Does worry cause cancer?

SIDNEY KATZ March 5 1955

Does worry cause cancer?

SIDNEY KATZ March 5 1955

THE RELENTLESS search for the causes and cure of cancer has now led medical scientists to a new and dramatic frontier: the human emotions. Surprising clues are being found which may some day answer such provocative questions as:

Can long-continued fear, worry and disappointment be an important cause of cancer?

Does cancer race through a patient’s body or slow down to a snail’s pace, depending on his attitude to life?

Do the cancer cells deliberately choose a specific organ to attack, the choice based on the particular kind of emotional problem plaguing the patient?

Do we all carry around cancer cells and do they only run wild when triggered by some mysterious process in which the emotions play a part?

A few years ago doctors felt that the emotions were influential chiefly in producing such conditions as asthma, peptic ulcer, hypertension, backaches and headaches. Cancer, they felt, was an exception. It was purely an organic disease. If the condition were untreated or untreatable the cells multiplied furiously, spread throughout the body, and death followed inevitably.

But doctors have lately been puzzled by cases where this did not happen. The patient either recovered completely from an allegedly “fatal” disease or went on to enjoy good health for several years. Furthermore, two patients with the same degree of illness, given exactly the same treatment, would respond differently. Such cases led to speculation that somehow the personality of the patient governed the course of the cancer. This theory was then tested in various clinics and hospitals with some rather surprising results:

At the Veterans’ Administration Hospital, Long Beach, Calif., doctors compared a group of twenty five patients with “fast-growing” cancer, with a similar number who had “slow-growing” cancer.

There was a dramatic difference in the personalities of the two groups.

In Chicago forty women who had been operated on for breast cancer were carefully studied. The women were found to have a similar pattern of personality and behavior. They had an aversion to sex; most of them didn’t want to have children; they had an unhealthy, unpleasant relationship with their mothers that they covered up with an outward show of sweetness and light.

The vast majority of sufferers with leukemia— the so-called “cancer of the blood”—are adults. After numerous and intimate contacts with leukemia patients, two Philadelphia physicians reported that most of them had had harrowing lives. A female patient of fifty-seven was a case in point. At twenty she fell madly in love but her parents forbade the marriage. At twenty-two she married another man, whom she didn’t love. Her husband was cruel, domineering and self-centred. At times she was forced to work outside the home. Overwork and worry led to a period of mental illness. When she recovered, her mother and father died, and shortly afterward her husband divorced her. Right up until her death from leukemia, her life had been a succession of disappointments.

The occurrence of emotional difficulties in patients with leukemia could be more than a coincidence, according to the Philadelphia doctors, who said that further research along these lines might be profitable.

Any broadening of our knowledge about cancer would come as a boon. Cancer is now Canada’s No. 2 killer, claiming eighteen thousand victims a year. In the past thirty years the total death toll has trebled. To be sure, there’s a bright side to the picture that shouldn’t be overlooked. The increase in deaths can be explained by the rapid growth of our population and the larger proportion of older people, who are particularly susceptible to cancer. Again, impressive strides have been made in diagnostic and treatment facilities. But eighteen thousand deaths is still a frightening figure—enough to bestir medical researchers to break new ground.

Doctors have frequently hinted that researchers could profitably look to the cancer patient’s mind for clues to the mystery. Dr. Joost Meerloo, a Columbia University psychiatrist, says, “Stress, mental shock or maladjustment may be a causative factor in cancer.” Dr. Ivan Smith, director of the Ontario Cancer Foundation, states, “One would do well to look for some relationship between a retardation of a cancerous growth and the personality of the patient.” Dr. John Lovatt Doust, a psychiatrist engaged in research at the Toronto Psychiatric Hospital, says, “The mind and the body cannot be separated. When a person breaks down physically, the site of the breakdown is not accidental. It is tied up with the person’s inheritance and his accustomed way of responding to difficulties. This might well influence the way the site of a cancer is chosen.”

