PSYCHO-ONCOLOGY

Psycho-Oncology 9: 367–371 (2000)

EDITORIAL

ADJUVANT PSYCHOLOGICAL THERAPY FORCANCER PATIENTS: PUTTING IT ON THE

SAME FOOTING AS ADJUNCTIVE MEDICALTHERAPIES

ALISTAIR J. CUNNINGHAM*Ontario Cancer Institute/Princess Margaret Hospital, Department of Epidemiology,

Statistics and Beha6ioral Science, Toronto, Ontario, Canada

SUMMARY

A comparison is made between the models guiding the administration of adjuvant material remedies, such aschemotherapy, and ‘adjunctive psychological therapy’ (APT), in the treatment of cancer. It is argued that patientswould benefit if APT were supplied subject to the same indications as adjuvant chemotherapy. Copyright © 2000John Wiley & Sons, Ltd.

INTRODUCTION

Imagine reading the following announcement:‘A medical oncology clinic run on rather no6el

lines has recently been established in a large NorthAmerican Health Centre. After due consultationwith experts, particularly in the mental health field,it has been decided to administer chemotherapyaccording to the principles that ha6e been used withsuch success in pro6iding psychological help forcancer patients in many settings.

The first of these principles is that physicians willnot, in general, recommend chemotherapy to theirpatients, in spite of the e6idence that it can alle6iatesymptoms, and e6en prolong life on occasion. It isconsidered that patients should be allowed to iden-tify their own needs, and that those who wantchemotherapy will ask for it. People will learnabout it from friends, or through the media, or fromchance references to it by health professionals.Thus, only a small minority of patients will actually

recei6e chemotherapy (with consequent sa6ings incosts to the hospital).

When chemotherapy is gi6en, staff members willconcoct a personal blend of agents that will bedetermined by their own experiences and personalpreferences; no need is seen to base the treatmenton any re6iew of current e6idence. After all,chemotherapy is just chemicals, and almost anyonecan decide what a patient needs. Thus, its composi-tion may differ from what is offered elsewhere, ande6en from time to time in the new clinic. The lengthof any course of chemotherapy used, and thedosages gi6en, will likewise be determined as amatter of con6enience to the staff; weekly adminis-tration is usually most con6enient, and gi6ing treat-ments for longer than about 6 weeks can put unduestrain on resources. No specific space or time willbe set aside for these treatments. which, it is con-sidered, can be adequately gi6en in 6arious rooms attimes that do not conflict with other business.

The staff engaged in this work will be expectedto 6olunteer for it, or at least to schedule it aroundmore important acti6ities. Special training is notseen as necessary. In general, relati6ely low-paidemployees, of 6arying backgrounds, can deli6er thiskind of treatment, as the chemistry in6ol6ed israther simple, and the procedures essentiallymechanical.

* Correspondence to: Ontario Cancer Institute/Princess Mar-garet Hospital, Department of Epidemiology, Statistics andBehavioral Science, 610 Universal Avenue, Toronto, Ontario,Canada M5G 2M9. Tel.:+1 416 946 2943; fax: +1 416 9462024; e-mail: cunningh@oci.utoronto.ca

Copyright © 2000 John Wiley & Sons, Ltd. Recei6ed 20 May 1998Accepted 28 April 1999

A.J. CUNNINGHAM368

There will, of course, be no need to e6aluate anyeffects of the chemotherapy; in general, it is feltthat adequate e6aluations of treatment efficacy canbe deri6ed from the subjecti6e impressions of thera-pists and from what the patients tell them from timeto time.

Finally, as all who ha6e had responsibility forrunning medical facilities will know, a great deal ofthe cost in6ol6ed comes from the tedious business offollowing patients long after their initial treatmentsha6e been completed. In the new clinic, this practicewill be dispensed with. In fact, the administratorsare looking closely at the possibility of eliminatingchemotherapy treatments altogether, along withdismissing the few employees who ha6e offeredthem in the past: it does not appear that there willbe any serious repercussions from following thiscourse of action ’.

Such a set of guidelines for a medical procedureis simply bizarre, yet in many settings, very simi-lar standards currently guide the provision of apotentially important and experimentally-validated type of treatment for cancer patients:professionally-led groups or individual coun-selling, offering support and usually some trainingin such basic coping skills as relaxation trainingand thought management. By analogy with adju-vant medical treatments (chemotherapy and radi-ation), and following Greer et al. (1991), we mightcall this kind of help ‘adjuvant’ or ‘adjunctivepsychological therapy’ (APT). The purpose of thisbrief paper is to ask what can we learn fromstandard medical practice that might act as aguide to more comprehensive and rational appli-cation of such psychosocial treatments.

