The document summarizes challenges faced when scientific evidence contradicts widely held beliefs. It discusses how storylines become entrenched and shape how evidence is perceived, often in a biased way that favors confirming existing beliefs. Even well-conducted studies showing no effect of psychosocial interventions on cancer outcomes have been misrepresented or ignored. The document calls for more transparent and honest reporting of results to establish a climate where null findings are valued rather than hyped results.

1. When Cherished Beliefs ClashWhen Cherished Beliefs Clash
with Evidence, Don’t Expect towith Evidence, Don’t Expect to
Be Thanked for What ScienceBe Thanked for What Science
Does BestDoes Best
James C. Coyne, Ph.D.
University of Pennsylvania School of Medicine and
University Medical Center, Groningen
jcoyne@mail.med.upenn.edu

2. Unpicking dodgy claims, unpacking the
evidence behind dodgy claims, isn’t a
kind of nasty carping activity; it socially
useful, but it’s also extremely valuable
explanatory tool. Because real science
is all about critically appraising the
evidence for someone else’s position.
--Ben Goldacre

3. MuckrakersMuckrakers
Investigative journalists who
reported on corruption, harmful
social conditions, pollution,
food and product safety
standards, sexual harassment,
unfair labor practices, and
fraud.
Came into prominence and
named as such in Progressive
Era of American Politics (1890-
1920).

5. The top journals are filled with noble lies and
fairy tales, promoting myths and claiming great
success in addressing important patient needs
and improving health outcomes, often where
there is none.
Articles appearing in top journals are not
reliable guides to the best evidence.

6. James C. Coyne 1,2
, Brett Thombs3
,Mariët Hagedoorn2
1
University of Pennsylvania, School of Medicine, USA
2
University Medical Center Groningen, the Netherlands
3
McGill University and Jewish General Hospital, Montreal, Canada
Ain’t Necessarily So: Review andAin’t Necessarily So: Review and
Critique of Recent Meta-AnalysesCritique of Recent Meta-Analyses
of Behavioral Medicineof Behavioral Medicine
Interventions inInterventions in Health PsychologyHealth Psychology

7. Storyline in Cancer CareStoryline in Cancer Care
 Much of what we know about psychosocial aspects
of cancer is mythical, even if the myths are
widespread, contrary to fact, taken for granted as
background assumptions, and resistant to evidence.

8. Myth or Storyline inMyth or Storyline in
Cancer CareCancer Care
• Stress, personality, and emotion play substantial
roles in incidence, progression, and outcome of
cancer and psychosocial interventions can
improve survival by strengthening the immune
system.
• Storyline is highly consistent with entrenched
cultural beliefs and fables about the triumph of
human will over adversity and mind over body and
its frailities.

9. Operation of Storylines in Scientific
Discourse

Storlines often have the quality of a promissory note, giving
favorable data more credence than is yet justified.

Storylines tend to exclude, minimize, or incorporate evidence
with a confirmatory distortion.

Yet storylines are the basis by which evidence enters into
clinical and public policy decisions and media depictions of
issues.

10.  Myths carry sentimentality, important emotional
baggage that must be dealt with in any effort to
counter the myth.
 Sentimentality of this cancer storyline countered by
articulation of concern that it hurts patients, not only
by squandering resources, but by blaming patients for
their morbidity and ultimate mortality.

11. We must not allow a shared commitment to
improving the wellbeing of cancer patients to be
exploited with exaggerated claims and poorly
conceived, poorly conducted, and poorly
reported clinical trials.

12. We Thought We WereWe Thought We Were
Done with Claims ThatDone with Claims That
Psychotherapy PromotesPsychotherapy Promotes
the Survival of Cancerthe Survival of Cancer
Patients….Patients….

