Psychophysiological complementarity in malignancies: past work and future vistas

The Risk and The Course of Cancer Among People with Severe Mental Illness

The paucity of data regarding patients with Serious Mental Illness (SMI) and cancer is alarming given the fact that people with SMI, especially schizophrenia, bipolar disorders and severe depressive disorders, have in general poorer access to physical health care and higher morbidity and mortality because of physical illnesses. The aims of this review were to examine the current evidence from existing literature on the risk of developing cancer and its course among people with SMI. Equivocal results emerge regarding the risk of developing some kind of cancer among people with SMI, with contrasting data on a possible higher, similar or lower risk in comparison with the general population. In contrast, a series of studies have pointed out that patients with SMI who develop cancer are less likely to receive standard levels of cancer care, both in terms of screening, diagnosis and treatment. Also, the mortality for cancer has been confirmed to be higher than the general population. A global sensitization about these problems is mandatory in an era in which community psychiatry has been developed in all countries and that policies of prevention, treatment, follow up, and palliative care should regard all the segments of the population, including people with SMI, through an interdisciplinary approach.

Interaction of psychosocial and physical risk factors in the causation of mammary cancer, and its prevention through psychological methods of treatment

Some 8059 healthy women (mean age 58 years) were studied in 1973 with the aim of establishing the presence or absence of a variety of physical and psychological risk factors for mammary cancer. Mortality was established in 1988. factor predictors were highly significant. Physical risk factors were more predictive than psychological ones, but both interacted synergistically to predict mortality. Alone, psychological (stress) factors had little effect, while-physical factors did. However, psychological factors seemed to potentiate the effect of physical factors, particularly in the middle range. The causal relevance of psychological factors was established in a special intervention study using autonomy training as a method of prophylactic therapy and comparing outcome with the effects of no therapy (control).

Denial in cancer patients

Denial is a basic mechanism for coping with stressful themes, common in healthy and sick individuals. This article deals with the role and functions of denial in cancer, reviewing empirical studies about the effects of denial on cancer prevention, screening, undergoing tests for early detection, delay in seeking medical attention and getting treatment, complying with medical instructions, and coping with the disease in different stages. Special sections are devoted to the possible role of denial as a risk factor for cancer, the effects of denial on disease course and survival, and the relation of denial to immunocompetence. Major conclusions are that denial may have a positive effect when applied in the first phase of coping, after diagnosis, because it reduces anxiety. This holds also for the terminal stage. The negative effects of denial are that it may interfere with getting treatment (e.g., delay in going to the doctor, not showing up for follow-ups, noncompliance), may disrupt the process of assimilating the stressful event, may affect adversely interpersonal relations, and constitutes a cumulative stressor depressing even immunocompetence. The use of denial varies with the severity of the situation, the patient's personality, and his or her familial and cultural background. A large body of research examined the hypothesis that a tendency toward denial could be one of the risk factors for cancer. Despite evidence supporting the occurrence of denial as a correlate of cancer, a lot of research is necessary to clarify the role of denial in general and of anger specifically as a factor affecting the occurrence of cancer and the course of disease and survival.

Colon cancer: personality factors predictive of onset and stage of presentation

This study examined premorbid personality correlates of colon cancer and stage of presentation of colon cancer to health care providers. Sixty-one male veterans who completed the MMPI between 1947 and 1975 and were then diagnosed with colon cancer between 1977 and 1988 were matched with control patients. A 21-factor solution of the MMPI [1] was used to seek potential personality differences between colon cancer cases and their controls in terms of presence of colon cancer and stage of presentation for this disease. A stepwise conditional regression analysis found significant differences between the colon cancer and control groups on the Aggressive Hostility variable (p < 0.018). A multivariate analysis of variance conducted across the stages of colon cancer presentation found that patients who presented later on for colon cancer had higher Phobia scores (p < 0.05). Religious Fundamentalism was also related to presentation (p < 0.05), but in a nonlinear manner. Discussion is related to previous findings regarding the relationship between personality and development of cancer, as well as to implications for patient screening.

Platelet serotonin uptake in patients suffering from pancreatic carcinoma, chronic physical disease and depression

Serotonin uptake by platelets was determined in 11 patients suffering from carcinoma of the pancreas, eleven patients hospitalized for chronic physical disease, 19 patients suffering from major depression unipolar type, and 19 healthy volunteers. The Vmax values of serotonin uptake were significantly lower in patients suffering from carcinoma of the pancreas (F = 18.6, df = 28, Ρ < 0.001) and chronic physical disease (F = 21.3, df = 28, Ρ < 0.0001) than in healthy volunteers. The Vmax values of the depressed patients were also significantly lower (F = 4.27, df = 36, Ρ < 0.05) than those in the control group. No difference was found between the carcinomatous and the chronically ill patients. Km values of serotonin uptake by platelets were significantly decreased in both groups of patients with organic disease (F = 5.91, df = 28, Ρ < 0.025; F = 4.44, df = 28, Ρ < 0.045 respectively) as compared to the control group, but were similar in the depressed and the control groups (F = 0.42, df = 20, P = 0.52). Since the patients with chronic disease were chronically medicated, the decreased serotonin uptake may not be disease-dependent but rather associated with medication. However, the carcinomatous patients were drug-free and in this group the decreased uptake and serotonin transporter hypersensitivity may have been disease-dependent. These results suggest the involvement of the presynaptic serotonergic system in the susceptibility of pancreatic carcinomatous patients to prodromal depression.

