PSYCHO-ONCOLOGY

Psycho-Oncology 8: 482–493 (1999)

GROUP PSYCHOTHERAPY FOR RECENTLY

DIAGNOSED BREAST CANCER PATIENTS: A
MULTICENTER FEASIBILITY STUDY
DAVID SPIEGELa,*, GARY R. MORROWb, CATHERINE CLASSENa, RICHARD RAUBERTASb, PHILLIP
B. STOTTc, NARAYAN MUDALIARd, H. IRVING PIERCEe, PATRICK J. FLYNNf, LAURA HEARDg and
GAIL RIGGSb
a
Department of Psychiatry & Beha6ioral Sciences, Stanford Uni6ersity School of Medicine, Stanford, CA, USA
b
Uni6ersity of Rochester Cancer Center, Rochester, NY, USA
c
Kalamazoo Community Clinical Oncology Program (CCOP), Kalamazoo, MI, USA
d
Wichita CCOP, Wichita, KS, USA
e
Northwest CCOP, Tacoma, WA, USA
f
Metro-Minnesota CCOP, Minneapolis, MN, USA
g
Virginia Mason Research Center CCOP, Seattle, WA, USA

SUMMARY
As many as 80% of breast cancer patients report significant distress during initial treatment, yet there is little in
the way of systematic psychotherapeutic interventions for women coping with the stress of a recent diagnosis of
breast cancer. The literature on psychotherapeutic treatment of cancer patients provides uniform evidence for an
improvement in mood, coping and adjustment as a result of group therapy. The present study examined the
feasibility of implementing a manualized treatment, supportive – expressive group psychotherapy, in busy oncology
practices across the US. This intervention was applied to women with primary breast cancer in a manner which
tests not only the efficacy of the approach but also its accessibility to group therapists not previously experienced
in its use. One hundred and eleven breast cancer patients within 1 year of diagnosis were recruited from ten
geographically diverse sites of the National Cancer Institute’s Community Clinical Oncology Program (CCOP) and
two academic medical centers. Two therapists from each site were trained in supportive – expressive group
psychotherapy. Training consisted of participation in a workshop, reading a treatment manual, and viewing
explanatory videotapes. Each patient participated in a supportive – expressive group that met for 12 weekly sessions
lasting 90 min. Assessment of mood disturbance was made at entry, 3, 6, and 12 months. Results indicated a
significant 40% decrease in the Total Mood Disturbance (TMD) scores of the Profile of Mood States (POMS)
(ANOVA F [2,174]=3.98, pB0.05). The total symptom score of the Hospital Anxiety and Depression Scale
(HADS) was likewise significantly reduced over the 6-month period (F [2,174]= 5.2, pB 0.01). Similarly, the total
score of the Impact of Event Scale (IES) was significantly reduced (F [2,174]= 4.0, pB 0.05). There was substantial
uniformity of treatment effect across sites. Outcome was independent of stage of disease (I 6s. II). We conclude
that this treatment program can be effectively implemented in a community setting and results in reduced distress
among breast cancer patients. Copyright © 1999 John Wiley & Sons, Ltd.

INTRODUCTION 1990), problems with sexual function (Morris et

Emotional distress is common among recently
diagnosed breast cancer patients, affecting as
many as 80% during initial treatment (Hughes,
1982). The most frequent problems are anxiety
about recurrence (Koocher and O’Malley, 1981;
Rieker et al., 1985; Quigley, 1989; Mahon et al.,
* Correspondence to: Stanford University School of Medicine,
401 Quarry Road, Room 2325, Stanford, CA 94305, USA.
al., 1977; Maguire et al., 1978), death anxiety, and
vocational difficulties (Fobair et al., 1986; Tross
and Holland, 1990). Treatment requires constant
attention to the illness, and can stimulate recur-
rent anxiety, induce conditioned anticipatory nau-
sea (Itano et al., 1983) and reduce compliance
(Cella et al., 1986). Although several early studies
reported good long-term adjustment of breast
cancer patients (Schottenfeld and Robbins, 1970;
Craig et al., 1974), a number of others indicate
that psychological distress remains high up to 18

