Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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I doubt that this study is usefull.
- Lawrence F Mahoney (9 November 2002)
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Positive people die too
- Gwen M Harlow (9 November 2002)
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What about quality of life?
- Frankie E Campling (12 November 2002)
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Influence of psychological coping on survival and recurrence: a response to the systematic review (P
- Maggie Watson, Janis Davidson-Homewood, Jo Haviland, Judith Bliss (14 November 2002)
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Influence of psychological coping on survival - Review is not systematic
- Alex J Mitchell, Manoj Kumar (Consultant in Psycho-oncology & Liaison Psychiatry), St James’ University Hospital, Leeds (15 November 2002)
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Mind and Cancer
- Alastair J. Cunningham (19 November 2002)
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A response to the systematic review
- Helen J Cooke, Cprnwallis Grove, Bristol, BS8 4PG (26 November 2002)
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Psychological coping styles, and cancer survival
- Gary M Orr, Jose Catalan (29 November 2002)
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Coping with cancer should be a matter of “living in the meanwhile”
- Anna V Ciardullo, Monica Daghio, Salvatore Panico (7 December 2002)
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IT REMAINS REASONABLE FOR CANCER PATIENTS TO PARTICIPATE IN THE FIGHT FOR RECOVERY
- Harold H. Benjamin (16 December 2002)
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Coping and cancer systematic review: reply
- Mark P Petticrew, Ruth Bell, Duncan Hunter (18 December 2002)
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Coping enables quality of life
- Arthur Soissons-Segal (20 October 2003)
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Wrong conclusions drawn from insufficient research
- Volker Tschuschke, Prof. Dr. (9 October 2005)
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Lawrence F Mahoney, 75 year old retired Engineer Green River WY, USA
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Nothing that I read mentioned the debilitating effects of the chemo or radiation therapy on the patients in the group. Years ago Cameron and Pauling published reports of the differences between patient in one wing of the Hospital in Scotland who were treated with chemo and radiation as contrasted to those in Dr. Camerons wing who were treated with large doses of Vitamin C. Have these guys been simply ignored or are they condemned for reporting their patients better and longer life because they chose Vitamins over conventional treatment. Since they lived longer and more pleasantly would that not imply that they had a positive attitude that helped them chooe the better treatment? I was personally well acquainted with only three cancer patients who chose conventional treatment--they were in misery from then until their demise. I have only read about those who chose non-conventional treatment and were better off for that choice. As a lifelong scientist I see little useful information in reports similar to the above. I would write a report like that for the media to republish in their special non-informational style. Best Regards, L Mahoney PS Will the raw truth about cancer treatment ever be published outside of a few outlaw sites on the internet? Competing interests: None declared |
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Gwen M Harlow, survivor of oesophageal cancer (7+years) Humberside Oesophageal Support Group, DN20 9HR
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Society has a wish to provide a solution to every ill, and hence the notion that a positive attitude might cure cancer. I have often thought how insulting this is to the memory of those who have died. I congratulate the authors on their research. Competing interests: None declared |
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Frankie E Campling, medical writer 88 Linkside Avenue, Oxford OX2 8JB
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There is surely a place for research into psychological interventions that improve quality of life for patients after diagnosis or treatment. Maybe happiness (or reduced unhappiness) has some effect on survival. Frankie Campling Competing interests: None declared |
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Maggie Watson, Consultant Clinical Psychologist Royal Marsden Hospital SM2 5PT, Janis Davidson-Homewood, Jo Haviland, Judith Bliss
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Influence of psychological coping on survival and recurrence in people with cancer: a response to the systematic review (Petticrew et al) Sir -The review by Petticrew et al (9 November BMJ, 2002) falls down on a number of counts. Firstly they attempt to compare fruit with vegetables. No mention is made of how coping styles were assessed in the different studies. What instruments were used? One of the problems, for example, is that something called "denial" in one measure might not be measuring exactly the same in another measure. It is very difficult to draw conclusions across studies if you are not comparing like with like. There is a great need for clear definition and consistent measurement in this area. They also pay little attention to the different lengths of follow up in the survival analyses published. Out of twenty eight studies, four have less than 1 year of follow up (the shortest length being only eight weeks); nine have between one and three years. Follow up of less than five years is likely to produce