Department of Psychosocial Cancer Research 1 Den 3. stressforsknings konference 2006 Mind and cancer...

Department of Psychosocial Cancer Research

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Den 3. stressforsknings konference 2006

Mind and cancer

Christoffer Johansen, M.D., Ph.D., DrMedSci.Head, Department of Psychosocial Cancer

ResearchInstitute of Cancer Epidemiology

Danish Cancer Society


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Background

• The Department of Psychosocial Cancer Research (2001) utilise the epidemiological

approach and combine register-based research with clinical studies in an effort to study the

association between psychological factors, social factors and cancer

• The department combines various methodological approaches to the subject and

employs a range of persons educated from anthropology to statistics


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Current research activities

Home visitEducationRehabilitationInternet groups

Home visitEducationRehabilitationInternet groups

Prognosis

PersonalityDepressionMoodSchizophreniaMajor life eventsPsychoactive drugsReligious belief

PersonalityDepressionMoodSchizophreniaMajor life eventsPsychoactive drugsReligious belief

Cause

Social lifePsychological well-beingDivorce IncomeWorkPsychiatric diseasesDepression Psychoactive drugsScreening for fam. BC

Social lifePsychological well-beingDivorce IncomeWorkPsychiatric diseasesDepression Psychoactive drugsScreening for fam. BC

Effect

Prevention

Smoking in adolescence


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The epidemiological approach in psychosocial oncology focus on:

• Risk factors

• Psychosocial effects

• Psychosocial factors as prognostic factors

• Prevention

Background


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Background

Risk factors

Prevention

Prognosis

Effects


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Background

• Mind is an independent risk factor as well as an independent prognostic factor in cancer

• How is it possible to investigate this paradigm ??

The central paradigm


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Background

Risk factors


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Background

• Numerous case-control studies, cross-sectional studies and retrospective follow-up studies have demonstrated the central paradigm – but only few acknowledge the limitations of these methods – especially when dealing with our mind


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Background

• This retrospective tradition has some ’inborn’ methodological problems:

• Recall bias among cases • Exposure assessment by interview• Exposure assessment after diagnosis• Limited adjustment for biological factors


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Background

Time

Exposureby ’mind’ factor

Cancer diagnosisExposureassessment

Basic principles/problems


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Risk factors

• Major life events

• Depression• Personality


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Johansen C. & Olsen JH. No effect of psychological stress on cancer incidence or

mortality from nonmalignant diseases.

British Journal of Cancer 1997; 75: 144-148

Major life events


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Didier Bar - the Loreto Village with the Vesuvio in eruption, Rome, private collection


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Major life events


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Etiology considerations

• Latency

• Duration

• Initiation

• Promotion

• Timing


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Latency

• The exposure to the diagnosis of cancer in a child and risk for cancer in parents (Johansen & Olsen JH. No effect of psychological stress on cancer incidence or mortality from nonmalignant diseases. British Journal of Cancer 1997; 75(1): 144-148)

• The death of a child and risk for cancer in parents (Li J et al. Cancer incidence in parents who lost a child: a nationwide study in Denmark. Cancer 2002; 95: 2237 – 2242)

• The exposure to various stressful life-events (Bergelt C et al. Stressful life-events and risk for cancer. European Journal of Cancer, in press 2006)


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Latency

• The diagnosis of scizophrenia in a child and risk for cancer in parents. (Dalton SO et al. Cancer incidence in parents who experience a child with schizophrenia – a major life event study in Denmark. British Journal of Cancer 2004; 90: 1364 – 66)

• Hospital admission for depression and subsequent risk for cancer (Dalton SO et al. Depression and risk for cancer: a register-based study of patients hospitalized with affective disorders, Denmark, 1969-93. American Journal of Epidemiology 2002; 155: 1088-95)


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Duration

• Schapiro I et al. Personality and risk for cancer. American Journal of Epidemiology 2001; 153: 757 – 763.

• Schapiro I et al. Psychic vulnerability and the associated risk

of cancer. Cancer 2002; 94: 3299 – 3306.

• Hansen PE et al. Personality traits, health behavior and risk for cancer: A prospective study of a Swedish twins cohort. Cancer 2005; 103: 1082 – 1091.

• Bergelt C et al. Vital exhaustion and risk for cancer: a prosepctive cohort study on the association between depressive feelings, fatigue and risk for cancer. Cancer 2005; 104: 1288 - 1295

Personality traits


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Duration

• A large prospective study of daily job strain among 26 936 women in the American Nurses Health study (Achat 2000)

• Perceived stress of daily activities in a Finnish

cohort of 10 519 women (Lillberg 2001)

• No increased risk for breast cancer


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Initiation or Promotion (?)

Time

Initiator establish gene defect

Promotor increase rate of malignant cell division

Cancer diagnosis


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Timing

Time

Cancer diagnosisBirth

When is the vulnerable exposure window (?)


