or be exacerbated following a diagnosis of cancer, and psychopharmacologic treatment can reduce distress and improve quality of life.

The chapter begins with a brief history of psychosocial intervention research in breast cancer followed by a discussion of methodological issues that are crucial to assessing the effectiveness of psychosocial interventions. An enumeration of research priorities to address identified knowledge gaps is outlined in Chapter 8.

HISTORY OF PSYCHOSOCIAL INTERVENTION RESEARCH

In the past decade, considerable resources have been allocated to research into the psychosocial aspects of breast cancer. Much of this research has focused on describing the emotional experience of women with breast cancer and developing interventions that reduce the psychosocial distress and improve coping and adjustment. Early intervention studies were done by Ferlic and colleagues (1979) and by Heinrich and Schag (1985), both with positive psychosocial results. A report by David Spiegel et al. that appeared in The Lancet in 1989 suggested, for the first time, that a psychological intervention (supportive–expressive group therapy) might prolong survival in women living with metastatic breast cancer (Spiegel et al., 1989). This observation heightened interest in survival effects of psychosocial interventions and led to a series of intervention studies in breast cancer (Classen et al., 2001; Cunningham et al., 1998; Edelman et al., 1999a; Goodwin et al., 2001) and other cancers (Fawzy et al., 1993; Ilnyckyj et al., 1994; Kuchler et al., 1999; Linn et al., 1982), conducted mainly in the 1990s. These studies attempted to confirm a beneficial effect of psychological interventions on survival. None of the subsequent studies in metastatic breast cancer has identified a survival effect of a range of psychological interventions (although one is ongoing) (Cunningham et al., 1998; Edelman et al., 1999a; Edmonds et al., 1999; Goodwin et al., 2001). Three studies in other malignancies (leukemia, melanoma, and mixed GI cancers) have reported survival benefits for brief interventions, delivered around the time of or shortly after diagnosis or during treatment (Fawzy et al., 1993; Kuchler et al., 1999, Richardson et al., 1990). These results have not been replicated. Nonetheless, throughout much of the 1990s, the focus of some members of the psycho-oncology research community shifted from evaluation of psychological effects of interventions to survival and intermediate biomedical effects, including enhancement of immune function. A growing recognition has developed that the survival effect in metastatic breast cancer that was seen by Spiegel et al. (Spiegel et al., 1989) has not been replicated and that little evidence supports the prognostic importance of intermediate outcomes such as cortisol levels that have been linked to psychosocial interventions, although it has been suggested that the Spiegel study at least indicated



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