inconclusive results especially in relation to early breast cancer. Secondly, the authors have swept aside our study1 relegating it to the realms of irrelevance by the simplistic statement " The recent large UK study (n=578), while of higher quality, reported mixed findings: helplessness/hopelessness predicted recurrence when those with high and low scores were compared but not when it was the predominant coping style". On the contrary, we did not report mixed findings. Our findings were very clear and cautiously stated. The reviewers have missed the main importance of our finding concerning 'helpless/hopelessness'. Attempting to define a predominant coping style is not easy - and possibly rather arbitrary, and thus may not give a convincing result. However, the 'helpless/hopelessness' scale on the Mental Adjustment to Cancer (MAC) questionnaire has been shown to be robust across many studies and attempts to re-factor this scale. Therefore a high score on the MAC helpless/hopeless sub-scale is a valid measure not to be dismissed in this cursory fashion. It also reflects a response to cancer that can be helped by certain psychological interventions. The importance of this finding was therefore to encourage the adequate provision of psychological care within oncology to counteract these feelings of hopelessness. Similarly our finding that there was a tendency to poorer outcome in severely depressed patients, though small, and therefore to be cautiously interpreted should nevertheless indicate the need to identify and help these patients. The onus therefore shifts from the patient's responsibility (and blame) to that of the medical profession to identify those at risk and provide the help they need at the time it is needed. It is correct to say that the quality of many of the studies in this area is poor. However, our study used rigorous methodology, controlled for known prognostic variables, had a large enough sample with a long follow up and found an effect on survival. It does no real service to the research to dismiss these findings. The authors might have concluded instead that there are a lot of poor studies that fail to answer the question of whether coping response has an effect on survival. However, there is some evidence from high quality studies which suggests that what we need is more good research. Meanwhile we must not be afraid to say that a helpless/hopeless coping response has an adverse impact on breast cancer outcome that argues in favour of providing better psychological resource to patients. Maggie Watson, Janis Davidson-Homewood Jo Haviland Judith Bliss Royal Marsden Hospital and Institute of Cancer Research, London and Sutton, UK. 1. Watson M, Haviland JS, Greer S, Davidson J, Bliss JM. (1999) Influence of psychological response on survival in breast cancer: a population-based cohort study. The Lancet. Vol 354 pp. 1331 -1336 Competing interests: None declared |
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Alex J Mitchell, Lecturer in Psychiatry University of Leeds, Manoj Kumar (Consultant in Psycho-oncology & Liaison Psychiatry), St James’ University Hospital, Leeds
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Petticrew, Bell and Hunter have attempted to answer a much debated question in medicine – do psychological factors influence cancer prognosis? Whilst we would congratulate them on trying to improve on the many narrative reviews of this topic, we want to raise several questions about the validity of their review.
Whilst superficially the review appears comprehensive, the search strategy used (shown on page 2) is inadequate. Searches that rely on only a handful of keywords in medical databases will miss many important articles.1 Some of these can be retrieved by citation searching (in Web of Science or BIDS) but often there is no alternative to hand-searching journals. This is not a minor point because the integrity of a systematic review depends on capturing every known paper no matter what the outcome. The end result here is that the authors have identified 26 prospective studies that examine psychological factors (not including personality) in relation to survival or relapse of patients with cancer. We are aware of 13 additional prospective studies in this field (3 of these consider relapse) amounting to an extra 1511 patients which appear to have been overlooked by this review. Of course, these studies are of varying quality but they would certainly require appraisal in a truly systematic review. The authors have chosen to exclude at least twelve non-prospective studies from their review but even retrospective studies can add valuable information to this debate when well conducted (for example Temoshok et al’s three year retrospective study of 119 patients with malignant melanoma).2
On the question of critical appraisal, we cannot understand why the authors consider an “early assessment of coping style” to be a measure of quality (couldn’t late coping style be equally important?) – unless this is a proxy marker of length of follow up. If the authors had adopted more stringent methodological criteria as they suggest, surely it is possible that studies with false negatives may be excluded as much as those with false positives? An example is the study from Andrykowski et al (1994) which the reviewers rate most highly, yet it recruited only 42 patients and had a 2 month follow-up period.3 The authors note that only four studies identified over 200 patients but in fact there are seven studies that have done this. The missing ones being Funch et al (1983) who examined 208 patients with early breast cancer over twenty years, Holland et al (1986) who examined 346 patients with Stage II breast cancer and finally Stavraky et al (1988) who looked at 224 patients with lung cancer.
