CANCER AND THE ROLE OF THE MIND
Alternative therapists claim that the causation and control of cancer has not only physical but psychological and spiritual factors as well. Orthodox medicine on the other hand accepts only the physical factors. What is the evidence that theories relating to psychological factors are valid and that therapy based on these theories actually works?
There are many factors which are claimed to be involved with the causation and control of cancer.
(a) physical factors such as:
- diet and nutrition, including salt, artificial colouring, flavouring, food processing and preservatives
- the environment, including water and airborne contaminants
- occupational exposure such as asbestos and radiation
(b) psychological factors such as:
- the mind, operating at both the conscious and unconscious level
- inherited predisposition
(c) spiritual factors such as
- the psyche, soul or spiritual identity
Orthodox medicine accepts only physical factors such as diet and occupational exposure, and then only as causative factors. They have several theories about the process of cancer causation and reject any claims that diet can have any effect on survival once malignancy is established.
They refuse to look at any theories other than the currently accepted one that the tumour is the disease. Surgery and radiotherapy are designed to kill or otherwise remove the tumour. When this fails and the “disease” has “spread” chemotherapy is then used.
Not surprisingly there is no evidence that surgery or radiotherapy has any effect on survival or mortality with any form of cancer except where the tumour is obstructing a vital organ or pressing on the brain1. The only evidence that orthodox methods can improve survival significantly is in a few areas where cancer is known to be systemic in its nature such as with some types of leukemia, and chemotherapy, a systemic therapy is used. In view of the extremely toxic nature of chemotherapy and it effect on the immune system it is not surprising that it is ineffective against solid tumours2.
The more honest medical scientists are at last starting to use the term “incurable” in relation to cancer3. This means incurable using orthodox methods.
What about other theories and paradigms?
Most alternative therapies are based on the theory that cancer is a systemic disease and tumours are only local expressions, symptoms or elements in this disease. Such therapies are then designed to restore the body’s metabolic functions, respiratory, digestive and endocrine systems so that the immune defences can work normally again.
Some therapies assume the immune defences have simply broken down because of psychological factors. For example the Simonton Therapy4, which involves visualisation and imagery techniques, assumes that stresses with which the individual cannot cope lead to emotional disturbances in the limbic region of the brain. Here the hypothalamus transfers these disturbances to the pituitary gland which in turn controls the body’s endocrine system and thereby the body’s immune defences.
Other therapies assume a breakdown of metabolic or endocrine systems which in turn lead to the “cancer milieu”5.
What is the evidence that theories relating to psychological factors are valid and that therapy based on these theories actually works?
We can look at both the cancer causation mechanism and the cancer control mechanism. Just as diet is claimed to contribute to cancer causation, nutritional therapies have been claimed to reverse cancer. So it is with psychological factors.
Let us first look at cancer causation. And this also provides some ideas for those who wish to prevent cancer.
Several workers such as Hans Selye6 and Lawrence Le Shan7 have identified personality factors that are claimed to be present in most cancer patients. In recent times these have been refined somewhat and some recent trials have described eight such characteristic factors for cancer patients:
- Involvement – Vacillate between extreme intimacy and extreme aloofness
- Feelings – Avoid the expression of feelings
- Rationality – Claim to be controlled by reason rather than emotions
- Anxiety – Deny fears or anxiety related to present or coming problems
- Harmonising – Avoid arguments and confrontation and are rarely aggressive
- Hopelessness – Feel pessimistic about life and expect the worst
- Helplessness – Feel out of control and need a lot of support but have never accepted help from others
- Self-sacrificing – Work for others’ benefits and ignore their own needs
Sometimes they can be grouped into inability to become involved or express feelings, hiding behind rationality (1-5), hopelessness/helplessness (6-7) and self-sacrifice (8). These are sometimes described as starving themselves of their own spiritual and human needs which humans have for giving and receiving love.
In 1980 Michael Wirshing et al8 from the Psychosomatic Clinic at Heidelberg University in Germany interviewed 56 women just prior to biopsy for breast cancer. Interviews lasted 30-50 minutes and were taped. Most subjects were from the lower social class. Using these 8 factors the interviewers correctly predicted 83% of the women who were
later diagnosed with cancer and 71% of those who had benign lumps. Others not involved in the interviews listened to the tapes and made separate assessments. These ‘blind’ raters predicted 94% of the cancer diagnoses and 68% of the benign diagnoses.
