A 43-Year-Old Woman Coping With Cancer
aainfoaainfoDavid Spiegel, MD, Discussant
DR PARKER: Mrs K is a 43-year-old woman with metastatic breast cancer. Formerly an elementary
school teacher, she now stays home with her husband and 5-year-old son. She has private insurance and
has experienced no restrictions in her complex care.
Her mother died of breast cancer at age 58 years. Therefore, Mrs K started breast self-examinations at
age 20 years and mammograms every 6 months at age 25 years. Due to the birth of her child and breastfeeding, she had an interval of 2 years without a mammogram. During that period in 1995, she detected a
breast lump, which was malignant. She underwent a modified radical mastectomy followed by
cyclophosphamide, methotrexate, and fluorouracil chemotherapy for 6 months. At the time of surgery,
lymph nodes were negative.
In 1996, she felt a lump in her abdomen. A computed tomography scan revealed both lung and liver
metastases. She was treated with a succession of chemotherapeutic drugs, including docetaxel,
vinorelbine tartrate, 5-fluorouracil, Herceptin (anti-Her2 antibody), and, currently, capecitabine, 100 mg
twice per day. The size of the metastases has remained stable and she feels remarkably well. She is
active with her family, exercises regularly, and volunteers as a peer counselor for a cancer support group.
Mrs K's medical history is remarkable for infertility, for which she joined a local "mind-body" program. She
learned the relaxation response and other stress reduction measures and later became pregnant. She
subsequently used these techniques to counter the stress of the cancer diagnosis and participated in the
medical center's cancer support group. She carried these skills forward and became a peer counselor for
others with cancer. She practices qi gong, which also affords relaxation.
Mrs K describes herself as an optimist. Although she cries at times, she does not recall any periods of
depression. She understands that her long-term prognosis is uncertain and specifically does not promise
her son that they will do certain activities in the distant future, such as take a trip to Disney World. Mrs K
is certain that the emotional, psychological, and spiritual aspects of her mind-body and support group
work have contributed to the quality of her life since her cancer diagnosis. She expresses her
appreciation for her physicians' openness to this and hopes that more health care professionals will
become involved with these concepts.
MRS K: HER UNDERSTANDING AND PERCEPTIONS
When I was diagnosed with metastatic breast cancer, it wasn't a shock, but it hit me hard. I felt that I had
been paying a lot of attention to my body and to everything. So, that sent me into a tailspin for a bit. But I
realized that I had 2 choices. Either I deal with it or I don't deal with it. Going through infertility taught me
that I had many choices. I could go through this alone with just my family or with the support of other
components. I had experienced the mind-body connection before, so I immediately decided that was
essential.
Through that experience, I learned the relaxation response and how to use it in almost every situation,
which I do readily now. I also learned that positive attitude can have an incredible effect on what happens
to you as a person—not just outside, but definitely inside. I came to believe that there is a connection
between what goes on in your mind and what goes on physically.
The biggest help that it gave me in dealing with the breast cancer was that I immediately felt I had
something I could rely on. I knew I had relied on it before. I did not think to myself, "If I use the mind-body
connection and the relaxation response, I'm going to cure myself." But it gave me a tool to use to help
whatever was going to take place positively in my body, and maybe it would enhance the drugs that they
were giving me. Maybe it would make me feel more at ease about receiving the chemotherapy or make
the drugs less harsh.
I'm not looking at this as a death sentence. I'm looking at it more as an adventure—it may not be a real
great one filled with a lot of fun—but it definitely is an adventure. What I got out of the cancer support
group was amazement at the amount of strength and sense of power that the people in the group were
getting from each other.
I absolutely believe I will live longer because of the positive stuff that I'm doing—no question in my mind.
It doesn't make sense for it to be any other way. I worked with many people over the years in lots of
different situations. From that experience, I know that feeling good about yourself, being positive about
what is going on with you, and encouraging this sense of being in control of what's happening to you is
important. I think for a cancer patient—especially for a cancer patient—having that feeling is imperative.