Personality as a risk factor in large bowel cancer: data from the Melbourne Colorectal Cancer Study

In a case control study which formed one arm of a large, population-based investigation of colorectal cancer incidence, aetiology and survival. 'The Melbourne Colorectal Cancer Study', among others, 22 psychosocially orientated questions were asked by personal interview of 637 histologically confirmed new cases of colorectal cancer and 714 age/sex frequency matched community controls, from Melbourne (population 2.81 million). Self-reported childhood or adult life 'unhappiness' was statistically significantly more common among the cancer cases, while 'unhappiness with retirement' was similarly distributed among cases and controls. Questions which were formulated to test a particular personality profile as a cancer risk, and which included the elements of denial and repression of anger and of other negative emotions, a commitment to prevailing social norms resulting in the external appearance of a 'nice' or 'good' person, a suppression of reactions which may offend others and the avoidance of conflict, showed a statistically significant discrimination between cases and controls. The risk of colorectal cancer with respect to this model was independent of the previously found risk factors of diet, beer intake, and family history of colorectal cancer, and was also independent of other potential confounding factors of socioeconomic level, marital status, religion and country of birth. Although the results must be interpreted with caution, the data are consistent with the hypothesis that this personality type may play a role in the clinical expression of colorectal cancer and merits further study.

Recent life change and large bowel cancer. Data from the Melbourne Colorectal Cancer Study

In a large, population based, epidemiological study of colorectal cancer, The Melbourne Colorectal Cancer Study, several etiological factors were investigated. Persons' recent life changes, as well as the degree of upset they experienced as a result of these changes, were included. Interviews with 715 histologically confirmed new cases of colorectal cancer occurring over a 12-month period in Melbourne, Australia, and with 727 age and sex matched community controls were conducted. As one of the methods of assessing any effect of recall bias, 179 hospital controls were also investigated. Major illness or death of a family member, major family problems and major work problems were found to be significantly more common for cases over the 5 years preceding diagnosis compared to controls. Cases also reported being significantly more upset with their recent life changes than did controls. No significant differences in results were found between males and females, or between colon cancer and rectal cancer patients. Although the possibility of recall bias, was not completely controlled for in this study, it was probably not an important factor in explaining case-control differences. Recent life changes, and their perceptions, may have significance in the development of large bowel cancer.

Psychophysiological aspects of cancer

"Cancer" refers to carcinoma, sarcoma, lymphoma, and leukemia. Hans Selye, with his stress-adaptation theory, opened the door for the holistic conceptualization of disease. Gotthard Booth laid a solid basis for the demonstration of an often important psychobiological (holistic) aspect of cancer, and also an overall theory of spontaneous regression. Booth was also a leader in demonstrating that severe masked depression generally long precedes cancer. Sir MacFarlane Burnet demonstrated in 1970 in Immunological Surveillance the enormous power and complexity of the cellular immune system, which apparently carries out surveillance against, detects, invades, and destroys many cancer cells daily in the normal human body. Cancer is thus far from a one-way process. The connection of the defensive process to the cerebral cortex is largely a discovery attributable to Selye, and to several Russian scientists. The course and outcome of cancer are notoriously unpredictable when age, sex, and lesion and spread are known. Two surgeons, Everson and Cole, in 1966 thoroughly documented 176 cases (previously published) of histologically proven untreated cancer which underwent proven so-called spontaneous regression. Several investigators, without known contradiction, have found that depression quite regularly long precedes cancer. "Spontaneous" regressions are basic.

The impact of a psychosocial support program on survival with breast cancer: the importance of selection bias in program evaluation

A retrospective follow-up study was conducted to assess the impact of a psychosocial support program on survival with breast cancer. One-hundred and two nonparticipants were individually matched to 34 participants on several prognostic factors, and both groups were followed from date of cancer diagnosis (1971-1980) until December, 1981. Preliminary findings suggest a strong beneficial effect of the program on survival, which is statistically significant. However, this observed effect is due largely to a selection bias caused by the failure to match on the duration of the lag period between cancer diagnosis and program entry. Correcting for this bias in the analysis results in a small, nonsignificant program effect. We are not able to rule out a possible effect, however, because of the relative lack of statistical power and because of a modest, though nonsignificant benefit observed for women who entered the program shortly after diagnosis. Furthermore, the program might have other beneficial effects on the quality of life.

