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Hanalis-Miller T, Ricon-Becker I, Sakis N, Trachtenberg E, Ohayon F, Wadhawker S, Birnboim Y, Magen A, Sharon E, Tarrasch R, Goldzweig G, Cole SW, Jacoby R, Ben-Eliyahu S. Peri-operative individually tailored psychological intervention in breast cancer patients improves psychological indices and molecular biomarkers of metastasis in excised tumors. Brain Behav Immun 2024; 117:529-540. [PMID: 38346596 DOI: 10.1016/j.bbi.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 01/31/2024] [Accepted: 02/04/2024] [Indexed: 02/24/2024] Open
Abstract
Perioperative stress and inflammatory signaling can invigorate pro-metastatic molecular processes in patients' tumors, potentially worsening long-term survival. Yet, it is unknown whether pre-operative psychotherapeutic interventions can attenuate such effects. Herein, three weeks before surgery, forty women diagnosed with stage I-III invasive ductal/lobular breast carcinoma were randomized to a 6-week one-on-one psychological intervention (6 meetings with a medical psychologist and bi-weekly phone calls) versus standard nursing-staff-attention. The intervention protocol was individually tailored based on evaluation of patients' emotional, cognitive, physiological, and behavioral stress response-patterns, and also included psychoeducation regarding medical treatments and recruitment of social support. Resected primary tumors were subjected to whole-genome RNA sequencing and bioinformatic analyses, assessing a priori hypothesized cancer-relevant molecular signatures. Self-report questionnaires (BSI-18, Hope-18, MSPSS, and a stress-scale) were collected three (T1) and one (T2) week before surgery, a day before (T3) and after (T4) surgery, and three weeks (T5) and 3-months (T6) following surgery. The intervention reduced distress (GSI), depression, and somatization scores (BSI-18: p < 0.01, p < 0.05, p < 0.05; T5 vs. T1). Additionally, tumors from treated patients (vs. controls) showed: (i) decreased activity of transcription control pathways involved in adrenergic and glucocorticoid signaling (CREB, GR) (p < 0.001), pro-inflammatory signaling (NFkB) (p < 0.01), and pro-malignant signaling (ETS1, STAT and GATA families) (p < 0.001, p < 0.01, p < 0.005); (ii) increased M1 macrophage polarization (p < 0.05), and CD4+ T cell activity (p < 0.01); and an unexpected increase in epithelial-to-mesenchymal-transition (EMT) signature (p < 0.005). This is the first randomized controlled trial to show beneficial effects of a psychological perioperative intervention on tumor pro-metastatic molecular biomarkers.
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Affiliation(s)
- Tsipi Hanalis-Miller
- Psychoneuroimmunology Laboratory, School of Psychological Sciences, Tel Aviv University, Tel Aviv, Israel; Stress, Hope and Cope Laboratory, School of Behavioral Sciences, The Academic College of Tel Aviv-Yafo, Tel Aviv, Israel
| | - Itay Ricon-Becker
- Cousins Center for Psychoneuroimmunology, Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Nahida Sakis
- Psychoneuroimmunology Laboratory, School of Psychological Sciences, Tel Aviv University, Tel Aviv, Israel
| | | | - Frida Ohayon
- Department of Surgery, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Sonya Wadhawker
- Department of Surgery, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Yehudit Birnboim
- Department of Surgery, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Ada Magen
- Department of Surgery, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Eran Sharon
- Department of Surgery, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | | | - Gil Goldzweig
- Stress, Hope and Cope Laboratory, School of Behavioral Sciences, The Academic College of Tel Aviv-Yafo, Tel Aviv, Israel
| | - Steve W Cole
- Cousins Center for Psychoneuroimmunology, Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Rebecca Jacoby
- Stress, Hope and Cope Laboratory, School of Behavioral Sciences, The Academic College of Tel Aviv-Yafo, Tel Aviv, Israel
| | - Shamgar Ben-Eliyahu
- Psychoneuroimmunology Laboratory, School of Psychological Sciences, Tel Aviv University, Tel Aviv, Israel; Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel.