DR B: HER UNDERSTANDING AND PERCEPTIONS
Mrs K's work in her mind-body avenues has really made it possible for her to cope with all of the stress of
this disease. I think that patients need every resource to deal with this condition. For many people, finding
a connection to their spiritual side and marshaling their mental energies are important parts of the way
they actively fight their disease.
It's very difficult to know how patients' attitudes about their health affect the course of their disease. Like
everything else in life, you have a choice about how to face this crisis. If you can find a way to do this in a
manner you consider gracious, it's that much easier for everyone else. Whether it affects the outcome of
your disease or it feels different is hard to know.
The concept I have the most difficulty with is the idea that one sometimes sees in the lay literature, that if
only you want badly enough and if only you try hard enough, you can overcome your cancer. Sometimes
that's just not true. The cancer is going to win in the end. And no matter how much you want it, that's the
way it's going to be. To make people feel guilty for not believing enough or not wanting enough, I think, is
terribly unfair.
Mrs K is an amazing person. I think in the end, the real challenge comes when things go badly. When, no
matter how much bravery, no matter how much spirituality, and no matter how much chemotherapy you
have, things don't go the way you want. That's the challenge at the end. But it's not just the end that it's all
about. It's about the whole journey there. For Mrs K, the journey is what she's made it. And the end will be
the end.
AT THE CROSSROADS: QUESTIONS FOR DR SPIEGEL
Do different coping styles affect the progression of chronic and terminal diseases? What data exist to
support or refute this? What nonpharmacological treatment modes exist? How does this affect the quality
of life of the cancer patient? What is the role of complementary medicine? What do you recommend for
this patient?
DR SPIEGEL: Mrs K is a remarkable 43-year-old woman with metastatic breast cancer. Her discussion of
her life illustrates a number of crucial points about helping people cope with life-threatening illness. The
oldest adage of medicine that our job is to "cure rarely, relieve suffering often, and comfort always" is oft
forgotten. At the end of the 20th century, it is as though that adage has been rewritten; that our job has
become to "cure always, relieve suffering if one has the time, and leave the comforting to someone else."
This case is a reminder of the importance of broader dimensions of medical care.
Using the Medical History
Mrs K has dealt extremely well with a tough life. She lost both parents in their 50s—her mother to the
same disease she has, suggesting a possible genetic vulnerability. She struggled with infertility, had a
son, and shortly thereafter was diagnosed as having breast cancer. She has undergone a variety of
treatments and is coping with metastatic disease now. Despite all this, she is an active wife and mother,
nurturing her son, helping at his school, and providing peer counseling for other cancer survivors. She is
assiduous in seeking the best medical treatment, exercises regularly, and engages in a variety of
approaches designed to help herself feel more in control, supported, and calm. She views her cancer as
an "adventure," rather than a "death sentence." She is an active coper, figuring out what she can do
about whatever challenge faces her. Coping with cancer involves managing a welter of information about
the disease and its courses, receiving a variety of treatments, many of which have serious adverse
effects, and balancing other aspects of life.1, 2 Doing this effectively entails navigating between the Scylla
of being so overwhelmed by threat that one feels helpless and the Charybdis of denial that the threat
exists. Getting that balance right is a constantly shifting and demanding process. It involves accepting
temporary crisis situations and using the disruption to formulate new plans of action. Caplan 3 pointed out
that the pattern of response established during an acute crisis was likely to become cemented in place,
regardless of its relative effectiveness. Thus, a little cogent support at the right time can go a long way. In
the Chinese language, the character for crisis is composed of 2 words, one meaning "danger" and the
other "opportunity." Effective coping involves processing the emotional reaction to the danger and seeking
a response that at least mitigates it (Table 1).
