Cognitive-behavioral stress management increases benefit finding and immune function among women with early-stage breast cancer

Psychosocial and sociodemographic correlates of benefit-finding in men treated for localized prostate cancer

BACKGROUND

Prostate cancer (PCa) treatment involves decrements in quality of life such as decreased sexual functioning and urinary/bowel incontinence. Prior work in other cancers has identified positive consequences (e.g. personal growth) following diagnosis and treatment, a phenomenon that has been referred to as benefit-finding (BF) and positively related to quality of life.

METHOD

The present study evaluated demographic and psychosocial correlates of BF in men treated for localized PCa. Participants were 250 men who were 6-18 months post treatment, who completed measures of coping strategies, perceived social support, and BF.

RESULTS

In regression models both coping and social support were positively related to BF scores, even after controlling for income, education and ethnic identification.

CONCLUSION

Active coping strategies and greater perceived social support are important correlates of greater BF following localized PCa treatment.

Randomized clinical trial on cognitive therapy for depression in women with metastatic breast cancer: Psychological and immunological effects

Objective:Depression is particularly prevalent in patients with advanced cancer. Cognitive therapy (CT) is an empirically supported treatment for depression in the general population. However, efficacy remains to be demonstrated in patients with advanced cancer. A prior controlled trial of CT in a group format showed improvements in depression, mood disturbance, and self-esteem; however, these effects were not maintained over time. Studies examining the efficacy of individual format CT interventions that may ensure more long-term maintenance of benefits are necessary. This study assessed the efficacy of CT for depression administered individually in women with metastatic breast cancer and its effect on immune function.

Method: Forty-five women were randomly assigned to either individual CT or to a waiting-list control (WLC) condition. CT was composed of eight weekly sessions of CT and three booster sessions administered at 3-week intervals following the end of treatment.

Results: Patients treated with CT had significantly lower scores on the Hamilton Depression Rating Scale at posttreatment compared to untreated patients. Pooled data from both groups indicated significant reductions of depressive symptoms from pre- to posttreatment, as well as reduction of associated symptoms including anxiety, fatigue, and insomnia symptoms. These effects were well sustained at the 3- and 6-month follow-up evaluations. CT for depression did not appear to have a significant impact on immune functioning.

Significance of results: Findings of this study support the efficacy of CT for depression in this population and suggest that the administration of individual and booster sessions after treatment termination may be instrumental in sustaining the treatment effects over time.

Changes in finding benefit after cancer surgery and the prediction of well-being one year later

Critical life events, such as cancer surgery, may result in finding some benefit in one's fate. In this longitudinal study with 117 cancer patients (73 men, 44 women) in hospitals in Berlin, we addressed three questions. (1) Do patients report benefit finding after surgery? (2) Are changes in benefit finding related to patients' well-being? (3) Is social support associated with finding benefits in cancer? Patients were interviewed and completed a questionnaire in the week before cancer surgery. They were invited to participate in the follow-up by letter with a questionnaire at one month and again at 12 months postsurgery. Benefit finding was measured by a seven-item scale assessing different facets of positive changes attributed to experiencing grave illness. Although benefit finding increased over one year, change was substantial only for those who started off at a low level. Well-being was not associated with benefit finding at any point in time. However, changes in benefit finding predicted subsequent well-being. Received support was associated with benefit finding. Changes in benefit finding as well as initial support emerged as joint predictors of well-being.

Emotional expression and diurnal cortisol slope in women with metastatic breast cancer in supportive-expressive group therapy: a preliminary study

We examined coded emotional expression during an initial therapy session and its association with a known physiological risk factor for early death, aberrant diurnal cortisol slope, in women with metastatic breast cancer. Out of 64 women with metastatic breast cancer randomized to a multi-site clinical intervention trial of supportive-expressive group therapy (SET), a subsample of 29 met eligibility criteria for this study. We tested whether longer mean durations of primary negative affect (fear, sadness, and anger) expression were associated with steeper diurnal cortisol slopes after adjusting for speaking time, repressive-defensiveness, anxiety, and the interaction between repressive-defensiveness and anxiety. We found that steeper cortisol slopes were related to lower repressive-defensiveness and greater primary negative affect expression in line with a priori hypotheses. Additionally we explored whether coded positive affect, defensive/hostile affect, constrained anger, and the interaction between primary negative affect and repressive-defensiveness explained additional variance in diurnal cortisol patterns.

A randomized clinical trial of group-based cognitive-behavioral stress management in localized prostate cancer: development of stress management skills improves quality of life and benefit finding

BACKGROUND

Recent literature has indicated that a significant percentage of oncology patients describe finding some benefit (e.g., improved personal growth, sense of meaning, and enhanced interpersonal relationships) in the cancer experience. However, few studies have investigated the role of group-based psychosocial interventions in improving benefit finding (BF), and virtually none have investigated these constructs in men.

