Journal of Behavioral Medicine, Vol. 29, No.

1, February 2006 (

C 2006)

DOI: 10.1007/s10865-005-9036-1

Cognitive Behavioral Therapy Techniques for Distress

and Pain in Breast Cancer Patients: A Meta-Analysis

Kristin Tatrow1,2,3,4 and Guy H. Montgomery2,3

Accepted for publication: April 18, 2005

Published online: January 7, 2006

This meta-analysis is the first to examine cognitive behavioral therapy (CBT) techniques for
distress and pain specifically in breast cancer patients. Twenty studies that used CBT tech-
niques with breast cancer patients were identified and effect sizes were calculated to de-
termine (1) whether CBT techniques have a significant impact on distress and pain, (2) if
individual or group treatments are more effective, (3) whether severity of cancer diagno-
sis influences distress and pain outcomes, and, (4) if there is a relationship between CBT
technique efficacy for distress and pain. Results revealed effect sizes of d = 0.31 for distress
(p < 0.05) and .49 for pain (p < 0.05), indicating that 62 and 69% of breast cancer patients in
the CBT techniques treatment groups had less distress and less pain (respectively) relative to
the control groups. Studies with individual treatment approaches had significantly larger ef-
fects compared to studies that employed group approaches for distress (p = 0.04), but not for
pain (p > 0.05). There were no significant differences in effects between those with or without
metastases (p > 0.05). The correlation between effect sizes for distress and pain was not sig-
nificant (p = 0.07). Overall, the results support the use of CBT techniques administered indi-
vidually to manage distress and pain in breast cancer patients. However, more well-designed
studies are needed.
KEY WORDS: breast cancer; distress; pain; cognitive behavioral; meta-analysis.

Breast cancer is the most commonly diag-
nosed cancer among women in the United States
(American Cancer Society [ACS], 2004). It is esti-
mated that there will be over 215,000 new breast can-
cer cases in the United States and close to 40,000
deaths from breast cancer in 2004 (ACS, 2004). De-
spite improvements in oncology treatments and sur-
vival rates (from 75% 5-year survival rates in the
1970s to 87% survival rates in the 1990s; ACS, 2004),
breast cancer and its treatment are still associated
1 Psychology
Department, Good Shepherd Rehabilitation Hospi-
tal, Allentown, PA.
2 Integrative Behavioral Medicine Program, Department of Onco-
logical Sciences, Mount Sinai School of Medicine, New York.
3 Biobehavioral Medicine Program, Department of Oncological
Sciences, Mount Sinai School of Medicine, New York.
4 To whom correspondence should be addressed at, Psychol-
ogy Department, Good Shepherd Rehabilitation Hospital,
501 Saint John St., Allentown, Pennsylvania, 18103; e-mail:
ktatrow@gsrh.org.
with numerous highly aversive symptoms and side ef-
fects. Perhaps the most prominent of these are dis-
tress and pain (Glanz and Lerman, 1992).
In fact, at least half of all breast cancer pa-
tients will experience emotional distress (Kornblith
and Ligibel, 2003). Breast cancer associated distress
can range from feelings of sadness and worry to more
disabling emotional problems such as depression
and anxiety (National Comprehensive Cancer Net-
work Distress Management Panel, 2005). As many
as a quarter of women with breast cancer will suf-
fer from clinically significant psychological problems
(Glanz and Lerman, 1992). Specific signs and symp-
toms of distress include concerns about illness and
decline in health, anger, sleep difficulties, poor ap-
petite, concentration difficulties and preoccupation
with thoughts of illness and death (National Com-
prehensive Cancer Network Distress Management
Panel, 2005). Fear of cancer recurrence may also be a
significant issue for breast cancer patients (Kornblith

