An emotional life-history pattern associated with neoplastic disease

Tumor Innervation: History, Methodologies, and Significance

Simple Summary

This comprehensive review of tumor innervation summarizes the literature from the earliest publications on the topic to the most recent. It addresses the positive and negative evidence of tumor innervation and the historical developments in thought and methodology that have led to the consensus that tumors are innervated. The role of the immune response is described, as are some important biochemical and physiological mechanisms relevant to regulation of cancer development.

Abstract

The role of the nervous system in cancer development and progression has been under experimental and clinical investigation since nineteenth-century observations in solid tumor anatomy and histology. For the first half of the twentieth century, methodological limitations and opaque mechanistic concepts resulted in ambiguous evidence of tumor innervation. Differential spatial distribution of viable or disintegrated nerve tissue colocalized with neoplastic tissue led investigators to conclude that solid tumors either are or are not innervated. Subsequent work in electrophysiology, immunohistochemistry, pathway enrichment analysis, neuroimmunology, and neuroimmunooncology have bolstered the conclusion that solid tumors are innervated. Regulatory mechanisms for cancer-related neurogenesis, as well as specific operational definitions of perineural invasion and axonogenesis, have helped to explain the consensus observation of nerves at the periphery of the tumor signifying a functional role of nerves, neurons, neurites, and glia in tumor development.

Attachment and Cancer: A Conceptual Integration

Cancer traditionally has been explained by the biomedical model; however, it is limited in comprehensively accounting for all factors in this disease. Recently, it has been suggested that a broader theoretical framework that includes psychosocial components in cancer is needed to complement the traditional approach. The purpose of this article, therefore, is to explore the utility of attachment theory as a biopsychosocial model of both development and health. Attachment, a developmental theory, explains how repeated interactions between caregiver and child in the early years establish lifelong psychosocial, physiological, affective, and cognitive patterns as well as enduring patterns of stress response to threat or illness. Despite attachment theory’s biopsychosocial foundation, the application of attachment security as a factor in physical health and psychosomatic medicine is relatively recent. The current work reviews attachment theory and psychosocial literature with regard to cancer and follows with a novel attempt to conceptually integrate both bodies of literature. A concluding integrative model of attachment theory and the type C behavior pattern is provided to illustrate potential links and integrative processes that may lead to disease resilience or vulnerability.

Influence of stress related to war on biological and morphological characteristics of breast cancer in a defined population

PURPOSE

To assess differences between patients with breast cancer before, during and after the 1991-1995 war in Croatia.

MATERIAL AND METHODS

We analyzed 660 patients of Pozesko-Slavonska County, during the three periods. Relative predictive values of patient's characteristics and stage of tumor were assessed using the X2-test, and survival with Kaplan-Meier analysis.

RESULTS

Tumors were significantly more often of higher stages (IIA and IIB) and with axillary lymph node metastases (N1) during the war, than in pre-war and post-war period.Breast cancer was significantly more frequent in patients who previously experienced death in the family (35,3%). The Kaplan-Meier analysis showed correlation between survival, T and N stages of tumor and clinical stage of tumor.

CONCLUSION

The war aggression towards Croatia with its impact on our patients, contributed to modification of characteristics of breast cancer in the analyzed period.

Attachment experiences in women with breast cancer

Research into relational experiences of cancer patients suggests possible links between attachment processes and cancer. Women with and without breast cancer were assessed regarding attachment history and early loss, closeness to parents, and adult attachment. Women with breast cancer reported significantly higher incidences of insecure histories and early loss, and scored significantly higher on avoidant attachment than women without cancer. The women in the cancer group also scored significantly lower on closeness to parents than women in the noncancer group. These findings are preliminary and indicate that more research is needed to understand the role that attachment may play in a multidimensional, biopsychosocial model of cancer.

Breast cancer, personality and the feminine role

This article argues that it may be illuminating to look at breast cancer also from a cultural point of view. It is built around a hypothesis which proposes that, on a certain level, breast cancer can be seen as an attempt by women to rid themselves of the breast as a symbol of some of the essential aspects of their femininity, as feminine qualities are seen as of little import in today's industrialized Western world. The argumentation begins by showing that there is a certain type of personality which is prone to cancer: One of the main characteristics of this personality is either the repression or the inability to express or feel anger. Furthermore, studies on sex-roles and defence mechanisms have shown that persons with feminine sex-role orientations use more repressive, self-blaming defence mechanisms. The author finally goes on to discuss the psychic mechanisms thought to lie behind somatization and cancer as a psychosomatic disease.