PURPOSE

This study examined whether a cognitive-behavioral stress management (CBSM) intervention improves BF and quality of life (QoL) in men recovering from treatment for localized prostate cancer.

METHODS

Participants in this study were 191 men (M age = 65.1) treated with radiation or radical prostatectomy for clinically localized (i.e., Stage I or II) prostate cancer. Participants were primarily non-Hispanic White (40%) or Hispanic (41%), followed by Black (18%) and other ethnicity (1%), were an average of 65.1 years old (SD = 7.7), and earned an average of 47,800 US dollars annually (SD = 41,000 US dollars). Participants were randomized to either a 10-week group-based cognitive-behavioral stress management intervention or a half-day educational seminar as a control condition. All participants provided demographic information and completed the Positive Contributions Scale-Cancer to assess BF, the Functional Assessment of Cancer Therapy to measure quality of life, and a measure of perceived stress management skills. Structural equation modeling was utilized for all analyses.

RESULTS

Results indicated that the CBSM condition led to increases in BF and QoL and that these changes were mediated by the development of stress management skills.

CONCLUSIONS

Results support the use of group-based cognitive-behavioral interventions in promoting QoL and BF in this population.

Psychotherapy in the medically ill: a commentary

OBJECTIVE

To overview the field of psychotherapy in the medically ill. Rather than attempting a systematic review of this very extensive area, the article seeks to capture some of the main threads and issues of importance.

METHOD

The subject is looked at under four headings: (i) which illnesses have attracted research interest in psychotherapy; (ii) which outcome measures have been chosen; (iii) which modes of intervention have been used; and (iv) finally a review of the methodology and the results obtained.

RESULTS

Some illnesses have attracted much more psychotherapeutic interest than others; the differences are haphazard. Outcome measures on the whole have focused on coping with illness and psychological distress, with a smaller number looking at disease outcome. Only short-term changes have been sought in the main. The most commonly used modalities of therapy have been cognitive-behavioural; additionally, supportive information-giving and group therapy have been trialled. Benefit in terms of all these have been reported, but the majority of studies are weakened by major methodological shortcomings.

CONCLUSION

There is an overall paucity of well-designed studies that clearly demonstrate psychotherapy as an efficacious treatment in the medically ill. The field is hampered by the lack of a clear conceptual thread recognizing the long-term and diverse experience of patients with medical illness and relating this to the question of the part psychotherapy should play. Future work needs to concentrate on appropriate selection of patients who might benefit, as well as including a wider range of more clinically relevant outcome measures and more stringent methodology.

The influence of bio-behavioural factors on tumour biology: pathways and mechanisms

Epidemiological studies indicate that stress, chronic depression and lack of social support might serve as risk factors for cancer development and progression. Recent cellular and molecular studies have identified biological processes that could potentially mediate such effects. This review integrates clinical, cellular and molecular studies to provide a mechanistic understanding of the interface between biological and behavioural influences in cancer, and identifies novel behavioural or pharmacological interventions that might help improve cancer outcomes.

A cognitive behavioral intervention for symptom management in patients with advanced cancer

PURPOSE/OBJECTIVES

To evaluate the effectiveness of a cognitive behavioral intervention in decreasing symptom severity in patients with advanced cancer undergoing chemotherapy.

DESIGN

Prospective, randomized clinical trial based on cognitive behavioral theory.

SETTING

Six urban cancer centers in the midwestern United States.

SAMPLE

124 patients 21 years of age or older were recruited and randomized to receive conventional care or conventional care and an intervention. Participants were newly diagnosed with stage III, stage IV, or recurrent cancer (solid tumor or non-Hodgkin lymphoma), undergoing chemotherapy, cognitively intact, and able to read and speak English.

METHODS

Data were gathered via telephone interviews at baseline and 10 and 20 weeks after randomization. Nurses with experience in oncology delivered a five-contact, eight-week intervention aimed at teaching patients problem-solving techniques to affect symptom severity.

MAIN RESEARCH VARIABLES

Gender, site of cancer, age, symptom severity and depressive symptoms at baseline, group (i.e., experimental versus control), and total symptom severity.

FINDINGS

Patients in the experimental group and those with lower symptom severity at baseline had significantly lower symptom severity at 10 and 20 weeks; the experimental difference at 20 weeks occurred primarily in those 60 years of age and younger. Depressive symptoms at baseline predicted symptom severity at 20 weeks; however, age, gender, and site of cancer did not affect symptom severity at either time point.

CONCLUSIONS

A cognitive behavioral intervention to teach problem-solving skills can be effective for patient symptom self-management during and following an intervention.

IMPLICATIONS FOR NURSING

Problem-solving strategies should be included in educational programs for patients with advanced cancer, particularly those 60 years of age and younger.

