Reaction to a diagnosis of breast cancer. Relationship between denial, delay and rates of psychological morbidity

Development and psychometric properties of a short form of the Illness Denial Questionnaire

BACKGROUND

Coping with chronic illness can be overwhelming for patients and caregivers, and may be inhibited by the denial mechanism, and therefore, denial represents a critical issue for health professionals. Assessing illness denial is far from easy, and brief tools suitable for medical settings are lacking. In this paper, the development of a short form of the Illness Denial Questionnaire (IDQ) for patients and caregivers is presented.

METHODS

In study 1, the IDQ was administered to 118 patients and 83 caregivers to examine the internal structure of denial; then the properties of the items (DIF, fit, and difficulty) were evaluated according to the Rasch model in order to select the best items for the Illness Denial Questionnaire-Short Form (IDQ-SF). Study 2 included 202 participants (113 patients and 89 caregivers). The internal structure of the IDQ-SF was tested via confirmatory factor analysis (CFA). Reliability and concurrent validity were also studied using the Anxiety and Depression Questionnaire-Reduced Form (AD-R).

RESULTS

The CFA showed a two-factor structure encompassing "Denial of negative emotions" and "Resistance to change". Results of the Rasch analyses led to the selection of 4 items for each dimension. The resulting IDQ-SF (8 items) showed a two-factor structure as well as good reliability and concurrent validity with AD-R.

CONCLUSION

The IDQ-SF represents a valid tool for quickly evaluating the core of illness denial in patients and caregivers. This brief and easily administrable questionnaire allows health professionals to outline the presence and severity of illness denial in order to set individually tailored interventions.

Communication in cancer: its impact on the experience of cancer care: communicating with the angry patient and the patient in denial

PURPOSE OF REVIEW

This review aims to describe the recent literature on communication between cancer care clinicians and angry patients and patients in denial.

RECENT FINDINGS

Clinicians had improved perceived self-efficacy in responding to patient anger after completing anger management training, with a focus on reframing anger as a normative response to unmet needs. Psychosocial and mindfulness programmes for cancer patients were found to be useful for modifying anger response to stressors. Existing clinician communication guidelines may not meet the complex needs of adolescents and individuals with anger-prone personality expressing anger. The detrimental effects of avoiding communication about cancer and dying in patients and families include increased stress and emotional burden, patient depression and anxiety and regret in bereaved family members. Further understanding of the complex interplay between the expression of instrumental and emotional concerns of patients may lead to improved clinician communication.

SUMMARY

Anger and maladaptive denial in patients with cancer have detrimental effects that can be seen across a wide range of cultural contexts, in not only the patient but also in their families and the involved clinicians. Training interventions for both patients and clinicians can benefit patient emotional response and perceived clinician self-efficacy.

Lung Cancer Screening Uncertainty among Patients Undergoing LDCT

OBJECTIVES

Lung cancer is the leading cause of cancer death, yet lung screening remains underutilized. Lung cancer screening uncertainty (LCSU), including referral clarity and the perceived accuracy of screening, may hinder utilization and represent an unmet psychosocial need. This study sought to identify correlates of LCSU among lung screening patients.

METHODS

Current and former smokers (N = 169) completed questionnaires assessing LCSU, sociodemographic variables, objective and subjective numeracy, stress, and anxiety, as part of a cross-sectional study of lung screening patients at an academic hospital.

RESULTS

Patients (52% current smok- ers) reported high clarity about the reason for their lung screening referral. Less clarity was as- sociated with lower education, not receiving Medicare, and greater stress and anxiety. Patients perceived lung screening to be moderately accurate, and levels were inversely related to objective numeracy. Subjective numeracy was higher among former versus current smokers (OR = 2.5), yet was unrelated to LCSU variables.

CONCLUSIONS

Several sociodemographic, numeracy, and emotional factors were associated with greater LCSU. With multiple policy and clinical guidelines purporting the uptake of annual lung screening, it is important to identify patients with LCSU and tailor shared decision-making to clarify their uncertainties.

A Longitudinal Study of Psychological Distress in Women with Breast Symptoms

The aim of the study was to measure psychological distress in women with breast symptoms over a period of three months following an outpatient appointment at a rapid access symptomatic breast clinic. Women were recruited (N = 150) at the weekly clinic and psychological distress was measured using the Hospital Anxiety and Depression Scale, the General Health Questionnaire-12 and the Spielberger State-Trait Anxiety Inventory. Information on age and diagnosis was collected from medical notes. Measures were repeated at two weeks and at three months. Participants were divided into three diagnostic categories: B 1 (benign diagnosis at clinic); B2 (benign after further investigations); and M (breast cancer). Overall, scores of anxiety and GHQ-12 decreased significantly during the follow- up period. However, participants in the B2 group remained significantly more distressed than the rest of the sample throughout the experimental period. Depression remained within the normal range throughout the follow-up period for all categories. The study suggests a relationship between symptomatic breast disease and psychological distress.

Coping with a diagnosis of breast cancer among Omani women

The aim of this study was to identify coping strategies experienced by Omani women after breast cancer diagnosis. Individual semistructured interviews were conducted with 19 women diagnosed with breast cancer. Several coping strategies were identified including denial, optimism, withdrawal, Islamic beliefs and practices, and the support of family members and health-care providers, but Islamic beliefs and practices were the commonest. Health-care professionals should be aware of and respect women's coping strategies and encourage them to use to reduce the psychological symptoms. They should also make family members and friends aware of their role in supporting and encouraging coping strategies.

