April 2, 2007

Zen and the Art of Biopsy — Researchers Examines Self-Hypnosis to Manage Pain During Needle Biopsy
By Beth W. Orenstein
For The Record
Vol. 19 No. 7 P. 28

More than 60% of women in the United States aged 40 and older will undergo mammography screening for breast cancer this year. Between 5% and 10% of their mammograms will result in abnormal or inconclusive findings that will require further study, according to the American Cancer Society. If a suspicious lump is found through mammography, or by palpitation, a large core needle biopsy (LCNB) is likely to be performed.

Found to be a reliable diagnostic tool, LCNB is typically performed in an outpatient setting, which limits the use of intravenous (IV) drugs in reducing pain and anxiety. The practical problem is that administering would make the procedure longer, and suite time is typically at a premium. Also, IV drugs limit the woman’s ability to drive or work after the procedure. “Many of the women we encounter have to juggle job, home, and family, and being out is something they can’t afford,” says Elvira V. Lang, MD, associate professor of radiology at Harvard University in Boston.

In addition, with the woman lying prone so her breasts are accessible through a hole in the table, IV drugs could be a danger. “If you give drugs and the patient would have any reaction, it would be difficult to resuscitate her in that position,” Lang says.

Studied for More Invasive Procedures
Having had success with self-hypnosis during more invasive surgical procedures, Lang and colleagues decided to investigate its use during LCNB. They conducted a study involving 236 women who were undergoing LCNB at the university-affiliated medical center between February 2002 and March 2004. Their research showed that self-hypnosis is not only a valuable pain management tool for women undergoing LCNB but also a cost-effective strategy.

Lang presented their findings at the Radiological Society of North America 2006 meeting in Chicago this past November. Previously, the research group had reported its findings in the September 2006 issue of Pain, the journal of the International Association for the Study of Pain. Lang’s research was supported by the U.S. Army Medical Research and Materiel Command and the National Institutes of Health National Center for Complementary and Alternative Medicine.

The women included in the study were required to give written consent and be able to hear and understand English; they also had to pass screenings for mental impairment and psychosis. The subjects were randomly assigned to one of three types of care: standard care, empathy, or hypnosis.

Seventy-six women received standard care with members of the biopsy team comforting the patients in their usual way. Eighty-two women received empathetic attention, where a person in the procedure room was assigned to be responsive to their needs, asking whether he or she could do anything to make the patient more comfortable. The person was also instructed to avoid negative language. For example, one would say, “This is the local anesthetic,” rather than, “You will feel a burn and a sting.”

The final group of 78 women was given empathetic attention and taught self-hypnosis techniques. For the hypnosis, a research assistant read a script instructing the patient on techniques that would help her relax. “The script invited patients to roll their eyes upward, close their eyes, breathe deeply, focus on a sensation of floating, and experience a pleasant setting of their choice with all their senses,” Lang says. The script also suggested how patients could transform their discomfort into a sensation of warmth, coolness, or tingling.

The research assistants included one male and one female physician, two female medical students, and one female premedical student with a background in mental health sciences. The script provided the consistency needed to administer the hypnosis techniques for the study. “We actually videotaped all the procedures to make sure that the assistants did what they were supposed to,” Lang says.

Reproducibility
Lang says the results may have been better had the assistants been able to improvise for each patient’s situation, “but we wanted something that the average, compassionate healthcare provider can do” and that can be easily replicated, Lang says.

The research assistants received standardized training, under supervision of physicians and psychologists, in empathetic structured attention and hypnosis. They also participated in workshops; used teaching videos, reading materials, and a Web-based course; and performed supervised practice with patients. The researchers then compared several factors, including levels of pain and anxiety, and procedure time and cost.

Lang says the women in the study had increased levels of anxiety, which is not surprising, adding that the women are undergoing the procedure because they may have breast cancer and “the prospect of having breast cancer can be very scary. One out of eight women will develop breast cancer in her lifetime. So the odds are very high that a woman undergoing an LCNB knows another woman who has had breast cancer, or worse, she knows someone who had a breast biopsy and had a bad experience.”

Time Is of the Essence
The researchers also found that the longer a patient is in the procedure room, the greater her pain. “I think even if you weren’t to do anything, just lying on the table in those surroundings increases the pain experience even more,” Lang says. “That’s why we wanted to give these women something to get through that and, specifically, to address the anxiety.”

