CORRESPONDENCE

Re: Systematic Review of Psychological Therapies for Cancer Patients: Overview and Recommendations for Future Research

Anne Brédart, Sandrine Cayrou, Sylvie Dolbeault

Affiliation of authors: A. Brédart, S. Cayrou, S. Dolbeault, Institut Curie, Psycho-Oncology Unit, Paris, France.

Correspondence to: Anne Brédart, Ph.D., Institut Curie, Psycho-Oncology Unit, 26 rue d’Ulm, 75.246 Paris cedex 05, France (e-mail: anne. bredart{at}curie.net).

In a systematic review of randomized controlled trials (RCTs) that tested psychological therapies in cancer patients, Newell and co-workers (1) concluded that "the results of this review [led them] to be considerably less enthusiastic about the likely benefits of psychological therapies for cancer patients than [did] the results of other recent reviews."

We are concerned about the potential impact of this negative message on hospital managers and doctors. They may well conclude that psychological therapies are worthless and thus decide to restrict the limited resources available for patients‘ psychological needs, even though it is well known that substantial proportions of cancer patients suffer from psychological distress or from psychiatric disorders.

We would like to reconsider the conclusions of Newell and co-workers from the perspective of our clinical practice and research in psycho-oncology. First, Newell and co-workers could not perform a meta-analysis of effectiveness trials because they combined various psychological therapies for cancer patients. For example, they gave equal weight to traditional formalized psychotherapeutic interventions that were provided by a trained professional and to unconventional therapies that were not provided by a therapist (e.g., self-practice). However, in the past decades, other meta-analyses of RCTs have demonstrated the benefits of psychotherapy in mental health (2) as well as in oncology (3,4). Newell and co-workers ignore these positive results.

Second, testing the effectiveness of psychological therapies by performing RCTs is only one of many ways to improve the psychological care of patients. For instance, considerable efforts are still needed to identify valid and sensitive measures of the effects of psychological therapies. Also unclear are the best ways to implement psychological therapies in cancer patients. RCTs can only confirm or refute the efficacy of specific interventions. It is unreasonable to expect that RCTs alone will advance our knowledge of the effects and mechanisms of psychological therapies. Sound clinical research on psychological interventions (including RCTs) should be viewed as part of an iterative process involving different methodologic approaches. The development and testing of hypotheses of treatment mechanisms may be better achieved within the framework of qualitative research methods (5).

Third, Newell and co-workers used indicators recommended by the Cochrane Collaboration to judge the methodologic rigor of psychological intervention trials. However, the authors did not acknowledge the inappropriateness or impracticability of these criteria in specific settings. For example, the criterion "patients blinded to treatment group" is not allowed by many Ethical Committees. The criterion "care-providers blinded to treatment group" is usually not applicable if the treatment group is to be compared with the group that received no treatment. The criterion "outcome blinded" is also difficult to implement when the goal of a psychological intervention is patients‘ well-being. Consequently, in these contexts, methodological rigor must be ensured through alternative design strategies.

Fourth, Newell and co-workers claim that it should not be too costly to improve the methodologic rigor of RCTs that evaluate psychological interventions. In this era of industrial drug development, methodologic requirements for the design and conduct of RCTs that test new drugs often require considerable financial investments. As with RCTs that test new drugs, RCTs that test psychological therapies also involve substantial costs. However RCTs for psychological therapies benefit from far less financial support than those for drugs. Given this disparity we hope that the conclusions reached by Newell et al. will not reduce the already-limited resources that are available to study how to improve the psychological care that is provided to cancer patients. The efforts actually provided by the psycho-oncology community to assess its practice and to introduce a rigorous methodology into the psychosocial field must be highlighted and should be encouraged.

References

1 Newell SA, Sanson-Fisher RW, Savolainen NJ. Systematic review of psychological therapies for cancer patients: overview and recommendations for future research. J Natl Cancer Inst 2002;94:558–84.[Abstract/Free Full Text]

2 Matt GE, Navarro AM. What meta-analyses have and have not taught us about psychotherapy effects: a review and future directions. Clin Psych Rev 1997;17:1–32.[Medline]

3 Meyer TJ, Mark MM. Effects of psychosocial interventions with adult cancer patients: a meta-analysis of randomized experiments. Health Psychol 1995;14:101–8.[Medline]

4 Sheard T, Maguire P. The effect of psychological interventions on anxiety and depression in cancer patients: results of two meta-analyses. Br J Cancer 1999;80:1770–80.[Medline]

5 Green J, Britten N. Qualitative research and evidence based medicine. BMJ 1998;316:1230–2.[Free Full Text]



             
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