The salience of existential concerns across the cancer control continuum

Despite significant improvement in cancer survival, the fear of death still remains rooted in individuals' beliefs about cancer. Existential fears pertaining to cancer cut across the cancer control continuum and taint decisions related to prevention, screening, surveillance, and follow-up recommendations, as well as the overall management of cancer-related issues. However, individuals are innately predisposed to cope with their cancer-related fears through mechanisms such as reliance on the process of meaning making. To better appreciate the potential impact of existential concerns across the cancer control continuum, the Temporal Existential Awareness and Meaning Making (TEAMM) model is proposed. This tripartite model depicts three types of perceived threats to life related to cancer including a “social awareness” (i.e., cancer signals death), “personalized awareness” (i.e., I could die from cancer), and the “lived experience” (i.e., It feels like I am dying from cancer). This construal aims to enhance our understanding of the personal and contextual resources that can be mobilized to manage existential concerns and optimize cancer control efforts. As such, existential discussions should be considered in any cancer-related supportive approach whether preventive, curative, or palliative, and not be deferred only until the advanced stages of cancer or at end of life. Further delineation and validation of the model is needed to explicitly recognize and depict how different levels of existential awareness might unfold as individuals grapple with a potential, actual, or recurrent cancer.

Impact of relaxation training according to Yoga In Daily Life® system on self-esteem after breast cancer surgery

OBJECTIVES

The purpose of this pilot study was to gather information on the immediate and short-term effects of relaxation training according to the Yoga In Daily Life(®) system on the self-esteem of patients with breast cancer.

DESIGN

This is a parallel-groups design.

SETTINGS/LOCATION

Baseline interventions took place at the Institute for Oncology of Ljubljana (Slovenia). At discharge, the experimental group was issued with audiocassette recordings containing the instructions for relaxation training to be practiced individually at home for an additional 3 weeks.

SUBJECTS

The convenience sample of 32 patients with breast cancer was recruited from an accessible population of hospitalized women. Patients were randomized to the experimental (n=16) and to the control group (n=16).

INTERVENTIONS

Both groups received the same standard physiotherapy for 1 week, while the experimental group additionally received a group relaxation training sessions according to the Yoga in Daily Life(®) system. At discharge, the experimental group was issued with audiocassette recordings containing similar instructions for relaxation training to be practiced individually at home for an additional 3 weeks.

OUTCOME MEASURES

Outcome measures were obtained by blinded investigators (physiotherapists) using standardized questionnaires (Rosenberg Self-Esteem Scale) at baseline (after the surgery); at 1 week (1 week postattendance; at discharge); and at 4 weeks (4 weeks postattendance); prior the commencement of radiation.

RESULTS

Analysis of variance showed that there were statistically significant differences between the experimental and control group in all measuring self-esteem scores over the study period (p<0.0005). At the same time, the control group's scores remained unchanged over the study period (p>0.05).

CONCLUSIONS

The results indicate that relaxation training according to the Yoga in Daily Life system could be a useful clinical physiotherapy intervention for patients who have breast cancer and who are experiencing low self-esteem. Although this kind of relaxation training can be applied to clinical oncology in Slovenia, more studies need to be done.

Impact of relaxation training according to Yoga In Daily Life® system on perceived stress after breast cancer surgery

The purpose of this pilot study was to gather information on the immediate and short-term effects of relaxation training according to Yoga In Daily Life(®) (YIDL) system on the psychological distress of breast cancer patients. 32 patients at the Institute for Oncology of Ljubljana were randomized to the experimental (N=16) and to the control group (N=16). Both groups received the same standard physiotherapy for 1 week, while the experimental group additionally received a group relaxation training sessions according to YIDL(®) system. At discharge the experimental group was issued with audiocassette recordings containing the similar instructions for relaxation training to be practiced individually at home (for further 3 weeks). An experimental repeated measures design was used to investigate the differences over 1 month period in stress levels, changes in mental health and psychological parameters. Measures were obtained at three time points during the study period: baseline, at 1 week, and at 4 weeks, by blinded investigators using standardized questionnaires General Health Questionnaire-12 (GHQ-12), Rotterdam Symptom Checklist (RSCL) psychological subscale, Perceived Stress Scale (PSS). Patients who received relaxation training reported feeling significantly less distressed during hospitalization and after discharge-period than did the controls that did not receive relaxation training. The results indicate that relaxation training according to Yoga in Daily Life(®) system could be useful clinical physiotherapy intervention for breast cancer patients experiencing psychological distress. Although this kind of relaxation training can be applied to clinical oncology in Slovenia, more studies need to be done.

Denial of Chronic Illness and Disability: Part II. Research Findings, Measurement Considerations, and Clinical Aspects

The concept of denial has been an integral part of the psychological and disability studies bodies of literature for over 100 years.Yet, denial is a highly elusive concept and has been associated with mixed, indeed conflicting theoretical perspectives, clinical strategies, and empirical findings. In part II the author reviews empirical findings, measurement strategies, and clinical approaches associated with denial, with particular emphasis on rehabilitation-specific findings and implications. It focuses on empirical findings linking the use of denial to a number of psychosocial outcomes, measures that have been employed in the assessment of denial and, intervention strategies to manage denial. Part II concludes with a brief discussion of the implications generated by the current understanding of denial to rehabilitation practitioners and researchers.

Denial of Chronic Illness and Disability

Denial has been an integral part of the psychological and disability literature for more than 100 years. Yet, denial is an elusive concept and has been associated with mixed, indeed conflicting, theoretical perspectives, clinical strategies, and empirical findings. In this two-part article, the author provides an overview of the existing literature on denial that addresses the most prominent and rehabilitation-relevant features of it. Part I provides a generic yet clinically based discussion of denial and focuses on the following: historical perspective of denial, the definitions of denial, the types or forms of denial most often encountered in the literature, the functions served by denial, the indicators or markers most frequently associated with denial, the dynamics and processes inherent in the operation of denial, and the costs and benefits of denial.

The denial of cancer interview: development and first assessment of psychometric properties in lung cancer patients

OBJECTIVE

Based on Weissman and Hackett's comprehensive definition of denial, a semi-structured interview was developed to measure denial in cancer patients. The denial in cancer interview (DCI) covers both the patients' recount of their illness experience and the expert's impression of the level of denial in the patient story. This paper describes the development and first psychometric analyses of the instrument.

