Patients who undergo hypnosis before breast cancer surgery may need less anesthesia and pain medication during the procedure and feel less postoperative pain, nausea, fatigue, discomfort, and emotional upset, according to a study published in the Journal of the National Cancer Institute (2007;99:1304–1312). The time and cost involved with the procedure were also reduced in the study.
“Hypnosis helped people feel better, reduced pain, nausea, and fatigue, and saved money,” concluded the lead author, Guy H. Montgomery, PhD, Associate Professor of Oncological Sciences at Mount Sinai School of Medicine. “I think this is a way we can help breast cancer patients improve their quality of life around surgery. Hypnosis makes them feel better at a very difficult time.”
The study is one of the building blocks needed for implementing procedural hypnosis, noted Elvira Lang, MD, a staff radiologist at Beth Israel Deaconess Medical Center and Associate Professor at Harvard Medical School, who was not part of the study.
“It's one more piece of the puzzle that tells the public and medical community that you can't ignore this intervention if you want to practice according to the best knowledge that is out there.”
Dr. Montgomery and his colleagues randomly assigned 200 women (mean age of 48.5) scheduled to undergo excisional breast biopsy or lumpectomy to a 15-minute presurgery hypnosis session or a “nondirective empathic” listening session.
The hypnosis sessions were scripted and provided by psychologists within one hour before surgery and included imagery for muscle relaxation and suggestions for pleasant visual imagery. Patients were also given hypnotic suggestions for experiencing reduced pain, nausea, and fatigue, as well as instructions about how to use hypnosis by themselves afterward.
The same psychologists led the nondirective empathic listening sessions, which did not include imagery or relaxation techniques. Patients were allowed to direct the conversation while psychologists listened attentively, provided supportive comments, and matched verbal and nonverbal communication patterns.
While patients could not be blinded to group assignment, the researchers did follow blinding procedures for the study's assessment personnel, anesthesiologists, and surgeons.
The investigators then evaluated the use of pain medication and sedatives during surgery, analgesics in the recovery room, and patient-reported pain and other side effects using a visual analog scale.
Overall, patients in the hypnosis group needed less intraoperative medication when compared with control patients—less of the sedative propofol (a mean difference of 32.63 μg) and the analgesic lidocaine (mean difference of 6.86 mL) during surgery.
However, the investigators did not find a statistically significant difference between the intervention and control groups in the use of the intraoperative analgesic fentanyl or the sedative midazolam. “Our anesthesiologist mentioned that those drugs are typically prescribed according to a clinical standard, rather than to how patients are doing at that point,” Dr. Montgomery explained. “Therefore, there is little variance between patients.”
Additionally, no difference was reported in the use of recovery room analgesics such as acetaminophen or acetaminophen/oxycodone between the two groups.
However, patients in the hypnosis group reported less post-surgical pain intensity, pain unpleasantness, nausea, fatigue, discomfort, and emotional upset than controls—all differences considered to be statistically significant.
In addition, the intervention group spent 10.60 fewer minutes in surgery than the control group did, which led to cost savings. Surgical breast cancer procedures at Mount Sinai typically cost about $8,561 per patient. Surgical costs in the intervention group were reduced by about $772.71 per patient.
“It's the rare kind of intervention that can help both patients and the bottom line of an institution,” Dr. Montgomery said.
Notable How Well Intervention Worked and How Simple It Was
Overall, the study was well done and reported some compelling outcomes, said Dr. Lang, who has published several studies over the years about hypnosis (Lancet 2000;355:1486–1490, J Clin Exp Hypn 1996;44:106–119, Pain 2006;126:155–164). She said that in her own experience, offering patients hypnosis while on an interventional radiology procedure table has helped to increase procedure safety and reduce the need for a lot of sedative or pain-relieving drugs or to eliminate the need for them altogether.
“What was notable about the study was how well the intervention worked and how simple it was,” said the author of an editorial that accompanied Dr. Montgomery's study, David Spiegel, MD, the Willson Professor in the School of Medicine and Associate Chair of the Department of Psychiatry & Behavioral Sciences at Stanford University School of Medicine.
How Hypnosis Works
Dr. Lang explained that one reason hypnosis is effective is that it calms the patient. “If the patient is scared, this rubs off on the clinicians in the room, which then feeds back to the patient.” Hypnosis can interrupt this cycle, making everyone much more focused, and this is why the procedure goes more quickly.
This is a stressful time for patients and being in an operating room is a novel situation, Dr. Spiegel said. Consequently, they pay more attention to signals like pain and anxiety to figure out how much danger they are in. “Hypnosis helps to turn down the amplifier to cope with what's coming with surgery and recovery,” he said.
Another reason hypnosis may be beneficial is that it appears to help patients become hemodynamically stable, Dr. Lang noted. It may also have an impact on how the brain perceives the intensity of pain that is transmitted to it.
Dr. Spiegel said that further research will help to determine which components of hypnosis are most important and to learn what's going on in the brain—for example, imaging studies show that hypnosis changes activity in parts of the brain involved in both sensory and affective pain perception.
Although there have been about a half dozen randomized trials indicating that hypnosis helps to relieve pain associated with surgery and invasive radiological procedures, there is still some skepticism about the procedure, Dr. Spiegel noted.
Although some patients and health care providers may still associate hypnosis with such stereotypes as dangling watches, people are increasingly recognizing the practice as a form of psychotherapy that uses a normal form of highly focused attention, he explained.
Hypnosis has been misunderstood as a means of taking control over someone, but it is actually a highly effective means of teaching people how to have better control over both mind and body, he said.
“There's some skepticism about hypnosis,” Dr. Montgomery agreed. “It's kind of a double-edged sword. This intervention generates a lot of interest, but some people still think it's quackery.”
How you present the intervention to people has a lot to do with how it's received, he explained. It needs to be discussed as a form of focused concentration and not as what people see on TV or in a stage show.
Dr. Lang noted that as Dr. Spiegel points out in the editorial, if hypnosis was a pill, the medical community would buy it, but because it involves the opening up of self to a person who is under duress, there may be some resistance.
She said she hopes that even if clinicians are not yet ready to introduce formal hypnosis to patients, it would be good for them to at least have a better understanding of how hypnotic language and suggestion affects people—“for example, remarks made in the operating room, such as, ‘That’s really bloody,' or ‘We're going to put you to sleep now,’ can be hurtful and stressful to the patient.”
Implementing a Program
Once skepticism is set aside, hospitals may need to find a way to make this intervention more accessible to people, Dr. Montgomery said. Although it won't be feasible for all hospitals to hire psychologists to offer hypnosis, it may be an option to train clinicians already on staff—for example, OR nurses and anesthesiologists.
“If we devote even a small amount or resources to this intervention, we will reap big benefits,” Dr. Spiegel concluded.