Surgery before or after?

Fighting Cancer With a Frown

Researchers are having second thoughts about a long-trusted piece of conventional wisdom: that a positive attitude can help patients beat cancer.

Until now, cancer care has included trying to find ways to improve a patient's attitude. Self-help books, cancer Web sites and loved ones often urge patients to stay positive, arguing that an optimistic outlook is a critical tool in overcoming the disease.

But a new body of work examining the biological underpinnings of attitude suggests that its connection to fighting cancer may be more complex. So far, the findings indicate that successful coping isn't necessarily about having a positive outlook.

Join a discussion with Journal reporter Amy Dockser Marcus about the debate over thinking positively and beating cancer.

More important may be coping in a way a patient is used to, which could involve anything from stress relief to exercise rather than simply striving for a cheery disposition. Indeed, if someone is a natural curmudgeon, then continuing to be a curmudgeon may be the very thing to help lower stress, bolster the immune system and, possibly, influence the success of the cancer treatment.

"Many pessimists cope well with cancer," says Jimmie Holland, the chair of psychiatric oncology at Memorial Sloan-Kettering Hospital in New York. "You can be as curmudgeonly or angry or whiny as you want and still survive cancer, as long as it doesn't cause your doctor to throw you out of the office."

The current work is being driven by what Dr. Holland calls "the tyranny of positive thinking" and its impact on patients. Many patients fear they are lowering their chances of survival if they don't feel positive, creating an additional burden at a time when they are overwhelmed by their diagnosis.

The research doesn't focus so much on patients' tendencies to look at the glass as half-full or half-empty and how they may influence survival outcomes. Instead, researchers are examining how different coping styles may affect indicators of disease-fighting ability, such as cortisol rhythms (a measure of stress levels) and natural killer cell counts (a measure of immune response). With better understanding of these variables, doctors and researchers hope to find ways, such as muscle relaxation or problem solving, to help patients keep stress and natural killer cells at levels that improve their chances of extending survival.

Cindy Miller, 46, was diagnosed in 2000 with breast cancer and had a mastectomy, eight rounds of chemotherapy and drugs. She says that she had many bad days when she felt angry, sad and scared. "Telling someone to feel positive makes you feel like you are not being understood," says the mother of two, who lives outside Philadelphia.

Ultimately, Ms. Miller says she did maintain an optimistic view that she could survive, but she doesn't believe that simply being positive improved her survival odds. More important, she says, was staying true to her regular coping style, which involved actively seeking out complementary care to bolster what her doctor was doing. She changed her diet to only organic foods, did massage to ease the pain and ran as much as she could. "I'm a naturally optimistic person," she says. "You are who you are, and you bring that to cancer."

The new approach also stems from the realization that after more than a decade of research trying to link optimism with improved cancer survival, the data haven't revealed much evidence of a connection. In February, the American Cancer Society journal, Cancer, published a report about 179 patients newly diagnosed with non-small-cell lung cancer who were followed for five years.

HEALING ATTITUDE Recent research suggests a new way of looking at positive thinking and cancer: • Patients do better sticking to their regular coping styles.   • High stress levels can weaken immune response.   • Patients with abnormal cortisol patterns, an indicator of stress, died sooner than those with normal patterns.   • Positive attitude can help some patients eat right, exercise and follow doctor's orders.

The investigators found that a patient's level of optimism didn't affect survival time. A British Medical Journal review in 2002 of 37 other studies on the effect of psychological coping styles found most also showed no connection between positive attitude and improved survival.

Mark Petticrew, a public-health researcher at the University of Glasgow in Scotland who helped lead the review, says positive thinking can still help. In a number of studies, it was associated with better compliance with the doctors' orders, improved mood and less pain. "But positive thinking is often sold as a cure all to cancer and it isn't," he said.

The latest work is different in that it is based on "a more complex measure of optimism," says David Spiegel, a psychiatrist at Stanford University School of Medicine, who is heading one of the studies. Back in 1989, he was the lead author on a seminal paper published in Lancet that looked at the effect of participating in support groups on 86 women with metastatic breast cancer. At the 10-year follow up, only three patients were alive -- all support group members -- and death records were obtained for the other 83 women. The study reported that women who participated in the group survived 36.6 months from entry into the study, compared with 18.9 months for the control group.

The results caused a stir, generating huge public and academic interest. Cancer patients were urged to join support groups. But in follow-up studies, the results weren't easily duplicated. In one major study designed to replicate Dr. Spiegel's original findings with metastatic breast-cancer patients, women assigned to a support group showed improved mood and the perception of less pain but didn't survive any longer than women not in the group. Dr. Spiegel says that some randomized trials looking at cancers besides breast cancer, such as melanoma, did find that effective psychological support could predict longer survival. But there were just as many that found it didn't.

