Content uploaded by Megan Olden
Author content
All content in this area was uploaded by Megan Olden
Content may be subject to copyright.
Pilot Randomized Controlled Trial of Individual Meaning-
Centered Psychotherapy for Patients With Advanced Cancer
William Breitbart, Shannon Poppito, Barry Rosenfeld, Andrew J. Vickers, Yuelin Li, Jennifer Abbey,
Megan Olden, Hayley Pessin, Wendy Lichtenthal, Daniel Sjoberg, and Barrie R. Cassileth
William Breitbart, Andrew J. Vickers,
Yuelin Li, Hayley Pessin, Wendy Lich-
tenthal, Daniel Sjoberg, and Barrie R.
Cassileth, Memorial Sloan-Kettering
Cancer Center; Megan Olden, Weill-
Cornell Medical College of Cornell
University, New York; Barry Rosenfeld,
Fordham University, Bronx, NY; Shan-
non Poppito, Memorial Sloan-Kettering
Cancer Center, New York, NY; and
Jennifer Abbey, Independent Practice,
Montclair, NJ.
Submitted March 29, 2011; accepted
December 16, 2011; published online
ahead of print at www.jco.org on
February 27, 2012.
Supported by grants from the Kohlberg
Foundation (W.B.) and from the Fetzer
Institute (W.B.).
Authors’ disclosures of potential con-
flicts of interest and author contribu-
tions are found at the end of this
article.
Corresponding author: William Breitbart,
MD, Department of Psychiatry and
Behavioral Sciences, Memorial Sloan-
Kettering Cancer Center, 641 Lexington
Ave, 7th Floor, New York, NY 10022;
e-mail: breitbaw@mskcc.org.
© 2012 by American Society of Clinical
Oncology
0732-183X/12/3012-1304/$20.00
DOI: 10.1200/JCO.2011.36.2517
ABSTRACT
Purpose
Spiritual well-being and sense of meaning are important concerns for clinicians who care for
patients with cancer. We developed Individual Meaning-Centered Psychotherapy (IMCP) to
address the need for brief interventions targeting spiritual well-being and meaning for patients
with advanced cancer.
Patients and Methods
Patients with stage III or IV cancer (N ⫽120) were randomly assigned to seven sessions of either
IMCP or therapeutic massage (TM). Patients were assessed before and after completing the
intervention and 2 months postintervention. Primary outcome measures assessed spiritual
well-being and quality of life; secondary outcomes included anxiety, depression, hopelessness,
symptom burden, and symptom-related distress.
Results
Of the 120 participants randomly assigned, 78 (65%) completed the post-treatment assessment
and 67 (56%) completed the 2-month follow-up. At the post-treatment assessment, IMCP
participants demonstrated significantly greater improvement than the control condition for the
primary outcomes of spiritual well-being (b⫽0.39; P⬍.001, including both components of
spiritual well-being (sense of meaning: b⫽0.34; P⫽.003 and faith: b⫽0.42; P⫽.03), and quality
of life (b⫽0.76; P⫽.013). Significantly greater improvements for IMCP patients were also
observed for the secondary outcomes of symptom burden (b⫽⫺6.56; P⬍.001) and
symptom-related distress (b⫽⫺0.47; P⬍.001) but not for anxiety, depression, or hopelessness.
At the 2-month follow-up assessment, the improvements observed for the IMCP group were no
longer significantly greater than those observed for the TM group.
Conclusion
IMCP has clear short-term benefits for spiritual suffering and quality of life in patients with
advanced cancer. Clinicians working with patients who have advanced cancer should consider
IMCP as an approach to enhance quality of life and spiritual well-being.
J Clin Oncol 30:1304-1309. © 2012 by American Society of Clinical Oncology
INTRODUCTION
A growing literature has highlighted the importance
of spiritual well-being and a sense of meaning for
patients with advanced cancer.
1
Supportive care ex-
perts increasingly recognize the significance of the
spiritual domain of care and identify the need for
interventions that target spiritual well-being.
2-5
In
response to this need, we developed Individual
Meaning-Centered Psychotherapy (IMCP), specifi-
cally tailored to the needs of patients with advanced
cancer.
6,7
This intervention is grounded in the writ-
ings of Frankl
8
and informed by the work of Spiegel
et al,
9,10
Yalom et al,
11
and Kissane et al.
12
A random-
ized controlled trial comparing Meaning-Centered
Group Psychotherapy (MCGP) with supportive
group psychotherapy demonstrated the efficacy of
MCGP in improving spiritual well-being, meaning,
and hopelessness.
