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Rapid Responses: Rapid Responses published:
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Widespread body pain, oncological terrain, and cancer.
- Sergio Stagnaro (22 September 2001)
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Why doesn't everyone in the UK have cancer?
- Andrew Vickers (22 September 2001)
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Other variables that could lead to cancer in patients with Fibromyalgia and Generalized pain
- Linda Carson (22 September 2001)
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Do happy patients develop cancer?
- F Clifford Rose (29 September 2001)
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Widespread body pain and cancer: caused by COX-2 overexpression?
- Sundar Santhanam (4 October 2001)
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Disease Psychology
- Peter Morrell (8 October 2001)
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In my opinion: A Logical argument from experience
- Diane L. Green (15 June 2002)
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Sergio Stagnaro, Specialist in Blood, Gastrointestinal and Metabolic Diseases Riva Trigoso (Genoa) Italy
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Sirs, G.J.Macfarlane et al have wrote an article realy intriguing, that appears to me interestingly in agreement with “Oncological Terrain” , I described earlier (http://digilander.iol.it/semeioticabiofisica and my Rapid Response on BMJ.com 16 / September / 2001). As a matter of fact, oncological terrain, conditio sine qua non of oncogenesis, is based on a derangement of different intensity of the Neuro-Psycho-Endocrine- Immunological System, which is characterized also by a lower level of tissue endorphins (1) as well as the inability to release emotion, the experience of stressful life events, psychosexual disturbance, and parental problems or separation in early life, notoriously factors linked to widespread body pain and cancer development. Moreover, I would like to know both the iron blood level and ferritin level of those individuals with widespread body pain, who subsequently were affected by cancer, because I observed in my long research on oncological terrain (when particularly severe) an “apparently” unaccountable iron deficiency syndrome, clinically detected by means of Biophysical Semeiotics (2), secondary really to Congenital Acidosic Enzyme-Metabolic Histangiopathy (3), caused by the impairement of iron up-take in the intestinal tract. In conclusion, the association between widespread pain and excess mortality from cancer, in the medium and long term, as well as an “apparently” unexplained iron deficiency syndrome are clearly indications to investigate the presence and the severity of the Oncological Terrain, which is in my mind the possible mechanism of this and other associations. Stagnaro Sergio MD., 1)Stagnaro S., Stagnaro-Neri M., Valutazione percusso-ascoltatoria del sistema degli oppioidi endogeni nei pazienti cefalalgici. Contributo alla definizione della costituzione emicranica. Epat. 33, 35 1987 2) Stagnaro S., Stagnaro-Neri M. Percussione Ascoltata della Sindrome Ferro-Carenziale. Med. Praxis 17, 4, 1 1986 3)11. Stagnaro S., Istangiopatia Congenita Acidosica Enzimo-Metabolica. Gazz Med. It. – Asch. Sci, Med. 144, 423 1985 |
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Andrew Vickers, Assistant Attending Research Methodologist Memorial Sloan-Kettering Cancer Center
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In attempting to explain the finding that bodily pain is prognostic of cancer, the authors make reference to psychological theories of cancer aetiology. They claim that "the inability to release emotion" may "predispose people to the development of cancer". So how come everyone in the UK doesn't have cancer? Why does Spain have higher rates of cancer than Japan? Why do Chileans have comparable cancer risk to the Chinese? These simplistic theories of cancer cause are out-of-date and should be rejected. The authors cite a 20 year old review, as well as the work of Speigel, whose randomized trial suggesting that psychological therapy aids cancer survival[1] has been replicated with negative findings [2], [3]. More recent studies casting doubt on the links between psychological state and cancer (as a fairly random example, see Roberts et al. [4]) are not cited. When we worshiped god, disease was sometimes seen as divine punishment for sins of a moral nature. Now that we worship the psyche, we use psychological sins as an explanation of disease. Surely it is time abandon the idea of sin as a cause of cancer. Andrew Vickers
(but born and raised in London) References 1. Spiegel D. Bloom JR. Kraemer HC. Gottheil E. Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet 1989;2(8668):888-91 2. Cunningham AJ, Edmonds CV, Jenkins GP, Pollack H, Lockwood GA, Warr D. A randomized controlled trial of the effects of group psychological therapy on survival in women with metastatic breast cancer. Psychooncology 1998;7(6):508-17 3. Goodwin PJ et al. The Breast Expressive-Supportive Therapy (BEST) Study: an RCT of the Effect of Group Psychosocial Support on Survival in Metastatic Breast Cancer (BC). Proc Am Soc Clin Oncol 2001 4. Roberts FD, Newcomb PA, Trentham-Dietz A, Storer BE. Self-reported stress and risk of breast cancer. Cancer 1996;77(6):1089-93 |
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Linda Carson, Registered nurse/Educator/Administrator Cleveland Institute of Dental/Medical Assistants, Inc.
