PURPOSE: To assess how patients' underlying anxiety affects their experience of distress, use of resources, and responsiveness toward nonpharmacologic analgesia adjunct therapies during invasive procedures. MATERIALS AND METHODS: Two hundred thirty-six patients undergoing vascular and renal interventions, who had been randomized to receive during standard care treatment, structured empathic attention, or self-hypnotic relaxation, were divided into two groups: those with low state anxiety scores on the State-Trait Anxiety Inventory (STAI, scores < 43; n = 116) and those with high state anxiety scores (> or = 43; n = 120). All had access to patient-controlled analgesia with fentanyl and midazolam. Every 15 minutes during the procedure, patients rated their anxiety and pain on a scale of 0-10 (0, no pain/anxiety at all; 10, worst possible pain/anxiety). Effects were assessed by analysis of variance and repeated-measures analysis. RESULTS: Patients with high state anxiety levels required significantly greater procedure time and medication. Empathic attention as well as hypnosis treatment reduced procedure time and medication use for all patients. These nonpharmacologic analgesia adjunct treatments also provided significantly better pain control than standard care for patients with low anxiety levels. Anxiety decreased over the time of the procedure; patients with high state anxiety levels experienced the most significant decreases in anxiety with nonpharmacologic adjuncts whereas patients with low state anxiety levels coped relatively well under all conditions. CONCLUSION: Patients' state anxiety level is a predictor of trends in procedural pain and anxiety, need for medication, and procedure duration. Low and high state anxiety groups profit from the use of nonpharmacologic analgesia adjuncts but those with high state anxiety levels have the most to gain.

Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, WCC 308, Boston, Massachusetts 02215, USA.

J Vasc Interv Radiol. 2005 Dec;16(12):1585-92.Click here to read

Among breast cancer survivors, we identified the prevalence and correlates of use of different types of complementary and alternative medicine (CAM). PATIENTS AND METHODS: We included 2,022 women diagnosed with breast cancer 1998-2003 who responded to a survey about CAM use. We performed logistic regression to determine demographic and disease factors associated with use of different CAM therapies (including relaxation/imagery, spiritual healing, yoga, energy healing, acupuncture, massage, chiropractic, high-dose vitamins, herbs, and homeopathy). We also measured quality of life (QoL) using the SF36 and optimism using LOT-R and fit linear regression models to compare mean scores among CAM users and nonusers. RESULTS: Sixty-two percent of respondents used CAM. Younger age was the most consistent correlate of CAM use, but factors associated with CAM use varied by type of CAM. Chemotherapy was associated with use of relaxation/imagery (OR 1.3 95%CI 1.1-1.7). Radiotherapy was associated with use of high-dose vitamins (OR 1.5 95% CI 1.2-2.0). Tamoxifen or anastrozole treatment was associated with use of homeopathy (OR 0.5 95%CI 0.3-0.9). Users of most types of CAM had worse QoL scores than nonusers, but better QoL was found among users of yoga. The lowest QoL scores were associated with the use of energy healing. Optimism was higher among users of relaxation/imagery. CONCLUSIONS: Factors associated with CAM use varied according to type of CAM. Our finding of worse QoL among women using energy healing and better QoL among women using yoga suggests the need for longitudinal studies to determine the temporal relationships between these therapies and QoL.

Division for Research and Education in Complementary and Integrative Medical Therapies, Harvard Medical School, Boston, MA, 02215-3325, USA, catherine_buettner@hms.harvard.edu.

Breast Cancer Res Treat. 2006 Nov;100(2):219-27. Epub 2006 Jul 5.

PURPOSE: To review the available literature on the use of complementary and alternative medicine (CAM) treatments for cancer-related fatigue with an aim to develop directions for future research. METHODS: PubMed, EMBASE, CINAHL, PsycINFO, and SPORTDiscus were searched for relevant studies. Original clinical trials reporting on the use of CAM treatments for cancer-related fatigue were abstracted and critically reviewed. RESULTS: CAM interventions tested for cancer-related fatigue include acupuncture, aromatherapy, adenosine triphosphate infusions, energy conservation and activity management, healing touch, hypnosis, lectin-standardized mistletoe extract, levocarnitine, massage, mindfulness-based stress reduction, polarity therapy, relaxation, sleep promotion, support group, and Tibetan yoga. Several of these interventions seem promising in initial studies. CONCLUSION: Currently, insufficient data exist to recommend any specific CAM modality for cancer-related fatigue. Therefore, potentially effective CAM interventions ready for further study in large, randomized clinical trials (eg, acupuncture, massage, levocarnitine, and the use of mistletoe) should be pursued. Other interventions should be tested in well-designed feasibility and phase II trials.

