Psychosocial Risk Factors for Lung Cancer R. L. HORNE, MD* AND R. S. PICARD, MD The existence of psychosocial risk factors for the development of malignancy has been postulated by many investigators. This study investigated selected psychosocial factors as predictors of malignancy. 110 male patients with undiagnosed subacute or chronic pulmonary x-ray lesions participated in a semistructured interview. Ratings were made of 5 subscales: 1) childhood instability, 2) job stability, 3) marriage stability, 4) lack of plans for the future, and 5) recent significant loss. The composite scale correctly predicted the diagnosis of 53 (80%) of the 66 patients with benign disease and 27 (61 %) of the 44 with lung cancer. The scale was at least as important as smoking history in predicting diagnoses. Thus, significant psychosocial risk factors for the development of malignant disease might well be incorporated in selecting highrisk individuals for cytological or other screening for lung cancer.
INTRODUCTION
Carcinoma of the lung offers a challenging opportunity in predictive oncology. It is a potentially curable disease, with a 5-year survival rate of up to 60% (6), if diagnosed early. The key to such early diagnosis is identifying small groups at very high risk, so that persuasive and diagnostic measures can be concentrated in an economically feasible way. One of the best-established risk factors for the development of lung cancer is cigarette smoking. Males who smoke at least 2 packs per day have 20 times as great a chance of dying from lung cancer as nonsmokers. However, less than 8% of this group will ever develop the disease (1). Smokers can use this figure and the 'Present address: Carrier Foundation, Belle Meade, New Jersey and the Department of Psychiatry, University of Pennsylvania, Philadelphia. From John Cochran VA Hospital and Washington University School of Medicine, St. Louis, Missouri and the VA Hospital, Shreveport, Louisiana. Address requests for reprints to: Dr. R.L. Home, Carrier Foundation, P.O. Box 147, Belle Meade, NJ 08502. Received for publication November 15, 1978; final revision received August 15, 1979.
"other guy" approach to rationalize their decision to continue to smoke and thus thwart antismoking campaigns. An alternative to persuasive techniques, screening all male smokers for lung cancer with chest x-rays, is ineffective and prohibitively expensive (29). If cytology is added to the screening program, diagnostic sensitivity is greatly improved, but the costs soar (29). Clearly, knowledge of additional risk factors would help delineate a smaller group at higher risk for lung cancer. Many epidemiological studies have identified several sociological and occupational risk factors associated with lung cancer. Among these are lower socioeconomic level (10), less education (26), urban residence (18), alcoholism (7), and industrial exposure to asbestos, iron oxide, arsenic, uranium, chromates, nickel, and various organic compounds (7, 9). Other investigators have turned to psychological factors in their attempts to select a high-risk group (3,4,19). The idea is not a new one. Galen, as early as the 2nd century AD, proposed that personality played an important role in the formation of neoplasms. Fourteen anecdotal studies,
Psychosomatic Medicine Vol. 4 1 , No. 7 (November 1979) Copyright c 1979 by the American Psychosomatic Society, Inc. Published by Elsevier North Holland, Inc.