Mrs K does not retreat, avoid, or deny, which are common responses to cancer. 4 Helplessness comes not
just from being confronted with an overwhelming problem but from not being able to formulate a plan
about what to do in the face of it. One feels quite different about a threat when a plan of action is in place
to cope with it. The top 3 priorities of 96% of patients in 1 study included family members, emotional
stress, and acquiring further information.5, 6 Consistent with these common concerns, the process of
coping has been classified as information-focused, emotion-focused, and problem-focused.7 Informationfocused coping involves learning more about the threat and avenues of dealing with it; for example, by
asking questions of physicians, mining the Internet, or talking with friends and family. Emotion-focused
coping includes facing and working through feelings aroused by the situation. This can require a painful
process of coming to terms with and accepting unpleasant and threatening information. Problem-focused
coping is composed of formulating plans for responding to portions of the threat. This latter component of
coping is more active and tends to counter the helplessness often experienced by physically ill patients.
Coping patterns, including attitudes toward illness, have proven to be relatively stable predictors of longterm adjustment. Carver et al8 studied 59 stage I and II breast cancer patients and found that a general
attitude of optimism at the time of diagnosis, before surgery, was predictive of better 3-, 6-, and 12-month
subjective well-being, measured by scores on the Profile of Mood States and measures of life
satisfaction, sexual fulfillment, thought intrusion, and pain. Optimism accounted for between one quarter
and one third of the variance in these psychological mood disturbance outcomes. An attitude of
acceptance and the use of humor predicted less distress, while denial and disengagement predicted
more distress. Realistic optimism, however, is not the same as blind hope. The differences in coping
styles are well summarized by Carver et al: "In particular, optimistic women appear to accept more readily
the reality of the challenge they face, whereas pessimistic women try to push this reality away.
Acceptance was tied to positive mood changes, and denial was tied to adverse changes. In considering
this pattern, we have suggested that acceptance is important, in part, because it keeps the patients
engaged in the active pursuit of the goals that define their lives." 9(p1219)
Patients at higher risk for poor coping include those who are socially isolated, have a history of recent
losses and/or multiple obligations, or use inflexible coping10 or fewer coping strategies.11 Thus, there is
evidence from many studies that cancer patients who learn to use more direct and confrontational coping
strategies are less distressed than those who use avoidance and denial (Table 2).4, 8, 12
Positive Aspects of a Positive Attitude
Mrs K personifies realistic optimism. I advise my cancer patients to face the worst but hope for the best.
Interestingly, facing a serious threat directly does not merely involve having a negative point of view:
intense stress can be associated with intensely positive as well as negative emotions. 13 Facing the worst
and tackling it head-on is not an admission of defeat or a sign that the patient is giving up. Rather, it
conveys determination to deal with whatever comes along, a state of mind that has been referred to as
fighting spirit,14 as seen in Mrs K. This attitude was associated with significantly lower rates of relapse in a
study of 69 women with primary breast cancer compared with those who felt stoic or helpless. 15 It should,
however, be noted that in this study, denial was also associated with better medical outcome. What
constitutes a truly positive attitude for a cancer patient is a complex problem. Being positive all the time
can verge on denial. This can inhibit obtaining necessary medical information and treatment. It can also
discourage family and friends from expressing appropriate emotions of sadness and fear. One of my
patients told her support group that when she started to cry in front of her husband about the progression
of her inflammatory breast cancer, he said, "Don't cry, you'll make the cancer spread." Another member of
the support group referred to this as the "prison of positive thinking." I see many cancer patients and
family members who are afraid that giving vent to these negative feelings will somehow unleash the
cancer itself, as though the uncontrolled feeling is the same as the uncontrolled disease. Yet, many
cancer patients are desperate to do anything they can to control the illness and are willing to exist in an
emotional straitjacket if they believe it will somehow improve their odds of survival.
Another downside of the positive attitude often recommended for cancer patients is that if the cancer
does progress, this provides fertile ground for inappropriate guilt, in which case the patient might think "If I
can control the spread of disease through my attitude, and the disease has progressed, then there must
be something wrong with my attitude."