The authors correctly note that there is considerable heterogeneity in the sample but in our opinion this should be accounted for rather than simply mentioned. This can be done by analysing those studies that have examined psychological factors in early cancer separately from those that have studied mixed or late stages. This is particularly important because psychological factors are certain to be outweighed by biological factors in aggressive stages yet may have an influence in milder forms, at least when studied over a long period. It is of more than passing interest that there are at least eight prospective studies in early cancer that report a positive effect of some aspect of psychological outlook on survival or recurrence. These are Greer et al 1979, Greer et al, 1990 (follow-up data), Funch et al 1983, Diclemente & Temoshok 1985, Pettingale 1985, Wirschung et al 1988, Dean & Surtees, 1989, and Levy et al 1991.
Although we agree with the authors that there are many contradictory studies in this area, we submit that this review does not clarify this question due to weaknesses in the methodology. Summarizing studies in table 1 as negative (column 8) which contained statistically significant associations between psychological outcome and survival (for example Andrykowski et al 1994, Butow et al 1999 & 2000 and Dean & Surtees 1989) really does not help the issue.
As clinicians, we often see patients with cancer who feel forced to carry a burden of positive thinking. It is gratifying that various strands of research evidence are coming together to challenge the assumption that ‘coping well’ equates with a longer survival. In our opinion it is inappropriate to either force superficial positive thinking or to blame patients for not thinking positively. However methodological rigour is required if research is to contribute to this debate.
References
1. Hopewell S, Clarke M, Lusher A, Lefebvre C, Westby M (2002) A comparison of handsearching versus MEDLINE searching to identify reports of randomized controlled trials. Statistics In Medicine 21 (11): 1625-1634.
2 Temoshok L. (1985) Biopsychosocial studies on cutaneous malignant melanoma: psychosocial factors associated with prognostic indicators, progression, psychophysiology and tumor-host response. Soc Sci Med. 1985;20:833-840.
3 Andrykowski MA, Brady MJ, Hensleedowney PJ (1994) Psychosocial factors predictive of survival after allogeneic bone-marrow transplantation for leukemia Psychosomatic Medicine 56 (5): 432-439
(further references quoted available on request) Competing interests: None declared |
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Alastair J. Cunningham, Senior Scientist Ontario Cancer Institute, 610 University Ave., Toronto ON M5G 2M9, Canada
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EDITOR - Petticrew et al summarise studies over several decades showing that what cancer patients say about their attitudes to their disease is not significantly related to survival outcomes. There is a danger that this will be interpreted to mean that there is nothing these people can do to help themselves live longer by psychological means. Such a conclusion would be unwarranted from evidence that is confined to administering self-report questionnaires at a single point in time. As in other fields, what people say, under such conditions where socially desirable responses are evident, is not nearly as important as what they actually do. One would not, for example, assess the health value of exercise solely by asking people whether they thought it was a good idea. It is the impression of many clinicians engaged in helping cancer patients help themselves with psychological and spiritual techniques that becoming strongly involved with such methods and philosophies can indeed make a difference to longevity in some cases. We have recently published some evidence from a rigorous, correlative study on this question. One of the difficult features of this research is that randomised controlled trials are of limited applicability, since relatively few patients are aware of, or motivated to make, the kinds of substantial mental changes that appear to be needed to strengthen the body's cancer-regulating mechanisms. Case by case analyses are thus required, to identify these unusually motivated people. While the issue is certainly not resolved as yet, it is important that we retain an open mind on the question of educating patients to help themselves as a potentially valuable additional resource in fighting serious chronic disease. Alastair J Cunningham, PhD, C.Psych,
No competing interest Petticrew M, Bell R, Hunter D. Influence of psychological coping on survival and recurrence in people with cancer: systematic review. BMJ 2002; (9 Nov) (Please note - pg #s not available from electronic copy) Cunningham A J, Edmonds C, Phillips C, Soots K, Hedley D, Lockwood G. A prospective, longitudinal study of the relationship of psychological work to duration of survival in patients with metastatic cancer. Psycho- oncology, 2000; 9: 323-339 Competing interests: None declared |
