Quotes of the Day

Being told you have cancer is obviously news from hell. Hearing some time later that the cancer is advanced - that it's spread to another part of your body and will almost certainly kill you, perhaps within months - is worse still. Which is why it requires no great effort of the imagination to believe the statistic that at least 3 in 10 people who receive the latter diagnosis spend much of the balance of their life in a funk. "The fear that I have with this cancer," says Shinta, 48, whose disease has spread to her sternum and the lining of her lungs, "is the process of death. I don't want it to be long. I don't want my family to have to cope with it for a long time." For a cure, Shinta and thousands of Australians like her are at the mercy of medical science, the slim possibility that a miracle drug might be discovered in time to save them. Rather than obsess about that, Shinta chose to set the bar a little lower. In 2000, she joined a group of women - all with advanced breast cancer - engaged in a Melbourne-based trial of Supportive-Expressive Group Therapy, in which the participants meet weekly to discuss their cancer, including their treatment and innermost thoughts and feelings.

The results of the seven-year trial - which ended last year and involved several institutions, including the University of Melbourne - are still being analyzed. Researchers want to know two things. The first is whether SEGT improved the women's quality of life by staving off negative feelings and encouraging them to embrace the time they have left. On this level, neither the researchers nor most participants doubt that the therapy works. The more contentious - and intriguing - question is whether cancer patients who undergo SEGT might live longer than those who don't.

SEGT comes from the new field of psycho-oncology, which explores the role the mind might play in both causing and treating cancer. It remains on the fringe of medicine, and insofar as it delves into causation is likely to remain so: while stress has been shown to compromise the immune system, there's no strong evidence that these changes are significant in the development of cancer. But as a treatment adjunct, psycho- oncology is creeping into the mainstream. Self-help groups for cancer patients at all stages of the disease are common in Australia. But SEGT, the brainchild of American psychiatrist Irvin Yalom, differs from standard group therapy in several ways. Most importantly, a psychiatrist or psychologist leads the 90-min. sessions, working from the original premise of SEGT: that serious illness offers a chance for personal growth. "Much of life involves periods in which people drift somewhat aimlessly, taking life for granted," the three therapists involved in the Melbourne trial write in a new book, A Life to Live: A Group Journey with Advanced Breast Cancer (PsychOz Publications). "Only . . . when death is faced . . . does an authenticity emerge that brings with it the capacity to live life truly and fully."

A Life to Live is mostly the work of a group called the Thursday Girls, a subset of the 227 women who took part in the Melbourne trial. A dozen or so Thursday Girls still meet weekly at a Salvation Army center in Melbourne's eastern suburbs. Sitting around the kitchen table at the home of member Jeanette, three of them explain how the therapy helped them after the shattering diagnosis of metastatic breast cancer. "I was spiraling down," says Sally, 47, whose cancer reappeared in the original site and on her spine eight years after she thought she'd beaten it. "I'm coping enormously better now, purely and simply because I can go to this group, this sanctuary. You can say what you like. No one's going to ridicule you, no one's going to laugh at you, no one's going to do anything but support you." And it's liberating, say Shinta and Jeanette, to see that life goes on after the death of a group member; that families find ways to cope. At the start of the trial and at six-monthly intervals for the next two years, subjects were tested for depression, stress and anxiety, and questioned about the health of their relationships and their exuberance for life. Two-thirds of the 227 underwent SEGT; the rest received relaxation therapy. While the results are not yet ready for release, they "indicate there are some significant benefits from SEGT," says project coordinator Brenda Grabsch. The women learned to mourn their fate, then "rise above these feelings to discover humor and creativity," says former Thursday Girls therapist David Kissane, now chairman of the department of psychiatry and behavioral sciences at Memorial Sloan-Kettering Cancer Center, New York City. By showing the women how to approach dying with courage and how "to say goodbye in poignant, meaningful ways while living to the end," Kissane adds, SEGT is worthwhile even if it turns out not to prolong life.

But can it prolong life? That tantalizing prospect was raised in 1989 with the publication of a smaller study of women with advanced breast cancer by Stanford University's David Spiegel, who found that participants who'd received SEGT lived an average 17 months longer than those in the control group. The implications seemed enormous: if psychological intervention could help people with advanced cancer, what might it do for those in the early stages of the disease? Alas, while several replication trials have since supported Spiegel's findings, an equal number have done the opposite. Kissane, along with the Thursday Girls' current therapists Christine Hill and Fiona McDermott, suspects variations in methods may explain the inconsistency and is looking to the Melbourne trial to break the deadlock.

Two explanations have been offered for how SEGT might extend life. The first is that by enhancing the women's joie de vivre, the therapy revs up the immune system, which keeps the cancer in check for longer. Some of the Thursday Girls subscribe to this theory, and science hasn't entirely discredited it. But the weight of evidence suggests it's flimsy. While depression has been shown to affect outcome in some conditions, there's no clear link with cancer. "One myth for sure is that avoiding stress and being positive has survival benefits," says Jane Turner, a Brisbane psychiatrist who treats young adults with cancer. "Most people find that being told to be positive is a burden, and one woman commented that people only say that to avoid hearing how hard it really is."

The preferred theory for how SEGT may extend life is that it affects patients' behavior: that is, they're more likely to persist with treatments with unpleasant side effects, or begin new ones. They may do this because they've been inspired by a fellow group member, or because they've heard first-hand that a certain drug or alternative therapy is worth a try. That the effect of this might be to give some women an extra year or more of life appears to be a "valid hypothesis," says New York therapist Kissane, but even when the results of his trial are known, "the debate is probably going to go on." Whether the Thursday Girls continue is less certain. Funding from Melbourne University's School of Social Work - which pays the therapists' wages - will cut out at year's end, and the women's efforts to secure a new source have been fruitless. While they could continue to meet without professional guidance, they're convinced it wouldn't work as well. The therapists agree, adding that SEGT "is an essential component of care that should be offered routinely to all women caught up in this stressful health predicament." While Shinta, Sally and Jeanette have learned to let go of feelings of misfortune, the crutch of the Thursday Girls is something they long to keep until the end.

• Daniel Williams
• Sharing fears and feelings helps women cope with advanced cancer - but can it also help them survive?