Bright-Sided (6 page)

The Simontons’ book was followed in 1986 by surgeon Bernie Siegel’s even more exuberant
Love, Medicine, and Miracles
, offering the view that “a vigorous immune system can overcome cancer if it is not interfered with, and emotional growth toward greater self-acceptance and fulfillment helps keep the immune system strong.”
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Hence cancer was indeed a blessing, since it could force the victim into adopting a more positive and loving view of the world.

But where were the studies showing the healing effect of a positive attitude? Could they be duplicated? One of the skeptics, Stanford psychiatrist David Spiegel, told me he set out in 1989 to refute the popular dogma that attitude could overcome cancer. “I was so sick of hearing Bernie Siegel saying that you got cancer because you needed it,” he told me in an interview. But to his surprise, Spiegel’s study showed that breast cancer patients in support groups—who presumably were in a better frame of mind than those facing the disease on their own—lived longer than those in the control group. Spiegel promptly interrupted the study, deciding that no one should be deprived of the benefits provided by a support group. The dogma was affirmed and remained so at the time I was diagnosed.

You can see its appeal. First, the idea of a link between subjective feelings and the disease gave the breast cancer patient something to
do.
Instead of waiting passively for the treatments to kick in, she had her own work to do—on herself. She had to monitor her moods and mobilize psychic energy for the war at the cellular level. In the Simontons’ scheme, she was to devote part of each day to drawing cartoonish sketches of battles among buglike cells. If the cancer cells were not depicted as “very weak [and] confused”
and the body’s immune cells were not portrayed as “strong and aggressive,” the patient could be courting death, and had more work to do.
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At the same time, the dogma created expanded opportunities in the cancer research and treatment industry: not only surgeons and oncologists were needed but behavioral scientists, therapists, motivational counselors, and people willing to write exhortatory self-help books.

The dogma, however, did not survive further research. In the nineties, studies began to roll in refuting Spiegel’s 1989 work on the curative value of support groups. The amazing survival rates of women in Spiegel’s first study turned out to be a fluke. Then, in the May 2007 issue of
Psychological Bulletin
, James Coyne and two coauthors published the results of a systematic review of all the literature on the supposed effects of psychotherapy on cancer. The idea was that psychotherapy, like a support group, should help the patient improve her mood and decrease her level of stress. But Coyne and his coauthors found the existing literature full of “endemic problems.”
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In fact, there seemed to be no positive effect of therapy at all. A few months later, a team led by David Spiegel himself reported in the journal
Cancer
that support groups conferred no survival advantage after all, effectively contradicting his earlier finding. Psychotherapy and support groups might improve one’s mood, but they did nothing to overcome cancer. “If cancer patients want psychotherapy or to be in a support group, they should be given the opportunity to do so,” Coyne said in a summary of his research. “There can be lots of emotional and social benefits. But they should not seek such experiences solely on the expectation that they are extending their lives.”
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When I asked Coyne in early 2009 whether there is a continuing scientific bias in favor of a link between emotions and cancer survival, he said:

He feels that the bias is especially strong in the United States, where skeptics tend to be marginalized. “It’s much easier for me to get speaking gigs in Europe,” he told me.

What about the heroic battles between immune cells and cancer cells that patients are encouraged to visualize? In 1970, the famed Australian medical researcher McFarlane Burnet had proposed that the immune system is engaged in constant “surveillance” for cancer cells, which, supposedly, it would destroy upon detection. Presumably, the immune system was engaged in busily destroying cancer cells—until the day came when it was too exhausted (for example, by stress) to eliminate the renegades. There was at least one a priori problem with this hypothesis: unlike microbes, cancer cells are not “foreign”; they are ordinary tissue cells that have mutated and are not necessarily recognizable as enemy cells. As a recent editorial in the
Journal of Clinical Oncology
put it: “What we must first remember is that the immune system is designed to detect foreign invaders, and avoid our own cells. With few exceptions, the immune system does not appear to recognize cancers within an individual as foreign, because they are actually part of the self.”
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More to the point, there is no consistent evidence that the immune
system fights cancers, with the exception of those cancers caused by viruses, which may be more truly “foreign.” People whose immune systems have been depleted by HIV or animals rendered immunodeficient are not especially susceptible to cancer, as the “immune surveillance” theory would predict. Nor would it make much sense to treat cancer with chemotherapy, which suppresses the immune system, if the latter were truly crucial to fighting the disease. Furthermore, no one has found a way to cure cancer by boosting the immune system with chemical or biological agents. Yes, immune cells such as macrophages can often be found clustering at tumor sites, but not always to do anything useful.

To my intense shock and dismay as a former cellular immunologist, recent research shows that macrophages may even
go over to the other side
. Instead of killing the cancer cells, they start releasing growth factors and performing other tasks that actually encourage tumor growth. Mice can be bred to be highly susceptible to breast cancer, but their incipient tumors do not become malignant without the assistance of macrophages arriving at the site.
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A 2007 article in
Scientific American
concluded that at best “the immune system functions as a double-edged sword. . . . Sometimes it promotes cancer; other times it hinders disease.”
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Two years later, researchers discovered that another type of immune cell, lymphocytes, also promote the spread of breast cancer.
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All those visualizations of courageous immune cells battling cancer cells missed the real drama—the seductions, the whispered deals, the betrayals.

