McCain is a fighter, no ques­tion. But can at­ti­tude af­fect can­cer?

Doc­tor and can­cer survivor ex­plains the re­search

The Washington Post Sunday - - OUTLOOK - Schat­tner Elaine

Mil­i­tary metaphors are com­mon­place when peo­ple talk about can­cer — or should we say the “fight against can­cer.” Since John McCain an­nounced his brain can­cer di­ag­no­sis, the se­nior sen­a­tor from Ari­zona has re­ceived a bar­rage of sup­port­ive state­ments fea­tur­ing mar­tial lan­guage. Politi­cians and other well-wish­ers have ex­plic­itly con­nected his war hero rep­u­ta­tion with a fa­vor­able out­come. “Can­cer doesn’t know what it’s up against,” for­mer pres­i­dent Barack Obama tweeted. Vice Pres­i­dent Pence wrote: “John McCain is a fighter & he’ll win this fight too.”

McCain’s daugh­ter Meghan posted a trib­ute on In­sta­gram, say­ing: “Can­cer may af­flict him in many ways: But it will not make him sur­ren­der. Noth­ing ever has.”

On tele­vi­sion, news­cast­ers dis­cussing McCain’s di­ag­no­sis talked up his tough­ness, too. “There is no­body who is the kind of fighter that John McCain is,” said CNN’s Dana Bash. “. . . He has a fighter pi­lot’s men­tal­ity.”

There’s no deny­ing McCain’s for­ti­tude. It was on full dis­play this past week, when he bucked his party to block the re­peal of the Af­ford­able Care Act. But can per­son­al­ity traits

al­ter the course of can­cer, as his well-wish­ers seem to want to be­lieve? Can a pos­i­tive men­tal stance tame an ag­gres­sive ma­lig­nancy such as glioblas­toma?

As a doc­tor and can­cer survivor, I know there is no ev­i­dence to sup­port the idea that per­son­al­ity can in­flu­ence the growth of ma­lig­nant cells. There is no can­cer for which at­ti­tude can halt the pro­gres­sion of dis­ease. And, de­spite med­i­cal progress against other tu­mors, glioblas­toma re­mains lethal. Even with treat­ment, pa­tients have a slim chance of liv­ing long with this con­di­tion; the five-year sur­vival rate is just over 5 per­cent. Both Sen. Ted Kennedy (DMass.) and for­mer vice pres­i­dent Joe Bi­den’s son Beau died within two years of di­ag­no­sis.

Still, the words of sup­port for McCain shouldn’t be writ­ten off as empty plat­i­tudes — phrases that be­long on My­lar bal­loons, as the At­lantic’s James Ham­blin sug­gested. Lan­guage can be a pow­er­ful tool in medicine. As with phys­i­cal reme­dies, there are po­ten­tial harms and risks to con­sider, but po­ten­tial up­sides, too.

The ques­tion­able re­la­tion­ship be­tween can­cer and psy­cho­log­i­cal traits has per­co­lated through sci­en­tific and pop­u­lar literature for decades.

In her land­mark 1978 es­say, “Ill­ness as Metaphor,” Su­san Son­tag railed against the view, pop­u­lar­ized by psy­cho­an­a­lyst Wil­helm Re­ich, that can­cer is “a dis­ease fol­low­ing emo­tional res­ig­na­tion — a bio-en­er­getic shrink­ing, a giv­ing up of hope.” Son­tag wrote: “Widely be­lieved psy­cho­log­i­cal the­o­ries of dis­ease as­sign to the luck­less ill the ul­ti­mate re­spon­si­bil­ity both for fall­ing ill and for get­ting well. And con­ven­tions of treat­ing can­cer as no mere dis­ease but a de­monic en­emy make can­cer not just a lethal dis­ease but a shame­ful one.” She re­jected these no­tions.

Mod­ern re­searchers have de­bunked the idea that neg­a­tive emo­tions heighten an in­di­vid­ual’s sus­cep­ti­bil­ity to de­vel­op­ing can­cer, or that main­tain­ing a pos­i­tive out­look can stave off can­cer’s re­turn or de­lay its pro­gres­sion. As Jim­mie Hol­land, a psy­chi­a­trist at New York’s Memo­rial Sloan Ket­ter­ing Can­cer Cen­ter, has said, “The idea that we can con­trol ill­ness and death with our minds ap­peals to our deep­est yearn­ings, but it just isn’t so.”

In 2007, the Ra­di­a­tion Ther­apy On­col­ogy Group con­fronted the be­lief that psy­chol­ogy af­fects can­cer pa­tients’ sur­vival. This well-es­tab­lished clin­i­cal-tri­als or­ga­ni­za­tion stud­ied more than 1,000 pa­tients with head and neck can­cers. Af­ter con­trol­ling for tu­mor stage and de­mo­graphic fac­tors, such as in­come, the re­searchers found no re­la­tion­ship what­so­ever be­tween pa­tients’ out­comes and their emo­tional well-be­ing.

An­other in­for­ma­tive, large study drew on per­son­al­ity ques­tion­naires com­pleted by nearly 60,000 Swedish and Fin­nish peo­ple. Years later, in­ves­ti­ga­tors iden­ti­fied 4,631 can­cer cases among the par­tic­i­pants. In 2010, they re­ported that nei­ther “ex­traver­sion” nor “neu­roti­cism” in­creased the like­li­hood of a can­cer di­ag­no­sis or sur­vival af­ter a can­cer di­ag­no­sis.

