1. Gallagher, Amy

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Patients with breast cancer commonly use complementary and integrative therapies as supportive care during cancer treatment to manage treatment-related side effects with the aim of providing psychological and emotional support through the relief of symptoms.


In 2017, the Society for Integrative Oncology issued guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment suggesting that hypnosis can be considered for fatigue during treatment, as well as guidelines that indicate hypnosis can be recommended as a therapy for pain.


At the 2021 San Antonio Breast Cancer Symposium held in December, sessions highlighting Evidence Based Integrative Therapies, During and Beyond Treatment, included the research by David Spiegel, MD, Medical Director of the Center for Integrative Medicine at Stanford University School of Medicine, who presented Hypnosis and Mindfulness, referencing the growing evidence supporting the use of hypnosis as an adjunctive treatment for medical patients experiencing pain.


Previous Research As Evidence

Although the practice of hypnosis among breast cancer patients is not common, Spiegel said many more cancer patients could benefit, especially given the dangers associated with chronic use of opioids, including accidental overdose. "There were approximately 100,000 drug overdose deaths in the U.S. last year," he said.


Spiegel has been studying the benefits of hypnosis for cancer patients over decades, beginning with his 1983 research (Psychosom Med 1983; doi: 10.1097/00006842-198308000-00007). The study demonstrated significantly less self-rated pain sensation (actually half) over the course of a year among the 34 women randomized to weekly group therapy with hypnosis compared to that of the 30 randomized to standard of care over the course of a year. All received comparable and low amounts of pain medication.


In 2009, Spiegel conducted a replication trial (Health Psychol 2009; doi: 10.1037/a0016124). The results from this study augmented the growing literature supporting the use of hypnosis as an adjunctive treatment for medical patients experiencing pain.


In 2012, Spiegel's collaborative research conclusively stated that "focused hypnotic concentration is a model for brain control over sensation and behavior" (Arch Gen Psychiatry 2012; doi:10.1001/archgenpsychiatry.2011.2190).


Hypnosis vs. Mindfulness

Hypnosis is a state of highly focused attention coupled with dissociation and heightened responsiveness to social cues, said Spiegel, noting that hypnosis is generally practiced to solve a problem, such as pain, stress, insomnia, or to stop smoking.


"Mindfulness, in contrast, is a practice that emphasizes body awareness, open presence (openly accepting all feelings, thoughts, and experiences), and developing compassion," he said.


According to previous electroencephalogram research, the data showed more left frontal theta activity during hypnosis (Int J Psychophysiol 1998; Aug;29(3):255-75)


To further explore the science behind hypnosis, Spiegel explained the connection between hypnosis and the brain's response using functional magnetic resonance imaging (Cereb Cortex 2017; doi:10.1093/cercor/bhw220).


The main findings have involved reduced activity in the dorsal anterior cingulate cortex, and higher functional connectivity between the left dorsolateral prefrontal cortex (DLPFC) and the insula, part of the salience and pain networks, Spiegel noted, adding "there is also inverse functional connectivity between the left DLPFC and the posterior cingulate cortex."


"Hypnosis involves reduced activity in the anterior cingulate cortex, part of the salience network (conflict detection), while mindfulness involves reduced activity in the posterior cingulate cortex, part of the default mode network (self-awareness)," he said.


Practice & Process of the Profession

Spiegel said the way in which a breast cancer patient receives hypnosis treatments depends on the specific problems with which they are dealing.


"We offer hypnosis sessions each week at the end of supportive-expressive group therapy," he said. "I also teach patients in single or multiple individual sessions depending on need, response, and number/type of problems, such as pain, stress, insomnia, and eating well with weight control."


The idea is for patients to learn and practice doing self-hypnosis as those symptoms warrant-if pain is worsening, practice it early and often, said Spiegel.


Mindfulness is usually taught as a daily 30-minute practice once or twice a day, and Spiegel also noted that apps are available, including Calm and Headspace. "We also now offer the Reveri downloadable hypnosis app to help with these problems."


Spiegel stated that professional licensure in a medically related discipline-MD or PhD-in psychology is advised for individual assessment for and use of hypnosis.


"Additionally, professional training from the Society for Clinical and Experimental Hypnosis, American Society of Clinical Hypnosis, or Division 30 of the American Psychological Association, assures appropriate training of professionals who use hypnosis," he said.


While hypnosis recommendations for breast cancer patients are becoming more common, the question remains as to whether or not health insurance covers the cost.


"There is a billing code, 90880, although hypnosis is sometimes billed as part of an evaluation and psychotherapy visit," said Spiegel.


The health insurance company, Aetna, considers alternative medicine interventions medically necessary if they are supported by adequate evidence of safety and effectiveness in the peer-reviewed published medical literature. The following are some of the alternative medicine interventions that Aetna considers medically necessary for properly selected members, subject to applicable benefit plan limitations and exclusions:


* Acupuncture-see CPB 0135 - Acupuncture


* Biofeedback-see CPB 0132 - Biofeedback


* Chelation therapy-see CPB 0234 - Chelation Therapy


* Chiropractic services-see CPB 0107 - Chiropractic Services


* Electrical stimulation-see CPB 0011 - Electrical Stimulation for Pain



Aetna considers the following alternative medicine interventions experimental and investigational, because there is inadequate evidence in the peer-reviewed, published medical literature of their effectiveness. While hypnosis is listed as "experimental" and "investigational," meditation and mindfulness didn't make the list:


Amy Gallagher is a contributing writer.