So there is clearly a cancer personality or profile. It is not black and white: for example between a quarter and a third of patients diagnosed with benign lumps exhibited the psychological profile of the cancer patient.
The next question to ask is:
Once people get cancer what personality types have the best survival?
Two trials provide some answers:
- Sandra Levy et al9 from the Pittsburgh Cancer Institute looked at survival figures for 36 women who had their first recurrence of breast cancer. They found that those with a positive mental attitude best described as “joy” had the longest survival. This included descriptions of glad, cheerful and joyous attitudes. On the other hand negative attitudes, where patients felt sad, hopeless, worthless, miserable or unhappy tended to have the shortest survival, typically surviving less than 2 years after recurrence. The same applied to those exhibiting hostility. Their report was in 1988.
- Keith Pettingale et al10 from King’s College on London reported in 1979 that psychological responses to cancer diagnosis taken from 57 women with early breast cancer 3 months after their operation predicted survival 5 years later.
Best survivals were found among those with a “fighting spirit” and those who practised “denial”; whereas worst survival was observed among those with “stoic acceptance” and a feeling of “helplessness” or a situation of “hopelessness”. They reported again 5 years later, 10 years after original diagnosis. 70% of those with a “fighting spirit” were still alive including one with metastases as were 50% of those exhibiting “denial”, 25% of “stoic accepters”, including one with metastases, and 20% of those who felt “hopeless/helpless”.
There were no initial biological differences observed, all four patient groups having similar clinical stage, approximate tumour mass, histological grade, mammographic appearance and hormonal an immunological profiles. The difference in host resistance was apparently related to psychological factors.
The next question to ask is, if the personality type predisposes certain people to get cancer and certain other personal attitudes appear to affect survival, can one’s personality type and attitude be changed to enable a building up of this host resistance?
For example can a person learn how to express feelings? Can he or she learn how to put their interests ahead of those of other people? Can a person change from feeling helpless to one with a strong fighting spirit? My answer to these questions is Yes!
What evidence is there that psychotherapy can improve survival or reduce mortality?
There are three trials offering some evidence that psychotherapeutic intervention can affect survival:
- Fawzy I. Fawzy et al11 from the Neuropsychiatric Institute at the UCLA School of Medicine analysed immunological responses in 61 cancer patients with malignant melanoma over six months. There were 28 men and 33 women randomised into two groups, a study group of 35 and a control group of 26. The study group was given a structured psychiatric group intervention which lasted about 1-1/2 hours per week for 6 weeks.
- Although not many changes were observable after six weeks there were significant differences observed between the two groups after six months. The study group which had received psychotherapy showed:
- a reduction in the level of psychological distress
- a greater use of active coping skills
- a significant increase in the percentage of larger granular lymphocytes (LGLs)
- a significant increase in the percentage of natural killer cells (NKs)
- an increase in NK cytotoxic activity
So the psychotherapy not only made the patients feel they were coping better with the disease; their immunological responses confirmed that they were. These results were reported in 1990.
2. David Spiegel et al12 from Stanford and Berkeley Universities in California reported on the effect of psychosocial intervention on survival with a group of 86 patients with metastatic breast cancer. These patients were randomised into two groups, a study group of 50 and a control group of 36. Both groups had routine oncological care, but the study group was offered weekly supportive group therapy and self-hypnosis for pain for 1 year.
The survival figures showed a divergence beginning 8 months after the psychosocial intervention ended, ie after 20 months. Average survival for the study group was 36.6 months compared with 18.9 months for the control group. The effect of the intervention was also to reduce anxiety, depression and pain.
The researchers were initially sceptical of claims that visualisation and imagery could improve survival so they did not use this technique. Rather they emphasised living as fully as possible, improving communications with family members and doctors, facing and mastering fears about death and dying, and controlling pain and other symptoms. An important factor observed was that the study group formed a bonding that countered the social alienation that often divides cancer patients from their well-meaning but anxious family and friends.
An unusual phenomenon observed was that the increased survival did not become apparent until nearly a year after therapy had finished. The authors attributed this to a mild cumulative effect.
The authors were not able to explain the results but speculated that neuro-endocrine and immune systems may be a major link between emotional processes and the course of cancer.
Two possible shortcomings of this trial were not knowing how representative the patients were of the wider community; and the limitation of matching in small groups by relying only on randomisation. Neither of these would have affected the validity of the result because the effect was so large.