17
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C 2006 Springer Science+Business Media, Inc.
18
and Ligibel, 2003). Distress can occur at varying
levels regardless of cancer stage or type of treatment
(Zabora et al., 1997, 2001). For example, anticipa-
tory distress prior to surgery is widespread in breast
cancer patients (Montgomery and Bovbjerg, 2004;
Montgomery et al., 2002a) and over half of all breast
cancer patients report medium to high levels of acute
distress following diagnosis (Tjemsland et al., 1996).
Lastly, distress has also been found to significantly in-
crease in women dying from metastatic breast cancer
(Butler et al., 2003).
Similarly, breast cancer patients typically expe-
rience pain at some point in their treatment. Pain is
one of the most common side effects of breast can-
cer and its treatment. For example, pain has been as-
sociated with surgery, chemotherapy, radiation, and
hormonal therapy (Lyne et al., 2002). Scar pain and
arm pain are the most common types of chronic
pain experienced by breast cancer patients (Tasmuth
et al., 1995). As with distress, pain can be experi-
enced at various stages of illness and treatment. At
least half of all breast cancer patients experience pain
(Tasmuth et al., 1995). For example, in one study,
pain occurred in 51% of breast cancer survivors
15 months postsurgery (Kornblith et al., 2003). Addi-
tionally, pain increases in breast cancer patients be-
fore death (Butler et al., 2003). Furthermore, there
is a significant association between psychological dis-
tress and physical pain (Montgomery and Bovbjerg,
2004; Zaza and Baine, 2002).
Pharmacological treatments have been used for
distress and pain in breast cancer patients. To com-
bat distress antidepressants, anxiolytics and hyp-
notics should be considered (National Comprehen-
sive Cancer Network Distress Management Panel,
2005). Commonly used medications for pain manage-
ment include nonsteroidal anti-inflammatory drugs,
opiods, and coanalgesics (Lyne et al., 2002). How-
ever, pharmacologic interventions have not com-
pletely eliminated distress and pain in cancer patients
and often come with their own set of side effects
(Golden, 2004; Holland, 1998; Portenoy and Lesage,
1999). Therefore, it is important to examine nonphar-
macologic approaches to control distress and pain.
Fortunately, a variety of psychological interven-
tions are available to help cancer patients manage
distress and pain (see Newell et al., 2002 for a recent
review). More specifically, cognitive behavioral
therapy (CBT) techniques have been shown to be
valuable tools to relieve distress and pain in various
cancer populations (Mundy et al., 2003) and several
such treatments have been empirically validated for
Tatrow and Montgomery
use with cancer patients (Compas et al., 1998). For
example both relaxation and imagery have been
found to be efficacious for chemotherapy patients,
while systematic desensitization, hypnosis and
distraction are possibly efficacious (Compas et al.,
1998). Additionally, cognitive behavioral group ther-
apy is possibly efficacious for distress (Compas et al.,
1998). Therapies such as relaxation are typically used
as adjuncts in cancer pain management and their
utility for all types of patients make them important
tools in managing pain (Lyne et al., 2002).
Numerous intervention studies with varying re-
sults have been published on the effects of CBT
techniques for cancer-related distress and/or pain
in breast cancer patients. These intervention stud-
ies have included a range of treatment components
including relaxation, hypnosis, cognitive restructur-
ing, biofeedback, skills training, etc. With the ex-
ception of one study (Bordelau et al., 2003), several
studies have successfully used relaxation, imagery or
hypnosis to treat distress in breast cancer patients
of various stages of illness (i.e., Arathuzik, 1994;
Hidderley and Holt, 2004; Larsson and Starrin, 1992;
Molassiotis et al., 2002; Montgomery et al., 2002c;
Walker et al., 1999; Williams and Schreier, 2004).
Results on distress with group treatment have been
mixed with some studies finding improvements in
distress (Fukui et al., 2000 Helgeson et al., 1999)
while others showing no change at follow-up (Edel-
man et al., 1999; Samarel et al., 1997 or worsening
compared to controls, Heiney et al., 2003). Studies
examining cognitive therapy alone or in conjunc-
tion with relaxation have also had mixed results.
A study with bone marrow transplant patients
(Gaston-Johansson et al., 2000) and a study with
breast cancer surgery patients (Larson et al., 2000)
found no significant changes on distress postinter-
vention. While, a telephone treatment using cog-
nitive therapy components found improvements in
distress in a group of newly diagnosed breast can-
cer patients (Sandgren et al., 2000), and cogni-
tive therapy alone helped to decrease depression in
postsurgery patients who were being treated with
chemotherapy (Marchioro et al., 1996). Other ther-
apies such as biofeedback and behavior therapy have
also had beneficial effects on measures of distress
(Christensen, 1983; Davis, 1986). Similarly, studies
aimed at reducing pain in breast cancer patients have
had mixed results with some indicating minimal or no
