Cognitive-Behavioral Therapy Plus Hypnosis Controls Fatigue in Breast Cancer Patients Receiving Radiotherapy


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Cognitive-Behavioral Therapy and Fatigue

The results support [cognitive-behavioral therapy plus hypnosis] as an evidence-based intervention to control fatigue in patients undergoing radiotherapy for breast cancer.

—Guy H. Montgomery, PhD, and colleagues

In a study reported in the Journal of Clinical Oncology,1 Guy H. ­Montgomery, PhD, Icahn School of Medicine at Mount Sinai, New York, and colleagues found that an intervention consisting of cognitive-behavioral therapy plus hypnosis produced better control of fatigue than supportive meetings with trained interventionists for women undergoing radiotherapy for breast cancer.

Study Details

In the study, 200 consecutive patients with breast cancer at Mount Sinai Medical Center, New York, who were scheduled for a 6-week course of external-beam radiotherapy were randomly assigned to receive cognitive-behavioral therapy/hypnosis with trained clinical psychologist interventionists (n = 100) or interventionist attention without cognitive-behavioral therapy/hypnosis (n = 100) during the period of radiotherapy.

In both groups, the initial intervention session, scheduled for the patients’ radiotherapy verification day, lasted for 30 minutes. Patients met with an interventionist twice weekly during the course of radiotherapy, with each session lasting 15 minutes. The final intervention session, scheduled for the penultimate day of radiotherapy, lasted for 30 minutes.

For control group patients, the interventionist did not lead the patient in cognitive-behavioral techniques of imagery, relaxation, or evaluation of thought processes or in discussion; the interventionist allowed the patient to direct the flow of the conversation and provided supportive/empathic comments.

Fatigue was measured using the Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue subscale, the primary outcome measure, and visual analog scales for fatigue and muscle weakness at baseline, end of radiotherapy, and at 4 weeks and 6 months after radiotherapy. Comparisons were made in the intent-to-treat population and were adjusted for multiple comparisons.

The cognitive-behavioral therapy/hypnosis group and the control group were balanced for age (mean, 56 years in both), education (college degree or higher for 66% in both), marital status (53% and 51% currently married), race (69% and 66% white), receipt of chemotherapy before radiotherapy (43% and 38%), Karnofsky performance score (mean, 94 in both), adjuvant hormone treatment (tamoxifen in 30% and 31%, aromatase inhibitor in 44% and 42%), disease stage (0 in 29% and 32%, I in 39% and 38%, II in 21% and 19%, and III in 11% in both), and total radiation dose (mean, 62 Gy in both).

Groups were also balanced for neuroticism (mean scores of 21 and 20 on the NEO Neuroticism Subscale) and treatment credibility (mean scores of 43 and 41 on a standardized fidelity checklist). There were no significant differences between groups in FACIT-Fatigue score or visual analog scores for fatigue or muscle weakness at baseline.

Reduced Fatigue and Muscle Weakness

The cognitive-behavioral therapy/hypnosis group had significantly lower levels of fatigue as measured by the FACIT-Fatigue scale at the end of radiotherapy (z = 6.73, P < .001), at 4-week follow-up (z = 6.98, P < .001), and at 6-month follow-up (z = 7.99, P < .001). This group also had significantly reduced fatigue according to visual analog scale scores at the end of treatment (z = 5.81, P < .001) and at 6 months (z = 4.56, P < .001), with a trend toward reduction at 4 weeks (z = 2.38, P < .07). Muscle weakness visual analog scale scores were significantly lower in the cognitive-behavioral therapy/hypnosis group at end of treatment (z = 9.30, P < .001) and at 6 months (z = 3.10, < .02), but not at 4 weeks (z = 2.1, P < .13).

The investigators concluded, “The results support [cognitive-behavioral therapy plus hypnosis] as an evidence-based intervention to control fatigue in patients undergoing radiotherapy for breast cancer. [Cognitive-behavioral therapy plus hypnosis] is noninvasive, has no adverse effects, and its beneficial effects persist long after the last intervention session. [Cognitive-behavioral therapy plus hypnosis] seems to be a candidate for future dissemination and implementation.” ■

Disclosure: The study was supported by National Cancer Institute and American Cancer Society grants. The study authors reported no potential conflicts of interest.

Reference

1. Montgomery G, Daniel D, Kangas M, et al: Randomized controlled trial of a cognitive-behavioral therapy plus hypnosis intervention to control fatigue in patients undergoing radiotherapy for breast cancer. J Clin Oncol 32:557-563, 2014.



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