METHOD

The development of the DCI was based on clinical observation, the expert opinion of eight specialised psychiatrist as well as three small pilot studies to assess feasibility. The DCI is composed of two parts: a semi-structured interview consisting of nine specific items to be answered by the patient and two items covering the interviewer's clinical impression of the patient's type and level of denial. Follow-up interviews were held at 8, 16 and 32 weeks after the baseline assessment (T2-4). To measure the inter-rater reliability, interviews were recorded and rated independently by one interviewer and one of the study's co-workers.

RESULTS

One hundred and ninety-five consecutive newly diagnosed lung cancer patients were interviewed. The internal consistency of the DCI (Cronbach's alpha) was 0.84 at first interview and 0.85, 0.82 and 0.83 at T2-4, respectively. The inter-rater agreement was good for the DCI overall and the patient's assessment scale, and satisfactory for the clinical impression items. Content validity was supported by clinical observation, in depth open interviewing and expert opinion.

CONCLUSION

The DCI proved to be a feasible and reliable instrument for measuring denial in lung cancer patients. Further testing in other oncology settings will provide insight in wider applicability.

PRACTICE IMPLICATIONS

The DCI can be used in future studies concerning denial in cancer patients. Insight in denial and its background will help us to adequately address denial in patients and communicate with them.

Denial in cancer patients, an explorative review

Denial is a clinically relevant concept in cancer patients. It has been investigated and discussed extensively. Its definition, however, has been subject to different theoretical trends over time. From a psychoanalytical viewpoint, denial is a pathological, ineffective defence mechanism. On the other hand, according to the stress and coping model denial can be seen as an adaptive strategy to protect against overwhelming events and feelings. In this explorative review the different concepts and the prevalence of denial in cancer patients are described. The relationship between denial and background characteristics and the influence of denial on quality of life are reviewed also. The prevalence of denial of diagnosis in cancer patients ranged from 4 to 47%, denial of impact occurred 8-70% and denial of affect in 18-42% of patients. Elderly cancer patients were more likely to deny. Cultural background seemed to play a role in the prevalence of denial. Neither type of cancer nor gender seemed to be related to denial. At the most, men might be more likely to deny during the terminal phase. In a limited number of longitudinal studies, a gradual reduction in denial was found over the course of the illness. The effect of denial on physical and social functioning remained unclear while the effect on psychological functioning seemed to depend on the concept of denial used. Distractive strategies were found to reduce distress, whereas passive escape mechanisms turned out to decrease psychological well-being. Future research on the prevalence and the (mal)adaptive properties of denial in cancer patients has to be based on a clear concept, longitudinal designs and careful recording of background variables.

Psychological outcome of patients following treatment of oral cancer and its relation with functional status and coping mechanisms

BACKGROUND

Traditionally health-care providers have measured outcome of treatment of disease by focusing on tumour response and disease-free survival. However, it has become increasingly apparent that the behavioural and functional impact of treatment on the patient is important. This study investigates the psychological outcome and its relationship with functional status and coping mechanisms following treatment of oral cancer patients.

MATERIAL AND METHODS

Sixty-eight patients were evaluated 6 months to 6 years after treatment (from October 1992 to October 1997) for oral cancer. The Hospital Anxiety and Depression Scale (HADS) was used for psychological evaluation, the University of Washington Quality of Life Questionnaire (UW-QOL) and The European Organisation for Research and Treatment of Cancer Questionnaire (EORTC QLQ-C30) for evaluating the head and neck specific and general functional status, respectively. Finally, the "Mental Adjustment to Cancer Questionnaire" (MAC-Q) was used for evaluation of coping mechanisms.

RESULTS

The incidence of anxiety and/or depression was 25% and the socio-demographic and medical characteristics showed poor correlation with the psychological outcome in this study. The results indicated that there was a strong association between psychological outcome and head and neck specific and general quality-of-life (QOL) domains, and style of coping. The p-value was less than 0.01 for most of the domains and items of functional status and the effective coping style.

CONCLUSION

Deteriorated functional status and ineffective coping strategies are strongly associated with poor psychological outcome in patients with oral cancer.

Psychometric analyses of the Mental Adjustment to Cancer (MAC) scale in a Greek palliative care unit

The purpose of the study was to assess the Mental Adjustment to Cancer (MAC) scale on a heterogeneous Greek sample of 200 advanced cancer patients. The results presented regard the validation analysis of the Greek version. The homogeneity of the original subscales proved to be satisfactory (alpha coefficients ranged from 0.81 to 0.91). A factor analysis was carried out using the LISREL 8.3 procedure. This yielded five factors, including 25 of the 40 original items (alpha coefficients 0.62-0.93). The resulting factors were called 'hopeless', 'positive attitude', 'acceptance', 'mental engagement', and 'fatalistic'. Correlations between the MAC scale and the disease severity as measured by the ECOG performance status have shown difference only between patients with 'good' versus 'poor' performance status in the 'hopeless' scale (p=0.047). The results suggest that the Greek version, as measured in advanced cancer patients attending a palliative care unit, is a reliable and valid clinical tool in Greece.

Psychological factors and patient delay in patients with head and neck cancer

There is a rising incidence of patients presenting with advanced cancer in the head and neck region. Late presentation may be due to a delay in seeking medical attention, which is sometimes surprisingly long. The aim of the present prospective study was to investigate the association between patient delay and the psychological factors of optimism, health hardiness, overall defensive functioning, coping styles and psychological distress in 277 patients with cancer of the head and neck. Significant correlations were found between patient delay and the psychological factors. Twenty-six percent of the patients waited more than three months before seeking medical attention and they reported less optimism (P = 0.0001), less health hardiness (P = 0.008), less active coping (P = 0.019) and less seeking support as a coping style (P = 0.017) than patients presenting within three months. Excessive drinkers (5+ alcoholic drinks/day) tended to show more delay than patients who did not drink or were moderate drinkers (0-2 drinks/day) or moderate-heavy drinkers (3-4 drinks/day). Together, the psychological factors could explain 25% of the variance of patient delay in excessive drinkers compared with 21% and 6% in moderate-heavy drinkers and non-drinkers to moderate drinkers, respectively. These results suggest that psychological factors affect health-care seeking behaviour. Health education aimed at the risk group of excessive drinkers should take psychological factors into account that influence their health behaviour.

