Can Attitudes Affect Cancer?

By Leon Jaroff.

In a 1976 New England Journal of Medicine article called "Anatomy of an Illness," Norman Cousins, then the erudite editor of the Saturday Review, described how he had cured himself of spinal arthritis by adopting a healthy mental attitude, laughing a lot and taking vitamin C. Other diseases, Cousins implied, might also succumb to positive thinking. The article struck a responsive chord. It was reprinted in other medical journals, supported by letters to Cousins from some 3,000 doctors, and eventually expanded by the author into a briskly selling 1979 book of the same name. Despite complaints from other doctors who studied the Cousins case and said that the author had misrepresented the nature and severity of his disease, Cousins' amateur foray into medicine eventually led to his appointment as a senior lecturer on the faculty at the UCLA medical school.

Cousins' writings, along with a glut of similar books, television features and articles -- some by doctors -- have convinced many Americans that a positive mental attitude can help prevent and even cure a variety of ills, including cancer, and, conversely, that a negative outlook can increase vulnerability to disease. Last week the New England Journal published a study and an editorial that cast doubt on that popular view and stirred a tempest in the medical community.

In the study, which began in 1982, a team led by Dr. Barrie Cassileth at the University of Pennsylvania Cancer Center in Philadelphia developed questionnaires for 204 patients with advanced cancer and another 155 who had been treated either for breast cancer or melanoma and were susceptible to a recurrence of the disease. The cancer victims were asked about such attitudes as satisfaction with their jobs and life in general, feelings about their health, and their degree of hopelessness or helplessness -- factors that some studies have shown to affect longevity. Using accepted psychological rating procedures, the team compiled psychosocial scores that measured the patients' outlooks.

In the 3 1/2 years since the study began, 154 of the 204 advanced cancer patients (75%) have died. Of the 155 people treated for melanoma or breast cancer, 41 (26%) have had recurrences. But the researchers could find no relationship between attitude and either the survival or recurrence rate. In general, the more cheerful patients showed no greater capacity than the depressed ones for fighting their cancers, and the pessimists were at no greater risk of death or recurrence than the optimists. Concluded the report: "Our study . . . suggests that the inherent biology of the disease alone determines the prognosis, overriding the potentially mitigating influence of psychosocial factors."

With proper scientific caution, the Pennsylvania team stressed that its conclusions applied only to patients with advanced cancer. It conceded that the study "did not address the possibility that psychosocial factors or events might influence either the cause of disease or the outcome for patients with more favorable cancer diagnoses."

The accompanying editorial by Dr. Marcia Angell, the Journal's deputy editor, went further. It was particularly critical of the kind of self-help medical advice given in the Cousins book and others (such as one by Carl and Stephanie Simonton of the Cancer Counseling and Research Center in Dallas, who prescribe for cancer patients mental-imagery techniques that include envisioning their vigorous white blood cells overpowering weak cancer cells). But it also questioned the effectiveness of positive thinking in fighting any disease. Medical literature, wrote Angell, "contains very few scientifically sound studies of the relation, if there is one, between mental state and disease . . . It is time to acknowledge that our belief in disease as a direct / reflection of mental state is largely folklore."

The views expressed in the Journal did not go unchallenged. Dr. Sandra Levy, a former chief of the behavioral medicine branch of the National Cancer Institute, agreed that biology is the major determinant. But she charged that what was measured in the Philadelphia study was "limited and superficial" and that science was not "well served" by the Journal's editorial position. Her own studies of women with breast cancer, Levy said, suggest that cancer patients who are passive, stoic and helpless fare less well than others.

Cousins took no exception to the study, insisting that his ideas have been misinterpreted. Still, he noted that in a UCLA study now under way, "we have seen in one or two cases that the number of immune cells can be increased under circumstances of deep confidence and determination."

But Cassileth was adamant. "Certainly, there is a role for mental state and emotional factors in illness," she said. "We just don't know what it is. We do know that it is not a direct cause-and-effect relationship." Some of those who insist that it is, she said, are actually causing harm. "There are increasing numbers of practitioners around the country who offer mind tricks as cures for cancer" -- a trend she called "most unfortunate" because patients are drawn away from conventional therapy, which "may very well help them."

Both Cassileth and Angell saw another unfortunate implication in the notion of conquering disease by positive thinking. "If the cancer spreads, despite every attempt to think positively," Angell asked, "is the patient at fault?" She pointed to remarks made by Humana Institute's Dr. Allan Lansing, who at a press conference expressed concern that Artificial Heart Recipient William Schroeder did not have the right attitude after his first stroke. The implication, she said, is that Schroeder was in some way responsible for his condition. At a time when patients are already suffering from disease, Angell concluded, "they should not be further burdened by having to accept responsibility for the outcome."

With reporting by Joelle Attinger/Boston and Cheryl Crooks/Los Angeles