There is simply no evidence that a positive attitude per se has any effect on the course of cancer. A longterm follow-up study on the work of 1 major exponent of the mind over matter approach 16 demonstrated
that breast cancer patients who participated in a program designed, among other things, to root out their
psychological "need" for cancer showed absolutely no difference in long-term survival compared with a
matched sample given routine care.17
The expression of emotions is important in reducing social isolation and improving coping, yet it is often
an aspect of cancer patient adjustment that is overlooked or suppressed. Emotional suppression and
avoidance are associated with poorer coping.14, 18 Indeed, those breast cancer patients who try to
suppress negative emotions are actually more depressed despite those efforts than those who give vent
more freely to their distress.1 At the same time, much can be done in both group and individual
psychotherapy to facilitate the expression of emotion appropriate to the disease. Doing so seems to
reduce the repressive coping strategy that decreases expression of all emotion. Emotional suppression
also reduces intimacy in families, limiting opportunities for direct expression of affection and concern.
Psychotherapeutic Intervention
Evidence suggests that those who are able to ventilate strong feelings directly cope better with cancer. 1921 More surprisingly, several psychotherapeutic approaches that involve directly confronting the threat of
cancer emotionally have been associated in some studies with longer survival time. 22-24 Our approach to
helping cancer patients is called supportive/expressive group psychotherapy because we emphasize the
development of intense bonds of support among group members and expression of emotions salient to
their illness. Mrs K's continued connection to the members of her infertility group and her current peer
counseling role in the cancer support group reflect this phenomenon. We found, to our initial surprise, that
women randomly assigned to a year of such weekly support not only felt less anxious and depressed 25
and had less pain26 but lived an average of 18 months longer.22 Differences in disease course were
independent of any differences in medical treatment received.27
Two other randomized trials have demonstrated a psychosocial treatment effect on survival time among
cancer patients. Richardson et al24 used a 4-cell design among patients with lymphomas and leukemias.
Patients were assigned to either a routine care condition or 1 of 3 educational and home-visiting
supportive interventions. The intervention groups had significantly longer survival time than the control
group (relative risk of death=0.39). The survival differences persisted even after adjusting for differences
in medication adherence.
Fawzy and colleagues28 published psychosocial, immunological, recurrence, and survival results of a
randomized trial involving 80 patients with malignant melanoma. Half were assigned to routine care and
the other half to a structured series of 12 support groups. These weekly meetings were designed to help
patients cope better with the illness and its effects on their families. In the first report, they found
significant reductions in mood disturbance on the Profile of Mood States and the use of more active
coping strategies in the intervention sample. In a companion report,29 they observed significant
differences in immune function at 3-month follow-up but not earlier, with an increase in natural killer
cytotoxicity and an increase in LEU56 cells in the intervention sample. A 6-year follow-up report23
demonstrated significantly lower rates of mortality among intervention patients (3 vs 10 deaths),
consistent with the findings among breast cancer patients in our laboratory.
Three other randomized trials, however, found no survival benefit to psychotherapy for cancer patients.
Linn et al30 offered individual psychotherapy to a group of patients with a variety of cancers, including
those of the lung and pancreas, in a randomized protocol, and found no difference in survival time. It may
be that since virtually all of the patients died during the follow-up year, their disease was too advanced to
be significantly influenced by psychotherapeutic support. Similarly, Ilnyckyj et al31 and Cunningham et al32
found no survival advantage for breast cancer patients randomly assigned to 1 of several group
psychotherapies. Neither of these trials demonstrated any psychological benefit and, therefore, the
relative inefficacy of the psychosocial interventions may account for the lack of medical effect. The
sample size in the study by Cunningham et al may have been too small to detect modest but important
differences. Alternatively, the results in other trials could have been positive by chance. Two major
randomized trials are currently addressing the question of whether intensive psychosocial support can
influence cancer progression,33-35 and results are expected within the next year.