As a result, he says his group is now in the 12th year of a similar study but taking a different approach. In the previous study, the only thing measured was length of survival time based on death certificates. In the current one, researchers are assessing the effects of stress and its management on the body, guided by the idea that the stress that cancer patients feel while coping may weaken their immune systems. Researchers are measuring the women's cortisol concentrations in their saliva, an indicator of stress, and counting their circulating natural-killer cells, a measure of immune response.

Although the study is ongoing, in a preliminary report published in 2000 in the Journal of the National Cancer Institute, the researchers found that patients whose cortisol levels were flat and didn't follow the typical pattern of declining throughout the day, died sooner than women with normal cortisol patterns. The finding, researchers believe, indicates that there may be psychological interventions that can boost disease-fighting ability, a notion that in the past has driven the focus on staying positive.

But what if the pressure to be upbeat raised someone's stress level? Researchers are now realizing that people cope with stress in vastly different ways, and that they need to find solutions that match someone's natural temperament and personality. The next step is finding the mechanisms that enable patients to keep their cortisol patterns and natural killer cells at optimum levels and hopefully extend their survival. "For some patients this may happen by being uncooperative and unpleasant rather than positive," Dr. Spiegel says.

At Ohio State University, an ongoing study is measuring not only survival rates but also endocrine responses and biological markers of immunity. Women participating in the study, all of whom share similar diagnoses for breast cancer, are learning muscle relaxation, problem solving, and time management techniques. They are making dietary changes, such as reducing fat and increasing fiber, and exercising, all in the hope that some methods will bolster the women's ability to fight and ultimately beat the disease.

