From the Wall Street Journal -

Researchers are having second thoughts about a long-trusted piece of
conventional wisdom - that a positive attitude can help patients beat
cancer.    

A new body of work examining the biological underpinnings of attitude
suggests that its connection to fighting cancer may be more complex.
The findings indicate that successful coping isn't necessarily about
having a positive outlook.    

More important may be coping in a way a patient is used to, which
could involve anything from stress relief to exercise, rather than
simply striving for a cheery disposition. Indeed, if someone is a
natural curmudgeon, then continuing to be a curmudgeon may be the very
thing to help lower stress, bolster the immune system, and possibly
influence the success of the cancer treatment.    

"Many pessimists cope well with cancer," says Jimmie Holland, the
chair of psychiatric oncology at Memorial Sloan-Kettering Hospital.
"You can be as curmudgeonly or angry or whiny as you want and still
survive cancer, as long as it doesn't cause your doctor to throw you
out of the office."    

The current work is being driven by what Dr. Holland calls "the
tyranny of positive thinking" and its impact on patients. Many
patients fear they are lowering their chances of survival if they
don't feel positive, creating an additional burden at a time when they
are overwhelmed by their diagnosis.   The research doesn't focus so
much on patients' tendencies to look at the glass as half-full or
half-empty and how they may influence survival outcomes. Instead,
researchers are examining how different coping styles may affect
indicators of disease-fighting ability, such as cortisol rhythms (a
measure of stress levels) and natural killer cell counts (a measure of
immune response).  

With better understanding of these variables, doctors and researchers
hope to find ways, such as muscle relaxation or problem solving, to
help patients keep stress and natural killer cells at levels that
improve their chances of extending survival.    

The new approach also stems from the realization that after more than
a decade of research trying to link optimism with improved cancer
survival, the data haven't revealed much evidence of a connection. In
February, the American Cancer Society journal published a report about
179 patients newly diagnosed with non-small-cell lung cancer who were
followed for five years. The investigators found that a patient's
level of optimism didn't affect survival time.  

A British Medical Journal review in 2002 of 37 other studies on the
effect of psychological coping styles found most also showed no
connection between positive attitude and improved survival.    

The latest work is different in that it is based on "a more complex
measure of optimism," says David Spiegel, a psychiatrist at Stanford
University School of Medicine, who is heading one of the studies. Back
in 1989, he was the lead author on a seminal paper published in Lancet
that looked at the effect of participating in support groups on 86
women with metastatic breast cancer. At the 10-year follow up, only
three patients were alive - all support group members - and death
records were obtained for the other 83 women. The study reported that
women who participated in the group survived 36.6 months from entry
into the study, compared with 18.9 months for the control group.    

The results caused a stir, generating huge public and academic
interest. Cancer patients were urged to join support groups. But in
follow-up studies, the results weren't easily duplicated. In one major
study designed to replicate Dr. Spiegel's original findings with
metastatic breast-cancer patients, women assigned to a support group
showed improved mood and the perception of less pain but didn't
survive any longer than women not in the group.  

Dr. Spiegel says that some randomized trials looking at cancers
besides breast cancer, such as melanoma, did find that effective
psychological support could predict longer survival. But there were
just as many that found it didn't.    

As a result, he says his group is now in the 12th year of a similar
study but taking a different approach. In the previous study, the only
thing measured was length of survival time based on death
certificates. In the current one, researchers are assessing the
effects of stress and its management on the body, guided by the idea
that the stress that cancer patients feel while coping may weaken
their immune systems. Researchers are measuring the women's cortisol
concentrations in their saliva, an indicator of stress, and counting
their circulating natural-killer cells, a measure of immune response.

Although the study is ongoing, in a preliminary report published in
2000 in the Journal of the National Cancer Institute, the researchers
found that patients whose cortisol levels were flat and didn't follow
the typical pattern of declining throughout the day, died sooner than
women with normal cortisol patterns. The finding, researchers believe,
indicates that there may be psychological interventions that can boost
disease-fighting ability, a notion that in the past has driven the
focus on staying positive.    

But what if the pressure to be upbeat raised someone's stress level?
Researchers are now realizing that people cope with stress in vastly
different ways, and that they need to find solutions that match
someone's natural temperament and personality.  

The next step is finding the mechanisms that enable patients to keep
their cortisol patterns and natural killer cells at optimum levels and
hopefully extend their survival. "For some patients this may happen by
being uncooperative and unpleasant rather than positive," Dr. Spiegel
says.