Effects of Psychological Treatment on Cancer Patients: A Critical Review R. W. TRIJSBURG, F. C. E. VAN KNIPPENBERG, S. E. RIJPMA Twenty-two studies on the effects of psychological treatment on cancer patients are reviewed. Only studies that compared one or more experimental conditions with at least one control group have been considered. The studies were evaluated with respect to a) research methods, b) psychological interventions, and c) results. Tailored counseling has been shown to be effective with respect to distress, self-concept, (health) locus of control, fatigue, and sexual problems. Structured counseling showed positive effects with respect to depression and distress. Behavioral interventions and hypnosis were effective with respect to specific symptoms such as anxiety, pain, nausea, and vomiting. The research methods, interventions and results of the studies are reviewed critically. Several recommendations for future research are made. Key words: psychotherapy; psychological intervention; cancer; quality of life.

INTRODUCTION

Over the past 20 years, the number of studies on the somatic, psychic, and social problems of cancer patients and their need for psychological help has been increasing (1-4). Several case reports on psychotherapy for cancer patients have also been published (5-10). The effects of relaxation, modeling, and hypnosis on nausea and vomiting, resulting from chemotherapy, have been described by Bos-Branolte (6). Kaye (8), and Dempster et al. (9). Other case reports have addressed such subjects as the effects of hypnosis on anxiety and pain during medical examinations (9), depression (8, 10),

From the Department of Medical Psychology and Psychotherapy, Erasmus University, Rotterdam, The Netherlands. Address reprint requests to: Dr. R.W. Trijsburg, Department of Medical Psychology and Psychotherapy, Medical Faculty, Erasmus University, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands. Received for publication January 31, 1991; revision received January 9, 1992

Psychosomatic Medicine 54:489-517 (1992) 0033-3174/92/5404-0489S03.00/0 Copyright © 1992 by the American Psychosomatic Society

loss of weight (8, 10), and dispnoeic attacks (10). As the interventions described in these and other case studies were beneficial, the question arose as to whether these effects could also be shown in controlled studies. In a review by Watson (11), some methodological shortcomings of empirical studies were pointed out, such as the absence of control groups and the incompleteness of data on crucial aspects, e.g., characteristics of interventions, refusals, attrition, and statistical techniques. After reviewing 12 controlled studies, Watson (11) concluded: "To the question of whether specialist support programs benefit patients, the answer is a qualified yes." (p. 843). This article supplements and extends the scope of Watson's review in two aspects. First, 22 controlled studies on the effects of psychological interventions on cancer patients were screened. Second, the current study highlights the methodological aspects and results of the studies in greater detail. The studies were reviewed on three aspects: methods, psychological intervention, and results. 489

R. W. TRIJSBURG et al.

Selection of the Studies The studies were selected from those published between 1976 and September 1990. As the scope of this review limits itself to the effects of psychological interventions, studies on the effects of educational programs or information per se, or self-help groups were not included. The review was limited to studies in which the intervention group was compared with one or more control groups.1 Table 1 presents an overview of the 22 studies selected. The first aspect to be reviewed is research methods.

RESEARCH METHODS Three questions were of relevance when reviewing the research methods. First, the question of whether the studies were designed in a way that permitted conclusions concerning the interventions. Second, whether the instruments used for outcome variables were valid and reliable, and finally, whether the patient selection procedure was adequate. Hence, the three topics to be reviewed were: 1. design (experimental conditions, comparability with respect to crucial variables, use of pretesting and post-testing); 2. instrumentation (psychometric aspects); and 3. patient selection.

1. Design Experimental Conditions (see Table 1, Coiumns 58j. In 11 studies, in addition to the experimental group (psychological intervention), there was one control group that received normal care. In three studies (12-14), one extra control group was used to control for nonspecific attention. In two studies (15, 16) two control groups were formed, which both

1 The studies by Golonka (16) and by Farash (19) were abstracts. Therefore, some of the aspects, which were relevant in the present review, could not be evaluated.