7
However, that study revealed
several logistical barriers that exist when providing
group interventions to patients with advanced can-
cer, resulting in substantial attrition. Because of the
inflexibility inherent in group interventions, we
adapted MCGP to an individual intervention in
hopes of reducing attrition and missed sessions
while maintaining the benefits.
Most psychotherapy intervention trials with
patients who have advanced cancer have used a
group format.
13-17
Of the handful of individual psy-
chotherapy interventions for patients with advanced
cancer, few have used randomized controlled re-
search designs. de Vries et al
18
conducted an open
JOURNAL OF CLINICAL ONCOLOGY ORIGINAL REPORT
VOLUME 30 䡠NUMBER 12 䡠APRIL 20 2012
1304 © 2012 by American Society of Clinical Oncology
trial of a 12-session individual experiential-existential counseling in-
tervention for patients with advanced cancer. Their intervention,
however, was ineffective in reducing depression or loneliness or in-
creasing patients’ sense of purpose in life. In a controlled study of
Dignity Therapy, Chochinov et al
19
found no benefit for depression,
quality of life, or spiritual well-being; however, patients reported sig-
nificant improvement in their end-of-life experiences in response to
postintervention questions. Thus, although potentially promising in-
terventions have been described, there clearly remains a need for
efficacious individual psychotherapeutic interventions that focus on
the existential needs of patients with advanced cancer. Further, the
effectiveness of such interventions must be demonstrated through
randomized controlled clinical trials that use well-validated out-
come measures.
Identifying an appropriate comparison for an individual psycho-
therapy intervention in patients with advanced cancer is challenging.
We chose therapeutic massage (TM) as the comparison intervention
to control for time and attention and in hopes of providing a poten-
tially beneficial clinical encounter. TM has been demonstrated to
benefit patients with cancer by reducing anxiety, mood disturbance,
and physical symptom distress when compared with standard
care.
20-22
This article describes the results of a pilot randomized con-
trolled trial comparing IMCP with a TM intervention. On the basis of
our prior research with MCGP,
7
we anticipated significantly greater
improvements in spiritual well-being, meaning, quality of life, and
hopelessness for patients receiving IMCP compared with those receiv-
ing TM. We also anticipated that TM would improve physical symp-
tom distress, leading to a lack of significant group differences on
this variable.
PATIENTS AND METHODS
Participants
Patients were recruited from outpatient clinics at Memorial Sloan-
Kettering Cancer Center (MSKCC) between July 2004 and September 2006.
Eligibility criteria included having a diagnosis of stage III or IV solid tumor
cancers or non-Hodgkin’s lymphoma, being ambulatory, being older than age
18 years, and speaking English. Patients were excluded from the study if, on the
basis of clinician assessment, they had significant cognitive impairment, psy-
chosis, Karnofsky performance scores below 50,
23
or other physical limitations
that precluded participation in weekly psychotherapy or massage therapy
sessions. Prospective participants were informed of the risks and benefits of
study participation, and they provided written informed consent. The study
was approved by the MSKCC and Fordham University Institutional Re-
view Boards.
Study researchers had contact with 617 potential participants
(CONSORT diagram, Fig 1). Of these initial contacts, 157 patients were inel-
Screened for eligibility
(N = 617)
Randomly assigned
(n = 120)
IMCP
(n = 64)
Therapeutic massage
(n = 56)
Post-treatment analyses
(n = 41)
Post-treatment analyses
(n = 37)
Follow-up analyses
(n = 33)
Follow-up analyses
(n = 34)
Not randomly assigned
Declined to participate
Did not meet inclusion criteria
Other: eg, did not follow-up
Discontinued intervention
Worsening illness/death
Drop-out
Discontinued intervention
Worsening illness/death
Drop-out
(n = 23)
(n = 11)
(n = 12)
Discontinued participation
Worsening illness/death
Drop-out
Discontinued intervention
Worsening illness/death
Drop-out
(n = 8)
(n = 4)
(n = 4)
(n = 3)
(n = 1)
(n = 2)
(n = 19)
(n = 5)
(n = 14)
(n = 497)
(n = 188)
(n = 157)
(n = 152)
Fig 1. CONSORT diagram. IMCP, Individ-
ual Meaning-Centered Psychotherapy.
Meaning-Centered Psychotherapy
www.jco.org © 2012 by American Society of Clinical Oncology 1305
igible, primarily because they did not have advanced cancer. An additional 188
individuals declined to participate in the study, and 152 expressed interest but
never followed up after an initial contact. Because none of these individuals
provided informed consent, no data were collected regarding nonparticipants.