CCC 1057–9249/99/080482–12$17.50 Recei6ed 1 May 1998

Copyright © 1999 John Wiley & Sons, Ltd. Accepted 26 February 1999
 GROUP PSYCHOTHERAPY AND BREAST CANCER
months after the initial diagnosis (Northouse,
1989; Maunsell et al., 1992). As many as 25% of
breast cancer patients have been found to suffer
severe distress for 2 or more years post-surgery
(Irvine et al., 1991; Ganz et al., 1992).
Hughes (1982) found 80% of patients had sus-
tained emotional distress at 12 month follow-up
with severe distress in 18%. Similarly, Goldberg et
al. (1992) found persistent anxiety and depression
in one quarter of a sample of 320 breast cancer
patients at 12 month follow-up. Dean (1987)
found persistent minor depression in 18% of a
sample at 12 month follow-up, but also observed
that the prevalence of major depression had
dropped from 9.7% at 3 months to 4.5% at 12
months, which is comparable to the prevalence in
the general population (Myers, et al., 1984). In
addition, women under 50 years were at higher
risk. Other studies show more decline in mood
disturbance. Hughson et al. (1988) showed a drop
in clinical depression from 32 to 13% between 1
and 24 month follow-up and in anxiety caseness
from 21 to 13% at 24 month follow-up. While
there are methodological limitations in a number
of studies (de Haes and van Knippenberg, 1985),
including differences in the severity criteria re-
quired for a diagnosis of an anxiety or depressive
disorder, they indicate that overall mood distur-
bance of breast cancer patients is persistent, even
though it declines slowly over time.
There is evidence that patients’ patterns of cop-
ing with a cancer diagnosis (Dunkel-Schetter et
al., 1992) and their psychosocial needs (Liang et
al., 1990) do not change significantly after the
initial diagnosis. The primary concerns expressed
by 96% of cancer patients in one survey included
effects of the disease on family members, emo-
tional stress, and acquiring further information
(Liang et al., 1990; Mahon et al., 1990). Patients
at higher risk for poor coping include those who
are socially isolated, have a history of recent
losses, have multiple obligations, or who employ
inflexible coping strategies (Rowland, 1990).
However, breast cancer patients who learn to use
more direct and confrontational coping strategies
were found to be less distressed than those who
used avoidance and denial (Holland and Row-
land, 1990). Recent research has shown that be-
liefs that one has control over the cause of the
disease leads to poor outcome, while belief in
control over the course of the disease leads to
better outcome (Watson et al., 1990).
Copyright © 1999 John Wiley & Sons, Ltd.
483
The literature on psychotherapeutic treatment
of cancer patients provides uniform evidence for a
positive systematic improvement in mood, coping
and adjustment as a result of group therapy. A
recent review found that 19 of 22 studies demon-
strated positive outcome (Trijsburg et al., 1992).
Many of the group psychotherapies which have
shown promise in improving emotional adjust-
ment, and even influencing survival time, involve
encouraging open expression of emotion and as-
sertiveness in assuming control over the course of
treatment, life decisions, and relationships
(Spiegel and Yalom, 1978; Spiegel et al., 1981,
1989; Fawzy et al., 1990). Supportive–expressive
group therapy for metastatic breast cancer pa-
tients has been shown to result in better mood,
fewer maladaptive coping responses, fewer phobic
symptoms (Spiegel et al., 1981), reduced pain
(Spiegel and Bloom, 1983), and longer survival
time (Spiegel et al., 1989). Supportive–expressive
group psychotherapy (Spiegel and Yalom, 1978)
has been compared in a randomized prospective
trial to cognitive–behavioral treatment in a sam-
ple of HIV infected patients (Kelly et al., 1993).
The emotionally expressive approach was found
to be more effective in reducing mood
disturbance.
While some studies show benefits for cancer
patients undergoing individual psychotherapy
(Gordon et al., 1980; Cain et al., 1986; Greer et
al., 1992) group therapy offers three unique ad-
vantages as a psychotherapeutic intervention:
(1) Social support. An often-noted benefit
(Tracy and Gussow, 1976; Toseland and Hacker,
1982) of attendance at support groups is that
members can relate to each other in special ways
that counter the social isolation they often experi-
ence after a cancer diagnosis. Being part of a
group can afford cancer patients a sense of com-
munity necessary for successful coping and
provide opportunities to learn from each other. In
a review of the social comparison literature, Tay-
lor and Lobel (1989) observe that cancer patients
seek interactions with other patients who have
either overcome their illness or are adjusting well.
(2) Helper-therapy principle. Mutual support in
a group setting provides what has been called the
‘helper-therapy principle’ (Riessman, 1965), in
which patients gain in self-esteem through their
ability to help others. The tragedy of having
cancer is converted into an asset which enables
one woman to provide concrete help to another.
It has been demonstrated that cancer patients find
Psycho-Oncology 8: 482–493 (1999)
484 D. SPIEGEL ET AL.
other patients to be most helpful when they model
successful coping and surviving (Taylor and
Dakof, 1988). Many newly recurrent cancer pa-
tients have reported that ‘it was helpful to discuss
their concerns objectively with someone outside of
their family’ (Mahon et al., 1990). Group therapy
increases the likelihood of constructive compas-
sion with other cancer patients (Yalom, 1995).
(3) Cost-effectiveness. Group therapy is clearly
more cost-effective than individual therapy in that
it makes limited professional resources available
to many more women, including underserved
populations. Economically, group therapy may be
up to four times more affordable for patients and
for institutions (Hellman et al., 1990; Yalom and
Yalom, 1990).
Several well-conducted meta-analytic studies
have illuminated a large literature demonstrating
that psychoeducational (Devine, 1992) and psy-
chotherapeutic (Mumford et al., 1984) interven-
tions produce cost-savings in medical treatment.
Effects on medical practice resulting from such
psychosocial interventions for medically ill patient
populations include more rapid recovery from
surgery (Devine, 1992), shorter hospital stays
(Mumford et al., 1984; Strain et al., 1991; Devine,
1992), and reduced distress-related outpatient vis-
its to doctors (Cummings and VandenBos, 1981;
Lorig et al., 1985; Browne et al., 1990).
Given that emotional distress is common
among newly diagnosed breast cancer patients,
that social support and coping styles influence
psychological adjustment, and that group therapy
has been found to improve psychosocial outcome
for cancer patients, a psychosocial intervention
for newly diagnosed breast cancer patients, which
places the focus on providing social and emo-
tional support and improving coping strategies,
should result in better adjustment, as a brief
preliminary report indicated (Spiegel and Mor-
row, 1996). Below we describe fully the applica-
tion of supportive – expressive group therapy to a
sample of women with primary breast cancer
within 1 year of diagnosis at 12 sites around the
US. Our aim was to determine the feasibility of
applying a brief supportive – expressive group
therapy for breast cancer patients in geographi-
cally diverse oncology programs and to explore
outcome within the confines of a non-randomized
trial. The training program we implemented to
train therapists in the supportive – expressive
group therapy model is described elsewhere
(Classen et al., 1997).
Copyright © 1999 John Wiley & Sons, Ltd.
METHOD
Sample
The sample consisted of 115 women recruited at
12 participating sites of the Community Clinical
Oncology Program (CCOP) funded by the Na-
tional Cancer Institute.
Subjects were included if they met all of the
inclusion criteria and did not meet any of the
exclusion criteria. Inclusion criteria were as
follows:
1. first occurrence biopsy-proven breast cancer,
either stage I or II disease;
2. being within 1 year of initial diagnosis;
3. no noticeable, detectable disease;
4. understands spoken English; and
5. willingness to participate in a group therapy
trial.
Exclusion criteria were as follows:
1. metastases beyond adjacent lymph nodes, in-
cluding chest wall involvement, bone, or
viscera;
2. recurrence to breast or other tissue;
3. other cancers (except basal cell or squamous
cell carcinoma of the skin or in situ cervical
cancer) or illness thought to be life-
threatening;
4. a history of major psychiatric illness (other
than depression or anxiety) for which patient
was hospitalized.
The mean time from initial diagnosis of breast
cancer to study entry was 8.0 months (S.D. 3.4;
median 8.4). Demographic characteristics of the
sample are summarized in Table 1.
Training of therapists
Each group was led by two leaders who had
been trained to lead brief supportive–expressive
psychotherapy groups. Therapists were selected
for training if they had previous experience in
leading psychotherapy groups or had worked with
breast cancer patients. All leaders were formally
trained in nursing, psychology or social work.
They were required to attend a 3-day workshop,
view a training videotape, and study the treatment
manual written specifically for this intervention.
The treatment manual described a brief support-
ive–expressive group therapy intervention for
Psycho-Oncology 8: 482–493 (1999)
 GROUP PSYCHOTHERAPY AND BREAST CANCER 485

