Wednesday, March 08, 2017

Evidence Of A Correlation Between Depression and Anxiety and Cancer Mortality

     On January 25, 2017, The BMJ, a respected British scientific journal, published the results of a research study in which the unpublished data from 16 prospective cohort studies initiated between 1994 and 2008 were pooled to examine the role of psychological distress (anxiety and depression) as a potential predictor of site specific cancer mortality. The participants in this research, 163,363 men and women, 16 years of age or older at the time of study induction, make up nationally representative samples drawn from health surveys for England and Scotland. Participants were initially free of a cancer diagnosis, and were asked to fill out questionnaires with items that were designed to capture symptoms of depression and anxiety over the previous four weeks. According to the study's authors, these questionnaires are widely used in population research and have been validated against standardized psychiatric interviews.

     The results of this pooling of unpublished data are interesting. They showed that those with the most psychological distress (depression and anxiety), had a higher rate of death from selected cancers than those with the lowest psychological distress. This was after adjusting for other known risk factors such as adverse health behaviors and reverse causality (it is well known that a diagnosis of cancer can give rise to psychological distress so these authors attempted to control for this by excluding participants with self reported cancer malignancy at study entry). The most consistently robust effects were evident for cancer of the colorectum, prostate, pancreas, esophagus and for leukemia.

     These authors state that their findings could be important in advancing understanding of the role of psychological distress in cancer etiology and cancer progression. They go on to explain that psychological distress could be considered along with other factors such as smoking and obesity to develop an algorithm that would have predictive utility for common cancer presentations such as colorectal, breast and prostate cancer.

     Among the limitations of this study cited by the authors is that the assessment of psychological distress with the instrument that they used, referred to the preceding four week period. A short bout of depression or anxiety is highly unlikely to be relevant to cancer etiology, but the authors state that there is evidence that rates of recurrence are high for psychological distress. Therefore they state that a single administration of a distress inventory seems to capture cases of long term depression and anxiety. Nevertheless, if serial assessments of depression and anxiety had been done over a period of time, that would lend more credence to the findings.

     The results of this study suggest associations between depression and anxiety and cancer mortality, and lend support to the idea that psychological distress could have some predictive capacity for the occurrence and lethality of some types of cancer. It is important to note that further research is required to clarify the extent to which each of the associations between psychological distress and cancer are likely to be causal and to examining the precise mechanisms by which they exert their influence. We would need to investigate exactly how depression and anxiety affect cancer. For example, how much of any effect that we see is related to poor lifestyle choices that a depressed person might make, such as compliance with treatment screenings or treatment regimens. Alternatively, we need to learn how much of the impact of psychological distress is associated with biological mechanisms, such as prolonged inflammatory responses.



Friday, March 20, 2015

Using Viruses to Cure Cancer - Getting The Word Out

On March 6th, just two weeks ago, an HBO television program called Vice aired a documentary about how viruses, some of which used to kill human beings in large numbers, are now being utilized to treat and actually cure cancer.  Major cancer research centers such as The Mayo Clinic in Minnesota, MD Anderson Cancer Center in Houston, Texas and The University of Pennsylvania in Philadelphia, are conducting groundbreaking trials with cancer patients using genetically modified viruses such as the common cold virus, the measles virus and the HIV virus. According to the physicians involved in these trials, we are on the verge of a major breakthrough in cancer treatment. As the maker of this documentary states, it is important to get the word out about this so that these technologies can be fast tracked and be made available to anyone who needs them.

Dr. John Bell at the Center for Innovative Cancer Research in Ottawa, Canada, is credited with being the first to discover that viruses can actually attack cancer cells without harming the healthy cells around them.  One of the most successful series of ongoing trials has been happening at The Children's Hospital of Philadelphia under the auspices of Dr. Carl June. Dr. June and his colleagues have for about the last four years, been using the HIV virus to treat leukemia in children whose cancer had progressed to the point where other standard cancer therapies were no longer of any use. In these trials, genetically engineered HIV is being used to reprogram the t-cells in the patients' bodies, so that the patients' immune systems can tell the difference between the cancer cells and normals cells, and begin to attack the cancer cells. In this documentary, Dr. June informs us that so far, thirty-nine children have participated, and ninety percent have experienced complete remission with no remaining trace of their cancer. Most seem to be staying in remission for several years. He goes on to tell us that this particular treatment is "probably going to be available and FDA approved in 2016", and that using modified viruses to treat cancer represents "a true paradigm shift".