Self-reported stress and risk of breast cancer

BACKGROUND

Many women attribute the development of their breast cancer to psychosocial factors such as stress and depression. Yet investigations of the relationship between breast cancer and stressful life events have had inconsistent outcomes, due in part to studies with small sample sizes and reliance on hospital-based populations.

METHODS

As part of a population-based, case-control study of breast cancer etiology, we evaluated the association between stressful life events and the risk of breast cancer among 258 breast cancer patients and 614 randomly selected population-based controls. Information on 11 stressful life events was collected in telephone interviews with women aged 50-79 who were participating in the ongoing study.

RESULTS

Breast cancer patients and controls experienced the same number of stressful life events in the five years prior to diagnosis or an equivalent reference date (controls), averaging 2.4 and 2.6 events, respectively. After adjustment for known breast cancer risk factors, there was no association between weighted stressful life event scores and the risk of breast cancer (odds ratio [OR] = 0.90 per unit increase; 95% confidence interval [CI], 0.78-1.05). Only one life event, death of a close friend, was significantly more often reported by controls (OR = 0.72; 95% CI, 0.52-1.00). Other life events were inconsistently and nonsignificantly associated with breast cancer risk. CONCLUSIONS. The results of this retrospective study do not suggest any important associations between stressful life events and breast cancer risk.

Are breast tumours innervated? Immunohistological investigations using antibodies against the neuronal marker protein gene product 9.5 (PGP 9.5) in benign and malignant breast lesions

The aim of the present study was to assess the innervation pattern of benign and malignant breast lesions using the neuronal marker protein gene product (PGP) 9.5. An unlabelled antibody technique (using streptavidin biotin complex formation) was used on paraffin wax sections of tissues fixed in neutral buffered formalin. In 2/4 cases of chronic mastopathy, PGP 9.5 immunoreactivity was seen in relation to blood vessels and the ductal system. No immunoreactivity for PGP 9.5 was seen in the affected tissues of 9/10 cases of fibroadenomata. In 9/16 breast cancers, PGP 9.5-labelled perivascular nerve fibres were detected in connective tissue stroma supporting carcinoma tissue, though not in the immediate vicinity of such tumour tissue. Labelled nerve fibres were detected in large bundles at the periphery of tumours, possibly unrelated to the latter. Our results indicate that the newly formed blood vessels within a tumour are not innervated, though major blood vessels which supply the tumour are innervated.

Life events, chronic difficulties and vulnerability factors preceding breast cancer

This study deals with the association between life events, family history of mammary carcinoma and breast cancer. It was guided by a model consisting of events, family disposition and age at the side of the independent variables. In addition to these factors 'lack of social support' was introduced. The latter is conceptualized as a vulnerability factor capable of aggravating the impact of events without having an independent effect. There was no hypothesis on chronic difficulties, so this is exploratory. This research was conducted as a so-called 'limited prospective' design. Women with a suspicious breast lump were interviewed before surgery. After having confirmed the outcome of the surgery the sample was divided into a group with cancer and cases with a benign diagnosis. Women with gall stones were introduced as another control group. The interviews were performed along a semi-structured schedule, tape recorded and analyzed by using Brown and Harris' Life Events and Difficulties Scale. The analyses were made with 33 women with cancer, 59 with a benign tumor and 20 with gall stones. In the 'malignant' group the severest events was four times as high as in controls. All other degrees of threat were equally distributed over the groups. Chronic difficulties of the highest degree of severity also occur more often in the cancer group. They are not independent from events so that analyzing them separately is not useful. The rate of family history of breast cancer does not differ between the tumor groups, but is much lower in the gall stone patients. In the cancer group there is an association between this possibly hereditary factor and severe events, in the 'benign' group both are uncorrelated. The life event effect is explained in context of a higher illness susceptibility due to a hereditary disposition. For events occurring without it an explanation remains unclear.

