When the Body Says No: The Cost of Hidden Stress (18 page)

Victory or defeat was shown to alter not only the hormonal balance but even the brain cells in a species of fish, the African cichlid. “In defeat, the fish’s hypothalamic cells shrink with consequent declines in reproductive hormones and shrinkage of the testes.” If the situation is manipulated to permit defeated fish to become dominant, there is a dramatic growth of the cells in the hypothalamus that produce a gonadotropin-releasing hormone (GRH), which stimulates the pituitary to produce hormones that act on the testes. The testes, in turn, will now increase in size, and the fish’s sperm counts will improve. “Most importantly, this research has clearly demonstrated …
that it is the behavioural changes
[i.e., the attainment of dominant status]
that lead to the subsequent physiologic changes.”
⁷

As highly evolved creatures, we may like to believe that our gonadal functioning is not as readily susceptible to life’s ups and downs as that of the lowly African cichlid. In fact, human hormone levels, like those in our African fish, may follow rather than precede changes in dominance relationships. Prof. James Dabbs, a social psychologist at Georgia State University in Atlanta, has researched the interaction of testosterone and behaviour. According to a report in
The New York Times
, after reviewing his nearly forty studies he has concluded that while testosterone does increase libido, “there is no proof it causes aggression.” On the other hand, there is proof that emotional states can rapidly alter testosterone
production: “Dr. Dabbs tested fans before and immediately after the 1994 World Cup of soccer final between Italy and Brazil. In what Dr. Dabbs considers proof of the axiom ‘basking in reflected glory,’ testosterone levels swelled among the victorious Brazilians and sank among the dejected Italians.”
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Not surprisingly, then, gonadal function is affected by psychological states in both men and women. In depressed men, the secretion of testosterone and other hormones connected with sexual functioning were found to be significantly diminished.
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A hormone-dependent malignancy like that of the prostate may be highly susceptible to biochemical influences related to stress and emotional states.

Cancer of the prostate is the second commonest malignancy of men. Only cancer of the lung occurs more frequently. Calculations vary, but in the United States in 1996 as many as 317,000 new cases were estimated, and about 41,000 deaths.
¹⁰
About 20,000 new cases are diagnosed in Canada each year.

Environmental factors must be significant. Japanese men migrating to Hawaii and the continental United States were found to have a higher incidence of the disease than those natives of the country who stayed in Japan: over two and a half times as great. Yet on autopsies of men without clinical disease, similar rates of inactive malignant cells were found regardless of geography.
¹¹
The question, then, is, Why do these inactive cells develop into cancerous tumours in one environment but not in another? There are highly suggestive epidemiological findings to indicate that stress crucially influences who will and who will not suffer illness and death from prostate cancer.

Family history increases the risk for prostate cancer, but it is not a major factor in most instances. No specific cancer-inducing environmental agents have been identified comparable to, say, cigarettes and lung cancer. Saturated fats may play a role. Given the wide geographic variation, so may genetic influences. The disease is most prevalent in the Scandinavian countries, least in Asia. The single racial/ethnic group at highest risk in the world are African Americans, among whom prostate cancer is twice as common as among the U.S. white population.

“African-American men have a poorer survival rate than whites for all stages of prostate cancer when the cancer is diagnosed at younger ages.”
¹²
One could ascribe this higher death rate to the reduced access to medical care generally available to lower-middle-class and working-class
people in the U.S. health system. However, the racial differences in prostate malignancy cut across class lines. In any case, greater access to medical care has not so far been shown to have any positive effect on survival. We could possibly attempt to explain the difference in death rates by referring to genetic factors, except that American blacks experience prostate cancer at a sixfold rate compared with black men in Nigeria. Here, too, the presence of clinically “silent” prostate cancer cells is the same in the two groups.
¹³

Now, if environmental factors such as caloric intake were responsible for the development of the disease, one would not expect much difference in the death rate between American whites and blacks. As it stands, only about 10 per cent of the black/white variation in cancer rate has been estimated to be due to the intake of saturated fats.
¹⁴
If, on the other hand, genetic influences were decisive, disease rates between blacks in the U.S. and Nigeria ought to be much closer than they are.

The historical, social and economic position of black people in U.S. society has undermined cohesion in black communities and black families and has imposed greater psychological stress on African Americans than their Caucasian fellow citizens or that blacks in Africa find themselves under. There is a parallel here in the higher occurrence of elevated blood pressure among American blacks. Hypertension is a condition clearly related to stress. In an analogous example, the rates of an autoimmune disease, rheumatoid arthritis, suffered by blacks in South Africa under apartheid increased as they migrated to the city from their native villages, even if in strict financial terms they may have gained by the move. The major factor would seem to be the psychological pressures of living in an environment where official racism directly and overtly deprived people of autonomy and dignity, while it uprooted people from their traditional family and social supports.

A finding consistent with what we have seen elsewhere in relationship to disease and emotional isolation is that men who are currently married, compared with men who are divorced or widowed, are less likely to be diagnosed with prostate cancer.
¹⁵
While I was not able to find in the literature any other investigation specific to prostate cancer and psychological factors, one study did look at men who had greater dependency needs than a comparable group—that is, men who were less able to experience themselves as individuated, self-reliant adults.
This study concluded that dependent men were more likely to develop a number of diseases, including prostate and other cancers.
¹⁶

What would be the practical implications if a holistic perspective gained more research support and was incorporated into the medical view of prostate cancer? First, the promotion of anxiety-producing examinations and tests would cease, at least until we had definite proof of their usefulness. In June 1999 the U.S. Postal Service planned to issue a stamp urging “annual checkups and tests” for cancer of the prostate. the
New England Journal of Medicine
warned against such foolishness, pointing out that the message was “inconsistent with current scientific evidence and thinking within the medical community.”
¹⁷
Second, we would not subject tens of thousands of men to invasive and potentially harmful surgery and other equally unproven interventions without fully informing them of the uncertainty that shrouds the treatment of prostate cancer.

