Colorectal cancer

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The idea that psychosocial factors may be implicated in the development and progression of cancer is not a new one.  Galenus, for example, over 2000 years ago, wrote that ‘melancholic’ women were prone to breast cancer (Mettler & Mettler, 1997).

It is widely agreed that initial disease severity is likely to be the most important factor in influencing the course of cancer.  However, there is a growing literature around the idea that psychological factors such as stressful life events, negative emotional states and repression, social relationships, coping and adjustment to illness, locus of control and personality factors, might also exert an influence (for a review, see Bleiker & Van der Ploeg, 1999; Garsen & Goodkin, 1999; Geyer, 1997; McKenna, Zevron, Corn & Rounds, 1999).  The most consistent finding in the literature is for the positive relationship between progression of cancer and emotional processing deficits, such as the control over, or failure to express negative emotion through denial, repression, suppression or avoidance (Dattore, Shontz & Coyne, 1980; Epping-Jordon, Compass & Howell, 1994; Jansen & Muenz, 1984; Jensen, 1987; Stavraky, Donner, Kincade & Stewart, 1988; Weihs, Simmens & Reiss, 1996).

Colorectal cancer: Characteristics and prognosis

All cancers are defined by unregulated cell growth and the eventual spreading of these abnormal cells to other parts of the body (Spratt, Donegan & Sigdestad, 1995). Colorectal cancer refers to any unregulated cell growth within any part of the large bowel, including the colon and rectum. Colon cancer occurs at roughly equal rates in both men and women, and rectal cancer is more common in men (Department of Health, 1997). Patients survive, on average, for three years after diagnosis (Mountney, Sanderson & Harris, 1994). The prognosis and effectiveness of treatment depend largely on the degree to which the cancer has spread.

Incidence and mortality rates

Colorectal cancer is responsible for about 10% of all new cancer cases in the United Kingdom population. It is the second most common cause of cancer deaths after deaths from lung cancer, being responsible for over 19,000 deaths per year in the United Kingdom.  Its incidence is 48 per 100,000 per year, rising sharply with age. The average age of patient diagnosis is just under seventy years (Department of Health, 1997).

Epidemiological risk factors

Approximately 5% of patients suffer from genetic syndromes associated with an exceptionally high risk of colorectal cancer and 1% have bowel disease, which increases susceptibility.  In general, the risk is greater for people with a family history of the disease (Department of Health, 1997). However, around 75% of patients have neither a positive family history, nor any condition known to predispose them to developing colorectal cancer (Winawer, Fletcher, Miller, Godlee, Stolar, Mulrow & Woolf 1997).  Given that the above risk factors cannot account for the development of cancer in such a large number of cases, other risk factors continue to be hypothesised , including the role of psychological factors.

What is the impact of emotional processing on physical health?

A wide range of evidence has accumulated which has demonstrated the physical health benefits associated with emotional expression, as well as the costs associated with inhibited expression.

Emotional Expression [Click here to go to Emotional Expression,Overlaps section]

Sherman, Bonanno, Weiner & Battles, (2000), for example, found that children who disclosed and discussed their HIV/AIDS status to friends during a 1 year period of study showed greater increases in immune response compared to children who had not disclosed their HIV/AIDS status. Psychological interventions in which a component involves the expression of emotion, have also been associated with reductions in distress and longer survival time (Fawzy, Kemeny, Fawzy, Elashoff, Morton, Cousins & Fahey 1990; 1993; Spiegel, Bloom, Kraemer & Gotthail, 1989)

Pennebaker (1990, 1993a, Pennebaker, Barger & Tiebout 1989) has highlighted the important health benefits of talking or writing about traumatic or stressful events.  He found that writing about traumatic experiences was associated with short-term increases in physiological arousal and negative mood, but over the long term, writing about trauma resulted in decreased health problems and increased immune system responsiveness. He suggests that writing helps individuals to structure, and ultimately understand and control their emotional reactions (Pennebaker, 1993a).

Emotional control [Click here to go to Emotional Regulation & Control, Overlaps section]

A whole range of research has led to an increasing acknowledgement that excessive emotional regulation through suppression of emotional experience or expression, may also be related to poor psychological functioning (Beutler, Engle, Oro-Buetler, Daldrup & Meredith, 1986; Grassi & Molinari, 1988), and may also be related to a number of major illnesses, including cardiovascular disease (Friedman & Booth-Kewley, 1987a; Friedman, Hall & Harris, 1985), cancer (Greer & Morris, 1978; Pettingale, Watson & Greer, 1984), and arthritis (Udelman & Udelman, 1981).

How might psychological factors influence cancer onset or progression?

There is mounting evidence that psychosocial variables and stress can suppress the immune system, and an impaired immune system predisposes to malignant growth (Ader, Felten & Cohen 1991; Cohen & Herbert, 1996; Morley, Benton & Solomon, 1991; Pettingale, Greer & Tee, 1977; Rabin, Cohen, Canguli, Lysle & Cunnick 1989).  A failure to express emotions by their suppression, repression or denial has been associated with decreased immune efficiency (see Schwartz, 1990 for a review), and emotional disclosure has been associated with improved immune function (Esterling, Antoni, Kumar & Schneiderman, 1990). There are considerable data now to suggest that when individuals actively inhibit emotional expression, they show measurable immunological change consistent with poorer health outcomes, such as higher serum antibody titers in subjects with latent Epstein-Barr virus infection (indicating poor immunological control), (Esterling et al., 1990). Shea, Burton & Girgis (1993) also reported that subjects classified as repressors showed lower cell-mediated immune responses than other groups of subjects.

