow aspiration, lumbar punctures, surgical
intervention). In five of these studies the psycholog-
ical intervention was aimed specifically at amelio-
rating the effects of the medical interventions, e.g.,
nausea and vomiting in reaction to the chemother-
apy (12,13, 32); reduction of pain and distress during
lumbar punctures and/or bone marrow aspirations
(14, 17) (see Table 1, column 4). In one study the
intervention started 3 months after the medical
treatment had ended. In two studies the intervention
started after surgery, although the time elapsed since
surgery was not specified. In seven studies, the psy-
chological intervention was also given during med-
ical treatment, but the medical treatments were not
specified. In four studies, there were no data con-
cerning medical treatment.
Seriousness of the Psychological Problems (TabJe
2J. In five studies, any patients with psychiatric
problems were excluded from the study. Christen-
sen (35) not only excluded patients with psychiatric
problems, but also patients who were in a state of
emotional crisis, e.g., marital. Worden and Weisman
(21) included only patients that were at risk for high
levels of emotional distress and low ability to cope.
Drop-Out Rate and Re/usaJs (see Table 5j. Most
studies gave due consideration to the percentage of
refusals and drop-outs. Reasons frequently given
were: death, too ill, and moving from one house to
another. The percentage of patients who refused or
dropped out varied across the studies.
Psychosomatic Medicine 54:489-517 (1992)
PSYCHOLOGICAL TREATMENT OF CANCER PATIENTS

TABLE 4A. Instruments (Psychological Variables)

(Health)
Anger, Hostility, _ .
Instruments Anxiety Depression % ' . Distress Selfconcept Locus of
Confusion
Control
POMS 26, 33, 34 22, 26, 33, 34 20,21,33,34 21,26,27,34
MAACL 13, 15,22 13, 15,32
HAS 18 15, 32
EO 13, 14, 17, 28 21, 28
28, 32
PSE 28 28
STAI 12, 16, 35
SCL90 25 25
BOS 6 6 6 6
ARS/DAL 16
VUL 21 21 21
HDRS 18
SRSS 27 27
BDI 19, 35
BDRI 19
SADS 23
PAIS 18, 25
LS 15
QL 25
PSI 35
PBRS-R 14
CANTRIL 22
24
SCQ 22
SHS 26
JFS 27
TSCS 35
RSE
22, 35
LC 12, 15, 26
HLC
The numbers in the cells represent references.
For full descriptions: see references.

PSYCHOLOGICAL INTERVENTIONS ('tailored counseling,' See Table 6A).

Counseling and support were the main
Psychological interventions differ in ingredients here. In some cases the inter-
goals and treatment techniques, depend-
ing on the particular problems confront- vention may also contain educational ele-
ing the patients, which in turn are asso- ments. The majority of these studies pre-
ciated with the sort of disease, its stage, sent an outline of the main objectives and
and whether or not medical treatments techniques. These studies do not offer a
are given. Many studies offer counseling definite, structured program, although
as treatment of choice. Most of these were the studies by Bos-Branolte (6-group
tailored to the needs of the patients therapy), Capone et al. (27) and Houts et

Psychosomatic Medicine 54:489-517 (1992) 495

 R. W. TRIJSBURC et al.

Psychosomatic Medicine 54:489-517 (1992)

PSYCHOLOGICAL TREATMENT OF CANCER PATIENTS

TABLE 5. Refusals and Drop-Outs

Number of Refusals Drop-Outs Drop-Outs E(xperimental)
Reference
Patients (%) (%) and C(ontrol) Group(s)
Bos-Branolte (6) 119 24% T3: 8% (E4%C 10%)
Burish and Lyles (32) 18 11% T5:?
Cain et al (18) 94 15% T3- 20%
Capone et al. (27) 111 13% T4:?
Christensen (35) ? ? T2: 0%
Farash(19) ? ? T2:? ?
Ferhc et al. (24) 70 15% T3: 55% (E 40% C 70%)
Forester et al. (23) i ? T5:? ?

Goldberg and Wool (33) i 23% T3: 62% (E6r.CC 64%)

Golonka (16) ? ? T2:? ?
Gordon et al. (15) ? 23% T4: 36% (E35%C41%C32%)
Heinnch and Schag (25) 81 14% T3: 8% ?
T2:27%
Houts et al. (34) 41 2% T3: 20% ?

Kuttner(14) ? ? T3: 28% ?

Linn et al. (22) 141 15% T6:? (E 85% C 76%)
Lyles etal. (13) 57 12% T5 > 40% ?

T4: 8%
Maguire et al. (28) 172 3% T3 9% ?
Morrow and Morrell (12) 87 11% T?: 22% ?

Spiegel et al. (26) 109 17% T4: 65% (E68%C61%)

Spiegel and Bloom (20) 109 17% T4: 63% (E 63% C 64%)
Worden and Weisman (21) 125" 22% T5: 39% ?

Zeltzerand LeBaron (17) 45 27% T?:? ?

Explanations:
Number of patients:
Number of patients asked to cooperate.
Refusals:
Percentages refer to the number of patients who refused to cooperate.
Drop-outs:
Percentages refer to the number of patients who dropped out after initial participation; T1 is first assessment,
T2 second assessment, etc.
Drop-outs experimental and control group(s):
Percentages are mentioned separately for the intervention (E) and control (C) group.
? = data were not available.
" In the study of Worden and Weisman, only data about the experimental group are given.

al. (34) contain some fixed elements. Next
to these studies there were studies that
offer an explicitly formulated structured
counseling program (18, 24, 25, 35) ('struc-
tured counseling,' see Table 6B). They
may contain educational aspects and be-
havioral instructions, and exercise may
also be given. Apart from the counseling
studies, there were studies that aim ex-
plicitly at overcoming anxiety or pain due
to medical procedures by employing be-
havioral techniques or hypnosis (12-14,
17, 32) ('behavioral/hypnosis,' see Table
6C). The study by Spiegel and Bloom (20)
combines supportive group therapy with
self-hypnosis (pain-control) in the exper-
imental condition.
Given these different approaches to