Discussion of possible physiological mechanisms underlying psychosocial intervention effects on disease
progression is beyond the scope of this article. However, a finite number of brain-body systems could
mediate these effects, including endocrine, neuroimmune, autonomic nervous, and neurobehavioral
systems. Each system is affected by stress and is influenced by the social environment. 36-39 Further
exploration of the effects of psychosocial intervention on disease progression is an exciting area for future
research in mind-body medicine.
Social Support
Mrs K has good social support and has worked to improve it. She describes her husband as a "rock" who
has helped her steer the course and discourages her from worrying: "He'll say don't worry about it—we've
got to wait to talk to the doctor." In my experience of working with husbands of breast cancer patients,
flexibility in roles and the handling of emotions is important. Sometimes reassurance works, but
sometimes acknowledging and sharing the anxiety helps more. One husband mentioned a time his wife,
a hard-driving corporate executive, dissolved into tears because she felt too weak after chemotherapy to
get up off the living room floor. "Everything I said just made her feel worse. I didn't know what to do, so I
just got down on the floor and cried with her. I thought I was a complete failure because I couldn't make
her feel better. But actually, that was what did make her feel better—when I stopped trying to fix it."
Open family exploration of fears and concerns actually helps patients cope better. 40 Having an
opportunity to ventilate anxiety, anticipate and plan for future problems, and feel understood and cared for
at times of stress reduces distress. In addition, such support seems to be good for body as well as soul.
Recent research provides growing evidence for a positive effect of social relationships on health. 41
Decreased survival has been found to be associated with low quantity or quality of social relationships in
several prospective studies.42-47 Even after adjusting for high-risk behavior, such as smoking and
alcoholism, the magnitude of the relationship between social isolation and mortality is as great as that
between serum cholesterol levels or smoking and mortality.41, 48-50 Higher mortality rates are often
reported during the first year after the loss of a spouse, and married cancer patients survive longer than
unmarried persons.44 The clinical salience of this general observation in the population is underscored by
evidence that marital status is a strong predictor of outcome among cancer patients. 44, 51, 52 Reynolds and
Kaplan51 examined data on 6928 adults and found that women who were socially isolated were at
substantially increased risk for dying of cancer. Those who had few social contacts and felt isolated had
an almost 2-fold increase in incidence and a 5-fold increase in relative risk for mortality due to hormonerelated cancers.
Ell and colleagues53 found that emotional support had a protective influence in regard to survival for
patients with earlier stages of breast, colorectal, or lung cancer. Hislop et al54 and Waxler-Morrison and
colleagues55 studied 133 patients with primary intraductal breast cancer and found that 6 of 11 measures
of social relationships were significantly associated with longer survival: marital status; support from
friends; contact with friends; total support from friends, relatives, and neighbors; employment status; and
social network size. In particular, expressive social activities and social support, not merely extroversion,
were related to longer survival time. Maunsell and colleagues 56 studied 224 women with newly diagnosed
breast cancer and found that married women had a relative death rate of 0.86 compared with unmarried
women over a 7-year follow-up. Women who had confidants in the few months after surgery had a
relative death rate of 0.55, and it was even lower among those who confided in more than 1 person.
Thus, the availability of social support proved to be a robust predictor of subsequent mortality. These data
confirm observations that emotional expression is associated with better medical outcome. 15, 21, 56-59
The reasons for the positive relationship between social support and cancer survival 60 are still unclear
and require further study.61 Despite the limited number of intriguing intervention trials described herein,
more evidence is needed about whether enhancing social support improves survival time as well as
quality of life.
Complimenting Complementary Treatments
Mrs K has fully used a variety of treatments often classified as complementary or alternative, including qi
gong, relaxation training, and group support. It is important that physicians see their patients' use of
complementary treatments as both a compliment and a complement, not a challenge. Some 42% of
Americans use some form of alternative treatment,62 up from one third in 1990,63 but more than two thirds
of them use standard medical treatment as well, suggesting that in the patient's mind these interventions
were complementary, rather than alternative. However, three quarters of these individuals did not tell their
primary care physicians that they were obtaining these alternative or complementary services.
