Barrie R. Cassileth

STRESS AND THE DEVELOPMENT OF BREAST CANCER : A PERSISTENT AND POPULAR LINK DESPITE CONTRARY EVIDENCE

The March 15, 1996 issue of Cancer published an article and editorial that raise questions regarding the role of psychosocial factors in the etiology of breast cancer. Using a retrospective case-control design, Roberts et al. found no relationship between life stressor frequency and the diagnosis of breast cancer. They concluded therein: ‘‘for clinicians, there is presently no evidence that commonly experienced difficult life events in any way constitute an increased risk of breast cancer.’’ In the editorial response to that article, Cassileth concludes more strongly that there is ‘‘powerful information. . .[that] provides evidence that cancer is not caused by stress’’ and that the role of ‘‘stress or other emotional factors in the etiology of cancer... would be relatively minor.’’ 2 Cassileth bases this conclusion on the study by Roberts et al. as well as three longitudinal studies in which people who experienced traumatic life stressors—war survivors, prisoners of war, and concentration camp incarceration victims—reported no higher rates of cancer than control groups. Before concluding that there is no link between life stressors and the etiology of breast cancer and cancer of other types, it is important to examine carefully what needs to be addressed to dismiss this line of research. A fair test to examine life stressors in cancer would require a number of elements. First, it is important to distinguish the terms ‘‘stressor’’ and ‘‘stress’’. A ‘‘stressor’’ is an environmental stimulus that has the potential to cause distress. Stress is the response, both psychologic and physiologic, to a stressor. Life stressor research has been confusing because of the lack of precision using such terms. Moreover, there is a complex interaction between a life stressor and the individual it affects. The individual response to the stressor is affected by the perception of the level of threat that the stressor poses. The perception of threat in both animal and human studies relates to a stressor’s duration and severity and its level of controllability and predictability. Furthermore, the stressor response can be mediated or buffered by both the individual coping responses to the stressor and the amount of social support that the individual can obtain. Therefore, any test of the role of life stressors in the etiology of cancer should examine this environment-individual interaction (i.e., ‘‘psychosocial context’’). Measuring this interaction can then provide data quantifying the internal distress that an individual experienced subsequent to exposure to an external life stressor. Distress, the response that an individSupported in part by NIMH R01 MH48628. ual develops in the face of a stressor, is the best predictor of an

Psychosocial Factors in Gastrointestinal Illness

Gastrointestinal (GI) illnesses represent a paradigm of psychosomatic medicine. Nearly half of patients seen in GI practice present with functional illnesses, and patients commonly complain of symptoms that have coexisting organic and functional etiologies. This chapter addresses the connected nature of psychosocial factors and GI function, disease and outcome in the context of the biopsychosocial model, which allows illness to be examined from the encompassing perspective of interacting system, from the cellular to the environmental. This perspective also helps explain why biologic events such as oncogene alteration can produce heterogeneous clinical and biological responses. Links between gut and brain, involving neuroendocrine associations of the enteric nervous system and its connections with the spinal, autonomic and central nervous systems, are well documented. Neural connections allow information to affect GI secretion and motility. Disturbances in one component of the system can lead to brain-gut effects, such as dysmotility and mood disturbance. Appropriate diagnosis and treatment require clear understanding of biologic, psychologic, and social contributory events. In chronic unexplained GI illnesses, the appropriate clinical approach may be to suspend the search for structural disease, and work instead to assess and treat the physical symptoms and psychosocial problems at hand.

History of psychotherapeutic intervention in cancer patients

Several important aspects of the history of psychotherapeutic interventions in cancer patients, such as the historical role of the “cancer personality,” the change in the conceptualization of the mind-body relationship and the influence of medical progress and social developments, are discussed.Several important aspects of the history of psychotherapeutic interventions in cancer patients, such as the historical role of the “cancer personality,” the change in the conceptualization of the mind-body relationship and the influence of medical progress and social developments, are discussed.

Complementary and Alternative Medicine Approaches in Colorectal Cancer

Complementary and alternative medicine (CAM) is now a highly visible feature of contemporary health care. No longer restricted to the lay sector and the medical fringe, CAM practices can be found in conventional care settings. They are widely and increasingly being subject to research and there is now good evidence that at least some techniques are potentially effective. In the United States, as in other countries of the developed world, many millions of patients spend billions of dollars each year on CAM.