A holistic approach that places the person at the centre, rather than the blood test or the pathology report, takes into account an individual life history. It encourages people to examine carefully each of the stresses they face, both those in their environment and those generated internally. In this scenario the diagnosis of prostate cancer could serve as a wake-up call rather than simply a threat. In addition to whatever treatment they may choose to receive or not receive, men who are encouraged to respond reflectively, taking into account every aspect of their lives, probably increase their chances of survival.

A transformation appears to have affected Rudy Giuliani, diagnosed with prostate cancer in April 2000, in the midst of his Senate race against Hillary Clinton. The former mayor of New York City has been described as a driven man, “a robo-mayor immune to fatigue, fear, or self-doubt,” who “lived and breathed the work ethic.”
¹⁸
He completely identified with his role, slept only four hours a day and worked most of the other twenty. It was said of him that he could not abide being away from the centre of the action. He had to have a hand in everything, needing to be in control, “barking orders like a general.” He had failed to show compassion to suffering individuals and groups and had displayed emotional tightness to an extreme degree. After his diagnosis, he made a remarkable public confession. Referring to his cancer, he said:

In contrast to prostate cancer, another hormone-related cancer of the male genital tract—that of the testicle—has been a success story of medical and surgical oncology. Whereas this rare disease used to be the third leading cause of cancer death among young men, it is no longer even in the top five. The cure rate with early diagnosis is now over 90 per cent. As the remarkable story of the quadruple Tour de France champion, Lance Armstrong, demonstrates, even men with advanced metastatic disease have hope of full recovery with a judicious combination of surgery, radiation or chemotherapy—and determination.

When I was working in palliative care, an oncologist at the British Columbia Cancer Agency asked me to speak with Francis, a thirty-six-year-old with cancer of the testicle—not because he needed palliation, but because he didn’t. Although the tumour had spread to his abdomen by the time Francis was diagnosed, with appropriate treatment he still had a better than fifty-fifty chance of a complete cure. The problem was that he was refusing all medical intervention. The oncologist hoped that my counselling skills might help to reverse his patient’s negative attitude.

The medical statistics promising cure—or, at least, prolonged life—did not interest Francis. He based his refusal on religious grounds, arguing that since God sent him this disease, it would be impious of him to resist it. He said he was not afraid of treatment—he simply felt it was wrong to even consider it. I tried to approach his obstinate denial of life from every angle that came to mind. Was it some childhood guilt that he felt merited punishment? It was evident that personally Francis was isolated in life, with no family or close ones. Was he depressed? Was this a form of medical suicide?

I asked, non-believer as I was, whether perhaps it was blasphemous in him to claim to know God’s will. If God, indeed, had sent him the cancer, could He not have intended it as a challenge for Francis to overcome and learn from? Further, if God was the source of the illness, was He not finally also the source of the medical knowledge that made a cure highly probable?

I asked all these questions, but mostly I just listened to Francis. What I heard was the voice of a very confused and lonely man who was adamant in his refusal to save his life. He stuck firmly to what he felt were unshakeable religious principles, despite the express disagreement about his ideas from the elders of his church. They told him that his interpretation of their denomination’s teaching was wayward and unjustified. They offered to support him through treatment and convalescence, all to no avail.

Francis is one of three or four men I have ever seen with cancer of the testicle. Although the incidence of this malignancy is rising, in the United States there are only about six thousand new cases each year, in Canada about one-tenth that number. There have been no studies of the emotional or personal histories of the men who develop it, only of the psychological consequences. There are remarkable similarities between what little I did learn of Francis’s life, the published autobiography of Lance Armstrong and the experiences of Roy, a young man I knew well, whom I interviewed for this chapter.

Armstrong first noticed a slight swelling of his testicle in the winter of 1996 and began to feel uncharacteristically short of breath next spring. His nipples felt sore, and he had to drop out of the 1997 Tour de France owing to a cough and low-back pain. “Athletes, especially cyclists, are in the business of denial,” Lance Armstrong writes.
¹⁹
It wasn’t until September, when he coughed blood and his testicle became painfully enlarged, that he finally sought medical attention. By then the cancer had spread to his lungs and brain.

When it comes to cancer of the testicle, it is not only cyclists who are in the business of denial. Thirty-year-old Roy first felt the swelling in his left testicle in mid-2000 but put off going to his family doctor for another eight months. In the meantime, he told no one. “I was a little embarrassed and secondly I was afraid of getting bad news,” he says. According to a British study, such reluctance to get help is not untypical
with this disease: “Delayed diagnosis is common, but is more often due to delay in seeking medical advice than to delay in the correct diagnosis being made by the physician…. The maximum period of delay between symptoms and orchidectomy was three years, with a … mean delay of 3.9 months.”
²⁰

It may be that young men are simply loath to accept that there is anything wrong with them, particularly with their sexual organs. But logic would suggest the opposite: if masculinity were the issue, young men would likely run for help as soon as they noticed an abnormality with their testes—just as they do, for example, when they notice their hair thinning owing to familial baldness. Certainly when we look at Roy’s life and at the autobiography of Lance Armstrong, we see deeper motives for the denial of their disease.