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The pain from fibromyalgia is documented to be a generalized pain versus a regional pain. As noted in the study, there is an increase in cancer found in patients who present with generalized pain which occurs after a diagnosis of fibromyalgia. This study was excellent in the content presented, however, if it had been taken a few steps further perhaps more answers would have been documented. One area that deserves investigation is studying the immune system of the patient who complains of generalized pain and is given the diagnosis of fibromyalgia. If the greater percentage of people with this diagnosis had immune disorders prior to diagnosis of fibromyalgia, it could be argued that the pain is a reaction to the body's natural defense system being compromised. If the study included quarterly blood studies of the immune system, it could be proven or disproven that the compromised immune system leads to pain; pain experienced long term could cause a predisposition to cancer. In addition to the study that investigates the possibility of a link between chronic pain from fibromyalgia and a depressed immune system, data could be collected to determine if there is any difference in the rate of deaths from cancer between those paients who receive pain management and those who receive no pain management. For patients with uncontrolled pain, stress is generally a factor that can be documented by psycho-social studies; ie; inability to work leading to a decrease in self-worth; deterioration of personal relationships (increase in divorce rates,ect); and inability to maintain previously important activities such as attendance at preferred place of worship or social activities. Stress can also be documented by maintaining records of the patients blood pressure and other vital signs; documentation of complaints of angina or other pain not associated with fibromyalgia pain; and changes in body weight; ie: appreciable increases and/or decreases just to name a few variables. Therefore, it would be of potential value to study the group of
people with complaints of regional pain who have
compromised immune systems proven by regular blood tests and the
percentage of those people who develop cancer dividing the group into:
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F Clifford Rose, Director London Neurological Centre
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I was interested in the article of Macfarlane et al (BMJ 2001, 323, P662-664). In the following commentary by Crombie (ibid, p664), he felt the findings were partly serendipitous. Would not the simplistic explanation be that patients with chronic widespread or regional pain often do not have an organic aetiology and that the symptoms are psychosomatic? It is well recognised that psychological disturbances may predispose to decreased immunity and that many cancers may have this as a basis for their development. A London surgeon, Sir Heneage Ogilvie, famous more than fifty years ago for cancer therapy, used to teach that he had never seen a happy patient develop cancer. |
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Sundar Santhanam, Specialist registrar Dept of Oncology, Osborne Building, Leicester Royal Infirmary
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Sir, Macfarlane et al have found an intriguing association between widespread body pain and subsequent cancer mortality 1. We feel this association is most likely to be due to biological factors rather than, as suggested by the authors, psychosocial factors. We hypothesize that enhanced activity of enzymes such as cyclooxygenase -2 (COX-2) may underlie this association. COX-2 overexpression is found in virtually all solid tumors including lung, breast and gastrointestinal cancers. High tumour levels of COX-2 are associated with poor prognosis. Recent studies indicate that COX-2 plays an important role in the carcinogenic pathway of many malignancies. Hence COX-2 is being targeted with selective inhibitors in cancer chemoprevention studies 2 3. The prostaglandins (PGs) are involved in the mediation of pain pathways. PGs such as PGE2 are end products of COX-2 enzymatic action on arachidonic acid. Induction of COX-2 and consequent augmentation of PGE2 production is associated with enhanced perception of pain 4 5. Thus COX-2 overexpression may explain the association between widespread body pain and cancer mortality. Conflict of interest: None Yours sincerely Sundar Santhanam Specialist registrar. Ken O’Byrne Senior lecturer. Dept. of Oncology Leicester Royal Infirmary Leicester LE1 5WW. References 1. Macfarlane GJ, McBeth J, Silman AJ, Crombie IK. Widespread body pain and mortality: prospective population based study. BMJ 2001;323:662- 5. 