Anxiety and pain were measured prior to entering the procedure room using a Spielberger State-Trait Anxiety Inventory. Anxiety was also evaluated in the procedure room using verbal scales of 0 to 10; a rating of 0 indicated no pain or anxiety while 10 indicated the worst pain and anxiety possible. Patients were asked to make pain and anxiety ratings every 10 minutes. “These scales were used because the patient’s self-report is considered the single most reliable descriptor of the pain experience,” Lang says.

Results of the study showed that anxiety increased significantly in the women in the standard care group, while anxiety did not change in the empathy group, and decreased significantly in the hypnosis group. All three groups reported pain during the procedure, but the empathy and self-hypnosis groups reported significantly less pain than the standard care group.

The researchers also measured time and cost and found that neither differed significantly among the groups, even though the empathy and hypnosis groups had an additional assistant. The hypnosis group had the shortest procedure time and the lowest cost. For standard care, the procedure was 46 minutes and calculated to cost $161; for empathy care, the time was 43 minutes and cost $163; and the time for the hypnosis group was 39 minutes and cost $152.

Relaxing Staff, Too
Lang attributes the shortened procedure time with hypnosis to the decreased level of stress. When using hypnosis, the stress is not only less for the patient, she says, but also for the treatment team. “The relaxation technique serves to calm and focus everyone involved in the procedure,” she says.

Lang adds that the patients learned a coping tool they can take with them and use to relieve anxiety through subsequent waits and workups related to their diagnosis and treatment. “We had women in the study who were found to have malignant cancer, which they had removed. During subsequent biopsies, they would ask to have self-hypnosis as well,” Lang says.

David Spiegel, MD, associate chair of psychiatry and behavioral sciences at Stanford University School of Medicine in California, says he is impressed by Lang’s methodology and conclusions. “She has demonstrated in a very convincing way that a little bit of self-hypnosis goes a long way in the radiology suite,” he says. The results are significant because the study was large scale, randomized, and “elegantly conducted,” he adds.

While Lang’s results showed hypnosis did more to relieve the women’s anxiety than it did their pain, Spiegel says, “large core needle biopsies aren’t that painful, so I don’t think there is much room for improvement in that regard.” The hypnosis clearly had other advantages as well, he says, including shorter procedure times with fewer complications and the need for fewer medications.

Some people fear hypnosis because they view it as inducing a loss of control, Spiegel says; however, the study shows the opposite is true. When used correctly, it can actually enhance the patient’s sense of control over their emotional and sensory experience.

In an editorial in the same issue of Pain as the Lang group study, Spiegel points out the irony that hypnosis, the oldest form of psychotherapy in Western culture, can be successfully wedded to one of the newest medical interventions: LCNB for breast cancer diagnosis. Obviously, he says, “this old technique of refocusing attention can be utilized with great effectiveness to reduce pain and anxiety during a variety of medical procedures.”

Overcoming Tradition
Spiegel also says that while physicians and their patients “may be skeptical of treatments that involve talk and relationships rather than medications and nerve blocks,” this study, as well as previous work by Lang and her colleagues, shows that “hypnosis works during medical procedures.” Spiegel hopes physicians won’t dismiss the idea of hypnosis simply because “there is no intervening pharmaceutical industry to sell the product. We don’t use dangling gold watches anymore,’” he writes.

Lang, who is now chief medical officer for a biomedical device company, says she plans to continue her research and promote hypnosis as a way of alleviating pain in patients undergoing procedures in the radiology suite. She has begun another large study of the use of hypnosis for patients undergoing an invasive procedure where the blood vessels supplying tumors are blocked.

Some physician groups have already adopted their model, Lang says. “The next step is to have a broader introduction into hospitals. We’ve already trained people in our interventional radiology division and are training more in our breast division. We’ve been asked by other radiology departments to help them learn how to do this.

“This research,” Lang says, “embraces a holistic approach combining ‘high-tech’ with ‘high-touch’ that respects the needs of women during the stressful times of breast biopsy and … that can be successfully applied to a number of other interventional procedures.”

— Beth W. Orenstein is a freelance medical writer who writes from her home in Northampton, Pa.