Anderson, K.O., Cohen, M.Z., Mendoza, T.R., Guo, H., Harle, M.T., & Cleeland, C.S. (2006). Brief cognitive-behavioral audiotape interventions for cancer-related pain: Immediate but not long-term effectiveness. Cancer, 107(1), 207–214.

To evaluate the effect of three brief cognitive behavioral interventions as adjunct treatment for chronic cancer-related pain

Patients were randomly assigned to one of four groups: relaxation, distraction, positive mood, or wait-list control. Patients in the relaxation, distraction, and positive-mood groups received audiotapes and instructions to practice a specific psychoeducational technique at least five times weekly.The relaxation group received a 20-minute audiotape providing standard progressive muscle relaxation instructions. Patients in the distraction group selected an audiotape on a topic such as history, foreign language, or geography. Patients in the positive-mood group received audiotapes of positive-mood statements and positive-imagery suggestions. The research nurse telephoned all patients periodically to answer questions and encourage use of the assigned tapes. Patients completed assessments at baseline and in weeks 2–3, weeks 4–5, and weeks 8–9. For the first seven weeks, patients rated pain, according to a visual analog scale (VAS), before and after using the audiotapes. 

• The sample was composed of 59 randomized patients, of whom 30 completed the study.
• Mean patient age was 52 years. Age range was 30–80 years.
• Of all patients, 79% were female and 21% were male.
• Of all patients, 67% had breast cancer. Other diagnoses in the sample were prostate and lung cancer and multiple myeloma.
• Of all patients, 72% were Caucasian; 23%, African American; and 5%, Hispanic. Of all patients, 54% were married, 21% were working, and 56% had an annual income greater than $40,000.

• Single site
• Outpatient
• MD Anderson Cancer Center, Houston, Texas

Randomized controlled trial

• Brief Pain Inventory (BPI)
• MD Anderson Symptoms Inventory
• Numeric Rating Scale (0–10)
• Functional Assessment of Cancer Therapy-General (FACT-G)
• Profile of Mood States questionnaire
• Outcome Expectancy and Self-Efficacy questionnaire

Subjects in the distraction and control groups reported a significant decrease (p < 0.05) in worst pain severity from baseline to follow-up at 2–3 weeks. Subjects in the positive-mood and control groups reported a significant decrease (p < 0.05) in BPI average pain score from baseline to the follow-up at 2–3 weeks. Analysis of mailed data showed that patients in the distraction group reported a mean reduction in pain severity of 1.16 (p = 0.004) and that, after listening to the tapes, patients in the relaxation group reported a mean reduction in pain severity of 0.9 (p = 0.023). Patients in the positive-mood group reported a nonsignificant increase in pain severity after audiotape use. Authors noted no differences between groups after 2–3 weeks. Authors noted no intervention effects on quality of life, mood, or perceived self-efficacy. There were no differences between groups in pain interference scores from the BPI. More than one-half the patients reported using the audiotapes at least five times per week. More than one-half the patients dropped out of the study or were lost to follow-up; 25% of these withdrew prior to the first follow-up assessment, at 2–3 weeks. The most common reasons for withdrawal were ineffectiveness of intervention and disease progression.

Distraction and relaxation audiotapes appeared to produce immediate short-term decreases in pain intensity. However, authors observed no long-term effects and no overall differences between intervention groups and the control group.

• The study had a small sample size, with fewer than 100 patients.
• The study had risks of bias due to no attentional control and no blinding.
• A large proportion of subjects dropped out of the study, resulting in an underpowered sample.
• Authors did not state the frequency of follow-up telephone calls. Whether the timing or frequency of calls was different, group to group, is unknown. Such differences could have affected results.
• Authors did not describe use of analgesics or changes in pain medications.
• Whether the types of audiotapes selected for distraction were indeed distracting is unclear.
• The intervention did not include education or cognitive restructuring, which are usually included in cognitive behavioral techniques.

The findings of this study do not support the use of the specified techniques with audiotapes and minimal direct patient contact via telephone. This study does not add to knowledge regarding full cognitive behavioral techniques, because this study did not include many aspects typical of these techniques.