Medical men are understandably cautious on the subject of the relationship between the emotions and cancer. Dr. Vernon W. Lippard, dean of the Yale School of Medicine, states, “Scientists are approaching this field cautiously because of the many variables and the possibility of misleading results.” Dr. O. H. Warwick, executive director of the Canadian Cancer Society, points out that “information is as yet scant and unconfirmed.” Dr. Cuyler Hammond, director of the statistical research section of the American Cancer Society, says that “it is conceivable that psychological factors play a role in the origins of cancer but this has yet to be conclusively proven. There is more reason to speculate that the state of mind has some influence on the course of the disease after it has developed.” Dr. T. A. Watson, director of Saskatchewan’s cancer services, expresses doubt that enough is known to justify conclusions.

However, the theory that personality traits are an influence in cancer is strengthened by the unpredictable nature of the disease. Cancer is a slower and less often fatal disease than it is commonly believed to be. Every doctor knows this from his own experience. Some patients mysteriously recover completely even after the malignant growth has “metastasized”—spread from the original site to other parts of the body. Other patients unaccountably live on for ten or twenty years. Many a doctor has damaged his reputation by predicting how long a cancer patient had to live.

Examples are not difficult to find. A busy Toronto physician, bothered by persistent stomach pain, asked for an exploratory operation. His surgeon reported inoperable gastric cancer and warned him that he only had a few months left to live. “Rubbish!” replied the physician, “It will take me at least two years to finish my book.” He lived for ten years. A woman of seventy-eight with cancer of the breast lived several more years. A deeply religious person, she consistently refused medical help. “I don’t need treatment,” she said. “God is saving me.”

Dr. Meerloo, of Columbia University, tells of a patient who was deeply depressed after being told that she had inoperable cancer. All her life she had wanted to travel. Her doctor convinced her that she should take her life’s savings and splurge. She returned home two years later, still with a tumor, but cheerful, healthy and interested in living. She died twenty-four years later.

The same phenomenon, on a broader scale, has frequently been noted in medical literature. As far back as 1918, Dr. G. L. Rhodenburg published in Cancer Research an account of three hundred and two cases where the malignant growth regressed rather than progressed with the passage of time. There were several dozen instances where the tumor vanished completely. A man with stomach cancer died two and a half years after the diagnosis was made; the autopsy showed no sign of cancer. A woman lived for twenty years after it was discovered that she had pelvic cancer; at the time of her death there was no trace of malignancy. In all these cases, diagnosis was established with absolute certainty.

The personal and inconsistent nature of cancer is perhaps best emphasized by studies of untreated cancer cases. Dr. Michael Shimkin, of the University of California, found that after five years twenty percent of untreated breast-cancer cases were still alive; so were ten percent of the chronic leukemia and bladder-cancer patients. In another study of a hundred and forty-three untreated lung cases, fifty percent died within a year after serious symptoms appeared; thirty-four percent within two years, while sixteen percent survived two years or more. In Hodgkin’s disease (cancer of the lymph glands) the span of survival may range from a few months to twenty-two years.

From these many exceptions a new concept of cancer has arisen. It was “Maybe everybody has had or will have cancer without even knowing about it” described at a symposium on “The Psychological Variables in Human Cancer” held by cancerologists, psychologists and psychiatrists at the Veterans’ Administration Hospital, Long Beach, Calif., in October 1953.

This concept is that the individual is not helpless when cancer cells attack him and that cancer should be viewed as a struggle between the malignant cells and the human body. It maintains that the body has a defense mechanism. If the defense mechanism is of superior strength, the cancer cells are vanquished and the person lives out a normal span of life. If the defense mechanism is almost a match for the invader, the attack is so slowed down that the person may live on for ten, fifteen or twenty years before succumbing. Of course, if the defense mechanism is weak, the person soon dies.

Another novel view presented at the California symposium was that we all carry within us a certain number of cancer cells, but that most of us possess a strong defense mechanism, so the disease never progresses to the point where we suspect its presence. The same is true of polio. Almost all adults can be shown to have had that disease. They didn’t know it at the time, however, because the body was able to check it before it produced anything more serious than a sore throat or a slight head cold.

The possibility that we all are hosts to cancer cells is described in a recent issue of the professional journal, Cancer. Dr. C. N. Edwards did autopsies on several men who had died of various causes. The results were revealing. In men over forty, sixteen percent had prostatic cancer; in men over fifty the proportion rose to forty-six percent. Obviously, most of these cancers remained stationary and the individuals died for other reasons. They may have had cancer for thirty or forty years but because of some defense system in the body it didn’t grow and nobody knew about it.