The first comparison to draw is between theprinciples or models that inform medicine andcurrent APT. It is common to give adjunctivepsychological care only or mainly to those fewpatients who request it, the result being that onlya tiny minority receive it in many settings. Forexample, in our own large cancer hospital, wherea programme of psycho-educational care has beenconducted continuously since 1982, and shown toimprove quality of life reliably, approximately 2%of the patients attend. The satirical scenario aboveemphasizes how unreasonable it is to expect pa-tients to direct their own course of a treatmentwhose benefits and rationale most do not under-stand. Professional advocacy is required: APTneeds to be an integral part of medical manage-ment before it will be sought and accepted bymost patients. Self-help groups, while often valu-

able, cannot take the place of skilled professionalpsycho-education. Individual consultations withpsychiatrists and other mental health profession-als will always be necessary for some patients.However, to continue the analogy withchemotherapy, being guided only by overt psy-chopathology is like restricting treatment to thosewith massive disease, and ignoring the evidencethat adjuvant treatment post-surgery, or in peoplewith less disseminated cancer, can often be ex-tremely helpful. As recent meta-analyses haveshown (Van’t Spijker et al., 1997), apart frombeing more depressed on average, cancer patientsdo not have significantly more psychological andpsychiatric problems than the non-cancer popula-tion. Most cancer patients are psychologicallynormal people subjected to extreme stress, and arereacting with anxiety and depression that canoften be alleviated by standard techniques.

If waiting for patient requests or treating onlyobvious pathology are not adequate models, whatguiding principle should be followed? Chemother-apy is administered whenever expert assessmentindicates that it is likely to benefit the patient, andnot cause undue harm. APT could logically beprovided subject to the same indications. There ismuch less need to be concerned about harm withpsychosocial than with chemotherapeutic inter-ventions. Is there evidence of benefit? If we fol-lowed this principle in our treatment centres, whatchanges in procedure would take place, and whatfurther research would be needed to optimize thiskind of care?

E6idence that adjuncti6e psychological care isbeneficial

The results of extensive research in this areasupport clinical observation and common sense:there is general agreement (Anderson, 1992; Trijs-burg et al., 1992; Devine and Westlake, 1995;Meyer and Mark, 1995; Fawzy et al., 1996) thatbrief, professionally-led support groups, often in-cluding training in active coping strategies, canreliably improve the quality of life of most cancerpatients. Some have suggested that there is nolonger any reason to test this proposition further(Meyer and Mark, 1995). We do, however, needto know more about what interventions work bestfor whom. Our own studies (Cunningham et al.,1993) show that a basic psycho-educational pro-gramme can improve quality of life in a wide

Copyright © 2000 John Wiley & Sons, Ltd. Psycho-Oncology 9: 367–371 (2000)

ADJUVANT PSYCHOLOGICAL THERAPY FOR CANCER PATIENTS 369

variety of subjects differing in age, educationalstatus, gender, marital status, religious orienta-tion, site and stage of disease, previous experi-ence, and expectations from the treatment. Weneed to learn how to reach different ethnic groupseffectively. There are also likely to be benefits totailoring treatments for different sub-groups, forexample, for young versus older age groups, andfor those with early or late-stage disease. We alsoneed to know why, given evidence for efficacy,relatively few people avail themselves of theseservices. This research will probably require in-depth interviewing of patients, family members,and health care professionals, particularly oncolo-gists (to ascertain attitudes to referral). Possiblesources for professional resistance are ignoranceof the nature and benefits of APT, fear of divert-ing patients from medical treatment (shown to beunfounded by Eisenberg et al., 1993), guilt orimpotence (not knowing how to help psychologi-cally, or finding the prospect frightening), or adesire to handle all aspects of a patient’s careoneself. Resistance in patients may, likewise, stemfrom unawareness of the advantages to be gainedor of misconceptions about such therapy, and fearof what may be uncovered or assumed aboutthem if they talk to others about their concerns.

Nature of the adju6ant psychological care

While we now know that APT is beneficial,very little research has been done on how toprovide it optimally. A common format is closedgroups running for 6–10 weekly sessions of about1.5 h each. Working with groups is obviously lessexpensive than providing individual therapy, andthere is some evidence that it produces greaterimprovements in quality of life (Fawzy et al.,1996), but this has not been subjected to a ran-domized comparison, as far as we know. Somepatients, and some issues (e.g. sexual), may re-quire individual help; some patients will only ac-cept one-to-one counselling.