490

received normal care. In one study (17), two forms of psychological intervention were compared, one serving as a control for the other. Five studies compared different forms of psychological intervention in addition to a control condition (6, 18-21). In four of these studies (18-21). the experimental groups were comparable in terms of duration and number of meetings. Comparability with Respect to Crucial Variables. In order to be able to compare treatment effects between groups, the groups need to be comparable as far as crucial variables are concerned. These variables are. medical and psychological status and sociodemographic characteristics. To check for unequal distributions of both conditions, statistical corrections should be applied. Finally, measurements need to take place at approximately the same time in both the experimental and control groups. Sociodemographic Variables. With respect to sociodemographic variables, the random assignment of patients to ensure comparability of the research groups was applied in 14 studies (Table 3, column 1). In 15 studies differences between the groups were checked retrospectively (Table 3. column 4). Medical Variables. Random assignment was applied in 14 studies (Table 3, column 1). In 14 studies, comparability regarding medical variables was checked retrospectively (Table 3, column 3). In several studies, variability of medical factors was minimized by the formation of homogeneous groups, e.g., with respect to the type of medical treatment, the time interval between medical treatment and psychological treatment, previous medical treatment, time period between diagnosis and the start of the study, the stage of the illness and the prognosis. However, data on medical variables often could not be traced (see Table 1). In 7 studies, it was stated that patients were treated medically during the period of the study, but the treatment was not specified. In four studies, no data were supplied (see Table 1, column 3). In two studies (18, 22), the prognosis of the illness was specified (see Table 2). Psychological interventions took place over the same period of time as the medical treatment, or subsequently. The timing of the psychological intervention appeared to be evenly spread across the conditions. In some studies medical variables were used as independent variables. For example, Lyles et al. (13) compared two types of drug administration that were being applied, and Gordon et al. (15) studied the interaction between psychological interventions and the type of cancer. Psychological Variables. Psychological trait vari-

Psychosomatic Medicine 54:489-517 (1992)

>Three cancer sites Gynecology Gynecology Breast Breasl >Three cancer sltes >Three cancer sltes Lung Breast Breast, melanoma, lung >Three cancer sltes Gynecology Leukernla >Three cancer srtes >Three cancer sites Uterus >Three cancer sites Breast Breast >Three cancer sltes Leukemia, neural tumors, nonHodgk~n

Bur~shand Lyles (32) Cam et al. (18) Capone et al. (27) Chr~stensen(35) Farash (19) Ferl~cet al. (24) Forester et al. (23) Goldberg and Wool (33) Golonka (16) Gordon et al. (15)

0.8 years ? ? ? 4-5 years 2 years Newly diagnosed 2 years

7

2 years Newly d~agnosed

Newly d~agnosed

i'

Newly d~agnosed

?

? Newly diagnosed

?

Newly d~agnosed Newly d~agnosed

T ~ m eSmce Diagnos~s

? Unspec~f~ed BMAs, LPs Unspecified Chemotherapy Surgery Chenlotherapy Unspec~f~ed Unspecif~ed ? BMAs, LPs

Chemotherapy Unspeched

Surgery Kad~otherapy Chenlotherapy Chemotherapy Unspec~t~ed Unspec~f~ed Surgery Surgery ?

Med~cal Treatment

Type of

Explanat~ons: Type of medical treatment: BMAs. LPs = Bone marrow aspirat~ons,lumbar punctures Timing of intervention and m e d d treatment: After = psychological treatment was gwen after medical treatment. During = psycholog~callntervention was gwen during med~caltreatment. During & after = psychological treatment was grven during and after medical treatment. Groups: - - there was no such group = intervention control group. ? = data on this aspect were not available.

H e ~ n r ~ cand h Schag (25) Houts et al. (34) Kuttner (14) Linn et al. (22) Lyles et al. (13) Magu~reet al. (28) Morrow and Morrell (12) Sp~egelet al. (26) Spiegel and Bloom (20) Worden and We~sman(21) Zeltzer and LeBaron (17)

Gynecology

Cancer S~te

60s-Branolte (6)

Reference

TABLE 1. Data on Patients and Groups

?