A total of 120 patients provided informed consent and were randomly as-
signed (by using randomly permuted blocks of random length) to a treatment
arm: 64 (52.3%) to IMCP and 56 (47.7%) to TM. The sample was predomi-
nantly female (60.5%; n ⫽72) and married (48.3%; n ⫽58), with an average
age of 54.4 years (standard deviation [SD], 11.6; range, 25 to 82). Participants
had completed an average of 16.9 years of education (SD, 3.2). The majority of
patients (82.4%) were white, with 6.7% black, 8.4% Hispanic, 1.7% Asian, and
one (0.8%) other. Religious background included Jewish (31.7%), Catholic
(30.8%), Protestant (14.2%), Baptist (1.7%), and other (14.2%); 6.7% re-
ported no religious affiliation. The most common cancer diagnoses were
breast (26.1%), colon (16.0%), pancreatic (9.2%), ovarian (8.4%), and lung
(3.4%). All patients had either stage III (33.3%) or stage IV (66.7%) disease.
Procedures
After providing informed consent, patients were randomly assigned to
one of the two study arms. Before random assignment, patients were asked to
rate how useful they anticipated the two treatments would be in helping them
cope with their illness. Random assignment was implemented through a
password-protected database, ensuring that allocation could not be guessed
before or changed after a participant was randomly assigned. Immediately
before the first session (typically in the waiting room), participants were
administered a battery of self-report questionnaires to assess spiritual and
psychological well-being (the preintervention assessment, described in Proce-
dures) and elicit relevant demographic and medical data. The assessment
battery was re-administered immediately following the last session (postinter-
vention) and a third time, approximately 2 months after completing treatment
(follow-up assessment).
The assessment battery included the Functional Assessment of Chronic
Illness Therapy (FACIT) Spiritual Well-Being Scale (SWB),
24
the McGill
Quality of Life Questionnaire (MQOL),
25
the Hospital Anxiety and Depres-
sion Scale (HADS),
26
the Beck Hopelessness Scale (BHS),
27
the Memorial
Symptom Assessment Scale MSAS),
28
and a clinical status assessment (eg,
cancer diagnosis, treatment history). Demographic information was collected
at baseline, and medical data were extracted from the patient’s electronic
medical record. Of note, the methodology, including participant population
and recruitment procedures, study measures, and statistical analyses, are vir-
tually identical with that in our prior study of MCGP,
7
with the exception of
the format of the intervention and the choice of comparison intervention.
IMCP
IMCP is a manualized 7-week intervention designed to assist patients
with advanced cancer in sustaining or enhancing a sense of meaning, peace,
and purpose in their lives as they face limitations due to progression of disease
and treatment. This intervention was adapted from MCGP, a manualized
group therapy intervention developed by Breitbart et al.
7
The individual for-
mat was intended to increase the flexibility of treatment implementation
because scheduling or illness-related problems often hinder attendance in a
group intervention, particularly with individuals who have advanced cancer.
IMCP uses didactics, experiential exercises, and psychotherapeutic techniques
(eg, reflection, clarification, and exploration) that promote the use of sources
of meaning as resources in coping with advanced cancer. Seven 1-hour ses-
sions address specific sources of meaning as well as themes related to cancer
and identity, legacy, hope, and the finiteness of life. Patients are also assigned
related readings and homework exercises (Table 1). The IMCP sessions were
conducted by either a clinical psychologist or psychology doctoral students, all
of whom received extensive training in IMCP before treating patients, and they
received ongoing supervision from the developers of the intervention.
TM
Patients randomly assigned to TM received seven 1-hour sessions with a
licensed massage therapist. TM involves manipulation of the soft tissue of the
whole body or particular areas of the body. Massage therapists at MSKCC use an
adaptation of Swedish massage that involves gentle touch for patients with cancer
who are frail.
21
All massage therapists had extensive clinical experience in TM with
patients who have cancer and received supervision from an experienced, licensed
massage therapist. The duration of TM sessions was comparable to the length of
IMCP sessions in a comparable setting, but massage therapists deliberately re-
stricted the nature and degree of verbal interaction during sessions.
Adherence to Treatment Format/Treatment Integrity
All IMCP sessions were audiotaped to ensure adherence to the treatment
manual and to provide clinical supervision. Review of these recordings re-
vealed a high degree of adherence (described in Adherence to Treatment
Format/Treatment Integrity); IMCP therapists (N ⫽4) followed the treat-
ment manual closely and engaged in the proscribed experiential exercises
associated with each weekly topic. When applicable, therapists were informed
of any deviations from the intervention format to provide corrective feedback.
