Religious Practice and Spirituality in the Psychological Adjustment of Survivors of Breast Cancer

Religion and spirituality are resources regularly used by patients with cancer coping with diagnosis and treatment, yet there is little research that examines these factors separately. This study investigated the relationships between religious practice and spirituality and quality of life (QoL) and stress in survivors of breast cancer. The sample included 130 women assessed 2 years following diagnosis. Using hierarchical multiple regression analysis, the authors found that spiritual well-being was significantly associated with QoL and traumatic stress, whereas religious practice was not significantly associated with these variables. The results suggest that it may be helpful for clinicians to address spirituality, in particular with survivors of breast cancer.

Abstract CN08-02: Psychological stress and disease progression

A randomized clinical trial was designed to test the hypothesis that cancer patients coping with a cancer diagnosis but receiving a psychological intervention would have reduced risk for disease progression (1994). Patients (N=227) surgically treated for regional breast cancer participated. Before beginning adjuvant cancer therapies, patients were assessed with psychological and behavioral measures, had a health evaluation, and a 60 mL blood sample was drawn. Patients were randomized to Psychological Intervention or Assessment only arms. The intervention was psychologist led, conducted in small groups, and included strategies to reduce stress, improve mood, alter health behaviors, and maintain adherence to cancer treatment. Earlier papers (2004, 2007) showed that, compared to the Assessment arm, the Intervention arm improved across all of the latter secondary outcomes. T cell blastogenesis was also enhanced. An interim paper (2007) clarified treatment mechanisms in the Intervention arm. First, patients were satisfied with the intervention, but it was group cohesion that related to better outcomes. Second, offering patients a stress conceptualization (Selye) and teaching them multiple coping strategies related to better health. Third, three relationships between treatment utilization and outcomes are noted: 1) Relaxation training was associated with both distress reduction and symptom lowering. 2) Patients' use of assertive communication with health care providers was associated with better health outcomes. 3) Intervention strategy use was also associated with fewer signs/symptoms and cancer treatment toxicities. After a median of 11 years follow-up, recurrence occurred for 62 of 212 (29%) women and death for 54 of 227 (24%). Intent to treat hazard analyses showed, as predicted, Intervention arm patients had a reduced risk of recurrence [Hazard Ratio (HR)=0.55, P=.034] and breast cancer death (HR=0.44, P=.016). Follow up papers (2009) have examined the covariation of inflammation and distress during the period of intervention delivery (2009) and in the months prior to recurrence diagnosis (2008). Learning Objective 1: Show that a randomized clinical trial has produced evidence that a behavioral intervention can reduce fatal and nonfatal regional breast cancer recurrence. Learning Objective 2: Demonstrate that patients' use of assertive communication with health care providers was associated with better health outcomes.

Citation Information: Cancer Prev Res 2011;4(10 Suppl):CN08-02.

Cancer patients with major depressive disorder: testing a biobehavioral/cognitive behavior intervention

OBJECTIVE

In this Phase II trial, we evaluated a novel psychological treatment for depressed patients coping with the stresses of cancer. Effectiveness of a combined biobehavioral intervention (BBI) and cognitive behavior therapy (CBT) was studied.

METHOD

Participants were 36 cancer survivors (mean age = 49 years; 88% Caucasian; 92% female) diagnosed with major depressive disorder. A single group pre-post design was used. Treatment consisted of up to 20 individual 75-min combined BBI/CBT sessions. Outcomes were change in interviewer (Hamilton Rating Scale for Depression; Williams, 1988) and self-rated depressive symptoms (Beck Depression Inventory-Second Edition; Beck, Steer, & Brown, 1996) as well as change in cancer relevant symptoms (Fatigue Symptom Inventory [Hann et al., 1998] and Brief Pain Questionnaire [Daut, Cleeland, & Flanery, 1983]) and quality of life (Medical Outcomes Study Short Form-36; Ware et al., 1995). Mixed-effects modeling, a reliability change index, and generalized linear models were used. All analyses were intent-to-treat.

RESULTS

Depressive symptoms significantly improved. In addition, 19 of 21 study completers met criteria for remission. Significant improvements were also noted in fatigue and mental health quality of life. Both concurrent anxiety disorders and high levels of cancer stress (Impact of Events Scale; Horowitz, Wilner, & Alvarez, 1979) were each associated with beginning and concluding treatment with greater depressive symptoms.

