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Rapid Responses: Rapid Responses published:
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Response
- G Mocan (18 October 1999)
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Perception of stress and coping styles are important
- Craig Hassed (3 December 1999)
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Methodology of Life Events Research
- David Protheroe (18 January 2000)
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personal stress
- Johannes N Schilder (29 September 2000)
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G Mocan
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I think so also, these findings do not support the hypothesis that severe life events are associated always with the onset of any type of cancer. |
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Craig Hassed
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Dear Editor, I read with interest two articles appearing on October 16 relating to psychosocial factors and cancer. One examined stressful life-events and the onset of breast cancer and found no relationship between them . The other showed a significant connection between psychological response and breast cancer survival where those with depression and high levels of helplessness and hopelessness had poorer survival and higher recurrence rates. Protheroe's findings were at variance with another study which found a strong relationship between adverse life-events and breast cancer . How do we explain such apparent inconsistencies which plague psycho-oncology and its sister science, psychoneuroimmunology (PNI)? Protheroe measured life-events but it was not clear who rated their severity, nor was mention made of personality and coping style. Was the patient's perception of stress taken into account? This is important because an event only produces stress according to the individual's perception and response. For example, two people undergoing divorce will respond differently according to their attitudes and coping styles. For one it may be a relief and for the other a trauma and so physiology and immune function will vary accordingly. A life-event scale may rate divorce as stressful regardless of the person's individual response. Early work in PNI was plagued by inconsistent findings where "standardised stressors" produced immuno-enhancement and immuno-suppression. Averaging the effects makes it appear that there is little effect of stress on immune function until one also takes into account perception and coping style. It is then found that those with positive perceptions and coping styles have immuno-enhancement while those with negative ones have immuno- suppression. An important and reliable finding can become easily obscured. Studies looking at breast and bowel cancer show strong correlations between life-events and cancer when the above factors are taken into account. Findings are often inconsistent not because the principles underpinning the phenomena we try to measure are inconsistent but because it is hard to quantify and define the non-physical aspects of human existence. If Protheroe and his team failed to take into account perception, personality and coping style then it was a significant oversight in methodology. If they did take these factors into account but failed to comment on them in their discussion then it was a significant oversight in reporting. In either case the oversight is one which may create unnecessary confusion and set the debate backwards. Dr Craig Hassed
1. Protheroe D., Turvey K., Horgan K., Benson E., Bowers D., House A. Stressful life events and difficulties and onset of breast cancer: case control study. BMJ 1999;319:1027-30. 2. Watson M., Haviland J., Greer S., Davidson J., Bliss J. Influence of psychological response on survival in breast cancer: a population-based study. Lancet 1999;354:1331-36. 3. Chen C., David A., Nunnerley H., Michell M., Dawson J., Berry H., Dobbs J., Fahy T. Adverse life events and breast cancer: a case control study. BMJ 1995;311:1527-30. 4. Jemmott J., Borysenko J., Borysenko M., McClelland D., Chapman R., Meyer D., Benson H. Academic stress, power motivation, and decrease in secretion rate of salivary secretory immunoglobulin A. Lancet 1983;1(8339):1400-2. 5. Kune S., Kune G., Watson L., Rahe R. Recent life change and large bowel cancer. Data from the Melbourne colorectal cancer study. J Clin Epidemiol 1991;44:57-68. |
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David Protheroe, Consultant Liaison Psychiatrist The Northern Hospital, 185, Cooper Street, EPPING, 3076, Australia
