EDITORIALS
Editorials
M IND M ATTERS — G ROUP T HERAPY
AND S URVIVAL IN B REAST C ANCER
H OW much does mind matter in the outcome of
cancer? The extent to which treatment of the
emotional aspects of cancer affects disease progression
is ultimately an empirical question. There are those
who believe that controlling cancer requires a simple
exertion of mind over matter, but that one might cure
cancer in the body by vanquishing it in the mind is
clearly wishful thinking. Indeed, the popular psycho-
logical notion that you get cancer because of some
deep emotional need for it has needlessly made many
patients with cancer feel guilty.
Others say that the mind has no role at all: cancer
is purely a physiological problem. Medical treatment
has focused almost exclusively on attacking the tumor,
and relatively little attention has been paid to neurally
controlled processes that could plausibly affect somatic
resistance to cancer. These include health-related be-
havior, adherence to treatment, and the effects of men-
tal states on hormonal, immunologic, and autonomic
nervous system function. Recent evidence supports
the notion of a link between psychosocial stress and
tumor progression that is mediated by endocrinologic
or immunologic mechanisms. For example, loss of the
normal diurnal variation in cortisol levels predicts ear-
ly death in patients with breast cancer.1 Thus, ignoring
how a patient with cancer is coping with disease-relat-
ed stress and distress is shortsighted. Patients justifi-
ably yearn for and seek medical care that takes into
account not only the biologic dimensions of their
illness, but also psychological and social factors. To
them, mind matters.
A study of the extent to which mind matters appears
in this issue of the Journal. Goodwin and colleagues 2
found that supportive–expressive group psychother-
apy for women with metastatic breast cancer improved
the quality of life but not its quantity: living better
did not mean living longer. This type of group psy-
chotherapy emphasizes creating a new social support
network, expressing emotion, confronting existential
issues, improving relationships with family and friends,
enhancing communication with physicians, and learn-
ing coping skills.3 This carefully conducted, large, mul-
ticenter trial involved rigorous assessment of patients,
extensive training and supervision of group therapists,
and sophisticated analyses of outcomes. The fact that
the patients who participated in group therapy had
significantly less distress and pain than control patients
is evidence of the effectiveness of the psychosocial
intervention. This finding confirms those of other
groups. Under ordinary circumstances, such a large-
scale confirmation of a positive effect of psychother-
apy would be notable in itself. However, the primary
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Copyright © 2001 Massachusetts Medical Society. All rights reserved.
hypothesis of the study was that such treatment would
prolong survival. The investigators found no increase
in the duration of survival among patients in the in-
tervention group as compared with controls, and thus
they did not replicate the earlier finding, in a study
by my colleagues and me, of a survival benefit from
group therapy.4
The difference between the findings of the two
studies may be explained by changes in treatment dur-
ing the past several decades. First, the medical treat-
ment of breast cancer has improved substantially, and
the notable reduction in breast-cancer mortality that
began in the late 1990s5 undoubtedly reflects the ear-
lier detection of cancer, the use of selective estrogen-
receptor modulators, and the development and use of
more effective chemotherapy.
Second, psychosocial support for patients with can-
cer has also improved substantially. When my col-
leagues and I started our trial in the late 1970s, the
main problem was convincing patients who were ran-
domly assigned to group therapy to attend the sessions
required for this novel intervention. In the 1990s, we
were faced with the problem of disappointing the pa-
tients who were assigned to a control group rather
than to group treatment. Patients with cancer, even
those in the control groups of current clinical trials,
are cognizant of the positive effects of psychosocial
intervention. They are far less likely now to be emo-
tionally isolated during their illness, because more
group support of various kinds is available, there is
greater public understanding of the illness, and ma-
jor efforts have been made to destigmatize patients
with cancer. In short, emotional support for patients
with cancer is far more readily available than it was
decades ago. Because medical and surgical treatments
are better now and emotional support has improved,
the effect of formal psychosocial intervention on sur-
vival time that was found in earlier studies is difficult
to replicate.