Table 1. Weekly Topics and Goals of IMCP
Session Weekly Topics and Goals
1 Concepts and Sources of Meaning: Introduction and Overview
Session Goals: Learn patient’s cancer story and introduce concepts and sources of meaning.
2 Cancer and Meaning: Identity Before and After Cancer Diagnosis
Session Goals: Develop a general understanding of one’s sense of identity and the impact cancer has made upon it.
3 Historical Sources of Meaning: Life as a Living Legacy (past, present, future)
Session Goals: Develop an understanding of one’s legacy through exploration of three temporal legacy modes: the legacy that’s been given
from the past, the legacy that one lives in the present; and finally, the legacy one will leave in the future. Participants also begin
developing a Legacy Project.
4 Attitudinal Sources of Meaning: Encountering Life’s Limitations
Session Goals: Explore one of Frankl’s core therapeutic principals, that ultimately we have the freedom and capacity to choose our attitude
toward suffering and life’s limitations and to derive meaning from that choice.
5 Creative Sources of Meaning: Engaging in Life via Creativity and Responsibility
Session Goals: Develop an understanding of the significance of “creativity”and “responsibility”as important sources of meaning in life.
6 Experiential Sources of Meaning: Connecting with Life via Love, Nature, and Humor
Session Goals: Foster an understanding of the significance of connecting with life through experiential sources of meaning—particularly
through experiencing love, beauty, and humor.
7 Transitions: Reflections and Hopes for the Future
Session Goals: Review the sources of meaning. Review of the Legacy Project. Reflections on the lessons and impact of the therapy,
discussion of hopes for the future, and the transition from being in the therapy to enacting the lessons learned in daily life as the therapy
comes to an end.
Abbreviation: IMCP, Individual Meaning-Centered Psychotherapy.
Breitbart et al
1306 © 2012 by American Society of Clinical Oncology JOURNAL OF CLINICAL ONCOLOGY
A subset of audiotaped IMCP sessions (n ⫽24) were rated for treatment
integrity by independent raters who were blind to therapist identity. These
ratings included five dichotomous (yes/no) content items (eg, “Therapist
facilitated the meaning experiential exercise” and “Introduced the week’s
meaning-related session theme or topics”), five process items (eg, “Facilitated
discussion on patients’ sources of meaning” and “Maintained or redirected
discussion back to sources of meaning”) rated on a 3-point scale (0 ⫽Not at
all, 1 ⫽Somewhat, 2 ⫽A great deal), and an overall rating assessing the extent
to which the session focused on enhancement of meaning (on a scale of 0 to 4,
ranging from “Not at all” to “A great deal”). Of the 24 sessions coded for
treatment adherence, 23 sessions were rated as highly adherent, with no more
than one of the 10 criteria rated as 0 for “Not at all”; only one of the 24 sessions
reviewed had more than one criteria rated 0.
Statistical Analysis
The analyses of treatment effect were performed by using a series of linear
regression models with follow-up score as the dependent variable, treatment
group as the predictor, and baseline score as a covariate (ie, an analysis of
covariance [ANCOVA] model). The primary dependent variables in these
analyses were spiritual well-being (SWB and its component subscales, Mean-
ing and Faith) and overall quality of life (MQOL). Secondary dependent
variables included measures of depression (HADS-D), anxiety (HADS-A),
hopelessness (BHS), symptom burden (MSAS-Sx), and symptom distress
(MSAS-Di). These analyses were conducted separately for the post-treatment
and follow-up assessments, and a mixed models analysis was used to incorpo-
rate data from all three time points. Within group effect sizes for change in
study variables reflect standardized mean differences in baseline SD units.
Univariate analyses were also used to analyze sample characteristics (eg, attri-
tion rates across treatment arm) and interventionist effects (ie, whether mag-
nitude of improvement differed by therapist) across and within treatment
arms. A priori power analyses, based on data from our pilot study of MCGP,
7
indicated that a sample size of 68 participants was needed in each treatment
arm to detect a 0.5-point change on the SWB (or a 1.25-point change on the
MQOL) in an ANCOVA model with power of 0.80 at
␣
⫽.05.
RESULTS
Attrition and Completion
Attrition was evaluated as the proportion of patients who re-
mained in the group throughout the 7-week intervention and by
comparing the number of sessions attended across the two interven-
tions. There was no difference in the number of sessions completed by
participants in the two treatment arms, and the proportion who com-
pleted all seven sessions was comparable across both conditions.
