The diagnosis and treatment of breast cancer are stressful, and stress may be associated with a poorer response to chemotherapy. There is a need, therefore, to develop and evaluate interventions that might enhance quality of life and, possibly, improve treatment response. The effects of relaxation combined with guided imagery (visualizing host defences destroying tumour cells) on quality of life and response to primary chemotherapy, to date, have not been adequately evaluated. Ninety-six women with newly diagnosed large or locally advanced breast cancer (T2 > 4 cm, T3, T4, or TxN2 and M0) took part in a prospective, randomized controlled trial. Patients were randomized following diagnosis to a control condition (standard care) or to the experimental condition (standard care plus relaxation training and imagery). Psychometric tests to evaluate mood and quality of life were carried out before each of the six cycles of chemotherapy and 3 weeks after cycle 6: tests of personality and coping strategy were carried out prior to cycles one and six. Clinical response to chemotherapy was evaluated after six cycles of chemotherapy using standard UICC criteria and pathological response was assessed from the tissue removed at surgery. As hypothesized, patients in the experimental group were more relaxed and easy going during the study (Mood Rating Scale). Quality of life was better in the experimental group (Global Self-assessment and Rotterdam Symptom Checklist). The intervention also reduced emotional suppression (Courtauld Emotional Control Scale). The incidence of clinically significant mood disturbance was very low and the incidence in the two groups was similar. Finally, although the groups did not differ for clinical or pathological response to chemotherapy, imagery ratings were correlated with clinical response. These simple, inexpensive and beneficial interventions should be offered to patients wishing to improve quality of life during primary chemotherapy.
American Psychiatric Association (1990). Structured Clinical Interview for DSM-IIIR American Psychiatric Press Inc: Washington, DC
Baider, L., Uziely, B. & De Nour, A. K. (1994) Progressive muscle relaxation and guided imagery in cancer patients. Gen Hosp Psychiatry 16: 340–347.
Bindemann, S., Soukop, M. & Kaye, S. B. (1991) Randomised controlled study of relaxation training. Eur J Cancer 27: 170–174.
Bond, A. & Lader, M. (1974) The use of analogue scales in rating subjective feelings. Br J Med Psychol 47: 211–218.
Bridge, L. R., Benson, P., Pietroni, P. C. & Priest, R. (1988) Relaxation and imagery in the treatment of breast cancer. Br Med J 297: 1170–1172.
Brittenden, J., Heys, S. D., Miller, I., Sarkar, T. K., Hutcheon, A. W., Needham, G., Gilbert, F., McKean, M., Ah-See, A. K. & Eremin, O. (1994) Dietary supplementation with L-arginine in patients with breast cancer (>4 cm) receiving multimodality treatment: report of a feasibility study. Br J Cancer 69: 918–921.
Burish, T. G., Vasterling, J. J., Carey, M. P., Matt, D. A. & Krozely, M. G. (1988) Post-treatment use of relaxation training by hypnosis patients. The Hospice Journal 4: 1–8.
Cheung, C. W. D. & Johnston, A. E. (1991) Carcinoma of the breast: measurement and management of treatment. Br J Radiol 64: 29–36.
Coates, A., Porzsolt, F. & Osoba, D. (1997) Quality of life in oncology practice: prognostic value or EORTC QLQ-C30 scores in patients with advanced malignancy. Eur J Cancer 33: 1025–1030.
De Haes, JCGM, Van Knippenberg, F. C. E. & Niejt, J. P. (1990) Measuring psychological and physical distress in cancer patients: structure and application of the Rotterdam Symptom Check List. Br J Cancer 62: 1034–1038.
Downer, S. M., Cody, M. M., McCluskey, P., Wilson, P. D., Arnott, S. J., Lister, T. A. & Slevin, M. I. (1994) Pursuit and practice of complementary therapies by cancer therapies receiving conventional treatment. Br Med J 309: 86–89.
Dreher, H. (1997) The scientific and moral imperative for broad-based psychosocial interventions for cancer. Advances: the Journal of Mind-Body Health 13: 38–49.