Mass surveys conducted among women for the early detection of cancer of the cervix reveal the same state of affairs. Doctors followed a large group of women who were found to have cervical cancer. However, in only twenty percent of the cases did the malignant cells get to the point where treatment was required. “We are confronted with the possibility,” says Dr. Phillip West, a University of California professor of biophysics, “that all of us may have had or will have some form of cancer but because of inherent natural control of this process, we will never know it.”

Dr. A. L. Mitchell, an English pathologist, has been able to find metastatic cancer cells (cells indicating that the cancer has spread) in the bone marrow of patients with localized tumors. If these findings are confirmed, it would mean that there is no such thing as eradicating a cancer in the sense of cutting out every last cancer cell. Only a majority of the cells could be removed and the natural defenses of the body would have to fight the rest. That is why Dr. Joseph Weinberg, a prominent California surgeon, recently remarked, “If I had to remove every tumor cell to effect a cure, I would never again operate on a patient.”

All of this suggests the presence of a defense mechanism. If this is so, what part do the emotions play in the precancerous and cancerous stage? This was the question to which Dr. Phillip West, of the University of California, and Drs. Frank Ellis and Eugene M. Blumberg, of the Veterans’ Administration Hospital, sought an answer.

Many of their patients puzzled them. For example, they would administer the same dosage of nitrogen mustard to two patients with the same degree of Hodgkin’s disease only to find that one would apparently recover and go on living in reasonable health for years, while the other would rapidly go into a decline and die. Since the disease and the treatment were the same, the physicians began to wonder about personality differences in the patients. On the basis of these differences they began predicting how different patients would respond to treatment. “We were right most of the time,” West says.

A scientific investigation then followed. They worked with fifty patients, war veterans who were suffering with inoperable cancer of the lung, prostate and testicle as well as some with leukemia. All were receiving palliative treatment. They were divided into two equal groups. One group was responding to treatment and the spread of the malignant growth was slow; the other group apparently received no help from therapy and the cancer’s growth was rapid. Both groups were studied psychologically.

Does a Good Cry Help?

The results were revealing. The "fast” group was made up of individuals who were painfully sensitive, over-nice, apologetic and overanxious to please. They bottled up their feelings and seemed to have no way of releasing their tension. A fifty-nine-year-old man was typical of this "fast” group. Only five months after being admitted to hospital he died from a form of cancer in which the average survival time is three to six years. He was anxious and worried about his condition but couldn’t show it. The doctors described him as "blocked, like a man who is afraid to reach for a gun to kill a tiger because he is afraid of the tiger.” He was quiet and well-behaved and never seemed to express what he felt.

A watchmaker in his fifties was representative of the "slow” group. He had carcinoma of the prostate and the disease had spread to his bones. In spite of his considerable illness, he was cheerful and appeared to be in excellent physical health. Although he did have anxiety about his health, he was able to work it off by outwardly noisy emotional behavior. For instance, every time he saw his doctor approaching his bedside be would break down and cry profusely. While demonstrations of this kind may have been a little wearing on those about him, they apparently had a favorable effect in retarding the progress of his illness.

This ability to express or work off feelings seemed to distinguish the two groups. Some members of the slow group would shout, cry or giggle; others were neurotics or psychopaths. Some relieved their feelings by keeping themselves busily engaged and showing in many ways that they were convinced that cancer was not so serious as the doctors made it out to be. The fast group, on the other hand, had no way of releasing their feelings. Many of those who died were sincere, intelligent and constructive members of society. The doctors concluded, "The data suggests that long-standing, intense emotional stress may exert a profoundly stimulating effect on the growth rate of an established cancer in man.”

If the emotions can speed up or slow down the growth rate of a malignant tumor, can they also select that part of the body where cancer will strike? Is it accidental, for example, that one person will develop lung cancer, another cancer of the breast and still another, leukemia?