improvement (Arathuzik, 1994; Bordelau et al., 2003;
Gaston-Johansson et al., 2000) and others indicating
significant improvement (Montgomery et al., 2002c;
Cognitive Behavioral Techniques for Breast Cancer
Sandgren et al., 2000; Spiegel and Bloom, 1983).
Relaxation techniques were used in all of these pain
outcome studies.
A quantitative way to aggregate these results
and draw conclusions across a literature is to con-
duct a meta-analysis. Meta-analysis is an established
method that allows for aggregation of outcomes
across multiple studies for the purpose of drawing
conclusions from a literature (Smith et al., 1980).
Specifically, meta-analysis involves the calculation of
effects sizes from previously published studies. An
effect size indicates the strength of the relationship
between two or more variables and allows for direct
comparisons of effects across studies.
There are seven meta-analyses examining the
effectiveness of various psychological interventions
for cancer patients (Devine, 2003; Devine and
Westlake, 1995; Graves, 2003; Luebbert et al., 2001;
Meyer and Mark, 1995; Rehse and Pukrop, 2003;
Sheard and Maguire, 1999). Overall, these meta-
analyses report promising results on the effectiveness
of psychological interventions for controlling distress
and pain. However, none have specifically addressed
the effectiveness of CBT techniques in breast can-
cer, which is surprising as breast cancer is the most
commonly diagnosed cancer among women in the
United States (ACS, 2004), and distress and pain are
common in these women (see above). Furthermore,
one might expect CBT trial results for breast can-
cer patients to differ from other cancer populations
because different types of cancer have different psy-
chological responses, as well as involve different eti-
ologies and sociodemographic factors (Compas et al.,
1998). Most importantly, patients may respond dif-
ferently to therapy depending on type of cancer, as
studies have reported differing levels of distress de-
pending on type of cancer (Anderson, 1992; Zabora
et al., 2001). Therefore, an examination of treatment
effects for distress and pain in breast cancer patients
is needed to examine clinical efficacy within this pop-
ulation. In addition, it is also unknown whether treat-
ment effectiveness of CBT techniques is similar for
pain and distress. We will explore this possibility
to hopefully shed light on the most effective means
for ameliorating breast cancer patients’ pain and
distress.
The goal of this study was to determine the
effectiveness of CBT techniques for alleviating
distress and pain in breast cancer patients. To our
knowledge, no other meta-analyses have focused on
this specific group of cancer patients despite breast
cancer being the most common type of cancer in
19
women (ACS, 2004). Additionally, most of the meta-
analyses on psychological treatments with cancer
patients have included a wide range of therapeutic
approaches in their analyses including psychody-
namic, existential, supportive/supportive expressive,
crisis intervention, education only, music therapy
and cognitive behavioral (Devine, 2003; Devine and
Westlake, 1995; Meyer and Mark, 1995; Rehse and
Pukrop, 2003; Sheard and Maguire, 1999), making
inferences specifically regarding CBT techniques
difficult to interpret.
The two previous meta-analyses focusing on
CBT techniques in cancer patients (e.g., Graves
2003; Luebbert et al., 2001) have supported this
approach. Graves’ (2003) meta-analysis of adult
cancer patients found that treatment packages with
a larger number of “social cognitive” components
had larger effect sizes. This meta-analysis focused
on quality of life and included both male and female
cancer patients. Additionally, though Graves does
not report what cancer diagnoses were represented,
from the reference list there appears to be several
types of cancer patients in the analysis including
but not limited to breast cancer, bladder cancer,
melanoma and gynecologic cancer. The only other
meta-analysis to examine CBT techniques was con-
ducted by Luebbert et al. (2001). This meta-analysis
focused exclusively on the effectiveness of one
CBT technique (i.e., relaxation) in adult male and
female cancer patients undergoing acute medical
treatment and found medium to large effect sizes
for pain and distress respectively. Again, various
types of cancer patients were included in the analysis
including breast, leukemia and lung. Though these
meta-analyses indicate the effectiveness of CBT
techniques in treating cancer patients they include of
a broad range of cancer patients, with great variabil-
ity in their diagnoses. Such variability makes focused
conclusions for breast cancer patients somewhat
tenuous since cancer diagnosis has an influence on
responses to therapy (Anderson, 1992; Zabora et al.,
2001). Further rigorous investigation on this specific
cancer population and psychotherapeutic approach
is needed so that interventions can be used in a man-
ner that most benefits breast cancer patients. This
paper adds to the current literature in three very im-
portant ways. First, by focusing on breast cancer, the
present meta-analysis eliminates heterogeneity due
to different treatments and mortality rates associ-