There are about 300 kinds of cancer. Which viruses attack which cancers most effectively? There is still a lot of research that needs to happen to answer this question. At the Mayo Clinic, they are reengineering the measles virus, and then using it to treat bone cancers.  At MD Anderson, they are treating glioblastomas or brain cancers with a modified common cold virus and patients who had no hope are going into remission.

View the entire VICE documentary here:



Friday, March 13, 2015

Treating Posttraumatic Stress in BRCA Survivors

In an earlier post, I described how breast cancer survivors are often the victims of posttraumatic stress, and frequently display many of the signs and symptoms that are associated with that psychological diagnosis. Things like heightened anxiety, hypervigilance, a change in outlook on life, negative beliefs and expectations about herself or her body, and a change in risk-taking behaviors may be present not just during treatment, but also after treatment has ended.

Now I am going to describe how psychodynamic psychotherapy can help with the disturbing PTSD symptoms that survivors may be experiencing. In addition to discussing problematic symptoms and how the survivor is coping with them, the psychotherapist will work on understanding and appreciating the significance to the client of not only having had breast cancer, but also of each of the treatment interventions to which she was exposed. Today's mainstream cancer treatments, i.e. surgery, radiation, and chemotherapy all act as powerful triggers of complex emotions and earlier traumatic experiences. It is crucial to understand how each breast cancer patient mentally engaged with each of them. Every woman’s breast cancer journey is unique, and is a function of not just her encounters with her medical providers, medical interventions and our health care system, but also of her earlier life experiences. How we engage with the present is always influenced by what we experienced in the past.

It is vital that the psychotherapist assist the client in uncovering and comprehending the psychological meaning to her of what she has been through. For example, what did each treatment modality symbolize to this particular client? Did the chemotherapy represent something positive that was going to destroy cancer cells and restore health, or did it feel like an evil intruder that was wreaking havoc throughout her body? Did the accompanying loss of hair, a well-known side-effect of chemotherapy cause the patient to feel less attractive to her spouse or to potential romantic/sexual partners? Was it experienced as the destruction of an important symbol of femininity? Did it feel like a potent connection to an early attachment figure was destroyed?  Perhaps an early caregiver who expressed love by fixing and combing her hair? Did it have both of these meanings as well as others?

How did all of the physiological and cognitive effects of the treatments (fatigue, nausea, memory loss, loss of mental sharpness etc.) affect things like self-esteem, perception of a benign world, sense of bodily vulnerability, or the person’s sense of their future possibilities?

In order to effectively treat symptoms like depression, anxiety and insomnia over the long term, it is often crucial that psychological meanings be patiently explored, in the context of a safe, psychotherapeutic relationship in which trust and mutual respect have been established and are being carefully nurtured.




Sunday, March 08, 2015

Posttraumatic Stress – A Frequent Consequence of Breast Cancer Diagnosis and Treatment

Given the limited state of our current medical knowledge, a diagnosis of breast cancer followed by extensive cancer treatment usually constitutes a prolonged trauma. Therefore when breast cancer survivors appear in psychotherapists' offices, they are likely to be suffering from some degree of post-traumatic stress even if their reasons for seeking treatment seem to be unrelated to their cancer experiences.

Patients, their families and their medical providers may be unaware that it is not unusual for survivors to continue to experience things like irritability, difficulty concentrating, trouble getting a good night's sleep or heightened anxiety for some time after breast cancer treatment has ended. An increased sense of vulnerability is also a very common aftereffect of cancer treatment even when the cancer was caught at an early stage, and patients are told at the end of their treatment that they are cancer-free.