About forty-five percent of female cancer is located in the primary and secondary sexual organs—the uterus, cervix and breasts. The proportion increases as the woman reaches her forties and fifties. Could it be that sexual conflicts play a role here? There are many problems of a sexual nature that plague women: fear of pregnancy, shame because of lack of attractiveness or physical defects, conflicts over premarital experiences, cessation of marital relations, the approach of menopause and so on. It has long been noted that breast cancer is more common among women who have not nursed their children than among those that have; that childless women and spinsters are more frequently attacked by cancer of the reproductive organs than married women with children. (Injuries due to childbirth are excluded from this estimate.) About twenty-five years ago Dr. E. Kehrer, a German gynecologist, observed: "Every woman with a fibroid tumor in the uterus has a history of psychosexual disturbance. From the size of the tumor you can judge the length of the disturbance with accuracy.”

About one third of all female cancers occur in the breast. Psychiatrists believe that a possible reason is that the breast is of deep significance to a woman. It is the symbol of both femininity and motherhood and it’s not difficult to understand how it can become a target organ for sexual conflicts. If the woman is frigid and masculine, she may regard her breasts with shame and hostility; or for some compensatory reason she may develop an excessive pride in them.

A number of recent studies underline the possibility of a close link between cancer of the sexual sites and conflict over sexual matters.

Three years ago Dr. Max Cutler, a leading cancer surgeon and former head of the Chicago Tumor Institute, and his associate Dr. Richard Renneker carefully studied forty women who had been operated on for breast cancer. A general pattern emerged. Of twenty childless women, nineteen said they would not want to become pregnant under any circumstances. Of twenty women with children, seventeen said they would have preferred to be childless. Almost all the women had a difficult and unhappy relationship with their mothers. They resented their close attachment and dependency on their mothers, yet were unable to express their hostility. Other clinics have made similar observations.

Dr. James Stephenson and Dr. William Grace, of the Cornell Medical School in Ithaca, N.Y., compared one hundred women with cancer of the cervix with a similar number with cancer in other sites. The typical cervical cancer case was revealed as a woman with poor adjustment in the field of sex, maternity and marriage. She was likely divorced or separated from her husband. She disliked intercourse and seldom derived pleasure from it. Her husband was likely to be alcoholic or unfaithful. "This knowledge can be useful in experimental carcinogenesis,” the two doctors concluded.

Their findings were bolstered by another investigation conducted by Dr. Milton Tarlau and Irwin Smalheiser at the New York City Cancer Institute. Describing twenty-two women with cancer of the breast and cervix, they wrote, "None of the patients ever received any kind of positive sex information. It consisted chiefly of warnings to stay away from men.”

Lacking information, the women met the onset of menstruation with fear, shame and disgust. Practically all of them had an aversion to marital relations, giving as their reasons pain, lack of pleasure, disgust or the feeling that it was not right or good. Tarlau and Smalheiser concluded: "There is some evidence that personality may play a role in the . . . (origin) . . . of cancer of the primary and secondary organs in predisposed individuals.”

Worry, fear and emotional tension all subject the body to a great deal of stress. Experimental work in recent years suggests that stress is the single cause of all diseases. Dr. Hans Selye, of the University of Montreal, believes that when the human body is under stress—be it through worry, disappointment, heat, cold or bacterial invasion—its chemistry is thrown off balance. Immediately, the glands try to restore this balance by working overtime, excreting hormones. If the stress is too prolonged, the gland mechanism breaks down and illness develops. Because leukemia—cancer of the blood—responds to ACTH and cortisone which are glandular products, there is reason to suspect a close tie between stress and cancer.

Another possible link between cancer and worry can be demonstrated by means of "oximetric measurement” — measuring the oxygen level in a person’s blood. At the Toronto Psychiatric Hospital, research psychiatrist John Lovatt Doust has repeatedly shown that when a person is depressed or worried the oxygen level in his blood goes down. It stays down until he becomes happy again. The significance of this has been pointed up by Dr. Harry Goldblatt and Gladys Cameron, of the University of California. Using animals, they have shown that cancerous cells grow better in a milieu in which the supply of oxygen is low.

The validity of linking oxygen supply and cancer recently received strong support from Dr. Otto Warburg, of Berlin, a Nobel Prize winner in medicine. He claims the lack of oxygen respiration in the body cells is a major cause of chronic damage to normal cells and their conversion into cancerous cells. Some doctors believe there are instances in which prolonged stress may have been the direct cause of cancer.