ated with different cancers (ACS, 2004). Such factors
could potentially influence conclusions. Second, the
current paper’s focus on cognitive behavioral tech-
20
niques previously reported to be effective in relieving
pain and distress in cancer patients (Compas et al.,
1998; Mundy et al., 2003), builds on the available
data rather than replicating it. Including noneffective
treatments would only add heterogeneity to the
present study, and potentially obfuscate the results.
Third, women who are facing cancer have issues that
can be completely different from those faced by men.
Issues of sexual identity and body image are common
for breast cancer patients (Henson, 2002; Petronis
et al., 2003). Furthermore, even healthy women
are extremely worried about breast cancer and its
treatment (Montgomery et al., 2003). Providing
information about effective interventions to ame-
liorate symptoms and side effects for breast cancer
will hopefully alleviate some small portion of their
distress.
With the use of meta-analytic techniques, data
from published literature was examined for the fol-
lowing: (1) an estimate of the overall effect size of
CBT techniques on distress and pain, (2) a compari-
son of effect sizes for individual versus group treat-
ment formats for distress and pain, (3) a compari-
son of effect sizes by severity of cancer (metastases
or no metastases) for distress and pain, and 4) an ex-
ploration of relations between effect sizes for distress
and pain.
METHODS
Between-group studies measuring pain and dis-
tress in breast cancer patients were reviewed for
potential inclusion in the meta-analysis. PsychInfo,
Medline, CancerLit, and CINAHL were searched
from 1974 to June 2004 using combinations of the
following terms: anxiety, behavior(al), biofeedback,
cancer, cognitive behavioral therapy, distress, de-
pression, hypnosis, imagery, pain, relaxation, and
treatment outcome(s). The computer search was set
to accept only randomized controlled trials and stud-
ies published in English. Additional studies were
obtained from literature reviews and meta-analyses
on the psychological management of cancer symp-
toms, as well as from reference lists associated with
these studies (Bottomley, 1996; Devine, 2003; Devine
and Westlake, 1995; Edelman, Craig, and Kidman
et al., 2000; Genuis, 1995; Graves, 2003; Luebbert
et al., 2001; Meyer and Mark, 1995; Mundy et al.,
2003; Newell et al., 2002; Noyes, 1981; Rehse and
Pukrop, 2003; Sheard and Maguire, 1999; Sims, 1987;
Trijsburg et al., 1992)
Tatrow and Montgomery
As the focus of this meta-analysis was the ef-
fectiveness of CBT techniques, studies not using
any CBT technique were excluded. In this paper
“CBT” was broadly defined and included any in-
tervention containing components of either behav-
ioral and/or cognitive techniques. Based on reviews
(Bottomley, 1996; Compas et al., 1998; Mundy et al.,
2003; Noyes, 1981; Trijsburg et al., 1992), stud-
ies were included if they utilized any CBT tech-
niques, containing any of the following: activity pac-
ing, assertiveness/communication training, autogenic
training, behavioral activation, biofeedback, cog-
nitive/attentional distraction, cognitive restructur-
ing, contingency management, goal setting, imagery,
hypnosis, meditation, modeling, pleasant activity
scheduling, problem-solving, relaxation training, role
playing, systematic desensitization or visualization.
Other inclusion criteria included the use of (1)
a no treatment or standard care control group in the
study design, (2) enough data to allow the calculation
of effect sizes (e.g., both the means and standard de-
viations or both p and n values), (3) randomization
(with exceptions see below), (4) prospective design,
and (5) measures of distress and pain. Measures that
contained questions examining sensory components
of pain (e.g., intensity, frequency, duration, or sensa-
tion) were included. Measures not directly assessing
pain (e.g., predicted ability to control pain) were not
included for two reasons. One, examination of sen-
sory pain is the most face valid approach and reduces
between study heterogeneity. Second, on a practi-
cal level, only half of the pain studies included other
measures of pain (e.g., pain control, affect secondary
to pain), making statistical analyses difficult. Distress
for the purposes of this paper focused on emotional
aspects and studies that utilized measures examining
distress, depression, anxiety, stress or mood were in-
cluded.
There were 61 available studies examining treat-
ment outcomes in breast cancer patients. First, as the
focus of this meta-analysis was on CBT techniques,
studies that did not contain any CBT techniques were
eliminated. A total of 12 studies were eliminated be-
cause the intervention did not appear to contain any
CBT techniques (e.g., treatment was described as
“counseling”, “supportive expressive”, “crisis inter-
vention,” etc.). Next, since the focus of this meta-
analysis was on distress and pain, studies that did
not include these outcome variables were eliminated.
Six studies did not examine distress and/or pain, and
were thus excluded. The most common measure of
distress was the Profile of Mood States, used in 7
Cognitive Behavioral Techniques for Breast Cancer 21