Continuing in an anthropomorphic vein, there’s an interesting parallel between macrophages and cancer cells: compared with the body’s other cells, both are fiercely autonomous. Ordinary, “good” cells slavishly subject themselves to the demands of the
dictatorship of the body: cardiac cells ceaselessly contract to keep the heart beating; intestinal lining cells selflessly pass on nutrients that they might have enjoyed eating themselves. But the cancer cells rip up their orders and start reproducing like independent organisms, while the macrophages are by nature free-ranging adventurers, perhaps the body’s equivalent of mercenaries. If nothing else, the existence of both is a reminder that the body is in some ways more like a loose, unstable federation of cells than the disciplined, well-integrated unit of our imaginings.

And, from an evolutionary perspective, why
should
the body possess a means of combating cancer, such as a form of “natural healing” that would kick in if only we get past our fears and negative thoughts? Cancer tends to strike older people who have passed the age of reproduction and hence are of little or no evolutionary significance. Our immune system evolved to fight bacteria and viruses and does a reasonably good job of saving the young from diseases like measles, whooping cough, and the flu. If you live long enough to get cancer, chances are you will have already accomplished your biological mission and produced a few children of your own.

It could be argued that positive thinking can’t hurt, that it might even be a blessing to the sorely afflicted. Who would begrudge the optimism of a dying person who clings to the hope of a last-minute remission? Or of a bald and nauseated chemotherapy patient who imagines that the cancer experience will end up giving her a more fulfilling life? Unable to actually help cure the disease, psychologists looked for ways to increase such positive feelings about cancer, which they termed “benefit finding.”
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Scales of benefit finding have been devised and dozens of articles published on the therapeutic interventions that help produce it. If you can’t count on recovering, you should at least come to see your cancer as a positive experience, and this notion has been
extended to other forms of cancer too. For example, prostate cancer researcher Stephen Strum has written: “You may not believe this, but prostate cancer is an opportunity. . . . [It] is a path, a model, a paradigm, of how you can interact to help yourself, and another. By doing so, you evolve to a much higher level of humanity.”
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But rather than providing emotional sustenance, the sugar-coating of cancer can exact a dreadful cost. First, it requires the denial of understandable feelings of anger and fear, all of which must be buried under a cosmetic layer of cheer. This is a great convenience for health workers and even friends of the afflicted, who might prefer fake cheer to complaining, but it is not so easy on the afflicted. Two researchers on benefit finding report that the breast cancer patients they have worked with “have mentioned repeatedly that they view even well-intentioned efforts to encourage benefit-finding as insensitive and inept. They are almost always interpreted as an unwelcome attempt to minimize the unique burdens and challenges that need to be overcome.”
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One 2004 study even found, in complete contradiction to the tenets of positive thinking, that women who perceive more benefits from their cancer “tend to face a poorer quality of life—including worse mental functioning—compared with women who do not perceive benefits from their diagnoses.”
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Besides, it takes effort to maintain the upbeat demeanor expected by others—effort that can no longer be justified as a contribution to long-term survival. Consider the woman who wrote to Deepak Chopra that her breast cancer had spread to the bones and lungs:

Even though I follow the treatments, have come a long way in unburdening myself of toxic feelings, have forgiven everyone, changed my lifestyle to include
meditation, prayer, proper diet, exercise, and supplements, the cancer keeps coming back.

Am I missing a lesson here that it keeps reoccurring? I am positive I am going to beat it, yet it does get harder with each diagnosis to keep a positive attitude.

She was working as hard as she could—meditating, praying, forgiving—but apparently not hard enough. Chopra’s response: “As far as I can tell, you are doing all the right things to recover. You just have to continue doing them until the cancer is gone for good. I know it is discouraging to make great progress only to have it come back again, but sometimes cancer is simply very pernicious and requires the utmost diligence and persistence to eventually overcome it.”
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But others in the cancer care business have begun to speak out against what one has called “the tyranny of positive thinking.” When a 2004 study found no survival benefits for optimism among lung cancer patients, its lead author, Penelope Schofield, wrote: “We should question whether it is valuable to encourage optimism if it results in the patient concealing his or her distress in the misguided belief that this will afford survival benefits. . . . If a patient feels generally pessimistic . . . it is important to acknowledge these feelings as valid and acceptable.”
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Whether repressed feelings are themselves harmful, as many psychologists claim, I’m not so sure, but without question there is a problem when positive thinking “fails” and the cancer spreads or eludes treatment. Then the patient can only blame herself: she is not being positive enough; possibly it was her negative attitude that brought on the disease in the first place. At this point, the exhortation to think positively is “an additional burden to an already devastated patient,” as oncology nurse Cynthia Rittenberg has written.
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Jimmie Holland, a psychiatrist at Memorial Sloan-Kettering
Cancer Center in New York, writes that cancer patients experience a kind of victim blaming:

It began to be clear to me about ten years ago that society was placing another undue and inappropriate burden on patients that seemed to come out of the popular beliefs about the mind-body connection. I would find patients coming in with stories of being told by well-meaning friends, “I’ve read all about this—if you got cancer, you must have wanted it. . . .” Even more distressing was the person who said, “I know I have to be positive all the time and that is the only way to cope with cancer—but it’s so hard to do. I know that if I get sad, or scared or upset, I am making my tumor grow faster and I will have shortened my life.”
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Clearly, the failure to think positively can weigh on a cancer patient like a second disease.

I, at least, was saved from this additional burden by my persistent anger—which would have been even stronger if I had suspected, as I do now, that my cancer was iatrogenic, that is, caused by the medical profession. When I was diagnosed I had been taking hormone replacement therapy for almost eight years, prescribed by doctors who avowed it would prevent heart disease, dementia, and bone loss. Further studies revealed in 2002 that HRT increases the risk of breast cancer, and, as the number of women taking it dropped sharply in the wake of this news, so did the incidence of breast cancer. So bad science may have produced the cancer in the first place, just as the bad science of positive thinking plagued me throughout my illness.