503 0033-31 74/79/O7O5O312$01.75
R. L. HORNE AND R. S. PICARD
which linked severe emotional stress or loss and subsequent development of cancer, appeared between 1701 and 1893 (24). Recently many others, including Bahnson (2), Booth (8), Green (12), Kissen (18), LeShan (22), and Schmale and Iker (28) have also suggested that various personality factors are involved in the pathogenesis of cancer. Kissen (17), LeShan (23), and LeShan and Worthington (24) have reviewed these studies. The most consistent factors reported seem to be: 1) the patients' loss of important relationships shortly before the development of the tumor, 2) the patients' inability to adequately express emotions, especially negative ones, and 3) the patients' lack of closeness to parents. Most of the reports in the literature are either retrospective or study a population in which an illness that is present may or may not be cancer. An exception is Thomas and Duszynski's (32) prospective study of 1008 Johns Hopkins medical students, of whom 30 developed cancer. They concluded: "subjects who later developed a malignant tumor perceived their relationship to their parents as one which gave evidence of a lack of closeness" (p. 265). Animal studies by other investigators, including Gross and Colmano (13) and Riley (27) have suggested mechanisms by which psychosocial factors could produce malignancy. The prevailing hypothesis is that stress and emotional distress, via the endocrine and central nervous systems, tend to suppress the functioning of the immunological system in its recognition and destruction of foreign tumor cells (25). The evidence has been reviewed by LaBarba (20), Solomon and Amkraut (30), and Stein et al. (31). Is it possible to combine the suggested causal factors to distinguish a group of 504
individuals likely to develop cancer? If so, they can be screened at an efficient cost. Bahnson and Bahnson (5) have suggested that a 59-item psychosocial questionnaire might reduce a population to be examined by 88%, and thereby increase the probability of diagnosing cancer sixfold (from 8/1000 to 1/20). Their questionnaire focused on items dealing with the present situation, including affect, smoking habit, ego defensive styles, attitudes, and philosophy of life. The present study used the same general approach, but focuses more on longitudinal variables. Its hypothesis is that a weighted set of psychosocial indicators can help identify a group at high risk for pulmonary malignancy. The psychosocial indicators selected for inclusion in the set (on the basis of a literature review and pilot data) are concerned with an unstable childhood, a very stable job and marital history, a lack of plans for the future, and recent significant loss (see Table 1). METHOD
Selection of Subjects All 130 subjects who were asked to participate in the study were male patients at one of two Veterans Administration Hospitals. The criterion for selection was the presence of an undiagnosed, subacute or chronic lung lesion visible on roentgenographic examination. Prior to requesting that they volunteer for the study, all subjects were informed that: 1) they had been selected by other doctors on the basis of their chest x-ray for inclusion in a study of lung disease, 2) the study would require their answering questions that were primarily historical in nature, 3) they either had no lung disease (and hence would be in a control group) or had an as yet undiagnosed lung disease, 4) the investigators who would be talking with them had no idea whether they did indeed have any lung disease,
Psychosomatic Medicine Vol. 4 1 , No. 7 (November 1979)
PSYCHOSOCIAL RISK FACTORS FOR CANCER TABLE 1.
Hypothesized Psychosocial Risk Factors for Malignancy
A. Child-hood Instability 1. Death of mother 2. Death of father 3. Separation or divorce of parents 4. Raised by substitute parents 5. Heavily drinking parent(s) 6. Parent(s) away from home frequently 7. Mother working outside the home 8. Chronic illness of sibling 9. Disability of parent(s) 10. More than four geographic moves in childhood
distinguished by whether the pulmonary lesions visible on x-ray were malignant or benign. The third, a Control group, consisted of those patients who were referred for inclusion in the study, but upon evaluation and reinspection of their chest x-rays, were found to have only chronic obstructive lung disease (COPD) or no lung disease.
Interview
All volunteers for the study received a semistructured interview that lasted for 35 to 70 minutes (mean = 47). After initial rapport was established, subjects were given the opportunity to discuss sigB. Job Stability nificant childhood events, their job history, their 1. Increased length of employment for one em- marital history, recent (past 5 years) life changes or ployer events, and their plans for the future. If necessary, 2. Increased length of employment in one type of specific questions were asked to obtain information job on 40 variables, which included all those in Table 3. Fewer than five jobs held after youth 1.*
C. Marriage Stability 1. Increased length of marriage 2. Married one time, never divorced or separated 3. Lack of remarriage after death of spouse 4. Lack of remarriage after divorce D. Lack of Plans for the Future 1. Absence of new interests for the future 2. Few hobbies E. Recent Significant Loss 1. Occurrence of significant loss in past 5 years 2. Loss occurred greater than 6 months prior to admission