Dur~ng Dur~ng During Durmg Durmg Durmg During Dur~ng

7

Dur~ng Dur~ng Durmg After After During D u r ~ n g& after During Dur~ng Durmg & after

After

Tim~ngof Intervention and Medlcjl Treatment Experimental Group(s)

Control Group(s)

Groups and Number of Pat~ents

R. W. TRIJSBURG et al. TABLE 2. Data on Patients and Groups: Remaining Characteristics and Screening Criteria Bos-Branolte (6)

Burish and Lyles (32) Cain et al. (18)

Christensen (35)

Farash (19) Ferhc et al (24) Forester et al. (23) Goldberg and Wool (33) Cordon et al. (15)

Heinnch and Shag (25)

Kuttner (14)

Linn et al. (22) Lyles et al. (13)

Morrow and Morell (12)

Spiegel et al. (26) Spiegel and Bloom (20) Worden and Weisman (21)

Zeltzer and LeBaron (17)

M: Patients had to be in complete remission for at least 6 months after medical treatment; without any other type of cancer P: Informed about the cancer diagnosis; free from manifest psychiatric pathology D: Not older than 70 M: Patients had exhibited anticipatory anxiety, nausea, and/or vomiting to chemotherapy treatments M: Expected survival of at least 1 year P: No previous history of severe psychiatric problems or exhibiting symptoms requiring referral to a psychiatrist D: Age between 18 and 75 years M: Patients' cancer was arrested and nonmetastatic; surgery had been completed 2 to 3 months prior to the study P: Absence of a crisis, such as divorce or unemployment; absence of a major emotional disturbance that would require prompt specialized attention D. The patient had a husband, who was also willing to participate M: Patients entered the study approximately 2 months following mastectomy M: Advanced cancer; no prior chemotherapy; not moribund; patients with primary or metastatic cancer of the brain were excluded M: Patients with abdominal cancer were excluded D: A significant key other was willing to participate M: No prior medical treatment for their present condition; no brain damage P: No previous psychiatric history or diagnosis of mental retardation D: Age between 18 and 75 M: Karnofsky performance status equal to 70 or higher; no brain disease P: No major psychiatric illness; no major cognitive deficits; no alcohol or drug abuse D: Age between 25 and 70 M: Patients had pain, distress, or anxiety during bone marrow aspiration or lumbar punctures D: Aged 3 to 7 M: End-stage cancer, at least three but no more than 12 months of survival M: Patients had received a minimum of two chemotherapy treatments and were scheduled for at least six additional treatments; they had exhibited anticipatory anxiety, nausea, and/or vomiting in response to chemotherapy treatments M: Patients had had anticipatory nausea and vomiting before their fourth chemotherapy treatment; patients with metastatic disease of the brain or obstruction of the alimentary canal were excluded M: Only patients with documented metastases were included M: Only patients with documented metastases were included M: Prognosis of at least 4 months P: At risk for high levels of emotional distress and poor coping D: Over 18 years of age M: Patients had pain and anxiety during bone marrow aspiration or lumbar punctures D: Aged 6 to 17

M, medical; P, psychological; D, demographic.

492

Psychosomatic Medicine 54:489-517 (1992)

PSYCHOLOGICAL TREATMENT OF CANCER PATIENTS ables should be comparable across the conditions, in the same way that medical variables should. Scores on outcome measures have been adjusted for the level of pretreatment scores in many studies (see Table 3, column 5). However, trait variables (e.g., neuroticism or trait anxiety) were not controlled for in the studies. The fact that psychological factors are important was shown in several studies. For example, BosBranolte (6) showed that the patients who refused psychotherapy were suffering less from psychological problems than those who received psychological treatment. Forester et al. (23) and Gordon et al. (15) made an explicit distinction between the number of

psychological problems and related the results to the effects of psychological intervention. It is generally assumed that the psychological status of the groups under study are comparable at the first measurement when randomization procedures are applied. Comparability was also controlled for by comparing the mean group scores at pretest (F test, or chisquare). Statistical corrections were made by means of change scores (24), the analysis of co-variance (14, 22, 25) or slope analysis (20. 26). VVorden and Weisman (21) corrected for distress scores, but were unclear about the procedure used. In two studies (27, 28), post-treatment scores were not adjusted for pre-

TABLE 3. Assignment to Groups and Baseline Comparison Assignment

Baseline comparison of crucial variables

Reference Bos-Branolte (6) Burish and Lyles (32) Cain et al. (18) Capone et al. (27) Chnstensen (35) Farash (19) Ferlic et al. (24) Forester et al. (23) Goldberg and Wool (33) Colonka (16) Gordon et al. (15) Hemrich and Schag (25) Houts et al. (34) Kuttner (14) Linn et al (22) Lyles et al. (13) Maguire et al. (28) Morrow and Morrell (12) Spiegel et al. (26) Spiegel and Bloom (20) Worden and Weisman (21) Zeltzer and LeBaron (17)

Random

Stratificatior i

Medical

1Demographic

Psychological

No Yes Yes ? Yes Yes No Yes Yes ? Other Other Other Yes Yes Yes Yes Yes Yes Yes No Yes

No Yes Yes

Yes No Yes Yes No

Yes No Yes Yes No

Yes Yes Yes Yes Yes

?

