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Section 15
Understanding Beliefs and Meaning in the Cancer Experience

Table of Contents | NCCAP/NCTRC CE Booklet

Cancer does not come from thoughts or feelings, but psychosocial treatment can help cancer patients.
As physicians and scientists try to puzzle out the causes of cancer, some of them have been driven to think about the relationship between the mind and physical illness. They wonder whether the solutions to what seem like two very different mysteries might have something in common. Do psychiatric disorders, personality, and emotional stress somehow contribute to the progress of cancer? Could psychotherapy, counseling, or mutual support groups help to preserve or prolong lives threatened by cancer? If any of these beliefs are correct or any of these hopes can be even partly fulfilled -- which remains doubtful -- it would be enormously important for the understanding of disease and the enhancement of health. Meanwhile, there is much evidence that psychological treatments can at least relieve suffering and improve the quality of life for cancer patients and their families.

Emotions and cancer rates
An opinion once widespread and still occasionally heard is that the risk for cancer is raised by depression or a depressive personality -- sad, submissive, with a tendency to suppress or repress feelings. Research findings are to the contrary. After correction for other risk factors, large studies and analyses of pooled data from many studies have found no evidence that personality or mood has any influence either in preventing or in promoting the onset of cancer. For example, surveys including thousands of women in Denmark, Australia, and the Netherlands have found no evidence of a cancer-prone personality or a higher-than-average rate of depression in people who develop cancer.

The influence of acute or chronic emotional stress is also doubtful. Danish researchers found that the death of a husband had no effect on the rate of breast cancer in women during the next 15 years. A study of all firefighters over age 43 in Stockholm, Sweden, found that they had the same rate of cancer as the general population, despite the strain of their occupation. Schizophrenic patients, although they are under severe stress and often depressed, have only an average rate of cancer.

It is important to adjust for the effects of smoking. Because people with a history of depression are more likely to smoke cigarettes -- and less likely to quit once they start (see Harvard Mental Health Letter, August 2002) -- they are at higher-than-average risk for any of the cancers associated with tobacco. Of all the disorders listed in the American Psychiatric Association's diagnostic manual, the only ones that directly increase the risk for cancer are nicotine dependence and alcohol dependence.

After the diagnosis
Researchers are still considering whether mood or personality influences the progress or recurrence of cancer. A number of studies have found that women with breast or ovarian cancer die sooner if they are unmarried or isolated or say that they lack intimate friends. In a seven-year study, women with early breast cancer were more likely to die if they had recently suffered a death in the family, divorce, or a financial crisis. In a study of middle-aged men with cancer, researchers in Finland found that hopelessness was associated with a high death rate in the next four years.

But a recent study of more than 200 women with breast cancer found no evidence that stress in the year before or five years after the diagnosis affected the rate of recurrence. A meta-analysis of 26 studies on fighting spirit, helplessness, hopelessness, denial, and fatalism among cancer patients found these attributes had no effect on survival or recurrence.

Another meta-analysis including 58 studies found that, on average, cancer patients are only slightly more depressed and anxious than healthy people. Their suicide rate is lower than average. Psychological symptoms are often most serious soon after the diagnosis and improve with time even if physical health worsens. Recent studies have found fewer psychiatric symptoms in cancer patients, possibly because they are getting the benefit of less stigma, earlier diagnosis, and better understanding and treatment.

Interpreting these findings is a problem, because controlled experiments may be impossible and causes are difficult to distinguish from effects. People may be more depressed, anxious, or distressed because the illness is more serious, and they may die sooner for the same reason. Symptoms of depression, cancer, and treatment side effects -- loss of appetite, insomnia, and fatigue -- can be confused. It is important not to exaggerate the influence of attitudes and emotions on the outcome of cancer. If people are led to think they can be cured by cultivating the right feelings, they may also blame themselves if they do not recover quickly.

Paths of influence
Emotions could affect the outcome of cancer in the same way they affect the outcome of any other illness: People with low morale are less likely to take care of themselves or get the best medical treatment. But some investigators believe this commonsense explanation is inadequate. They think another answer will be found in the study of stress hormones and the immune system (see Harvard Mental Health Letter, April and May 2002).

This path of influence runs through the hypothalamic-pituitary-adrenal (HPA) axis, which coordinates the body's response to life-threatening emergencies. Depression or chronic stress may cause long-term overexposure to the adrenal hormones epinephrine (adrenaline) and cortisol. Cancer and cancer treatment can make this situation worse. More than 10% of bone marrow transplant patients, according to one study, have post-traumatic stress disorder, and many others have some of the symptoms. Another study found that women with advanced breast cancer died a year sooner if they had shown abnormal daily patterns in cortisol secretion. And in still another study, women with early breast cancer who underwent group therapy had lower cortisol levels than those put on a waiting list.

An overactive HPA axis producing high levels of cortisol tends to depress the immune system. How much difference that makes to cancer patients is unclear. It could mean delayed healing of wounds after surgery. Loss of immune function could also promote the growth of tumors. In experiments on rats with an implanted tumor, repeated electrical shocks reduced the activity of natural killer cells, which are particularly important for the defense against tumors. Overcrowding and bullying by dominant rats in a colony also hasten the growth of implanted tumors in subordinate animals. According to some research, natural killer cell activity is higher in breast cancer and melanoma patients who participate in group psychotherapy.

Experiments have shown that immune reactions can be learned by association. Rats were given water containing saccharin along with a drug that suppresses the immune system. After the drug was removed, they responded to sweetened water by developing an unusually high rate of infections. By association with the immunosuppressive drug, a sweet taste provoked a conditioned response that depressed immune function. The same process may be at work when patients who have undergone repeated chemotherapy show lower immune activity before their next session.

Skeptics say this research is inconclusive because the effects are small, the studies are not always carefully controlled, and the measures of stress and immune activity are unreliable or partial. In a healthy person, emotion rarely has a dramatic effect on the immune system. A meta-analysis of 59 studies showed that stress management, relaxation techniques, and hypnosis have little effect on the immune system in a variety of illnesses. Still, even a small effect might tip the balance for some seriously ill patients, including those with cancer or undergoing chemotherapy. The National Cancer Institute is sponsoring a project that will evaluate the role of psychoneuroimmunology - the discipline that studies the relationship between the mind and the immune system -- in the understanding and treatment of cancer.

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Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 225 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Personal Reflection Exercise #1
The preceding section contained information regarding cancer and the mind. Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 15
Under what circumstances are women with breast and ovarian cancer more likely to die? Record the letter of the correct answer the NCCAP/NCTRC CE Booklet.

NCCAP/NCTRC CE Booklet
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