Psychosomatic Medicine 54:489-517 (1992) 497

 TABLE 6A. Interventions and Outcome in Studies Using Tailored Counseling
Reference
60s-Branolte (6)
Capone et al. (27)
Farash (19)
Forester et al. (23)
Goldberg and Wool (33)
Golonka ( 1 6)
Cordon et al. (15)
Houts et al. (34)
L~nnet al. (22)
Magulre et a!. (28)
Sp~egelet al. (26)
Worden and Weisman (21)
Intervention
Group therapy (progressive muscle relaxa-
tion, role-play~ng,learn~ngby im~tation);
lndiv~dualtherapy (same format)
lndiv~dualcounseling (reality-oriented, fac~li-
tatrng attainment, adaptrve behavior
change)
Self-help counselmg group;
lndwidual cris~s~nterventlon
lndividual supportive psychotherapy (educa-
tional, interpretive, cathartic)
Psychosocial intervent~onw ~ t hsignrf~cantkey
other (maintam soc~alsupport system, pro-
mote autonomy of patient, advocate for
patlent, encourage communication, facili-
tate mutual expression of emotion)
Supportive group counseling (exam~ning
problems, verbahzing emotions)
lndividual psychosocial rehabilltation (educa-
tional, counseling, env~ronmentalmanipu-
lat~on)
lndividual counselmg (telephone) by former
cancer patients
lndiv~dualcounsellng concerning death and
dying
Individual counselrng by speclallzed nurse
(prevent~onof psychiatric morbidity)
Supportive group meetmgs focusing on prob-
lems of terminal ~llness,improving relatron-
ships, "livlng as fully as possible in the face
of death")
Problem oriknted indiv~dualcounseling;
lndividual training of problem solving skills
?
Outcome 3
(At 9 months) Improvement In self-esteem, well-being, 4
body image, partner relationship. The latter two im- -
=
proved more In indiv~dualthan in group therapy V)
(At 12 months) Less confusion and contradiction in
rn
self-perception, positive effects in return to voca- s
tional and sexual funct~ons C,
No differences In effectweness between self-help and
indiv~dualcounselrng; in mastectomy patients coun-
2
seling assists wlth the resolut~onof body image dis- k
turbance
Emotional (depression, pessimism, anxiety) and physi-
cal (anorexia, fatigue, nausea and vomrting) symp-
toms Improved
(At 6 months) No different~alchange over trme for
significant key other or pat~entsin emotional, soclal,
and physical functronlng
No differences in anx~ety
(At 6 months) Less psychosocial problems, more rapid
decl~neof anxiety, host~l~ty, depression, more realls-
t~c outlook on life, greater proport~onreturning to
former vocatronal status, more actlve usage of tlme
(At 3 months) No d~fferencesin emotional status, one
aspect of coplng differing in d~rect~onopposite to
prediction
(At 12 months) Improvement in quality of life (depres-
sion, self-esteem, Ilfe-sat~sfact~on,
alienation, locus
of control); no differences in functional status or
survival
(12 to 18 months after mastectomy) Much less psychi-
atric morbid~tyIn counseled than In control group
(At 12 months) Decrease in mood-d~sturbance,fewer
maladaptwe coping responses, less phobic com-
plaints
(At 6 months) S~gnif~cantlylower levels of distress, de-
n~al,and higher rates of ~ r o b l e mresolution
PSYCHOLOGICAL TREATMENT OF CANCER PATIENTS

problems, there still were substantial dif-

ferences within a subgroup of studies with
o> A
respect to the setting, the number and
duration of sessions, the duration of the
O J2 T3 intervention period, the aims of the treat-
c -D~ ra
= ^ S ment, treatment techniques, and the type
" j i
C 11 />o 0.0= -
D. ? >S
r Q. C
of therapist. These aspects are discussed
01
o> ~ O r-~ below. However, in some cases, relevant
c -c
DO
O DO information was either not given, or
rather difficult to reconstruct (see Table
0)-DS5>E"ra"D
"""111 S
a.
5- c
7).
-J-5ij5'5:5<u3lS - ^ o5 .y
-= o ^ ^ o S
E
- a i 5sI
1X5 +_, ZZ 7~\ U fO
E "5
<
0) S a g- JJ
" u E a Z 'o 1. Treatment Setting
Tailored counseling was given individ-
bi <u ually in seven studies (Table 6A). In two
~ -S M studies, treatment was restricted to group
2 3 2z
sessions. In one study group therapy was
compared with individual treatment. In
o. g J the study by Farash (19), individual ther-
nl Oi
apy was compared with self-help groups.
Another study addressed itself to the "sig-
9- a. nificant key other" (33). Worden and
^ S' Weisman (21) offered two forms of coun-
seling, one being more didactic than the
other. Structured counseling programs
I gill were given in various ways (see Table 6B).
3 --T P <U 3
Group therapy was applied in one study.
One study compared group with individ-
ual treatment. The other two studies con-
sidered patients and partners either indi-
vidually (35) or in a group (25).
Behavioral interventions and hypnosis
were applied individually in all cases (see
Table 6C). with the exception of Spiegel
and Bloom (20). In this study, training in
self-hypnosis was given during the last 5
to 10 minutes of supportive group
sessions.

Psychosomatic Medicine 54:489-517 (1992) 499

 TABLE 6C, Interventions and Outcome i n Studies Using Behavioral Interventions or Hypnosis
Reference Intervention Outcome
Bur~shand Lyles (32) lnd~vidualprogressive muscle relaxation traln- During and after tra~ningsessions, less emo-
Ing; guided relaxation imagery during tlonal distress, nausea, and phys~ological
chemotherapy arousal
Kuttner (14) Individual hypnotic trance induction (favorite Reduction of distress, pain, and anxiety d u r ~ n g
story telling technique) BMA, sustained at subsequent medical pro-
Distractions with physical objects cedures (only behavioral checklist and self-
report NS)
Lyles et al. (13) lndiv~dualprogressive muscle relaxation train- Considerable reduction in many of the s ~ d e
ing plus gu~dedrelaxation imagery effects (systolic blood pressure, patlent-
Individual support and encouragement rated nausea, nurse-rated anx~ety)
Morrow and Morell lndiv~dualsystemat~cdesensitization More SD patients reported no antlclpatory
(12) Individual counsel~ng nausea than patlents glven counselmg; less
severe antlc~patorynausea and vornitlng,
w shorter durat~onof ant~c~patorynausea ~n
.(" SD group
r Splegel and Bloom (20) Supportwe group therapy wlth self-hypnosis (At 12 months) Both groups less self-rated
i (concerning pain) pain sensation and suffer~ng,self-hypnos~s
Croup therapy w~thoutself-hypnosis group best in controlling pain sensation;
changes correlate w ~ t hself-rated mood d ~ s -
2.
3 turbance (total, anxiety, depression, and fa-
t~gue) ?
E Zeltzer and LeBaron lndiv~dualhypnosis (a~dedby Imagery, fan- Less pain and anx~etyw ~ t hhypnos~s(BMA and
2. r
tasy, story tell~ng) lumbar punctures); nonhypnotic techniques
(D (17)
lndiv~dualnonhypnotic techn~ques(deep only effectwe with pain in BMA and anxiety -I
~n

z breathing, d~straction) ~nlumbar punctures -w

V,
0) m
'a C
wl
-L
4' R
A
A
bo z
N
bo
- L
 TABLE 7. Formal Characteristics of Psychological Interventions