14. No trial has ever found that psychotherapy improved
the median survival time of women with metastatic
breast cancer.
No trial in which survival was chosen as the outcome
of interest ahead of time has demonstrated a survival
effect for patients with any type of cancer, when
psychotherapy was not confounded with improved
medical surveillance or treatment.
Coyne JC, Stefanek M, Palmer SC. Coyne JC, Stefanek M, Palmer SC.
Psychotherapy and survival in cancer: the Psychotherapy and survival in cancer: the
conflict between hope and evidence. conflict between hope and evidence.
Psychol Bull.Psychol Bull. 2007;133:367-394.2007;133:367-394.

15. Now classic 1989 Lancet Now classic 1989 Lancet
study of Spiegel and study of Spiegel and
colleagues: Was there colleagues: Was there
ever an effect there?ever an effect there?

17.  No one can replicate odd survival curve of
control group in intervention or observational
studies, suggesting something went wrong.
 Curve of Spiegel’s intervention group
approximated by both intervention and control
groups in subsequent studies, suggesting it was
inert.

18. “The results suggest that we can help breast cancer
patients make positive steps that may help them live
longer and make recurrence less likely. We already knew
a psychological intervention program could help breast
cancer patients to handle their stress, function more
effectively, and improve their health. Now we know it
does even more.”
Andersen, B. L., H. C. Yang, et al. (2008). Andersen, B. L., H. C. Yang, et al. (2008).
"Psychologic Intervention Improves "Psychologic Intervention Improves
Survival for Breast Cancer Patients A Survival for Breast Cancer Patients A
Randomized Clinical Trial." Randomized Clinical Trial." CancerCancer
113(12): 3450-3458.113(12): 3450-3458.

19. •No survival effect found in simple analyses, claims
depend on inappropriate multivariate analyses.
•No differences between intervention and control
groups in recurrence or survival.
•Psychosocial intervention consisting of a mixture of
relaxation training, problem solving and health behavior
promotion.
•Null and weak results across 8 measures of mood (No
effects on mood), 15 measures of immune function, and
4 measures of adherence.
A Closer look at Andersen, et al.A Closer look at Andersen, et al.
(2008). (2008). CancerCancer 113(12): 3450-3458. 113(12): 3450-3458.

20. Psychosocial Psychosocial
Intervention, Immune Intervention, Immune
Function, and Function, and
Progression of Cancer: Progression of Cancer:
Unproven MedicineUnproven Medicine

21. Cameron LD, et al. Cognitive and Cameron LD, et al. Cognitive and
affective determinants of decisions to affective determinants of decisions to
attend a group psychosocial support attend a group psychosocial support
program for women with breast cancer. program for women with breast cancer.
Psychosomatic MedicinePsychosomatic Medicine 2005;67:584-589. 2005;67:584-589.
Many breast cancer patients are attending group therapy
with the belief that they are fighting their cancer by
strengthening their immune system.

22. Weak or No Effects, But Positive Results Emphasized,
Strong Confirmatory Bias in Reporting New Results
and Recounting of Past Studies.
Doubtful Clinical Significance Even If Results Were
Obtained.
Confused, Simplistic View of Role of Immune System
in Cancer Progression.
Claims That Psychosocial Claims That Psychosocial
Intervention Strengthens the Intervention Strengthens the
Immune SystemImmune System

23. Each of the measures used in this literature represents only a
small facet of a complex, highly redundant system. It would
therefore be inappropriate to conclude that intervention-related
changes in any specific immune parameter signal a state of
"immune enhancement" or altered susceptibility to immune-
mediated disease. The normal functioning range for most
immune measures is very broad, and psychological
interventions typically do not induce changes of sufficient
magnitude to move people outside of these boundaries (p. 48).
Miller GE, Cohen S. Psychological Miller GE, Cohen S. Psychological
interventions and the immune system: A interventions and the immune system: A
meta-analytic review and critique. meta-analytic review and critique. HealthHealth
Psychology.Psychology. Jan 2001;20(1):47-63.Jan 2001;20(1):47-63.