CONCLUSIONS

CBT components were successfully incorporated into a previously efficacious intervention for reducing cancer stress. The BBI/CBT intervention warrants further research in evaluating its efficacy compared with well-established treatments for depression.

Psychological stress is associated with altered levels of myeloid-derived suppressor cells in breast cancer patients

Our group has shown in a randomized clinical trial that psychological intervention to reduce stress in patients with stages II and III breast cancer led to enhanced immune function, fewer recurrences and improved overall survival. We hypothesized that patients with high levels of stress would have alterations in myeloid-derived suppressor cells (MDSC) compared to patients with lower stress. PBMC from 16 patients with high stress (n = 8) or with low stress (n = 8) after surgery as measured by the Impact of Event Scale (IES) questionnaire were evaluated for the presence of MDSC. Patients with higher IES scores had significantly elevated salivary cortisol levels (P = 0.013; 13 μg/dl vs. 9.74 μg/dl). Levels of IL-1Rα were also significantly elevated in the higher IES group (45.09 pg/ml vs. 97.16 pg/ml; P = 0.010). IP 10, G-CSF, and IL-6 were all higher in the high stress group although not to a significant degree. Flow cytometric analysis for CD33+/HLA-DR-neg/CD15+/CD11b+ MDSC revealed increased MDSC in patients with lower IES scores (P = 0.009). CD11b+/CD15+ cells constituted 9.4% of the CD33+/HLA DR-neg cell population in patients with high IES, vs. 27.3% in patients with low IES scores. Additional analyzes of the number of stressful events that affected the patients in addition to their cancer diagnosis revealed that this type of stress measure correlated with elevated levels of MDSC (P = 0.064). These data indicate the existence of a complex relationship between stress and immune function in breast cancer patients.

The pain, depression, and fatigue symptom cluster in advanced breast cancer: covariation with the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system

OBJECTIVE

Neuroendocrine-immune models have been proposed to account for the frequent co-occurrence of pain, depression, and fatigue (PDF) among cancer patients.

DESIGN

In a cross-sectional observational study of advanced cancer patients (N = 104), we tested the hypothesis that the PDF cluster covaries with proposed biological mediators: hormones of the sympathetic nervous system (SNS) and the hypothalamic-pituitary-adrenal (HPA) axis.

MAIN OUTCOME MEASURES

PDF symptoms were measured using the Brief Pain Inventory, Fatigue Symptom Inventory, and the Center for Epidemiological Studies Depression scales. HPA activation was indicated by plasma levels of cortisol and adrenocorticotropic hormone, and SNS activation was indicated by plasma epinephrine and norepinephrine.

RESULTS

Preliminary analyses supported the use of covariance structure modeling to test whether shared variance among hormone levels predicted shared variance among PDF symptoms. Latent variable analysis indicated that neuroendocrine levels predicted PDF (standardized beta = .23, p = .039), while controlling for important disease and demographic variables.

CONCLUSION

Previous studies have linked individual symptoms to individual biomarkers. The observed significant paring of the 4 hormones to the PDF cluster provides the first evidence suggestive of stress hormones as a common mechanism for the co-occurrence of pain, depression, and fatigue symptoms.

Sexual morbidity associated with poorer psychological adjustment among gynecological cancer survivors

OBJECTIVES

Sexual morbidity is a distressing and undertreated problem in gynecological cancer survivorship known to occur early and persist well beyond the period of physical recovery. Although often studied as a separate domain, sexuality represents an integral component of psychological adjustment and quality of life (QoL) that is adversely affected by cancer treatments. The present study tests the association between sexual morbidity, and adverse psychological adjustment and QoL outcomes.

METHODS

A cross-sectional design was used. The participants were gynecological (cervical, endometrial, ovarian, and vulvar) cancer survivors who were partnered (N = 186), whose cancer was diagnosed 2 to 10 years previously, and who were at least 6 months post any cancer therapy. Most had been found to have early-stage disease (70%) and were treated with hysterectomy (77%), chemotherapy (43%), and/or radiotherapy (23%). Sexual morbidity was operationalized as a multidimensional construct including sexual behavior, sexual functioning, and subjective sexual satisfaction, assessed by patient self-report. Outcomes included self-reported depressive symptoms, traumatic stress symptoms, cancer-specific stress, stress about body changes, and QoL. Nurse-rated of performance status and disruptive signs/symptoms of treatment toxicity, as well as relevant sociodemographic and disease variables were collected as potential controls.