Table I. Study Characteristics and Mean Effect Sizes

Cognitive behavioral Treatment
Reference techniques Mets Outcome measures type n d
Arathuzik (1994) Relaxation and visualization Yes Distress (POMS) Individual 16 0.00
Pain (Johnson Pain Intensity) 0.62
Cognitive restructuring, Yes Distress (POMS) Individual 16 0.72
distraction, relaxation,
and visualization
Pain (Johnson Pain Intensity) 0.72
Bordelau et al. Relaxation Yes Distress (EORTC QLQ-C30) Group 215 0.07
(2003)
Pain (EORTC QLQ-C30) 0.00
Christensen (1983) Behavioral practice and role No Distress (BDI & STAI) Couples 20 0.44
play
Davis (1986) Biofeedback and relaxation No Distress (STAI) Individual 14 0.83
Stress coping training Distress (STAI) Individual 12 1.31
(identification of
dysfunctional attitudes,
positive imagery, positive
self-talk, coping behaviors
and relaxation)
Edelman et al. Behavioral activation, Yes Distress (POMS) Individual 92 0.16
(1999) cognitive restructuring,
positive self-talk,
communication training,
goal setting, problem
solving and relaxation
Fukui et al. (2000) Coping skills training, stress No Distress (POMS & HADS) Group 50 0.15
management (imagery
and relaxation)
Gaston-Johansson Cognitive restructuring, Mixed Distress (BDI & STAI) Individual 110 0.39
et al. (2000) imagery, and relaxation
Pain (Painometer) −0.18
Helgeson et al. Relaxation No Distress (Affect scales) Group 156 0.17
(1999)
Relaxation (w/peer No Distress (Affect scales) Group 159 0.04
discussion)
Heiney et al. (2003) Stress management (active No Distress (POMS) Group 66 −0.45
coping and stress
awareness)
Hidderley and Holt Autogenic training No Distress (HADS) Individual 31 0.56
(2004)
Larson et al. (2000) Problem-solving and Mixed Distress (CES-D, DES-IV, and Individual 41 −0.31
relaxation IES)
Larsson and Starrin Autogenic training and Mixed Distress (Faces mood scale) Individual 64 0.30
(1992) relaxation
Marchioro et al. Cognitive therapy (based on No Distress (BDI) Individual 36 0.39
(1996) Beck’s model)
Molassiotis et al. Imagery and relaxation No Distress (POMS & STAI) Individual 71 0.47
(2002)
Montgomery et al. Hypnosis No Distress (VAS) Individual 20 2.11
(2002a,b,c)
Pain (VAS) 1.46
Samarel et al. Communication, problem No Distress Group 117 −0.10
(1997) solving, role playing and
stress management with
coaching
22 Tatrow and Montgomery

Table I. Continued
Cognitive behavioral Treatment
Reference techniques Mets Outcome measures type n d
Communication, problem No Distress Group 123 0.20
solving, role playing and
stress management
without coaching
Sandgren et al. Cognitive restructuring, No Distress Individual 53 0.24
(2000) coping skills training,
problem solving and
relaxation
Pain 0.31
Spiegel and Bloom Hypnosis Yes Pain (Pain rating scale) Group 54 0.04
(1983)
Walker et al. (1999) Guided imagery Mixed Distress (Mood rating scale Individual 96 0.14
(visualization) and & HADS)
relaxation
Williams and Relaxation Mixed Distress (STAI) Individual 71 0.55
Schreier (2004)
Note. Beck Depression Inventory (BDI), Center for Epidemiological Studies-Depression scale (CES-D), Differential Emotions Scale-
IV (DES-IV), European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30),
Hospital Anxiety and Depression Scale (HADS), Impact of Event Scale (IES), Medical Outcomes Scale (MOS), Profile of Mood States
(POMS), State Trait Anxiety Inventory (STAI), and Visual Analogue Scale (VAS).