24. How Does Sticking to a How Does Sticking to a
Storyline Get Enforced?Storyline Get Enforced?
No Conspiracy Theory No Conspiracy Theory
Needed.Needed.

25. “Confirmatory Bias Has Existed Even in
Historical Periods When There Were No
Incentives, in Terms of Fame or
Fortune.”
-Robert K. Merton

26. Copyright ©2005 American Heart Association
Loscalzo, J. Circulation 2005;112:3026-3029
Incentives and Pressures to Fit Incentives and Pressures to Fit
Research to a StorylineResearch to a Storyline

27. ‘‘By the time many young people figure out the
system, they are so much a part of it, so obsessed
with keeping their grants, that their imagination
and instincts have been so muted (or corrupted)
that their best work is already behind them. This
is made much worse by the US system in which
assistant professors in medical schools will soon
have to raise their own salaries. Who would dare
to pursue risky ideas under these circumstances?
Who could dare change their research field,
ever?”
-Ted Cox, Director of the Program on Biophysics,
Princeton University

28. Do Americans Do ItDo Americans Do It
Bigger and Better?Bigger and Better?

31. Scandinavian Data SetsScandinavian Data Sets
 Democratic socialist countries with integrated health
system and uniform medical and death records
 Despite concern with social inequalities and
disparities, Scandinavia lacks the gross differences
found in the US due to race/ethnic status, income,
and insurance status.

32. Nakaya et al (2010)Nakaya et al (2010)
 The [Finnish] cohort consists of all …same-sex twin pairs born
before 1958, of which both members were alive in 1975.
 The Swedish twin cohort was identified from the population-
based Swedish Twin Registry, the largest of its kind in the
world, which has information on more than 140,000 twins.
 Information on cancer diagnoses was obtained by record
linkage to the national cancer registries …using the unique
identification numbers assigned to everyone residing in those
countries.
 Data on emigration and death were obtained in Finland by
record linkage to the Population Register Centre and in Sweden
by record linkage to the National Population Register.

34. The Danish StudiesThe Danish Studies
 Ross et al (2009): Between September 1996 and May 1999,
we sought to include all patients aged 18 or over who were
being treated for a primary colorectal cancer by abdominal
surgery at the surgical departments of eight hospitals in the
eastern part of Denmark.
 Boesen, et al (2007): In this population-based, randomized
trial conducted in a society with free hospital treatment,
psychoeducation for patients treated for cutaneous malignant
melanoma did not influence time to recurrence or survival.

35. Why Don’t the Danes Get theWhy Don’t the Danes Get the
Attention They Deserve forAttention They Deserve for
What is the Best-of-Its-KindWhat is the Best-of-Its-Kind
Research?Research?

36. Danish Psycho-OncologyDanish Psycho-Oncology
Research Lacks Hype,Research Lacks Hype,
Confirmatory Bias of AmericanConfirmatory Bias of American
ResearchResearch

37. Telling It Like It Ain’t: How toTelling It Like It Ain’t: How to
Succeed in Psycho-OncologySucceed in Psycho-Oncology

Have Lots of Endpoints and Ignore Negative Results
in Main Analyses of Primary Endpoints.

Favor Secondary Analyses, Subgroup Analyses, and
Endpoints Developed Post Hoc Over Negative
Findings for Primary Analyses.

Ignore Methodological Shortcomings That Would
Make Trial or Meta Analyses Invalid.

38. Telling It Like It Ain’t: How toTelling It Like It Ain’t: How to
Succeed in Psycho-OncologySucceed in Psycho-Oncology
• Present Negative Findings as if Positive in Subsequent
Publications and Exaggerate Findings That Are
Positive

Assess Multiple Endpoints and Treat Any Significant
Finding as if it were a Replication of Past Findings

Create a False Consensus and Seeming Unanimity in
the Literature by Cherrypicking Findings That Can be
Construed as Positive and Ignoring the Rest

