Effects of behavioral intervention on plasma cortisol and lymphocytes in breast cancer patients: An exploratory study

Biobehavioral influences on cancer progression

This review focuses on the contributions of stress-related behavioral factors to cancer growth and metastasis and the biobehavioral mechanisms underlying these relationships. Behavioral factors that are important in modulation of the stress response and the pivotal role of neuroendocrine regulation in the downstream alteration of physiologic pathways relevant to cancer control, including the cellular immune response, inflammation, and tumor angiogenesis, invasion, and cell signaling pathways are described. Consequences for cancer progression and metastasis, as well as quality of life, are delineated. Behavioral and pharmacologic interventions with the potential to alter these biobehavioral pathways for patients with cancer are discussed.

Psychosocial adaptation and cellular immunity in breast cancer patients in the weeks after surgery: An exploratory study

BACKGROUND

The period just after surgery for breast cancer requires psychosocial adaptation and is associated with elevated distress. Distress states have been associated with decreased cellular immune functioning in this population, which could have negative effects on physical recovery. However, little is known about relations between psychological status [negative and positive mood states and overall quality of life (QOL)] and cellular signaling cytokines that could account for these associations in women undergoing treatment for breast cancer.

METHODS

The present study examined associations between psychological adaptation indicators (mood, QOL) and T-helper cell type 1 (Th1) cytokine production from stimulated peripheral mononuclear cells in women who had recently undergone surgery for early-stage breast cancer but had not yet begun adjuvant therapy. These associations were evaluated while controlling for relevant disease/treatment, sociodemographic, and health behavior covariates.

RESULTS

Lower anxiety related to greater production of the Th1 cytokine interleukin-2 (IL-2), while greater positive mood (affection) related to greater production of the Th1 cytokines IL-12 and interferon-gamma (IFN-gamma). Better QOL related to greater production of the Th1 cytokine, tumor necrosis factor-alpha (TNF-alpha).

CONCLUSION

Individual differences in psychosocial adaptation in women with breast cancer during the period after surgery relate to biological parameters that may be relevant for health and well-being as they move through treatment.

Cognitive behavioral stress management effects on psychosocial and physiological adaptation in women undergoing treatment for breast cancer

BACKGROUND

A diagnosis of breast cancer and treatment are psychologically stressful events, particularly over the first year after diagnosis. Women undergo many demanding and anxiety-arousing treatments such as surgery, radiation and chemotherapy. Psychosocial interventions that promote psychosocial adaptation to these challenges may modulate physiological processes (neuroendocrine and immune) that are relevant for health outcomes in breast cancer patients.

METHODS

Women with Stages 1-3 breast cancer recruited 4-8 weeks after surgery were randomized to either a 10-week group-based cognitive behavioral stress management (CBSM) intervention or a 1-day psychoeducational control group and completed questionnaires and late afternoon blood samples at study entry and 6 and 12 months after assignment to experimental condition.

RESULTS

Of 128 women initially providing psychosocial questionnaire and blood samples at study entry, 97 provided complete data for anxiety measures and cortisol analysis at all time points, and immune assays were run on a subset of 85 of these women. Those assigned to a 10-week group-based CBSM intervention evidenced better psychosocial adaptation (lower reported cancer-specific anxiety and interviewer-rated general anxiety symptoms) and physiological adaptation (lower cortisol, greater Th1 cytokine [interleukin-2 and interferon-gamma] production and IL-2:IL-4 ratio) after their adjuvant treatment compared to those in the control group. Effects on psychosocial adaptation indicators and cortisol appeared to hold across the entire 12-month observation period. Th1 cytokine regulation changes held only over the initial 6-month period.

CONCLUSIONS

This intervention may have facilitated a "recovery or maintenance" of Th1 cytokine regulation during or after the adjuvant therapy period. Behavioral interventions that address dysregulated neuroendocrine function could play a clinically significant role in optimizing host immunologic resistance during a vulnerable period.