Preventing anxiety and depression in gynaecological cancer: a randomised controlled trial

OBJECTIVE

To examine the effect of counselling and relaxation intervention on psychological symptoms in patients with gynaecological cancer between the post-operative period and the six-week review.

DESIGN

Randomised controlled trial.

PARTICIPANTS

Fifty-three patients with gynaecological cancer.

SETTING

Three Australian tertiary referral hospitals.

METHODS

Fifty-three patients were randomised to control or intervention and completed the baseline Hospital Anxiety and Depression Scale (HADS) and General Health Questionnaire-28 (GHQ-28) questionnaires. The intervention consisted of a relaxation and counselling session performed by a senior doctor. Follow up questionnaires were completed at six weeks. Demographic and tumour data were collated independently.

RESULTS

Complete data were available on 50 patients. There were no significant differences in demographic, social support or tumour characteristics between the two groups. Multivariate analysis determined that only the intervention and baseline score were significant predictors of outcome. The intervention was associated with a significant reduction in total HADS score (P = 0.002). The reduction was seen in both anxiety and moderate depression subscales (P = 0.001 and P = 0.02). The intervention was also associated with a significant reduction in total GHQ-28 score and in three of the four subscale scores (somatisation, anxiety and personality development; all P < 0.02). However, no significant difference was found in the fourth subscale of major depression.

CONCLUSION

A relaxation and counselling intervention performed by a treating doctor reduces psychological symptoms in women with a new diagnosis of gynaecological cancer.

Functional status of patients with oral cancer and its relation to style of coping, social support and psychological status

Sixty-eight patients were evaluated 6 months to 6 years after treatment for oral cancer using standardized questionnaires to explore the influence of age, sex, site and stage of tumour, and primary treatment on their functional status measured by the University of Washington Quality of Life Questionnaire (UW-QoL), and the association between functional status and psychological outcome measured by the Hospital Anxiety and Depression Scale (HADS), style of coping measured by the Mental Adjustment to Cancer Questionnaire (MAC-Q), and social support measured by the Short-Form Social Support Questionnaire (SSQ-6). Young patients, women, patients with advanced tumours, those with oropharyngeal tumours and those who had been treated with both surgery and radiotherapy reported worse function. The worse the functional domain, the more likely it was to be associated with anxiety, depression and ineffective coping style, and better functional scores were weakly associated with fighting spirit, level of social support and satisfaction with that support. We have identified patients at need and highlighted their problems. Dealing with these problems may ultimately improve the perception of function after treatment of oral cancer.

Adjustment to cancer - coping or personal transition?

The term 'adjustment' is widely used within the psycho-oncology literature and, although it is a topic of central importance to the lived experience of people with cancer, the psychological mechanisms of adjustment have rarely been described. Rather than regarding it as the absence of psychopathology or the end-point of coping with the global threat of cancer, adjustment refers to the psychological processes that occur over time as the individual, and those in their social world, manage, learn from and adapt to the multitude of changes which have been precipitated by the illness and its treatment. However, these changes are not always for the worse: sometimes they precipitate 'healthy personal growth' in a number of areas. It is only from explicit theories of adjustment that progress can be made in understanding how and why psychological disorders so frequently develop in cancer and what steps may be taken to prevent them. This paper combines the complementary assets of coping theory and social-cognitive theory and proposes the Social-Cognitive Transition (SCT) model of adjustment, a clinical model which also accounts for the frequent reports of healthy personal growth associated with cancer.

A psychosocial group intervention for Japanese women with primary breast carcinoma

BACKGROUND

To the authors' knowledge, there had been no evidence for the efficacy of psychosocial intervention among Japanese cancer patients. The objective of this study was to determine the effect of a psychosocial group intervention in reducing psychologic distress and enhancing coping in this population in a randomized controlled trial.

METHODS

The patient selection criteria were age younger than 65 years, lymph node metastasis positive and/or histologic or nuclear Grade 2-3, and surgery undergone within the previous 4-18 months as of the start of the study. We conducted a 6-week, structured, psychosocial group intervention. The intervention consisted of health education, coping skills training, stress management, and psychologic support. Subjects were assessed for psychologic distress and coping by administering the Profile of Mood States (POMS), Mental Adjustment to Cancer (MAC) scale, and Hospital Anxiety and Depression (HADS) scale at the baseline, at 6 weeks, and at 6 months.

RESULTS

Fifty (33%) of the 151 patients participated and were randomized, and 46 (30%) completed the study. The experimental group had significantly lower scores than the controls for total mood disturbance and significantly higher scores for vigor on the POMS, and significantly higher scores for fighting spirit on the MAC at the end of the 6-week intervention. These improvements were sustained over 6 months of follow-up.

CONCLUSIONS

The results of this study suggest that a short term psychosocial group intervention produces significant long term improvement in the quality of life of Japanese patients with primary breast carcinoma.

Psychometric properties of the Japanese version of the Mental Adjustment to Cancer (MAC) scale

This paper describes a study of the psychometric properties of the Japanese version of the mental adjustment to cancer (MAC) scale developed in England. The scale was completed by 455 Japanese cancer patients. The internal consistency was similar to that of the original version (Cronbach's alpha coefficients for the subscales ranged from 0.60 to 0.78) and the Japanese version had moderate to moderately high stability (correlation coefficients were above 0.64). Correlations between the MAC scale score and emotional states measured by the Profile of Mood States (POMS) indicated the concurrent validity. The results suggest that the Japanese version, like the original MAC scale, is a reliable and valid clinical research tool in Japan.