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Hanalis-Miller T, Nudelman G, Ben-Eliyahu S, Jacoby R. The Effect of Pre-operative Psychological Interventions on Psychological, Physiological, and Immunological Indices in Oncology Patients: A Scoping Review. Front Psychol 2022; 13:839065. [PMID: 35572335 PMCID: PMC9094613 DOI: 10.3389/fpsyg.2022.839065] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 02/22/2022] [Indexed: 11/19/2022] Open
Abstract
Introduction The stressful pre-operative period exerts a profound impact on psychological, physiological and immunological outcomes. Oncological surgeries, in particular, elicit significantly higher stress responses than most other surgeries. Managing these responses through psychological interventions may improve long-term outcomes. The purpose of the current research was to review studies that have explored pre-operative psychological interventions in cancer patients in order to map the types of current interventions and provide an initial assessment of whether these interventions improved psychological, physiological, and/or immunological indices as well as long-term cancer outcomes. Methods A systematic literature search for studies that included pre-operative psychological interventions in oncology patients was conducted, using the databases PubMed and Web of Science. Inclusion criteria included studies pertaining to oncological surgery in adults, study designs that included a clearly defined pre-operative psychological intervention and control group. Results We found 44 studies, each using one of the following interventions: psychoeducation, cognitive interventions, relaxation techniques, integrated approaches. All the studies reported improved immediate post-operative psychological, physiological, and/or immunological outcomes. Only a few studies addressed long-term cancer outcomes, and only one reported improved survival. Conclusions Research on pre-operative interventions with cancer patients is missing systematic methods. Studies provide varying results, which makes it difficult to compare them and reach reliable conclusions. There is considerable heterogeneity in the literature regarding the specific intervention used, the timing of intervention, the characteristics of the patients studied and the outcome measures. In order to improve research in this field, including the measurement of long-term outcomes, we suggest some steps that should be taken in further research.
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Affiliation(s)
| | - Gabriel Nudelman
- School of Behavioral Sciences, The Academic College of Tel Aviv-Yaffo, Tel Aviv-Yafo, Israel
| | - Shamgar Ben-Eliyahu
- Sagol School of Neuroscience and School of Psychological Sciences, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Rebecca Jacoby
- Stress, Hope and Cope Laboratory, School of Behavioral Sciences, The Academic College of Tel Aviv-Yaffo, Tel Aviv-Yafo, Israel
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Eckerling A, Ricon-Becker I, Sorski L, Sandbank E, Ben-Eliyahu S. Stress and cancer: mechanisms, significance and future directions. Nat Rev Cancer 2021; 21:767-785. [PMID: 34508247 DOI: 10.1038/s41568-021-00395-5] [Citation(s) in RCA: 106] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/23/2021] [Indexed: 02/08/2023]
Abstract
The notion that stress and cancer are interlinked has dominated lay discourse for decades. More recent animal studies indicate that stress can substantially facilitate cancer progression through modulating most hallmarks of cancer, and molecular and systemic mechanisms mediating these effects have been elucidated. However, available clinical evidence for such deleterious effects is inconsistent, as epidemiological and stress-reducing clinical interventions have yielded mixed effects on cancer mortality. In this Review, we describe and discuss specific mediating mechanisms identified by preclinical research, and parallel clinical findings. We explain the discrepancy between preclinical and clinical outcomes, through pointing to experimental strengths leveraged by animal studies and through discussing methodological and conceptual obstacles that prevent clinical studies from reflecting the impacts of stress. We suggest approaches to circumvent such obstacles, based on targeting critical phases of cancer progression that are more likely to be stress-sensitive; pharmacologically limiting adrenergic-inflammatory responses triggered by medical procedures; and focusing on more vulnerable populations, employing personalized pharmacological and psychosocial approaches. Recent clinical trials support our hypothesis that psychological and/or pharmacological inhibition of excess adrenergic and/or inflammatory stress signalling, especially alongside cancer treatments, could save lives.