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Helen J Cooke, Director of Therapy Bristol Cancer Help Centre, Cprnwallis Grove, Bristol, BS8 4PG
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A response to the systematic review - ‘Influence of psychological coping on survival and recurrence in people with cancer: systematic review”. Petticrew M et al. BMJ. 2002;325:1066-1085 The Bristol Cancer Help Centre agrees with the authors that people with cancer should not feel pressurised into adopting a particular coping style. This is unlikely to be helpful at a time when they are already under a great deal of pressure. However we do believe that psychological interventions have an important part to play in not only improving the quality of life for people with cancer, but also quite possibly prolonging survival. Leslie Walker in his recent review (1) states that not only is there substantial evidence that psychological interventions are helpful in alleviating stress, but also that there is a growing body of evidence to suggest they may influence survival. Although many of the studies reported in the review were reported as methodologically sound, several used psychological self-report inventories that have since been widely criticised. It is now recognised by researchers such as Temoshok (2) that the most effective way of looking at emotional responses to the diagnosis of cancer is by clinical profiling. Cunningham (3,4) also suggests that rather than self-report inventories we need to use qualitative methods that allow a much more in depth analysis of the patients. His work that combines qualitative analysis with a quantitative rating, is carried out with people who have metastatic cancer undergoing a psychological programme intervention. His studies demonstrate a significant relationship between the degree that people are involved with the psychological work and survival. His hypothesis is that enhanced survival depends not only on psychological attributes, but also on the application of the techniques used in therapy. This is with the understanding that if the mind is to affect the regulation of cancer progression via endocrine or immune intermediary mechanisms, there needs to be a change in mental status. This may then result in the change of some of these physiological regulators. The study by Watson and colleagues (5), in which a positive score on a depression score six weeks after the diagnosis of primary breast cancer significantly reduced survival, points to the importance of psychological states to outcome. The work of Sephton and colleagues (6) shows that those women with cortisol disregulation at the time of the recurrence of breast cancer had a significantly reduced survival time. These studies suggest that psychological state affects the biology of tumour progression. Without such influences the disease is likely to continue to progress at the same time. Rather than looking back, surely now is the time to look ahead at developing further creative research designs such as Cunningham’s that can intelligently capture the benefits of effective coping styles, and any psychological intervention that may enable these to be bought about. We also believe that it will become possible to measure the internal physiological states suggesting disregulation of mind body biorhythms using such measures as Capnography and heart rate variability that reflect the flexibility or otherwise of the internal physiology. Maybe then in another ten years we will be seeing a very different picture emerging from the data. Helen Cooke - Director of Therapy, Dr David Beales - Member of the Therapy
Advisory Board
1. Lewis et al. (2002) The Psychoimmunology of Cancer. 2nd Edition. Oxford University Press (P 252) 2. Watson M et al. (1999) Influence of psychological response on survival in breast cancer: a population-based cohort study. Lancet. 354. 13331-1336 3. Temoshok L R . Letter page. Lancet. Jan 2000. Vol (355) 4. Cunningham et al. (2002) ‘Fighting for life: A qualitative analysis of the process of psychotherapy-assisted self-help in patients with metastatic cancer. Integrative Cancer Therapies.1(2):146-161 5. Cunningham et al. (2000) ‘A prospective longitudinal study of the
relationship of psychological work to duration of survival in patients
with metastatic breast cancer’. Psycho-oncology, 9: 323-339
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Gary M Orr, Specialist Registrar in Psychiatry Chelsea and Westminster Hospital SW10, Jose Catalan