RESULTS

Hierarchical multiple regression analyses tested sexual morbidity as a predictor of poor outcomes. All statistical models were significant, accounting for 12% to 53% of the variance in psychological adjustment/QoL. Sexual morbidity covaried with worsened depressive symptoms, body change stress, and psychological QoL beyond the negative contributions of (older) age, (poorer) performance status, and (greater) fatigue. Notably, disease and treatment variables were not statistically significant correlates of psychological adjustment or QoL.

CONCLUSIONS

These findings suggest that prevention or treatment of sexual morbidity might foster improved psychological adjustment/QoL. Given the high rates of sexual morbidity in this population and the connection between sexuality and broader psychological adjustment/QoL, there is a clear need for better integration of sexuality rehabilitation into routine clinical care.

Biobehavioral, immune, and health benefits following recurrence for psychological intervention participants

PURPOSE

A clinical trial was designed to test the hypothesis that a psychological intervention could reduce the risk of cancer recurrence. Newly diagnosed regional breast cancer patients (n = 227) were randomized to the intervention-with-assessment or the assessment-only arm. The intervention had positive psychological, social, immune, and health benefits, and after a median of 11 years the intervention arm was found to have reduced the risk of recurrence (hazard ratio, 0.55; P = 0.034). In follow-up, we hypothesized that the intervention arm might also show longer survival after recurrence. If observed, we then would examine potential biobehavioral mechanisms.

EXPERIMENTAL DESIGN

All patients were followed; 62 recurred. Survival analyses included all 62. Upon recurrence diagnosis, those available for further biobehavioral study were accrued (n = 41, 23 intervention and 18 assessment). For those 41, psychological, social, adherence, health, and immune (natural killer cell cytotoxicity, T-cell proliferation) data were collected at recurrence diagnosis and 4, 8, and 12 months later.

RESULTS

Intent-to-treat analysis revealed reduced risk of death following recurrence for the intervention arm (hazard ratio, 0.41; P = 0.014). Mixed-effects follow-up analyses with biobehavioral data showed that all patients responded with significant psychological distress at recurrence diagnosis, but thereafter only the intervention arm improved (P values < 0.023). Immune indices were significantly higher for the intervention arm at 12 months (P values < 0.017).

CONCLUSIONS

Hazards analyses augment previous findings in showing improved survival for the intervention arm after recurrence. Follow-up analyses showing biobehavioral advantages for the intervention arm contribute to our understanding of how improved survival was achieved.

Stress generation over the course of breast cancer survivorship

Depressive symptoms are frequently elevated following breast cancer diagnosis. The stress generation hypothesis states that people with depression generate stressful events and these stressors lead to subsequent depression. This study tested the stress generation hypothesis over the first 5 years of cancer survivorship. Women with stage II or III breast cancer (N = 113) were accrued. Five mediation models were constructed, one for each year. Each model tested whether stressful events in each year mediated the relationship between depression at the beginning and end of that year. Stress generation was observed in the first 2 years following cancer diagnosis but not from 2 to 5 years after diagnosis. The relationship of depression to future stress in breast cancer patients may be moderated by phase of survivorship. Screening and treatment of depressive symptoms in cancer survivors may need to consider the generation of stressful events.

Social and cultural factors are related to perceived colorectal cancer screening benefits and intentions in African Americans

Models that explain preventive behaviors, such as colorectal cancer (CRC) screening, do not account for social and cultural factors relevant to African Americans. This exploratory study examined the relationship between socio-cultural factors (e.g., traditional acculturative strategy, group-based medical mistrust, physician ethnicity, and group-level perceptions of susceptibility) and perceived benefits, perceived barriers, and CRC screening intentions among African Americans (N = 198; Age: M = 59.7, SD = 9.9; 65% female; 44% household income $50,000+). Hierarchical multiple regression was used to test the following models with perceived benefits, perceived barriers, and screening intentions as the outcomes: (a) traditional acculturative strategy x medical mistrust; (b) physician's ethnicity x medical mistrust; (c) group susceptibility x medical mistrust; and (d) group susceptibility x traditional acculturative strategy. Results revealed that perceiving high group susceptibility while being both more culturally traditional and less mistrustful was associated with more perception of screening benefits. Greater intention to be screened was associated with perceiving high group susceptibility while having a more traditional cultural orientation and low levels of mistrust in those with African American physicians. These results suggest that it may be beneficial to include these social and cultural factors in behavioral interventions to increase CRC screening among African Americans.

