Influence of psychological coping on survival and recurrence in people with cancer: systematic review
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7372.1066 (Published 09 November 2002) Cite this as: BMJ 2002;325:1066All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Specialist registrar
Jose Catalan
Consultant liaison psychiatrist
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
Competing interests: No competing interests
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
Bristol Cancer Help Centre
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
Competing interests: None declared
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,
Senior scientist
Ontario Cancer Institute,
610 University Avenue,
Toronto, ON, M5G 2M9, Canada.
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
Competing interests: No competing interests
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
Competing interests: 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.
Influence of psychological coping on survival and recurrence: a response to the systematic review (P
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
Competing interests: No competing interests
Wrong conclusions drawn from insufficient research
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
Competing interests: No competing interests