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Timing

• We currently study the risk of cervical dysplasia among young women exposed the death of one or two parents during childhood and adolescence (Magtengaard 2006)

• We also study the risk for cancer after the death of spouse, divorce or separation (Ross 2007)


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Etiology considerations

• Latency

• Duration

• Initiation

• Promotion

• Timing


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Depression

S Oksbjerg Dalton, L Mellemkjær, JH Olsen and C Johansen, , PB Mortensen.

Depression and cancer risk: A register-based study of patients hospitalized with affective

disorders, Denmark, 1969-93

American Journal of Epidemiology 2002; 155: 1088-95


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Louis N. Kenton (1865–1947)


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Tobacco-related cancer risk

Total First year of follow-up

1 years of follow-up

Obs SIR Obs SIR Obs SIR

Reactive depression 2075 1.13* 184 1.62 1891 1.10*

Tobacco related1 663 1.41* 58 2.03* 605 1.37*

Non-tobacco-related 1412 1.03 126 1.48 1286 1.00

Dysthymia 2285 1.18* 118 1.32* 2167 1.17*

Tobacco related1 714 1.56* 30 1.58* 684 1.56*

Non-tobacco-related 1571 1.06 88 1.25 1486 1.06*

*95% CI excludes 1.001Cancers of the buccal cavity, larynx, lung, esophagus, pancreas, kidney and urinary bladder


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Conclusions

This study gives no further support to the hypotheses that depression increases the risk for cancer

The increased risk observed in this study canprobably be ascribed to increased smoking


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Personality

Schapiro I, Falgaard Nielsen L, Jørgensen T, Boesen E, Johansen C.

Psychic vulnerability and the associated risk of cancer.

Cancer 2002; 94: 3299-3306


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Edvard Munch (1863-1944)


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A number of studies have reported that personality influence the risk of cancer

Hagnell 1966, Huggan 1968, Abse et al. 1974, Dattore et al.1980, Kirkcaldy & Kobylinska 1987, Scherg 1987, Grossarth-Maticek et al. 1988, Quander-Blaznik 1991


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The Cohort

Invited7734

Participants5812(75%)

Excluded676

(12%)

Study population5136(88%)


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Psychic vulnerability

A reaction readiness defined by a low threshold of being influenced and a risk of inexpedient reactions in social interaction or in a psychosomatic direction


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Cox proportional hazard analyses included information of:

• Age• Sex• Personality

measurement• Marital status• Social class• Alcohol consumption• Tobacco smoking • Body mass index

Analyses


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Variable Multivariate adjusted HR

95% CI

Vulnerability 1.160.85-1.57

Current smokers 1.391.05-1.83

Alcohol consumption> 14 units of alcohol per week

1.501.05-2.15

Adjusted risk of cancer


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Discussion

• Exposure information (mind factor) from administrative sources versus based on personal interviews or questionnaires

• Lack of confounder information (biology)

• Recall bias in case control studies – a serious problem


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Discussion

• The association between the mind factor and behaviour

• Smoking, alcohol and diet are self-medications in order to cope with major life events, depression and personality

• Policies to prevent smoking and alcohol consumption may focus more on well defined groups at risk for developing these behaviours


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Discussion

• Do stress prevent cancer ?

• Nielsen et al. BMJ 2005: High endogenous concentrations of oestrogen are a known risk factor for breast cancer, and impairment of oestrogen synthesis induced by chronic stress may explain a lower incidence of breast cancer in women with high stress.

• Impairment of normal body function should not, however, be considered a healthy response, and the cumulative health consequences of stress may be disadvantageous.


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Discussion

Biological mechanism

Mind Immunefunction Cancer


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Discussion

• Contrary to the ‘mind – cancer’ hypothesis we did not identify an increased risk for immune system related cancers such as leukemia, lymphoma and liver cancer in any of the studies published so far.

• In addition we did not observe an increased risk for hormone related cancers such as breast cancer or ovary cancer.


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Conclusion I

A. The cancer-prone mind model

B. The mind-health behaviour model

Mind Pathophysiological

processes

Impaired immunesystem

Cancer

Mind

Health behaviour Pathophysiological

processes

Cancer


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Conclusion I

Stress does not cause cancerIARC 4:

The agent (mixture) is probably not carcinogenic to humans


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Conclusion II

Policies to prevent smoking and alcohol consumption may focus more on well defined groups at risk for developing these behaviours


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Conclusion III

• Social inequality is probably the ‘new’ risk factor for risk behaviour and thus increased risk for certain lifestyle associated cancer types will be more prevalent in lower social classes compared to higher social classes

• Social class determines survival


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Adriaen Brouwer (Flemish, 1606?–1638)


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Information and contact

[email protected]

www.cancer.dk

Department of Psychosocial Cancer Research 1 Den 3. stressforsknings konference 2006 Mind and cancer...

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