PSYCHO-ONCOLOGY
Psycho-Oncology 13: 850852 (2004)
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pon.880
COMMENTARY ON CARLSON & BULTZ REVIEW
WHAT ARE THE NEEDS OF PATIENTS
DIAGNOSED WITH CANCER?
MICHAEL BAUM*
Patients diagnosed with cancer have many needs
to relieve them of distress. The diagnosis comes as
a shock and maybe for the rst time the individual
is facing up to his or her mortality. So before we
even think about the role of medicine we must
consider their needs for moral and spiritual
support. At times like this a close supportive
family and membership of a faith community are
invaluable and should not be medicalized. Sadly
there are many cancer suerers who lack family
support and in these secular days have no spiritual
mentor. Such people may be drawn to new age
belief groups in order to ll this aching void. If this
provides some kind of spiritual solace I have no
problem but if this is dressed up as cure by magic
I draw the line.
The next need for the cancer subject is to be free
of whatever symptoms plague their life as a result
of the disease i.e. physical distress. Of course in the
early stages the patients may be symptom free but
in the later stages suering from pain, nausea and
weakness. Here we need collaboration by a team
that includes doctors, nurses, and practitioners in
professions that are complementary to medicine to
help the patient feel better and improve the quality
of life. The science of pain control is well
established and palliative care for those close to
the end is a well-developed specialty in the UK
thanks to our hospice movement. Relatively new is
the discipline of Psycho-social oncology which
aims to identify and manage the more subtle
subjective symptoms of cancer such as anxiety and
depression i.e. mental distress. This eld of activity
really took o about 20 years ago with the
development of psychometric instruments that
could identify these often hidden problems. I chair
the psycho-social Oncology Research Committee
of our National Cancer Research Institute
Copyright # 2004 John Wiley & Sons, Ltd.
(NCRI), which includes membership from our
consumers group in addition to nurses, psychia-
trists, psychologists and cancer clinicians. In this
domain I believe there is a role for interventions
such as psychotherapy and counseling to help the
patient feel better provided it is evidence based but
again I draw the line at claims that these
approaches alone can inuence the natural history
of the disease. I concede that there exists a mind
body nexus that in theory could be modulated to
inuence the natural course of cancer and through
our committee we are trying to encourage such
research but at present Im unaware of any reliable
evidence that a psycho-somatic approach can
replace or even act as an adjuvant to proven
medical therapy.
The third need of cancer victims is to be cured or
at least have their lives prolonged. In the last 200
years we have learnt much about the exquisite
mechanisms of the body at molecular, cellular,
whole organ and whole person levels. These
realities are more beautiful, awesome and myster-
ious than ever dreamt of in the philosophy of the
proponents of alternative medical belief systems.
In the late 19th century with the development of
anesthesia and antisepsis radical surgery began to
replace irrational nostrums. Not long after this
radiotherapy was introduced that increased the
chances of local control of the cancer. These early
successes in functional and symptomatic relief lead
to a period of complacency in my profession which
began to be shaken with the development of
eective (albeit toxic) chemotherapy regimens and
less toxic hormonal agents for hormone sensitive
cancers such as those of the breast and prostate
about 30 years ago. At the same time, the
randomized controlled trial was introduced to
critically evaluate combinations of these three
 COMMENTARY
modalities measuring both ecacy (improvement
in survival) and tolerability. Using this approach
we have made slow incremental improvements and
can now negotiate with our patients trade os
between increasing length of life and the toxicity/
side eects of the treatments with a degree of
precision and individualization that increases with
each trial completed. And yet over half our patients
seek out alternative and complementary medicine
at some point in their cancer journey (Ernst, 2000).
The proponents of alternative medicine do not
have a monopoly on compassion and empathy
and the promotion of unproven therapies or
the diversion of scarce resources from rational
treatment to the practices popular in the dark
ages, is unlikely to contribute greatly in reducing
the sum of human suering. So what has
gone wrong and what is missing from our daily
practice?