Mrs K did not consider the use of qi gong, group support, or relaxation training exercises to be an
alternative to the aggressive medical treatment she was receiving but, rather, a means of enhancing her
control at the margins of disease—reducing symptoms, increasing her sense of mastery over the tension
that naturally accompanies serious illness, and developing a network of support. Furthermore, her
experience with her infertility support group helped her believe that such approaches may make a
physical as well as a psychological difference, whether or not the group had a direct causal effect on
infertility.
The growth in interest in complementary and alternative medicine at a time when medical science and
knowledge have given us cures or effective treatments for many diseases seems paradoxical. However,
more people are now living with chronic disease rather than dying of acute disease. The leading killers of
Americans—heart disease, stroke, and cancer—are by and large chronic and progressive rather than
curable illnesses.
Relying on a curative model when disease management is the norm leaves both doctors and patients
dissatisfied and disappointed. Burnout is lowest among those oncologists with the best communication
skills,64 suggesting that these physicians, who often deal with inability to cure, find other ways to
effectively understand and address their patients' needs and concerns. Palliative care physicians show
relatively low levels of job stress, in part because their well-defined goal is care rather than cure.65 They
have reduced stress in a difficult situation by changing goals.
The modern model of medical intervention may pay lip service to the integration of mind and body, but in
Western medicine we are primarily closet cartesians. Emphasis is placed on somatic intervention with
curative intent, while talking, comforting, guiding, and educating patients is viewed as less important. An
illness can be a lonely journey, and patients crave people who understand what the journey is like and
who can stay with them during its course. The process of communicating even dire information can be as
important as the content. The doctor usually knows more about the patient's disease trajectory than
anyone else. If the patient is treated in a dismissive or impersonal manner, this can convey the message
that nothing of value is left in the patient's life or that the patient has failed the doctor by getting sicker.
Conversely, patients are deeply grateful for direct, caring attention from doctors and other health care
personnel. One breast cancer patient put it this way: "Tell me anything you have to tell me. Just hold my
hand and look me in the eyes when you do it." Thus, the apparent appetite for complementary and
alternative medicine may stem from a need for attention and compassion that many patients feel they are
not receiving from modern biotechnological medical care, with its burden of paperwork and authorization
phone calls. Overwork, either imposed or self-inflicted, as well as not understanding that carefully
structured compassion can go a long way, desiccates medical practice (Table 3).
Mrs K also views the complementary techniques as a means of enhancing her control over anxiety, and
she now regularly practices these techniques. A variety of well-established and thoroughly studied
methods are available for teaching patients how to increase their control over mental distress and
concomitant somatic discomfort. Hypnosis, for example, is a state of aroused, attentive focal
concentration that has proven effectiveness in facilitating anxiety control and analgesia. 26, 66, 67 The ability
of hypnotizable individuals to dissociate, or separate psychological from somatic response, can be used
to maintain physical relaxation, even in the face of emotional distress. 68 Other techniques involving
breathing exercises, self-monitoring and regulation,69 and meditation techniques70 have proven quite
effective in reducing anxiety. One intriguing recent study demonstrated significantly faster healing of
psoriatic skin lesions when medical treatment was randomly combined with meditation. 71 Even if relief of
symptoms is a small but real effect, when the big picture is overwhelming, small amounts of mental and/or
physical control can go a long way toward reassuring patients that they can manage the course of their
life with disease. The term disease comes from roots that mean dis-ease. The distress and discomfort
that accompany medical illness should always be taken into account in designing its treatment. Anything
physicians can do to enhance a patient's sense of being cared about and increase his or her sense of
control over those aspects of the disease that are manageable will put the heal back in health care.