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The systematic review by Petticrew and co workers (1) fails to find a link between psychological coping style and survival or recurrence in cancer, extending their previously reported findings about the absence of an association between stressful life events and the diagnosis of cancer (2). The authors discuss a number of methodological inadequacies that may have contributed to the earlier positive findings. Another possible factor that may explain the lack of association between coping style, stress and survival, in spite of the theoretically plausible mechanisms that might be expected to show a link is that of the relative strength of effect of biological, treatment-related and psychosocial factors. It is quite possible that even if psychosocial factors have some influence on survival, their power is negligible compared, for example, with the biological characteristics, and tumour staging of both the patient and the cancer. The association between cancer outcomes and psychosocial antecedents can be traced to second century medical texts, but the inclusion of personality factors and coping styles into a risk equation that aims to determine overall survival for people with cancer does not show any effect (3). It is to be hoped that the work of Petticrew and co-workers will help to dispose of the myth of the personal psychological contribution to the outcome of cancer. Feelings of distress and guilt are not uncommon in people with cancer, the socially defined meanings of the disease sometimes acquiring a momentum of their own (4). The added expectation that the person must fight, not become anxious or depressed, or show any hint of avoidance or emotional suppression lest survival be put at risk, does not make the process of living with the condition any easier and can have devastating consequences, in particular if the illness recurs, suggesting that the person has not tried hard enough (3). There is a problem, however, between professionals and the public when attempting to present and discuss the results of evidence-based work of this kind, which seems contrary to strongly held popular views. In our post-modern world it is easy for the personal views and experience of individuals either to be given prominence against what is seen as dry, biased, impersonal, in other words, scientific evidence, or else to be dismissed by professionals as irrelevant. In the field of mental health this conflict is evidently present (5) but the consumer-led approach to health care currently prevalent extends the possible conflict to other specialties. Although Greenhalgh has attempted to reconcile both the narrative and biomedical approaches (6), it would seem that the challenge for mental health is to integrate scientific evidence, with the individual narrative. Gary Orr
Jose Catalan
Psychological Medicine,
South Kensington & Chelsea Mental Health Centre,
1 Nightingale Place,
London SW10
References: 1. Petticrew M., Bell R., Hunter D., Influence of psychological coping on survival and recurrence in people with cancer: systematic review BMJ, 2002, 325, 1066-1069 2. Petticrew M., Fraser J. M., Regan M. F., Adverse Life events and risk of breast cancer: A meta-analysis 3. Orr G (unpublished) MSc Thesis – Imperial College of Science Medicine and Technology The psychosocial aspects of breast cancer: A systematic review of the literature 1999 (unpublished 4. Sontag S., Illness as Metaphor; AIDS and its Metaphors Penguin Books; London: 1991 5. British Journal of Health Psychology: 1999, 4, 1-17Bracken P., & Thomas P., Post-psychiatry: a new direction for mental health. BMJ, 2001, 332, 724 – 727 6. Greenhalgh T., Narrative based medicine in an evidence based world. In: Narrative Based Medicine Eds. Greenhalgh T., & Hurwitz B., BMJ Publishing, London, 1998 Competing interests: None declared |
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Anna V Ciardullo, MD MSc “Lab for Citizen Empowerment” – Azienda USL - Viale Muratori, 201 - 41100 - Modena, Italy, Monica Daghio, Salvatore Panico
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EDITOR - Dear sir, we read the paper of Petticrew and collegues (1) showing that there is no consistent association between psychological coping and survival from or recurrence of cancer. We found it a very interesting systematic review on the issue. Here we focus on the following statement: «Overall we found little evidence that coping styles play an important part in survival from cancer. This is an important finding because there is often pressure on patients with cancer to engage in "positive thinking," and this may add to their psychological burden (2-3). It has been suggested that clinicians need to detect coping styles such as helplessness or hopelessness and treat them vigorously (4). Our findings show that such interventions may be inappropriate, at least when they are used with the aim of increasing survival or reducing the risk of recurrence» (1). We found it very useful from a patient’s perspective. In fact, the common belief on an imaginary role of the “positive thinking” on cancer outcomes could be finally defeated