of the 19 studies. To measure pain, visual analogue
scales were commonly employed (see Table I for a
complete list of distress and pain measures). An ad-
ditional 23 studies failed to meet inclusion criteria
for the following reasons: 14 lacked adequate control
groups or failed to report between-group differences,
seven were missing minimum statistical information
needed to calculate effect sizes (e.g., mean, standard
deviation), and two studies were retrospective. Some
of the studies were eliminated for more than one rea-
son. A total of 20 studies were included in the present
meta-analysis.
Thirty effect sizes were calculated from 20 stud-
ies (23 effect sizes for distress and seven for pain).
The total number of subjects was 1649 for distress
and 484 for pain. Nearly all the included studies
used strict random assignment, with four exceptions:
stratified random sampling (Bordelau et al., 2003;
Marchioro et al., 1996; Walker et al., 1999) and block
randomization (Hidderley and Holt, 2004). These
studies were included as their effect sizes were within
the range of our overall sample, and their violations
to strict random assignment were not dramatic. If
a study contained more than one treatment group,
only those groups containing CBT techniques were
compared to the control group. Consistent with the
published literature, effect sizes were calculated by
treatment rather than by study (Smith et al., 1980).
If more than one measure of a given outcome (e.g.,
two measures of distress) or postintervention time
period (e.g., 1 month and 3 months postinterven-
tion) were included in the study design, effect sizes
were calculated as the average of the measures or
time periods. For example, if a study contained two
separate interventions (i.e., two treatment groups)
and one control group, the study would have two ef-
fect sizes (Treatment A vs. Control; Treatment B vs.
Control). If a study had a measure of distress over
two follow-up phases, there would be a single ef-
fect size. If there were three distress measures, again
there would be a single effect size calculated by av-
eraging across the effect sizes associated with each
measure. Only four of the studies had more than
one effect size due to multiple intervention groups
(Arathuzik, 1994; Davis, 1986; Helgeson et al., 1999;
Samarel et al., 1997).
Effect sizes (d) were calculated for pain and
distress by taking the difference between the con-
trol group mean and the experimental group mean,
then dividing by the standard deviation of the control
group (Smith et al., 1980). In studies where this infor-
mation was unavailable, effect sizes were estimated
based on procedures described in Appendix 7: For-
mulas and Conventions for Calculating Effect Sizes
by Smith et al. (1980). Effect sizes were estimated for
five of the twenty studies (Arathuzik, 1994; Larson
et al., 2000; Molassiotis et al., 2002; Sandgren et al.,
2000; Williams and Schreier, 2004). There were no
differences in effect size between those studies with
estimated effects and those without (p = 0.80).
Secondary analyses were conducted comparing
effect sizes for treatment format (group versus indi-
Cognitive Behavioral Techniques for Breast Cancer
vidual therapy) and for cancer severity (metastases
or no metastases). Only one study involved couples
counseling (Christensen, 1983). We chose to catego-
rize this study as individual therapy rather than group
therapy, as the focus of the treatment was on the in-
dividual breast cancer patient. Experiences were not
shared among other patients. In this study, patient
scores were also reported separately from their part-
ner’s scores, and therefore we were able to calculate
effect sizes for breast cancer patients alone. Addi-
tionally, the correlation between effect sizes for pain
and distress were examined.
RESULTS
Mean effect sizes, sample size, treatment type,
type of CBT technique and outcome measure(s) for
each study included in the analyses are presented in
Table I. The overall effect size (d) was 0.31 for dis-
tress and 0.49 for pain. These results indicated that
62% of patients in the treatment groups did better
than those in the control groups in regard to dis-
tress. Also, 69% of the patients in the treatment
groups did better than those in the control groups
in regard to pain. Ninety-five percent CIs indicated
that these effect sizes are significantly different from
zero (distress [0.07 to 0.55], p < 0.05 and pain [0.09 to
0.90], p < 0.05). Overall, breast cancer patients who
were administered CBT techniques had significantly
less distress and pain compared to those in control
groups. According to Cohen’s criteria (1992) these
effect sizes are in the small to medium range.
Results were then adjusted according to pub-
lished procedures (Hunter and Schmidt, 1990) in or-
der to take into account variations in study sample
sizes (D and VarD respectively). Examination of the
average adjusted D (weighted for sample size) re-
vealed that 55% of the patients treated with CBT
techniques did better than controls on distress scores,
and 56% of the patients treated with CBT tech-
niques did better than controls on the pain scores.
Mean adjusted D was 0.13 for distress and 0.15 for
pain. Ninety-five percent CIs indicated that the ad-
justed effect sizes were not statistically different from
zero for both distress [−0.02 to 0.29, p > 0.05] and
pain [−0.13 to 0.42, p > 0.05]. These data suggest that
studies with larger samples had smaller effects.
Interestingly, studies that employed group in-
terventions were the larger studies (perhaps due to
design practicalities). Therefore, it was also of inter-
est to estimate effect sizes based on treatment for-
mat (i.e., individual or group therapy format) without
23
adjusting for sample size, as sample size and study
methodology were not independent. Mean unad-