IMCP participants attended an average of 5.3 sessions (SD, 2.6) versus
5.0 for TM participants (SD, 2.9; t, 0.53; P⫽.6). Of the 59 individuals
who began IMCP, 39 (66%) attended all seven sessions versus 33
(61%) of 54 TM participants (
2
⫽9.41; P⫽.22). Patients with better
physical functioning (higher Karnofsky scores) attended more ses-
sions, although this association did not reach statistical significance
(r
s
⫽.17; P⫽.06).Within the IMCP arm, there were no differences in
attendance or attrition between the different study therapists.
Impact of Treatment on SWB, Quality of Life, and
Psychological Adjustment
As detailed in Table 2, ANCOVA analyses revealed significantly
greater treatment effects at post-treatment for IMCP compared with
Table 2. Changes in Spiritual Well-Being and Psychological Functioning After IMCP vTM
Variable
Baseline Post-Treatment
Between-Group Effects
IMCP
(n ⫽40)
TM
(n ⫽37)
IMCP
(n ⫽40)
TM
(n ⫽37)
Mean SD Mean SD Mean SD Within-Group dMean SD Within-Group dDifference 95% CI P
SWB 2.22 0.82 2.46 0.76 2.72 0.83 0.60 2.52 0.68 0.08 0.39 0.17 to 0.61 ⬍.001
SWB-M 2.49 0.76 2.64 0.73 2.98 0.69 0.68 2.72 0.65 0.12 0.34 0.12 to 0.56 .003
SWB-F 1.70 1.27 2.12 1.19 2.15 1.38 0.35 2.14 1.21 0.02 0.42 0.04 to 0.80 .03
BHS 7.58 4.38 6.38 4.67 4.70 4.04 ⫺0.68 5.03 4.59 ⫺0.29 ⫺0.93 ⫺2.54 to 0.68 .3
MQOL 5.89 1.65 6.55 1.70 7.18 1.45 0.83 6.78 1.55 0.14 0.76 0.17 to 1.35 .013
HADS-D 2.09 0.61 1.85 0.49 1.98 0.29 ⫺0.23 1.97 0.27 0.30 ⫺0.02 ⫺0.13 to 0.10 .8
HADS-A 2.39 0.61 2.14 0.60 2.24 0.23 ⫺0.31 2.19 0.21 0.12 0.03 ⫺0.08 to 0.14 .6
MSAS-Sx 18.73 7.10 17.32 8.18 16.00 8.19 ⫺0.36 19.70 7.98 0.29 ⫺6.56 ⫺9.83 to ⫺3.30 ⬍.001
MSAS-Di 1.95 0.71 1.67 0.77 1.53 0.70 ⫺0.59 1.76 0.75 0.12 ⫺0.47 ⫺0.72 to ⫺0.21 ⬍.001
2-Month Follow-Up
(n ⫽33) (n ⫽34)
SWB 2.22 0.82 2.46 0.76 2.60 0.78 0.56 2.54 0.78 0.22 0.20 ⫺0.11 to 0.51 .2
SWB-M 2.49 0.76 2.64 0.73 2.78 0.67 0.55 2.77 0.76 0.29 0.09 ⫺0.22 to 0.40 .6
SWB-F 1.70 1.27 2.12 1.19 2.25 1.38 0.43 2.08 1.20 0.05 0.45 ⫺0.01 to 0.90 .054
BHS 7.58 4.38 6.38 4.67 4.84 3.98 ⫺0.69 4.91 4.25 ⫺0.39 ⫺0.58 ⫺2.35 to 1.20 .5
MQOL 5.89 1.65 6.55 1.70 6.88 1.42 0.76 6.86 1.74 0.25 0.36 ⫺0.34 to 1.07 .3
HADS-D 2.09 0.61 1.85 0.49 1.89 0.52 ⫺0.44 1.77 0.50 ⫺0.23 ⫺0.02 ⫺0.23 to 0.19 .9
HADS-A 2.39 0.61 2.14 0.60 2.16 0.57 ⫺0.43 2.18 0.51 ⫺0.06 ⫺0.13 ⫺0.34 to 0.08 .2
MSAS-Sx 18.73 7.10 17.32 8.18 17.53 7.77 ⫺0.16 17.42 8.43 0.06 ⫺0.85 ⫺4.36 to 2.66 .6
MSAS-Di 1.95 0.71 1.67 0.77 1.85 0.75 ⫺0.59 1.68 0.84 0.03 ⫺0.05 ⫺0.39 to 0.29 .8
NOTE. Within-group changes are standardized by dividing through by standard deviation (SD); between-group changes are given in terms of the measurement scale.