Emotional suppression has most frequently been associated with the onset or progression of cancer (Gross, 1989).  A number of investigations have found a repressive personality style was significantly associated with poorer natural killer (NK) cell activity, the most readily measurable element of immune function with relevance to the control of tumours (Levy, Heberman, Maluish, Schlien & Lipman, 1985).  It was also associated with the diagnosis of malignancy (Greer & Morris, 1975; Kissen, Brown & Kissen, 1969) and with subsequent death from cancer (Graves & Thomas, 1981; Pettingale, Morris, Greer & Haybittle, 1985; Shaffer, Graves, Swank & Pearson, 1987).

Emotional Control and Cancer

These studies have suggested the role of a cancer prone personality type – the Type C personality, and its link with the onset or progression of cancer (Bleiker, 1995; Eysenck, 1988, 1994; Greer & Morris, 1975; Grossarth-Maticek, Bastiaans & Kanazir, 1985; Kissen, et al., 1969; LeShan, 1959; Schmale & Iker, 1961; Van der Ploeg, Kleijn, Mook, Van Donge, Pieters & Leer, 1989). After an extensive research programme on personality and cancer, Eysenck (1994), summarised the various traits that constitute Type C as follows:- ‘being over-co-operative, appeasing, unassertive, over-patient, avoiding conflict, suppressing emotions like anger and anxiety, using repression and denial as coping mechanisms, self-sacrificing, rigid, predisposed to experience hopelessness and depression’ (p168). 

In relation to the Type C personality, Kneier and Temoshok (1984), pointed out that, ‘…coping strategies in which anxiety-provoking events, emotions, or ideas are denied, suppressed, repressed, minimised, rationalised away or otherwise avoided, are often associated with higher incidences of cancer with poorer prognosis” (p 145).Greer and Watson (1985) emphasised that, ‘suppression of emotional responses, particularly when angry, appears to be central to this behaviour pattern’ (p774). Bleiker (1995), after an extensive study with women with breast cancer and healthy women, in which several type C dimensions were assessed, concluded that, ‘…anti-emotionality was found to be a significant predictor of cancer’ (p174.).

Of all the factors that constitute the Type C personality, only the inability to express emotions has been consistently reported.  Because of this, research is now beginning to focus more specifically on aspects of emotion and emotional processing deficits and their relationship to cancer.

Whereas emotional suppression, inhibition and constraint are generally used to refer to conscious attempts to avoid emotional expression, emotional repression and the repressive coping style, are often used to refer to an unconscious process of keeping distressing feelings and thoughts from coming into awareness (Singer & Sincoff, 1990; Weinberger, 1990).

Other studies have failed to find a relationship between repression and cancer. Persky, Kempthorne-Raeson and Shekelle (1987) did not find a relationship between repression, as measured by the Minnesota Multiphasic Personality Inventory (MMPI) and later onset of cancer.  Similarly, Hahn and Petitti (1988), using the same questionnaire, also failed to find a relationship.

Intervention studies

Intervention studies have provided the most convincing evidence regarding a causal link between emotion factors and cancer.  Two studies are of importance.

The first by Spiegel et al. (1989) involved randomising women with metastatic breast cancer to either weekly group support sessions for a year, or to a control condition.  Both groups received standard medical care.  After a year, the women in the support group reported decreased mood disturbance and fearfulness, less pain and suffering and engaged in fewer maladaptive coping strategies such as denial, in comparison to the control group.  But most significantly, women in the initial support group survived, on average, 18 months longer than those in the control group, after controlling for disease related variables.

Fawzy et al., (1993) obtained similar results with women with malignant melanoma.  Six months after the intervention, those in the support group showed improved psychological adjustment and enhanced immune functioning, compared with those in the control group.  Five years later, those in the support group had a lower recurrence rate and a longer survival time than those in the control group.

The role of emotional processing deficits in colorectal cancer

 Only one known study to date has examined the relationship between personality or emotional factors and colorectal cancer.  Kune, Kune, Watson and Bahnson (1991) compared 637 new cases of colorectal cancer with 714 age and sex matched controls, for repression and suppression of emotions.  The findings indicated a modest but significant difference in denial and repression of emotions, suppression of reactions that may offend others and an avoidance of conflict in the cancer group, as compared to the control group.  These factors were able to significantly discriminate between the cancer and control groups.

During her third year doctoral clinical psychology course, Sharon Lothian conducted her doctoral thesis on Emotional Processing Deficits in Colorectal Cancer (Lothian 2001) with supervision and support from the Dorset Research & Development Support Unit.  The research has now been written up as a journal article (Lothian, Hickish, Baker, Horn, Thomas, Thomas & Owens 2003) submitted.  The research showed significant differences between the colorectal and non-patient control groups in specific subscales of the Emotional Processing Scale (EPS).  The profile of scoring the EPS was distinctly different from that of the groups we have assessed with different psychological disorders.  The study is cross-sectional so it would not allow us to conclude that emotional processing deficits preceded the emergence of colorectal cancer.  It does help us to identify a pattern of emotional processing related to colorectal cancer and not psychological disorder or healthy non-patient groups.