39. A credible scientific journal should publish all studies with
‘‘null’’ results provided they acknowledge their limitations.
Conversely, such a journal should be cautious about publishing
‘‘positive’’ results, most of which are false. Independent
replication is important and should be done by different teams,
preferably by competitors. ‘‘Null’’ results should be published
promptly in print in short versions, with more extensive details in
web-based files.
Ioannidis, J. P. A. (2006). JournalsIoannidis, J. P. A. (2006). Journals
should publish all "null" results andshould publish all "null" results and
should sparingly publish "positive"should sparingly publish "positive"
results.results. Cancer EpidemiologyCancer Epidemiology
Biomarkers & PreventionBiomarkers & Prevention 15(1): 185-15(1): 185-
186.186.

40. Ioannidis, J. P. A. (2006). JournalsIoannidis, J. P. A. (2006). Journals
should publish all "null" results andshould publish all "null" results and
should sparingly publish "positive"should sparingly publish "positive"
results.results.
“Positive” results should be published equally promptly,
but only on the web, pending independent replication;
once refuted, the original article and the refutation could
be printed as a single nice null report; the rare validated
findings should appear in print with full details.

41. The GoalThe Goal

To Create a Climate in Which Honest Reporting Of
Well Conducted, But Negative Trials is More Valued
than Hyping and Hiding of Results.

To Value the Weight of Evidence, Whatever That May
Be, Over Noble Lies and Fairy Tales That Make
Health Psychology Look Good.

42. Taking Heat…Taking Heat…

43. Resistance to criticism of what isResistance to criticism of what is
published.published.
“[The authors’] frustration with the work of others is
not enough to appoint themselves as the Supreme
Judges of the work of others - however flawed this
work might be.” [Anonymous reviewer, Tell It Like It
Ain’t..article].

44. It is with a heavy heart that I have concluded that Dr. Coyne
suffers from an incurable illness: narcissistic myopia. He is a
depression researcher, so successful treatment of mere anxiety
symptoms appears meaningless to his limited vision. It … seems
to permit him to dismiss the results of 25 years of my and many
other colleagues' research demonstrating positive effects of group
support for cancer patients. I can live with his distortion of the
published data…but when he insults my patients by informing us
that our supportive/expressive groups are a "waste of seriously ill
patients' potentially short remaining lives," my tolerance for his
obvious impairment vanishes. One of my patients who attended
our supportive/expressive group for six years said: "This group is
the least superficial thing I do in my life." She and her family
thanked me for it when I visited her home shortly before she
died.
-David Spiegel, M.D., Stanford University (Listserv post)

45. Response to David Spiegel:Response to David Spiegel:
Well, David, seeing that no one, not even you, has
been able to replicate the findings for survival reported
in your 1989 supportive-expressive therapy article in
Lancet, might you now consider the possibility that
the 1989 findings were spurious? What further data
would it take for you to consider that possibility?

46. Barbara Andersen on CoyneBarbara Andersen on Coyne
“Dr. Coyne’s writing strategy is, in the first
portion of a sentence, to mischaracterize an
aspect of a study and then, in the second part,
assert why the aspect is methodologically
flawed.
“Dr. Coyne uses wording such as “the authors’
claim” or sarcasm that are [sic] not appropriate
to scientific discourse.”

47. Response to Barbara Andersen:Response to Barbara Andersen:
Well, Barbara, even if you wouldn’t respond to our
peer-reviewed article suggesting that you did not get
an effect on survival, might you consider publishing
standard, unadjusted outcomes, such as a Kaplan-
Meier estimate of the survival function so that readers
can decide for themselves? After all, strong claims
require strong data.

48. When anWhen an
investigator, wellinvestigator, well
armed with aarmed with a
hypothesishypothesis
consistent withconsistent with
entrenched culturalentrenched cultural
beliefs...beliefs...

49. encounters a gang of unruly data...encounters a gang of unruly data...

50. only the investigator walks away,only the investigator walks away,
with his hypothesis unscathed.with his hypothesis unscathed.