Effects of a yoga program on cortisol rhythm and mood states in early breast cancer patients undergoing adjuvant radiotherapy: a randomized controlled trial

Objectives. This study compares the effects of an integrated yoga program with brief supportive therapy in breast cancer outpatients undergoing adjuvant radiotherapy at a cancer center.

METHODS

Eighty-eight stage II and III breast cancer outpatients are randomly assigned to receive yoga (n = 44) or brief supportive therapy (n = 44) prior to radiotherapy treatment. Assessments include diurnal salivary cortisol levels 3 days before and after radiotherapy and self-ratings of anxiety, depression, and stress collected before and after 6 weeks of radiotherapy.

RESULTS

Analysis of covariance reveals significant decreases in anxiety (P < .001), depression (P = .002), perceived stress (P < .001), 6 a.m. salivary cortisol (P = .009), and pooled mean cortisol (P = .03) in the yoga group compared with controls. There is a significant positive correlation between morning salivary cortisol level and anxiety and depression.

CONCLUSION

Yoga might have a role in managing self-reported psychological distress and modulating circadian patterns of stress hormones in early breast cancer patients undergoing adjuvant radiotherapy.

Stress management intervention reduces serum cortisol and increases relaxation during treatment for nonmetastatic breast cancer

OBJECTIVE

To examine the effects of a cognitive-behavioral stress management (CBSM) intervention, which was composed of relaxation, cognitive restructuring, and coping skills training on late afternoon serum cortisol and relaxation indicators in women who were undergoing treatment for nonmetastatic breast cancer.

METHODS

Participants (N = 128) were randomly assigned to receive a 10-week CBSM group intervention or a 1-day psychoeducation seminar. Serum cortisol was collected and ability to relax was assessed at study entry and again at 6- and 12-month follow-up visits. Data were analyzed using latent growth curve modeling.

RESULTS

There was a significant effect of study condition on change across time for both cortisol and perceived ability to relax. Women receiving CBSM had significantly greater reductions in cortisol levels across the 12 months compared with those in the control group, who had no appreciable decline. Women receiving CBSM reported greater increases in ability to relax than controls across time. Perceived ability to relax did not mediate CBSM-related reductions in cortisol.

CONCLUSIONS

Women who participate in a 10-week CBSM intervention during treatment for breast cancer show decreases in physiological stress in parallel with increases in perceived relaxation skills. This is the first study demonstrating well-maintained reductions in cortisol after a CBSM intervention in cancer patients during and just after treatment.

Immune responses to guided imagery during breast cancer treatment

BACKGROUND

The use of relaxation and guided imagery to reduce stress and improve immune function has great potential benefits for patients with breast cancer.

METHODS

This pilot study used a pretest-posttest experimental design with 28 breast cancer patients, aged 25 to 75 years, with the diagnosis of stage 0, 1, or 2 breast cancer. The experimental group received a relaxation and guided imagery intervention and the control group received standard care. The effects of the intervention on immune function were measured by natural killer (NK) cell cytotoxicity and IL-2-activated NK cell activity prior to surgery and 4 weeks postsurgery. NK cell activity was measured using a 15-hr incubation chromium release assay. Cytotoxicity of NK cells was measured against chromium-labeled K-562 target cells. IL-2 was used to enhance reactivity of NK cells against tumor cells. After incubation for 15 hr, cytotoxicity was measured through the release of radioactive chromium.

RESULTS

Significant differences between groups were found at 4 weeks postsurgery. T-tests showed increased NK cell cytotoxicity for the intervention group at 100:1, 50:1, and 25:1 effector cell: target cell ratios (E:T) (p < .01 to p < .05) and increased activation for IL-2 at 100:1, 50:1, 25:1, and 12.5:1 (E:T) (p < .01 to p < .05) for the intervention group as compared to the control group.