Abbreviations: BHS, Beck Hopelessness Scale; HADS-A, Hospital Anxiety and Depression Scale, Anxiety subscale; HADS-D, HADS, Depression subscale; IMCP,
Individual Meaning-Centered Psychotherapy; MQOL, McGill Quality of Life Scale; MSAS-Di, Memorial Symptom Assessment Scale, Global Distress Index;
MSAS-Sx, MSAS, Symptom Burden; SD, standard deviation: SWB, Functional Assessment of Chronic Illness Therapy, Spiritual Well-Being Scale; SWB-F, SWB, Faith
subscale; SWB-M, SWB, Meaning/Peace subscale; TM, therapeutic massage.
Meaning-Centered Psychotherapy
www.jco.org © 2012 by American Society of Clinical Oncology 1307
TM for SWB (total score, b⫽0.39; P⬍.001), as well as for the
Meaning (b⫽0.34; P⫽.003), and Faith subscales of the SWB
(b⫽0.42; P⫽.03). There was also significantly greater improvement
for IMCP participants compared with TM participants in overall
quality of life (MQOL: b⫽0.76; P⫽.013), number of physical
symptoms endorsed (MSAS-Sx: b⫽⫺6.56; P⬍.001), and physical
symptom distress (MSAS-Di: b⫽⫺0.47; P⬍.001). There were no
significant differences between groups in reducing anxiety (HADS-A),
depression (HADS-D), or hopelessness (BHS).
To examine the basis for the group differences observed, we analyzed
standardized mean differences within each treatment arm. As evident in
Table 2, participants in the IMCP arm improved on the SWB total score
(d⫽0.60) and the Meaning (d⫽.68) and Faith subscales (0.35), as well as
on the MQOL (d⫽0.83), MSAS-Sx (d⫽⫺0.36), and MSAS-Di
(d⫽⫺0.59). However, a markedly different pattern was observed for
participants receiving TM (Table 2), with little or no discernible improve-
ment on these measures at the end of treatment (ie, small effect sizes for
within-group comparisons). There were no differences in improvement
across the different IMCP study therapists.
We followed a similar approach for the analysis of the long-term
benefits of treatment by using a series of ANCOVA models to evaluate
the differential impact of treatment on spiritual well-being and psy-
chological functioning at the 2-month follow-up assessment. The
differences were not statistically significant on any of the outcome
variables at the 2-month follow-up assessment.
Finally, we used a series of mixed models to incorporate all three
time points into the analysis of treatment effects (essentially compar-
ing change trajectories across treatment groups). These analyses were
largely consistent with the ANCOVA models, with a significant group-
by-time interaction effect for SWB total score (F⫽3.70; P⫽.03),
MQOL (F⫽3.40; P⫽.04), MSAS-Sx (F⫽5.06; P⫽.008), and
MSAS-Di (F⫽7.02; P⫽.002), The group-by-time interaction was
not significant for the two SWB subscales of Meaning (F⫽2.49;
P⫽.09) and Faith (F⫽3.05; P⫽.06). There was also no significant
group-by-time interaction for hopelessness, anxiety, or depression.
DISCUSSION
Existential and meaning-based interventions aimed at enhancing quality
of life and spiritual well-being of patients with advanced cancer are among
the most pressing needs for optimal supportive and palliative care.
4,5
Our
group has developed, refined, and pilot-tested IMCP to address this
need.
7
We initially focused on a group format for this intervention. How-
ever, it became clear that high rates of attrition and missed sessions neces-
sitated a more flexible, individual format. This study represents our initial
attempt to evaluate the effectiveness of an individual-format, meaning-
based intervention in improving quality of life and spiritual well-being.
These results provide evidence that IMCP is effective in improv-
ing spiritual well-being, a sense of meaning, overall quality of life, and
physical symptom distress in patients with advanced cancer. For many
of the outcome variables (spiritual well-being, quality of life, and
physical symptom distress), the improvements observed for IMCP
patients at the post-treatment assessment were significantly stronger
than those observed in our control condition (TM). Although no
significant differences in treatment effects were observed at the
2-month follow-up assessment, most of the significant post-treatment
findings were echoed in the mixed models analyses that included all
three time points. Attrition was also substantially less in this study of
IMCP, because 66% of participants completed all seven treatment ses-
sions compared with only 29% of participants in our MCGP trial.
7
These
results replicate and extend the findings of our randomized, controlled
trial of a group format of MCGP in patients with advanced cancer but
with markedly lower attrition rates.