Reference weeks= EEZ;! Counselor/Therapist

Type' Mlnutesb
A. Individual and group counselrng
Bos-Branolte (6) G Psychologist
I Psychologist
Capone et al. (27) I ?
Farash (19) G
I
Forester et al. (23) I 7
Goldberg and Wool (33) 0 Social worker or psycholog~st
Golonka (16) G ?
Gordon et al. (15) I Psychologist, soclal worker or nurse
Houts et al. (34) I Social worker (ex-patient)
Linn et al. (22) I Trained counselor
Maguire et al. (28) I Tralned nurse
Spiegel et al. (26) G Psychiatrist or social worker with patient
Worden and Weisman (21) I Psychologist
I Psychologist
B: Structured counseling programs
Cain et al. (18) G Social worker and other experts
I
Chrlstensen (35) 0 ?
Ferllc et al. (24) G Social worker and other experts
Heinrich and Schag (25) 0 ?
C: Behavioral interventions or hypnosis
Burish and Lyles (32) I 4-5/var. ?
Kuttner (14) I 3/? ?
Lyles et al. (13) I 5/var. Psychologist or nurse
I 5/var
Morrow and Morrell (12) I 2/60" ?
I 2/60" ?
Spiegel and Bloom (20) G 40/90" (e) Psychiatrist, social worker, or patient
(hypnosis by psychiatrist)
G
Zeltzer and LeBaron (17) I Pedlatrlcian, pediatric psychologist
I
"Types are: Individual, Group, or Other (e.g., patient and partner) treatment.
" Sessions/rninutes: number of sessions and duratlon of a session in minutes.
Weeks: number of weeks of treatment or of the study.
" OpenIFixed: Open-ended treatment or number of sesslons or treatment period fixed in advance.
'Supportive group sessions, including 5-10 minutes self-hypnosis training versus supportive group sesslons only.
?: Data are unavailable.

2. Number of Sessions and Period of
Time
In tailored counseling therapies the
number of sessions varies from three to
40, and from 20 to 90 minutes per session
(see Table 7). Likewise treatments last
from 4 to in excess of 52 weeks. They may
be open-ended (6-individual therapy, 22,
26-28), or have a fixed number of sessions
(6-group therapy, 15,16, 19, 21, 23, 33, 34)
(See Table 7). Structured counseling pro-
grammes took four to eight sessions of
different duration (90 or 120 minutes).
The treatment period was 2 to 8 weeks.
All are for a fixed number of sessions.
In the majority of cases of behavioral
interventions or hypnosis, two to five ses-
sions of variable duration were given. The
time period is between 2 and 8 weeks.
Given the fact that Spiegel and Bloom's
study (20) took 1 year, hypnosis training
may have been given on up to 52
occasions.
3. Goals of Treatment
In many of the (tailored and structured)
counseling studies, the objectives of psy-
chological treatment were defined glob-
ally. In studies using a tailored approach
(see Table 6A) global objectives were, for
instance, enhancing the quality of life (6,
22. 26, 33), diminishing distress and other
adverse effects of medical treatment (21,
23), reducing psychosocial problems and
discomfort, enhancing social adjustment
(15, 27), and increasing effective coping
strategies (21, 34). Structured treatment
studies (see Table 6B) focused in particu-
lar on reducing stress and increasing ef-
fective coping strategies (18, 24, 25, 35).
However, most of the studies which
referred to global objectives, gave detailed
502
R. W. TRIJSBURG et al.
specifications. Frequently stated objec-
tives were: enhancing adequate coping
strategies, e.g., adequate contact with the
medical staff (11 studies), expressing feel-
ings and concerns (10 studies), preserving
the social support system of the patient
and improving communication within the
system (nine studies), increasing knowl-
edge, removing misunderstandings and
myths, e.g., about the illness, the care
system, dieting (eight studies), promoting
hope, a positive self-image and adequate
sexual relationships (five studies), en-
couraging relaxation (nonspecific) (five
studies), and increasing insight by means
of clarification and interpretation (four
studies).
Objectives incidentally referred to,
were, among others, promoting the auton-
omy of the patient, enhancing a realistic
attitude, accepting the finite nature of life,
finding solutions with respect to religious
problems, and enhancing the subject's
perspective on the future, his activity
level, his compliance, and his insight into
the past. In some cases goals were derived
from a specific problem, e.g., sexual and
self-image problems in reaction to mastec-
tomy (6,19) and problems related to death
and dying in terminal patients (20, 22).
In behavioral or hypnosis studies (see
Table 6C) the objectives of the psycholog-
ical treatment were specifically derived
from the type of problem. For example, in
cases of distress such as anxiety, nausea,
and vomiting caused by chemotherapy,
specific interventions were applied,
which aimed at reducing these (condi-
tioned) reactions (12, 13, 32). The same
applies to specific forms of pain, e.g., in
reaction to bone marrow aspiration (14,
17, 20).
Psychosomatic Medicine 54:489-517 (1992)
PSYCHOLOGICAL TREATMENT OF CANCER PATIENTS