Write to Amy Dockser Marcus at amy.marcus@wsj.com

NOVEMBER 15-30, 2007		VOLUME 4 NO. 19
PATIENTS & PRACTICE
Good cheer's no cure for cancer: study Experts face off over positive thinking's impact on CA survival By Owen Dyer Lance Armstrong may have a lot to answer for, if a new study challenging the notion that a positive attitude can cure cancer is anything to go by. The study will appear in December in the journal Cancer. We hear so many stories about heroes like Mr Armstrong facing up to their cancer these days with strength and good cheer, that oncologists refer to it as the "prison of positive thinking." That phrase describes the pressure which faces a patient newly diagnosed with cancer, who not only has to deal with possible imminent death, but also feels obliged to show everyone how strong and cheerful they are about it. Well the pressure is now off. Psychologist James Coyne, PhD, of the University of Pennsylvania, and colleagues conclude that emotional well-being had no influence on the survival of 1,093 head and neck cancer patients. MIND OVER MATTER In popular culture, we are told how people are battling cancer with their strength of will. The obvious implication is that strength of will improves their chances of winning the battle. The obvious flip-side implication is that weakness, self-pity or depression actually reduce patients' chances of surviving cancer. So those with negative feelings about it all - a natural enough response to cancer - end up feeling doubly bad, because they must worry that their worrying is making them sicker. At the extreme, patients can even blame their mental state for the development of their cancer. A 2001 survey of nearly 400 Canadian breast cancer patients by University of Toronto researchers found that 42% cited stress as one of the main causes of their disease, considerably more than blamed either genetic or environmental causes. "I think cancer survival is basically biological," said Dr Coyne. "Cancer patients shouldn't blame themselves - too often we think if cancer were beatable, you should beat it. You can't control your cancer. For some, this news may lead to some level of acceptance." REALITY CHECK Dr Coyne's study is by no means the first to address this question, but it's certainly the biggest to home in ruthlessly on survival, dismissing surrogate endpoints that the authors believe have muddied the waters in previous research. At the study's outset, the 1,093 subjects completed a validated questionnaire often used to measure quality of life in cancer, the Functional Assessment of Cancer Therapy-General (FACT-G). It includes five questions that measure emotional well-being. Of these patients, 646 died during the course of the study, which is considerably more deaths than the overall number of subjects in previous trials. After controlling for tumour size and known socioeconomic variables, the researchers found that "no statistically significant univariate or multivariate effects were observed for emotional well-being." These latest findings, Dr Coyne said, "may not end the debate, but they provide the strongest evidence to date." DEBATE HEATS UP Writing in the journal Psycho-Oncology this month, Dr Coyne suggested that ending the debate might be a good idea: "Belabouring the argument that psychotherapy promotes survival is not scientifically justified and risks slighting the important benefits that psychological interventions may have for some patients in terms of reducing their distress." Dr Coyne was particularly critical of a landmark 1989 Lancet study by a leader in the field, Dr David Spiegel of Stanford University, which he said became a gold-standard study despite what he considers an underpowered sample and a "less appropriate analytic technique." He didn't stop there: "Unsubstantiated claims about benefits for survival, however well intended and hopeful, are medical claims and just as objectionable as when unsubstantiated claims are made about herbs or coffee enemas as cures of cancer." Ouch. Dr Spiegel, needless to say, isn't taking that lying down. "Dr Coyne was a solid depression researcher who is a newcomer to this field and is trying to establish himself by attacking me and others," he told NRM. "He has crossed the line of polite debate, and I've actually had to make some complaints." TOUCHY TOPIC Head and neck cancer, says Dr Spiegel, is a poor choice to search for emotional factors impacting survival, because it's known to have a minimal hormonal component, and hormones are the main mechanism by which emotions are postulated to effect survival. Dr Spiegel pointed to a study in September's Journal of Psychosomatic Research which found that women with recurrent breast cancer who reported traumatic events in their lives had seen average remissions less than half as long as those who reported stress-free lives. The weight of research is still balanced between positive and null results, he said. He himself is currently conducting research aimed at replicating his famous 1989 results. Dr Coyne and his allies had simplified and mischaracterized his findings, said Dr Spiegel. "Talk of a 'prison of positive thinking' is misplaced. Looking after patients' emotional well-being has never been about telling patients to 'put on a happy face'. There is more than one kind of positive thinking in cancer: no-one advocates encouraging blind optimism that you'll be cured. The patients who benefit from their mental attitude are those who find the strength to face the possible bad consequences, those who learn to live with the possibility of death."   previous page Pancreatic Cancer Slideshow Latest Cancer News Taking Aim at Relapse of Leukemia in Kids Radiation May Raise Stroke Risk After Hodgkin's Racial Clusters Affect Access to Colon Care VA Faces Questions Over Tainted Colonoscopies Virtual Colonoscopy: Who Should Get It? Want More News? Sign Up for MedicineNet Newsletters! Study Shows Positive Thinking by Patient Has No Impact on Surviving Cancer By Salynn Boyles WebMD Health News Reviewed By Louise Chang, MD Oct. 22, 2007 -- Having a positive attitude may help cancer patients deal with their disease, but it doesn't directly affect survival, according to one of the largest and most rigorously designed investigations ever to examine the issue. The study included more than 1,000 people treated for head and neck cancer; the emotional state of patients was found to have no influence on survival. The findings add to the growing evidence showing no scientific basis for the popular notion that an upbeat attitude is critical for "beating" cancer, says University of Pennsylvania School of Medicine behavioral scientist James C. Coyne, PhD, who led the study team. "I wish it were true that cancer survival was influenced by the patient's emotional state," he tells WebMD. "But given that it is not, I think we should stop blaming the patient." 'The Tyranny of Positive Thinking' Jimmie Holland, MD, agrees. The Memorial Sloan-Kettering Cancer Center psychiatrist is a longtime critic of the "mind over cancer" proponents who tell patients they must stay positive to survive their disease. In her book The Human Side of Cancer, Living with Hope, Coping with Uncertainty, Holland coined the term "the tyranny of positive thinking" to describe the belief. "The idea that we can control illness and death with our minds appeals to our deepest yearnings, but it just isn't so," she tells WebMD. "It is so sad that cancer patients are made to believe that if they aren't doing well it is somehow their own fault because they aren't positive enough." Holland does acknowledge the benefits of staying positive during cancer treatment, and she is an advocate of techniques like relaxation, meditation, support groups, and prayer to help patients cope with their disease. But she says there is no credible evidence that positive thinking alone directly influences tumor growth. "People really want to believe this, so even very good studies like this one probably won't change public thinking," she says. "But the scientific community is getting the message." Attitude and Cancer Survival The newly published study included 1,093 patients with head and neck cancer who completed quality-of-life questionnaires during their treatment. Coyne says the study group was limited to patients with a single cancer who had similar treatments to better assess the impact of state of mind on survival. A total of 646 patients died during the study follow-up. Even after acounting for other variables that could affect survival, a patient's emotional state was found to have no bearing on whether or not he or she lived or died. The study appears in the Dec. 1 issue of the American Cancer Society (ACS) journal Cancer. In a separate review of other studies published earlier this year, Coyne, University of Pennsylvania colleague Steven Palmer, PhD, and ACS researcher Michael Stefanek, PhD, found insufficient evidence that participation in psychotherapy or cancer support groups plays a role in survival. In that report, the researchers concluded that the hope that emotional state is a driving factor in cancer outcomes "appears to have been misplaced." "If cancer patients want psychotherapy or to be in a support group, they should be given the opportunity to do so," they wrote in the journal Psychological Bulletin. "There can be lots of emotional and social benefits. But [patients] should not seek such experiences solely on the expectation that they are extending their lives." SOURCES: Coyne, J.C. Cancer, Dec. 1, 2007; vol 110: online edition. James C. Coyne, PhD, department of psychiatry, University of Pennsylvania Health System, Philadelphia. Jimmie Holland, MD, Memorial Sloan-Kettering Cancer Center, New York City. Coyne, J. Psychological Bulletin, 2007; vol 133: no. 3. © 2007 WebMD Inc. All rights. Connie