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Key Words

Breast cancer, hypnosis, supportive care, complementary and alternative medicine. (Definitions of many terms related to cancer can be found in the Cancer.gov Dictionary.)

Summary

Women undergoing surgery for breast cancer who received a brief hypnosis session before entering the operating room required less anesthesia and pain medication during surgery, and reported less pain, nausea, fatigue, and discomfort after surgery than women who did not receive hypnosis. The overall cost of surgery was also significantly less for women undergoing hypnosis.

Source

Journal of the National Cancer Institute, Sept. 5, 2007 (see the journal abstract).
(J Natl Cancer Inst. 2007 Sep 5;99(17):1304-12. Epub 2007 Aug 28)

Background

Surgery for breast cancer, either for diagnosis or treatment, can cause side effects, including pain, nausea, fatigue, and discomfort. While drugs including traditional pain medications can help provide relief, they can have side effects of their own and increase the overall cost of a surgical procedure.

Researchers have become interested in finding approaches other than drugs to help relieve the side effects of surgery. One technique under study is hypnosis, a type of guided relaxation in which participants become more open to suggestion.

The study described below tested whether a brief hypnosis session before breast cancer surgery could reduce the need for anesthesia and pain medication, reduce side effects experienced after surgery, or ease recovery.

The Study

Investigators from Mount Sinai Medical Center in New York City recruited 200 women scheduled to undergo either surgical breast biopsy for diagnosis or lumpectomy for treatment of breast cancer. The investigators randomly assigned participants to either the hypnosis group or a control group. Women scheduled for biopsy were randomized separately from women scheduled for lumpectomy, to evenly distribute the two types of surgery between the groups.

Women in the hypnosis group received a 15-minute hypnosis session within one hour prior to surgery. Psychologists trained in the use of hypnosis in the medical setting used a script including suggestions for relaxation, pleasant thoughts, and reduced experience of pain, nausea, and fatigue, as well as instructions on self-hypnosis for use after surgery. Women in the control group spent an equal amount of time with the psychologists within an hour of surgery to talk and receive emotional support.

All women received the drugs propofol and midazolam (anesthetics), and fentanyl and lidocaine (pain medications) during surgery. They also had access to additional pain medications after surgery, as needed.

Before leaving the hospital, the women reported their experiences of pain intensity, pain unpleasantness, fatigue, nausea, physical discomfort, and emotional upset. The investigators also collected information on the amount of anesthesia and pain medication used during and after surgery, the time spent in surgery, and the cost of the procedures, medications, and staff time.

Because the women knew their group assignment, the investigators took several precautions to reduce potential bias in the results.

• The same psychologists met with patients in both groups.
• The hypnosis and control sessions took place in a private room away from the anesthesiologists and surgeons, who did not know the group assignments.
• Data on anesthesia used was taken from computer records, not recorded by clinical staff.
• The psychologists did not collect the patient-reported data after surgery. Instead, research assistants who did not know the group assignments asked the women about their perceptions of pain and discomfort.

Results

Women in the hypnosis group required significantly less propofol and lidocaine, the doses of which were adjusted for individual patients as needed during surgery, than women in the control group. Use of fentanyl and midazolam did not differ significantly. Although use of pain medication after surgery did not differ between groups, women in the hypnosis group reported significantly less pain intensity, pain unpleasantness, nausea, fatigue, discomfort, and emotional upset than women in the control group.

Women in the hypnosis group also spent an average of about ten and a half fewer minutes in surgery than women in the control group. The researchers weren’t able to say why this was so, only that the finding was statistically significant and resulted in cost savings. On average, the surgical procedures cost about $770 less per patient in the hypnosis group.

Limitations

One limitation of the study was that group assignment could not be hidden from participating women, since they actively participated in either the hypnosis or control sessions. When both participants and researchers in a study are unaware of the final group assignments, this is called a double-blind clinical trial, and is considered the best way to reduce potential bias in collecting results.

However, the researchers took precautions to make sure that the results were collected by staff that did not know which of the women had received hypnosis. The authors believed that their precautions “make it unlikely that either research or clinical staff were aware of study group assignment.”

Also, in this study, the hypnosis was performed by specially trained psychologists, who may not be available at every hospital. More research is needed, explained the authors, to test whether other members of the clinical team could be taught to effectively give a similar hypnosis session.

The trial design did not allow for a definitive answer as to why the hypnosis group spent less time in surgery. "It is possible that the shorter procedure times in the hypnosis group were due to the patients being easier to prepare for surgery and to sedate or due to less time having been spent administering medications to patients,” write the authors. “However, we did not investigate these mechanisms, and therefore, these possibilities are highly speculative."

Comments

“Overall, our results support the present hypnosis intervention as a brief, clinically effective means for controlling patients’ pain, nausea, fatigue, discomfort, and emotional upset following breast cancer surgery beyond traditional pharmacotherapeutic approaches,” stated the authors. “The present brief hypnosis intervention appears to be one of the rare clinical interventions that can simultaneously reduce both symptom burden and costs.”

“If you can decrease the amount of pain using a technique such as hypnosis, and you can also at the same time reduce the cost involved in treating these patients, I think it’s beneficial both ways,” said Sonia Jakowlew, Ph.D., program director in the National Cancer Institute’s (NCI) Cancer Cell Biology Branch. “It helps the patients and it helps the physicians as well.”

Further studies are needed, explained the authors, to measure which specific parts of the hypnosis intervention are most effective, to see whether hypnosis had a long-term effect on the control of pain and discomfort, and to test hypnosis in patients with different types of cancer and from different demographic backgrounds. “Investigators should attempt to replicate [this study] and see if these are consistent findings,” agreed Jeffrey White, M.D. director of NCI’s Office of Cancer Complementary and Alternative Medicine.

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