5. Treatment Techniques RESULTS

In order to replicate a study, it is nec- Nineteen of the 22 studies report posi-
essary to know how a specific psycholog- tive effects of psychological interventions
ical treatment was carried out (11). In in at least some aspects of the psycholog-
three out of 11 tailored (15, 26, 33) and ical and somatic functioning of patients
three out of four structured counseling (see Table 6A-C). Since all studies de-
therapies (18, 24, 35), technical proce- scribed used at least one control group,
dures were described in reasonable detail. the conclusion is warranted that psycho-
The other studies on counseling gave am- logical treatment of cancer patients is
biguous (6, 21, 23, 27, 34) or incomplete beneficial to at least some extent. With
(16, 19, 22, 28) information. However, the exception of studies using survival
seven studies referred to relevant publi- analysis, positive effects were found up to
cations or treatment manuals (15, 21, 26- about 1 year after the intervention.
28, 33, 35). Three studies referred to the After giving this overall and encourag-
use of aids, such as video and audiotapes, ing representation of the effectiveness of
notebooks, reading material, and home- psychological interventions, we will now
work assignments (6, 34, 35). In eight stud- turn to a more critical analysis of the
ies, there were no references that would effects, which were specifically tested
aid future investigators to replicate the (See Table 8A, Psychological effects, and
study (6, 16, 18, 19, 22-24, 34). Clinical 8B, Somatic and other). The studies are
case material was presented in two stud- grouped by type of intervention: tailored
ies (23, 26). counseling, structured counseling, and
In behavioral or hypnosis studies stand- behavioral/hypnosis. Only those vari-
ardized treatments, such as systematic de- ables that were used in more than one
sensitisation (12), relaxation with guided study are discussed. Outcome measures
imagery (13, 32) and hypnosis (14, 20) which were used only incidentally (in-
were described in a way that enables rep- cluding attitudes towards the hospital
lication without much difficulty. Kuttner staff, expression of emotions, denial, abil-
(14) and Zeltzer and LeBaron (17) also ity to cope, loneliness, life-events, evalu-
present case material. Some studies re- ation of care, partner relationships, and
ferred to relevant technical specifications psychiatric referrals) are not presented
in other publications or treatment man- here. Measurement instruments are rep-
resented in Table 4A (Psychological vari-
uals (14, 17, 20). ables) and 4B (Somatic and other). No
distinction is made as to whether instru-
ments are self- or observer-rated.
6. Qualifications of Therapists The effects described refer to compari-
sons between one or more intervention
In 13 cases the professional status of the groups and one or more control groups.
therapists was stated (see Table 7). This Positive effects are defined as those which
occurs .in eight out of 12 tailored counsel- were evaluated as positive changes in the
ing studies, in two out of four structured intervention (psychological treatment)
counseling studies, and in three out of six groups, and which significantly exceeded
behavioral/hypnosis studies. the same changes in the control groups.

Psychosomatic Medicine 54:489-517 (1992) 503

 R. W. TRIJSBURG et al.

TABLE 8A. Outcome (Psychological Variables)

Ang/Hos . Self
Reference E/FUa Anxb Deprc Distr"e , HLC8
Confd cone
A: Tailored counseling
Bos-Branolte (6) FU (9 m) 0 0 - + +/0 -
Capone et al. (27) FU(3, 6, 12 m) 0 0 0 0 + (3 m) -
Farash (19) E - 0 - - + -
Forester et al. (23) E - - - + -
FU (4 w) +
Goldberg and Wool (33) E 0 0 0 - - -
Golonka(16) E 0 - - - - -
Gordon etal. (150 E 0 0 0 0 0
+ (3m) + (3m)
Houts et al. (34) E 0 0 0 0 -
Linn et al. (22) E - 0 - + + +
+ (3m)
Maguire et al. (28)'' FU(18m) + + - + - -
Spiegel et al. (26)' E + 0 - + 0 0
Worden and Weisman (21) FU (2, 4, 6 m) ? ? + + - -
B: Structured counseling
Cain etal. (18y E +/0 0/0 - 0/0 -
FU (6 m) +/+ +/+ +/+
Christensen (35) E 0 + - + 0 0
Ferlic et al. (24) E - - - - + -
Heinrich and Schag (25) FU (2 m) 0 0 - 0 -
C: Behavioral interventions or hypnosis
Burish and Lyles (32) FU + + + - - -
Kuttner (14)fc E +/0 - - + - -
Lyles etal. (13) FU +/0/0 0 - - - -
Morrow and Morrell (12) FU 0 - - - - 0
Spiegel and Bloom (20) E - - - - - -
Zeltzerand LeBaron (17)k E + - - - -
+: significant effect in the expected direction.
0: no significant effect.
: this variable not measured.
" E, measurement at the end of psychological intervention; FU, at follow-up (m, months; w, weeks).
6
Anxiety.
c
Depression.
d
Anger/hostility, confusion.
" Distress.
'Self-concept.
B
Health locus of control.
h
Psychiatric morbidity interpreted as distress.
1
Slopes analysis.
' Individual/group intervention.
k
Measurement(s) during medical procedures.

504 Psychosomatic Medicine 54:489-517 (1992)

PSYCHOLOGICAL TREATMENT OF CANCER PATIENTS

TABLE 8B. Outcome (Somatic and Other Variables)

Reference E/FU FA N/V PA ST AC FS LA WK LW P/B SR
A: Tailored counseling
Bos-8ranolte (6) FU _ _ _ _ _ _ _ _ _ _ +/Q
Caponeetal. (27) FU _ _ _ _ _ _ _ n _ _ +
Farash(19) E _ _ _ _ _ _ _ _ _ _ _
Forester et al. (23) E + + _ _ _ _ _ _ + _ _
FU 0 0 0
Goldberg and Wool (33) E 0 - - - - 0 0 - - - -
Golonka(16) E _ _ _ _ _ _ _ _ _ _ _
Gordon etal. (15) E - - - - + - 0 0 - - -
Houts et al. (34) E n - - - - - - - - - -
Linnetal. (22) E _ _ _ 0 - 0 - - - - -
Maguire et al. (28) FU _ _ _ _ _ _ _ _ _ _ +
Spiegel et al. (26)J E + _ _ _ _ _ _ _ _ _ _
Spiegel et al. (36) +
Worden and Weisman (21) FU 2,4, 6 m + - _ _ _ _ _ _ _ _ _
B: Structured counseling
Cain etal. (18)" E - - - - - - 0/0 0/0 - - 0/0
FU +/+ +/+ +/+
Christensen (35) E _ _ _ _ _ _ _ _ _ _ +
Ferhc et al. (24) E _ _ _ _ _ _ _ _ _ _ _
Heinrich and Schag (25) FU _ _ _ _ n - 0 - - - -
C1 Behavioral interventions or hypnosis
Burish and Lyles (32) FU _ + _ _ _ _ _ _ _ +PR
Kuttner(14) c E - - +/0 - - - - - - - -
Lyles etal. (13) FU - +/0 - - - - - - - +BP -
+PR
Morrow and Morrell (12) E _ + _ _ _ _ _ _ _ _ _
Spiegel and Bloom (20)'1 E _ _ + _ _ _ _ _ _ _ _
Zeltzer and LeBaron (17)c E _ _ + _ _ _ _ _ _ _ _
+: Significant effect in the expected direction.
0: No significant effect.
: This variable not measured.
E/FU: End of treatment/Follow-up (for specifications see Table 8A).
FA: Fatigue.
N/V: Nausea and vomiting.
PA: Pain.
ST: Survival time.
AC: Activities.
FS: Functional status.
LA- Leisure activities.
WK: Work.
LW: Loss of weight.
P/B- Pulse rate (PR)/blood pressure (BP = systolic).
SR: Sexual relationship.
a
Slopes analysis.
6
Individual/group intervention.
c
Measurement(s) during medical procedures.

