Spiegel and Moore draw an important distinction between the use of psychological techniques to
promote quality of life and their use to promote quantity of life. On the one hand, a considerable body of research documents that hypnosis and other psychological techniques improve the quality of life of cancer patients. On the other hand, only limited empiric evidence supports the view that imagery and other psychological techniques increase the quantity of life of cancer patients.
Moreover, in the few studies showing that the use of psychological techniques by cancer patients is associated with increased survival,[1,2] the techniques studied were fairly traditional in nature and not of the "alternative medicine" variety. For example, in the study by Spiegel et al, the intervention consisted of supportive-expressive group therapy and instruction in self-hypnosis for pain control. The study of Fawzy et al employed health education, training in problem solving and stress management, and supportive group therapy. As noted in the article by Spiegel and Moore, both interventions were also found to improve the quality of life of cancer patients. Taken together, these findings suggest that interventions that improve the quality of life of cancer patients may also confer a modest survival benefit.
In their review of psychological interventions, Spiegel and Moore focus on the use of hypnosis for cancer pain control. Clinicians and cancer patients need to be aware of other psychological techniques that can be used to enhance quality of life. A recent survey of comprehensive cancer centers indicated that, next to support groups, relaxation training was the most widely offered form of psychological care.
The widespread use of relaxation training among cancer patients can be attributed to several factors. First, training in relaxation techniques can usually be accomplished in a brief period. Thus, it is well suited for use in oncology, in which rapid control of aversive symptoms and emotional distress is desirable.
Second, relaxation training is readily accepted by patients, who perceive its potential benefits as including a greater sense of personal control.
Third, and perhaps most important, empiric research has repeatedly shown that relaxation training enhances the quality of life of cancer patients. Results of controlled studies indicate that interventions incorporating relaxation training are effective in relieving pain, nausea and vomiting, and emotional distress.[6,7]
Relaxation training refers to a variety of mental and physical exercises that can be used to induce subjective and physiologic relaxation. Among the exercises typically included in relaxation training programs are tensing and releasing of muscles, abdominal breathing, distraction, suggestion, and the use of relaxing mental imagery.
In our institution, relaxation training is generally conducted by a mental health professional (psychologist, social worker, or psychiatric nurse). The initial training can be accomplished in as little as 1 hour. The patient is given an audiotape of the training session, and thus, additional training can be accomplished by practicing the exercises at home. In addition, the patient can subsequently listen to the audiotape whenever he or she wishes to induce relaxation to reduce stress or promote symptom control.
Increasing the Availability of Psychological Interventions
The cost and availability of psychological interventions are major barriers to their more widespread use in oncologic settings. Many treatment centers do not have either the economic or human resources required to provide professionally administered psychological interventions on a routine basis.
Several modifications have been devised to address this issue. One alternative is to train oncology staff or paraprofessionals to deliver psychological interventions. Along these lines, Morrow and colleagues demonstrated that an intervention that included relaxation training was equally effective in reducing nausea and vomiting among chemotherapy patients when it was provided by oncologists, oncology nurses, or mental health professionals. In contrast, Carey and Burish found that relaxation training was not as effective when provided by paraprofessional volunteers as when provided by professional therapists.
At Moffitt Cancer Center, we recently initiated a National Cancer Institute-funded study to examine the effectiveness of a patient self-administered psychological intervention. Patients scheduled to begin chemotherapy receive specially prepared audiovisual materials (a videocasstte, an audiocassette, and a brochure) that provide information and instruction in relaxation training and other stress management techniques. This self-administered intervention is being compared to a professionally administered intervention and to a no-intervention control condition. Both the clinical efficacy and cost-effectiveness of the self-administered program in improving quality of life are being assessed.
The development of an effective self-administered program that requires minimal professional contact and costs little more than usual care has the potential to greatly increase patient access to psychological interventions in oncologic settings. As a result, many more patients who would otherwise never receive a psychological intervention could experience better quality of life during cancer treatment.