Sexual self schema as a moderator of sexual and psychological outcomes for gynecologic cancer survivors

Gynecologic cancer patients are at high risk for emotional distress and sexual dysfunction. The present study tested sexual self schema as an individual difference variable that might be useful in identifying those at risk for unfavorable outcomes. First, we tested schema as a predictor of sexual outcomes, including body change stress. Second, we examined schema as a contributor to broader quality of life outcomes, specifically as a moderator of the relationship between sexual satisfaction and psychological statue (depressive symptoms and quality of life). A cross-sectional design was used. Gynecologic cancer survivors (N = 175) 2-10 years post treatment were assessed during routine follow up. In regression analyses controlling for sociodemographic variables, patients' physical symptoms/signs as evaluated by nurses, health status, and extent of partner sexual difficulties, sexual self schema accounted for significant variance in the prediction of current sexual behavior, responsiveness, and satisfaction. Moreover, schema moderated the relationship between sexual satisfaction and psychological outcomes, suggesting that a positive sexual self schema might "buffer" patients from depressive symptoms when their sexual satisfaction is low. Furthermore, the combination of a negative sexual self schema and low sexual satisfaction might heighten survivors' risk for psychological distress, including depressive symptomatology. These data support the consideration of sexual self schema as a predictor of sexual morbidity among gynecologic cancer survivors.

Hopelessness as a predictor of depressive symptoms for breast cancer patients coping with recurrence

OBJECTIVE

The Hopelessness Theory of Depression provides the framework to test feelings of hopelessness and social support as predictors of depressive symptoms in women recently diagnosed with a recurrence of breast cancer.

METHODS

Patients (N=67) were assessed within weeks of receiving their recurrence diagnosis (initial) and again 4 months later (follow-up).

RESULTS

Controlling for their current physical and depressive symptoms, hopelessness at diagnosis was a significant predictor of the maintenance of depressive symptoms among patients. A corollary of the theory was also confirmed: social support (i.e. the presence/absence of a romantic partner) interacted with hopelessness.

CONCLUSIONS

Women who reported feelings of hopelessness and who were alone (i.e. without a partner) were especially vulnerable to later depressive symptoms. The data provide support for the Hopelessness Theory and suggest factors conferring risk for depressive symptoms for those coping with a worsened cancer prognosis.

Psychologic intervention improves survival for breast cancer patients: a randomized clinical trial

BACKGROUND

The question of whether stress poses a risk for cancer progression has been difficult to answer. A randomized clinical trial tested the hypothesis that cancer patients coping with their recent diagnosis but receiving a psychologic intervention would have improved survival compared with patients who were only assessed.

METHODS

A total of 227 patients who were surgically treated for regional breast cancer participated. Before beginning adjuvant cancer therapies, patients were assessed with psychologic and behavioral measures and had a health evaluation, and a 60-mL blood sample was drawn. Patients were randomized to Psychologic Intervention plus assessment or Assessment only study arms. The intervention was psychologist led; conducted in small groups; and included strategies to reduce stress, improve mood, alter health behaviors, and maintain adherence to cancer treatment and care. Earlier articles demonstrated that, compared with the Assessment arm, the Intervention arm improved across all of the latter secondary outcomes. Immunity was also enhanced.

RESULTS

After a median of 11 years of follow-up, disease recurrence was reported to occur in 62 of 212 (29%) women and death was reported for 54 of 227 (24%) women. Using Cox proportional hazards analysis, multivariate comparison of survival was conducted. As predicted, patients in the Intervention arm were found to have a reduced risk of breast cancer recurrence (hazards ratio [HR] of 0.55; P = .034) and death from breast cancer (HR of 0.44; P = .016) compared with patients in the Assessment only arm. Follow-up analyses also demonstrated that Intervention patients had a reduced risk of death from all causes (HR of 0.51; P = .028).

CONCLUSIONS

Psychologic interventions as delivered and studied here can improve survival.

Breast cancer survivors' health-related quality of life : racial differences and comparisons with noncancer controls

BACKGROUND

Small samples with few minority women and/or the absence of comparisons to peers without cancer histories have limited previous research suggesting racial differences in breast cancer survivors' health-related quality of life (HRQoL). This study not only compared HRQoL of African American and white breast cancer survivors, but also compared the HRQoL of these women to that of same-race women with no cancer history.