Patient delay in cancer. A view from the crisis model

Despite widespread cancer awareness programs, deleterious delays in seeking diagnosis and care for cancer are as prominent now as as they were 50 years ago. These delays may be seen as attempts to resolve or postpone the crisis brought on an individual by the suspicion of terminal illness. The use of denial-like processes in the cognitive appraisal employed to assess this crisis is influenced by a variety of personal, social, and physical factors. Case material is examined to discuss the integration of these factors by the crisis model of physical illness and to examine the implications of such an approach for earlier detection and treatment of cancer.

Psychosocial factors in breast cancer and their possible impact upon prognosis

Breast cancer is the most common cancer form in women. Numerous biological factors have now been identified and accepted as important risk factors and prognosticators. Psychosocial factors are also considered to be of probable importance. A review of the literature studying these factors reveals major methodological problems in evaluating data: small sample size, retrospective design, lack of cross-referencing for other important factors, cross-sectional studies instead of longitudinal studies, and insufficient statistical analysis. Regarding psychosocial factors, some of the most valid studies indicate that the risk of getting breast cancer may be connected with difficulties in expressing feelings, especially ones of aggression; while coping strategy, amount of stress, and level of activity, seem to be of possible influence to the prognosis. A possible connection between psyche and the immunological system has been proposed, but there has been little data so far. Although a series of studies have shown some influence of psychosocial factors on breast cancer, the methodological problems are so large as to leave open the question whether psychosocial factors have any impact upon the disease.

The Rorschach with hospice cancer patients and surviving cancer patients

Two groups, terminally ill hospice female lung and breast cancer patients and surviving female lung and breast cancer patients (mean age = 74.3 years), were given the Rorschach to discern the underlying personality structure. The hospice patients were found to be withdrawn, anxious, depressed, and unable to express their deep, fearful emotions. The surviving patients met life and death head-on and seemed richer for the experience.

Stressful life events and illness occurrence in rural versus urban women

Stressful life events and illness occurrence were examined in a sample of rural and urban Wyoming women (N = 157). Modified versions of Norbeck's Life Experiences Survey (LES) for Women and Wyler's Seriousness of Illness Scale were used. The results indicated no significant rural-urban differences in the number or intensity of stressful life events. A strong positive correlation between stressful life events and illness occurrence, particularly in relation to the total number of events experienced, was found.

Psychological aspects of cancer and chemotherapy

Research in the psychological aspects of cancer and chemotherapy has reached an exciting stage of development. More acceptable standards of scientific rigour are being applied to thinking and research, spanning a wide range of important issues from prognostic indicators to the evaluation of treatment trials. It is important to remember that patients do not exist in isolation and that the impact of disease and treatment is also felt by their care givers. The burden which falls on spouses and other primary carers and the importance of their contribution to patients' adaptation to illness should not be underestimated. By the same token the emotional demands particularly on nursing and junior medical staff are increasingly recognized with developing interest in optimal means of providing staff support. Thus the field is still expanding. It requires the continuing collaborative effort of a wide range of professional disciplines to improve our understanding of the psychological aspect of oncology for all cancer patients and those who care for them.

Minnesota Multiphasic Personality Inventory-rated depression and the incidence of breast cancer

Using data from the Walnut Creek Contraceptive Drug Study (a prospective study begun in 1969 and continuing to the present), Minnesota Multiphasic Personality Inventory-(MMPI) measured scores for depression of 8932 women were studied in relation to the incidence of breast cancer. No statistically significant association between MMPI scores for depression and the subsequent development of breast cancer was found. There was neither an association of risk of breast cancer with repression/sensitization as measured on the MMPI nor with scores on the MMPI lie scale. This study is unique because it represents the largest reported prospective cohort in which the association between depression and breast cancer development has been examined.

Associations between selected life events and cancer

This case control study compares 508 women with cancer with 1,563 controls with respect to four different life events as indicators for an increased cancer risk: (1) death of the father during childhood; (2) death of the mother during childhood, both before the age of 16; (3) divorced, separated, or widowed at any time; (4) at least one traumatic World War II experience. The age-adjusted relative risks were 1.10, 1.71, 1.45, and 1.33, respectively. The only variable not showing a significant association with cancer was "death of father." Inferences from the results are limited by the retrospective study design and by the inability to isolate events that are cancer specific from those specific to illness in general.