Cancer and the mind. Maudsley Bequest Lecture delivered before the Royal College of Psychiatrists, February 1983

1848, as every student of history knows, was a revolutionary year in Europe. During that year, a minor, long forgotten revolution occurred in London medical circles when a physician, John Elliotson, published a paper entitled ‘Cure of a true cancer of the female breast with mesmerism’ (Elliotson, 1848). It is, as far as I can ascertain, the first recorded case of its kind. The author hypnotized his patient, a 42-year-old single woman, for “5 years and upwards … and for the greater part of the period three times a day”; during that time, Elliotson observed a ‘cancerous tumour’ in her right breast shrink away completely. No less than seven physicians and surgeons independently attested to the diagnosis of breast cancer, but no pathological examination was carried out. Elliotson was roundly abused, not for using hypnosis to treat cancer, but for using hypnosis at all—a practice condemned by certain physicians of fervid imagination as “indecent, disgraceful … liable to excite lascivious passions … an infernal system … the workings of Satan” (Elliotson, 1848).

Youthful habits of work and recreation and later cancer among physicians

Scores on seven factors derived from a Habits of Work and Recreation Survey administered to 1,038 white male medical students 17 to 35 years ago were used to compare students who subsequently developed some form of major cancer with those who did not. With the Type I error rate controlled through use of multivariate analysis of variance and age and smoking ruled out as possible confounding variables, the two groups were significantly differentiated, primarily in terms of intellectual interests--cancer cases having fewer. Students at or below the overall mean on the intellectual interests measure were more than three times as likely to develop cancer as were students with scores above the mean. In this population, the results appear interpretable in terms of the stamina concept, in which few intellectual interests may reflect an absence of stamina and spontaneity and/or failure to meet subcultural expectations--factors possibly associated with increased cancer risk.

Psychological concomitants of cancer: current state of research

An increasing interest in the psychological concomitants of neoplastic diseases has led to a burgeoning literature in recent years. The present review identifies five major areas of psychiatric research, documents the current state of knowledge, and indicates fruitful avenues for further study.

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.

Premorbid psychological factors as related to cancer incidence

In planning for studies relating psychological factors and/or stress (PF&/oS) to cancer, one should be aware of epidemiological findings that might contribute to or even account wholly for any found relationships. Most studies have not examined the known biological causes of cancer, nor have they described a rationale for relationships sought. The two broad mechanisms leading to cancer, carcinogens and lowered resistance to it, include physical and chemical causes, viruses and chronic infection, medication, genetic predisposition, hormonal stimuli, and aging. Interfering variables may bias or dilute a real relationship. Validity and reliability of instruments measuring PF&/oS are so variable as to warrant considerable care in their use. The latent periods of different cancers are measured in years, not months, with consequent potent impact on possible inferences drawn from prebiopsy and short prospective studies. In these and in retrospective studies, cancer can have strong and biasing effects on apparently straightforward PF&/oS measurements, as can iatrogenic effects. Some theoretical issues are discussed. The known prospective studies are discussed and reasons are given for the view that they are less convincing then many seem to think. A sketch of a model relating PF&/oS to cancer appearance is outlined, with some theoretical implications, and issues in research design are addressed.

Psychosocial factors related to the incidence of cancer

The recent data concerning the relationship between psychosocial factors and the incidence of cancer have been reviewed covering life events, personality factors, psychiatric diagnoses, and loss-separation-hopelessness. The multiple methodological and design problems in this area of investigation are the factors that stand out and make interpretation difficult. Nevertheless, an association between oncogenesis and a number of factors such as extraversion, neuroticism, and lack of closeness to family is suggested. Many studies raise additional questions without providing definitive answers. A long term prospective study which has been designed to look at cancer outcome and multiple psychosocial factors is needed to determine if such factors add to the risk of oncogenesis.

The existential plight in cancer: significance of the first 100 days

The Existential Plight in cancer is a poorly recognized but significant period. It starts with the definite diagnosis and continues for two to three months into the illness, approximately 100 days. The chief signs are the predominance of life/death concerns, e-en over worries about health or physical symptoms. One hundred and twenty newly diagnosed cancer patients were interviewed, tested, and followed from about ten days after diagnosis at four to six week intervals until three to four months had elapsed. Plight was analyzed from the viewpoint of coping strategies, resolution of problems, vulnerability, total mood disturbance, and predominant concerns. Patients who had higher emotional distress during this period had many regrets about the past, were pessimistic, came from a multiproblem family, and had marital problems. The widowed or divorced had higher vulnerability, as did patients who anticipated little or no support from significant others. Although vulnerability increased with advanced staging and many symptoms, at the time of diagnosis psychosocial distress crossed diagnostic and prognostic boundaries, enabling investigation to predict within limits those patients who will cope effectively or fail to cope with cancer and its ramifications.

Studies in medical psychology: a brief survey

An understanding of the individual's personality structure may be used to help patients employ their strengths effectively in combating physical illness. Models of personality types based upon psychoanalytic psychology may be utilized. A large number of recent articles on medical psychology are surveyed as representative of current interests in this field, and a few studies are discussed which deal more fully with personality and illness.