METHODS

Data from the Women's Health Initiative-Observational Study were used, including 5021 cancer survivors and 88,532 women without a history of cancer. Multivariate regression analyses estimated differences in breast cancer survivors' baseline HRQoL (RAND36), depressive symptoms (CES-D short-form), and sleep quality (WHIIRS).

RESULTS

African American breast cancer survivors reported worse physical functioning and general health compared with white survivors. Among African Americans, survivors reported worse role limitations due to physical health, pain, general health, and vitality than women without a history of cancer. This was most evident in those with more recent diagnoses. Most significant differences between groups were small in magnitude (Cohen d = .21-.36).

CONCLUSIONS

These results add to the increasing knowledge of cancer disparities by showing that African American women have small, but clinically meaningful, decrements in physical HRQoL compared with white survivors and with African American women without cancer. Because African American women also face diagnosis with higher grade tumors and higher breast cancer mortality, more research is needed to examine the physical and psychosocial experiences of African American breast cancer survivors to elucidate the mechanisms leading to poorer outcomes.

Immune, endocrine, and behavioral precursors to breast cancer recurrence: a case-control analysis

BACKGROUND

A period of tumor growth precedes the clinical detection of breast cancer recurrence. We explore immune, endocrine, and behavioral parameters during this period.

METHODS

We conducted a phase III clinical trial in which women with surgically treated stage II/III breast cancer (N = 227) were randomized to receive a psychological intervention or assessment-only and then regularly assessed for 10 years. Patients who recurred (R, n = 48) were matched with patients remaining disease-free (DF, n = 48) on demographic and prognostic characteristics, treatment, and duration of disease-free follow-up. Data at three assessment points, occurring, on average, 17, 11, and 4 months before the recurrence was detected clinically, with equivalent time points for the disease-free group, were examined. Mixed-effects models tested for group differences in immune cell counts and function as well as endocrine and behavioral parameters.

RESULTS

In the 17 months prior to recurrence detection, patients exhibited higher white blood cell count, neutrophil, lymphocyte, and natural killer cell counts, relative to DF patients. R patients also showed higher cortisol, worse physical functioning, fatigue, and quality of life. Follow-up analyses showed patients with local recurrences to differ from those with distant recurrence, with the former exhibiting elevated natural killer cell cytotoxicity, lymphocyte proliferative response, fatigue, pain, and emotional distress (depression, anxiety), and the latter exhibiting higher neutrophil, lymphocyte, and natural killer cell counts.

CONCLUSION

Patients who would recur showed reliable biobehavioral alterations more than a year prior to their diagnosis. This novel observation may contribute to our understanding of the disease relapse processes.

Delayed emotional recovery after taxane-based chemotherapy

BACKGROUND

There are few patient-reported data regarding quality of life after taxane-based adjuvant chemotherapy and none regarding mental health outcomes.

METHODS

This was a naturalistic, longitudinal study that used a case-control design. Data were derived from a randomized clinical trial in patients who had stage II/III breast cancer (N = 227). Paclitaxel (Taxol) was approved for use midway during the accrual period (1994-1999). Patients who received taxanes as part of their adjuvant chemotherapy (the taxane group; n = 55) were matched with patients receiving regimens without taxanes (the no-taxane group; n = 83) on trial arm, lymph node status, surgery type, menopausal status, and partner status. Mixed-effects models tested for group differences in nurse evaluations of patients' symptoms and Karnofsky performance status and in patient-reported quality of life (the 36-item Medical Outcomes Study Short Form) and emotional distress (Profile of Mood States; Center for Epidemiological Studies Depression scale).

RESULTS

As expected, patients in the taxane group experienced significantly higher rates of selected toxicities, including arthralgia/myalgia (45% vs 26%) and ataxia (20% vs 5%). Patients in the taxane group also had significantly worse emotional distress and mental quality of life throughout adjuvant treatment. Rates of probable clinical depression also were high. In contrast, these outcomes were improving for patients in the no-taxane group (all P < .023). Emotional recovery for patients in the taxane group required 2 years on average versus 6 to 12 months for patients in the no-taxane group. During Years 3 through 5, the groups had similar outcomes.

CONCLUSIONS

These data suggested that taxane-based chemotherapies confer risk for significant psychological symptoms. Depression, in particular, should be monitored.