Clustering of personality traits in youth and the subsequent development of cancer among physicians

Using 14 personality measures obtained while the subjects were in medical school, the resulting profiles of 972 physicians were clustered into five groups using a two-stage cluster analysis procedure. Subjects were followed over a 30-year period to determine the cumulative survival rate (proportion of subjects remaining free of cancer) in each group. Statistically significant group differences in survival rate were found, with the group characterized by acting out and emotional expression having the most favorable curve (less than 1% developing cancer). The group characterized as "loners," who may well have suppressed their emotions, had the most unfavorable survival curve and was 16 times more likely to develop cancer than was the group characterized by acting out and emotional expression.

Psychobiological factors predicting the course of breast cancer

Drawing on a carefully controlled sample of 52 women with a history of breast carcinoma and 34 healthy controls, this prospective study examined empirical associations between psychological factors and the progression of neoplastic disorders over a follow-up period averaging 624 days. Psychological variables were psychometrically assessed by self-report measures. A multiple regression analysis which controlled for disease stage at original diagnosis, age, total length of disease course, hematological factors, and blood chemistries measured at study onset showed neoplastic spread to be associated with a repressive personality style, reduced expression of negative affect, helplessness-hopelessness, chronic stress, and comforting daydreaming. The identified model of medical and psychological variables accounted for 56% of the observed variance. A psychobiological model of brain-body disregulation provided the best account of the observed associations between psychological functioning and the progression of disease. Future research is necessary to examine the role which psychological functioning may exert upon health-relevant behaviors that might blunt the benefits of professional health care.

Stress, immunity and illness--a review

Psychological factors have long been thought to play a contributing role in either the predisposition, onset or course of various physical illnesses. Recently, rapid advances in immunology have created interest in the interaction between psychosocial factors, behaviour and the immune system. This paper reviews some of the models proposed to explain the relationship between psychological variables and physical illness and presents evidence for a contribution of psychological factors to certain illnesses in which abnormalities in immunologic state are thought to be important. From a somewhat different perspective, animal studies have demonstrated complex effects of stress, on disease susceptibility. Recent human studies have demonstrated consistent immunologic changes in people undergoing acute naturally occurring psychological stress such as bereavement or an important examination. In humans, the effects of chronic stress may be different from acute stress, corresponding to the findings in animals. Abnormalities in immunologic functioning and physical illness are reviewed for different psychiatric disorders--depression, anorexia nervosa and schizophrenia; depression is the only disorder which consistently demonstrated immunologic changes. Possible mechanisms for the stress/immune-change relationship are suggested.

Cancer from a biobehavioural and social epidemiological perspective

Malignant neoplasm should not be viewed as a 'psychogenic' nor as a 'primarily organic' disease but as an interaction of various forces, in which psychosocial factors may play an important role. To understand the increase in neoplastic disease, which has taken place in this century, requires a theoretical framework including social, psychosocial and behavioural dimensions, as well as the endocrine and immunologic mechanisms acting as pathogenic pathways. Recent theoretical developments in health psychology and allied disciplines on coping behaviour and social support should be integrated into biomedical models of the aetiology, pathogenesis and clinical course of malignant neoplasia. Environmental stressors, as well as mediating variables at the cognitive, affective, behavioural and physiological levels of adaptation, are suggested as major components of a model of multidimensional pathology. A growing body of research on the role of psychosocial factors in adjustment to cancer and its treatment has contributed new insights into possible variables and causal mechanisms which may be relevant in the aetiology of the disease. Closeness to parents in childhood and the ability to form close interpersonal relationships in later adult life very possibly influence the ability of the individual to cope effectively with environmental stressors prior to neoplastic disease and with the considerable stresses of being a cancer patient subsequent to diagnosis and treatment. Pathogenic pathways for future investigation include mental health variables, such as self-esteem and sense of control, at the psychological level and immunity surveillance at the biological. An integration and cross-fertilization of current work in the aetiology of and adjustment to cancer is suggested linking psychosomatic and somatopsychic models.

Towards a psychobiological model of cancer: psychological considerations

To date, the evidence relating to the role of stress and psychological variables in cancer aetiology and promotion is contradictory. We have attempted to clarify the issues by presenting an hypothetical psychobiological model. Two components of this model are described: (1) a characteristic behaviour pattern (Type C) which may mediate stress reactions and (2) the biological concomitants of this behaviour pattern. The mechanisms of cancer initiation and promotion are described in a companion paper (Pettingale). The main hypothesis advanced by this model is that the psychological factors described may promote cancer development; the model is offered for investigation.