No No Yes No No

?

?

?

No Yes Yes

Yes Yes Yes ? Yes Yes Yes No Yes No Yes Yes Yes Yes Yes No

Yes Yes Yes ? Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes

?

?

Yes Yes No No No Yes No No No No No Yes

Yes Yes No No Yes Yes Yes Yes Yes Yes Yes No

Explanations: Assignment: Other = other design, e.g., nonequivalent control group design with time-: Demographic: Demographical factors, mostly age, sex, race, and marital status. Psychological: Dependent variables, mostly psychological factors. No, no random assignment/no stratification/no control afterwards. Yes, random assignment/stratification/control afterwards. ?, data on this subject were not available.

Psychosomatic Medicine 54:489-517 (1992)

493

R. W. TRIJSBURG et al. treatment scores. No data were available for two other studies (16, 19). Use of Pretesl and Posl-Test. In 19 studies, the times of testing were the same for both the intervention and control groups. In Farash's (19) and Capone et al.'s (27) study, there were no pretreatment measurements of dependent variables, so the effects could not be adjusted for scores at pretest. However, Capone et al. were able to compare the results of the intervention group with those from a normal group. In the study by Maguire et al. (28), which addressed the development of psychiatric complaints during and after medical treatment, no pretests were used for the self-rating of anxiety and depression. Therefore, the post-test scores of patient-rated anxiety or depression could not be controlled for. On the other hand, pre-existing psychiatric problems were assessed shortly after surgery, thus making the effects of the intervention to some extent comparable at the level of psychiatric morbidity. In Warden and Weisman's (21) study the intervention and control groups were tested several times, but the intervals between measurements differed from one group to the next.

2. Instrumentation (see Table 4A and B) The instruments used for measuring personality characteristics or psychological state should be reliable and valid (29-31). In 21 out of the 22 studies, at least some of the instruments used are known to be reliable and valid (e.g., POMS, PAIS, and STAI), or their psychometric qualities could be validated with the aid of literature references indicated in the text. Relevant information was unavailable in the case of the Patient Perception Test (24), the Cancer Information and QL tests (25), and the BDRI (19). In 11 (6, 13-15, 17, 20, 21, 28, 32-34) out of the 22 studies, the measurement instruments were specially designed for specific purposes. In five out of these studies (6,14,15, 21, 33), references were given for the relevant psychometric data. In some cases, existing instruments had been adapted for use in the study (22, 24, 35). In these studies, no relevant psychometric data were presented.

3. Selection of Patients The basis for patient selection was rather variable across the studies. The most commonly chosen as-

494

pects were: type of cancer, time elapsed since diagnosis, drop-out rate and refusals, and seriousness of the psychological problems. Type of Cancer. In 10 studies, patients were selected on the basis of having different types of cancer (eight studies covered more than three types, two covered three types). In one of these studies (15) statistical analyses were carried out on a subsample of patients with lung cancer: this sample contained the largest number of patients in the study. The stage of illness, the prognosis and the general physical condition of the patients were rarely given. The remaining 12 studies each addressed one type of cancer (Table 1, column 1). Time Elapsed Since Diagnosis (Table 1, coiumn 2). In five studies, the patients had known their diagnosis for 8 months or longer. In seven studies, newly diagnosed patients were selected. In 10 studies, the time elapsed since the diagnosis was not given. Type and Timing of Medical Treatment (see Table 1, columns 3 and 4). Eight out of the 22 studies were concerned with psychological interventions during medical treatment (chemotherapy, radiotherapy, bone marrow aspiration, lumbar punctures, surgical intervention). In five of these studies the psychological intervention was aimed specifically at ameliorating the effects of the medical interventions, e.g., nausea and vomiting in reaction to the chemotherapy (12,13, 32); reduction of pain and distress during lumbar punctures and/or bone marrow aspirations (14, 17) (see Table 1, column 4). In one study the intervention started 3 months after the medical treatment had ended. In two studies the intervention started after surgery, although the time elapsed since surgery was not specified. In seven studies, the psychological intervention was also given during medical treatment, but the medical treatments were not specified. In four studies, there were no data concerning medical treatment. Seriousness of the Psychological Problems (TabJe 2J. In five studies, any patients with psychiatric problems were excluded from the study. Christensen (35) not only excluded patients with psychiatric problems, but also patients who were in a state of emotional crisis, e.g., marital. Worden and Weisman (21) included only patients that were at risk for high levels of emotional distress and low ability to cope. Drop-Out Rate and Re/usaJs (see Table 5j. Most studies gave due consideration to the percentage of refusals and drop-outs. Reasons frequently given were: death, too ill, and moving from one house to another. The percentage of patients who refused or dropped out varied across the studies.