5) the investigators did not know, and did not want to know, about the symptoms that had resulted in hospitalization, 6) they could decline to answer any question or terminate the interview at any time, and 7) the interview would be tape recorded. There were three samples of patients at two hospitals who were seen by one or both of the authors. Patients were referred for the study by members of the Departments of Medicine at both hospitals and the Department of Radiology at one hospital. Of the 130 patients referred, 7 refused to participate, 9 were excluded because of eventual diagnosis of malignancy without lung involvement, and no diagnosis had been made on 4 men at follow-up Thus, 110 men remained in the study. These patients were retrospectively divided into 3 groups. The first two, Malignant and Benign, were
Psychosocial Scale Each patient was given a score on a 1 - 5 scale in each of 5 dimensions: 1) Childhood Instability, 2) Job Stability, 3) Marriage Stability, 4) Lack of Plans for the Future, and 5) Recent Significant Loss. The variables entering into each dimension are listed in Table 1. The scores in dimensions 1. 2, and 5 were doubled and all 5 were summed to give a possible range of scores from 8 to 40. Both investigators independently scored the first 35 patients interviewed. The interrater reliability coefficient was 0.94 for the overall Psychosocial Scale scores. As an example of how the specific scores were derived, consider a patient who had worked for 25 years as a truck driver, but had not worked for any one employer for more than 7 years. Although there were three potential sources of information relevant to this category (see Table 1), only two were applicable to this patient. He would receive 2 points because his longest length of employment for one employer was greater than 5, but less than 10 years. He would then be given an additional 2 points because he had been employed in one type of job for more than 20 years. Thus, his total Job Stability Subscale score
*A complete list may be obtained from National Auxiliary Publication Service, c/o Microfiche Publications, 440 Park Avenue South, New York, NY 10016.
Psychosomatic Medicine Vol. 4 1 , No. 7 (November 1979)
505
R. L. HORNE AND R. S. PICARD
graphic lesions.* The control group consisted of ten patients with COPD and eight patients with no active lung disease. There were no significant differences on any recorded variable between the patients in the control group and those with benign pulmonary disease, so they were combined for the analysis reported here. In addition, there were no significant difPostinterview Procedures ferences between the hosptials in distribuSubsequent io the interview and prediction of betions of patients on the recorded variables, nign or malignant disease, the following information including age (mean 57.7 years) or race was obtained from the patients' charts, or if neces(60% white) or actual diagnosis (x2 = sary from additional questioning of the patients: 1) smoking histdry 2) exposure to carcinogens, 3) 2.67, d/ = 2), so the patients from the two psychiatric diagnosis, if any, 4) duration of present- hospitals were also combined. ing symptoms prior to admission, and 5) initial The 8-40 point Psychosocial Scale dediagnostic impression of the admitting physician. rived from the hypotheses correctly preActual pathological diagnosis was obtained in a dicted the diagnosis of 53 (80%) of the 66 follow-up review of the patients' charts from 15 to 38 months after the interview (mean = 26). individuals with benign disease and 27 (61 %) of the 44 with malignant disease (x2 = 19.8, d/ = 1, p < 0.0001, overall perRESULTS centage = 73). (See Table 2.) Table 3 presents the frequency of Final diagnoses revealed 44 patients had malignant pulmonary disease. Of several levels on the Psychosocial Scale these 28 (64%) had squamous cell car- and the corresponding actual diagnoses. If cinoma, 13 (30%] had undifferentiated the arbitrary dividing point for the prediccarcinoma, 2 (4%) had adenocarcinoma, tion of malignancy had been below the and 1 (2 %) had a metastatic tumor. Of the midpoint of the scale, i.e., 23.5 instead of 48 patients with benign disease, 22 (46%) had tuberculosis, 10 (21%) had definite Based on Psychobacterial pneumonia, 6 (12%) had proba- TABLE 2. Results of Predictions social Scale 9 ble pneumonia, 1 (2%) had fungal disPredicted Diagnoses ease, and 9 (19%) had other benign radio- Pathological
would be 4 out of a possible 5 points. The operational definitions for all of the risk factors listed in Table 1 are available.* It was predicted that individuals with low scores (arbitrarily defined as at or below the midpoint, i.e., 8-24) would have benign disease and that those with high scores (above the midpoint, i.e., 25-40) would have malignant disease.t