Psychosocial predictors of survival: metastatic breast cancer

BACKGROUND

Research interest in psychosocial predictors of the onset and course of cancer has been active since the 1950s. Recently we reported associations between psychological factors and survival in patients with metastatic melanoma. We now report a replication of this study in a sample of women with metastatic breast cancer.

PATIENTS AND METHODS

Ninety-nine patients with metastatic breast cancer completed questionnaires measuring cognitive appraisal of threat, coping, psychological adjustment, perceived aim of treatment, social support and quality of life, approximately four months after diagnosis. Survival was measured from date of study entry to date of death or censored at the date of last follow-up for surviving patients.

RESULTS

In a multivariate analysis, four factors independently predicted outcome. Patients with metastases in the liver, lung or pleura survived for a shorter duration (P < 0.001); older patients (P < 0.001) and those with a better appetite (P < 0.05) also lived for a shorter time. Patients who minimised the impact of cancer survived longer (a median of 29.1 vs. 23.9 months after study entry, P < 0.01).

CONCLUSIONS

Minimisation was also significantly associated with outcome in patients with metastatic melanoma who participated in an identically designed study, reported elsewhere. This suggests that minimisation may have a general impact on cancer progression and deserves closer scrutiny in other cancers.

Denial in cancer patients

Denial is a basic mechanism for coping with stressful themes, common in healthy and sick individuals. This article deals with the role and functions of denial in cancer, reviewing empirical studies about the effects of denial on cancer prevention, screening, undergoing tests for early detection, delay in seeking medical attention and getting treatment, complying with medical instructions, and coping with the disease in different stages. Special sections are devoted to the possible role of denial as a risk factor for cancer, the effects of denial on disease course and survival, and the relation of denial to immunocompetence. Major conclusions are that denial may have a positive effect when applied in the first phase of coping, after diagnosis, because it reduces anxiety. This holds also for the terminal stage. The negative effects of denial are that it may interfere with getting treatment (e.g., delay in going to the doctor, not showing up for follow-ups, noncompliance), may disrupt the process of assimilating the stressful event, may affect adversely interpersonal relations, and constitutes a cumulative stressor depressing even immunocompetence. The use of denial varies with the severity of the situation, the patient's personality, and his or her familial and cultural background. A large body of research examined the hypothesis that a tendency toward denial could be one of the risk factors for cancer. Despite evidence supporting the occurrence of denial as a correlate of cancer, a lot of research is necessary to clarify the role of denial in general and of anger specifically as a factor affecting the occurrence of cancer and the course of disease and survival.

Perceptions of women living with coronary heart disease: a pilot investigation

This qualitative study describes how forty-one perimenopausal and postmenopausal women with coronary heart disease (CHD) perceive their illness experience. Five focus groups were conducted by a professional facilitator at two community hospitals in New Jersey. All data were collected and analyzed based on the grounded theory approach. Findings indicate that participants often failed to recognize the significance of risk factors and symptoms, and even denied the presence of disease following diagnosis and treatment. Consequences of illness centered on women's efforts to maintain control over their health and their lives. Findings also indicate that there is a gap between the desire for knowledge and the ability to access and assimilate information in key areas regarding CHD and personal health behaviors. The insights provided by these women have several implications for future research and contribute valuable information related to the needs of this population.

Coping with breast cancer: a cluster analytic approach

The aim of this study was to generate distinct clusters of women with breast cancer, and to evaluate differences between clusters with respect to decisional control, psychological adjustment, and frustration expression. Thirty-seven Stage I and 33 Stage II newly diagnosed breast cancer patients from two medical oncology clinics participated. A cluster analysis of the coping data produced three distinct patient clusters. The primary finding was that women from the low avoidance coping cluster were significantly better adjusted than women from the remaining clusters. Women from the low avoidance coping cluster also preferred more active involvement in treatment decision-making. Further research is needed to prospectively detail the mechanisms by which cognitive avoidance hampers psychological adjustment to cancer.

Clarification of the conceptualization and measurement of denial in psychosocial oncology research

Denial represents an important area of study in individuals with cancer. It may be related to recognizing symptoms, seeking medical help, psychological adjustment to diagnosis and illness, and perhaps progression of the disease. However, denial has been defined theoretically and measured in a variety of ways. These differences are due to a lack of consensus as to whether denial is unconscious versus conscious, a trait versus a state, an indication of psychological disturbance versus a normal response to a life-threatening disease, or a broad versus a narrow concept. In addition, there is a lack of congruence between theoretical definitions and the operational definitions used in empirical studies investigating denial in the context of cancer. This inconsistency may be responsible for the mixed findings concerning the importance and function of denial in individuals with cancer. In this article, the ways in which denial has been conceptualized and operationalized are examined, and an overview of the research examining denial in cancer patients is provided. We recommend that future studies provide explicit definitions of denial, use multiple measures assessing different modalities and outcomes, measure denial at several times over the course of illness, and take into account aspects of the individual's situation to ensure that denial is not identified erroneously.

Misunderstanding in cancer patients: why shoot the messenger?

AIM

We aimed to document the prevalence of misunderstanding in cancer patients and investigate whether patient denial is related to misunderstanding.

PATIENTS AND METHODS

Two hundred forty-four adult cancer outpatients receiving treatment completed a survey assessing levels of understanding and denial. Doctors provided the facts against which patient responses were compared. Multiple logistic regression analyses determined the predictors of misunderstanding.

RESULTS

Most patients understood the extent of their disease (71%, 95% CI: 65%-77%) and goal of treatment (60%, 95% CI: 54%-67%). Few correctly estimated the likelihood of treatment achieving cure (18%, 95% CI: 13%-23%), prolongation of life (13%, 95% CI: 8%-17%) and palliation (18%, 95% CI: 10%-27%). Patient denial predicted misunderstanding of the probability that treatment would cure disease when controlling for other patient and disease variables (OR = 2.20, 95% CI: 0.99-4.88, P = 0.05). Patient ratings of the clarity of information received were also predictive of patient understanding.