women with primary breast cancer (Classen et honest expression of thoughts and emotions, re-
al., 1993). ceiving and offering support and learning new
ways to cope with having breast cancer. A cen-
tral aim was to help each patient face and man-
Inter6ention age her worst fears rather than merely hoping
for the best. Another was to facilitate patient
The groups met once a week for 12 weeks transition from passive to active coping strate-
and each session was 90 min in length. The em- gies, beginning with information and emotion-
phasis in each group was on allowing open and focused approaches and moving toward
problem-focused resolution of these issues.
Specific self-hypnosis stress and pain manage-
Table 1. Demographic characteristics (n = 115)
ment exercises were also taught (Spiegel and
n (%) Bloom, 1983; Spiegel and Spiegel, 1987). These
exercises, which occupied the concluding 5 min
Education of each group, were designed to be experiential
Graduate school 18 (16) rather than didactic, teaching patients how to
College 28 (24) use self-hypnosis to reduce tension and the per-
Partial college 40 (35) ception of pain. Unlike the practice in typical
High school 28 (24) psychotherapy groups, cancer patient members
Junior high 1 (1) were encouraged to see one another outside the
Current therapy formal meeting times to aid in the development
No 98 (85) of social support.
Yes 16 (14) The role of the therapists was to guide the
with psychiatrist 1 (1) conversations toward being personal, specific,
with psychologist 9 (8)
emotionally expressive, and relevant to others in
with MSW 5 (4)
Other 1 (1)
the group. Topics of concern were allowed to
emerge naturally from the group. However,
Marital status group leaders were also trained to facilitate the
Never married 12 (10) exploration of issues that we have found to be
Currently married 77 (67)
of universal concern to breast cancer patients
Separated 2 (2)
Divorced 15 (13)
and to discourage discussion of unrelated topics.
Widowed 7 (6) The topics we have found to be important in-
Living with partner 2 (2) clude: (1) building bonds of support and coun-
tering social isolation; (2) coping with feelings of
Household income ($)
B20 000 10 (9)
uncertainty, helplessness and lack of control; (3)
20 000–39 000 29 (25) detoxifying fears of dying; (4) reordering life pri-
40 000–59 000 25 (22) orities; (5) enhancing relationships with family
60 000–79 000 16 (14) and friends; (6) improving communication with
80 000–99 000 11 (10) physicians and other health care providers; (7)
\100 000 9 (8) adjusting to a changed self- and body-image;
Age and (8) learning pain and anxiety management.
Mean 52 Therapists were trained not to lecture or provide
S.D. 10 specific information or medical advice. A typical
Employed
intervention involved restating an emotionally-
Yes 47 (41) laden issue raised by a patient, and assisting the
No 67 (59) patient in deepening her exploration of the topic
or facilitating an active coping strategy. For ex-
Ethnic
ample, ‘It must have been upsetting to you to
Asian/Pacific Islander 1 (1)
African American 3 (3)
learn that you needed an additional round of
Hispanic/Latino 2 (2) chemotherapy. How can we help you to deal
Native American 2 (2) with it?’ Therapists were instructed to avoid
European American 107 (93) analysis of personality, historical causes of
present problems or direct confrontation.