Survivors may display ways of coping that are typical for persons who have experienced trauma. They may for example, become hypervigilant with respect to cancer. Every time they have a new ache or pain that does not have an obvious cause, they may begin to think that the cancer has returned and experience acute emotional distress. Similarly every time they hear that a food, a product or something else in the environment may be correlated with an increased risk of cancer, they may immediately try to avoid that substance. This is of course, a common and reasonable way that humans try to increase their sense of control and decrease their level of free-floating anxiety. However in today’s news/media environment, research study results are often reported without the media outlet taking the time to determine which of the studies have been well designed and which are merely preliminary or speculative. One media outlet after another may pick up and report the same story without ever investigating the actual significance of a study’s results, yielding to the pressure of our twenty-four hour news cycle. It is easy to see how a person who is trying to reduce her exposure to environmental toxins can end up feeling more stressed and overwhelmed.

Posttraumatic stress symptoms are often part of “the new normal”, a phrase that has been adopted by oncologists to describe how their patients are different after cancer treatment from how they were before cancer treatment. These symptoms often make up a significant part of “the new normal” and they can linger for a long time. Fortunately psychotherapists now know a lot about how to identify and treat them, so that survivors can obtain relief and an increased sense of control over their lives.

Saturday, September 06, 2014

Sexuality And Breast Cancer Treatment

There are many ways in which standard breast cancer treatments affect a woman's sexuality, both in the short and long term.  The removal of even part of a breast (lumpectomy), let alone the complete removal of one or both breasts, represents a loss and a change in a part of the body that is loaded with sensitive nerve endings and very involved in sexual arousal.  Having only a lump removed along with surrounding tissue, can involve severing nerves that were very involved in producing physical sensation in that area. In addition, the alteration in physical appearance caused by breast surgery, may cause a woman to experience herself as less womanly and less sexually desirable. As if that is not enough to process, females who undergo chemotherapy, will usually be thrown into menopause, with all of the changes that entails, such as fatigue, possibly severe hot flashes and decreased vaginal lubrication. Being jolted into menopause via chemotherapy is a very different physical and psychological experience than the experience of a natural and gradual cessation of menses occurring over a period of years. Adding to the menopausal effects of chemotherapy, drugs like tamoxifen and aromatase inhibitors are routinely prescribed to further reduce and suppress estrogen. Sex can become painful, and the walls of the vagina can atrophy and become very thin and dry. Vaginal yeast infections and urinary tract infections are also more likely to occur. (For more information on this, see Dr. Michael Krychman's blog post http://community.breastcancer.org/blog/sex-matters-vaginal-dryness/.)

The good news is that breast cancer survivors are still very capable of experiencing sexual desire and sexual pleasure. However, due to all of the physiological changes induced by breast cancer treatment, women often come to feel that they need to become acquainted all over again with who they are as sexual beings. This realization may come as a surprise, since oncologists often glide over these sexual sideeffects, in their zeal to rid the body of cancer, and because psycho/sexual/emotional aspects of cancer treatment are complex and outside of their area of expertise and comfort. It is important for cancer survivors and psychotherapists who work with them, to understand that along with physical and emotional healing, time and patience may be required for patients to uncover the sexual trauma related to the treatment, and to discover who they now are as sexual beings. Living in the realm of "the new normal", cancer survivors may need to learn what works now for them sexually.  For example, where and for how long they want to be touched in order to achieve sexual arousal and gratification, may be different from before cancer treatment. Partners of cancer survivors also need to be educated that what was pleasing and stimulating before the treatment, may be different now, and that their partners' bodies may not function in the same way.



Tuesday, August 19, 2014

Reflections on the Psychology of Prophylactic Mastectomy

In an earlier blog post,  Psychology and Prophylactic Mastectomy, I summarized an op ed piece written by Peggy Orenstein titled "The Wrong Approach to Breast Cancer" that appeared on Sunday, July 26th, 2014 in the New York Times.  In her article, Ms. Orenstein offered some possible psychological motivations for why women choose to have a healthy breast removed after being diagnosed with breast cancer in the other breast, despite the fact that survival is not increased by doing so.  I would like to offer additional thoughts on psychological motivation.