CONCLUSIONS

Patient denial appears to produce misunderstanding, however, doctors' ability to communicate effectively is also implicated. The challenge that oncologists face is how to communicate information in a manner which is both responsive to patients' emotional status and sufficiently informative to allow informed decision-making to take place.

Using two factor structures of the Mental Adjustment to Cancer (MAC) scale for assessing adaptation to breast cancer

The validity and reliability of two factor structures of the Mental Adjustment to Cancer (MAC) scale for assessing coping style was assessed by examining the relationship between the subscales, psychological distress, and quality of life (QOL) among Stage II and Stage IV breast cancer patients in four phases. First, MANOVAs assessed differences in coping, distress, and QOL across disease stages. Second, for each MAC factor structure, canonical correlation analyses assessed the relationship between coping styles, distress, and QOL, for each disease-stage group separately. Third, structural equation modeling (SEM) assessed the relationship among coping styles, distress, and QOL for all participants. Finally, the internal consistency of both MAC factor structures was assessed using Chronbach's alpha. The results were as follows: (1) significant differences across disease stages were found for coping styles using either the Watson or the Schwartz MAC subscales, but there were no differences in levels of distress or QOL; (2) for both MAC factor structures, coping style was found to be highly related to emotional distress and QOL, however, the strengths of the correlations between individual coping styles and distress/QOL indicators varied across disease stages; (3) SEM indicated that coping style was significantly related to distress and QOL when stage of disease was not considered, and that coping style and indicators of distress/QOL are separate, but highly correlated factors, as opposed to a single latent construct; and, (4) the Watson MAC subscales showed slightly better internal consistency than the Schwartz MAC subscales. Taken together, these findings highlight: (i) the validity of both MAC factor structures for clinical and research use with American breast cancer patients; (ii) the role of coping style as a mediator between disease stage and psychological distress and QOL; and, (iii) the need for refinement of certain Watson and Schwartz subscales.

Can preoperative psychological defensive strategies, mood and type of lower urinary tract reconstruction predict psychosocial adjustment after cystectomy in patients with bladder cancer?

OBJECTIVES

To assess if there is relationship between: (i) preoperative psychological defensive strategies, mood and type of lower urinary tract reconstruction, and (ii) psychosocial adaptation after radical cystectomy for bladder cancer.

PATIENTS AND METHODS

Fifty-seven consecutive patients (44 men and 13 women, mean age 62 years, range 34-81) undergoing radical cystectomy (ileal conduit urinary diversion in 17, continent cutaneous diversion in 22 and orthotopic bladder replacement in 18) were assessed preoperatively using the meta-contrast technique (MCT), a projective test to reveal individual defensive strategies. From the results the patients were classified as hypothetical 'at risk' or 'no risk' patients for postoperative psychosocial complications. An 'at risk' patient was designated as one who showed neurotic defensive strategies in coping with threats, i.e. primitive, immature or regressive strategies or even lack of defence in connection with pronounced anxiety. All patients completed a questionnaire and were interviewed; 10 questions dealt with mood, five reflecting anxiety and five the depressive states. The questionnaire and the interview were repeated 3 and 12 months, and 5 years after surgery.

RESULTS

The remembered difficulties during the first month after discharge from hospital differed between the 'risk' and 'no risk' groups after 1 and 5 years. On a visual analogue scale (VAS) the 'risk' patients had very low scores (less difficulty) or very high, while the 'no risk' patients had intermediate scores. VAS score were also higher, although not significantly so, in patients using primitive defence strategies. The psychosocial situation did not differ between the groups in the first year, but at 5 years there were differences in self-esteem and interpersonal contact-seeking. High depression scores before surgery were associated with high VAS scores at 3 months when recalling the first month after discharge, but the anxiety score was not predictive. Men with orthotopic bladder replacement adapted less well throughout the 5 year follow-up. Elderly patients with stereotypy (the commonest defensive strategy at these ages) adapted relatively well to ileal conduit diversion. About 20% of patients had difficulty in accepting the postoperative situation, regardless of urinary diversion modes.

CONCLUSION

The combination of defensive strategies assessed using the MCT and selected on hypothetical grounds was less discriminatory than expected for those at risk of postoperative psychosocial problems. However, those with primitive strategies apparently had a long-term risk of poor adaptation. The search for an optimal instrument for the identification of patients at risk is warranted. In this study, patients with a 'wet' stoma did not seem to fare less well than those with a continent reconstruction.

Predictors of patients' mental adjustment to cancer: patient characteristics and social support

Because being diagnosed with cancer is considered to be extremely stressful, cancer patients' mental adjustment has been widely studied. Previous studies have revealed that cancer patients' mental adjustment is correlated with the quality of life and the degree of psychological distress and have suggested that one of the most adaptive adjustments is 'fighting spirit' whereas one of the most maladaptive is 'helplessness/hopelessness'. However, little is known about the association between patients' mental adjustment to cancer and their spouses characteristics or social support network. This paper describes a study of cancer patients' characteristics and social support factors as predictors of the patients' responses to having cancer. A total of 455 ambulatory cancer patients completed the Mental Adjustment to Cancer (MAC) scale and participated in a structured interview about their characteristics and social support. The results of multiple regression analysis suggested that size of household, performance status, support from physicians and satisfaction with support were predictive of patients' fighting spirit, whereas age, education, size of household, performance status and satisfaction with support were predictive of helplessness/hopelessness.

Psychosocial aspects of palliative care

OBJECTIVES

To provide information about factors that affect psychosocial adjustment among individuals and families who are faced with chronic illness; to discuss assessment guidelines and risk factors that may indicate a need for professional intervention; and to review psychosocial interventions that are used to minimized distress and promote adaptation.

