Recent research has demonstrated that stress-related psychosocial factors may be associated with the risk of recurrence and death in patients with breast cancer. Evidence has supported the use of psychological intervention programs for these patients to help them manage stress, improve health, and function more effectively. Other evidence suggests that these programs can lead to better survival rates among disease sufferers. However, past studies haven’t been designed to specifically evaluate the effect of psychological interventions on recurrence and survival rates. In the December 15, 2008 issue of Cancer, my colleagues and I published a study designed to evaluate these endpoints in patients with breast cancer who received a psychological intervention.
In our investigation, over 200 newly-diagnosed patients who were surgically treated for regional breast cancer were randomized to receive a psychological intervention and assessment or only an assessment. We hypothesized that stress accompanying a cancer diagnosis may trigger psychological, behavioral, and biologic responses that are relevant to subsequent disease outcomes. An assessment of immunity was also included in the trial in order to evaluate the effects of psychological interventions on it. Currently available research evaluating the correlation between stress and cancer has focused on suppressed immune responses. The physiological link between stress and its effect on natural killer cells, however, requires further research.
The Psychological Intervention
The intervention used for our study in Cancer consisted of small group sessions led by clinical psychologists who discussed strategies to reduce stress, improve mood, alter health behaviors, and maintain adherence to cancer treatment and care for patients surgically treated for regional breast cancer. Patients were first educated on how stress manifested in their behavior, thoughts, feelings, and body. The intervention group was then taught the following strategies:
- Progressive muscle relaxation.
- Problem solving for common difficulties such as fatigue.
- Effective communication to obtain social support.
- Assertive communication to ensure that psychological and medical needs are met.
- Increasing daily activity.
- Improving dietary habits.
- Coping with treatment side effects.
- Maintaining cancer treatment adherence follow-up.
Positive Findings Emerged
Multivariate analyses verified that patients randomized to the intervention group had a significantly lower risk of death from breast cancer when compared with those who only received assessments during clinical care. After a median follow-up of 11 years, intent-to-treat hazard analyses showed a 56% risk reduction in breast cancer death for the intervention arm. Results also showed a 45% risk reduction in recurrence. Furthermore, after excluding patients who were randomized to the intervention group but attended fewer than 20% of the intervention sessions, the remaining participants had a 68% lower risk of breast cancer death.
We had previously reported that immunity for the intervention group was also enhanced. Patients in the intervention arm who had the greatest reductions in distress and physical symptoms within the first year following diagnosis were using the intervention strategies at the recommended frequency. Greater efforts must be made to disseminate psychological intervention opportunities to more cancer patients to facilitate their recovery during active treatment, optimize their transition to follow up, and, perhaps, improve their disease course.
Andersen BL, Yang HC, Farrar WB, et al. Psychologic intervention improves survival for breast cancer patients: a randomized clinical trial. Cancer. 2008;113:3450-3458.
Andersen BL, Farrar WB, Golden-Kreutz DM, et al. Psychological, behavioral, and immune changes after a psychological intervention: A clinical trial. J Clin Oncol. 2004;22:3570-3580.
Andersen BL, Farrar WB, Golden-Kreutz D, et al. Stress and immune responses following surgical treatment of regional breast cancer. J Natl Cancer Inst. 1998;90:30-36.
Thaker PH, Han LY, Kamat AA, et al. Chronic stress promotes tumor growth and angiogenesis in a mouse model of ovarian carcinoma. Nat Med. 2006;12:939-944.
Chida Y, Hamer M, Wardle J, Steptoe A. Do stress-related psychological factors contribute to cancer incidence and survival? Nat Clin Pract Oncol. 2008;5:466-475.