Loss Of Control

Breast cancer patients like other cancer patients where extensive treatment is required, usually undergo the experience of a profound loss of control over their lives. Asking the question, “Why me?" is one way that cancer patients attempt to regain some control or at least some understanding about possible causation.  Some spend a lot of mental energy reviewing their lives and wondering what may have triggered or contributed to the development of the cancer.

Humans want and need to feel that they have a certain amount of control over their lives in order to function in calm, organized and productive ways. We want to believe that if we eat properly, exercise often, avoid cigarettes, get enough sleep, maintain the correct weight, and so on, then we will be able to avoid serious physical illnesses, at least until old age.  Mass media plays to these hopes. Our newspapers, health newsletters, and journals are replete with reports of studies in which associations have been found between a myriad of foods, vitamins, and behaviors and a lower or higher incidence of some type of cancer, continually reinforcing the idea that if we can just figure out what to do and then do it, we will be able to greatly reduce our chances of getting cancer. People are encouraged to imagine that they have more control over what happens to their bodies then they, in fact, have. When a cancer diagnosis is made, it is often a shocking reminder of how little control we actually do have. In addition to feeling shocked or frightened, a patient may also feel a sense of shame over having failed to do what was necessary to prevent the cancer.  Making the decision to have a healthy breast removed may offer a chance to regain some sense of being in control, and may also serve to diminish any guilt or shame over not having done the "right" things to prevent the cancer.

Religious Contributions

In some religions, such as Roman Catholicism, sex is viewed as primarily for procreation, and for the pleasure of married men.  Roman Catholic women are encouraged to engage in sexual relations only to have children and to please their spouses. Women who engage in sex for their own pleasure, or who use some form of birth control, are induced to experience varying degrees of conscious or unconscious guilt or shame. Sexuality may be experienced as a burden, something that has to be managed and dealt with, something that can lead to sinful behavior and eternal damnation. Breast cancer may be consciously or unconsciously viewed as a punishment, and giving up a breast, as a way to pay for one's sins, thereby restoring a sense of virtue as well as the possibility of a blissful afterlife in heaven with God.

Other psychological issues

Some women are conflicted about their sexuality or sexual attractiveness because they grew up in families in which their physical beauty or sexuality was the cause of jealousy, anxiety or sexual abuse.   In these situations, sacrificing a healthy breast may serve to expiate guilt or shame and the patient may actually experience relief when the breast is gone.

Prophylactic mastectomy has not been shown to affect survival in those who are not at increased genetic risk for breast cancer.  One can have still have a cancer recurrence in the tissue that's left or in some other part of the body.

Saturday, August 09, 2014

Psychology and Proplylactic Mastectomy

On Sunday, July 26th, 2014, the New York Times printed an opinion piece written by Peggy Orenstein titled "The Wrong Approach to Breast Cancer" in which Ms. Orenstein relays the results of a study published in 2009 in The Journal of Clinical Oncology, showing that the rates of mastectomy with contralateral proplylactic mastectomy (removal of the unaffected breast) jumped dramatically for those with very early stage breast cancer between 1998 and 2005 (Tuttle et al, 2009).  Most of these women did not have an increased genetic risk for the disease. Ms Orenstein points out that this occurred even though this surgical procedure has virtually no survival benefit, i.e. women who choose to have this, are apparently not living longer according to a recent study that appeared in the Journal of the National Cancer Institute.  In one study, young women chose to have this done even though the majority knew that this procedure would not prolong life.  They even often cited enhanced survival as the reason.  In addition, there are often complications and side effects associated with contralateral proplylactic mastectomy (CPM) and breast reconstruction such as infections, ruptured implants and lack of sensation in the reconstructed breast.

Why are women apparently so willing to give up a healthy breast even when they are informed that it will not increase their survival?  Ms. Orenstein cites several possible psychological  motivations such as the desire to flee from the diagnosis and put the whole thing behind them as quickly as possible. She mentions the power of "anticipated regret" - i.e. women want to feel that they have done everything they can to prevent a recurrence, especially when they have young children. "Patients will go to extremes to restore peace of mind, even undergoing surgery, that paradoxically, won't change the medical basis for their fear."  She aptly points out that self-sacrifice has long defined what it means to be a good mother.