A third study demonstrating the efficacy of group or behavioural therapy in the treatment of cancer is one by Hans J Eysenck and R Grossarth-Maticek from the University of London13.
In the Eysenck and Grossarth-Maticek paper, published two years after Spiegel’s, there was improved randomisation. Patients suffering stress were first matched into pairs based on sex, age, smoking, cholesterol level, blood pressure and personality type. Only after both members of a matched pair had agreed to participate in the trial were they randomised into therapy and control groups. This guaranteed that the therapy and control groups were accurately matched despite their small sizes. Cancer prone (Type 1 or “Type C”) and coronary heart disease (CHD) prone (Type 2 or “Type A”) patients were treated separately in some of the studies.
They carried out six studies to test various hypotheses:
- the effect on the prevention of cancer and coronary heart disease of
- individual therapy
- group therapy
- bibliotherapy (learning the therapy from a text);
- effect of behaviour therapy on preventing absence through illness requiring hospitalisation;
- the effect of behaviour therapy on survival of terminal cancer
- a comparison of the effects of behaviour therapy and chemotherapy on the survival of cancer patients.
Results were as follows:
Study 1 – Extended Individual Therapy
Patients were aged 30-69, mean age 50yrs; half were men and half were women; matching of pairs prior to randomisation was on the basis of age, sex, degree of stress, intensity of cigarette smoking, blood pressure, blood sugar level and cholesterol. Six to twelve months after completing therapy their personality types were reassessed using the same questionnaire as before to measure any short-term changes to the personality that might explain the effects of treatment.
Results: After 13 years of follow-up, none of the 50 treated in the cancer prone group had died compared with 16 of the 50 in the control group. 13 had cancer compared with 21 in the control group, 5 had died of other causes (cf 15) and 90% were still alive compare with 38% in the control group.
Personality retyping showed the therapy group’s cancer proneness scores had fallen from 9.8 to 5.7. As expected there was no change in score (9.8) for the untreated control group.
Study 2 – Group Therapy
This was similar to Study 1 except that 245 patients received therapy in groups of 20-25 people; the untreated control group also contained 245 people; sessions lasted several hours depending on the wishes and progress of the participants; there were 6-15 sessions altogether.
Results: After 7 years follow-up there were 18 cancer deaths in the 239 treated group compared with 111 of the 234 in the control group (A few could not be contacted). 75 were alive with cancer compared with 129 in the control group.; 10 had died of CHD compared with 36 in the control group, CHD incidence was 29 (cf 45); 20 had died of other causes (cf 33) and 80% were still alive compare with 24% in the control group.
Study 3 – Bibliotherapy (therapy described in an article and explained in 3-5 hours of discussion)
There were 600 in the study group and 600 in the control group. (The latter were given an article that did not include any treatment techniques for them to use.)
Results: After 13 years follow-up there were 27 cancer deaths in the 600 treated group compared with 106 deaths in the 600 in the control group; 99 were alive with cancer compared with 162 in the control group; 47 had died of CHD compared with 145 in the control group, CHD incidence was 132 (cf 203); 115 had died of other causes (cf 164) and 68.4% of those treated were still alive compare with 16.3% in the control group.
Study 4 – Illness, Absence, hospitalisation
362 pairs of males suffering stress were randomised in the usual way after matching and one group was treated. During the following 13 years the number of days spent in hospital was measured for the two groups.
A total of 6194 days were spent in hospital by the treated group averaging 19 days each.
This compares with 10,136 days in hospital by the control group, averaging 28 days each.
Study 5 – Therapy on Terminal Cancer Patients.
This study involved 24 pairs of cancer patients with six different types of inoperable cancer, including scrotal (1), stomach (2), bronchiolar (7), corpus uteri (4), cervical (5) and colorectal (5).
Survival times of the treated group averaged 5.07 years (ranging from 1.7 yrs for bronchiolar to 9.5 yrs for colorectal). For the control group survival averaged 3.09 years (ranging from 1.0 yrs for bronchiolar to 4.9 yrs for colorectal)
Study 6 – Behaviour therapy vs Chemotherapy
129 women metastasised breast cancer for whom chemotherapy had been proposed were asked to participate. 17 refused psychotherapy and 56 refused chemotherapy. 50 of those who accepted chemotherapy were divided into pairs matched for age, social background, extent of cancer and medical treatment. One of each pair was then randomised to receive psychotherapy. Similarly 50 of those who refused chemotherapy were matched then one of each pair was randomised to receive psychotherapy.