7
The consistency of these findings
across the two studies provides evidence that Meaning-Centered Psycho-
therapy, whether in an individual or group format, is an effective interven-
tion for existential distress in patients with advanced cancer, despite
having less impact on symptoms of anxiety or depression.
We compared IMCP with TM to control for time and attention.
Past studies have suggested that TM enhances psychological well-
being and reduces symptom distress, but little improvement was evi-
dent for TM participants in this study. This null finding for TM may
reflect the timing of our post-treatment assessments, because studies
of TM have typically assessed patients 24 to 48 hours after treatment
rather than 7 weeks later.
20
However, it is also possible that TM was
helpful in that patients did not worsen. Without treatment, the trajec-
tory of psychological distress and quality of life in patients with
advanced cancer may decline. Future research should include a no-
treatment condition to analyze the trajectory of distress in patients
with cancer who have not been treated.
The possibility that psychological well-being deteriorates over time
without intervention might also explain the somewhat weaker treatment
effects observed at the 2-month follow-up assessment, because IMCP
participants showed some attenuation in the improvements made during
treatment (ie, smaller within-group effect sizes). However, the mixed
models analysis suggests that the attenuation in treatment effects was
modest. Nevertheless, the lack of significant improvements at the
follow-up assessment in this study differs from our findings with MCGP,
7
in which improvements were stronger 2 months post-treatment. The
differences between our IMCP and MCGP studies may reflect unique
benefits of a group-based intervention in this population.
This study has several limitations. As is true of many intervention
studies focusing on patients with advanced cancer, we encountered
difficulties in recruitment and attrition, resulting in a modest sample
of well-educated patients who were willing to participate in a random-
ized clinical trial (limiting generalizability). Sample size limitations
also hindered our statistical power, because our sample was roughly
half as large as recommended by our a priori power analyses. Thus,
despite observing substantial within-group effect sizes for many vari-
ables in the IMCP arm that indicated clinically significant improve-
ment for IMCP participants, some between-group differences were
not statistically significant. Likewise, sample size limitations and the
unequal allocation of patients to therapists (one therapist treated 43
participants, and the remaining 21 IMCP participants were divided
among three different therapists) hindered analysis of whether some
IMCP therapists were more effective than others or whether particular
patient characteristics predicted treatment response. Therapists were
also confounded with treatment arm because trained massage thera-
pists conducted TM and psychologists conducted IMCP. Treatment
adherence was methodically assessed; however, the inter-rater reliabil-
ity of adherence ratings was not evaluated. Finally, because study
participation was not contingent on having a requisite level of distress,
participants with relatively little distress had less opportunity to im-
prove following intervention than those with more distress.
Despite these limitations, this pilot randomized controlled trial
provides preliminary support for the efficacy of IMCP in enhancing
Breitbart et al
1308 © 2012 by American Society of Clinical Oncology JOURNAL OF CLINICAL ONCOLOGY
spiritual well-being, a sense of meaning, and overall quality of life and
reducing physical symptom distress in patients with advanced cancer.
The need for empirically supported interventions for patients strug-
gling with existential distress and end-of-life despair has been widely
acknowledged, and this study provides support for IMCP as a means
to accomplish this important goal.
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS
OF INTEREST
The author(s) indicated no potential conflicts of interest.