DISCUSSION

These findings suggest that a relaxation intervention such as guided imagery could have an effect on NK cell cytotoxicity and NK cell cytotoxicity after activation with IL-2 in patients undergoing surgery for breast cancer.

Relaxation and guided imagery program in patients with breast cancer undergoing radiotherapy is not associated with neuroimmunomodulatory effects

OBJECTIVE

Treatment of breast cancer is usually associated with significant psychological stress. In this study, we examined the effects of relaxation and visualization therapy (RVT) on psychological distress, cortisol levels, and immunological parameters of breast cancer patients undergoing radiotherapy.

METHODS

Participants were randomly assigned to either the experimental (n=20) who underwent group RVT for 24 consecutive days or control group (n=14) who were on radiotherapy only. Psychological scores (stress, anxiety, and depression) were measured by structured clinical interviews. Salivary cortisol was assessed along the day. Lymphocytes were isolated and cultured to measure T-cell proliferation and sensitivity to glucocorticoids (GCs).

RESULTS

RVT was effective to reduce stress, anxiety, and depression scores (all P<.05). However, cortisol levels as well as proliferation remained unchanged following RVT. Although T cells of experimental group were more sensitive to GCs than cells of controls at baseline, no changes were noted following RVT. Cortisol levels were positively correlated to anxiety and depression scores and inversely correlated to T-cell proliferation and sensitivity to GCs.

CONCLUSION

We conclude that the psychological intervention was capable to attenuate the emotional distress presented during radiotherapy treatment. A longer RVT or worse psychological morbidity at baseline may be necessary to translate psychological into biological changes.

Increases in a marker of immune system reconstitution are predated by decreases in 24-h urinary cortisol output and depressed mood during a 10-week stress management intervention in symptomatic HIV-infected men

BACKGROUND

Stress management interventions reduce distress symptoms and hypothalamic-pituitary-adrenal (HPA) axis hormones such as cortisol, which has been related to a down-regulation of immune system components relevant to the human immunodeficiency virus (HIV) infection. We previously showed that HIV+ men assigned to a 10-week cognitive behavioral stress management (CBSM) intervention showed more CD4+CD45RA+CD29+ lymphocytes, an indicator of immune system reconstitution, at a 6- to 12-month follow-up compared with controls. Here, we tested whether reductions in urinary cortisol output and depressed mood during the 10-week CBSM intervention period mediated its effects on this immune system reconstitution marker at follow-up.

METHODS

Twenty-five HIV-infected men randomized to either a 10-week CBSM intervention or a wait-list control provided 24-h urine samples and psychological responses pre- to postintervention, which were related to changes in immune status over a 6- to 12-month follow-up period.

RESULTS

Greater reductions in cortisol output and depressed mood during CBSM appeared to mediate the effects of this intervention on this indicator of immune system reconstitution over the 6- to 12-month follow-up period. Changes in mood were maintained over the follow-up period, although these did not add explanatory information beyond the cortisol and mood changes that were observed during the 10-week intervention period. These findings were not explained by the changes in medications or health behaviors during follow-up.

CONCLUSION

A time-limited CBSM intervention may affect the rate of immune system reconstitution in HIV-infected men by modifying the stress of symptomatic disease. This intervention may work by decreasing depressed mood and normalizing HPA axis functioning.

Group interventions for patients with cancer and HIV disease: Part II. Effects on immune, endocrine, and disease outcomes at different phases of illness

There has been great interest in the potential impact of group interventions on medical outcomes. This article reviews the effects of professionally-led groups on immune activity, neuroendocrine function, and survival among patients with cancer or HIV disease. We examine findings concerning different types of group services at different phases of illness. Results are mixed, but the most prominent changes in immune and endocrine activity were associated with structured group interventions for patients with early-stage disease. These findings offer provocative illustrations of relevant mind-body interactions, but their clinical importance has yet to be demonstrated empirically. Group interventions have not been tied consistently to improved survival rates for patients with advanced cancer; few studies as yet have focused on survival outcomes among patients with early-stage cancer or HIV disease.

Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress and levels of cortisol, dehydroepiandrosterone sulfate (DHEAS) and melatonin in breast and prostate cancer outpatients

OBJECTIVES

This study investigated the relationships between a mindfulness-based stress reduction meditation program for early stage breast and prostate cancer patients and quality of life, mood states, stress symptoms, and levels of cortisol, dehydroepiandrosterone-sulfate (DHEAS) and melatonin.

METHODS

Fifty-nine patients with breast cancer and 10 with prostate cancer enrolled in an eight-week Mindfulness-Based Stress Reduction (MBSR) program that incorporated relaxation, meditation, gentle yoga, and daily home practice. Demographic and health behavior variables, quality of life, mood, stress, and the hormone measures of salivary cortisol (assessed three times/day), plasma DHEAS, and salivary melatonin were assessed pre- and post-intervention.

RESULTS

Fifty-eight and 42 patients were assessed pre- and post-intervention, respectively. Significant improvements were seen in overall quality of life, symptoms of stress, and sleep quality, but these improvements were not significantly correlated with the degree of program attendance or minutes of home practice. No significant improvements were seen in mood disturbance. Improvements in quality of life were associated with decreases in afternoon cortisol levels, but not with morning or evening levels. Changes in stress symptoms or mood were not related to changes in hormone levels. Approximately 40% of the sample demonstrated abnormal cortisol secretion patterns both pre- and post-intervention, but within that group patterns shifted from "inverted-V-shaped" patterns towards more "V-shaped" patterns of secretion. No overall changes in DHEAS or melatonin were found, but nonsignificant shifts in DHEAS patterns were consistent with healthier profiles for both men and women.

CONCLUSIONS

MBSR program enrollment was associated with enhanced quality of life and decreased stress symptoms in breast and prostate cancer patients, and resulted in possibly beneficial changes in hypothalamic-pituitary-adrenal (HPA) axis functioning. These pilot data represent a preliminary investigation of the relationships between MBSR program participation and hormone levels, highlighting the need for better-controlled studies in this area.

Current Research Promises and Challenges in Behavioral Oncology

The Behavioral Oncology Interest Group of the American Society of Preventive Oncology held a Roundtable session on March 10, 2002, at the American Society of Preventive Oncology annual meeting in Bethesda, Maryland, to discuss the current state-of-the-science in behavioral approaches to cancer prevention and control and to delineate priorities for additional research. Four key areas were considered: (a) behavioral approaches to cancer genetic risk assessment and testing; (b) biological mechanisms of psychosocial effects on cancer; (c) the role of risk perceptions in cancer screening adherence; and (d) the impact of tailored and targeted interventions on cancer prevention and control research. The evidence reviewed indicates that behavioral approaches have made significant contributions to cancer prevention and control research. At the same time, there is a need to more closely link future investigations to the underlying base of behavioral science principles and paradigms that guide them. To successfully bridge the gap between the availability of effective new cancer prevention and control technologies and the participants they are meant to serve will require the development of more integrative conceptual models, the incorporation of more rigorous methodological designs, and more precise identification of the individual and group characteristics of the groups under study.

Stress, coping, and immune function in breast cancer

Research has found suggestive links between emotional distress and immune and neuroendocrine measures in cancer patients. Furthermore, several studies have reported that participation in psychological support groups is associated with better health outcomes for cancer patients. However, controversy exists surrounding these findings, and the mechanisms behind such effects are unclear. This article integrates current evidence from several lines of research concerning the relations among coping, psychological adjustment, cortisol and immune function, and disease progression in breast cancer patients. A biopsychosocial model is evaluated in which coping and psychological adjustment are associated with alterations in cortisol levels, immune function, and potential long-term medical outcomes in breast cancer patients. Although strong evidence suggests that coping and psychosocial intervention can improve psychological outcomes for breast cancer patients, potential effects on physiological outcomes remain speculative.

