THE STUDY

“Emotional Well-Being Does Not Predict Survival in Head and Neck Cancer Patients” by James Coyne et al., published in the December 1, 2007, issue of Cancer.

THE QUESTION Do emotions influence a cancer patient’s prognosis? In one of the largest, longest, and most controlled studies of its kind, researchers investigated whether the emotional state of cancer patients has any relationship to their survival.

THE METHODS University of Pennsylvania psychologist James Coyne and his colleagues followed 1,093 adults, all of whom had advanced head and neck cancer with nonspreading tumors. All patients received standardized medical care through clinical trials run by the Radiation Therapy Oncology Group (RTOG).

At the start of the study, the participants completed a 27-item questionnaire used to evaluate the physical, social, and emotional quality of life in people with cancer and other chronic diseases. Five items targeted emotional state, asking patients to rate, on a scale of 0 to 4, the extent to which statements like “I feel sad” and “I am losing hope in my fight against my illness” had been true for them over the past seven days. The researchers then calculated a score for each person’s initial emotional well-being.

Coyne tracked patients for an average of nine years, until they either dropped out of the study or died. The study reported 646 deaths. Once the records for the participants were complete, researchers analyzed the data. “We were surprised to find absolutely no relationship” between emotion and survival, Coyne says.

The researchers then looked at emotion and survival in greater detail, examining data for the most buoyant optimists, the most despondent individuals, and patients with complicating factors like smoking. In none of these analyses did emotional well-being affect survival. Because the study was so large and long, it gathered far more information than previous investigations of emotion and cancer survival. In smaller studies, Coyne says, it can be difficult to tell whether deaths were related to a factor like emotion or were simply due to chance.

While the huge pool of subjects and the controlled clinical trial conditions give the study statistical heft, Coyne acknowledges a few limitations. Having only people with head and neck cancers in the study eliminates the variability of a group suffering from different forms of the disease, but it also eliminates information about whether patients with other forms of cancer would show the same results. Additionally, patients had to be judged “mentally reliable”—able to follow instructions and keep appointments—in order to qualify for the clinical trials, so their emotional scores might not represent the full spectrum of psychological states among cancer patients.

THE MEANING

Coyne says this is the most in-depth study of its kind, and until a study with a similar sample size proves otherwise, he is convinced there is no conclusive relationship between emotional well-being and cancer survival. Many cancer patients struggling to maintain a positive outlook—and fearing that their lives depended on it—have contacted Coyne to express relief that their survival may not be dependent on their emotions. “Having a positive outlook is not going to extend the quantity of life,” Coyne says. “Not everybody is capable of being positive when they have cancer.”

STATS BEHIND THE STUDY • A 2004 study found that 72 percent of the public and 86 percent of cancer patients believe psychological factors affect cancer survival. Only 26 percent of oncologists agree. • About 25 percent of breast cancer patients who joined support groups told researchers in a 2005 study that they attended to improve their immune systems. • Four previous studies indicate that people with better psychological function do survive longer with cancer—but four others suggest that a healthier psychological condition predicts shorter survival time. More than a dozen studies have found no relationship between the two variables. • A 2007 study found that the emotional, physical, and social questionnaire Coyne used is effective at predicting depression. • Major depression afflicts about 25 percent of all cancer patients. • The two clinical trials in Coyne’s study were conducted by the RTOG, which had a $13 million budget in 2007 and is funded by the National Cancer Institute. • The American Cancer Society cited 1.4 million new cases of cancer in the United States in 2007 and more than 500,000 cancer deaths, with about 11,000 due to head and neck cancer.

SECOND OPINION While this study attempts to correct factors that muddied previous research, few experts think the question of cancer and emotion is closed. Stanford psychiatrist David Spiegel notes that coping strategies are an important part of the picture and that they were not addressed by Coyne’s research. He points to a study of breast cancer patients that provides evidence that survival has to do more with how people deal with emotions than how they feel. (Coyne believes the sample size in that study was inadequate and says larger studies oppose Spiegel’s contention.) Spiegel says support groups and other therapies might improve outcomes by helping patients manage stress and improve communication with doctors. Coyne acknowledges the possibility that psychological support could affect survival by mechanisms other than emotional well-being but says no methodologically sound study has yet shown a relationship.