Psychosomatic Medicine 54:489-517 (1992) 505

 R. W. TRIJSBURG et al.

Effects are specified according to the time out of three studies for each), anxiety (one
of measurement as end-of-treatment (E), out of three studies) and self-concept (one
or as follow-up after treatment (F), where out of two studies). In Cain et al.'s study
the latter included those where no end- (18) both types of counseling used (indi-
of-treatment measurement had been vidual and group) were effective at fol-
made. low-up after 6 months. All in all, struc-
tured types of intervention yielded posi-
tive results in 50% of the variables
measured.
Psychological Effects Behavioral interventions and hypnosis
Positive results were found with respect were effective with respect to anxiety
to all variables measured (see Table 8A- (four out of five studies), depression (one
C). out of two), anger, hostility, or confusion
Tailored counseling interventions were (one study) and distress (one study). In
effective with respect to distress (six out one study (12) health locus of control was
of nine studies), to self-concept (four out measured, but no effect found. In Kutt-
of five studies), and to (health) locus of ner's study (14) observer-rated anxiety
control (two positive out of three studies). yielded significant effects, but patient-
These interventions were the least effec- rated anxiety did not. Although hypnosis
tive with respect to anxiety (two out of was more effective, there were also some
eight studies yield positive results), positive results using a distraction tech-
depression (two positive out of nine stud- nique. In Lyles' study (13) one out of three
ies), anger, hostility or confusion (two pos- anxiety measures yielded significant re-
itive out of five studies). Results with re- sults. In Zeltzer and LeBaron's study (17)
spect to anxiety and depression could not hypnosis was more effective with respect
be interpreted for the Worden and Weis- to bone marrow aspiration than to lumbar
man (21) study. Two studies yield some- punctures. In summary, positive effects
what ambiguous results (15, 22). Both were found with respect to seven out of
were significantly effective in some re- 10 variables measured.
spects during the period of intervention,
but not at the end of the intervention
period. The intervention in Bos-Branolte's
study (6) was effective in patients having Somatic and Other Effects
moderate problems, but less so in patients Many symptoms related to somatic
with severe problems. One positive effect treatment were studied, e.g., fatigue, nau-
found at follow-up (3 months) in Capone's sea and vomiting, loss of hair, tremor,
study (27) was not substantiated at follow- problems with hearing (deafness), dry
up after 6 and 12 months. In summary, mouth, loss of taste, coughing, diarrhea,
46% of the variables measured showed itching, pain, weight loss, inflammations,
positive results, whereas 54% were and irritations. The somatic effects of the
negative. psychological treatment most frequently
In structured counseling interventions measured were fatigue, (anticipatory)
positive results were found in three stud- nausea and vomiting, and pain. Fatigue
ies. Positive effects were shown with re- (or malaise) and notably nausea and vom-
spect to depression and distress (in two iting are well-known reactions to cyto-

506 Psychosomatic Medicine 54:489-517 (1992)

PSYCHOLOGICAL TREATMENT OF CANCER PATIENTS

toxic chemotherapy. Apart from assessing months) than patients in the control
the level of adaptation to the (changed) group.
situation, other variables are also indica- Survival was measured in two studies
tive of somatic functioning, e.g., func- (22, 36). Linn et al. (22) did not find any
tional status, activity level, leisure time differences between the intervention and
activities, work, and sexual relationship. control groups. Spiegel et al. (36) showed
Work resumption, often irrelevant to the a substantial difference in the survival
patient group under study, was rarely ex- time in favor of the intervention group.
amined. Apart from this, two studies (This study is a correlation of the 1981
measuring survival time (22, 36) are in- study by the same group, see reference
cluded in this review. (Two further stud- 26.)
ies measuring survival time (37, 38) were Structured counseling studies were
not included in this review. The study by concerned with activity level (25), leisure
Morgenstern et al. (37) was not included activities (18, 25), work (18), and sexual
since the control group was not ade- relations (18, 35). Of the six variables
quately selected, and the study by Rich- measured, four yielded positive effects.
ardson et al. (38) used an educational Cain et al. (18) showed positive effects
program.) concerning leisure activities, work and
Tailored Counseling.. Ten out of 19 sexual relations, both for individual and
variables measured (53%) yielded positive for group counseling, at follow-up. The
effects. These effects concerned fatigue study by Christensen (35) yielded positive
(21, 23, 26), nausea and vomiting (23), effects with respect to sexual relations.
weight loss (23), activity level (15), sexual The findings of Heinrich and Schag (25)
relations (6, 27, 28), and survival (36). were not significant, but differences were
Functional status (22, 33) work (15, 27), in the direction predicted.
and leisure activities (15, 33), yielded no As behavioral interventions aim at re-
significant effects compared with a con- lieving (anticipatory) nausea and vomit-
trol group in all studies concerned. ing, it is evident that they measure so-
In Forester's study (23) the positive matic variables concerning these symp-
findings concerning fatigue, nausea and toms. In the same vein the variables
vomiting, and work were not substanti- measured in studies using hypnosis are
ated at follow-up (4 weeks). They also concerned with anxiety and pain, since
showed positive effects on weight loss in hypnosis is used during medical proce-
patients receiving radiotherapy, which dures which are particularly frightening
did not persist at follow-up. Concerning and/or painful. It can be concluded that
sexual or intimate relationships, Bos- all variables measured yield positive
Branolte's study (6) was effective with results.
patients having moderate problems, but Morrow and Morell (12) showed a re-
not with patients having severe problems. duction in the seriousness and duration
In Capone et al.'s study the effects on the of anticipatory nausea as well as a reduc-
sexual relationship were positive at all tion in the seriousness of anticipatory
follow-up measurements (3, 6 and 12 vomiting in patients receiving systematic
months). In Maguire et al.'s study (28) desensitisation. Burish and Lyles (32) and
fewer patients in the intervention group Lyles et al. (13) showed a positive effect
had sexual problems at follow-up (18 on nausea during and after chemother-