Managing cancer side effects to improve quality of life: a cancer psychoeducation program

This study aimed to develop and pilot test a community-based education program that addresses the prevention and management of the major side effects of cancer and its treatment according to a Patient Active Empowerment Model. This piloted program evaluated the health and quality of life outcomes for patients with cancer. The program was implemented through a half-day patient education conference. This conference included clinical information concerning disease and treatment-related side effects, an overview of treatment methods, information to help improve communication between the patient and healthcare team, education materials and experiences to empower patients and caregivers, and integration of specific mind-body techniques to strengthen key educational messages and reinforce the importance of side effect management. A total of 32 patients completed both the program and psychometric assessments on the day of the intervention and 30 days later. The participants were primarily white women with an average age of 57 years. Breast cancer was the most prevalent type of cancer experienced by the participants. The pilot results for this small sample showed that from baseline to follow-up evaluation, patients reported significant decreases in depressive symptoms and problems with work or other daily activities that resulted from emotional distress. Some improvements in health and well-being were greater for those who had not experienced fever or infection, those who had no children, and those who were working. Participants indicated that the program was useful in its ability to help them manage treatment side effects. Although the findings presented in this article are based only on a pilot program evaluation and a small sample, they do suggest that the program may be effective in educating patients about specific cancer side effects and empowering them to cope more effectively with their illness. Results showing that subgroups of individuals may have benefited more from the intervention provide important information about specific components of the program that may be particularly salient and potential changes that might be usefully implemented.

Health psychology: psychosocial and biobehavioral aspects of chronic disease management

Psychosocial factors appear to impact upon the development and progression of such chronic diseases as coronary heart disease, cancer, and HIV/AIDS. Similarly, psychosocial interventions have been shown to improve the quality of life of patients with established disease and seem to influence biological processes thought to ameliorate disease progression. Small-scale studies are useful for specifying the conditions under which psychosocial factors may or may not impact quality of life, biological factors, and disease progression. They are also useful for informing us about the conditions under which psychosocial interventions can serve as adjuvants (e.g. adherence training) to medical treatments. Only large-scale clinical trials, however, can determine the extent to which these psychosocial interventions may impact morbidity and mortality.

Cognitive-behavioral stress management reduces distress and 24-hour urinary free cortisol output among symptomatic HIV-infected gay men

BACKGROUND

Stress management interventions can reduce symptoms of distress as well as modulate certain immune system components in persons infected with human immunodeficiency virus (HIV). These effects may occur in parallel with reductions in hypothalamic-pituitary-adrenal (HPA) axis hormones such as cortisol, which has been related in other work to a down-regulation of immune system components relevant to HIV infection. The present study tested the effects of a multimodal cognitive-behavioral stress management (CBSM) intervention on 24-hour urinary free cortisol levels and distressed mood in symptomatic HIV+ gay men.

METHODS

Symptomatic HIV-infected gay men who were randomized to either a 10-week group-based CBSM intervention or a 10-week wait-list period provided psychological responses and urine samples pre-post intervention.

RESULTS

Of the 59 participants providing matched questionnaire data, men assigned to CBSM (n = 40) showed significantly lower posttreatment levels of self-reported depressed affect, anxiety, anger, and confusion than those in the wait-list control group (n = 19). Among the 47 men providing urine samples (34 CBSM, 13 controls), those assigned to CBSM revealed significantly less cortisol output as compared to controls. At the individual level, depressed mood decreases paralleled cortisol reductions over this period across the entire sample.

CONCLUSION

A time-limited CBSM intervention reduced distress symptoms and urinary free cortisol output in symptomatic HIV+ gay men and greater reductions in some aspects of distress, especially depressed mood, paralleled greater decreases in cortisol over the intervention period. If persisting stressors and depressed mood contribute to chronic HPA axis activation in HIV-infected persons, then interventions such as CBSM, which teaches them to relax, alter cognitive appraisals, use new coping strategies, and access social support resources, may decrease distress and depressed mood and normalize HPA axis functioning.

