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EUROPEAN JOURNAL OF MEDICAL RESEARCH
Abstract
Objective: Superstition is common and causes discom-
fiture or fear, especially in patients who have to under-
go surgery for cancer. One superstition is, that moon
phases influence surgical outcome. This study was per-
formed to analyse lunar impact on the outcome fol-
lowing lung cancer surgery.
Methods: 2411 patients underwent pulmonary resec-
tion for lung cancer in the past 30 years at our institu-
tion. Intra- and postoperative complications as well as
long-term follow-up data were entered in our lung-
cancer database. Factors influencing mortality, mor-
bidity and survival were analyzed.
Results: Rate of intra-operative complications as well
as rate of post-operative morbidity and mortality was
not significantly affected by moon phases. Further-
more, there was no significant impact of the lunar cy-
cle on long-term survial.
Conclusion: In this study there was no evidence that
outcome of surgery for lung cancer is affected by the
moon. These results may help the physician to quite
the mind of patients who are somewhat afraid of
wrong timing of surgery with respect to the moon
phases. However, patients who strongly believe in the
impact of moon phase should be taken seriously and
correct timing of operations should be conceded to
them as long as key-date scheduling doesn’t constrict
evidence based treatment regimens.
Key words: Lung cancer, Superstition, Moon phases,
Survival, Surgical complications
Abbreviations: CI = Confidence interval, χ
2
= Chi-
square test, LOC = Locus of control
INTRODUCTION
Superstition is very common, especially in some rural
areas where nearly one-fifth of the population be-
lieves in the impact of moon phases on various phe-
nomena and, among other things, outcome of med-
ical treatment [1-3]. These patients may be anxious,
especially when they have to undergo surgery for can-
cer [4]. The rationale for these anticipated effects have
been credited to variations in the brightness of moon-
light, weather conditions, geomagnetic variations as
well as interstellar solar corpuscular radiation [5, 6].
“Why should the moon, which causes the tides,
doesn’t influence human beings, who consist predom-
inantly of water?” is a common believe. Consequently,
many patients are essentially afraid of wrong timing
of surgery with respect to moon phases, which might
manipulate nurses and surgeons [3, 7]. Thus, the im-
pact of lunar cycles on treatment related complica-
tions, postoperative mortality and morbidity as well as
long-term survival has been widely discussed by tele-
vision shows, lay press and newsgroups in the inter-
net. Several scientific studies have reported on the in-
fluence of moon phases on birth rates, birth compli-
cations, suicide, psychiatric crises, or outcome of
surgery for breast cancer [4]. Since some studies un-
derline significant influence of moon phases on hu-
man life [5, 8-11], other reports have failed to confirm
these results [2, 4, 12, 13]. It is well known, that physi-
ological processes of the organism, i.e. the endocrine
system, the autonomic nerve system, the liberation of
growth factors or the limbic system are influenced by
the moon cycle [4]. In addition, it is also postulated
that significant impact of lunar phases is mediated by
endogenous mechanisms [10]. In patients who have to
undergo surgery for cancer, fear of operative compli-
cations and poor outcome is very widespread. In
some cases, lunar phases are believed to be relevant
for success of treatment. Therefore, this retrospective
study was performed to analyse the influence of the
moon phases on mortality, morbidity and long-term
survival following lung cancer surgery at our institu-
tion.
PATIENTS AND METHODS
We retrospectively reviewed the files of 2411 patients
with complete long-term follow-up who received re-
sective surgery for lung cancer between January 1980
and December 2007 at the Department of Surgery at
our institution. The cohort included 1854 males and
557 females with a median age of 62.2 ± 9.9 years.