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Editor, Hassed highlights some important issues in our paper on stressful life events and the onset of breast cancer1 concerning the retrospective measurement of life events, coping strategies and personality. We employed the standard procedures described by Brown and Harris2 in their work on life events and difficulties. The interviewer reads out a full description of the event to other trained researchers who remain blind to the physical and psychological state of the subject. The full context of the event is described in detail but the emotional state, coping strategies and personality of the patient are ignored. The event is rated according to a detailed set of rules and a manual of several thousand rated vignettes. If there is doubt the rating is referred to one of the originators of the scale. Subjects have little difficulty in recalling details of major traumas but the assessment of subjective severity of events, coping strategies and personality is altered by the length of time since the event, subsequent events and a reporting bias known as effort after meaning. This refers to a tendency for subjects who believe themselves to be ill to respond differently in an attempt to explain their illness. Thus, a woman suspecting cancer may exaggerate the trauma of a recent divorce perhaps believing that it is in part responsible for the cancer. The events studied in the Melbourne colo-rectal study3 were not clearly defined. The subjects were not blind to their diagnosis and exercised considerable discretion on which events to include and their own rating of severity. The positive association between life events and bowel cancer could thus be explained by effort after meaning. Population studies have failed to show an association between life stresses and breast cancer 4 5 6 7 and a prospective interview study would be unfeasible. 1. Protheroe D, Turvey K, Horgan K, Benson E, Bowers D, House A. Stressful life events and difficulties and onset of breast cancer: case control study. BMJ 1999; 319:1027-30. 2. Brown GW, Harris TO. The social origins of depression: a study of psychiatric disorder in women. London: Bedford College, University of London, 1978. 3. Kune S, Kune GA, Watson LF, Rahe RH. Recent life change and large bowel cancer. Data from the Melbourne colorectal cancer study. J Clin Epidem 1991; 44, 1, 57-68. 4. Ewertz M. Bereavement and cancer. Brit J Cancer 1986; 53, 701-703. 5. Jones DR, Goldblatt PO, Leon DA. Bereavement and cancer: some data on deaths of spouses from the longitudinal study of Office of Population Censuses and Surveys. BMJ 1984; 289, 461-464. 6. Kvikstad A, Vatten LJ, Tetli S, Kvinnsland S. Death of a husband or marital divorce related to risk of breast cancer in middle aged women. A nested case control study among Norwegian women born 1935-1954. Eur J Cancer 1994; 30A, 4, 473-477. 7. Martikainen P, Valkonnen T. Mortality after the death of a spouse: rates and causes of death in a large Finnish cohort. Am J Pub Health 1996; 86, 1087-1093. *David Protheroe
Allan House
*Correspondence |
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Johannes N Schilder, emergency physician/psycho-oncology practice OLVG, Amsterdam / private practice
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Madam, Sir, Stressfull life events and their possible relationship to bodily diseases makes me to report this experience. Ten years back I was offered to receive two experimental sailing vessels by a friend. These were huge and professionally built prototypes of so called amarans, measuring twelve by ten and seventeen by fourteen meters respectively (length by width of the respective vessels). I was enthusiast but I also had a terrible nightmare about a cancer in a quadrant of my eye. This nightmare was during the night that I slept at his place, after discussing the ships. I didn't understand what it was about and I received the ships. An old profesor in theology and a good friend and sailing mate of mine told me that he didn't like how I was getting these ships. Something in it or in the way I was dealing with it was wrong for me, according to him. I didn't get it. When sailing the first craft I noticed a spontaneous bleeding spot on the left side of my nose, right in the quadrant of my left eye. I was immediately reminded of my nighmare and I was struck with fear. I now came to understand that although these boats were marvellous, they pushed aside my own work in experimental yacht development. I return the boats, which still took a lot of effort to accomplish, and the bleeding defect on my nose came to a rest. I do not know whether this has been a precancerous lesion or not. But that's not the most important issue here. The fact is that without these dreams and the subsequent spontaneous bleeding, I would never have recalled this event of receiving great vessels as a stressfull life event. Only with help of these dreams and with more general knowledge of possible psycho-oncological relationships, I came to see that this event was about to threaten essential activities and experiences of my own. If Protheroe and colleques are able to identify events that threaten essential aspects of the persons under study -whether these persons or the scientists would lable the events as stressfull or not- I'd like to see the outcomes with regard to the onset of cancer. Sincerely, Johannes N. Schilder, Amsterdam |
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