DATA SOURCES

Research studies, review articles, and book chapters.

CONCLUSIONS

The majority of cancer patients experience emotional turmoil that occurs at transition points along the illness trajectory. Psychosocial issues faced by patients and their families are influenced by individual, sociocultural, medical, and family factors.

IMPLICATIONS FOR NURSING PRACTICE

Supportive psychotherapeutic measures help to minimize distress, enhance feelings of control, and improve quality of life.

Illness awareness in cancer patients: a conceptual framework and a preliminary classification hypothesis

The study describes the initial phases of research aimed at developing a methodology for assessing awareness in cancer patients. A first sample of cancer patients (n = 36) was interviewed about their knowledge of the diagnosis and their perception of treatment goals and outcomes. Thirteen domains which refer both to cognitive and emotional areas were identified, and considered as content valid by a panel of six experts. A second sample of patients (n = 54) participated in a semi-structured interview developed to explore awareness by means of the domains identified. Seven patterns of awareness were identified, ranging from 'completely aware patient' to 'completely unaware patient'. Twenty of the 54 patients (37.0%) were completely aware, 19 (35.2%) were partially aware with defence mechanisms and 15 (27.8%) were not aware of their diagnosis. Patients from the National Cancer Institute were more frequently aware (54.3%) compared with the patients interviewed in the community hospitals (5.3%) (p < 0.001). A computerized content analysis allowed the identification of two main groups of patients on the basis of the content of the recorded interviews. This independent classification agreed with the classification of the patients performed by the psychologists, suggesting the validity of the procedure of awareness evaluation proposed in this study.

Psychological sequelae of cancer diagnosis: a meta-analytical review of 58 studies after 1980

OBJECTIVE

In a review of the literature from 1980 to 1994 on psychological and psychiatric problems in patients with cancer, the prevalence, severity, and the course of these problems (i.e., depression, anxiety, and general psychological distress) were studied with the help of meta-analyses and qualitative analyses. Apart from this, qualitative analyses were also applied with respect to other relevant variables.

METHOD

A literature search in MEDLINE was conducted and cross-references of articles identified via MEDLINE. Meta-analysis was applied when possible.

RESULTS

There seemed to be a wide variation across studies in psychological and psychiatric problems. Meta-analysis showed no significant differences between cancer patients and the normal population with respect to anxiety and psychological distress. However, cancer patients seemed to be significantly more depressed than normals. Compared with psychiatric patients, cancer patients were significantly less depressed, anxious, or distressed. Compared with a sample of other medical patients, cancer patients showed significantly less anxiety. With respect to course, a significant decrease was found in the meta-analysis for anxiety, but not for depression. Further meta-analyses showed significant differences among groups of cancer patients with regard to tumor site, sex, age, design of the study, and year of publication. From the qualitative analyses, it seemed that medical, sociodemographic, and psychological variables were related inconsistently to psychological and psychiatric problems.

CONCLUSION

With the exception of depression, the amount of psychological and psychiatric problems in patients with cancer does not differ from the normal population. The amount of psychological and psychiatric problems is significantly less in cancer patients than in psychiatric patients. The amount of anxiety is significantly less in cancer patients than in other groups of medical patients with mixed diagnoses, whereas depression is not. Future studies should aim at exploring possible causes for the sometimes impressive differences in psychological or psychiatric problems among patients with cancer.

Anxiety and depression in hospitalized patients with cancer: agreement in patient-staff dyads

Patient and staff perceptions of patient anxiety and depression were determined in 53 dyads of hospitalized cancer patients and their nursing staff. Patient anxiety and depression were assessed with the Hospital Anxiety and Depression Scale. In addition, anxiety was measured by a numerical (0-10) scale. A staff person who had been caring for a certain patient the previous 3 days assessed that patient's anxiety and depression with staff versions of the same instruments. For one subsample (n = 18), staff were also asked to estimate their own hypothetical anxiety were they to have the same disease as the patient. Results indicate that staff overestimated patient anxiety systematically and showed limited ability to adequately assess patient anxiety and depression in terms of rank. Patients and staff agreed about individual patients' levels of anxiety and depression only to a limited degree. Discrepancies between patient and staff ratings of patient anxiety predominantly concerned patients reporting low anxiety levels. Several explanations for these findings are discussed. One possible explanation, the "requirement of mourning" hypothesis, is supported by our findings that staff estimation of patient anxiety was strongly associated with their estimation of their own hypothetical anxiety if they were to be in the patient's situation.

Adjustment to breast cancer: the psychobiological effects of psychosocial interventions

This review focuses on the effects of psychosocial interventions on psychological and biological functioning of breast cancer patients. Once in their lifetime, one out of eleven women receive a diagnosis of breast cancer. A diagnosis of breast cancer is a severe stressful life event with profound consequences on all aspects of human life. Whether a woman will regain emotional balance and accept the idea of living with a potentially life threatening disease depends on her psychological resiliency. Provision of psychosocial interventions can improve these women's coping abilities and reduce emotional distress and feelings of isolation, and improve psychosexual functioning. Additionally, there exists some evidence that psychotherapy may prolong survival. Prolongation of survival may be related, in part, to an increase in certain aspects of immune function (e.g., natural killer cell activity). This is plausible because the function of the immune system seems to be related to mammary tumor growth. Therefore, future research should examine the degree to which the effects on mammary tumor growth relate to immune system changes.