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Affiliation(s)
- Anabel Eckerling
- Sagol School of Neuroscience and School of Psychological Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Itay Ricon-Becker
- Sagol School of Neuroscience and School of Psychological Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Liat Sorski
- Sagol School of Neuroscience and School of Psychological Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Elad Sandbank
- Sagol School of Neuroscience and School of Psychological Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Shamgar Ben-Eliyahu
- Sagol School of Neuroscience and School of Psychological Sciences, Tel Aviv University, Tel Aviv, Israel.
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Ricon I, Hanalis-Miller T, Haldar R, Jacoby R, Ben-Eliyahu S. Perioperative biobehavioral interventions to prevent cancer recurrence through combined inhibition of β-adrenergic and cyclooxygenase 2 signaling. Cancer 2018; 125:45-56. [DOI: 10.1002/cncr.31594] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 06/22/2018] [Accepted: 07/13/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Itay Ricon
- Psychoneuroimmunology Laboratory, School of Psychological Sciences; Tel Aviv University; Tel Aviv Israel
| | - Tsipi Hanalis-Miller
- Psychoneuroimmunology Laboratory, School of Psychological Sciences; Tel Aviv University; Tel Aviv Israel
| | - Rita Haldar
- Psychoneuroimmunology Laboratory, School of Psychological Sciences; Tel Aviv University; Tel Aviv Israel
| | - Rebecca Jacoby
- Medical Psychology Graduate Program, School of Behavioral Sciences; Tel Aviv-Yaffo Academic College; Tel Aviv Israel
| | - Shamgar Ben-Eliyahu
- Psychoneuroimmunology Laboratory, School of Psychological Sciences; Tel Aviv University; Tel Aviv Israel
- Sagol School of Neuroscience, Tel Aviv University; Israel
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Yang N, Cao Y, Li X, Li S, Yan H, Geng Q. Mediating Effects of Patients' Stigma and Self-Efficacy on Relationships Between Doctors' Empathy Abilities and Patients' Cellular Immunity in Male Breast Cancer Patients. Med Sci Monit 2018; 24:3978-3986. [PMID: 29891832 PMCID: PMC6029513 DOI: 10.12659/msm.910794] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Doctors' empathy is closely related to patients' health. This study aimed to examine whether patients' stigma and self-efficacy play a mediating role in the relationship between doctors' empathy abilities and patients' cellular immunity in male patients with breast cancer. MATERIAL AND METHODS Doctors' empathy scores and patients' demographic data, disease condition, stigma, and self-efficacy were measured. Patient T cell subset was tested at admission and 3 months after the operation and was compared by paired t test. The multivariate linear regression model was applied to analyze the factors influencing the immune index. Pearson correlation analysis and structural equation modeling were applied to explore the relationships among patients' stigma, self-efficacy, and cellular immunity and doctors' empathy abilities. RESULTS At the 2 time points, only the change in NK subset was statistically significant, while the changes in percentage of CD3+, CD4+, CD8+, and B cells were not statistically significant. The doctors' empathy abilities were negatively correlated with patients' stigma and were positively related to patients' self-efficacy. Patients' stigma was negatively related to NK subset, while self-efficacy was positively associated with NK subset. Patients' stigma and self-efficacy played a mediating role in the relationship between doctors' empathy abilities and patients' NK subset, and stigma had a stronger effect than self-efficacy. CONCLUSIONS Doctors' empathy abilities affected breast cancer patients' NK subset through their stigma and self-efficacy. The mental health of male breast cancer patients need more attention and empathy education needs to be improved.