thus allowing to all the cancer patients that have the great sin not being “positive” the right to be discouraged or depressed from their situation. Furthermore, this paper might indirectly contribute to take off the terrific “ghost” raised by the supporters of complementary medicine about patient’s responsibility towards his/her disease; for example, «Cancer is expression of our time and our conceptions of the world. We experience in the form of cancer just what we ourselves live. People have the cancer because people themselves are cancer» (5). By the way, what we are attempting to state here is that the cancer patients have to fight not only against their disease but also against the “common hypocrisy” to project on the suffering people the whole incapability of our western society to face their needs. The article of Petticrew and collegues1 is certainly useful to hand out with these problems. Nevertheless, we think it should be essential to consider that the appropriateness of such interventions might take into account another important outcome, i.e. the improvement of patient’s “living in the meanwhile”. In other words, we think that the authors failed to include a major outcome related to cancer survival, i.e. the quality of “life while being ill” that could also have a different value from patient’s perspective, perhaps even greater than a longer life. Ciardullo Anna Vittoria, MD, MSc Daghio Maria Monica, MA “Lab for Citizen Empowerment” - Azienda USL, Modena, Italy Salvatore Panico, MD MSc Department of Clinical and Experimental Medicine, “Federico II” University, Naples, Italy References: 1 Petticrew M, Bell R, Hunter D. Influence of psychological coping on survival and recurrence in people with cancer: systematic review. BMJ 2002 ; 325:1066-75 2 Wilkinson S, Kitzinger C. Thinking differently about thinking positive: a discursive approach to cancer patients' talk. Soc Sci Med 2000; 50: 797- 811 3 De Raeve L. Positive thinking and moral oppression in cancer care. Eur J Cancer Care 1997; 6: 249-256 4 Watson M, Haviland J, Greer S, Davidson J, Bliss J. Influence of psychological response on survival in breast cancer: a population-based cohort study. Lancet 1999; 354: 1331-1336 5 Gazzola F. Il ruolo degli shock emozionali nella genesi dei tumori. Naturalis Medicina.it http://www.naturalismedicina.com/articolo.asp?i=153, site visited in 2002, 6th December Competing interests: None declared |
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Harold H. Benjamin, Founder The Wellness Community
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The most significant conclusion to be drawn from an article published in the British Medical Journal of November 9, 2002, (Petticrew article)(1), is a reiteration of what scientists interested in the study of the mind/body relationship have known for at least 25 years: it is biologically plausible that the psychosocial efforts of a cancer patient may extend survival. However, the tone of the article and the comments of one of its co-authors, stating definitively that the efforts of the patient can have no such effect, have been a source of unnecessary discouragement to a great many people with cancer. “Experts” have a duty to continue to tell those with cancer that their psychosocial efforts may have a positive effect on the course of the disease, without the possibility of blame if their efforts do not turn out as hoped. “Experts” should not discourage cancer patients from participating in the fight for recovery unless there is clear evidence that there is no cause and effect relationship between their efforts and outcome. The evidence at this time is that such relationship is biologically plausible. What the Petticrew article asked, in practical terms, is the following question: do the psychological efforts of a cancer patient affect the outcome of cancer? The actual title is Influence of psychological coping on survival and recurrence in people with cancer: systematic review. The authors conducted a “systematic review of [26] published and unpublished prospective, observational studies” to summarize the effect of psychological coping styles on survival and recurrence in patients with cancer. The article considered the affect on the illness of fighting spirit, hopelessness/helplessness, denial or avoidance, stoic acceptance, and fatalism. The authors’ conclusions are as follows: “Conclusion: Although the relation is biologically plausible, there is at present little scientific basis for the popular lay and clinical belief that psychological coping styles have an important influence on overall or event-free survival in patients with cancer. “Our findings show that such [psychosocial] interventions may be inappropriate, at least when they are used with the aim of increasing survival or reducing risk of recurrence.” Mark Petticrew, co-author of the study is quoted in the Los Angeles Times Health Section, 