Copyright © 1999 John Wiley & Sons, Ltd. Psycho-Oncology 8: 482–493 (1999)
486 D. SPIEGEL ET AL.
Measures
The following measures were taken at baseline
before the group began and were repeated at 3
and 6 months:
Profile of Mood States (POMS). The POMS
(McNair et al., 1971) is a 65-item, adjective-rating
scale designed to measure affective states. We
used the bipolar form, which yields a score for
TMD, ranging from 0 to 60, as well as a score for
each of six subscales: tension – anxiety, depres-
sion–dejection, anger – hostility, vigor – activity,
fatigue–inertia, and confusion – bewilderment. It
has been shown to have good internal consistency,
test–retest reliability, and concurrent validity.
Studies of short-term therapy and controlled drug
trials indicate that the POMS is sensitive to
change associated with treatment. In a study on
the effects of supportive – expressive group ther-
apy for women with metastatic breast cancer,
there were significant decreases in total mood
disturbance, tension – anxiety, fatigue, and confu-
sion over the course of treatment (Spiegel et al.,
1981).
Hospital Anxiety and Depression Scale (HADS).
This 14-item scale (Zigmond and Snaith, 1983)
evaluates two major indices of emotional distress,
anxiety and depression, and is designed to be used
with medical outpatients. Scores can range from 0
to 21 for each subscale. This measure has good
internal consistency and construct validity. The
POMS screens for normal variation in mood dis-
turbance, while the HADS specifically measures
symptomatology of clinical depression (HADS-D)
and anxiety (HADS-A) with two subscales and a
total score.
The Impact of E6ent Scale (IES). The IES is a
15-item self-report scale assessing the degree of
subjective distress experienced following a stress-
ful life event, defined in this study as having been
diagnosed with breast cancer. Individuals are
asked to rate the frequency with which they have
had intrusive or avoidant experiences in the 7
days prior to testing. Intrusive experiences include
unbidden thoughts, and feelings or images of the
trauma. Avoidant experiences include having tried
to avoid reminders of the trauma or to dull their
emotional reactions to it. The IES has been
demonstrated to have good reliability and validity
(Zilberg et al., 1982). It has also been shown to be
Copyright © 1999 John Wiley & Sons, Ltd.
sensitive to change associated with psychothera-
peutic treatment. Responses are recorded on a
4-point scale (0= not at all, 1= rarely, 3=some-
times, 5= often), with scores ranging from 0 to
75.
Data analysis
Each of the mood disturbance measures was
analyzed using a mixed-model analysis of vari-
ance. Stage of disease (I or II), observation time
(baseline 3, 6, and 12 months) and their interac-
tion were fixed effects in the models. Site, patient,
and site–time interaction were random effects.
Restricted maximum likelihood estimates of
parameters were obtained using the MIXED pro-
cedure of SAS. Contrasts were used to test for
changes in mean mood disturbance values from
baseline to the 3, 6, and 12 month follow-ups. A
p value of 0.05 or less was used to define statisti-
cal significance.
RESULTS
Of the 115 women recruited for the study, four
dropped out quickly without completing the base-
line assessment. Ninety-two women completed all
assessments through 12 months. All available data
for the 19 women with incomplete follow-up were
included in analyses; final samples sizes are noted
in the tables.
(1) Change in mood disturbance
Table 2 summarizes mean mood disturbance
scores at each of the assessments. Means declined
over time for all measures. Table 3 gives adjusted
estimated changes in means from baseline to the
3, 6, and 12 month assessments. These estimates
are from the fitted ANOVA models and are ad-
justed for patient, site, and disease stage effects in
the models.
The mean score on the POMS TMD scale was
significantly lower at 6 and 12 months compared
to baseline (Table 3). The estimated reduction at 6
months was 8.3 (S.E.M. 3.4) points, about 33% of
the baseline mean. This reduction was similar to
that observed in the treatment portion of our
original study with metastatic breast cancer patients
(Spiegel et al., 1981). The decline in mood distur-
bance was comparable across POMS subscales,
Psycho-Oncology 8: 482–493 (1999)
 GROUP PSYCHOTHERAPY AND BREAST CANCER 487