2. Dannenberg AJ, Altorki NK, Boyle JO, Dang C, Howe LR, Weksler BB, et al. Cyclo-oxygenase 2: a pharmacological target for the prevention of cancer. Lancet Oncology 2001;2(9):544-51. 3. O'Byrne KJ, Dalgleish AG. Chronic immune activation and inflammation as the cause of malignancy. Br J Cancer 2001;85(4):473-83. 4. Yaksh TL, Dirig DM, Conway CM, Svensson C, Luo ZD, Isakson PC. The acute antihyperalgesic action of nonsteroidal, anti-inflammatory drugs and release of spinal prostaglandin E2 is mediated by the inhibition of constitutive spinal cyclooxygenase-2 (COX-2) but not COX- 1. J Neurosci 2001;21(16):5847-53. 5. Zhang Y, Shaffer A, Portanova J, Seibert K, Isakson PC. Inhibition of cyclooxygenase-2 rapidly reverses inflammatory hyperalgesia and prostaglandin E2 production. J Pharmacol Exp Ther 1997;283(3):1069-75. |
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Peter Morrell, Researcher, History and Philosophy of Medicine UK
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Sir, This is a very interesting article [1], but Andrew Vickers’ letter [2], does it scant justice. The original article does not refer exclusively to psychology, but also refers to diet and lifestyle factors in cancer aetiology. By choosing to focus solely upon what he somewhat derisorily calls “simplistic psychological theories of cancer,” [2], Vickers merely seems to distort the contentions made in it. However, he does raise some interesting conceptual issues. Firstly, as it is not conclusively proven that British people are “unable to release their emotions,” [2], how therefore can he imply that cancer should be more prevalent here than it already is? Nor would such a contention, even if true, comprise what he chooses to call a “psychological theory of cancer aetiology,” [2]. It is also hard to see how being “born and raised in London,” [2] in any sense qualifies anyone to accurately depict any supposed 'English mentality', if there is such an entity. Even if strong correlations between some mental states and certain diseases were shown to exist, this would still not comprise a full-blooded cause and effect mechanism except to a mind blindly predisposed towards simple biological reductionism. Such correlations, should they exist, would merely be associations, and much further research would be required to show whether they are anything stronger than that. As MacFarlane rightly points out: “the precise nature of any such associations is necessarily speculative,” [1]. His article in no sense therefore proposes any such monistic “simplistic theory of cancer cause,” [2], as Vickers maintains. Vickers’ letter also seems to carry an implicit assumption that mind cannot be a ‘substance’ in its own right, being merely a product of molecular processes in the brain - a very old chestnut! While the most characteristic features of mind and body can be identified – and they are very different from each other - yet they are intimately commingled and co -dependent 'things', and some mental aspects undoubtedly ‘adhere’ to many physical illnesses. This state of affairs may also reflect our derivation of large elements of our own sense of identity and self-worth from our body, which in a certain manner we helped to create and maintain and which, in a very important sense, is 'ours'. Illness, in any form, is an unwanted malfunction or derangement of something that is under our ownership, stewardship and care [the body], and upon which our continued happy existence very much depends. Clearly also, to those minds of a materialistic stamp, the body is all there is. Although mind is sunk into the body, as it were, so also is every particle of the body pervaded by mind [consciousness]. Both are profoundly affected by each other. Furthermore, illness inevitably contains an element of fear and anxiety, and in an important sense, it is also about failure, of succumbing to an unwanted external force and surrendering parts of one's life control. Some ill people feel this innate sense of failure very acutely, such that it dominates their waking life. Clearly, more serious health disorders carry a very acute sense of failure, sadness and disappointment compared with