Hypnosis and cognitive-behavioral therapy during breast cancer radiotherapy: A case report

American Journal of Clinical Hypnosis,  Jan 2008  by Schnur, Julie B,  Montgomery, Guy H

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Abstract

This case report describes an effort to control two primary side-effects of breast cancer radiotherapy (fatigue and skin discomfort) that used a combination of cognitive-behavioral therapy with hypnosis (CBTH). Two patients, matched on demographic and medical variables (marital status, employment status, number of children, cancer diagnosis, surgical history, radiation dose), were compared: one who received a CBTH intervention and one who received standard care. Results were consistent with the view that CBTH was effective in managing fatigue and skin discomfort, and increasing relaxation.

Keywords: Breast cancer, radiotherapy, CBT, hypnosis.

Over 178,000 women will be diagnosed wim breast cancer in 2007 (American Cancer Society, 2007). One of the key approaches to prolonging survival and improving localized tumor control in these women is radiotherapy. Yet despite its medical benefits, the radiotherapy experience can be a grueling one for many patients, as indicated by decreased quality of life during the treatment period (Whelan, Levine, Julian, Kirkbride, & Skingley, 2000). In terms of specific side effects, breast cancer radiotherapy is most often related to fatigue (Jereczek-Fossa, Marsiglia, & Orecchia, 2002) and skin toxicity (Porock & Kristjanson, 1999). Indeed, over the course of radiotherapy, up to 90% of patients report fatigue (with 30% describing it as ranging from severe to intolerable), and 74%-100% of patients experience skin irritation (Wengstrom, Haggmark, Strander, & Forsberg, 2000; Knobf & Sun, 2005; Berthelet et al., 2004) which can range from painful redness (erythema), to open wounds (desquamation), ulceration, and necrosis (Cox, Stetz, & Pajak, 1995). Both fatigue and skin irritation can take a substantial toll on women's quality of life (Berthelet et al., 2004; Bolderston, Lloyd, Wong, Holden, & Robb-Blenderman, 2006; Bower et al., 2000; Porock & Kristjanson, 1999). Also, skin irritation can necessitate treatment breaks, which can reduce local disease control and survival (Bese, Sut, & Ober, 2005).

Currently, there is no gold standard treatment to manage this set of radiotherapy side effects. Consequently, the development of new intervention strategies is required. Based on literature suggesting that: cognitive-behavioral therapy (CBT) is an effective treatment for managing fatigue symptoms in patients undergoing medical treatments for cancer (Gaston-Johansson et al., 2000; Jacobsen et al., 2002); hypnosis is effective in reducing pain (Montgomery, DuHamel, & Redd, 2000; Patterson, Everett, Burns, & Marvin, 1992); and that the average patient undergoing CBT in conjunction with hypnosis benefits more than about 70% of clients receiving CBT alone (Kirsch, Montgomery, & Sapirstein, 1995); we hypothesized that a psychotherapeutic treatment package (CBTH) combining CBT and hypnosis would be effective in managing breast cancer radiotherapy-related fatigue and skin discomfort.

Therefore, the goal of the present report is to describe data collected on two patients, one of whom (Ms. T) received the CBTH treatment, and one of whom (Ms. C) received standard clinical care and served as a comparison patient. The cases are unique in that they are the first published cases, to our knowledge, of breast cancer radiotherapy patients treated with this combination of hypnosis and CBT throughout the course of their radiotherapy treatment with the intent of improving fatigue and skin discomfort.

Case History

The participants were closely matched in that both were Caucasian women in their early 50s, unemployed, married with two children, without any comorbid medical conditions, diagnosed with ductal carcinoma in situ (DCIS) (Stage 0) in the right breast; both underwent initial surgery (lumpectomy) to treat the condition, began radiotherapy approximately one month subsequent to lumpectomy, and received the same radiotherapy protocol (i.e., 4860cGy to the whole breast delivered in 26 daily fractions of 180 cGy, followed by a boost of 1400 cGy delivered in seven daily fractions of 200cGy). During treatment, both patients received Biafene radiodermatitis emulsion and Aquaphor healing ointment to manage skin irritation.

Description of Treatment

CBTH - Hypnosis Component

One week prior to radiotherapy, the therapist (JS) met with Ms. T in the radiation oncology clinic to conduct a brief (15 minute) hypnosis session which consisted of: 1) addressing common misconceptions about hypnosis; 2) a hypnotic induction including direct suggestions for mental and physical relaxation (adapted from Rhue, Lynn, & Kirsch, 1993 specifically for breast cancer radiotherapy patients); 3) guided imagery of a peaceful and safe place; 4) a deepening component with suggestions for increased hypnotic depth; and 5) specific, direct symptom-focused suggestions for decreased fatigue, decreased skin discomfort, and decreased distress. Following these suggestions, Ms. T was given a cue word, which she was instructed she could use to enter hypnosis whenever she liked. Finally, the therapist ended the hypnosis session, and gave Ms. T a pre-recorded hypnosis CD of the intervention to listen to at home. The development of the hypnosis component of the intervention was guided by Response Expectancy Theory (Kirsch, 1985,1990).