Table 2. Mean (S.E.M.) of mood disturbance measures, by time

Outcome Baseline 3 months 6 months 12 months

(n=111) (n = 106) (n = 104a) (n =99b)

POMS 24.8 (3.0) 22.4 (3.4) 15.9 (3.3) 14.1 (3.1)

HADS-A 6.8 (0.4) 6.1 (0.4) 6.0 (0.4) 5.5 (0.4)
HADS-D 3.7 (0.3) 3.3 (0.3) 2.7 (0.3) 2.4 (0.3)
HADS total 10.5 (0.6) 9.4 (0.6) 8.7 (0.6) 7.9 (0.6)
IES-I 14.5 (0.7) 13.8 (0.7) 12.8 (0.6) 11.9 (0.6)
IES-A 16.1 (0.6) 15.9 (0.7) 15.4 (0.7) 14.7 (0.7)
IES combined 24.8 (1.3) 23.7 (1.3) 21.7 (1.3) 19.4 (1.3)

a
At 6 months, n=103 for POMS, IES-I, IES-A; n = 102 for IES combined; and n = 104 for
HADS and its subscales.
b
At 12 months, n= 97 for POMS; n= 98 for IES-I and IES combined; and n = 99 for IES-A
and HADS and its subscales.

with the greatest change over 6 months being a 3
point drop in mean fatigue and the least a 1.1
point decrease in confusion. Significant reductions
at 6 and 12 months were also observed for all
other measures except the IES avoidance score.
From baseline to the 3-month assessment, scores
generally decreased, but the reductions were not
statistically significant.
Women with Stage II disease had higher mean
POMS and HADS scores at baseline than women
with Stage I disease (unadjusted means shown in
Table 4), but the differences were not statistically
significant. Women with Stage I disease had little
or no decline in mean scores from baseline to 3
months. Patients with Stage II disease experienced
larger declines over this period, bringing their
means close to those of Stage I patients. However,
the difference in pattern of change between Stage
I and Stage II patients (stage – time interaction)
was not statistically significant for any outcome
measure.
(2) Uniformity of inter6ention effect across sites
The site-time random effect term in the
ANOVA models was not statistically significant
for any of the outcome measures. This indicates
that there were not significant differences between
sites in the pattern of changes in mood distur-
bance during the study.
(3) Recruitment
Subjects were recruited for the study quickly
and with little difficulty, due to the clinical and
research experience of the CCOP. The total pe-
riod required to enroll the 111 subjects was 6
months.
(4) Adherence to the treatment protocol
Adherence was relatively good. Patients at-
tended an average of 8.8 (S.D.=3.2, median 10)
of the 12 sessions. There was no ‘dose’ effect, in
that the number of sessions attended was uncorre-
lated with reduction in mood disturbance (R=
0.08, NS).
(5) Duration and timing
Mood disturbance reduction was not significant
at the 3-month follow-up, which coincided with
the end of active treatment (see Table 2). Im-
provement continued and became significant at 6
months. Therapists were polled and felt that the
12-week time structure was suitable, although
some groups continued to meet informally after
the intervention had ended. However, there was
no correlation between attendance at these extra
sessions and reduction in POMS TMD (R=
−0.08, n= 110, NS).
(6) Participation in other psychotherapy
Sixteen women in the sample reported partici-
pating in outside psychotherapy experiences.
When this variable was entered into a regression
equation as an independent variable along with
baseline mood disturbance, using slope of TMD