Sood A, Barton DL, Bauer BA, Loprinzi CL. Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA. sood.amit@mayo.edu

Epidemiological and clinical researches in the borderline domain between psychology and cancer have produced consequent results, despite the large variety of employed approaches and aimed goals: these results permit to define domains where new investigations still appear promising. If randomized prospective controlled trials that test the impact of psychosocial interventions, constitute to our mind a strategy that must not be bypassed, a special attention should be focussed on the following topics: 1) it seems necessary to add to standard goals (survival and quality of life) the evaluation of the impact on immunity and main biological rhythms (circadian and ultradian). Specific questionnaires should be included (pain, sleep, mood, self-esteem, life events...) and others may need to be developed or adapted (sexuality, spirituality, coping with death); 2) among types of psychosocial management, hypnosis and/or learning of self-hypnosis appears to be a modality of choice since some results have already been obtained on immune pathologies and also on cancer. Mixed to an approach of clinical psychology, such a management could arouse behavior changes toward pathology but also promote an improvement of biological rhythms (action on sleep...) and perhaps, by the way, an immune rebound; 3) on a methodological point of view, trials cannot be double-blind. The effort must then concern sample sizes, that were often insufficient in many trials, but also targeted populations: palliative cancer patients with a good performance status seem more relevant for this type of investigation, since psychosocial interventions usually improve quality of life.

Centre Jean-Perrin, centre de lutte contre le cancer, 58, rue Montalembert, BP 392, 63011 Clermont-Ferrand, France.

Medical procedures in outpatient settings have limited options of managing pain and anxiety pharmacologically. We therefore assessed whether this can be achieved by adjunct self-hypnotic relaxation in a common and particularly anxiety provoking procedure. Two hundred and thirty-six women referred for large core needle breast biopsy to an urban tertiary university-affiliated medical center were prospectively randomized to receive standard care (n=76), structured empathic attention (n=82), or self-hypnotic relaxation (n=78) during their procedures. Patients' self-ratings at 1 min-intervals of pain and anxiety on 0-10 verbal analog scales with 0=no pain/anxiety at all, 10=worst pain/anxiety possible, were compared in an ordinal logistic regression model. Women's anxiety increased significantly in the standard group (logit slope=0.18, p<0.001), did not change in the empathy group (slope=-0.04, p=0.45), and decreased significantly in the hypnosis group (slope=-0.27, p<0.001). Pain increased significantly in all three groups (logit slopes: standard care=0.53, empathy=0.37, hypnosis=0.34; all p<0.001) though less steeply with hypnosis and empathy than standard care (p=0.024 and p=0.018, respectively). Room time and cost were not significantly different in an univariate ANOVA despite hypnosis and empathy requiring an additional professional: 46 min/161 dollars for standard care, 43 min/163 dollars for empathy, and 39 min/152 dollars for hypnosis. We conclude that, while both structured empathy and hypnosis decrease procedural pain and anxiety, hypnosis provides more powerful anxiety relief without undue cost and thus appears attractive for outpatient pain management.

Lang EV, Berbaum KS, Faintuch S, Hatsiopoulou O, Halsey N, Li X, Berbaum ML, Laser E, Baum J. Beth Israel Deaconess Medical Center/Harvard Medical School, Department of Radiology, Boston, MA, USA. elang@caregroup.harvard.edu

By Judith E. Pearson, Ph.D.

In 1978 Richard Bloch, co-founder of H&R Block, was diagnosed with cancer. The prognosis was that he would be dead in three months. After two years of aggressive therapy he recovered. Wanting to make a difference in the lives of others struggling with cancer, he sold his interest in H&R Block and founded The Cancer Hotline in 1980, and the Block Cancer Support Center in 1986. He sponsored a national computer database, the Physician's Data Query, with the latest research and treatment protocols for every known form of cancer. Today this database is operated by the National Cancer Institute in Bethesda, Maryland.