Physical sequelae and depressive symptoms in gynecologic cancer survivors: meaning in life as a mediator

BACKGROUND

Continuing symptoms and poor health following cancer treatments may alter meaning in life for cancer survivors. Gynecologic cancer survivors are particularly troubled with physical sequelae. In addition, for the most common sites of disease, such as breast and gynecologic cancers, the prevalence of depression is also high.

PURPOSE

This study tests meaning in life as a mechanism for the relationship between physical symptoms and depressive symptoms.

METHODS

Gynecologic cancer survivors (N = 260) participated. Measures of physical sequelae (nurse rated symptoms/signs, patient-reported gynecologic symptoms), meaning in life (harmony, life purpose, spirituality, and conversely, confusion and loss), and depressive symptoms were obtained at the time of a routine clinical follow-up visit 2-10 years following the completion of treatment. Latent variables were defined, and structural equation modeling tested a mediator model.

RESULTS

Analyses support partial mediation. That is, survivors with more physical sequelae also reported lower levels of meaning in life, which was associated with higher levels of depressive symptoms.

CONCLUSIONS

Gynecologic cancer patients have been neglected in psychosocial research, and findings highlight the importance of existential issues in their lives. While many adjust well, those with persistent physical functioning deficits may experience depressive symptoms. By appreciating the role of meaning in their experience, we may help survivors foster their own growth and perspectives important for their future.

PTSD diagnoses, subsyndromal symptoms, and comorbidities contribute to impairments for breast cancer survivors

The clinical importance of posttraumatic stress disorder (PTSD) symptomatology for cancer patients is unclear. The association between the magnitude of cancer-related PTSD symptoms, comorbidity, and functioning is tested. Breast cancer patients (N = 74) were assessed at diagnosis/surgery, followed, and screened for cancer-related PTSD 18 months later. Participants then completed diagnostic interviews and PTSD (n = 12), subsyndromal PTSD (n = 5), and no symptom (n = 47) patient groups were identified. Posttraumatic stress disorder cases were distinguished by having experienced violent traumas and anxiety disorders predating cancer, whereas subsyndromal cases were not. Also, longitudinal data show that PTSD covarys with poorer functioning and lower quality of life among breast cancer survivors. Both PTSD and subsyndromal PTSD were associated with employment absenteeism and the seeking of mental health services.

Surviving recurrence: psychological and quality-of-life recovery

BACKGROUND

To the authors' knowledge, data characterizing patients' psychosocial experiences after a recurrence diagnosis are limited. This report provides the physical, psychological, and quality-of-life trajectories of patients with recurrent breast cancer. In addition, patients with a well-documented trajectory -- patients with their initial diagnosis of breast cancer -- were included as a referent group, providing a metric against which to gauge the impact and course of cancer recurrence.

METHODS

Patients with a newly diagnosed, recurrent (n = 69) or initial (n = 113) breast cancer were accrued. The groups did not differ with regard to age, race, education, family income, or partner status (all P values > .18). All patients were assessed shortly after diagnosis (baseline) and 4 months, 8 months, and 12 months later. Mixed-effects models were used to determine health status, stress, mood, and quality-of-life trajectories.

RESULTS

In the year after a recurrence diagnosis, patients' physical health and functioning showed no improvement, whereas quality of life and mood generally improved, and stress declined. Compared with patients who were coping with their first diagnosis, patients with recurrence had significantly lower anxiety and confusion. In contrast, physical functioning was poorer among recurrence patients, quality-of-life improvement was slower, and cancer-related distress was high as that of the initially diagnosed patient. Slower quality-of-life recovery was most apparent among younger patients (aged <54 years).

CONCLUSIONS

Despite the physical burden, patients with recurrent breast cancer exhibit considerable resilience, with steady improvements in psychological adjustment and quality of life during the year after diagnosis. Management of patients' physical symptoms is particularly important, because patients cope with recurrent breast cancer as a chronic illness.

Stress and quality of life in breast cancer recurrence: moderation or mediation of coping?

BACKGROUND/PURPOSE

Diagnosis with breast cancer recurrence often brings high levels of stress. Successful coping to alleviate stress could improve patients' quality of life (QoL). The intervening role coping plays between stress and QoL may depend on the types of stress encountered and the types of coping strategies used. The present study investigates the longitudinal relationships between stress, coping, and mental health QoL.