The literature is now evenly divided: 5 of 10 pub-
lished trials report that psychotherapy prolongs sur-
vival, usually moderately, in patients with cancer.2,5-13
The randomized trial we began in the 1970s was based
on the hypothesis that psychosocial group therapy
would lessen distress in women with breast cancer but
would not influence survival. We found, however, an
18-month survival advantage for patients who received
group therapy, and this was not accounted for by dif-
ferences in medical treatment.6 Since then, four other
randomized trials7-10 also found that various forms of
psychotherapy for patients with cancer were associat-
ed with both psychological benefit and longer sur-
vival time.
Now, with the addition of the study by Goodwin
et al., five published trials have not found any survival
benefit from various forms of psychotherapy. Three of
these studies reported only transient11 or no12,13 psy-
chological benefit of any kind. Only one of the other
negative studies14 showed a positive effect on the
psyche but none on the body. But a psychological in-
 The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne
tervention that does not help emotionally is not likely
to provide physical benefit. In the study by Goodwin
et al., the quality of the group therapy was confirmed
by reductions in distress and pain. The greatest benefit
was among those who were the most anxious and de-
pressed initially, which is not surprising. This finding
suggests a useful direction for future research: iden-
tifying the populations that are most likely to need
and respond to emotional support.
What can we conclude now about how much the
mind matters in cancer? The published reports make
it clear that in group therapy a direct confrontation
with the possibility of dying from metastatic breast
cancer is emotionally helpful and not physically harm-
ful. It is now well documented that the secrecy that
surrounded cancer in the medical practice of yester-
year undermined rather than enhanced the patient’s
well-being. Facing the realities of metastatic breast
cancer does not cause physical deterioration or has-
ten death. Indeed, the study by Goodwin et al. con-
firms that bearing and sharing all the emotions asso-
ciated with advancing cancer in a supportive setting
reduces distress and pain. The literature is divided on
the question of a survival benefit, and more trials are
being conducted, both in the United States15 and over-
seas.16 In the meantime, group therapy for patients
with cancer can be prescribed for its psychological
benefit, if not necessarily for any prolongation of sur-
vival. Curing cancer may not be a question of mind
over matter, but mind does matter.
DAVID SPIEGEL, M.D.
Stanford University School of Medicine
Stanford, CA 94305-5718
REFERENCES
1. Sephton SE, Sapolsky RM, Kraemer HC, Spiegel D. Diurnal cortisol
rhythm as a predictor of breast cancer survival. J Natl Cancer Inst 2000;
92:994-1000.
2. Goodwin PJ, Leszcz M, Ennis M, et al. The effect of group psycho-
social support on survival in metastatic breast cancer. N Engl J Med 2001;
345:1719-26.
3. Spiegel D, Classen C. Group therapy for cancer patients: a research-
based handbook of psychosocial care. New York: Basic Books, 2000.
4. Spiegel D, Bloom JR, Kraemer HC, Gottheil E. Effect of psychosocial
treatment on survival of patients with metastatic breast cancer. Lancet
1989;2:888-91.
5. Peto R , Boreham J, Clarke M, Davies C, Beral V. UK and USA breast
cancer deaths down 25% in year 2000 at ages 20-69 years. Lancet 2000;
355:1822.
6. Kogon MM, Biswas A, Pearl D, Carlson RW, Spiegel D. Effects of med-
ical and psychotherapeutic treatment on the survival of women with met-
astatic breast carcinoma. Cancer 1997;80:225-30.
7. Richardson JL, Shelton DR, Krailo M, Levine AM. The effect of com-
pliance with treatment on survival among patients with hematologic ma-
lignancies. J Clin Oncol 1990;8:356-64.