This study therefore involved 100 women with metastasised breast cancer, in four similar groups of 25 who received chemotherapy + psychotherapy, chemotherapy alone, psychotherapy alone and no therapy. Of the 50 who received psychotherapy 24 received creative novation behaviour therapy (as in studies 1 and 2), 12 received depth psychotherapy and 14 received orthodox behaviour therapy (relaxation training and desensitisation). 30 hrs of psychotherapy was given.
Results: Mean survival times for the 100 patients was 15.7 months, ranging from 11.28 for those who received no therapy (having refused chemotherapy), to 14.08 for chemotherapy alone, to 14.9 for psychotherapy alone to 22.4 months for chemotherapy + psychotherapy.
The authors state that chemotherapy alone increased mean survival by 2.80 (14.08-11.28) and psychotherapy alone increased it by 3.64 (14.9-11.28). Theoretically by adding these two effects chemotherapy + psychotherapy should have increased survival by only 6.44 months to 17.72 months. In fact it increased it to 22.4 months exceeding the additive value by 4.68 months, suggesting a synergistic interaction between these two therapies.
It was also observed that the lymphocyte count of those receiving psychotherapy continued to rise over time whereas those not receiving psychotherapy fell, suggesting that the psychotherapeutic intervention may have had its effect through the involvement of the immune system.
The authors recognise that the trial was not one to test the effect of chemotherapy versus no chemotherapy, so there was no need to randomise patients into “chemotherapy” and “no chemotherapy” groups. This was done by self-selection: those refusing chemotherapy became the source for selecting and matching 50 women who would receive no chemotherapy but would be randomised to receive or not receive psychotherapy. This is in contrast to psychotherapy where in each case there was proper randomisation into the treatment and no treatment groups.
The process of self-selection introduces an unknown factor into the trial. Earlier trials of mammogram screening have shown that those who refuse various therapies have such different personality profiles from those who accept them that that their mortality rates are quite different. This means that while comparison of survivals between psychotherapy and no psychotherapy groups remain valid, similar comparison between chemotherapy and no chemotherapy are less reliable statistically.
In all of the above evidence the number of participants in the trials has been small. However, providing:
- the results are based on comparing two groups that have been randomised;
- the groups after randomisation are found to be very similar in their makeup in relation to the age and socioeconomic level of patients and the stage of disease;
- the difference in survival or mortality between the study and control groups is quite large; and
- the only factor varied was the addition of the particular therapy;
the results of such comparative trials are quite valid.
It is therefore clear from the available evidence that:
- psychological factors play an important part in determining
- a person’s susceptibility to getting cancer;
- survival once cancer has been diagnosed with cancer.
- therapies based on changing these psychological factors can have a significant impact on the course of the disease.
It is therefore important that all cancer control programs incorporate some form of psychotherapy as an integral part.
- Benjamin, D. Efficacy of surgical treatment of cancer. Medical Hypotheses 1993; 40:129-138,.
- Langlands, A. Battling breast cancer with dollars and sense, MJA 18 July 1994:161.
- Ulrich Abel Abel, U. Chemotherapy of advanced epithelial cancer: a critical review. Biomedicine & Pharmacotherapy 1992; 46: 439-452.
- Simonton, S. & C. Getting Well Again, Bantam, New York 1978.
- Issels, J. Cancer A Second Opinion, Hodder & Stoughton, London 1975.
- Selye, H. The Stress of Life, McGraw-Hill, New York, 1956.
- Le Shan, L. Psychological states as factors in the development of malignant disease: a critical review, J. Nat. Cancer Inst 1959; 22: 1-18.
- Wirshing, M. et al. Psychological identification of breast cancer patients before biopsy. J. of Psychosomatic Research 1982; 26: 1-10.
- Levy, S. et al. Survival hazards analysis in first recurrent breast cancer patients: Seven-year follow-up, Psychosomatic Medicine 1988; 50: 520-528.
- Pettingale, K. et al. Mental attitudes to cancer: an additional prognostic factor. The Lancet, March 30, 1985.
- Fawzy, Fawzy I. et al. A structured psychiatric intervention for cancer patients. Arch Gen Psychiatry August 1990; 47: 729-735.
- Spiegel, D. et al. Effect of psychosocial treatment on survival of patients with metastatic breast cancer, The Lancet, October 14, 1989.
- Eysenck, H and Gross-Maticek, R. Behaviour Research and Therapy 1991; 29(1): 17-31.