Psychosomatic Medicine 54:489-517 (1992)

PSYCHOLOGICAL TREATMENT OF CANCER PATIENTS TABLE 4A. Instruments POMS MAACL HAS EO PSE STAI SCL90 BOS ARS/DAL VUL HDRS SRSS BDI BDRI SADS PAIS LS QL PSI PBRS-R CANTRIL

Instruments (Psychological Variables)

Anxiety

Depression

26, 33, 34 13, 15,22 18 13, 14, 17, 28, 32 28 12, 16, 35 25 6 16 21

22, 26, 33, 34 13, 15,32

Anger, Hostility, % ' . Confusion

_ . Distress

20,21,33,34

21,26,27,34

Selfconcept

(Health) Locus of Control

15, 32 28

21, 28

28 25 6 21 18 27 19, 35 19

SCQ SHS JFS TSCS RSE LC HLC

6

6

21 27

23 18, 25 15 25 35 14 22 24 22 26 27 35 22, 35 12, 15, 26

The numbers in the cells represent references. For full descriptions: see references.

PSYCHOLOGICAL INTERVENTIONS

('tailored counseling,' See Table 6A). Counseling and support were the main Psychological interventions differ in ingredients here. In some cases the intergoals and treatment techniques, depending on the particular problems confront- vention may also contain educational eleing the patients, which in turn are asso- ments. The majority of these studies preciated with the sort of disease, its stage, sent an outline of the main objectives and and whether or not medical treatments techniques. These studies do not offer a are given. Many studies offer counseling definite, structured program, although as treatment of choice. Most of these were the studies by Bos-Branolte (6-group tailored to the needs of the patients therapy), Capone et al. (27) and Houts et Psychosomatic Medicine 54:489-517 (1992)

495

R. W. TRIJSBURC et al.

Psychosomatic Medicine 54:489-517 (1992)

PSYCHOLOGICAL TREATMENT OF CANCER PATIENTS TABLE 5. Refusals and Drop-Outs Reference Bos-Branolte (6) Burish and Lyles (32) Cain et al (18) Capone et al. (27) Christensen (35) Farash(19) Ferhc et al. (24) Forester et al. (23) Goldberg and Wool (33) Golonka (16) Gordon et al. (15) Heinnch and Schag (25) Houts et al. (34) Kuttner(14) Linn et al. (22) Lyles etal. (13) Maguire et al. (28) Morrow and Morrell (12) Spiegel et al. (26) Spiegel and Bloom (20) Worden and Weisman (21) Zeltzerand LeBaron (17)

Number of Patients

Refusals (%)

Drop-Outs (%)

119

24%

18 94

11%

T3: 8% T5:? T3- 20% T4:? T2: 0% T2:? T3: 55% T5:? T3: 62% T2:? T4: 36% T3: 8% T2:27% T3: 20% T3: 28% T6:? T5 > 40% T4: 8% T3 9% T?: 22% T4: 65% T4: 63% T5: 39% T?:?

111 ?

15% 13% ?

?

?

70

15% ?

i

?

23% ? 23%

81

14%

41

2% ?

i

?

? 141

15%

57

12%

172 87

3% 11%

109 109

17% 17%

125"

22%

45

27%

Drop-Outs E(xperimental) and C(ontrol) Group(s) (E4%C 10%)

?

(E 40% C 70%) ?

(E6r.CC 64%) ?

(E35%C41%C32%) ? ?

? (E 85% C 76%) ?

? ?