Copyright © 1999 John Wiley & Sons, Ltd. Psycho-Oncology 8: 482–493 (1999)
488 D. SPIEGEL ET AL.
as the dependent variable, it was not significantly
related to outcome (b = − 0.34, df 2, 106, p \
0.6).
(7) Initial distress and treatment outcome.
In order to better understand the characteristics
of those who improved and those who did not, we
divided the sample into those whose POMS TMD
scores improved over the year (n = 82), and those
whose scores did not improve or worsened (n=
28). Baseline distress was significantly different
between the two groups. POMS TMD scores were
28.0 (S.D. = 31.8) among those who improved,
and 10.1 (S.D. 24.9) among those who did not
(t =2.7, pB 0.008). This is consistent with the
idea that those who benefitted least were relatively
well adjusted to begin with, but the finding could
also be consistent with regression to the mean
over time.
Our sample as a whole showed relatively mod-
est levels of distress, with baseline mean scores of
24.8 (S.D.=3.0) being lower than those found
among women with myeloma, gastric, pancreatic,
and lung cancers (37.0, S.D. =36.3) (Cella et al.,
1986), as well as college student (44.8) and psychi-
atric patient (80.6) norms (McNair et al., 1971).
DISCUSSION
These data support four principal conclusions
about the feasibility and utility of conducting
supportive–expressive group therapy with re-
cently diagnosed primary breast cancer patients.
First, they demonstrate that the techniques of
conducting this therapy can be taught readily and
fairly uniform results can be achieved. Second, the
Table 3. Estimated changes (S.E.) in mean from baseline to outcome, 3, 6, and 12 months
Outcome 3 months p*
POMS −1.1 (3.4) 0.74
HADS-A −0.57 (0.32) 0.08
HADS-D −0.22 (0.33) 0.51
HADS total −0.78 (0.55) 0.17
IES-I −0.59 (0.65) 0.37
IES-A 0.01 (0.65) 0.99
IES combined −0.64 (1.1) 0.55
* p value for test that mean change is zero.
Copyright © 1999 John Wiley & Sons, Ltd.
results indicate that this treatment approach is
applicable in clinical settings. Third, they provide
preliminary evidence of the efficacy of this ap-
proach in reducing mood disturbance among re-
cently diagnosed breast cancer patients. Fourth,
they suggest that the timing and length of this
intervention is adequate to produce positive thera-
peutic benefit.
(1) Uniformity of results across treatment sites
Significant improvement was found on all three
of the mood disturbance measures employed in
the study. While there were some differences in
outcome across sites, there was no main effect for
site of treatment in addition to the interaction
with the site, suggesting that the overall conclu-
sion that the intervention was efficacious in reduc-
ing mood disturbance stands, even though some
sites were apparently better than others on some
but not all measures.
The results suggest a uniformity of the treat-
ment effect across sites. The program was imple-
mented at 12 sites across the US. Two were
university-based with a history in research in psy-
chotherapy and psychosocial oncology. The other
ten were private practice oncology groups partici-
pating in the NCI CCOP. Thus the interventions
were conducted by group leaders who varied in
experience and training and took place in a wide
range of community settings. These conditions
reflect what we could expect if this type of inter-
vention was widely available to breast cancer
patients. More than 80% of cancer patients are
treated in community settings and not at research
medical institutions. The therapists in this study
were nurses, social workers and clinical psycholo-
gists who varied considerably in age, training, and
prior group experience. Whenever possible, we
6 months p* 12 months p*
−8.3 (3.4) 0.022 −10.1 (3.5) 0.006
−0.71 (0.32) 0.033 −1.2 (0.32) 0.001
−0.90 (0.33) 0.010 −1.1 (0.33) 0.002
−1.6 (0.55) 0.006 −2.3 (0.56) B0.001
−1.6 (0.66) 0.022 −2.5 (0.67) 0.001
−0.64 (0.65) 0.337 −1.1 (0.66) 0.097
−2.7 (1.1) 0.017 −4.8 (1.1) B0.001
Psycho-Oncology 8: 482–493 (1999)
 GROUP PSYCHOTHERAPY AND BREAST CANCER 489