Psychosomatic Medicine 54:489-517 (1992) 507


apy, due to muscle relaxation combined
with guided imagery. In Lyles et al.'s
study [13) the effects at follow-up were
positive for home-recorded severity of
nausea, approaching significance for pa-
tient-recorded nausea during chemother-
apy, and negative for nurse-rated nausea
during chemotherapy.
In relation to nausea and vomiting,
Burish and Lyles (32) and Lyles et al. (13)
found a positive effect on systolic blood
pressure (13) and on pulse rate (13, 32)
immediately after chemotherapy. In the
study by Burish and Lyles (32), the effects
were again found at follow-up (14 days).
Spiegel and Bloom (20) found that hyp-
nosis had a beneficial effect on pain sen-
sation. No differences in the duration and
frequency of pain were found between
the intervention and control groups. In
the study by Zeltzer and LeBaron (17)
hypnosis was particularly effective in the
group undergoing lumbar punctures. In
the group receiving bone marrow aspira-
tions, hypnosis and distraction were
equally effective. In the study by Kuttner
(14), hypnosis was more effective in re-
ducing pain in patients undergoing bone
marrow aspiration than distraction or no
special intervention at all (pain judged by
independent observers). Differences were
not found when the patients rated the
pain themselves.
It is concluded that tailored counseling
has been shown to be most effective with
respect to distress, self-concept, (health)
locus of control, fatigue, and sexual prob-
lems. Studies applying structured coun-
seling have shown positive effects mainly
with respect to depression and distress.
When behavioral interventions or hyp-
nosis were applied, positive effects were
found with respect to specific symptoms
such as anxiety, pain, nausea and
vomiting.
508
R. W. TRIJSBURG et al.
DISCUSSION
In the preceding sections, 22 studies
were described with respect to research
methods, psychological interventions,
and results. The discussion is divided up
in the same way. The last section contains
several recommendations.
Research Methods
Comparability of Groups. All the stud-
ies reviewed compared one or more ex-
perimental groups receiving psychologi-
cal intervention with one or more control
groups. It was stressed that groups should
be comparable in particular aspects. Com-
parability, however, may have been influ-
enced by several factors, thus leading to
difficulties in interpretating the effects of
intervention. First, comparability may
have been influenced by the design of the
study.
1. Patients in control groups who are
not given psychological help may come to
the conclusion that taking part in the
study is not beneficial in the light of their
own psychosocial problems. This could
lead to a higher drop-out rate in the con-
trol groups. Any effects found in the ex-
perimental group may then be significant
due to distorted control groups. In fact,
the studies which did report drop-out
rates, showed no tendency for control
groups to have higher percentages of
drop-out. Thus, there is no justification
for the suggestion that control groups
might have been biased.
2. All studies assume that the experi-
mental groups would experience positive
effects due to the specific psychological
intervention. However, only studies that
apply behavioral interventions or hypno-
sis (12-14, 17) controlled for nonspecific
Psychosomatic Medicine 54:489-517 (1992)
PSYCHOLOGICAL TREATMENT OF CANCER PATIENTS
effects which, among others, could have
resulted from extra attention being given
to the experimental groups. In other cases
positive results could be explained as ef-
fects of attention, rather than the specific
psychological intervention. Further study
is needed to find out whether nonspecific
factors account for the effects in studies
applying counseling and supportive
therapies.
Second, medical factors, e.g., type of
cancer, stage of the disease, the intensity
and duration of medical treatment and
practical conditions of treatment, may in-
fluence the effects of psychological inter-
ventions by contributing to the amount of
distress during and after medical treat-
ment (39-43). Also the interaction be-
tween medical variables and psychosocial
variables is still unclear (44). It is, there-
fore, necessary to control for the compa-
rability of groups with respect to medical
variables. Many studies did in fact either
control for these effects, or selected ho-
mogeneous groups. However, in the cur-
rent review, only two studies used medi-
cal variables as independent variables in
their design (13, 15). In addition, many
studies gave no information on medical
variables, thus making interpretation of
the results problematic.
Third, although intervention and con-
trol groups were comparable in many
studies with respect to sociodemographic
variables, other relevant psychosocial
variables, such as the type of social sup-
port and premorbid personality character-
istics, were not controlled for.
The factor social support is of special
interest in this respect. The possibility
exists that control group patients (suffer-
ing from psychosocial problems and not
receiving psychological treatment in the
study) seek support from other care-pro-
viders, e.g., clergy, herb doctors, or self-
Psychosomatic Medicine 54:489-517 (1992)
help groups. It is also possible that these
patients receive extra help from their own
social environment. This could lead to a
decrease in the problems in the control
group. Although this does not reduce the
value of any conclusions from controlled
studies (in fact it would make it more
difficult to show any intervention effect),
it would be of interest to study (levels of)
social support as an independent variable
in intervention studies, or to control for
any effects engendered by this variable.
This is of special importance since social
support has a documented effect on the
quality of life in cancer patients (45-47).
The current situation is that social sup-
port was not introduced into any study as
an independent variable, nor was this
variable controlled for.
With respect to personality character-
istics, variables known to have an influ-
ence on adaptation, such as ego strength
(48), the habitual style of coping with and
defending against stress (49-54), neuroti-
cism (55), and trait anxiety (56), were not
studied as independent variables, nor
were the effects of these characteristics
controlled for. Differences regarding these
aspects both between the patient groups
and within a group may, however, ac-
count for the differences in results (44,
55). Only Forester et al. (23) introduced
an independent psychological variable
into the design, namely knowledge of the
diagnosis. This variable contributed to the
amount of distress experienced by the
patient, thus emphasizing the importance
of this type of variable.
Instrumentation. In the majority of
studies, at least one validated instrument
was used for measuring effects. However,
it is difficult to compare the results be-
tween one study and another, due to the
heterogeneity of the variables measured
and due to the lack of information on the
509