justed effect sizes (d) by treatment format (based on
16 individual format effect sizes and seven group for-
mat effect sizes) for distress were as follows: Individ-
ual d = .48, 95%CI = 0.17 to 0.78; Group d = −0.06,
95% CI = −0.22 to 0.09. The mean effect size for
Individual format was significantly greater than the
Group format, t(21) = 2.23; p < 0.05]. In regard to
pain, there were seven effect sizes, five of which were
in Individual format, two in Group format. Mean un-
adjusted effect sizes (d) by treatment format for pain
were as follows: Individual d = 0.61, 95% CI = 0.08
to 1.13; Group d = 0.20, 95% CI = −0.20 to 0.60. The
mean effect size for Individual format was not signif-
icantly greater than the Group format, p > 0.05, but
the effect was in the same direction as distress based
on this small sample of studies.
Comparison of mean unadjusted effect sizes be-
tween women with metastases and those without
metastases revealed no significant differences. Means
for distress were 0.43 (metastases) versus 0.18 (no
metastases), t(16) = 0.73, p = 0.478. Means for pain
were 0.46 (metastases) versus 0.89 (no metastases),
t(4) = 0.97, p = 0.389.
To examine the relationship between distress
and pain, two additional analyses were conducted.
First, a between groups t-test was performed to de-
termine if there were differences between the ef-
fect sizes for distress and pain. Results showed no
significant differences between distress and pain,
t(28) = −0.72, p = 0.475]. Next to determine the ex-
tent of the relationship between distress and pain, the
correlation between the two was examined. Due to
the differences in number of effect sizes between dis-
tress (n = 23) and pain (n = 7), only studies that in-
cluded both measures were included, resulting in an
examination of the correlation between effect sizes
for distress and pain in six studies. The correlation
between distress and pain in these six studies was
r = 0.78 (p = 0.07).
Due to the large variation in number of sessions
across studies (ranging from 1 to 52 or more sessions)
we examined whether amount of patient contact was
correlated with effect size. The correlation between
amount of patient contact and effect size was not sig-
nificant (r = 0.03, p = 0.41).
DISCUSSION
Distress and pain are common and aversive side
effects of breast cancer and its treatment. The re-
24
sults of the present meta-analysis indicated that CBT
techniques help the majority of patients control their
distress and pain relative to control groups. The
present effect sizes for distress and pain were con-
sistent with previously published meta-analyses [0.36
to 0.73 for various measures of distress (Luebbert
et al., 2001 Rehse and Pukrop, 2003; Sheard and
Maguire, 1999) and 0.41 to 0.44 for pain (Luebbert
et al., 2001)]. It appears that although the present
study focused on breast cancer patients, the findings
were congruent with the overall effects seen in cancer
patients more generally. However, separate exami-
nation of this specific cancer population was vital and
added to the current literature in several ways. First,
the present study is different from previous meta-
analyses (i.e., Graves 2003; Luebbert et al., 2001) be-
cause of the focus on breast cancer patients, thereby
reducing heterogeneity associated with including a
broad range of cancer patients, with great variabil-
ity in their diagnoses. As response to therapy is influ-
enced by cancer diagnosis (Anderson, 1992; Zabora,
et al., 2001) separate examination of cancer diagnoses
is warranted. Second, this meta-analysis allowed for
the focus on techniques that have been shown to
be effective, again reducing heterogeneity. Addition-
ally, it should be noted that overlap of studies with
the previous two meta-analyses was minimal. Third,
examination of breast cancer apart from other can-
cers is warranted because women in general have
heightened levels of worry and distress associated
with breast cancer (Montgomery et al., 2003), as well
as specific gender related issues such as body image
distress (Henson, 2002; Petronis et al., 2003).
Results also revealed that adjusting for sample
size reduced effect sizes associated with CBT tech-
niques to control distress and pain in breast cancer
patients. This finding was somewhat counterintuitive,
as larger samples typically demonstrate greater cen-
tral tendency in their distributions. In other words,
variance is reduced. As variance within a sample is
entered into the effect size equation in the denomi-
nator, decreased variance within a study should lead
to greater effect sizes, all things being equal. Due
to these unanticipated findings, additional analyses
were indicated.
Inspection of Table I revealed that studies with
larger sample sizes tended to be those which em-
ployed group interventions. Analyses of the effects
of individual versus group formats indicated that for
distress outcomes, patients were significantly better
off in individual therapy formats. Effects of ther-
apy format on breast pain were in the same di-
Tatrow and Montgomery
rection, but not significant. However, it should be
noted that pain analyses were based on a total of
seven studies, and should therefore be viewed with
caution. Together, these data suggest that the pat-
tern of smaller effect sizes for distress and pain with
larger sample sizes may be accounted for by the dif-
ferential effects of treatment format. This is not to
imply that individual therapy is always better than
group therapy, but rather that for the outcomes of
distress and pain, an individual approach may be
more beneficial for breast cancer patients. Of course,
outcomes not evaluated by the present study (e.g., in-
creased social support, decreased social constraints)
may be more responsive to group interventions. Fur-