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Affiliation(s)
- Ningxi Yang
- School of Health Sciences, Wuhan University, Wuhan, Hubei, China (mainland).,Institute of Medical Humanities, Peking University Health Science Center, Beijing, China (mainland)
| | - Yingnan Cao
- Medical Insurance Office, Beijing Jishuitan Hospital/4th Medical College of Peking University, Beijing, China (mainland)
| | - Xiaoyan Li
- School of Health Sciences, Wuhan University, Wuhan, Hubei, China (mainland)
| | - Shiyue Li
- School of Health Sciences, Wuhan University, Wuhan, Hubei, China (mainland)
| | - Hong Yan
- School of Health Sciences, Wuhan University, Wuhan, Hubei, China (mainland)
| | - Qingshan Geng
- Guangdong General Hospital, Guangzhou, Guangdong, China (mainland)
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Yang N, Xiao H, Wang W, Li S, Yan H, Wang Y. Effects of doctors' empathy abilities on the cellular immunity of patients with advanced prostate cancer treated by orchiectomy: the mediating role of patients' stigma, self-efficacy, and anxiety. Patient Prefer Adherence 2018; 12:1305-1314. [PMID: 30087556 PMCID: PMC6063254 DOI: 10.2147/ppa.s166460] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The empathy of doctors is closely related to patients' outcomes. This research aimed to examine whether patients' stigma, self-efficacy, and anxiety mediate the relationship between doctors' empathy and cellular immunity in patients with advanced prostate cancer treated by orchiectomy. PARTICIPANTS AND METHODS Data on the empathy of doctors and the demographics, disease condition, stigma, self-efficacy, and anxiety of patients were collected. Patients' psychological indicators and cellular immunity were measured at admission, after 14 days, and after 3 months. The variance analysis test was used to compare the immune indices at the three time points. At T3, a multivariate linear regression model was used to analyze the factors that influenced the immune index. Pearson correlation analysis and structural equation modeling were used to examine the relationships among patients' stigma, self-efficacy, anxiety, and cellular immunity and doctors' empathy. RESULTS At the three time points, all three psychological indicators of the patients were statistically significant. Among the immune indices, only the change in the percentage of NK cells (NK subset) was statistically significant, while the changes in the percentages of CD3+, CD4+, CD8+, and B cells were not statistically significant. The doctors' empathy showed negative relationships with patients' stigma and anxiety and a positive relationship with patients' self-efficacy. Patients' stigma and anxiety were negatively associated with NK subset, while patients' self-efficacy showed a positive relationship with NK subset. Anxiety was positively related to stigma and negatively related to self-efficacy. Therefore, the effect of the doctors' empathy on the patients' NK subset was mediated by the patients' stigma, self-efficacy, and anxiety. CONCLUSION Doctors' empathy affected the NK subset in advanced prostate cancer patients and was related to the patients' stigma, self-efficacy, and anxiety. In addition, anxiety directly affected stigma and self-efficacy. Thus, medical staff should focus on improving their empathy toward patients. Interventions that focus on patients' anxiety, stigma, and self-efficacy may be helpful to improve immunity.