Social support, psychological distress, and natural killer cell activity in ovarian cancer

PURPOSE

Psychosocial stress has been related to impaired immunity in cancer patients. However, the extent to which these relationships exist in immune cells in the tumor microenvironment in humans has not been explored. We examined relationships among distress, social support, and natural killer (NK) cell activity in ovarian cancer patients in peripheral-blood mononuclear cells (PBMC), ascitic fluid, and tumor-infiltrating lymphocytes (TIL).

PATIENTS AND METHODS

Patients awaiting surgery for a pelvic mass suspected of being ovarian cancer completed psychological questionnaires and gave a presurgical sample of peripheral blood. Samples of tumor and ascites were taken during surgery, lymphocytes were then isolated, and NK cytotoxicity and percentage were determined. The final sample, which was confirmed by surgical diagnosis, included 42 patients with epithelial ovarian cancer and 23 patients with benign masses.

RESULTS

Peripheral NK cell activity was significantly lower among ovarian cancer patients than in patients with benign masses. Among ovarian cancer patients, NK cytotoxicity in TIL was significantly lower than in PBMC or ascitic fluid. Social support was related to higher NK cytotoxicity in PBMC and TIL, adjusting for stage. Distress was related to lower NK cytotoxicity in TIL. A multivariate model indicated independent associations of both distress and social support with NK cell activity in TIL.

CONCLUSION

Psychosocial factors, such as social support and distress, are associated with changes in the cellular immune response, not only in peripheral blood, but also at the tumor level. These relationships were more robust in TIL. These findings support the presence of stress influences in the tumor microenvironment.

Randomized study on the efficacy of cognitive-behavioral therapy for insomnia secondary to breast cancer, part II: Immunologic effects

PURPOSE

Cross-sectional studies suggest that clinical insomnia is associated with immune downregulation. However, there is a definite need for experimental studies on this question. The goal of this randomized controlled study was to assess the effect of an 8-week cognitive-behavioral therapy (CBT) for chronic insomnia on immune functioning of breast cancer survivors. Previous analyses of this study showed that CBT was associated with improved sleep and quality of life, and reduced psychological distress.

PATIENTS AND METHODS

Fifty-seven women with chronic insomnia secondary to breast cancer were randomly assigned to CBT (n = 27) or to a waiting-list control condition (WLC; n = 30). Peripheral-blood samples were taken at baseline and post-treatment (and postwaiting for WLC patients), as well as at 3-, 6-, and 12-month follow-up for immune measures, including enumeration of blood cell counts (ie, WBCs, monocytes, lymphocytes, CD3+, CD4+, CD8+, and CD16+/CD56+) and cytokine production (ie, interleukin-1-beta [IL-1beta] and interferon gamma [IFN-gamma]).

RESULTS

Patients treated with CBT had higher secretion of IFN-gamma and lower increase of lymphocytes at post-treatment compared with control patients. Pooled data from both treated groups indicated significantly increased levels of IFN-gamma and IL-1beta from pre- to post-treatment. In addition, significant changes in WBCs, lymphocytes, and IFN-gamma were found at follow-up compared with post-treatment.

CONCLUSION

This study provides some support to the hypothesis of a causal relationship between clinical insomnia and immune functioning. Future studies are needed to investigate the clinical impact of such immune alterations.

Cognitive and affective determinants of decisions to attend a group psychosocial support program for women with breast cancer

OBJECTIVE

This prospective study assesses the roles of illness beliefs, emotion regulation factors, and sociodemographic characteristics in decisions to participate in a group support program for women recently diagnosed with breast cancer.

METHOD

Women recruited during clinic visits 2 to 4 weeks after diagnosis completed measures of affective and cognitive factors identified by Leventhal's Common-Sense Model of illness self-regulation: cancer-related distress, avoidance tendencies, beliefs that the breast cancer was caused by stress and altered immunity, and personal control beliefs. Measures of general anxiety and depression, social support, and demographic characteristics were also completed; prognostic status information was obtained from medical records. All women were encouraged to participate in a free, 12-week program offering coping skills training and group support. Participation was recorded by program staff.

RESULTS

Of the 110 women, 54 (49%) participated in the group support program and 56 (51%) did not. Logistic regression analyses revealed that participation was predicted by stronger beliefs that the cancer was caused by altered immunity, higher cancer-related distress, lower avoidance tendencies, and younger age.

CONCLUSIONS

Participation in the group psychosocial support program appeared to be guided by cognitive and affective factors identified by the Common-Sense Model. Psychosocial support programs and informational materials promoting their use may attract more participants if they are tailored to focus on resolving cancer-related distress rather than on general anxiety or depression, appeal to those with high avoidance tendencies, address the role of immune function in cancer progression, and meet the needs of older participants.