There are many other facets of APT awaitingcomparative research. Length of programmes isan example: are longer groups more effective thanshorter ones, and for whom? Two trials demon-strating prolongation of life from APT usedgroup interventions of very different lengths: a6-session behavioural programme (Fawzy et al.,1993) versus a year of weekly supportive discus-sions (Spiegel et al., 1989). This suggests that

some factors other than length, but common tosuch widely different interventions, were responsi-ble for the effects; careful analytic research will beneeded to find out what those factors may be.Another way of organizing APT that deservesmore controlled investigation is to use ‘modules’,or 6–8 week packages of progressively more ad-vanced or intensive psychological help, so that allpatients can receive a basic module, and thenmove on to more advanced kinds of group train-ing (in meditation and spirituality for example) asthey see the possibility of benefit for themselves,and at different points in their disease trajectory(Cunningham and Edmonds, 1996). Furthermore,what frequency or intensity of intervention ismost helpful? Weekly group meetings and a‘weekend intensive’ (useful in sites distant frommain centres) have been shown to yield approxi-mately the same improvements in quality of life(Cunningham et al., 1995). Bolletino and LeShan(1995) have described an even more intensiveprogramme, a week of full-time intervention. Per-haps, following the model sometimes used to treataddictions, a prolonged period of residence in aretreat centre would foster adjustment and healingmore effectively than the current norm of weeklymeetings with patients who continue to live intheir usual home environment. Such a model hasbeen explored at the ‘Commonweal’ centre inCalifornia (Lerner and Remen, 1987). Moreover,apart from format, what content of APT is opti-mal, and for whom? For psychological therapy, asfor chemotherapy, a number of possible ‘agents’ isnow known, varying in ‘aggressiveness’ (to use adescription applied to chemotherapeutic drugs),and is thus potentially applicable to differentmembers of the patient population. Different peo-ple obviously benefit more from different kinds oftreatment. One way of classifying interventions isto arrange them according to the amount of per-sonal change required from participants (Cun-ningham and Edmonds, 1996). Research onadjunctive psychological therapies for cancer pa-tients is in its infancy, and seems to be at a pointanalogous to that reached in chemotherapy re-search some 40 or 50 years ago.

E6aluation and monitoring

When chemotherapy is administered, there isroutine and careful monitoring of effects ontumours and of unwanted side-effects such as

Copyright © 2000 John Wiley & Sons, Ltd. Psycho-Oncology 9: 367–371 (2000)

A.J. CUNNINGHAM370

gastro-intestinal upsets and impairment of im-mune function. The checking is typically frequentduring active treatment, and continued into afollow-up period with gradual tapering off. Muchthe same patterns could profitably be adopted forAPT. Patients might be regularly monitored,using self-report inventories and interviews,during the treatment phase and at follow-up.

Staff training and standardization of treatment

Conducting a support group probably seemseasy to many who have not tried it. It is, after all,just ‘sitting around and talking’, very ‘low-tech’,something we all (apparently) do socially. Yethigh quality treatment of this kind, knowing whatto say and to whom, requires extensive trainingand experience, no less so than administration ofmedical remedies. Basic psychosocial interventionis often left to health care workers who are moti-vated to help patients in this way, but have littlerelevant training. Why does this not happen withchemotherapy? Presumably, because medicaltreatments are highly valued, and are seen todemand expert knowledge. There is much more ofa tradition of being guided by research findings,and of standardizing remedies. While psychologi-cal therapies are, perhaps, less amenable to stan-dardization (in that the relevant variation betweenpatients is probably much greater in the psycho-logical than the physiological domain), it could beargued that better quality APT will come fromtreating it more like a medical intervention, de-manding high standards of training for providers,and targeting tailored interventions of proven effi-cacy to specific populations.

Cost

Providing APT to most or all patients wouldraise health care costs initially, although theremight be a counteracting tendency for patients tohandle some problems themselves with suitablebehavioural training. However, new drugs, even ifthey are extremely expensive and offer only verylimited chance of additional benefits (e.g. taxol inbreast cancer), tend to be introduced as soon asthey are available. Psychosocial care is not expen-sive in comparison with many medical proce-dures: the cost of a single bone marrow transplant(approximately $150000) would cover a basicpsychological group programme for up to 1000

patients! The issue is one of priorities rather thancost, and psychosocial care is currently less valuedby western medicine than is allopathic treatment.