Eysenck, H. J. & Eysenck, S. B. G. (1991). Manual of the Eysenck Personality Scales (EPS Adult). Hodder and Stoughton: London
Fallowfield, L. J. (1997) Offering choice of surgical treatment to women with breast cancer. Patient Education and Counselling 30: 209–214.
Fawzy, F. I., Cousins, N., Fawzy, N. W., Kemeny, M. E., Elashoff, R. & Morton, D. (1990) A structured psychiatric intervention for cancer patients: changes over time and methods of coping and affective disturbance. Arch Gen Psychiatry 47: 720–726.
Fawzy, F. I., Fawzy, N., Hyun, L. S., Elashoff, R., Guthrie, D., Fahy, J. L. & Morton, D. L. (1993) Malignant melanoma: effects of an early structured psychiatric intervention, coping and affective state on recurrence and survival 6 years later. Arch Gen Psychiatry 50: 681–689.
Fraser, S. C. A., Ramirez, A. J., Ebbs, S. R., Fallowfield, L. J., Dobbs, H. J., Richards, M. A., Bates, T. & Baum, M. (1993) A daily diary for quality of life measurement in advanced breast cancer trials. Br J Cancer 67: 341–346.
Greer, S., Moorey, S., Baruch, J. D., Watson, M., Robertson, B. M., Mason, A., Rowden, L., Law, M. G. & Bliss, J. M. (1992) Adjuvant psychological therapy for patients with cancer: a prospective randomised trial. Br Med J 304: 675–680.
Gruber, B. L., Hall, N. R., Hersch, S. B. & Dubois, P. (1988) The immune system and psychologic changes in metastatic cancer patients whilst using ritualised relaxation and guided imagery. Scand J Behav Ther 17: 24–46.
Gruber, B. L., Hersh, S. P., Hall, N. R. S., Waletsky, L. R., Kunz, J. F., Carpenter, J. K., Kverno, K. S. & Weiss, S. M. (1993) Immunological responses of breast cancer patients to behavioural interventions. Biofeedback Self Regul 18: 1–22.
Hermann, C. (1997) International experiences with the Hospital Anxiety and Depression Scale – a review of validation data and clinical results. J Psychosom Res 42: 17–41.
Holland, J. C., Morrow, G. R., Schmale, A., Derogatis, L. & Stefanek, M. (1991) A randomised clinical trial of alprazolam versus progressive muscle relaxation in cancer patients with anxiety and depressive symptoms. J Clin Oncol 9: 1004–1011.
Hopwood, P., Howell, A. & Maguire, P. (1991) Screening for psychiatric disorder in patients with advanced breast cancer: validation of two self-report questionnaires. Br J Cancer 64: 353–356.
Hutchings, D. F., Denney, D. R., Basgall, J. & Houston, B. K. (1980) Anxiety management and applied relaxation in reducing general anxiety. Behav Res Ther 18: 181–190.
Ibbotson, T., Maguire, P., Selby, P., Priestman, T. & Wallace, L. (1994) Screening for anxiety and depression in cancer patients: the effects of disease and treatment. Eur J Cancer 33A: 37–40.
Johnson, V. C., Walker, L. G., Whiting, P. H., Heys, S. D. & Eremin, O. (1996) Can relaxation training and hypnotherapy modify the immune response to acute stress, and is hypnotisability relevant?. Contemporary Hypnosis 13: 100–108.
Lorr, M. & McNair, D. M. (1984). Manual of the Profile of Mood States. Educational and Industrial Testing Service: San Diego
Maguire, G. P., Lee, E. G., Bevington, D. J., Kuchemann, C. S., Crabtree, R. J. & Cornwell, C. E. (1978) Psychiatric problems in the first year after mastectomy. Br Med J 1: 963–965.
Miller, A. B., Hoogstraten, B. & Staquet, M. et al ( (1981) Reporting results of cancer treatments. Cancer 47: 207–214.
Paraskevaidis, E., Kitchener, H. C. & Walker, L. G. (1993) Doctor–patient communication and subsequent mental health in women with gynaecological cancer. Psycho-Oncology 2: 195–200.