Classification of tumor stages according to UICC
2002 was 41%, 21%, 21%, 6%, and 11% for stadium I,
II, IIIa, IIIb and IV, respectively. Type of surgery con-
178
E
ur J Med Res (2009) 14: 178-181 © I. Holzapfel Publishers 2009
THE DARK SIDE OF THE MOON: IMPACT OF MOON PHASES ON
LONG-TERM SURVIVAL, MORTALITY AND MORBIDITY OF SURGERY FOR
LUNG CANCER
A. Kuehnl
1
,2
, M. Herzog
1
, M. Schmidt
3
, H.-M. Hornung
1
, K.-W. Jauch
1
, R. A. Hatz
1
, C. Graeb
1
1
Department of Surgery, Klinikum Grosshadern, Ludwig-Maximilians-University, Munich, Germany
2
Clinic for Vascular Surgery, Klinikum rechts der Isar, Technische Universität München, Germany
3
Department of Medical Informatics, Biometry and Epidemiology, Ludwig-Maximilians-University, Munich, Germany
6. Ku?hnl##:Umbruchvorlage 28.03.2009 15:57 Uhr Seite 178
sisted pneumonectomies in 18%, lobectomies and
bilobectomies in 68%, and lesser resections in 14% of
all cases. The date of definitive surgery was allocated
to the days of lunar cycle as well as to the dates of the
four main lunar phases, that are new moon (n = 89),
waxing moon (n = 1058), full moon (n = 77) and wan-
ing moon (n = 1187). Patients were grouped according
t
o these four phases, as described by Moore and co-
w
orkers [14].
Patients long-term follow up was performed at our
institution completed by data from the Munich Cancer
Registry as well as updated by data from all GPs, com-
munity hospitals, chemoradiotherapy units and regis-
tration offices in Munich and its greater area. Median
long-term follow-up was 25 months, ranging from 1 to
326 months.
Since January 1996, detailed data of perioperative
complications occurring during the operation until pa-
tients discharge from hospital were available for all pa-
tients (n = 834) included in our lung cancer database
[15]. General complications like dysfunction of the
cardio-pulmonary system, myocardial infarction, dys-
rhythmia, pulmonary embolism, renal or liver failure,
central nervous dysfunction, sepsis, pneumonia and
postoperative bleeding requiring blood transfusion
were recorded. Empyema, bronchopleural fistula,
pneumothorax, chylothorax, wound infection, atelecta-
sis or prolonged air leak, leading to an operative revi-
sion were generally classified as specific complications.
Validity of data was assessed by comparing the four
groups according to the distributions of main prog-
nostic variables influencing long-term survival, mor-
bidity and mortality in lung cancer patients (age, gen-
der, TNM status, grading, completeness of resection
status, treatment and histopathology).
Statistical significance was evaluated using multiple
logistic regression analysis [16]. Rates and proportions
analyzes were performed using the Chi-square (χ
2
)-
test. An univariate survival analysis for each prognos-
tic variable on overall survival was estimated according
to the Kaplan-Meier method [17] including 95% confi-
dence intervals [18]. The terminal event was death at-
tributable to all causes. The statistical significance of
the differences in survival distributions among the
p
rognostic groups was evaluated by the log-rank test.
T
he statistical difference was considered to be signifi-
cant if the P value was below 0.05. Data were analyzed
using MedCalc® for Windows, Version 9.2.0.1 (Med-
Calc Software, Mariakerke, Belgium).
RESULTS
With respect to the lunar cycle, there were no signifi-
cant differences in the distribution of TNM-Status (P
= .739), grading (P = .488), completeness of resection
(P = .638), age (P = .706), gender (P = .273), treat-
ment (P = .797) and histopathology (P = .466). Rate
of intraoperative complications was 1.7%, whereas the
rate of postoperative complications needing invasive
or prolonged treatment was 16.4%. The 30-day mor-
tality rate was 3.2%. Overall median survival was 28.7
months with a survival rate of 36.0% at five years. In
contrast to age, gender, tumour stage, histopathology,
grading and completeness of resection, which have
been identified to be independent predictors affecting
long-term survival significantly (Table 1), timing of
surgery with respect to the moon phases showed no
significant impact on long-term survival (Table 2).
Lunar phases showed neither influence on intraop-
erative complications rate, nor on overall morbidity or
mortality. However, as shown in Table 2, also alloca-
tion of patients to single days of lunar cycle as well as
allocation to waning and waxing phases revealed no
significant impact on surgical outcome.
