The Paradox of Positive Thinking

DOI: 10.1200/JCO.2011.34.7450 Although his symptoms had been festering for months, it was not until James sank his teeth into a peanut butter and jelly sandwich that he finally knew with certainty that something was horribly wrong. His nose had been draining incessantly, but numerous evaluations and attempts at treatment— including a septoplasty and course after course of antibiotics—had not solved the problem. He kept smiling his increasingly crooked smile while explaining himself to a multitude of physicians. Eventually, on that fateful day, James felt a sharp twinge while taking a bite and quickly pulled the sandwich out of his mouth. He inspected the slice of bread and found one of his teeth buried inside of it. I first met thirty-five-year-old James about 3 weeks later, after at long last the necrotic mass that was at the root of his problem had been discovered near his hard palate. Detection of the mass was quickly followed by a biopsy—two biopsies, actually, because the first sample was nondiagnostic. After soliciting an array of pathologist opinions, a specific diagnosis was finally made: natural killer/Tcell lymphoma, nasal type. Natural killer/T-cell lymphomas are rare neoplasms that carry a poor prognosis even when detected at an early stage and are usually rapidly fatal when metastatic. At that point, we did not know much else, but that did not stop me from facing James and a hospital room filled with his family and friends to explain the basics of his diagnosis. I described the type of tumor he had, the likely severity of its involvement in his skull, and the need for many additional tests. I suspect I was appropriately morose. Yet after my somber monologue stirred the growing tension that had been simmering in his room since he was admitted to the hospital, James turned to me and said, “I feel great, so this won’t be a problem. I’ve got to stay positive.” I smiled, offered encouragement, and left the room. The next day, James underwent a positron emission tomography/computed tomography scan. I was still hopeful that he had only localized disease, but the mass had likely been present for quite a while, and I felt compelled to remain properly pessimistic. When the imaging study showed a suspicious liver mass, I was not surprised. I returned to the patient’s room, again faced an explosion of family and friends standing at his bedside, and explained the bad news. “I understand it has spread. That won’t stop me. I’m going to be fine.” His crooked smile, which had become slightly more jagged with the continued invasion of the tumor into his palate, returned. Was I communicating the bad news ineffectively? Did he truly understand his grim situation? I repeated the information and the need for another procedure to biopsy the liver mass. He laughed and reassured his family that everything would be fine. I did not correct him. Although I knew I was explaining his scenario in approachable terms, he was not responding in kind. I smiled, offered further encouragement, and left the room. I began wondering whether James’s staypositive coping strategy was part of a larger accepted modality among patients with cancer. I discovered that numerous investigators have attempted to correlate the way patients handle a cancer diagnosis with the patients’ eventual outcomes. Although a few smaller studies have suggested a survival benefit in maintaining a persistently positive mental approach no matter how grim the situation, the bulk of data strongly supports the notion that there is no difference in outcome, regardless of the coping mechanism a patient chooses. In fact, many of the claims made in the positive psychology literature have been refuted or are so vague that they are not testable with any degree of scientific rigor. Perhaps, I thought, for some patients like James, positive thinking is a reflex, a means of facing the seemingly insurmountable struggle that lies ahead. Was it then my responsibility to meet him where he was and try to sustain his artificially created state of mind or instead to try to force him to convert to my own more realistic view of his situation? The liver mass was biopsied, and it confirmed metastatic disease. After the findings were explained to the patient, he turned to his family and smiled. They smiled back at him. “It’s just a small bump in the road. I’m going to be fine.” Was he suffering under the weight of his family’s expectations to fight on, a common phenomenon among patients with cancer that many find unbearable, yet simultaneously immutable? I explained to him that I admired his steadfast positivity in the wake of this challenge, which he seemed to appreciate greatly. JOURNAL OF CLINICAL ONCOLOGY T H E A R T O F O N C O L O G Y VOLUME 29 NUMBER 19 JULY 1 2011