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Affiliation(s)
- Ningxi Yang
- Department of Epidemiology, School of Health Sciences, Wuhan University, Wuhan, Hubei, People's Republic of China,
- Department of Medical Humanities, Institute of Medical Humanities, Peking University, Beijing, People's Republic of China,
| | - Han Xiao
- Department of Epidemiology, School of Health Sciences, Wuhan University, Wuhan, Hubei, People's Republic of China,
| | - Wei Wang
- Department of Epidemiology, School of Health Sciences, Wuhan University, Wuhan, Hubei, People's Republic of China,
| | - Shiyue Li
- Department of Epidemiology, School of Health Sciences, Wuhan University, Wuhan, Hubei, People's Republic of China,
| | - Hong Yan
- Department of Epidemiology, School of Health Sciences, Wuhan University, Wuhan, Hubei, People's Republic of China,
| | - Yifang Wang
- Department of Medical Humanities, Institute of Medical Humanities, Peking University, Beijing, People's Republic of China,
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Horowitz M, Neeman E, Sharon E, Ben-Eliyahu S. Exploiting the critical perioperative period to improve long-term cancer outcomes. Nat Rev Clin Oncol 2015; 12:213-26. [PMID: 25601442 PMCID: PMC5497123 DOI: 10.1038/nrclinonc.2014.224] [Citation(s) in RCA: 333] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Evidence suggests that the perioperative period and the excision of the primary tumour can promote the development of metastases—the main cause of cancer-related mortality. This Review first presents the assertion that the perioperative timeframe is pivotal in determining long-term cancer outcomes, disproportionally to its short duration (days to weeks). We then analyse the various aspects of surgery, and their consequent paracrine and neuroendocrine responses, which could facilitate the metastatic process by directly affecting malignant tissues, and/or through indirect pathways, such as immunological perturbations. We address the influences of surgery-related anxiety and stress, nutritional status, anaesthetics and analgesics, hypothermia, blood transfusion, tissue damage, and levels of sex hormones, and point at some as probable deleterious factors. Through understanding these processes and reviewing empirical evidence, we provide suggestions for potential new perioperative approaches and interventions aimed at attenuating deleterious processes and ultimately improving treatment outcomes. Specifically, we highlight excess perioperative release of catecholamines and prostaglandins as key deleterious mediators of surgery, and we recommend blockade of these responses during the perioperative period, as well as other low-risk, low-cost interventions. The measures described in this Review could transform the perioperative timeframe from a prominent facilitator of metastatic progression, to a window of opportunity for arresting and/or eliminating residual disease, potentially improving long-term survival rates in patients with cancer.
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Affiliation(s)
- Maya Horowitz
- School of Psychological Sciences, Sharet Building, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Elad Neeman
- School of Psychological Sciences, Sharet Building, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Eran Sharon
- Department of Surgery, Rabin Medical Center, Beilinson Hospital, Petach-Tikva 49100, Israel
| | - Shamgar Ben-Eliyahu
- School of Psychological Sciences, Sharet Building, Tel Aviv University, Tel Aviv 6997801, Israel
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Depressive symptoms and cortisol variability prior to surgery for suspected endometrial cancer. Psychoneuroendocrinology 2013; 38:241-9. [PMID: 22762895 PMCID: PMC3473116 DOI: 10.1016/j.psyneuen.2012.06.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Revised: 05/17/2012] [Accepted: 06/05/2012] [Indexed: 11/23/2022]
Abstract
Endometrial cancer (EC) is the most common type of gynecologic cancer affecting women; however, very little research has examined relationships between psychological factors and hypothalamic-pituitary-adrenal (HPA) axis dysregulation in this population. The current study examined relations between depressive/anxious symptoms and salivary cortisol diurnal rhythm and variability in women undergoing surgery for suspected endometrial cancer. Depressive and anxious symptoms were measured prior to surgery using the Structured Interview Guide for the Hamilton Depression Inventory (SIGH-AD). Saliva was collected four times a day for the 3 days prior to surgery and then assayed by ELISA to obtain cortisol concentrations. Cortisol slopes and intraindividual variability were then calculated across subjects. Relations between depressive/anxious symptoms and cortisol indices were examined using multilevel modeling and linear regression analyses. Participants were 82 women with nonmetastatic endometrial cancer. Anxious symptoms were not associated with either cortisol slope or intraindividual variability, and depressive symptoms were unrelated to cortisol slope. However, after controlling for presence of poorer prognosis cancer subtypes, greater depressive symptoms (excluding symptoms possibly/definitely due to health/treatment factors) in the week preceding surgery were significantly related to greater cortisol intraindividual variability (β=.214; p<.05). These results suggest that depressive symptoms prior to surgery for suspected endometrial cancer are related to greater cortisol intraindividual variability, which is suggestive of more erratic HPA axis arousal. Future research should examine whether mood symptoms may be associated with compromised health outcomes via erratic HPA axis arousal in this population.
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