Richard and his wife, Annette, wrote Fighting Cancer, a book offering self-help advice. Their second book, A Guide for Cancer Supporters1, is for family and friends of those who have cancer. Both books offer inspiration and hope, encouraging cancer patients to fight to live, instead of waiting to die. These books also recommend that cancer patients supplement medical interventions with psychotherapy, guided imagery, and clinical hypnotherapy. In the 1970's the use of such therapies in the treatment of disease was almost unheard of and to suggest such an idea bordered on heresy. Three decades later, supplemental therapies such as hypnotherapy, acupuncture, therapeutic massage, nutritional counseling, and neuro-feedback are widely considered as essentials in the holistic approach to health and the treatment of disease.

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: Complementary and alternative medicines (CAM) use among cancer patients is becoming more prevalent; however, our understanding of factors contributing to patients' decisions to participate in CAM is limited. This study examined correlates of CAM use among colorectal cancer (CRC) survivors, an understudied population that experiences many physical and psychological difficulties. MATERIALS AND METHODS: The sample was 191, predominantly white, CRC survivors (mean age = 59.9 +/- 12.6) who were members of a colon disease registry at a NYC metropolitan hospital. Participants completed assessments of sociodemographic characteristics, psychosocial factors [e.g., psychological functioning, cancer specific distress, social support (SS), quality of life (QOL)], and past CAM use (e.g., chiropractic care, acupuncture, relaxation, hypnosis, and homeopathy). MAIN RESULTS: Seventy-five percent of participants reported using at least one type of CAM; most frequently reported was home remedies (37%). Younger (p < 0.01) or female patients (p < 0.01) were more likely to participate in CAM than their older male counterparts. Among psychosocial factors, poorer perceived SS (p = 0.00), more intrusive thoughts (p < 0.05), and poorer overall perceived QOL (p < 0.05) were associated to CAM use. In a linear regression model (including age, gender, SS, intrusive thoughts, and perceived QOL), only age remained a significant predictor of CAM use. CONCLUSION: These findings demonstrate that CAM use is prevalent among CRC survivors and should be assessed routinely by providers. CAMs may serve as a relevant adjunct to treatment among CRC patients as well as an indication of need for additional SS, especially among younger patients.

Department of Oncological Sciences, Mount Sinai School of Medicine, 1425 Madison Avenue, P.O. Box 1130, New York, NY, 10029, USA, Catalina.Lawsin@mssm.edu

Despite widespread popular use of complementary and alternative medicine (CAM) therapies, a rigorous evidence base about their efficacy for cancer-related pain is lacking. This is a systematic review of randomized controlled trials (RCTs) evaluating CAM therapies for cancer-related pain. METHODS: RCTs using CAM interventions for cancer-related pain were abstracted using Medline, EMBASE, CINAHL, AMED, and Cochrane database. RESULTS: Eighteen trials were identified (eight poor, three intermediate, and seven high quality based on Jadad score), with a total of 1,499 patients. Median sample size was 53 patients, and median intervention duration was 45 days. All studies were from single institutions, four had sample size justification, and none reported any adverse effects. Seven trials reported significant benefit for the following CAM therapies: acupuncture (n = 1), support groups (n = 2), hypnosis (n = 1), relaxation/imagery (n = 2), and herbal supplement/HESA-A (n = 1, but study was of low quality without control data). Seven studies reported immediate postintervention or short-term benefit of the following CAM interventions: acupuncture (n = 2), music (n = 1), herbal supplement/Ai-Tong-Ping (n = 1), massage (n = 1), and healing touch (n = 2). Four studies reported no benefit of CAM interventions (music, n = 2; massage, n = 2) in reducing cancer pain compared with a control arm. CONCLUSION: There is paucity of multi-institutional RCTs evaluating CAM interventions for cancer pain with adequate power, duration, and sham control. Hypnosis, imagery, support groups, acupuncture, and healing touch seem promising, particularly in the short term, but none can be recommended because of a paucity of rigorous trials. Future research should focus on methodologically strong RCTs to determine potential efficacy of these CAM interventions.

Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA.

Cachexia is among the most debilitating and life-threatening aspects of cancer, and is more common in children and elderly patients.

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Burish, Snyder and Jenkins, the highly regarded Vanderbilt University team known for its many studies of imagery and chemotherapy, assessed the effectiveness of biofeedback and relaxation training in reducing the aversive side effects of cancer chemotherapy on 81 patients.

