The SIO Research Committee is pleased to offer this third installment in a new blog series known as "Myths of Cancer". In this series we will address some of the most common myths and misperceptions that arise around cancer risk and treatment related to diet and natural health products, as well as other complementary therapies such as yoga, acupuncture and meditation. If you have a question you'd like us to address or comments about this post, please send your suggestions to: info@integrativeonc.org.

We hope you enjoy the series!
Linda Carlson and Eugene Ahn, Research Co-Chairs.

The Role for Hypnosis in Cancer Care: Overcoming Misconceptions to Engage in Evidence-Based Care

 By:  Eugene Ahn, MD, Linda Carlson, PhD, and Lorenzo Cohen, PhD

Quick Answer Box

There is a solid evidence-base to support the use of hypnosis in reducing distress, anxiety, nausea, pain and other symptoms during invasive medical procedures and reducing medical costs. Yet misconceptions related to the practice of hypnosis have limited its integration into cancer care.


Earlier this year, the critically acclaimed film Get Out (99% on Rotten Tomatoes) amassed $175 million at the box office winning audiences over with its mix of dark humor, horror, and social commentary. One of the plot twists (SPOILER ALERT) involves a psychiatrist who uses hypnosis to “mind-control” her guests. By tapping her cup of tea, she can sedate her clients into submission. To those who practice hypnosis or have trained in it, this representation of hypnosis is inaccurate and frustrating, requiring suspension of disbelief because those who know hypnosis well are aware that we cannot make a client do something they do not want to do. Yet this is the misunderstanding and fear of loss of control that hypnosis carries today.

Before delving into the research on hypnosis in an oncology setting, let’s first clarify the definition of hypnosis. Hypnosis is the procedure by which a person enters an altered state of consciousness resulting in increased suggestibility. Another term for this state of consciousness is “trance” and it can be differentiated from other states of consciousness such as being awake, sleep, dream state, or relaxation by an electroencephalogram (EEG), the electrical measurement of brain waves.

Hypnosis is an old practice and is mentioned in Hindu texts as “temple sleep” and by Avicenna (980-1037 AD) who wrote in The Book of Healing about the distinction between sleep and hypnosis. Despite its long history, hypnosis has had memorable runs of being stigmatized. One of the historical lightning-rod figures of hypnosis was Franz Anton Mesmer (1734-1815) who theorized that the benefits of hypnotic suggestions he saw in his practice were due to “animal magnetism”. He was particularly well known for healing “hysterical conditions” or what we now refer to as psychosomatic illness. In fact, the less often used synonym for hypnosis (due to its association with magnetism), “mesmerism”, originates from his work.

 

But over the past 15 years, several research groups have examined the impact of hypnosis on multiple patient outcomes when undergoing various medical procedures, including surgery1-3. Hypnosis in these studies involved inducing surgical patients into a hypnotic state through deep breathing, guided imagery, and a focus on a floating sensation4. In a variety of surgical populations, patients induced into hypnotic relaxation during their procedure report significantly less anxiety and pain and request less analgesic medication than controls1,3.  Additionally, patients are more cooperative with providers and spend less time in the procedure room5,6, which has resulted in reduced costs associated with medical procedures6,7 or, in the case of breast biopsy, neutral costs even with the addition of the extra staff member delivering the intervention8. These studies have also demonstrated beneficial physiological responses to self-hypnosis, including decreased heart rate, lower blood pressure, and reduced cortisol8,9.  In addition to the above benefits, hypnosis has consistently been shown not to increase side effects or complications from medical procedures, whereas staff simply “being nice” or “empathic” as a control arm in several hypnosis studies actually increased side effects and complications.10

Most of the studies have either been conducted prior to invasive surgical procedures, like breast cancer surgery, where patients are under general anesthesia, or during less invasive procedures, where the patients are conscious such as breast biopsy or bone marrow biopsy in children. For example, Montgomery, et al.11 found in a mixed population of women either undergoing hypnosis during biopsy or before lumpectomy surgery that the hypnosis group reported significantly less pain intensity. Furthermore, the hypnosis group used significantly less propofol and lidocaine pain medications than the control group and reported significantly less fatigue, discomfort, nausea, pain unpleasantness, and were less emotionally upset than the control group after the surgery was completed.

Meta-analyses by Schnur et al.3 and Tefikow et al.12(26 randomized controlled trials (RCTs) with 2342 participants and 34 RCTs with 2597 participants, respectively) suggest that hypnosis results in medium to large effect sizes on reduction of symptoms during and/or after a surgical procedure. Schnur et al. also noted that the effects were larger when hypnosis was delivered before and during the medical procedures (as well as greater effect size for children) compared to just before the procedure. Tefikow et al.12 reported a medium effect size for emotional distress, pain unpleasantness, pain intensity and medication consumption, and smaller but significant effect sizes for recovery, procedure time, and physiological parameters, with enhanced effects when the hypnosis was done before and during the procedures.

