Effect of cognitive-existential group therapy on survival in early-stage breast cancer.

Kissane DW, Love A, Hatton A, et al:  From the Memorial Sloan-Kettering Cancer Center, New York, NY  J Clin Oncol 22:4255-4260, 2004


Since the report by Spiegel stating that group therapy extends survival in women with metastatic breast cancer, nine other studies have yielded mixed results, with the recent Canadian multisite trial failing to replicate the original findings.The focus throughout has been on an advanced stage of cancer. In women with early-stage breast cancer, helplessness and/or hopelessness and depression have been negatively linked with survival, whereas factors proposed as relevant to survival (eg, fighting spirit and the cancer-prone personality) have not been confirmed as exerting an influence. Resistance to progression of cancer could be mediated through enhancement of coping strategies, improved adherence to anticancer treatment overall, the salutary effect of social support, and the endocrine, immune, and autonomic nervous systems.

Given this state of knowledge, a prospective trial of the impact of group therapy at a much earlier stage of breast cancer seemed warranted. We devised cognitive-existential group therapy (CEGT) for women receiving adjuvant chemotherapy with the goals of promoting active coping and mutual support.CEGT has a beneficial effect on mood and family relationships. In this brief report, we focus on the impact of CEGT on survival in women with early-stage disease.

Cognitive-existential group therapy (CEGT) was developed to improve mood and mental attitude toward cancer in women with early-stage breast cancer receiving adjuvant chemotherapy. Given the debate about group therapy's association with increased survival in women with metastatic breast cancer, we were curious to check its effect at a much earlier stage in the cancer journey. We randomly assigned 303 women with early-stage breast cancer who were receiving adjuvant chemotherapy to either 20 sessions of weekly group therapy plus three relaxation classes (n = 154) or to a control condition of three relaxation classes alone (n = 149). The primary outcome was survival.

CEGT did not extend survival; the median survival time was 81.9 months in the group-therapy women and 85.5 months in the control arm. The hazard ratio for death was 1.35. In contrast, histology and axillary lymph node status were significant predictors of survival. Low-grade histology yielded a hazard ratio of 0.342, and axillary lymph nodeľnegative status yielded a hazard ratio of 0.397.

The use of CEGT in the context of early-stage breast cancer did not prolong survival. Despite group therapy reducing anxiety and sustaining family relationships, no beneficial effects with respect to survival were demonstrable. These findings are consistent with those of Goodwin et al, Cunningham and Edelman for women with advanced breast cancer, generating a series of studies that suggest that psychosocial interventions are not able to prolong survival. In contrast, tumor histology and axillary lymph node status, two well-recognized prognostic factors for breast cancer, were significant predictors of survival in this study.

Because all patients were receiving adjuvant chemotherapy, a behavioral impact on adherence to such treatment, as demonstrated in the study by Richardson  is unlikely with this design. We must conclude that a direct effect of an adjuvant psychological therapy like CEGT on survival has not been substantiated. This should not detract from its benefits in promoting adjustment in patients who are at risk of psychosocial distress. Indeed, we concur with Goodwin's recent advocacy for professionally led group therapy to be more widely available for women with breast cancer.

CONCLUSION: CEGT does not prolong survival in women with early-stage breast cancer.