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Hot flashes are a significant problem for many breast cancer survivors and can cause discomfort, insomnia, anxiety, and decreased quality of life. In the past, the standard treatment for hot flashes has been hormone replacement therapy. However, recent research has found an increased risk of breast cancer in women receiving hormone replacement therapy.

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Researchers at the Dana-Farber Cancer Institute in Boston conduct guided interviews with bone marrow transplant patients, as a first step to improve the actual design of a mindfulness meditation study.

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Blair Justice, Mary Ann Richardson and their cohorts at the University of Texas-Houston School of Public Health, conducted a pilot study to differentiate the effects of imagery vs. support on coping, attitude, immune function and emotional well-being after breast cancer. Subjects were randomly assigned to one of 3 groups: standard care, weekly support (for 6 weeks) or imagery sessions (for 6 weeks).

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Many people with cancer experience pain, anxiety, and mood disturbance. Conventional treatments do not always satisfactorily relieve these symptoms, and some patients may not be able to tolerate their side effects. Complementary therapies such as acupuncture, mind-body techniques, massage, and other methods can help relieve symptoms and improve physical and mental well-being. Self-hypnosis and relaxation techniques help reduce procedural pain.

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Katherine Kolcaba, PhD, RN (U of Akron) and Christine Fox, PhD, (U of Toledo) found guided imagery to be an effective intervention for increasing comfort and reducing anxiety in 53 women with early stage breast cancer undergoing Radiation Therapy. The investigators designed and recorded imagery specifically for this study. Subjects were most likely to listen just before a treatment.

More and more women are now successfully being treated for breast cancer, and wind up searching for ways to hedge their bets on staying strong and well after treatment is completed. A recent survey out of Western Oregon University asked 551 ex-breast cancer patients about their use of 15 different complementary and alternative (CAM) therapies after completion of allopathic therapy for breast cancer. These were women in the Portland OR area who were diagnosed an average of 3.5 years earlier.

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Researchers at the Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine in Seoul, South Korea studied the effectiveness of progressive muscle relaxation training (PMRT) and guided imagery (GI) in reducing the anticipatory nausea and vomiting (ANV) and postchemotherapy nausea and vomiting (PNV) and in increasing quality of life for patients with breast cancer.

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Researchers at Oregon Health and Science University study the effect of guided imagery on immune function in patients being treated for Stage I or II breast cancer.

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Researchers from the School of Nursing at the University of Michigan evaluate a post-treatment self-regulation program of self-management for 25 breast cancer patients and find it highly effective.

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Researchers at the Tom Baker Cancer Centre in Calgary, Canada studied the effects on early stage breast and prostate cancer patients of a mindfulness-based stress reduction meditation program, on quality of life, mood states.

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The aim of this review was to find the evidence for or against the use of hypnotherapy in the treatment of symptoms in terminally ill adult cancer patients. The title and abstract were evaluated following a search through Index Medicus/MEDLINE, EMBASE, CINHAHL, CancerLit, AHMED, Psychinfo, CISCOM, Cochrane and DARE. Search terms included hypnotherapy, cancer, terminal care and palliative care. Inclusion criteria included systematic reviews, randomized controlled trials, observational and prospective studies, retrospective surveys, case studies and reports. A total of 27 papers were evaluated. Two reviewers assessed the studies, one extracted the relevant data and 10% were evaluated independently by a third reviewer. The 27 papers comprised a randomized controlled trial, an observational study, a retrospective questionnaire and 24 case studies. Hypnotherapy was used to treat a variety of symptoms, including pain, anxiety and depression. The poor quality of the studies and heterogeneity of the study population limited further evaluation; further research is required to understand the role of hypnotherapy in managing symptoms.

Department of Palliative Care and Policy, King's College, London, UK. m9era@hotmail.com

The study group included 17 cancer patients, aged 25-55, (stage III-IV), mostly suffering melanoma. All of them received hypnosuggestive therapy to correct psycho-emotional disorders. Significant decrease in anxiety-related indices (p < 0.001) due to therapy pointed to rehabilitation of psychological defenses. Clinical rehabilitation was manifested by improved quality of life (p < 0.01), better habitus and adaptation (p < 0.01). The modulating effect on the macrophageal and phagocytic components of the immune system (p < 0.05) was matched by a significant correlation between psychological defense indices and those of immunological status. Our data have contributed to the existing knowledge about relationships of mind and immunity in cancer patients.