11/18/2002 as saying: “The [Petticrew] study adds to what we know by showing that coping styles don’t affect cancer out come” (emphasis added.) This is difficult to understand because they support their conclusion that “coping styles [psychosocial efforts] don’t [can’t] affect the out come of cancer” and “may be inappropriate,” by a specifically contrary phrase indicating it is biologically plausible that coping styles may affect the outcome of cancer. They state in their conclusion, using their words in slightly different structure “Although the relation[ship] is biologically plausible, that psychological coping styles have an important influence on overall or event free survival in patients with cancer, there is at present little scientific evidence [of that fact.]” This is, of course, the state of our knowledge and, in addition to acknowledging that patients who choose to fight for recovery in groups report improved quality of life (no small benefit), what all reputable scientists have been saying for many years. Further, the authors of the studies that show such a relationship have consistently refrained from interpreting their results as definitive. Only charlatans promise recovery from psychosocial efforts. That this is the state of our knowledge is reinforced by Donald Rosenstein, M.D., chief of the psychiatry consultation service at the National Institutes of Health Clinical Center. In an NCI Internet posting dated 01/23/2002 concerning the efficacy of cancer support groups, a psychosocial intervention, Dr. Rosenstein makes the following statement: “Whether support group participation may extend survival is an open question. There is a lot we still don’t know about the effects a cancer patient’s mindset may have on their disease. . . .There is some data to suggest that some individuals’ lives may be prolonged. There may be variables associated with longer survival that we have not yet identified.” As is said in the Patient Active Concept, which is the basis for The Wellness Community: “Cancer patients who participate in their fight for recovery along with their physicians will improve the quality of their lives and may enhance the possibility of recovery” (2). Finally, to inform the public that “the popular lay and clinical belief [is] that psychological coping styles have an important influence on overall or event-free survival in patient with cancer,” is just wrong, and phrases such as “ . . .there is often pressure on patients with cancer to engage in ‘positive thinking,’” without some type of evidence that such pressure is exerted and by whom, is not only broadly inaccurate but counter productive. I find it even more difficult to understand coming from those whose stated purpose is to be helpful to those with cancer. ENDNOTES (1) Petticrew M, Bell R, Hunter D. Influence of psychological coping on survival and recurrence in people with cancer: systematic review. BMJ 2002; 325: 1066 (9 November). http://bmj.com. (2) Those interested in knowing more about the Patient Active Concept or The Wellness Community should consult www.thewellnesscommunity.com. Competing interests: None declared |
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Mark P Petticrew, Associate Director MRC SPHSU, Ruth Bell, Duncan Hunter
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We agree with Watson et al. that there is a fruit and vegetables issue here, in that are a number of ways of measuring coping in these studies, and coping itself is not always clearly defined, however a review which aimed to only include homogenous coping styles would rightly be accused of taking too narrow a view of coping. We aimed therefore to include any measure. As regards the importance of helplessness/hopelessness, we feel that there is little good evidence here that it has an important influence on outcome. Moreover it also remains to be shown that interventions to reduce helplessness/hopelessness, or indeed any other psychological intervention have any impact on survival or recurrence. However this would be better addressed in a systematic review of trials. Mitchell and Kumar suggest that we have missed 13 studies and that the integrity of a review depends on capturing every known paper, irrespective of the outcome. This is doubtful. It actually depends on identifying those papers which meet the inclusion criteria. We had seen and excluded most of these 13 studies and refer Mitchell and Kumar back to the methods section of our review. Specifically, we were aiming to include prospective studies of the association between coping and outcome, and most of their 13 studies do not fulfill these criteria. For example, one of the studies which they appear to suggest we should include is an RCT (Spiegel, 1989) with no data on psychological coping. Most of the other studies assess psychological variables such as locus of control, social support, general wellbeing, personality (16PF), Rorschach data, and so on. However this was clearly not a review of the effects of "any" psychosocial factor - if it were, we could have included at least 20 other studies (apart from these 13). Instead, we sought to include only studies of psychological coping in response to cancer. "Locus of control", for example, may be an important factor but is not a 'coping style' as defined by our review. Similarly, social support may be an important factor influencing outcome, and may well be worth reviewing in its own right, but, as the title of our paper suggests, this was not a review of social support. Two studies out of the 13 however may meet the inclusion criteria - one was an abstract which reports little data or methods (n=117 patients) (Diclemente et al., 1985), and the other a book chapter (n=52 patients) (Wirsching et al.,1988). The latter study appears to use Grossarth-Maticek's measure of rationality/anti-emotionality - we are unclear at present whether this could be considered to be a measure of coping, but in short Mitchell and Kumas's claim that we missed a significant portion of the literature, and over a thousand patients, is simply wrong. Mitchell and Kumar also claim that they cannot understand why we consider an early assessment of coping style to be a measure of quality. The 'early measurement of coping style' is a basic criteria for causality - if a factor is postulated to be causal, logically it has to operate before the outcome occurs. Measuring coping style close to diagnosis seems the most appropriate way to assess this factor - the longer after diagnosis, the greater the possibility that coping style may be a result of the disease progression (or the experience of treatment) rather than an effect. This is why we included only prospective studies: because it is difficult to measure coping in an unbiased fashion after the event. Similarly we do not know what basis they have for saying that psychological factors are more likely to be important in 'mild' (sic) disease than aggressive disease. This seems to be an untested assumption on their part. Finally, Watson and several other respondents raise the issue that there is a need for more good research in the area. This is also echoed by Cooke who also implies a need in the longer term to keep an eye on emerging data. We would not disagree with either of these, though trials of psychological interventions are likely to be particularly useful (even given some of the respondents criticicisms of RCTs). Mark Petticrew Ruth Bell Duncan Hunter Competing interests: None declared |
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Arthur Soissons-Segal, Retired Winnetka, CA 91306
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My experience as a psychologist is that coping strengthens an individual's quality of life. Rather than die in a depressed state, the individual takes the opportunity to feel meaningful, and to pass on feeling that he has contributed to living. The word "Coping" is a vague. It covers a respose to the cancer and its meaning varies person to person. Coping is an exercise in healing and must be practiced over time. The success of coping is dependent not only on the patient but on the teacher- therapist as well as on support from spouse and others. Nor will any one coping strategy work consistently on every individaul, just as particular medicages and dosages will vary with the patient. The Petticrew study did not account, and probably could not account, for these significant variables. Competing interests: None declared |
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Volker Tschuschke, Prof. Dr., Head of Department of Medical Psychology University Hospital, Cologne, Germany
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As I have mailed Dr. Petticrew right after having published the article in BMJ, I referred particularly to the insufficient state of the art in psychooncology research. Studies using large symples - as it is the case in Dr. Petticrews studies, too - use questionnaires to investigate coping in patients (for reasons of convenience). This is the very reason for mixed or confusing results. What patients believe what they do is not valid! We as researchers have to go the 'extra-mile' and have to use qualitative/quantitative interviews. On a high methodological level with high interrater reliabilities, qualitative content analyses of semi- strucured interviews (sentence by sentence ratings following excplicit rating manuals as we have done in our study, Tschuschke et al., 2001) one succeeds in predicting survival by objective ratings of coping behavior (as it is seen as a strong tendency in Dr. Petticrews article: nearly all smaller studies used interviews as basis for coping assessments and found evidence for a relationship between coping and survival!). Competing interests: None declared |
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