Bereavement and cancer: some data on deaths of spouses from the longitudinal study of Office of Population Censuses and Surveys

Registration of cancer and mortality after the death of a spouse were assessed using data from the longitudinal study of the Office of Population Censuses and Surveys (OPCS). The study population comprised 1% of the people counted in England and Wales in the 1971 census, for whom data on subsequent vital events were linked with their census records. There was little evidence of an increase in registrations of cancer after the death of a spouse and only a slight suggestion of increased mortality from cancer. For other causes of death there was some evidence of increases in mortality during widow(er)hood. In so far as the death of a spouse is often a very stressful event, these data may be interpreted as providing little support for the hypothesis that stress is implicated in the aetiology of cancer.

Psychosocial status in chronic illness. A comparative analysis of six diagnostic groups

Assumptions that psychological attributes are specific to particular diagnoses characterize many investigations of chronically ill patients. We studied 758 patients, each of whom had one of six different chronic illnesses, to determine and compare their scores on the Mental Health Index. Five groups of physically ill patients (with arthritis, diabetes, cancer, renal disease, or dermatologic disorders) did not differ significantly from one another or from the general public, but all had significantly higher scores for psychological status when compared with the sixth group, patients under treatment for depression. There was a significant direct relation between higher mental-health scores and advancing age across all patient populations. Patients with recently diagnosed illness in all groups had poorer mental-health scores than did patients whose illness had been diagnosed more than four months previously. A direct relation between declining physical status and mental-health scores was observed. These results suggest that psychological adaptation among patients with chronic illnesses is remarkably effective and fundamentally independent of specific diagnosis.

The social-psychological precursors to cancer

This article attempts to review the research literature relating the possible psychosocial precursors to cancer. It explores the evidence linking personality predispositions and adverse life events to cancer, providing an indication of where future research should be pursued.

Psychosocial factors and smoking as risk factors in lung carcinoma

In a retrospective study as part of a larger study 419 male patients with bronchial carcinoma were questioned by means of a 'biographical questionnaire' concerning their life history, their personality, and their approach to life. Furthermore questions with regard to their smoking habits (tobacco smoke condensate exposure) were asked. Only patients who smoked cigarettes regularly were involved in the interrogation and the results were compared with those of smoking healthy controls and patients with non-malignant lung diseases (N = 162). For each pair group-controls a discriminant analysis was carried out. By reclassification a correct assignment of approx. 62% in each case could then be obtained. In addition, the answer pattern of the carcinoma patients was compared with a group of patients with non-malignant lung diseases. The results obtained were similar to those of the comparison with the healthy control group.

The experience of cancer during early and advanced stages: the views of patients and their mates

Problems, coping mechanisms and problem resolution were assessed in 112 individuals: patients with early stage cervical cancer or pre-cancer (N = 42) and their mates (N = 19), and patients with advanced stage breast or gynecological cancer (N = 31) and their mates (N = 20). The most common source of concern for all groups was the disease itself; the men were also more likely than the patients to be disturbed by the possibility of the women dying. Taking firm action was the most frequently-mentioned coping strategy; information-seeking was also common among the early stage groups, and religious faith often cited by the advanced stage respondents. Analysis of a particular problem--fear of cancer--showed different coping strategies to be predominant; mates, in contrast to patients, were likely to take direct action and advanced stage groups more likely to discuss their fear of cancer with others. Problem resolution did not vary from group to group. Overall, the similarities among reactions of early and advanced stage patients and mates were more striking than differences, indicating the profound impact of cancer over the course of the disease on patient and family alike.