This single arm, pilot study investigated the use of hypnosis to reduce hot flashes in 16 breast cancer survivors. Each patient provided baseline data and received 4 weekly sessions of hypnosis that followed a standardized transcript. Patients were also instructed in self-hypnosis. Throughout the clinical care, patients completed daily diaries of the frequency and severity of their hot flashes. Patients also completed baseline and post-treatment ratings of the degree to which hot flashes interfered with daily activities and quality of life. Results indicated a 59% decrease in total daily hot flashes and a 70% decrease in weekly hot flash scores from their baselines. There was also a significant decrease in the degree to which hot flashes interfered with daily activities for all measures including work, social activities, leisure activities, sleep, mood, concentration, relations with others, sexuality, enjoyment of life, and overall quality of life. This pilot study suggests that clinical hypnosis may be an effective non-hormonal and non-pharmacological treatment for hot flashes. A randomized, controlled clinical trial is planned to more definitively elucidate the efficacy and applicability of hypnosis for reducing hot flashes. Copyright (c) 2006 John Wiley & Sons, Ltd.

Mind-Body Cancer Research Program, Scott and White Memorial Hospital, Temple, TX, USA.

The use of complementary/alternative medicine (CAM) has been well documented among children with cancer. This report summarizes the research evidence on the role of CAM therapies for prevention and treatment of the most commonly reported cancer-related symptoms and late effects among children with cancer. Small clinical trials document evidence of effectiveness for select therapies, such as acupuncture or ginger for nausea and vomiting, TRAUMEEL S for mucositis, and hypnosis and imagery for pain and anxiety. Several relatively small clinical trials of varying quality have been conducted on these CAM therapies in children with cancer. Some herbs have demonstrated efficacy in adults, but few studies of herbs have been conducted in children. Larger randomized clinical trials are warranted for each of these promising therapies. Until the evidence is more conclusive, the providers' role is to assess and document the child's use of CAM, critically evaluate the evidence or lack of evidence, balance the potential risks with possible benefits, and assist the family in their choices and decisions regarding use of CAM for their child with cancer.

Division of Pediatric Oncology, Integrative Therapies Program for Children with Cancer, Columbia University, 161 Ft. Washington, New York, NY 10032, USA. ejd14@columbia.edu

The aim of this study was to systematically review and critically appraise the evidence on the effectiveness of hypnosis for procedure-related pain and distress in pediatric cancer patients. A comprehensive search of major biomedical and specialist complementary and alternative medicine databases was conducted. Citations were included from the databases' inception to March 2005. Efforts were made to identify unpublished and ongoing research. Controlled trials were appraised using predefined criteria. Clinical commentaries were obtained for each study. Seven randomized controlled clinical trials and one controlled clinical trial were found. Studies report positive results, including statistically significant reductions in pain and anxiety/distress, but a number of methodological limitations were identified. Systematic searching and appraisal has demonstrated that hypnosis has potential as a clinically valuable intervention for procedure-related pain and distress in pediatric cancer patients. Further research into the effectiveness and acceptability of hypnosis for pediatric cancer patients is recommended.

Faculty of Health and Social Work, Portland Square, University of Plymouth, Drake Circus, Plymouth, Devon PL4 8AA, United Kingdom. janet.richardson@plymouth.ac.uk

Although psychosocial coping techniques and supportive care services have been shown to improve cancer patients' quality of life, there is evidence that many of these strategies have not been widely integrated into the routine care of cancer patients. This study examined: (1) the extent to which cancer patients use certain coping strategies; (2) reasons for non-use; (3) perceived effectiveness of the coping strategies; (4) participants' interest in trying the strategies; and (5) if the strategies were recommended to participants. At the Northwestern Ontario Regional Cancer Centre in Thunder Bay, Ontario, Canada, 292 outpatients (98% response rate) completed an in-person interview with a research assistant concerning seven individual coping strategies (music, breathing exercises, meditation, prayer, muscle relaxation, visualization/imagery, hypnosis/self-hypnosis) and four coping strategies offered through supportive care services (individual counselling, family counselling, support groups, religious support). Of all the coping strategies presented, prayer was used by the highest number (n = 186) of participants (64%). Music was the next most commonly used strategy, used by 43% (n = 124) of participants, and all other strategies were used by less than 30%of participants. The individualized approaches that are used for disseminating disease and treatment information to cancer patients should also be used to provide them with information on effective coping strategies.

Centre for Behavioural Research and Program, University of Waterloo, Canada.