relationships between the instruments.
The comparability of the results could
have been enhanced if standardized in-
struments had been applied in a more
uniform way. In addition, statistical pa-
rameters should be more accessible, thus
enabling meta-analysis of effects, e.g.,
using methods for comparing standard-
ized effect size, such as Cohen's d. At
present meta-analysis can be carried out
with 12 out of the 22 studies. This is
currently being prepared by the authors.
Selection of Patients. The studies dif-
fered strongly with respect to variables
used for patient selection.
1. The type of cancer differed not only
from one study to another, but also within
the studies. Differences between the type
of cancer yielded prognostic differences,
which roughly correlated with the differ-
ences between the type and seriousness
of the psychological problems.
2. Medical treatments differed with re-
gard to the amount and seriousness of the
side-effects. Some more than others inter-
fered significantly with adaptation.
3. The time interval since medical treat-
ment differed from one study to another,
thus making the results difficult to com-
pare. For one given type of cancer, e.g,
gynaecological, the patients in one study
may be initially more distressed than
those in another and may benefit more,
or less, from the intervention than those
in any other study, depending on the time
of intervention.
Interventions
The setting (individual, group, partner
relationship]. The present level of knowl-
edge is insufficient for definite conclu-
sions to be drawn with respect to the
setting. Three studies compared psycho-
510
R. W. TRIJSBURG et al.
logical treatment in groups with individ-
ual counseling (6, 18, 19). Of these, two
showed no differences in effect (18, 19).
The study by Bos-Branolte (6) showed that
patients receiving individual treatment
generally responded more positively in
some respects. However, treatment con-
ditions in this study were not comparable
due to selection bias and a different num-
ber of sessions. In view of this, the ques-
tion of whether or not group therapy is
more effective than individual therapy
cannot be answered as yet (11, 26). This
applies equally to any comparison be-
tween the treatment of individuals and
that of (married) couples.
Format of the Intervention. Some stud-
ies presented a time-limited, structured
treatment program, whereas others were
more tailored to the patients' needs. The
studies reported did not allow definite
conclusions to be drawn concerning the
relative effects of structured versus tai-
lored psychological treatments, since no
intercomparison of treatment types was
made during any of the studies.
Furthermore, the frequency and dura-
tion of psychological interventions were
also rather variable across the studies. A
premature suggestion was drawn in three
studies (18, 23, 25) concerning the advan-
tages of time-limited, structured psycho-
therapy on the basis of cost-efficiency
considerations. There were no studies
which compared the effects of time-lim-
ited treatment to prolonged (spaced-out)
treatment. On the contrary, with the ex-
ception of two (6-individual-, 26), many
studies stayed below 12 sessions. After 1
year of group sessions, Spiegel and Bloom
(20) and Spiegel et al. (26, 36) produced
some excellent results. The patients in
this study were allowed to stay on in their
group for as long as they wished, which
may account for the unique findings con-
Psychosomatic Medicine 54:489-517 (1992)
PSYCHOLOGICAL TREATMENT OF CANCER PATIENTS
cerning survival (36). It may be that, as
Watson stated in 1983 (11), "some psycho-
logical responses to the stress of cancer
can only be changed through protracted
therapeutic intervention." (p. 842). A pref-
erence for structured and time-limited
forms of psychological treatment can only
be justified if it would be shown that
prolonged (spaced-out) treatment is less
or equally effective.
Moreover, the studies reviewed did not
show that psychological treatment was
cost-effective. Our present knowledge on
the structure of interventions precludes
straightforward conclusions over what
should be done, or, for that matter, should
not be done in order to alleviate distress
(11). It is significant in this respect that no
study reported on the adverse effects of
psychological treatment.
Techniques and Goals. Comparisons be-
tween studies with respect to psychologi-
cal techniques are hindered by the sub-
stantial differences across studies regard-
ing the combination of specific treatment
goals and specific treatment techniques
(11). Apart from this, counseling treat-
ments tended to take the form of a "pack-
age deal," which leads to difficulties in
specifying the essential elements account-
ing for the success in achieving specific
treatment objectives.
The studies were generally in agree-
ment with each other as to the relevance
of specific therapeutic techniques in spe-
cific situations, e.g., behavioural inter-
ventions in the case of nausea and vom-
iting; counseling and support in dying pa-
tients. However, the amount and clarity
of information concerning treatment
techniques differed greatly from one
study to the next.
There was no controversy over the gen-
eral treatment goal for different patient
groups. For example, ego-strengthening
Psychosomatic Medicine 54:489-517 (1992)
was the main treatment goal with newly
diagnosed patients and with patients in
remission, whereas support and emo-
tional adaptation were the main issues in
terminal cancer cases.
Qualifications of Therapists. Some au-
thors imply that psychological treatment
could be applied by different types of
professionals, irrespective of supplemen-
tary training or supervision. However,
there were no studies that support such a
view. In the study by Houts et al. (34), the
results of counseling by former cancer
patients did not exceed those of the con-
trol condition. However, the authors re-
ported that psychological support, which
was routinely given to patients in the con-
trol condition, was excellent in its own
right. Furthermore, both therapists in the
experimental group were social workers
by profession. Because of the possible
cost-effectiveness, it would be of interest
in future research to compare the relative
effects of psychosocial interventions from
different types of professionals.
Results
In 19 out of 22 studies at least some
positive effects of psychological interven-
tions were found. For the three studies
(16, 33, 34) that did not find differences
between intervention and control-groups,
the reasons may be self-explanatory in
two cases due to the treatment conditions.
The study by Goldberg and Wool (33) was
directed at the spouses of patients with
lung carcinoma. The effects thus had to
be gained indirectly which could have
been too complex an approach. The study
by Houts et al. (34) added a minimum of
individual counseling (three telephone
calls) to an already extensive supportive
program given to intervention and control
511

