There is no single "how to live with cancer." Different things work for different people.
But there has been a recent debate about the effect of a patient's attitude on recovery which may be obscuring an important fact for anyone who gets this disease.
The fact is this: Whether or not the "right" attitude makes for a better chance for recovery, it can certainly make the time left to live better, whether that is measured in months or decades.
About the debate:
Some doctors and medical scientists have been maintaining for years that an optimistic or positive mental attitude -- or, some say, an "angry" or "combative" attitude, rather than passive or stoic acceptance -- can improve the chance of a cure.
Some patients have come to believe this so deeply that when their cancer spread or recurred, they blamed themselves for not having the right mindset. Many have reached the end of their lives feeling guilty.
Dr. Barrie Cassileth, medical sociologist and director of psychosocial programs at the University of Pennsylvania Cancer Center in Philadelphia, set out to test mental attitude's effect. She and associates began following 359 cancer patients, 204 of them with advanced disease and poor prospects and another 155 with breast cancer or malignant melanoma, which often recur.
They found no difference in attitude or way of living between those who died and those who survived. "Something in their own biology," Cassileth said, not attitude or good cheer or optimism or pessimism or depression, determined who would and would not survive.
"We continue to follow these patients," she reports. "Just 10 percent of those with the poor prognoses are still alive. We have searched in vain to find differences between them and all those who have died -- in emotional approach, life style, relation with physicians. You name it, we've looked for it and can find absolutely nothing."
"I can say unequivocally," she adds, that a bad attitude doesn't kill patients nor a good one save them. "I would have been pleased to come out with a positive result," one showing that a good attitude makes a difference in survival. And she calls this study "among the first methodologically sound" investigations of the question in cancer.
"It is time to acknowledge that our belief in disease as a direct reflection of mental state is largely folklore," editorialized Dr. Marcia Angell, deputy editor of the highly regarded New England Journal of Medicine, which published the Pennsylvania report. Patients already suffering from cancer should not have to "accept responsibility" or feel "at fault" if their treatment fails, she argued.
The American Psychological Association called the Angell editorial "inaccurate and unfortunate," saying it ignored many studies showing a relation between psychological factors and health.
Dr. Susan Fiester of the National Institute of Mental Health's psychosocial treatment research branch has said: "Controlled clinical trials have found psychosocial interventions can produce measurable benefits" in various physical illnesses, and "cancer patients have shown increased survival rates and improved physiological states." Researchers at Kings College Hospital, London, reported finding a strong apparent relationship between emotional responses three months after a mastectomy -- removal of a cancerous breast -- and survival 10 years later. Among 57 women in all, those with a "fighting spirit" did best, with seven of 10 still alive. Of 32 who accepted their fate stoically, rarely complaining, only eight still lived.
Several researchers say central nervous system responses -- some of which are plainly subject to emotions -- can modify the responses of the body's immune system, which then may affect a person's ability to stave off disease.
Cassileth concedes that there is "clearly" a relationship between the state of the mind and the fate of the body, but its nature and physiological mechanism is still to be determined -- "And the trouble is when people extend this to maintain that if you have the proper attitude you can cure cancer . . . For every anecdote about a cancer patient with a good attitude who lived, I can give you 200 about those who had good attitudes and died."
Cancer patients should know that there is one point on which most -- not all -- researchers agree: whether or not psychology or emotions play a part in recovery, the most important things that determine whether or not a cancer patient gets well are (1) the basic biology of the patient's cancer; (2) the medical or surgical treatment.
How, then, should a cancer patient try to react? How, by unanimous agreement, does attitude indeed matter? It matters without doubt in two ways.
It can determine whether or not the patient gets himself or herself into prompt treatment and sticks with the treatment, even when the treatment gets rough.
"There are some people who become disheartened or depressed because of their diagnosis and fail to pursue treatment that might very well bring about cure or long-term remission," Cassileth reports. "To me, these are among the most tragic situations I see."
In staying with an often difficult treatment like chemotherapy, she says, "If you're depressed and unwilling to put up with short-term problems, you certainly diminish your opportunity for full benefit. You increase it if you can keep your sights on the future and endure the difficulties for just a few months down the road."
Attitude, finally, shapes the rest of a patient's life.
A nurse in a New York hospital told a promising young pianist who lost her hand when a deranged man shoved her off a subway platform: "You have five minutes a day to feel sorry for yourself, and the rest of the time you've got to get up and do something."
Barrie Cassileth works with patients on their way to a possible cure, and she works with the terminally ill.
"What we see over and over again," she says, "is that people who have a positive attitude, whatever their hope for a cure, have much more satisfying lives, much better interactions with other people, much better family existence.
"Some people unfortunately let the disease consume them. We all have numerous roles to play in life. But when people become cancer patients, they sometimes give up all but one, that of patient.
"A woman might be a mother, she might have a job, she might belong to a bridge club. She gets cancer and gives up everything. She gets her treatments and goes home and sits in a room.
"Another person gets up first thing in the morning and goes off to work, determined to lead a normal life just as fully as possible.
"We work with people to help them see their illness as just one part of their existence. They can't let it become their entire existence, they have to maintain other activities, because that is what life is all about.
"I can tell you that, in fact, the vast majority of people with malignant disease are able to put their illness in perspective and go about living the rest of their lives in as normal a fashion as they can."
In short, attitude -- the subject of some debate -- cannot help us live forever. It can help us live today.
Next week: Getting on with life.