*A complete set of algorithms for scoring the Psychosocial Scale can be obtained from National Auxiliary Publication Service, c/o Microfiche Publications, 440 Park Avenue South, New York, NY 10016. tWhen an individual scored 24 points, an additional prediction of benign or malignant disease was made, based on the "clinical judgment" of the interviewer. This was designed as a check on possible investigator bias resulting from the appearance or nonverbal behavior of the patient. These predictions were correct in 5 of the 10 patients who scored 24. This does not depart from chance expectations. 506
total
Diagnoses
benij;n
malignant
Benign Malignant
53 17
13 27
66 44
70
40
110
r=i,p
INTRODUCTION
Carcinoma of the lung offers a challenging opportunity in predictive oncology. It is a potentially curable disease, with a 5-year survival rate of up to 60% (6), if diagnosed early. The key to such early diagnosis is identifying small groups at very high risk, so that persuasive and diagnostic measures can be concentrated in an economically feasible way. One of the best-established risk factors for the development of lung cancer is cigarette smoking. Males who smoke at least 2 packs per day have 20 times as great a chance of dying from lung cancer as nonsmokers. However, less than 8% of this group will ever develop the disease (1). Smokers can use this figure and the 'Present address: Carrier Foundation, Belle Meade, New Jersey and the Department of Psychiatry, University of Pennsylvania, Philadelphia. From John Cochran VA Hospital and Washington University School of Medicine, St. Louis, Missouri and the VA Hospital, Shreveport, Louisiana. Address requests for reprints to: Dr. R.L. Home, Carrier Foundation, P.O. Box 147, Belle Meade, NJ 08502. Received for publication November 15, 1978; final revision received August 15, 1979.
"other guy" approach to rationalize their decision to continue to smoke and thus thwart antismoking campaigns. An alternative to persuasive techniques, screening all male smokers for lung cancer with chest x-rays, is ineffective and prohibitively expensive (29). If cytology is added to the screening program, diagnostic sensitivity is greatly improved, but the costs soar (29). Clearly, knowledge of additional risk factors would help delineate a smaller group at higher risk for lung cancer. Many epidemiological studies have identified several sociological and occupational risk factors associated with lung cancer. Among these are lower socioeconomic level (10), less education (26), urban residence (18), alcoholism (7), and industrial exposure to asbestos, iron oxide, arsenic, uranium, chromates, nickel, and various organic compounds (7, 9). Other investigators have turned to psychological factors in their attempts to select a high-risk group (3,4,19). The idea is not a new one. Galen, as early as the 2nd century AD, proposed that personality played an important role in the formation of neoplasms. Fourteen anecdotal studies,
Psychosomatic Medicine Vol. 4 1 , No. 7 (November 1979) Copyright c 1979 by the American Psychosomatic Society, Inc. Published by Elsevier North Holland, Inc.
503 0033-31 74/79/O7O5O312$01.75
R. L. HORNE AND R. S. PICARD
which linked severe emotional stress or loss and subsequent development of cancer, appeared between 1701 and 1893 (24). Recently many others, including Bahnson (2), Booth (8), Green (12), Kissen (18), LeShan (22), and Schmale and Iker (28) have also suggested that various personality factors are involved in the pathogenesis of cancer. Kissen (17), LeShan (23), and LeShan and Worthington (24) have reviewed these studies. The most consistent factors reported seem to be: 1) the patients' loss of important relationships shortly before the development of the tumor, 2) the patients' inability to adequately express emotions, especially negative ones, and 3) the patients' lack of closeness to parents. Most of the reports in the literature are either retrospective or study a population in which an illness that is present may or may not be cancer. An exception is Thomas and Duszynski's (32) prospective study of 1008 Johns Hopkins medical students, of whom 30 developed cancer. They concluded: "subjects who later developed a malignant tumor perceived their relationship to their parents as one which gave evidence of a lack of closeness" (p. 265). Animal studies by other investigators, including Gross and Colmano (13) and Riley (27) have suggested mechanisms by which psychosocial factors could produce malignancy. The prevailing hypothesis is that stress and emotional distress, via the endocrine and central nervous systems, tend to suppress the functioning of the immunological system in its recognition and destruction of foreign tumor cells (25). The evidence has been reviewed by LaBarba (20), Solomon and Amkraut (30), and Stein et al. (31). Is it possible to combine the suggested causal factors to distinguish a group of 504
individuals likely to develop cancer? If so, they can be screened at an efficient cost. Bahnson and Bahnson (5) have suggested that a 59-item psychosocial questionnaire might reduce a population to be examined by 88%, and thereby increase the probability of diagnosing cancer sixfold (from 8/1000 to 1/20). Their questionnaire focused on items dealing with the present situation, including affect, smoking habit, ego defensive styles, attitudes, and philosophy of life. The present study used the same general approach, but focuses more on longitudinal variables. Its hypothesis is that a weighted set of psychosocial indicators can help identify a group at high risk for pulmonary malignancy. The psychosocial indicators selected for inclusion in the set (on the basis of a literature review and pilot data) are concerned with an unstable childhood, a very stable job and marital history, a lack of plans for the future, and recent significant loss (see Table 1). METHOD