The answers, in my opinion, are to be found in
the vitally important editorial by Carlson and
Bultz on the ecacy and cost eectiveness of
psychosocial interventions in cancer care. Here
they clearly dene the notion of distress in
pychosocial and emotional terms and review the
literature on the ecacy and cost utility of
interventions ranging from providing information,
emotional support, behavioral training in coping
skills, psychotherapy and spiritual/existential ther-
apy. The last of which I would place in a
compartment reserved for faith system surrogates.
Although Im in broad sympathy with the aims
and tone of this report I do not share their
conviction that there is a sucient evidence base to
cost these intervention for health care delivery and
claim that they should be placed on the same
footing as adjuvant medical therapy and that, it
would seem unethical not to provide these services
to cancer patients. Although it was beyond my
remit to read all of the 70 plus references, I picked
out two that apparently are given equal weighting.
The rst by Cunningham et al. (1998) describes a
trial of 66 women with metastatic breast cancer
randomized to cognitive behavioral therapy in an
attempt to prolong survival; only a small sub-set
was found to benet. A small sub-set out of a total
population of 36, comes o it! Like most of such
trials, they are grossly underpowered or wildly
optimistic in their claims. In contrast the paper by
Newell et al. (2002) was a systematic review of
psychological therapies for cancer patients looking
at 329 intervention trials. Although using the
randomized controlled design the majority was
Copyright # 2004 John Wiley & Sons, Ltd.
851
methodologically awed and overall there was a
lack of adequate evidence of ecacy. Carlson and
Bultz claim, The lack of adequate evidence of
ecacy does not constitute evidence of lack
of ecacy. I could not agree more but what this
tells us is that the design and execution of such
trials in the future must rise to the same rigorous
standard as expected for trials of adjuvant
systemic therapy, if they to be treated to similar
cost/utility calculations for introduction into
standard care.
The same conclusions were reached by the
Report of the UK NCRI (2004) strategic planning
group on supportive & palliative care in July of
this year.
I believe that the agenda for psycho-social
oncology research for the next decade has been
set by this editorial and the NCRI report. We can
only get it right with adequate funding from the
research funding bodies but of even greater
importance with rigorous experimental design that
does not compromise on scientic integrity. If we
get it right then perhaps the phantoms of alter-
native medicine will melt away into the darkness
where they belong and in so doing release billions
of dollars back into the mainstream of the
enlightened world.
REFERENCES
Cunningham AJ, Edmonds CV, Jenkins GP, Pollack H,
Lockwood G, Warr D. 1998. A randomized con-
trolled trial of the eects of group psychological
therapy on survival in women with metastatic breast
cancer. Psycho-Oncology 7: 508517.
Ernst E. 2000. Prevalence of the use of complementary/
alternative medicine: A systematic review. Bull WHO
78: 252257.
NCRI strategic Planning Group on Supportive
and Palliative Care. 2004. Supportive and Palliative
Care Research in the UK. NCRI: London.
www.ncri.org.uk
Newell SA, Sanson-Fisher RW, Savolainen NJ.
2002. Systematic review of psychological therapies
for cancer patients: Overview and recommenda-
tions for future research. J Natl Cancer Inst 17:
558584.
*Correspondence to: The Portland Hospital, 212214
Great Portland Street, London, W1W 5QN, UK.
E-mail: michael@mbaum.freeserve.co.uk
Psycho-Oncology 13: 850852 (2004)
852 M. BAUM

Michael Baum is emeritus professor of surgery and
visiting professor of medical humanities at Uni-
versity College London. He has also held chairs of
surgery at Kings College London and the Institute
of Cancer Research/ Royal Marsden Hospital. In
addition he currently chairs the Psycho-social
oncology clinical development group of the UK
National Cancer Research Institute. Apart from
his major research interest in clinical trials of
treatment for early breast cancer, he was also a
pioneer in the development of instruments for
measuring quality of life for cancer patients.

Copyright # 2004 John Wiley & Sons, Ltd. Psycho-Oncology 13: 850852 (2004)