thermore, other authors have reported results sup-
porting group, rather than individual, therapy for-
mats with cancer patients for anxiety and depression
(Sheard and Maguire, 1999). As their results may
have been influenced by outliers, large sample stud-
ies comparing individual and group therapy formats
are needed to further clarify this issue.
Fifteen of the 20 studies in this meta-analysis
focused on women with early stage disease or ad-
vanced (metastatic) cancer. Of those that included
mixed stages (Gaston-Johansson et al., 2000; Larsson
and Starrin, 1992; Larson et al., 2000; Walker et al.,
1999; Williams and Schreier, 2004), none conducted
specific statistical analyses examining treatment out-
come comparing those with advanced versus early
stage cancer. Sheard and Maguire’s (1999) meta-
analysis of anxiety and depression in cancer patients
found significant differences in effect sizes for de-
pression but not anxiety when comparing those with
advanced versus good/mixed prognoses. As it may
be possible that CBT techniques to control distress
and pain may be influenced by breast cancer severity
(metastic vs. nonmetastatic), we decided to compare
13 studies examining distress and five studies exam-
ining pain on this factor (the five studies containing
patients with mixed stages were not included in the
analysis). Our results did not reveal significant differ-
ences due to disease severity. However, based on the
limited literature on the influence of disease sever-
ity on CBT techniques’ effectiveness, it appears that
more controlled trials of CBT techniques, including
disease severity as a factor, are needed.
Based on both between group t-tests and within-
group correlational approaches, effects of CBT tech-
niques on distress and pain were similar. That is,
though both distress and pain are well-validated con-
structs, CBT techniques led to improvements in both,
and the effect sizes associated with each did not
Cognitive Behavioral Techniques for Breast Cancer
significantly differ. This finding is consistent with
previous studies (e.g., Zaza and Baine, 2002) and the
literature suggesting that these constructs do share
some variance (Syrjala and Chapko, 1995)
Additionally, to examine non specific effects
of therapy, we looked at the relationship be-
tween amount of therapist contact and effect sizes.
However, there did not appear to be a relation-
ship between amount of contact and treatment
outcome.
Though it is beyond the scope of the present
study, an inspection of Table I reveals that the largest
treatment effect size was associated with a hypno-
sis intervention; a commonly used CBT technique
with cancer patients (Mundy et al., 2003). The ef-
fect size reported in the present paper is consis-
tent with previous meta-analyses on the efficacy of
hypnosis in a wide variety of patients (e.g., Kirsch
et al., 1995; Montgomery et al., 2000, 2002b). This
literature has strongly supported the use of hypno-
sis as an adjunct to cognitive behavioral interven-
tions for pain and distress, and further studies on the
efficacy of hypnosis with breast cancer patients are
needed.
No study is without its limitations, and the
present one is no exception. First, some of the com-
parisons were based on small numbers of effect sizes.
As such, those comparisons should be viewed with
caution. However, the present paper benefits from
its specific focus on the use of CBT techniques to
reduce distress and pain in breast cancer patients,
and on its rigorous study selection criteria. It is hope
that the present paper will be viewed as both a com-
mentary on the lack of studies in the breast can-
cer literature as well as a catalyst for future well-
designed research. Second, there are many remain-
ing fine-grained comparisons that were beyond the
scope of the present paper (e.g., comparisons of spe-
cific CBT techniques). As the literature grows, it is
our hope that such areas of research will be pur-
sued. Lastly, due to the state of the existing litera-
ture, studies with larger samples were also those that
employed group formats. Though it is reasonable to
presume that the effects reported here are due to
differences between individual and group formats, it
can not be formally ruled out that the differences
were simply due to sample size. Additional large
sample studies of individual treatment format (which
could be included in future meta-analyses), as well as
studies directly comparing individual to group treat-
ment format, are needed to completely address this
issue.
25
In summary, to our knowledge this is the first
meta-analysis to examine the impact of CBT tech-
niques on distress and pain in breast cancer patients.
Effects found here are consistent with those reported
in the published literature on cancer patients. Fu-
ture research in this area will allow more fine-grain
analyses, but it also appears that study of differential
effects of individual and group cognitive behavioral
treatment formats should take precedence in studies
of CBT techniques for breast cancer patients. In ad-
dition, the data suggest that hypnosis may be an es-
pecially effective therapeutic technique for this pop-
ulation. Findings reported here were consistent with
those in the broader hypnosis literature. After con-
sidering study limitations, the overall results of the
present paper were consistent with positive effects of
CBT techniques for control of distress and pain, with
the majority of breast cancer patients benefiting.
ACKNOWLEDGMENT
This work was supported by NCI Grant nos.
CA86562, CA87021, and CA88189; ACS Grant
no. 00-312-01; and Department of Defense Grant
DAMD17-99-1-9303. The content of the informa-
tion contained in this study does not necessarily
reflect the position or policy of the United States
Government
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