Selection of Subjects All 130 subjects who were asked to participate in the study were male patients at one of two Veterans Administration Hospitals. The criterion for selection was the presence of an undiagnosed, subacute or chronic lung lesion visible on roentgenographic examination. Prior to requesting that they volunteer for the study, all subjects were informed that: 1) they had been selected by other doctors on the basis of their chest x-ray for inclusion in a study of lung disease, 2) the study would require their answering questions that were primarily historical in nature, 3) they either had no lung disease (and hence would be in a control group) or had an as yet undiagnosed lung disease, 4) the investigators who would be talking with them had no idea whether they did indeed have any lung disease,
Psychosomatic Medicine Vol. 4 1 , No. 7 (November 1979)
PSYCHOSOCIAL RISK FACTORS FOR CANCER TABLE 1.
Hypothesized Psychosocial Risk Factors for Malignancy
A. Child-hood Instability 1. Death of mother 2. Death of father 3. Separation or divorce of parents 4. Raised by substitute parents 5. Heavily drinking parent(s) 6. Parent(s) away from home frequently 7. Mother working outside the home 8. Chronic illness of sibling 9. Disability of parent(s) 10. More than four geographic moves in childhood
distinguished by whether the pulmonary lesions visible on x-ray were malignant or benign. The third, a Control group, consisted of those patients who were referred for inclusion in the study, but upon evaluation and reinspection of their chest x-rays, were found to have only chronic obstructive lung disease (COPD) or no lung disease.
Interview
All volunteers for the study received a semistructured interview that lasted for 35 to 70 minutes (mean = 47). After initial rapport was established, subjects were given the opportunity to discuss sigB. Job Stability nificant childhood events, their job history, their 1. Increased length of employment for one em- marital history, recent (past 5 years) life changes or ployer events, and their plans for the future. If necessary, 2. Increased length of employment in one type of specific questions were asked to obtain information job on 40 variables, which included all those in Table 3. Fewer than five jobs held after youth 1.*
C. Marriage Stability 1. Increased length of marriage 2. Married one time, never divorced or separated 3. Lack of remarriage after death of spouse 4. Lack of remarriage after divorce D. Lack of Plans for the Future 1. Absence of new interests for the future 2. Few hobbies E. Recent Significant Loss 1. Occurrence of significant loss in past 5 years 2. Loss occurred greater than 6 months prior to admission
5) the investigators did not know, and did not want to know, about the symptoms that had resulted in hospitalization, 6) they could decline to answer any question or terminate the interview at any time, and 7) the interview would be tape recorded. There were three samples of patients at two hospitals who were seen by one or both of the authors. Patients were referred for the study by members of the Departments of Medicine at both hospitals and the Department of Radiology at one hospital. Of the 130 patients referred, 7 refused to participate, 9 were excluded because of eventual diagnosis of malignancy without lung involvement, and no diagnosis had been made on 4 men at follow-up Thus, 110 men remained in the study. These patients were retrospectively divided into 3 groups. The first two, Malignant and Benign, were
Psychosocial Scale Each patient was given a score on a 1 - 5 scale in each of 5 dimensions: 1) Childhood Instability, 2) Job Stability, 3) Marriage Stability, 4) Lack of Plans for the Future, and 5) Recent Significant Loss. The variables entering into each dimension are listed in Table 1. The scores in dimensions 1. 2, and 5 were doubled and all 5 were summed to give a possible range of scores from 8 to 40. Both investigators independently scored the first 35 patients interviewed. The interrater reliability coefficient was 0.94 for the overall Psychosocial Scale scores. As an example of how the specific scores were derived, consider a patient who had worked for 25 years as a truck driver, but had not worked for any one employer for more than 7 years. Although there were three potential sources of information relevant to this category (see Table 1), only two were applicable to this patient. He would receive 2 points because his longest length of employment for one employer was greater than 5, but less than 10 years. He would then be given an additional 2 points because he had been employed in one type of job for more than 20 years. Thus, his total Job Stability Subscale score
*A complete list may be obtained from National Auxiliary Publication Service, c/o Microfiche Publications, 440 Park Avenue South, New York, NY 10016.