Given that there is a large evidence-base showing that patients who received hypnosis in multiple clinical settings have decreased medical costs (or net-even) and reduction in numerous patient reported symptom outcomes, the next question is why are we not utilizing hypnosis more frequently for surgical or diagnostic procedures? One common answer is that we need larger randomized clinical trials or “it worked fine at Harvard, but it is different here”.  However, this argument ignores the quantity of the existing data, is not aligned with the practice of evidence-based medicine, and ignores the approximately 40% of patients with cancer who experience significant distress, pain and unmanaged symptoms.

Less openly expressed issues are the taboos associated with hypnosis that Get Out exemplifies: primarily the loss of control over self-will. However, this is an unfortunate misconception and in the research studies cited above, hypnosis is provided as a scripted and standardized intervention. Patients at no point lose personal will and it is not possible to hypnotize someone without their consent. Providers of medical hypnosis are usually mental health or medical professionals who have undergone specific training in medical hypnosis from a reputable training organization such as the American Society of Clinical Hypnosis (http://www.asch.net/), and will hold a certificate to practice. Patients seeking medical hypnosis should verify that practitioners have received appropriate training. Lastly, it is important to note that previous studies on hypnosis generally exclude patients with significant psychiatric illnesses like schizophrenia and therefore we cannot make statements of safety in such patients.

In summary, with hypnosis we have a proven, underutilized, and safe modality to help improve the patient experience. If we espouse the practice of evidence-based medicine, then it is time to start using hypnosis alongside the standard of care to improve the patient experience during the numerous medical procedures happening daily within our medical system.


 

References

  1. Flory N, Salazar GM, Lang EV: Hypnosis for acute distress management during medical procedures. Int J Clin Exp Hypn 55:303-17, 2007
  2. Montgomery GH, David D, Winkel G, et al: The effectiveness of adjunctive hypnosis with surgical patients: a meta-analysis. Anesth Analg 94:1639-45, table of contents, 2002
  3. Schnur JB, Kafer I, Marcus C, et al: Hypnosis to manage distress related to medical procedures: A meta-analysis. Contemp Hypn 25:114-128, 2008
  4. Schupp CJ, Berbaum K, Berbaum M, et al: Pain and anxiety during interventional radiologic procedures: effect of patients' state anxiety at baseline and modulation by nonpharmacologic analgesia adjuncts. J Vasc Interv Radiol 16:1585-92, 2005
  5. Lang EV, Benotsch EG, Fick LJ, et al: Adjunctive non-pharmacological analgesia for invasive medical procedures: a randomised trial. Lancet 355:1486-90, 2000
  6. Lang EV, Rosen MP: Cost analysis of adjunct hypnosis with sedation during outpatient interventional radiologic procedures. Radiology 222:375-82, 2002
  7. Lang EV, Ward C, Laser E: Effect of team training on patients' ability to complete MRI examinations. Acad Radiol 17:18-23, 2010
  8. Lang EV, Berbaum KS, Faintuch S, et al: Adjunctive self-hypnotic relaxation for outpatient medical procedures: a prospective randomized trial with women undergoing large core breast biopsy. Pain 126:155-64, 2006
  9. Martin ML, Lennox PH, Buckley BT: Pain and anxiety: two problems, two solutions. J Vasc Interv Radiol 16:1581-4, 2005
  10. Lang EV, Berbaum KS, Pauker SG, et al: Beneficial effects of hypnosis and adverse effects of empathic attention during percutaneous tumor treatment: When being nice does not suffice. J Vasc Interv Radiol 19:897-905, 2010
  11. Montgomery GH, Bovbjerg DH, Schnur JB, et al: A randomized clinical trial of a brief hypnosis intervention to control side effects in breast surgery patients. J Natl Cancer Inst 99:1304-12, 2007
  12. Tefikow S, Barth J, Maichrowitz S, et al: Efficacy of hypnosis in adults undergoing surgery or medical procedures: a meta-analysis of randomized controlled trials. Clin Psychol Rev 33:623-36, 2013
  13. Berliere M, Lamerant S, Piette P, et al: Abstract P2-18-03: Potential benefits of hypnosis sedation on different modalities of breast cancer treatment. Cancer Research 75:P2-18-03, 2015
  14. Barabasz AF. Whither spontaneous hypnosis: a critical issue for practitioners and researchers. Am J Clin Hypn 48:91-7 2005
  15. Cheek DB: Importance of recognizing that surgical patients behave as though hypnotized. Am J Clin Hypn 4: 227-31 1962