Al­though a hand­ful of stud­ies have found that women who are anx­ious or de­pressed are more likely to suf­fer re­cur­rences of breast can­cer and die from the con­di­tion, it’s plainly true, and un­der­stand­able, that dy­ing women are more likely to be anx­ious and de­pressed. These analy­ses are con­founded by the fact that at­ti­tudes in­flu­ence pa­tients’ treat­ment de­ci­sions: their will­ing­ness to par­tic­i­pate in clin­i­cal tri­als, try new drugs, seek sec­ond opin­ions and travel for their care.

What’s more, so­cial de­ter­mi­nants of health — education and eco­nomic cir­cum­stances — can mask what might be con­strued as grit or a fight­ing spirit. Many peo­ple can­not af­ford to try new can­cer med­i­ca­tions or seek mul­ti­ple opin­ions. In some dis­ad­van­taged com­mu­ni­ties, fa­tal­ism about can­cer af­fects whether pa­tients get screened, go for check­ups upon notic­ing wor­ri­some symp­toms or, even af­ter a di­ag­no­sis, ac­cept care pro­vided by on­col­o­gists.

Mean­while, some doc­tors and ad­vo­cacy groups worry about the po­ten­tial harms of ap­ply­ing bat­tle lan­guage to the ex­pe­ri­ence of hav­ing can­cer. Pa­tients may feel they are to blame if they fail to “beat” the tu­mor. They may think that their re­cur­rence, or im­pend­ing death, is not due to the na­ture of their ma­lig­nancy but a fail­ure of will.

An added con­cern is that mil­i­tary lan­guage and tales of courage can dis­cour­age ac­cep­tance of pal­lia­tive care. Pa­tients may be­come trapped by a pos­i­tive men­tal­ity — pres­sured by fam­ily and friends who en­cour­age them to keep try­ing more treat­ments, or com­pelled by an in­ter­nal drive to fight to the end — and they may push them­selves be­yond what’s sen­si­ble or real­is­tic.

Yet I re­call some of my pa­tients who liked to say they were “fight­ing” can­cer. So did my fa­ther, who lived with lym­phoma for three decades be­fore dy­ing at age 83 from a pan­cre­atic tu­mor. When I re­ceived my own breast can­cer di­ag­no­sis, in 2002, I didn’t think of it in terms of bat­tle lan­guage. I’m not a mil­i­tary-ori­ented per­son; al­though I aspire to men­tal for­ti­tude, fight­ing words don’t suit me. How­ever, I ac­cept that just as some peo­ple de­rive strength and com­fort in prayer and oth­ers don’t, pa­tients’ re­sponses to words, im­ages and sto­ries about can­cer do vary.

Re­cent re­search sug­gests that par­tic­i­pat­ing in sup­port groups can re­duce can­cer pa­tients’ anx­i­ety, fa­tigue and de­pres­sion. We can’t dis­miss the pos­si­bil­ity that em­brac­ing an op­ti­mistic at­ti­tude to­ward can­cer may help some in­di­vid­u­als to feel hap­pier and en­joy a bet­ter qual­ity of life even while bad cells grow and spread.

McCain may be one of those peo­ple. He dis­played a bat­tling mind-set this past week, telling his Se­nate col­leagues that, af­ter treat­ment, “I have ev­ery in­ten­tion of re­turn­ing here and giv­ing many of you cause to re­gret all the nice things you said about me.”

McCain’s di­ag­no­sis serves as a re­minder that can­cer does not dis­crim­i­nate; ev­ery­one is vul­ner­a­ble. But he also has the po­ten­tial to in­spire and im­prove the lives of other can­cer pa­tients.

When I heard about his di­ag­no­sis, I thought of the por­trait of McCain that David Foster Wal­lace wrote for Rolling Stone in 2000. The de­scrip­tion of the sen­a­tor as a young Navy pi­lot is es­pe­cially mem­o­rable. As Wal­lace tells it, in Oc­to­ber 1967, McCain was fly­ing a bomb­ing mis­sion over Hanoi when his plane was hit by en­emy fire. He ejected from the craft, break­ing his arms and a leg be­fore land­ing in a lake. “The crowd pulled him out and then just about killed him,” Wal­lace wrote. “. . . McCain got bay­o­neted in the groin; a solider broke his shoul­der apart with a ri­fle butt.” When he ar­rived at the in­fa­mous Hoa Lo prison, “they made him beg a week for a doc­tor and fi­nally set a cou­ple of the frac­tures with­out anes­thetic.”

Months later, McCain was of­fered the chance to leave. Ev­i­dently the North Vietnamese sought to ap­pease his fa­ther, Adm. John S. McCain Jr., who’d been pro­moted to lead Pa­cific naval forces. John S. McCain III, “100 pounds and barely able to stand, re­fused,” Wal­lace wrote. He didn’t want to vi­o­late the code that pris­on­ers who had been de­tained longer should be re­leased first. And so he spent much of the next four years alone in a small, dark “pun­ish­ment cell.”

Just as his brav­ery 50 years ago can in­spire peo­ple who have never fallen from a plane into a hos­tile crowd, been im­pris­oned or ex­pe­ri­enced tor­ture, McCain might now set an ex­am­ple for oth­ers, in­clud­ing pa­tients who are less strong, less for­tu­nate and with fewer re­sources, as he moves for­ward and chooses his treat­ment.

Per­haps he’ll find a way to avoid en­trap­ment by the tyranny of pos­i­tive think­ing. It takes a cer­tain strength, and maybe even fierce­ness, to se­lect a plan of care that doesn’t nec­es­sar­ily match the ex­pec­ta­tions of fam­ily, doc­tors and the pub­lic. He might opt for ag­gres­sive glioblas­toma treat­ment. He might be brave enough to choose a pal­lia­tive care plan, with or with­out po­ten­tially cu­ra­tive ther­apy. For sure, McCain will find sup­port among Amer­i­cans, who ad­mire him for his years of ser­vice and his courage.


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