AUTHOR CONTRIBUTIONS
Conception and design: William Breitbart, Shannon Poppito, Barry
Rosenfeld, Andrew J. Vickers, Hayley Pessin, Barrie R. Cassileth
Collection and assembly of data: William Breitbart, Shannon Poppito,
Barry Rosenfeld, Jennifer Abbey, Megan Olden, Hayley Pessin,
Wendy Lichtenthal
Data analysis and interpretation: William Breitbart, Barry Rosenfeld,
Andrew J. Vickers, Yuelin Li, Hayley Pessin, Daniel Sjoberg,
Barrie R. Cassileth
Manuscript writing: All authors
Final approval of manuscript: All authors
REFERENCES
1. Sinclair S, Pereira J, Raffin S: A thematic
review of the spirituality literature within palliative
care. J Palliat Med 9:464-479, 2006
2. Breitbart W, Gibson C, Poppito SR, et al:
Psychotherapeutic interventions at the end of life: A
focus on meaning and spirituality. Can J Psychiatry
49:366-372, 2004
3. Chochinov HM, Cann BJ: Interventions to
enhance the spiritual aspects of dying. J Palliat Med
8:S103–S115, 2005
4. Institute of Medicine: Improving Palliative
Care for Cancer. Washington, DC, National Acade-
mies Press, 2001
5. Puchalski C, Ferrell B, Virani R, et al: Improv-
ing the quality of spiritual care as a dimension of
palliative care: The report of the Consensus Confer-
ence. J Palliat Med 12:885-904, 2009
6. Breitbart W: Spirituality and meaning in sup-
portive care: Spirituality- and meaning-centered
group psychotherapy interventions in advanced can-
cer. Support Care Cancer 10:272-278, 2002
7. Breitbart W, Rosenfeld B, Gibson C, et al:
Meaning-centered group psychotherapy for patients
with advanced cancer: A pilot randomized controlled
trial. Psychooncology 19:21-28, 2010
8. Frankl VF: Man’s Search for Meaning (ed 4).
Boston, Massachusetts, Beacon Press, 1992
9. Spiegel D, Yalom ID: A support group for
dying patients. Int J Group Psychother 28:233-245,
1978
10. Spiegel D, Bloom JR, Yalom I: Group support
for patients with metastatic cancer: A randomized
outcome study. Arch Gen Psychiatry 38:527-533,
1981
11. Yalom ID, Greaves C: Group therapy with the
terminally ill. Am J Psychiatry 134:396-400, 1977
12. Kissane DW, Bloch S, Smith GC, et al:
Cognitive-existential group psychotherapy for women
with primary breast cancer: A randomised controlled trial.
Psychooncology 12:532-546, 2003
13. Fawzy FI, Fawzy NW: Group therapy in the
cancer setting. J Psychosom Res 45:191-200, 1998
14. Goodwin PJ, Leszcz M, Koopmans J, et al:
Randomized trial of group psychosocial support in
metastatic breast cancer: The BEST study—Breast-
Expressive Supportive Therapy study. Cancer Treat
Rev 22:91-96, 1996
15. Edelman S, Bell DR, Kidman AD: A group
cognitive behaviour therapy programme with meta-
static breast cancer patients. Psychooncology 8:295-305,
1999
16. Edmonds CV, Lockwood GA, Cunningham
AJ: Psychological response to long-term group ther-
apy: A randomized trial with metastatic breast can-
cer patients. Psychooncology 8:74-91, 1999
17. Coward DD. Facilitation of self-transcendence
in a breast cancer support group: II. Oncol Nurs
Forum 30:291-300, 2003
18. de Vries MJ, Schilder JN, Mulder CL, et al:
Phase II study of psychotherapeutic intervention in
advanced cancer. Psychooncology 6:129-137, 1997
19. Chochinov HM, Kristjanson LJ, Breitbart W, et
al: Effect of dignity therapy on distress and end-of-
life experience in terminally ill patients: A random-
ized controlled trial. Lancet Oncol 12:753-762, 2011
20. Ahles TA, Tope DM, Pinkson B, et al: Mas-
sage therapy for patients undergoing autologous
bone marrow transplantation. J Pain Symptom Man-
age 18:157-163, 1999
21. Cassileth BR, Vickers AJ: Massage therapy
for symptom control: Outcome study at a major
cancer center. J Pain Symptom Manage 28:244-
249, 2004
22. Post-White J, Kinney ME, Savik K, et al:
Therapeutic massage and healing touch improve
symptoms in cancer. Interg Cancer Ther 2:332-344,
2003
23. Karnofsky DA, Burchenal JH: The clinical eval-
uation of chemotherapeutic agents in cancer, in
MacLeod CM (ed): Evaluation of Chemotherapeutic
Agents. New York, NY, Columbia University Press,
1949, pp. 191-205
24. Brady MJ, Peterman AH, Fitchett G, et al: A
case for including spirituality in quality of life mea-
surement in oncology. Psychooncology 8:417-428,
1999
25. Cohen SR, Mount BM, Strobel MG, et al: The
McGill Quality of Life Questionnaire: A measure of
quality of life appropriate for people with advanced
disease—A preliminary study of validity and accept-
ability. Palliat Med 9:207-219, 1995
26. Zigmond AS, Snaith RP: The hospital anxiety
and depression scale. Acta Psychiatr Scand 67:361-
370, 1983
27. Beck AT, Weissman A, Lester D, et al: The
measurement of pessimism: The hopelessness
scale. J Consult Clin Psychol 42:861-865, 1974
28. Portenoy RK, Thaler HT, Kornblith AB, et al:
The Memorial Symptom Assessment Scale: An
instrument for evaluation of symptom prevalence,
characteristics and distress. Eur J Cancer 30A:1326-
1336, 1994
■■■
Meaning-Centered Psychotherapy
www.jco.org © 2012 by American Society of Clinical Oncology 1309