Table 4. Mean (S.E.M.) of mood disturbance measures, by time and stagea

Outcome Stage Baseline 3 months 6 months 12 months

POMS I 19.7 (4.4) 21.3 (4.6) 15.1 (4.7) 14.3 (4.3)

II 29.1 (4.1) 23.4 (5.1) 16.6 (4.7) 14.0 (4.4)
HADS-A I 6.3 (0.6) 6.1 (0.5) 5.8 (0.5) 5.7 (0.5)
II 7.3 (0.6) 6.2 (0.5) 6.2 (0.5) 5.3 (0.5)
HADS-D I 3.3 (0.4) 3.3 (0.4) 2.7 (0.4) 2.7 (0.4)
II 4.0 (0.4) 3.4 (0.4) 2.6 (0.4) 2.1 (0.4)
HADS total I 9.5 (0.8) 9.3 (0.8) 8.6 (0.8) 8.4 (0.8)
II 11.3 (0.9) 9.5 (0.9) 8.8 (0.8) 7.4 (0.8)
IES-I I 15.1 (1.0) 14.9 (0.9) 13.2 (0.9) 11.8 (0.8)
II 14.0 (1.0) 12.8 (0.9) 12.5 (0.8) 11.9 (0.8)
IES-A I 16.0 (0.9) 17.0 (1.1) 15.7 (1.1) 15.3 (1.0)
II 16.2 (0.8) 15.1 (0.9) 15.1 (0.9) 14.2 (1.0)
IES combined I 25.5 (1.7) 26.6 (1.9) 22.6 (2.0) 20.6 (1.7)
II 24.3 (1.9) 21.4 (1.8) 21.0 (1.8) 18.4 (2.0)

a
At baseline n= 51 for Stage I, n=60 for Stage II; at 3 months n = 48 for Stage I, n =58 for
Stage II; at 6 months n= 45–47 for Stage I and n =57 for Stage II; at 12 months n = 44–46 for
Stage I and n= 53 for Stage II.

found it most efficacious to combine one co-
therapist with considerable experience in treating
cancer with another whose primary expertise was
in group psychotherapy. We are currently evaluat-
ing the performance of the group leaders to deter-
mine each leader’s adherence to the treatment
manual and therapeutic competence.
It is worth noting that for the majority of the
therapists this was the first time they had led a
therapy group with their co-therapists and for
some it was their first group therapy experience
altogether. Thus, it is possible that as they gain
experience, outcomes will improve further. Our
current protocol will allow for examination of this
question as two subsequent groups will be run
at each site in a larger, randomized, treatment–
control study.
(2) Applicability of treatment to clinical oncology
programs
These results suggest that the model of support-
ive expressive group therapy studied here is appli-
cable to community settings. The oncology
programs that participated in this study are busy,
with many pressing patient care priorities.
Nonetheless, every site easily recruited the requi-
site number of patients for the research protocol.
Indeed there were more sites that wished to par-
ticipate and conduct such groups than could be
accommodated. Ten of the 12 of the sites are
carrying on with the randomized trial and have
expressed interest in applying the model to the
treatment of other cancers as well. Anecdotally,
they reported that the offering of this psychother-
apy service to their patients was a professionally
rewarding experience and improved the standing
of their practice, by demonstrating to patients and
the community that they were interested in the
problems of the whole person facing the illness
and not simply in fighting the disease. Their suc-
cessful implementation of the approach indicates
that it is not such a drain on resources that it
interferes with other aspects of conducting busy
oncological practices.
(3) Efficacy of treatment
Our findings are exploratory at best, because of
the absence of a control group. This study cannot
rule out the possibility that the emotional course
of these patients would have been the same with-
out the intervention. However, the results are
consistent with a number of earlier studies sug-
gesting that group therapy is efficacious in helping
patients with breast cancer (Ferlic et al., 1979;
Spiegel et al., 1981; Fawzy et al., 1990). By now
there is substantial evidence that psychotherapy,