Psychological interventions and the immune system: a meta-analytic review and critique

This article reviews evidence for the hypothesis that psychological interventions can modulate the immune response in humans and presents a series of models depicting the psychobiological pathways through which this might occur. Although more than 85 trials have been conducted, meta-analyses reveal only modest evidence that interventions can reliably alter immune parameters. The most consistent evidence emerges from hypnosis and conditioning trials. Disclosure and stress management show scattered evidence of success. Relaxation demonstrates little capacity to elicit immune change. Although these data provide only modest evidence of successful immune modulation, it would be premature to conclude that the immune system is unresponsive to psychological interventions. This literature has important conceptual and methodological issues that need to be resolved before any definitive conclusions can be reached.

Cognitive-behavioral stress management reduces serum cortisol by enhancing benefit finding among women being treated for early stage breast cancer

OBJECTIVE

This study examined the effects of a cognitive-behavioral stress management (CBSM) group intervention on serum cortisol levels in women being treated for stage I or II breast cancer.

METHODS

Participants were randomly assigned to undergo a 10-week intervention (N = 24) within 8 weeks after surgery or were placed on a waiting list (N = 10). Cortisol was assessed by means of a radioimmunoassay of blood samples collected at the same time of day just before the start of the intervention and immediately after its completion. The women also reported the degree to which breast cancer had made positive contributions to their lives.

RESULTS

Intervention participants showed increased benefit finding and reduced serum cortisol levels, whereas control subjects experienced neither change. Path analysis suggested that the effect of CBSM on cortisol was mediated by increases in benefit finding.

CONCLUSIONS

These findings suggest that positive growth enhanced during a time-limited intervention can influence physiological parameters such as cortisol among women with early stage breast cancer.

Cognitive-behavioral stress management intervention effects on anxiety, 24-hr urinary norepinephrine output, and T-cytotoxic/suppressor cells over time among symptomatic HIV-infected gay men

The present study tested the effects of a multimodal cognitive-behavioral stress management (CBSM) intervention on anxious mood, perceived stress, 24-hr urinary catecholamine levels, and changes in T-lymphocyte subpopulations over time in symptomatic HIV+ gay men. Seventy-three men were randomized to either a group-based CBSM intervention (n = 47) or a wait-list control (WLC) condition (n = 26). Men assigned to CBSM showed significantly lower posttreatment levels of self-reported anxiety, anger, total mood disturbance, and perceived stress and less norepinephrine (NE) output as compared with men in the WLC group. At the individual level, anxiety decreases paralleled NE reductions. Significantly greater numbers of T-cytotoxic/suppressor (CD3+CD8+) lymphocytes were found 6 to 12 months later in those assigned to CBSM. Moreover, greater decreases in NE output and a greater frequency of relaxation home practice during the 10-week CBSM intervention period predicted higher CD3+CD8+ cell counts at follow-up.

Effectiveness of a short-term group psychotherapy program on endocrine and immune function in breast cancer patients: an exploratory study

Cancer patients who had been treated for early stage breast cancer and were diagnosed with either positive axillary lymph nodes or distant metastases were randomly assigned to either a 13-week experiential-existential group psychotherapy (EEGP) program or a waiting list control (WLC) condition. Endocrine and immune measures were obtained before and after the intervention period. The findings of this study are that, after the 13 weeks of the experiment, patients in the EEGP group showed lower levels of plasma cortisol and lower levels of prolactin as well as lower percentages of natural killer cells, CD8 cells, and CD4 cells in addition to a lower proliferative response to pokeweed mitogen than patients in the WLC group. Importantly, this was only found in those breast cancer patients presenting relatively high endocrine and immune baseline levels, suggesting that the patients' profile with regard to endocrine and immune function at the start of a program can have an important effect. If replicated on a larger scale, the current results may be relevant for the treatment of breast cancer.