group patients. This could have given rise
to a minimal residual gain. The report by
Golonka (16) (which is a summary) did
not give any indications as to why the
results were negative.
Five studies (6, 19, 21, 27, 28) have
methodological shortcomings, so that cau-
tion needs to be exercised when inter-
preting the effects. Treatment conditions
were not comparable in Bos-Branolte's (6)
study. In Worden and Weisman's (21)
study, the control group differed in cer-
tain respects from the treatment groups.
In the Farash (19), Capone et al. (27), and
Maguire et al. studies (28), there were no
pretreatment measurements of dependent
variables, so that the effects could not be
adjusted for scores at pretest. Since the
study by Maguire et al. (28) was con-
cerned with psychiatric morbidity in the
long run (at 12 to 18 months after mastec-
tomy), the self-reported anxiety and
depression at 12 to 18 months could be
relatively unimportant compared with
the recognition of psychiatric problems.
The psychological treatment of cancer
patients has been shown to be beneficial
in at least some respects. With the excep-
tion of studies using survival analysis,
positive effects were found up to 1 year
after the psychological intervention.
When studied in detail, the results are
somewhat less conclusive. The overall
picture is that positive psychological ef-
fects were achieved for 31 out of 61 vari-
ables (51%). With respect to somatic and
other variables, positive effects were
found for 22 out of 33 variables (67%).
A tailored counseling approach has
been shown to be particularly effective
for distress, self-concept, (health) locus of
control, fatigue, and sexual problems.
Open-ended counseling could be effective
for (future) psychiatric problems (28) and
problems associated with death and dying
512
R. W. TRIJSBURG et al.
(20, 26, 36). Structured counseling yielded
the best results with respect to depression
and distress. Specific symptoms such as
anxiety, pain, nausea and vomiting were
shown to benefit from interventions
aimed directly at relieving them, e.g., be-
havioral therapy or specific instructions.
After excluding the studies by Caine et
al. (18), Maguire et al. (28), and Spiegel et
al. (26), the four remaining studies (13, 14,
17, 32) used specific anxiety-reducing
techniques to relieve anxiety.
In three studies positive effects were
found for fatigue. As these studies did not
select patients who particularly com-
plained of fatigue, further study on se-
lected patients is needed to demonstrate
the positive effects of behavioral interven-
tions. It would also be pertinent to study
the role of depression in the genesis and
continuation of fatigue and malaise, thus
contributing to the differential diagnosis
and selection of therapy in these
conditions.
Positive effects were found in all four
studies which aimed at the reduction of
nausea and vomiting. Behavioral thera-
peutic interventions to reduce anticipa-
tory nausea and vomiting are acceptable
intervention strategies (57). Another pos-
itive finding was that hypnosis, or a story-
telling technique (guided imagery), gave
rise to a reduction in pain resulting from
medical intervention. The value of behav-
ioral therapeutic techniques, such as de-
sensitization, in this respect, has not been
studied yet.
The role of variables that mediate pain
perception, such as emotional support and
depression, is still unclear. Spiegel and
Bloom (20) showed that changes in pain
sensation and suffering correlated with
changes in mood disturbance. Apart from
the interwoven and reinforcing character
of changes in mood disturbance and pain,
Psychosomatic Medicine 54:489-517 (1992)
PSYCHOLOGICAL TREATMENT OF CANCER PATIENTS
and the direct alteration of the patients'
perception of pain due to hypnosis, they
postulate that pain may serve to signal
emotional problems. When these prob-
lems are discussed, pain could diminish
or disappear. Further study of the effects
of variables that mediate pain perception
would clarify this issue.
Several variables yield inconsistent
findings. Anxiety, depression, distress,
sexual problems, and somatic symptoms,
e.g., fatigue, nausea and vomiting, and
pain would be the most promising vari-
ables for future research.
CONCLUSIONS AND
RECOMMENDATIONS
1. There were rather great differences
between studies with respect to design
(experimental conditions, and group com-
parability in the area of sociodemo-
graphic, medical and psychological vari-
ables), instruments, patient selection, psy-
chological interventions (the setting,
structure, goals, treatment techniques),
and outcome variables. Due to these dif-
ferences, it is difficult to draw general
conclusions regarding the effects of psy-
chological interventions in cancer pa-
tients. It is therefore recommended that
future studies use more precise designs
and more restrictive criteria in the selec-
tion of patients, treatment targets, psycho-
logical interventions and outcome
measures.
2. Studies that introduce behavioral
therapy or hypnosis tend to introduce at-
tention and support as independent vari-
ables. In order to demonstrate the effec-
tiveness of a specific technique, this is a
necessary procedure. Depending on the
sort of intervention it may often be vir-
Psychosomatic Medicine 54:489-517 (1992)
tually impossible (if not unethical) to use
(levels of) attention and social support as
independent variables. It is therefore rec-
ommended that these variables are con-
trolled for in future studies in order to
gain more understanding of the specific
role of the various interventions.
3. Some studies aim at strengthening
social support within the treatment group,
thus leading to changes in attitude to-
wards medical treatment and the medical
profession (36, 58). This change may have
led to a more effective adaptation to the
illness and this may have contributed to
prolonging survival. It is therefore rec-
ommended that the effects are studied of
(group and individual) counseling aimed
particularly at strengthening the social
support system and assertiveness during
contact with the medical profession. This
could be compared with the effects of
counseling aimed, for instance, at reduc-
ing the emotional distress caused by the
illness itself. Naturally, the use of medical
services should be measured in order to
find out whether qualitative and quanti-
tative changes take place.
4. Most studies controlled for sociode-
mographic and medical variables. How-
ever, psychological variables (e.g., trait
anxiety, neuroticism, level of premorbid
functioning) were not taken into account.
As the effects of psychological interven-
tions may be influenced by the level of
functioning before the onset of the disease
(coping and defending), it is recom-
mended that psychological variables are
controlled for in future studies.
5. With the exception of the studies by
Spiegel and Bloom (20) and Spiegel et al.
(26, 36), Linn et al. (22, Maguire et al. (28),
and Capone et al. (27), all other counseling
studies either did not study the effects at
follow-up, or the follow-up period stayed
significantly less than 1 year. In addition,
513
 R. W. TRIJSBURG et al.

many studies appear to have consciously comparisons between self-help groups

kept the number of sessions to a mini- and psychological interventions.
mum. Although the development of cost-
effective and less time-consuming inter-
ventions may appear attractive in a num-
ber of respects, intensive and long-term SUMMARY
counseling yields significant changes in
several essential functional areas (20, 26, Twenty-two studies on the effects of
36). Therefore, it would be appropriate to psychological treatment on cancer pa-
study the differential effects of (spaced- tients were reviewed. The studies were
out) long-term counseling and short-term evaluated with respect to a) research
interventions. Longer follow-up periods, methods, b) psychological interventions,
extending over several years, could yield and c) results. Research methods are de-
important findings concerning adaptation scribed in terms of design, instrumenta-
and survival. tion and patient selection. Psychological
6. Depending on the sort of cancer, the interventions were evaluated with re-
stage, medical treatments, the time at spect to the setting, goals, techniques and
which emotional problems were assessed qualifications of the therapists. The out-
and the criteria used, the percentage of come is separately described in terms of
patients who develop serious emotional psychological and physical effects. Psy-
problems ranges from 25% to 70% of the chological interventions have been shown
sample being studied (28, 39, 41, 43, 47, to be effective in at least some aspects.
55, 59-69). Control group designs consist- When studied in detail, the effects are
ing of patients selected at random yield somewhat less conclusive. Tailored coun-
results that do not differentiate between seling was effective with respect to dis-
patients who are most in need of help and tress, self-concept, (health) locus of con-
patients who could have done well with- trol, fatigue and sexual problems. Struc-
out it (11). Therefore, it would be inter- tured counseling showed positive results
esting to develop instruments to identify with respect to depression and distress.
patients at risk and to study the effects of Behavioral interventions and hypnosis
psychological treatment on these partic- were effective with respect to anxiety,
ular patients (11, 70). pain, nausea and vomiting. The studies
7. Since studies on the effects of edu- did not control for nonspecific attention
cational programs or of information per se (except for some behavioral and hypnosis
were not sighted in this review, we did studies), nor for personality characteris-
not compare their effectiveness with that tics or social support. The variables meas-
of psychological interventions. Naturally, ured and patient selection were rather
such intervention programs, for instance variable across the studies. The replica-
one aiming directly at improving compli- tion of studies could be difficult at times
ance to the medical treatment (38), could due to vague descriptions of the psycho-
result in improvements comparable to or logical intervention. Several recommen-
excelling those engendered by psycholog- dations for future research are made.
ical interventions. It is therefore recom-
mended that the effects of such programs
are compared with those of psychological This project was supported by a grant
interventions. This applies equally to from the Dutch Cancer Society {1KR 88-04).

514 Psychosomatic Medicine 54:489-517 (1992)

PSYCHOLOGICAL TREATMENT OF CANCER PATIENTS

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