QUESTIONS AND DISCUSSION
MRS K: Thank you, Dr Spiegel. I think what you had to say was absolutely wonderful. I'm curious to
know, for patients who are living longer because of participating in support groups, if there is a difference
given the composition of the support group? You mentioned that women tend to do better when they are
with a group of women. My first experience with the infertility group was with women, but the cancer
group was mixed. Do you have any thoughts about the effect of group makeup?
DR SPIEGEL: You're suggesting an interesting line of research. Now that we think support groups have
some effect, the next logical question is what matters and what doesn't? We are trying to analyze the
components of our groups to better understand which ones make the difference. What I have seen so far
suggests that the groups that deal more directly with hard emotional issues seem to be more effective. I
think commonality of situation is also important. It is harder to run a group, for example, with people with
primary and recurrent disease. The clinician has to be certain that everyone feels they have equal time
and that the more advanced patients do not trump the problems of the other patients. The discipline of
dealing with the hard issues is important. I do not yet have the data to support it, but my clinical
impression is that the groups that go the deepest on the emotional issues do the best.
A PHYSICIAN: What is the mechanism by which emotional support translates into bodily robustness? Is it
the secondary infections? Is it metastases? Where does this really bite down on the cancer, or does it?
DR SPIEGEL: We are not sure. We looked at causes of death in the treatment and control samples and
didn't see any overall difference, although this was based on the scanty information from death
certificates. It may involve the hypothalamic-pituitary-adrenal axis or the immune system. But cancer is a
very puzzling illness. We have some patients who had brain metastases 8 years ago and are fine now.
Why is that? Nobody knows. One of the great mysteries of chemotherapy is that sometimes, you can
make tumors melt away and have very little effect on survival time. The link between somatic resistance
and disease progression, even from a purely oncological point of view, is still very hard to tease apart.
A PSYCHIATRIST: Cancer in a parent has profound effects on children. Have you developed a
component of your intervention program for the children of cancer patients?
DR SPIEGEL: We have monthly family support groups, in which we primarily have spouses. But we have
also invited late adolescent and young adult children to participate, and it has been beneficial for them.
They can discuss some issues in these groups that are hard to say within their own families.
A PSYCHIATRIST: Aside from the role of genetics, what about issues of loss early in life and changes in
the immune system with low-level chronic depression, which might increase vulnerability to getting cancer
in the first place? Do you think this occurs?
DR SPIEGEL: It makes sense to the extent that there is a delicate balance going on in the body, affected
by psychosocial factors. You have the tumor and host resistance, and brain mind-body control systems
that regulate host resistance. It remains uncertain what happens at the cellular level at the cancer's onset.
It used to be thought that depression-cancer link was dead, but a recent study72 showed a link between
depression and more rapid cancer progression.
Author/Article Information
Author Affiliation: Dr Spiegel is Professor and Associate Chair, Psychiatry and Behavioral Sciences,
Stanford University School of Medicine, Stanford, Calif.
Reprints: Erin E. Hartman, MS, Division of General Medicine, Beth Israel Deaconess Medical Center,
330 Brookline Ave, LY318, Boston, MA 02215.
This conference took place at the Combined Longwood Psychiatry Grand Rounds of the Massachusetts
Mental Health Center, the Beth Israel Deaconess Medical Center, and the Brigham and Women's
Hospital, Boston, Mass, and was held at Beth Israel Deaconess Medical Center on February 16, 1999.
Editor's note: Mrs K died in May 1999.
Funding/Support: Clinical Crossroads is made possible by a grant from the Robert Wood Johnson
Foundation.
Acknowledgment: We thank the patient, her family, and her doctor for sharing their stories in person and
in print.
Clinical Crossroads at Beth Israel Deaconess Medical Center is produced and edited by Thomas L.
Delbanco, MD, Jennifer Daley, MD, and Richard A. Parker, MD; Erin E. Hartman, MS, is managing editor.
Clinical Crossroads section editor: Margaret A. Winker, MD, Deputy Editor, JAMA.
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