(E68%C61%) (E 63% C 64%) ?

?

Explanations: Number of patients: Number of patients asked to cooperate. Refusals: Percentages refer to the number of patients who refused to cooperate. Drop-outs: Percentages refer to the number of patients who dropped out after initial participation; T1 is first assessment, T2 second assessment, etc. Drop-outs experimental and control group(s): Percentages are mentioned separately for the intervention (E) and control (C) group. ? = data were not available. " In the study of Worden and Weisman, only data about the experimental group are given.

al. (34) contain some fixed elements. Next to these studies there were studies that offer an explicitly formulated structured counseling program (18, 24, 25, 35) ('structured counseling,' see Table 6B). They may contain educational aspects and behavioral instructions, and exercise may also be given. Apart from the counseling studies, there were studies that aim exPsychosomatic Medicine 54:489-517 (1992)

plicitly at overcoming anxiety or pain due to medical procedures by employing behavioral techniques or hypnosis (12-14, 17, 32) ('behavioral/hypnosis,' see Table 6C). The study by Spiegel and Bloom (20) combines supportive group therapy with self-hypnosis (pain-control) in the experimental condition. Given these different approaches to 497

lndividual counselmg (telephone) by former cancer patients lndiv~dualcounsellng concerning death and

Houts et al. (34)

L~nnet al. (22)

Worden and Weisman (21)

Sp~egelet al. (26)

Magulre et a!. (28)

Cordon et al. (15)

Individual counselrng by speclallzed nurse (prevent~onof psychiatric morbidity) Supportive group meetmgs focusing on problems of terminal ~llness,improving relatronships, "livlng as fully as possible in the face of death") Problem oriknted indiv~dualcounseling; lndividual training of problem solving skills

dying

Psychosocial intervent~onw ~ t hsignrf~cantkey other (maintam soc~alsupport system, promote autonomy of patient, advocate for patlent, encourage communication, facilitate mutual expression of emotion) Supportive group counseling (exam~ning problems, verbahzing emotions) lndividual psychosocial rehabilltation (educational, counseling, env~ronmentalmanipulat~on)

Goldberg and Wool (33)

Golonka ( 1 6)

lndividual supportive psychotherapy (educational, interpretive, cathartic)

Group therapy (progressive muscle relaxation, role-play~ng,learn~ngby im~tation); lndiv~dualtherapy (same format) lndiv~dualcounseling (reality-oriented, fac~litatrng attainment, adaptrve behavior change) Self-help counselmg group; lndwidual cris~s~nterventlon

Intervention

(At 6 months) S~gnif~cantly lower levels of distress, den~al,and higher rates of ~ r o b l e mresolution

plaints

(At 12 months) Improvement in quality of life (depression, self-esteem, Ilfe-sat~sfact~on, alienation, locus of control); no differences in functional status or survival (12 to 18 months after mastectomy) Much less psychiatric morbid~tyIn counseled than In control group (At 12 months) Decrease in mood-d~sturbance,fewer maladaptwe coping responses, less phobic com-

prediction

(At 6 months) Less psychosocial problems, more rapid decl~neof anxiety, host~l~ty, depression, more reallst~c outlook on life, greater proport~onreturning to former vocatronal status, more actlve usage of tlme (At 3 months) No d~fferencesin emotional status, one opposite to aspect of coplng differing in d~rect~on

No differences in anx~ety

(At 9 months) Improvement In self-esteem, well-being, body image, partner relationship. The latter two improved more In indiv~dualthan in group therapy (At 12 months) Less confusion and contradiction in self-perception, positive effects in return to vocational and sexual funct~ons No differences In effectweness between self-help and indiv~dualcounselrng; in mastectomy patients counseling assists wlth the resolut~onof body image disturbance Emotional (depression, pessimism, anxiety) and physical (anorexia, fatigue, nausea and vomrting) symptoms Improved (At 6 months) No different~alchange over trme for significant key other or pat~entsin emotional, soclal, and physical functronlng

Outcome

TABLE 6A. Interventions and Outcome in Studies Using Tailored Counseling

Forester et al. (23)

Farash (19)

Capone et al. (27)

60s-Branolte (6)

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Effects of psychological treatment on cancer patients: a critical review.

Twenty-two studies on the effects of psychological treatment on cancer patients are reviewed. Only studies that compared one or more experimental cond...
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