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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;325:1066

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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

14 November 2002
Maggie Watson
Consultant Clinical Psychologist
Janis Davidson-Homewood, Jo Haviland, Judith Bliss
Royal Marsden Hospital SM2 5PT