Copyright © 1999 John Wiley & Sons, Ltd. Psycho-Oncology 8: 482–493 (1999)
490 D. SPIEGEL ET AL.
particularly in a group setting, is helpful to breast
cancer patients (Trijsburg et al., 1992). One of the
problems that has plagued this literature, how-
ever, has been considerable variation in the tech-
niques employed and a lack of specific definition
of the parameters of effective intervention. This
study attempts to extend this literature by utiliz-
ing a clearly documented and manualized treat-
ment: supportive — expressive group therapy,
which has been developed through considerable
work with breast cancer patients and applied in a
manner which tests not only the efficacy of the
approach but its accessibility to group therapists
not previously experienced in its use.
The data indicate that women who participated
in this 12-week group therapy program benefited,
showing reduced mood disturbance on the
POMS, HAD and IES. Although this study is
limited by the absence of a control group, the
POMS TMD score decreased significantly follow-
ing the intervention in a manner similar to that
seen in our previous research examining the effi-
cacy of group psychotherapy for women with
metastatic breast cancer (Spiegel et al., 1981). The
HADS and the IES also showed significant
changes consistent with those on the POMS and
provided further confirmation of significant im-
provement across several dimensions of distress.
In addition, the literature suggests that significant
improvement in mood disturbance is not the typi-
cal course of women with recently diagnosed
breast cancer. Indeed our own work with
metastatic breast cancer indicates that a downhill
emotional course is more typical of untreated
women (Spiegel et al., 1981) consistent with five
other studies (Hughes, 1982; Dean, 1987; Nort-
house, 1989; Goldberg et al., 1992; Maunsell et
al., 1992). These studies demonstrate persistent
anxiety and depression in breast cancer patients.
However, since several other studies show a de-
crease in mood disturbance over time (Hughson et
al., 1988; Lee et al., 1992; Stanton and Snider,
1993), it is possible that the improvements ob-
served in this study would have occurred anyway.
Clearly the only way to definitively answer this
question is a randomized prospective trial which
is currently underway.
(4) Timing and length of inter6ention
The psychiatric literature on crisis intervention
(Caplan, 1964) suggests that the effectiveness of
Copyright © 1999 John Wiley & Sons, Ltd.
an intervention is strongly related to its timing.
During a crisis, individuals are actively seeking
new ways of coping, while afterwards, even mal-
adaptive adjustment seems to be consolidated and
perpetuated. We have observed that the initial
diagnosis and the period immediately after initial
treatment ends are times of special stress (Fobair
et al., 1986). The distress caused by the diagnosis
is obvious, but is often mitigated by preoccupa-
tion with and hope in treatment procedures, cou-
pled with supportive contact from health care
personnel. The period after active treatment ends
is surprisingly stressful, largely due to the with-
drawal of frequent medical contact and support
and the temporary cessation of active treatment
which counters anxiety as well as cancer. While
there has been no systematic evaluation of the
timing of psychosocial intervention for cancer
patients, in one study (Edgar et al., 1992) a be-
havioral psychoeducational-based intervention
produced greater long-term gain as measured by
reduced mood disturbance among those treated
16 rather than 10 weeks post-diagnosis.
Many of the group psychosocial interventions
reported have lasted only 6 weeks (Ferlic et al.,
1979; Heinrich and Schag, 1985; Telch and Telch,
1986; Fawzy et al., 1990). Some demonstrated
clear improvement in psychosocial functioning at
the end of the intervention (Telch and Telch,
1986), while in others the effects of the interven-
tion were more pronounced at the 6-month fol-
low-up (Fawzy et al., 1990). The impact of
psychosocial interventions encompassing an 8-
week time block has also been investigated (Ja-
cobs et al., 1983; Cain et al., 1986). Again results
vary, although they are generally positive. Our
previous work (Spiegel et al., 1981) demonstrates
clear psychosocial adjustment differences between
treatment and control patients with metastatic
breast cancer during a year-long intervention. The
treatment-related improvement in mood distur-
bance was linear over time, and was highly signif-
icant at 1 year. Patients with primary breast
cancer, however, are more likely to desire and
benefit from briefer treatment due to their better
prognosis, and in this sense are more analogous to
the cancer patients treated effectively in structured
brief treatment (Fawzy et al., 1990).
Thus, this study provides evidence that time-
limited group psychotherapy for women with
newly diagnosed breast cancer is feasible in the
setting of busy oncology practices, is readily
teachable, and may contribute to reduced distress
Psycho-Oncology 8: 482–493 (1999)
 GROUP PSYCHOTHERAPY AND BREAST CANCER
among recently diagnosed breast cancer patients,
especially those with high initial distress.
ACKNOWLEDGEMENTS
This study was funded by grant cCA37420 from the
National Cancer Institute and a grant from the Nathan
Cummings Foundation. The authors gratefully ac-
knowledge the participation of: Richard J. Rosenbluth,
MD, Northern New Jersey CCOP; Christopher Desch,
MD, MCV/CMH MBCCOP of Virginia; Santo M.
Difino, MD, Syracuse Hematology–Oncology CCOP;
Vincent P. Vinciguerra, MD, North Shore University
Hospital CCOP; and Ronald Hart, MD, Community
Oncology SC. Thanks also to Jim Spira, PhD, and Ami
Atkinson, BA.
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