METHODS

Breast cancer patients recently diagnosed with recurrence (N = 65) were assessed shortly after the diagnosis and 4 months later. Four moderation and four mediation models were tested using hierarchical multiple regressions and path analyses. In the models, either traumatic stress or symptom-related stress at recurrence diagnosis was a predictor of mental health QoL at follow-up. Both engagement and disengagement coping strategies were tested as moderators or mediators between stress and QoL.

RESULTS

Engagement coping moderated the effect of symptom stress on mental health QoL, whereas disengagement coping mediated the effects of both traumatic stress and symptom stress on mental health QoL.

CONCLUSION

The findings imply that interventions teaching engagement coping strategies would be important for patients experiencing high symptom stress, while discouraging the use of disengagement coping strategies would be important for all patients.

RCT of a psychological intervention for patients with cancer: I. mechanisms of change

Little is known about the therapeutic processes contributing to efficacy of psychological interventions for patients with cancer. Data from a randomized clinical trial yielding robust biobehavioral and health effects (B. L. Andersen et al., 2004, 2007) were used to examine associations between process variables, treatment utilization, and outcomes. Novel findings emerged. Patients were highly satisfied with the treatment, but their higher levels of felt support (group cohesion) covaried with lower distress and fewer symptoms. Also, specific treatment strategies were associated with specific outcomes, including lower distress, improved dietary habits, reduced symptomatology, and higher chemotherapy dose intensity. These data provide a comprehensive test of multiple therapeutic processes and mechanisms for biobehavioral change with an intervention including both intensive and maintenance phases.

Meaning in life mediates the relationship between social and physical functioning and distress in cancer survivors

OBJECTIVES

Impairments in physical and social functioning are often associated with distress for the cancer survivor. Impaired functioning may also lead individuals to question previously held beliefs about meaning in life. Meaning in life was hypothesized to mediate the relationship between functioning and distress.

DESIGN AND METHODS

Two studies were conducted. In the cross-sectional study (I), cancer survivors (N=420) were accrued via the Internet and completed measures of social and physical functioning, meaning and distress. In the longitudinal study (II), breast cancer survivors (N=167) completed measures of functioning at 18 months, meaning at 24 months and distress at 30 months post-diagnosis.

RESULTS

In Study I, meaning in life was a significant, partial mediator for both of the effects of physical and social functioning impairments on heightened distress. In Study II, significant indirect effects of functioning impairments on distress through meaning were replicated even when functioning and distress were measured 1 year apart. The relationship of social functioning and distress was fully mediated by meaning in life, whereas the relationship of physical functioning and distress was partially mediated by meaning.

CONCLUSIONS

The negative social and physical sequelae of cancer are associated with heightened distress, and this association appears to be accounted for, in part, by patients' loss of meaning in their lives.

Distress reduction from a psychological intervention contributes to improved health for cancer patients

PURPOSE

Psychological interventions are efficacious in reducing emotional distress for cancer patients. However, it is not clear whether psychological improvements are, in turn, related to improved health. A clinical trial tests whether a psychological intervention for cancer patients can do so, and also tests two routes to achieve better health: (a) reducing patients' Emotional Distress, and/or (b) enhancing their functional immunity.

METHODS

Post-surgery, 227 breast cancer patients were randomized to intervention or assessment only Study Arms. Conducted in small groups, intervention sessions were offered weekly for 4 months and followed by monthly sessions for 8 months. Measures included psychological (distress), biological (immune), and health outcomes (performance status and evaluations of patient's symptomatology, including toxicity from cancer treatment, lab values) collected at baseline, 4 months, and 12 months.

RESULTS

A path model revealed that intervention participation directly improved health (p<.05) at 12 months. These effects remained when statistically controlling for baseline levels of distress, immunity, and health as well as sociodemographic, disease, and cancer treatment variables. Regarding the mechanisms for achieving better health, support was found for an indirect effect of distress reduction. That is, by specifically lowering intervention patients' distress at 4 months, their health was improved at 12 months (p<.05). Although the intervention simultaneously improved patients' T-cell blastogenesis in response to phytohemagglutinin (PHA), the latter increases were unrelated to improved health.

CONCLUSION

A convergence of biobehavioral effects and health improvements were observed. Behavioral change, rather than immunity change, was influential in achieving lower levels of symptomatology and higher functional status. Distress reduction is highlighted as an important mechanism by which health can be improved.