Bringing adjuncti6e psychological therapy intomainstream cancer management

What will it take to make APT a valued modal-ity for cancer management on a par with, say,adjuvant chemotherapy? This paper has suggestedsome changes that would help to position it as atreatment to be taken seriously. There is currentlyno lack of evidence for effects on quality of life,but this may not be sufficient to promote changesin medical practice. Further studies adding to thegrowing evidence that APT can prolong life(Spiegel et al., 1989; Richardson et al., 1990;Fawzy et al., 1993; Ratcliffe et al., 1995) mayprove more compelling. Education of both thepublic and health care professionals is needed.The question is ultimately one of treatment mod-els, however; do we value psychological, socialand spiritual functioning as much as physicalstate? If so, we need to ensure that treatments forthese dimensions of the patient are applied ac-cording to the same indications as allopathic med-ical treatments.

REFERENCES

Anderson BL. 1992. Psychological interventions forcancer patients to enhance the quality of life. JConsult Clin Psychol 60: 552–568.

Bolletino RC, LeShan L. 1995. Cancer patients andmarathon psychotherapy: a new model. Ad6: J Mind-Body Health 11: 19–35.

Cunningham AJ, Edmonds CVI. 1996. Adjuvant grouppsychological therapy for cancer patients: a point ofview, and discussion of the hierarchy of options.Internat J Psychiat Med 26: 51–82.

Cunningham AJ, Lockwood GA, Edmonds CVI. 1993.Which cancer patients benefit most from a brief,group, coping skills program? Internat J PsychiatMed 23: 383–398.

Cunningham AJ, Edmonds CVI, Jenkins G, LockwoodG. 1995. A randomised comparison of two forms ofa brief, group, psychoeducational program for cancerpatients: weekly sessions versus a ‘weekend intensive’.Internat J Psychiat Med 25: 171–187.

Devine EC, Westlake SK. 1995. The effects of psycho-educational care provided to adults with cancer:meta-analysis of 116 studies. Oncol Nurs Forum 22:1369–1381.

Copyright © 2000 John Wiley & Sons, Ltd. Psycho-Oncology 9: 367–371 (2000)

ADJUVANT PSYCHOLOGICAL THERAPY FOR CANCER PATIENTS 371

Eisenberg DM, Kessler RC, Foster C, NorlockFE, Calkins DR, Delbanco TL. 1993. Unconven-tional medicine in the United States. Prevalence,costs, and patterns of use. New Engl J Med 328:246–252.

Fawzy FI, Fawzy NW, Wheeler JG. 1996. A post-hoc comparison of the efficiency of a psycho-educational intervention for melanoma patients de-livered in group versus individual formats: an analy-sis of data from two studies. Psycho-Oncology 5:81–89.

Fawzy FI, Fawzy NW, Hyun CS, Elashoff R, GuthrieD, Fahey JL, Morton DL. 1993. Malignantmelanoma. Effects of an early structured psychiatricintervention, coping and affective state on recurrenceand survival 6 years later. Arch Gen Psychiat 50:681–689.

Greer S, Moorey S, Baruch J. 1991. Evaluation ofadjuvant psychological therapy for clinically referredcancer patients. Br J Cancer 63: 257–260.

Lerner M, Remen RN. 1987. Tradecraft of the Com-monweal cancer help program. Ad6: J Mind-BodyHealth 4: 11–25.

Meyer TJ, Mark MM. 1995. Effects of psychosocialintervention with adult cancer patients: a meta-analy-sis of randomized experiments. Health Psychol 14:101–108.

Ratcliffe MA, Dawson AD, Walker LG. 1995. Eysenckpersonality inventory L-scores in patients withHodgkin’s disease and non-Hodgkin’s lymphoma.Psycho-Oncology 4: 39–45.

Richardson JL, Shelton DR, Krailo M, Levine AM.1990. The effects of compliance with treatment onsurvival among patients with hematologic malignan-cies. J Clin Oncol 8: 356–364.

Spiegel D, Bloom JR, Kraemer HC, Gottheil E. 1989.Effects of psychological treatment on survival ofpatients with metastatic breast cancer. Lancet ii:888–891.

Trijsburg RW, Knippenberg ECC, Rijpma SE. 1992.Effects of psychological treatment on cancer patients:a critical review. Psychosom Med 54: 489–517.

Van’t Spijker A, Trijsburg RW, Duivenvoorden HJ.1997. Psychological sequelae of cancer diagnosis:meta-analytical review of 58 studies after 1980. Psy-chosom Med 59: 280–293.

Copyright © 2000 John Wiley & Sons, Ltd. Psycho-Oncology 9: 367–371 (2000)