Optimism Plays a Vital Role in Outcomes for Patients With Cancer

Maurie Markman, MD

These are clearly challenging times. The current political climate in our country, the soaring number of deaths resulting from the coronavirus disease 2019 (COVID-19) pandemic, the ongoing struggle with the COVID-19 vaccine rollout, and the intensity of anti-vaccine rhetoric are among the negative developments that unfortunately may serve as the focus of our thoughts and discussions.

For individuals with cancer, the pandemic has brought additional challenges: substantial delays in obtaining recommended screenings, medical attention for worrisome signs or symptoms (eg, new onset of a persistent cough in a smoker), or care for an established diagnosis—all while grappling with concerns about the safety of in-person appointments and essential therapeutic interventions. To this list one must add the rather poorly defined risks potentially associated with developing a COVID-19 infection during or following active therapy, as well as anxiety about the ever-escalating costs associated with medical care and existing and future antineoplastic agents.

But rather than focus on these important, concerning aspects of the cancer journey, this commentary highlights how individuals respond to these and multiple other challenges that patients with cancer may have to confront. Let’s focus on optimism, a topic that is fraught with as much controversy as any in the oncology arena.

Consider, for example, reports over the last decade in the peer-reviewed medical literature suggesting that a majority of patients with advanced metastatic cancer do not appear to acknowledge that currently available therapy cannot cure their malignancy. These reports imply that the patients’ oncologists either inappropriately or inadequately convey information or that patients are unable to understand the facts regarding outcomes.^1,2 Apparently, some analysts view as inappropriate a patient’s refusal to allow this terrible diagnosis of cancer to prevent them from maintaining an optimistic perspective.

In his landmark and stunningly effective essay, “The Median Isn’t the Message,” the eminent evolutionary biologist, the late Stephen Jay Gould, PhD, had this perspective on the survival curve for abdominal mesothelioma after being diagnosed with the malignancy and given only a few months to live: “The distribution was, indeed, strongly right skewed, with a long tail (however small) that extended for several years above the 8-month median. I saw no reason why I shouldn’t be in that small tail, and I breathed a very long sign of relief.”³

Is such an optimistic focus harmful? Remarkably, to some, the answer appears to be yes. In one commentary, the author directly challenges the assertion of Dr Gould, declaring: “If patients focus only on the tail of the survival curve to become exceptional responders, then by definition the overwhelming majority will be unprepared for their fate. Thus viewed, ‘the median isn’t the message’ is dangerous.”⁴ So much for a patient with cancer attempting to maintain an optimistic perspective despite a catastrophic diagnosis. So much for the value of the human spirit and faith.

Benefits of Faith and Positive Thinking

Although more should surely be said in strong opposition to this view, it is important to focus on peer-reviewed articles that provide increasingly robust support for the relevance of optimism and faith in the face of serious medical conditions, including cancer.

In a population-based study, investigators who followed more than 74,000 individuals for 16 years found a lower mortality rate among women who attended weekly religious services vs those who never attended services; the research team suggested that “participation may enhance the social integration that promotes healthy (eg, tobacco-free) behaviors and provides social support, optimism, or purpose.”⁵ Findings from a meta-analysis of 15 cohort studies involving 229,391 participants revealed that an objectively measured optimistic vs pessimistic perspective after a cardiovascular event was significantly associated with a reduced risk of a subsequent cardiovascular event (relative risk [RR], 0.65; P < .001) and all-cause mortality (RR, 0.86; P < .001).6

In the cancer arena, strong evidence exists for the impact of distressing or destabilizing life events to negatively affect relevant outcomes. A population-based study in Sweden revealed a striking increase in suicide during the first week and first year following a diagnosis of malignancy, particularly when a poor prognosis was predicted.⁷ Similarly, a large population-based report using the Surveillance, Epidemiology, and End Results Program database found that recent divorce, likely representing a major disruption in an individual’s life, is associated with inferior cancer outcomes.⁸

Evolving data provide provocative support for the relevance of an optimistic vs a pessimistic perspective in influencing outcomes in serious malignant conditions. Investigators from the Mayo Clinic examined survival outcomes in 534 patients with lung cancer who had completed a personality assessment 18 years prior to their diagnosis; a nonpessimistic explanatory style was associated with a 6-month improvement in overall survival.⁹ And, in a report involving interviews with 26 long-term survivors of ovarian cancer (23 with advanced disease), investigators noted that these individuals “had a strong life purpose, which manifested as positivity, taking charge of their lives and advocating for themselves.”¹⁰

Clearly, this commentary has only barely scratched the surface regarding the potential for optimism to favorably influence a patient’s cancer journey, but hopefully these observations will generate meaningful discussion and debate.

References

1. Weeks JC, Catalano PJ, Cronin A, et al. Patients’ expectations about effects of chemotherapy for advanced cancer. N Engl J Med. 2012;367(17):1616-1625. doi:10.1056/NEJMoa1204410

2. Chen AB, Cronin A, Weeks JC, et al. Expectations about the effectiveness of radiation therapy among patients with incurable lung cancer. J Clin Oncol. 2013;31(21):2730-2735. doi:10.1200/JCO.2012.48.5748

3. Gould SJ. The median isn’t the message. Virtual Mentor. 2013;15(1):77-81. doi:10.1001/virtualmentor.2013.15.1.mnar1-1301

4. Jacobson JO. Managing cancer patients’ expectations amid hope and hype. Health Aff (Millwood). 2019;38(2):320-323. doi:10.1377/hlthaff.2018.05259

5. VanderWeele TJ, Balboni TA, Koh HK. Health and spirituality. JAMA. 2017;318(6):519-520. doi:10.1001/jama.2017.8136

6. Rozanski A, Bavishi C, Kubzansky LD, Cohen R. Association of optimism with cardiovascular events and all-cause mortality: a systematic review and meta-analysis. JAMA Netw Open. 2019;2(9):e1912200. doi:10.1001/jamanetworkopen.2019.12200

7. Fang F, Fall K, Mittleman MA, et al. Suicide and cardiovascular death after a cancer diagnosis. N Engl J Med. 2012;366(14):1310-1318. doi:10.1056/NEJMoa1110307

8. Dinh KT, Aizer AA, Muralidhar V, et al. Increased vulnerability to poorer cancer-specific outcomes following recent divorce. Am J Med. 2018;131(5):517-523. doi:10.1016/j.amjmed.2017.11.039

9. Novotny P, Colligan RC, Szydlo DW, et al. A pessimistic explanatory style is prognostic for poor lung cancer survival. J Thorac Oncol. 2010;5(3):326-332. doi:10.1097/JTO.0b013e3181ce70e8

10. Alimujiang A, Khoja L, Wiensch A, et al. “I am not a statistic” ovarian cancer survivors’ views of factors that influenced their long-term survival. Gynecol Oncol. 2019;155(3):461-467. doi:10.1016/j.ygyno.2019.10.007