more trivial ailments. Perhaps the aura of sadness and loss that attends physical illness derives from the loss of freedom, an erosion of self-determinism, knowledge of increasing dependency and a closer intimation of one’s mortality that much chronic illness inspires. Those patients who have been witness to serious disease and had parts or organs removed must harbour the sadness and sense of failure that such events bring with them. Their body has failed them and they have failed their body - this inevitably is what such a situation means. At a deep psychological level, failure and loss of freedom pervade all disease, which comes to each of us as if unbidden. As Vickers rightly alludes, this might be construed as a religious dimension of disease and suffering. Prolonged and serious illness signifies the inevitability of one’s own impending death. What sentiment could be more depressing and anxiety- inducing than that? Cancer, more than most other diseases, does induce precisely such feelings in most people. For Andrew Vickers to denounce any "psychological theory of cancer aetiology" as "simplistic" denotes therefore a considerable lack of insight into, or deeper reflection upon, the general psychology of all illness, and it also seems to suggest a narrowly focused mono-causal attitude seeking gratification only in reductionist theories of ill-health. When Wilson, Holt and Greenhalgh say "few if any human illnesses can be said to have a single cause or cure," [3] and also when they say that the body "is not a machine and its malfunctioning cannot be adequately analysed by breaking the system down into component parts and considering them in isolation," [3], they are clearly identifying and denouncing the limitations of any strictly reductionistic approach to healthcare. It is also true that those people who must sadly live in situations of constant fear, exhaustion and stress, or suffer abuses to their sense of self-worth, self-determinism and usefulness, who are bullied and oppressed [brutalised], all such people [including many doctors!] are more susceptible to illness of every kind. Certainly, these are life-shortening lifestyle factors. Is it any wonder? In which case it is clear, that certain mental states can and do affect the body and act as associative causes of those derangements in physiology that lead ultimately to major disease. Would such a view really comprise a “simplistic psychological theory of cancer,” [2]? Therefore, given the points outlined here, any theory that links psychological factors with the development of cancer [mind and body] should be explored dispassionately and open-mindedly, rather than derided or denounced in advance. Such an approach would not necessarily be so simplistic as to demand a full cause and effect relationship, but it is nevertheless to be welcomed that such a line of inquiry [psychological associations] is part of the picture of cancer research, that has become - like much else in medicine - an almost exclusively molecularised domain. Regarding his views of ancient medicine, sin, suffering, and morality, this is indeed an interesting area of medical history. Unless Vickers believes in reincarnation, then he should not say ‘we’, but should say that modern medicine itself no longer has much respect for any alleged religious causes of illness. Although it is true that medicine generally no longer believes that God is a cause of disease, yet many people do still hold superstitious views about their life and suffering. Then as now, people blame ‘unseen forces’ and their own bad actions as causes for their suffering: ‘why me?’ patients say, and "What have I, what have I, what have I done to deserve this?" [4]. This type of belief persists in spite of the rationalising effect of science and materialism in the modern world. It is a remarkable fact that so many people today still find comfort in “the religious and metaphysical frameworks that belonged to various ages and civilisations,” [5; 7], and which are written off by most scientists as “a cloud of obscure metaphysical notions unconnected with empirical tests,” [5; 5]. Yet, religious ideas do allow one to contemplate one's own mortality, and raise one’s awareness of that impermanence that saturates all created things: "The oak is felled in the acorn,