Leukemia is a case in point. "The increased tempo of life in the last forty-five years may have aided in increasing the number of deaths from leukemia,” is the observation of Drs. H. W. Jones and F. R. Miller, of the Jefferson Medical College Hospital, Philadelphia. It has long been known that excessive exposure to physical irritants such as X-rays, radium and benzol can produce leukemia. But the Philadelphia doctors suggest that the same condition is encouraged by chronic exposure to emotional irritants—anxiety, depression and chronic worry. They offer two case histories as typical of a large group of patients with chronic mycloid leukemia who have been under their care:

In the first case, the patient was worried about money all his life. When he was at high school he lay awake wondering how he could stave off the financial disaster that threatened his father. At college, in spite of taking on a number of jobs, he never knew where he would find enough money to meet his bills. In his last year at school he was frequently so upset that he would gag on his food. He fell in love with a girl but had to prolong the engagement for five years until he could support a wife. Finally, after many tribulations and postponements, he married. Eighteen months later he died of leukemia.

The second case concerns a man of fifty-three who also worried all his life. He was a caretaker on an estate and he felt that he wasn’t doing his job well. He went to work on a new estate where the owner committed suicide. This shocked him. He was further depressed and shocked by the death of his father soon afterward. He changed jobs frequently. At one point he spoke of wanting to die because everybody had it in for him. At times, he would walk the streets and go for days without eating or sleeping. He began complaining to his doctor that he had pains in his hips and knees and that his feet tingled. He died two years after the diagnosis of leukemia was made.

Is a Pipe Smoker Calm?

Mental patients with cancer are casting some light on the influence of the emotions on the course of the disease. A prefrontal lobotomy is sometimes performed on psychotic patients. If the result is successful, the patient suffers far less anxiety. Doctors describe cases where the reduction of anxiety was accompanied by a reduction in the size of the tumor. In some cases, the cancers disappear completely but no explanation has been offered.

Various investigators have also noted that as the cancer patient becomes psychotic, the rate of his growth is often slowed down or even arrested. When he starts to recover and reenters the world of reality with all its conflicts and worries, the growth may start again. Significantly perhaps, this does not apply to conditions such as paranoid schizophrenia where the patient thinks he is being persecuted.

Is emotional stress the forgotten factor in the current cigarette smoking lung cancer controversy? Drs. E. Kahn and Dr. E. F. Gildea have noted in the Connecticut State Medical Journal that the cigarette smoker—more than the pipe or cigar smoker—tends to be a tense and nervous individual. He inhales deeply to relieve tension. The relief, however, is only temporary because smoking actually increases nervousness. Dr. Charles Oberling, a leading European cancerologist, has often observed that "nervousness and tension which cause people to smoke also harm the human body.” Some medical men have speculated that the tension that leads to heavy cigarette smoking, and not cigarette smoking itself, is the more important factor in lung cancer.

Since there is a relationship between the emotions and cancer, it has often been suggested that educational programs warning the public about cancer can produce harmful effects. Can a morbid preoccupation with the disease give a person cancer? It has been suggested that this sometimes happens.

But what is much commoner than a morbid fear of cancer is a moderate fear. Doctors report that at one time or another most women suspect that they have cancer. If this suspicion leads to a periodic checkup by a qualified physician, then the net result of educational programs is good. For early detection and treatment are still the best defenses against a malignant growth.

The psychosomatic approach is that the body and the mind cannot be separated; that cancer is less often fatal than it is thought to be; that the body has a built-in defense mechanism that can resist the invading cancer cells; that it would be profitable to give more attention to the promotion of lifelong mental health; and that psychological medicine may be as important as physical medicine to cure the cancer patient or prolong his life.

But medical authorities agree that the link between the emotions and cancer must still be regarded as largely speculative. One Toronto specialist, Dr. Norman C. Delarue, says, in fact: "It is certainly my impression that there is no relationship between the personality and cancer.” Without doubt, no conclusions can yet be reached; no hard and fast rules drawn. The data already gathered are often contradictory. Leukemia, for example, sometimes claims very young children; it is unlikely that prolonged stress could have been a factor in the disease. Furthermore, it is a commonplace observation that the chronic worrier sometimes survives to a ripe old age, then dies of a condition other than cancer.

Years of arduous research in this field lie ahead. For no medical problem is so complex as cancer; and no psychological problem is so delicate as the mysterious relationship that exists between the body and the mind. ★