The creation of protection and hope in patients with malignant brain tumours

The malignant brain tumour disease condenses much of the anguish of cancer diseases. The brain is a vital and delicate organ, and the prognosis is generally unfavourable. The patient is exposed and has to rely on cognitive manoeuvres to manage the mental stress. The purpose of this study was to generate new insights into how the patient constructs a new sense of reality when confronted with the malignant brain tumour diagnosis. Within grounded theory methodology, 30 patients with malignant gliomas were interviewed twice, in direct connection with diagnosis, surgery and radiotherapy. In addition, their partners were interviewed, and quantitative instruments (SMMSE, RDCQ) were used as additional references for assessing the patients cognitively and emotionally. Eleven patients were excluded from the final analysis because of cognitive impairment of personality change. Most of the patients were aware of the fact that the brain tumour exposed them to grave danger, but they were also able to use various cognitive manoeuvres to create protection and hope. This process originated from different sources: the body; helpful relations; cognitive schemata; and the handling of information. The importance of the body to raise hope is emphasized. In the discussion we consider this process as an expression of how the patient brings together reality and hope, thus creating her/his own illusion. These findings are also related to adjacent psychoanalytic theory, proposing a theoretical reference with clinical implications when discussing "What to tell cancer patients."

Anxiety, depression and worry in gastrointestinal cancer patients attending medical follow-up control visits

Anxiety, depression and worry were assessed in 141 consecutive gastrointestinal cancer patients scheduled for follow-up control visits. Participants completed two questionnaires, one including the Hospital Anxiety and Depression Scale (HAD) in conjunction with the visit and one completed after. The overall levels of anxiety before, during and after the visit were low. There were no differences between those who were considered cured and those who were not. Anxiety levels after the visit were higher for those patients for whom less than one year had passed since diagnosis. Mean HAD scores for anxiety and depression were 4.2 and 4.3 respectively. Women reported a higher degree of anxiety than men. Using a score of 8 or more for 'borderline-possible cases', 15% fell into these categories on the anxiety scale and 12% on the depression scale. About 30% of the patients worried about seeing a new physician and 25% about what the examination or tests would show. It is concluded that regular, scheduled control visits pose a significant threat to the psychological well-being of only a minority of gastrointestinal cancer patients.

Well-being and coping in oral and pharyngeal cancer patients

Patients with oral and pharyngeal cancer often suffer serious functional impairments. To achieve a broader understanding of the patients' situation it is important to include their appraisal of present functioning. There may also be other factors of importance in the evaluation of well-being such as personality and coping. 42 patients with oral and pharyngeal cancer answered the Oral and Pharyngeal Nursing Care Questionnaires 12 months after treatment. The questionnaires contain 25 conditions (grouped as Therapy- or Psychosocial-related Conditions) from three perspectives: perceived severity, received support and received information. Other questionnaires included in the study were the Sense of Coherence Scale, Somatic Anxiety Scale (from the Karolinska Scale of Personality) and Health Index. The patients were classified with regard to the extensiveness of their surgery. Severe disturbances related to therapy were significantly correlated to weaker sense of coherence (r = -0.34), more anxiety (r = 0.31) and to worse feelings about general health (r = -0.37). The corresponding data with regard to severe disturbances related to psychosocial situation were r = -0.44, 0.52 and -0.65, respectively. There was no significant correlation between perceived severity and surgical extensiveness. The support and information concerning Psychosocial-related Conditions were evaluated as less than those concerning Therapy-related Conditions. The level of support and information was not significantly correlated to sense of coherence, anxiety, general health or surgical procedure. The patient's subjective appraisal of the seriousness of the circumstances connected with oral and pharyngeal cancer and its treatment is an important parameter in the care of these patients.

Psychological and sexual well-being, philosophical/spiritual views, and health habits of long-term cancer survivors

The results of a survey on various aspects of quality of life for 191 women who were long-term cancer survivors are presented. We explored six areas--somatic concerns, health habits, psychological state, sexual satisfaction, social/emotional support giving, and philosophical/spiritual view--and whether differences existed in them among the women on the basis of age, educational level, income level, length of survival, location of residence (urban, suburban, or rural), cancer site, and whether a recurrence of the cancer had been experienced. Generally, the women reported good psychological states and relative satisfaction with their sexual lives. However, women who had experienced a recurrence of their cancer, were longer term survivors, or suffered from breast cancer all reported higher levels of somatic concerns. Women with higher levels of education or income and those who had had a recurrence of their cancer indicated a greater willingness to provide social and emotional support to other women newly diagnosed with cancer. Women who had a positive philosophical/spiritual outlook were more likely to have good health habits and be supportive of others. There was no statistically significant variation among the women in either health habits or psychological state for any of the factors considered.

Do Women with Inoperable Breast Cancer have a Psychological Profile?

This study attempts to answer the following question: do women with inoperable breast cancer have a psychological profile? The study is based on a group of thirty cancer patients that is compared to a matched group of thirty operable breast cancer patients at two oncological institutes in the north of Israel. The participants completed both the Omega Vulnerable Scale and the Brief Symptom Inventory Scale (BSI). The statistical analysis of the psychological variables of inoperable breast cancer patients indicates that these women received higher scores in denial, exhaustion, hopelessness, worthlessness, depression (Omega Vulnerable Scale), somatization, depression, hostility, psychoticism, and additional items (BSI Scale) compared to the control group. The profile of inoperable breast cancer patients did not present a specific psychiatric classification but rather different kinds of psychological symptomatology, which may explain the delay in seeking medical advice.

Coping with chronic pain. Some patients suffer more

BACKGROUND

A multi-dimensional approach was used to examine coping in chronic pain. The following hypotheses were tested: (a) patients who cope maladaptively also cope generally in a similar way; (b) patients' maladaptive coping is associated with childhood adversity.

METHOD

Cross-sectional and retrospective data were collected from 68 consecutive patients (aged 18-70) at a pain clinic where their disease was non-systemic and the pain had lasted for at least three months. Sixty-one patients were interviewed using the Structured Clinical Interview for DSM-III-R, and the Measure of Parental Care in Childhood. All patients completed questionnaires on their pain and personality.

RESULTS

Two coping styles emerged from factor analysis. One was associated with chronicity, psychiatric morbidity, harm avoidance, immature defence style and reporting parental indifference.

CONCLUSION

Patients may be predisposed to cope maladaptively after the experience of parental indifference in early life. Such coping is likely to reflect more general patterns.