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
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
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 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
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
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."
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
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
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."