Family attitudes in youth as a possible precursor of cancer among physicians: a search for explanatory mechanisms

A measure of youthful family attitudes, the Closeness to Parents Scale, has continued to be predictive of cancer among physicians in a prospective study of medical students. Nonetheless, questions have remained concerning the meaning and reliability of this measure and whether its predictive value is diminishing over time. Perhaps more important, it is necessary to ascertain whether the relationship is the result of some methodological artifact or whether it is mediated by an association with known risk factors, such as smoking, drinking, and radiation exposure. Each of these issues was examined in turn, using a variety of statistical techniques to refine the scale and to equate cancer and control groups with respect to risk factors as well as possible artifacts. In a group of 913 men, it was found that the scale is primarily a function of good father-son relationships and that its association with later cancer persists even after the influence of possible mediating and artifactual variables is statistically controlled. Several possible explanations for these findings are discussed.

Behavioral--physiological factors in the development and management of cancer

Recent clinical and animal model studies have demonstrated an effect of behavioral variables on the course of cancer. Unrelieved anxiety, helplessness, depression, and the inability to modulate the expression of anger have been implicated as specific predictors of poor prognosis. The endocrinological sequelae of these emotional states may affect certain parameters of cell-mediated immunity involved in host resistance to neoplasia. Both corticosteroids and catecholamines are likely mediators of behavioral effects on immunological function. Hormonal variations may also affect growth of tumors directly, or through nonimmunological tissue specific mechanisms. Behavioral interventions based on elicitation of the relaxation response provide a means of influencing affective and physiological states that may have particular relevance to cancer. Practice of such interventions reduces anxiety and provides a substrate for coping that enhances the patient's sense of control. Such "immunization" against helplessness can forestall depression. Physiological effects of such behavioral interventions occur both on a direct and an indirect level. Elicitation of the relaxation response per se produces physiological alterations consistent with decreased arousal of the sympathetic nervous system. Furthermore, by reducing fear and helplessness, physiological changes related to such dysphoric states may be minimized

Social factors in the etiology of chronic disease: an overview

Our intention in this introductory article is to emphasize what we consider to be certain critical points in the current state of research into the social epidemiology of chronic disease. As will be outlined, these critical points need to be considered in future research. To begin with we provide a mild critique of research in this area which has had its tradition specified by social epidemiology, a term which has recently come into favor to describe research concerned with social factors in the etiology of chronic disease. Next we briefly summarize critical available evidence on an etiological relationship between social factors and cardiovascular disease, cancer and multiple disease outcomes. Following this a major emphasis will be placed on issues which directly relate to problems of methodology in social factors assessment. Finally, an emphasis will be given to the critical question of mechanisms which need to be clarified in this type of multivariate research.

Interpersonal repression as a predictor of cancer

This paper examines the possible relationship between two specific styles of interactive behavior which reflect active and passive coping with stressful experiences, and attendant illness susceptibility. In a longitudinal study of 1353 inhabitants of a Yugoslav town from 1965 to 1975 data show that being a passive receiver of repression is associated with subsequent incidence of cancer. Being an active emitter of interpersonal repression is found more commonly among subjects who experience cardiovascular and other circulatory diseases later on. Data are presented and discussed in the framework of recent findings in environmental physiology, neuroendocrinology and psychosomatics.

Cancer and stress: counselling the cancer patient

In addition to the commonly accepted aetiological agents of cancer, such as chemical carcinogens, oncogenic viruses, hereditary factors, irradiation, and chronic trauma, multiple psychological factors are also important. Among these are psychological depression, impaired emotional outlets, and perceived lack of closeness to parents. The effect of addressing these factors in addition to standard medical factors in addition to standard medical management is an important question to be answered. A pilot study is in progress, in which patients with medically advanced malignant disease are being counselled in addition to receiving appropriate medical treatment. Standard mental health processes of counselling are employed in a combination of individual and group counselling sessions. From 1974 through 1978, a total of 193 patients with medically advanced malignant disease have received counselling in addition to their medical treatment. The three most frequent diagnoses are breast cancer (71), bowel cancer (28), and lung cancer (24). These are also the three most common diagnoses in the United States. In this study we have observed median survival times of 38.5 months in advanced breast cancer, 22.5 months in advanced bowel cancer, and 14.5 months in advanced lung cancer. These survival times are considerably longer than expected median survival times reported in the literature. Our primary concern in using this approach was that the counselling be helpful and not detrimental to the duration of life, quality of life, and quality of death of the individual. Preliminary results indicate that counselling can be helpful and can also be detrimental, depending upon the dynamics of the relationships among the counsellor, the patients, the medical team and the family. This is a preliminary study, and many major questions remain unanswered.