Ratcliffe, M. A., Dawson, A. A. & Walker, L. G. (1995) Eysenck Personality Inventory L-scores in patients with Hodgkin’s disease and non-Hodgkin’s lymphoma. Psycho-Oncology 4: 39–45.
Razavi, D., Delvaux, N., Farvacques, C. & Robaye, E. (1990) Screening for adjustment disorders and major depressive disorders in cancer in-patients. Br J Psychiatry 156: 79–83.
Richardson, J. L., Shelton, D. R., Krailo, M. & Levine, A. M. (1990) The effect of compliance with treatment on survival among patients with hematologic malignancies. J Clin Oncol 8: 356–364.
Simonton, O. C., Matthews-Simonton, S. & Sparks, T. F. (1980) Psychological intervention in the treatment of cancer. Psychosomatics 21: 226–233.
Spiegel, D., Bloom, J. R., Kramer, H. C. & Gottheil, E. (1989) Effects of psychosocial treatment on survival in patients with metastatic breast cancer. Lancet ii: 888–891.
Tabachnik, B. G. & Fidell, L. S. (1996). Using Multivariate Statistics, 3rd edn. Harper-Collins: New York
UICC (International Union Against Cancer) (1987). TNM Classification of Malignant Tumours. UICC: Berlin
Walker, L. G. (1992) Hypnosis and cancer. Am J Prev Psychiat Neurol 3: 42–49.
Walker, L. G. (1998) Hypnosis and cancer: host defences, quality of life and survival. Contemp Hypnosis 15: 34–39.
Walker, L. G. & Eremin, O. (1996) Psychological assessment and intervention: future prospects for women with breast cancer. Semin Surg Oncol 12: 76–83.
Walker, L. G., Walker, M. B., Heys, S. D., Lolley, J., Wesnes, K. & Eremin, O. (1997a) The psychological and psychiatric effects rIL-2: a controlled clinical trial. Psycho-Oncol 6: 290–301.
Walker, L. G., Walker, M. B., Simpson, E., Fielden, S., Ogston, K., Segar, A., Heys, S. D., Ah-See, A. K., Hutcheon, A. W. & Eremin, O. (1997b) Guided imagery and relaxation therapy can modify host defences in women receiving treatment for locally advanced breast cancer. Br J Surg 84: 31
Walker, L. G., Heys, S. D. & Eremin, O. (1998). Surviving cancer: does the fighting spirit help? J Psychosom Res (in press)
Watson, M. & Greer, S. (1983) Development of a questionnaire measure of emotional control. J Psychosom Res 27: 299–305.
Weeks, J. (1992) Quality of life assessment: performance status upstaged?. J Clin Oncol 10: 1827–1829.
Wesnes, K. A., Walker, M. B. & Heys, S. D. et al ( (1997) What does a weekend ‘on call’ in a surgical ward do to cognitive performance and mood?. Br J Surg 84: 493–495.
Zigmond, A. S. & Snaith, R. T. (1983) The Hospital Anxiety and Depression Scale. Acta Psychiat Scand 67: 361–370.
About this article
Cite this article
Walker, L., Walker, M., Ogston, K. et al. Psychological, clinical and pathological effects of relaxation training and guided imagery during primary chemotherapy. Br J Cancer 80, 262–268 (1999). https://doi.org/10.1038/sj.bjc.6690349
- breast cancer
- quality of life
- randomized trial
A randomized trial of nurse‐administered behavioral interventions to manage anticipatory nausea and vomiting in chemotherapy
Cancer Medicine (2020)
American Journal of Clinical Hypnosis (2019)
A Multicenter Comparison of Complementary and Alternative Medicine (CAM) Discussions in Oncology Care: The Role of Time, Patient‐Centeredness, and Practice Context
The Oncologist (2019)
Current Urology Reports (2018)
Alleviation of Side Effects and Distress in Breast Cancer Patients by Cognitive-Behavioral Interventions: A Systematic Review and Meta-analysis
Journal of Clinical Psychology in Medical Settings (2018)