EUROPEAN JOURNAL OF MEDICAL RESEARCH 179
Table 1. Impact of several oncological factors on long-term survival in our cohort.
outcome parameter test used independent factor P value
Survival log-rank T status < 0.001
log-rank N status < 0.001
log-rank M status < 0.001
log-rank tumour grading 0.015
log-rank completeness of resection < 0.001
log-rank pathohistology 0.003
Table 2. Impact of lunar cycle on intra- and postoperative morbidity, mortality and long-term survival. Outcome parameters are
not significantly affected by moon phase.
outcome parameter test used independent factor
day of lunar cycle 4 moon phases waxing full moon
vs. each other vs. each other vs. waning moon vs. remaining phases
Survival log-rank P = .459 P = .646 P = .631 P = .110
operative complications χ
2
P = .963 P = .430 P = .579 P = .941
post-OP mortality χ
2
P = .885 P = .952 P = .756 P = .920
post-OP morbidity χ
2
P = .846 P = .910 P = .967 P = .970
6. Ku?hnl##:Umbruchvorlage 28.03.2009 15:57 Uhr Seite 179
DISCUSSION
This study revealed that moon phases had generally no
measurable impact on outcome after surgery for lung
cancer.
In accordance to our results, Peters-Engl and col-
leagues [4], reporting their results on outcome of 3757
women operated for breast cancer, revealed no effect
of moon phases on surgical or patient outcome. Arliss
et al. [2] examined the influence of the lunar cycle on
the frequency of deliveries and delivery related com-
plications, but also failed to demonstrate predictable
influence of moon phases on patients included in the
study. In addition, Kumar et al. [13] report about miss-
ing evidence that full moon have significant influence
on post-tonsillectomy haemorrhage. Postoperative
mortality with respect to moon phases was analyzed
by Smolle and coworkers [3], but they also failed to
demonstrate an impact of lunar phases on outcome.
According to these and other studies [1], there was no
evidence in our series, that long-term survival was dif-
ferent in any of the four primary moon phases. The
overall median survival in this study was 29 months
with a 5-year survival of 36%, which is comparable to
international reported survival rates after pulmonary
resection for cancer [19,20].
Román and associates [10] described that hospital
admission for gastrointestinal bleeding was significant-
ly increased during full moon. In our series postopera-
tive bleeding events were not significantly more fre-
quent during the full moon. To our opinion, this is due
to the circumstance, that in the series described by
Román et al. the bleeding event was definitively during
full moon, in contrast to our study, where bleeding
events were always linked to the moon phase at the
time of surgery.
IMPLICATIONS FOR GENERAL AND CLINICAL PRACTICE
In this study there was no evidence that outcome of sur-
gery for lung cancer is affected by the moon. These re-
sults may help the physician to quite the mind of patients
who are somewhat afraid of wrong timing of surgery
with respect to the moon phases. On the other hand, lo-
cus of control is a well known individual factor within
the coping strategies of many patients being in such
desperate situations. In whatever these patients trust
(internal LOC, powerful other’s LOC or chance exter-
nal LOC), it may supports them handling their disease.
Therefore, patients who strongly believe in the im-
pact of moon phase should be taken seriously and
correct timing of operations should be conceded to
them as long as key-date scheduling doesn’t constrict
evidence based treatment regimens.
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EUROPEAN JOURNAL OF MEDICAL RESEARCH180
Fig. 1. Rate of postoperative complications in % on each day of the lunar cycle when initial surgery took place. Rhombi indicate
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Received: July 25, 2008 / Accepted: September 26, 2008
Address for correspondence:
PD Dr. med. Christian Graeb
Chirurgische Klinik und Poliklinik Großhadern
Ludwig-Maximilians Universität München
Marchioninistraße 15
81377 München
Germany
Tel.: +49 89/7095 3510
Fax: +49 89/7095 3508
E-mail: christian.graeb@med.uni-muenchen.de
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