Psychosomatic Medicine Vol. 4 1 , No. 7 (November 1979)
505
R. L. HORNE AND R. S. PICARD
graphic lesions.* The control group consisted of ten patients with COPD and eight patients with no active lung disease. There were no significant differences on any recorded variable between the patients in the control group and those with benign pulmonary disease, so they were combined for the analysis reported here. In addition, there were no significant difPostinterview Procedures ferences between the hosptials in distribuSubsequent io the interview and prediction of betions of patients on the recorded variables, nign or malignant disease, the following information including age (mean 57.7 years) or race was obtained from the patients' charts, or if neces(60% white) or actual diagnosis (x2 = sary from additional questioning of the patients: 1) smoking histdry 2) exposure to carcinogens, 3) 2.67, d/ = 2), so the patients from the two psychiatric diagnosis, if any, 4) duration of present- hospitals were also combined. ing symptoms prior to admission, and 5) initial The 8-40 point Psychosocial Scale dediagnostic impression of the admitting physician. rived from the hypotheses correctly preActual pathological diagnosis was obtained in a dicted the diagnosis of 53 (80%) of the 66 follow-up review of the patients' charts from 15 to 38 months after the interview (mean = 26). individuals with benign disease and 27 (61 %) of the 44 with malignant disease (x2 = 19.8, d/ = 1, p < 0.0001, overall perRESULTS centage = 73). (See Table 2.) Table 3 presents the frequency of Final diagnoses revealed 44 patients had malignant pulmonary disease. Of several levels on the Psychosocial Scale these 28 (64%) had squamous cell car- and the corresponding actual diagnoses. If cinoma, 13 (30%] had undifferentiated the arbitrary dividing point for the prediccarcinoma, 2 (4%) had adenocarcinoma, tion of malignancy had been below the and 1 (2 %) had a metastatic tumor. Of the midpoint of the scale, i.e., 23.5 instead of 48 patients with benign disease, 22 (46%) had tuberculosis, 10 (21%) had definite Based on Psychobacterial pneumonia, 6 (12%) had proba- TABLE 2. Results of Predictions social Scale 9 ble pneumonia, 1 (2%) had fungal disPredicted Diagnoses ease, and 9 (19%) had other benign radio- Pathological
would be 4 out of a possible 5 points. The operational definitions for all of the risk factors listed in Table 1 are available.* It was predicted that individuals with low scores (arbitrarily defined as at or below the midpoint, i.e., 8-24) would have benign disease and that those with high scores (above the midpoint, i.e., 25-40) would have malignant disease.t
*A complete set of algorithms for scoring the Psychosocial Scale can be obtained from National Auxiliary Publication Service, c/o Microfiche Publications, 440 Park Avenue South, New York, NY 10016. tWhen an individual scored 24 points, an additional prediction of benign or malignant disease was made, based on the "clinical judgment" of the interviewer. This was designed as a check on possible investigator bias resulting from the appearance or nonverbal behavior of the patient. These predictions were correct in 5 of the 10 patients who scored 24. This does not depart from chance expectations. 506
total
Diagnoses
benij;n
malignant
Benign Malignant
53 17
13 27
66 44
70
40
110
r=i,p