Each patient is perfectly at liberty to formulate and express their own interpretation of their medical condition, whether MDs listen to such views or not. The philosophical, psychological, anthropological and metaphysical view of cancer as a civil war of the cells, is a valid view based upon dispassionate looking. It is valid to deeply contemplate the psychology of a person who ‘allows’ the slow disintegration of their own body in a cellular civil war and its eventual extinction. What it is, at the psychological level, in their life that might have inspired them to permit such an event to occur is also a highly pertinent question. Such a line of inquiry on this matter is just as valid as the molecular view of the geneticist, immunologist and biochemist. As Dr F Clifford Rose says in another illuminating BMJ letter: "A London surgeon, Sir Heneage Ogilvie, famous more than fifty years ago for cancer therapy, used to teach that he had never seen a happy patient develop cancer," [7]. Or, to put it another way, could a truly happy person become ill at all? This is primarily a religious question as a scientific answer to it is not possible. It shows that precise point of contact between medical science and spirituality. I guess a lot depends on what you mean by ‘truly happy’. "I don't care if Mondays black
If falling in love, improved self-belief and religion can make people feel happy, then it is hard to see the problem with treatments that specifically help patients become happier. An ever-widening range of published articles can also be cited [9, 10, 11, 12], which lend some weight to the view that 'patient attitudes' very much influence survival rates for many diseases. Sources [1] PAPERS, Widespread body pain and mortality: prospective population based study • Commentary: An interesting finding, but what does it mean? MacFarlane et al. (22 September 2001) http://www.bmj.com/cgi/eletters/323/7314/662 [2] BMJ letter, Why doesn't everyone in the UK have cancer?, Andrew Vickers, 22 September 2001, http://www.bmj.com/cgi/eletters/323/7314/662#EL2 [3] T Wilson, T Holt and T Greenhalgh, Complexity Science and Clinical Care, BMJ, 22 September 2001, 323; 685-688 http://www.bmj.com/cgi/content/full/323/7314/685 [4] What Have I done to Deserve This? Song by Pet Shop Boys with Dusty Springfield, 1987 [5] Isaiah Berlin, 1979, Concepts and Categories – Philosophical Essays, Oxford Univ. Press, UK [6] Dylan Thomas, poem, The Ballad of the Long-legged Bait, 1952 [7] BMJ letter, Do happy patients develop cancer? 29 September 2001, Dr F Clifford Rose, http://www.bmj.com/cgi/eletters/323/7314/662#EL4 [8] Friday I'm In Love, song, The Cure, 1991: http://www.thecure.com/ALL%20CURE%20LYRICS%20html%20Folder/1991- 1993words.html [9] Lewis SC, Dennis MS, O'Rourke SJ, Sharpe M. Negative attitudes among short-term stroke survivors predict worse long-term survival. Stroke 2001 Jul;32(7):1640-5 [10] Bardage C, Isacson D, Pedersen NL. Self-rated health as a predictor of mortality among persons with cardiovascular disease in Sweden. Scand J Public Health 2001 Mar;29(1):13-22. [11] de Graeff A, de Leeuw JR, Ros WJ, Hordijk GJ, Blijham GH, Winnubst JA. Sociodemographic factors and quality of life as prognostic indicators in head and neck cancer. Eur J Cancer 2001 Feb;37(3):332-9. [12] Tijhuis MA, Elshout JR, Feskens EJ, Janssen M, Kromhout D. Prospective investigation of emotional control and cancer risk in men (the Zutphen Elderly Study) (The Netherlands). Cancer Causes Control 2000 Aug;11(7):589-95. |
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Diane L. Green, Church Secretary First Presbyterian Church, 9675 Main Street, Clarence, New York, 14031
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As a person who has suffered from chronic pain for over 50 years, I have an observation pertaining to this study. Most people who suffer from long term chronic pain use some variety of pain relieving medications in order to have any kind of a life. The constant use of such medications may have masked the initial symptoms of the more serious and life threatening diseases such as cancer. In addition, when finally aware of a new pain or increased pain, chronic pain sufferers tend to attribute this to the condition they have been enduring, and not seek additional help until it is more obvious that something else is wrong. To make matters worse, many physicians are guilty of this attitude as well, thus delaying discovery and proper treatment and resulting in increased mortality. This may not be a cited argument, but it is certainly what I have seen and experienced. |
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