Mind Over Cancer: Are We Neglecting Something Important?
ABSTRACT & COMMENTARY
Synopsis: The power of the mind is only beginning to be appreciated, but, sadly, there is little evidence that attitude can alter the natural history of cancer. However, a strong social support system and the presence of spirituality and religion seem to be consistent contributors to maintaining a high quality-of-life in people with advanced cancer.
Source: Creagan ET. Mayo Clin Proc 1997;72:160-164.
Bookstores are loaded with tomes that focus on the mind-body-spirit connection and how it can be harnessed to fight cancer. It has long been appreciated that the diagnosis of cancer is like no other. A 52-year-old man with tight aortic stenosis who develops his first sign of congestive heart failure has about eight months to live (barring heart transplantation). Yet aside from the decreased exercise capacity, the man functions rather normally. Often he can continue to work for some time, his role in the family remains unchanged, and he is viewed as having a diseased part ("a bum ticker"). The same man diagnosed instead with advanced pancreatic cancer has about the same eight months to live, but the impact of the diagnosis is devastating on both him and his family. He is instantly disabled. He no longer holds the same position in his household or at work. It is he himself who is diseased rather than a part of him. Cancer overwhelms the coping mechanisms of all but the most foolish, who do not understand it.
To a very great extent, we do not understand all that the mind can do to help us cope. One of the happy byproducts of the proliferation of self-help books in this area is that many patients have chosen to take a more active (rather than passive) role in their management and to focus all their healthy and positive imagery on fighting the disease. This seems like a good idea, even though it has not been shown to make a difference in survival. However, there is a downside that is important to keep in mind. Patients who believe that being actively engaged in the battle will help them fight the cancer receive a pretty depressing backlash when the disease recurs or progresses. The books often preach that the patient is responsible for his/her own health and wellness and that his/her attitude is important to promoting that wellness. Clearly, then, if the treatment is ineffective, a patient might conclude that he/she has not been trying hard enough with the positive imagery. An unintended outcome of this "take responsibility" movement is that the patient may feel guilty when the natural history of the disease is not clearly affected by their actions. Creagan has recently reviewed some relevant literature on this topic.
Is attitude a determinant of cancer survival? What do we know? Cassileth et al studied the influence of social ties, marital history, satisfaction with life, and hopelessness and helplessness measures on the outcome in 204 patients with unresectable solid tumors and 155 patients at high risk of recurrence following resection of melanoma or breast cancer.1 They concluded that none of these factors, either individually or in combination, had a discernible influence on survival or time to recurrence. The biologic disease process was the dominant factor influencing outcome.
However, social science has determined that there are important social and behavioral determinants of survival in a population. People with few or no social relationships are much more likely to die than those who are socially well connected to friends and family. Being married is beneficial to health and being widowed is detrimental to health, especially in men. It is possible that this connectedness is a predictor for individuals who maintain a healthy lifestyle in terms of nutrition, rest, and exercise, and who will rigidly adhere to medical regimens.2
Does this have anything to do with cancer patients? It might. One study demonstrated that the absence of close personal ties and access to emotional support was related to poorer survival in black and white patients with breast cancer.3 Another study suggested that an absence of perceived social support in patients was associated with a decrease in peripheral blood NK cell activity.4 Of course, no one has demonstrated that peripheral blood NK activity is a predictor for any cancer-related outcome.
There are at least three randomized studies that show an improved survival in patients with metastatic breast cancer,5 malignant melanoma,6 or hematologic malignancy7 in patients randomized to supportive psychiatric group therapy compared to those not participating in a group support activity. The advantages for the intervention in each of these studies were dramatic, not subtle; chemotherapy studies are only rarely as positive as these psychological support interventions appear to be. Yet there appears to be no standard psychological or personality profile that identifies the patient more likely to be a long-term survivor.8,9
Spirituality is another factor that has been suggested as a predictor of survival in patients with cancer. The difficulty of measuring this factor is clear. The "death-bed conversion" is such a common phenomenon that it has become a cliché and the subject of jokes. When he was found by a friend to be leafing through the Bible during his terminal illness, W.C. Fields was asked what he was doing, since he was not known as a religious man. "Looking for loopholes" is what he is reputed to have answered. Yet religious beliefs are well suited to facilitate coping with fatal illness. Does it matter whether someone has attended church their whole life or just in the last year of life? Additional studies in this area are needed.
Creagan concludes that among patients with cancer, the biology of the disease is the most significant determinant of survival, but that psychosocial and spiritual factors may modify quality-of-life and possibly survival in selected patients.
I would bet that nearly all of us have seen patients recover when we did not think they could. Multisystem failure, terrible APACHE scores, and multiple tubes coming out of the patient make survival exceedingly unlikely. Everything that can be done has been done for them, and it does not seem like enough. We tell the family to hope for the best but prepare for the worst. This often leads the family to pray. And without clear explanation, almost miraculously, the patient recovers. I get Christmas cards from some of my fantastic anecdotes. But little can be learned from such exceptions to the rules. They simply contribute to a sense of humility; I don't understand how they recovered.
As a group, oncologists are a pretty skeptical lot. We have seen too much death, too much suffering. There are things that we are willing to believe without understanding them, for example, that leucovorin will rescue the normal tissues from the toxicity of high-dose methotrexate but will not rescue the tumor; and there are things that we are unwilling to believe without understanding them (e.g., that administering drugs based on circadian rhythms is more effective and less toxic). The role of psychosocial factors in cancer survival is, in my view, in the latter category for most of us.
Yet experimental research has demonstrated some pretty remarkable things about the power of the mind. It is possible to immunosuppress an animal on the basis of operant conditioning, by coupling an unrelated conditioned stimulus with an immunosuppressive agent. After a while the conditioned stimulus will produce immunosuppression. My colleagues, David Rubinow, Don Rosenstein, Pat Duffey and I attempted to condition a human immune response to interferon-g. We gave the interferon together with a distinctive taste stimulus and found that the taste stimulus alone was able to fool the immune system into thinking that it had encountered the cytokine. The results were statistically significant, but not overwhelming in magnitude. I was surprised by the result. How in the world is it possible for an immunologically neutral taste to elicit an immune response? It is clear that we do not know everything that the mind may be capable of doing. Thus, it would be foolish to reject, out of hand, the notion that we can learn how to use it better in our efforts to control cancer.
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