8. Fawzy FI, Fawzy NW, Hyun CS, et al. Malignant melanoma: effects of
an early structured psychiatric intervention, coping, and affective state on
recurrence and survival 6 years later. Arch Gen Psychiatry 1993;50:681-9.
9. Kuchler T, Henne-Bruns D, Rappat S, et al. Impact of psychotherapeu-
tic support on gastrointestinal cancer patients undergoing surgery: survival
results of a trial. Hepatogastroenterology 1999;46:322-35.
10. Ratcliffe MA, Dawson AA, Walker LG. Eysenck Personality Inventory
L-scores in patients with Hodgkin’s disease and non-Hodgkin’s lymphoma.
Psychooncology 1995;4:39-45.
11. Edelman S, Lemon J, Bell DR, Kidman AD. Effects of group CBT on
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the survival time of patients with metastatic breast cancer. Psychooncology
1999;8:474-81.
12. Ilnyckyj A, Farber J, Cheang MC, Weinerman BH. A randomized con-
trolled trial of psychotherapeutic intervention in cancer patients. Ann R
Coll Physicians Surg Can 1994;27:93-6.
13. Cunningham AJ, Edmonds CVI, Jenkins GP, Pollack H, Lockwood GA,
Warr D. A randomized controlled trial of the effects of group psychological
therapy on survival in women with metastatic breast cancer. Psychooncology
1998;7:508-17.
14. Linn MW, Linn BS, Harris R. Effects of counseling for late stage can-
cer patients. Cancer 1982;49:1048-55.
15. Classen C, Butler LD, Koopman C, et al. Supportive-expressive group
therapy and distress in patients with metastatic breast cancer: a randomized
clinical intervention trial. Arch Gen Psychiatry 2001;58:494-501.
16. Kissane DW, Bloch S, Clarke DM, Smith GC. Australian RCT of
group therapy for breast cancer. Presented at the American Psychiatric As-
sociation Annual Meeting, New Orleans, 2001.
Copyright © 2001 Massachusetts Medical Society.
C OMPUTED T OMOGRAPHY OF THE
H EAD BEFORE A L UMBAR P UNCTURE
IN S USPECTED M ENINGITIS — I S I T
H ELPFUL ?
M ENINGITIS remains a formidable foe because
it often progresses rapidly and causes substan-
tial morbidity and mortality.1-3 The rational manage-
ment of meningitis has generally included a lumbar
puncture to substantiate the diagnosis and help iden-
tify the cause. In rare cases, however, this maneuver
is followed by cerebral herniation, which is some-
times fatal.4-6 Lumbar puncture generally results in
a small, transient decrease in cerebrospinal fluid pres-
sure throughout the subarachnoid space as a result of
both the removal of fluid and the continued leakage
of cerebrospinal fluid from the opening made in the
arachnoid membrane.4 In the presence of a space-
occupying inflammatory lesion (e.g., subdural empy-
ema, brain abscess, or toxoplasma encephalitis), tumor,
or hemorrhagic lesion, especially one that is rapidly
expanding, the increased pressure gradient brought
about by the lumbar puncture may downwardly dis-
place cerebral and brain-stem structures, leading to
catastrophic herniation. This event may also occur af-
ter lumbar puncture in patients with bacterial or fun-
gal meningitis that is accompanied by large and rapid
increases in cerebrospinal fluid pressure as a result of
cerebral edema, thrombosis of the sagittal sinus or cor-
tical vein, or inflammatory occlusion of the arachnoid
villi or ventricular foramina, preventing the outflow of
cerebrospinal fluid.4-6 Some elevation of intracranial
pressure, however, is almost always present in patients
with pyogenic meningitis,7 and cerebral herniation oc-
casionally occurs in those who have not undergone
lumbar puncture.6
The predicament facing clinicians is how to identify,
among patients suspected of having meningitis, the
rare ones in whom the valuable diagnostic procedure
of lumbar puncture should not be performed because
it will lead to brain herniation. Computed tomography