Life events and breast cancer prognosis

Depression increases cancer mortality by 23-83%: a meta-analysis of 65 studies across five major cancer types

Depression is a prevalent but often underrecognized comorbidity among cancer patients. Emerging evidence suggests that psychological distress may adversely impact cancer outcomes, but the magnitude of its effect on survival remains unclear. This meta-analysis evaluates the association between depression diagnosed after cancer diagnosis and cancer-specific and all-cause mortality across major cancer types. A systematic search of PubMed, Web of Science, Google Scholar, and the Cochrane Library was conducted to identify cohort studies examining the impact of depression on cancer mortality. Studies were included if they assessed clinically diagnosed depression or depressive symptoms using validated scales and reported hazard ratios (HRs) for mortality outcomes. A random-effects meta-analysis was performed to pool HR estimates, with heterogeneity assessed via Cochran's Q and I2 statistics. Funnel plots and Egger's test were used to evaluate publication bias. A total of 65 cohort studies were included. Depression was associated with significantly increased cancer-specific mortality in colorectal cancer (HR 1.83, 95% CI 1.47-2.28), breast cancer (HR 1.23, 95% CI 1.13-1.34), lung cancer (HR 1.59, 95% CI 1.36-1.86), and prostate cancer (HR 1.74, 95% CI 1.36-2.23). When considering mixed cancer types, depression was linked to a 38% increased risk of cancer mortality (HR 1.38, 95% CI 1.20-1.60). Significant heterogeneity was observed across studies (I2 range 56-98%), suggesting variations in study populations and methodologies. Sensitivity analyses confirmed the robustness of the findings, and trial sequential analysis indicated sufficient evidence for a conclusive association. Depression after cancer diagnosis is associated with a significantly increased risk of cancer-specific mortality across multiple cancer types. These findings highlight the urgent need for integrating routine mental health screening and interventions into oncology care. Future research should focus on mechanistic pathways and targeted interventions to mitigate the negative impact of depression on cancer survival.

Early quality-of-life and psychological predictors of disease-free time and survival in localized prostate cancer

PURPOSE

The constructs evaluated in investigating association between psychosocial factors and cancer survival has varied between studies, and factors related to quality of life (QOL) have shown contradictory results. We investigated the effect of socioeconomic and early QOL and psychological factors on disease-free time and survival in localized prostate cancer.

METHODS

A consecutive sample of patients with localized prostate cancer (T1-3, N0, M0) treated with external beam radiotherapy completed validated questionnaires on coping with cancer (the Ways of Coping Questionnaire WOC-CA), anger expression (the Anger Expression Scale), life events (the Life Experience Survey), and various aspects of QOL (the Rotterdam Symptom Checklist, the Depression Scale DEPS, the EORTC QLQ-C30, the LENT-SOMA outcome measure) approximately 4.5 months after diagnosis. Cox regression analyses were used to determine the predictors of the disease-free and overall survival times measured from the date of diagnosis to the date of a PSA-relapse and date of death.

RESULTS

After controlling for biological prognostic factors, age, and adjuvant hormonal therapies, moderate and high socioeconomic status and an increased level of pain predicted longer survival, whereas an increased level of prostate-area symptoms and fatigue and, especially, reports of no/few physical symptoms were predictors of a shorter survival time. A longer PSA-relapse-free time was predicted by Cognitive Avoidance/Denial coping, whereas problems in social functioning, hopelessness, and an excellent self-reported QOL predicted a shorter PSA-relapse-free time.

CONCLUSIONS

Higher socioeconomic status was prognostic for longer survival, as previously reported. Patients with a seemingly good QOL (few physical complaints, excellent self-reported QOL) had poorer prognoses. This association may due to the survival decreasing effect of emotional non-expression; patients with high emotional non-expression may over-report their wellbeing in simple measures, and thus actually be in need of extra attention and care.

Association between life events after diagnosis of breast cancer and metastasis

The objective was to examine the association between life events post diagnosis of breast câncer and metastasis. Cross-sectional study with 300 women attending a reference hospital in oncology in the Espírito Santo. Was used the instrument Life Events Units-LEU/VAS to evaluate life events reported by women. Data were analyzed by using the nonparametric Wilcoxon and chi-square tests. It was performed odds ratio calculation for the variables associated with metastasis. It was found that 21% of the sample reported at least one life event post diagnosis. Of the 46 women who developed metastases, 20 reported one or more life events (p = 0.001). The odds ratio calculated shows that having life events post diagnosis increases by 2.59 (1,37 - 4,91; p = 0,003) times the chance of developing metastasis. When considering the time between diagnosis and the onset of metastasis there was a median of 18.0 months. The study shows a relationship between life events and metastasis, however emphasize the importance of a more complex analysis to better understand the impacts of these events on the onset and progression of breast cancer.

Association of striking life events with primary breast cancer in 265 Chinese women: a case-control study

The current case-control study investigated the relationship between striking life events and breast cancer in Chinese women. A total of 265 primary breast cancer patients and 265 controls were enrolled with matching for age and completed questionnaires. Logistic regression analysis was used. Thirty-nine breast cancer patients reported striking life events and twenty-four of the controls reported striking life events. The number of striking life events was significantly greater in patients (p = 0.04). It indicated a striking life event led to a 1.726-fold increased HR (95% CI 1.005-2.965, p < 0.05) for breast cancer with adjustment for age, and a 1.811-fold increased HR (95% CI 1.021 - 3.212, P < 0.05) with adjustment for age, BMI, and late age at menopause. High BMI (OR: 1.680, 95% CI: 1.258-2.196, p < 0.05) and a family history of breast cancer (OR: 2.244, 95% CI: 1.065-4.729, p < 0.05, respectively) increased the risk of breast cancer, and late age at menopause decreased the risk for breast cancer (OR: 0.513, 95% CI: 0.303-0.868, p < 0.05). Our findings indicate a significant association between striking life events and breast cancer in Chinese women, especially in the subpopulation with high BMI or family history of breast cancer.

Stressors, stress response, and cancer recurrence: a systematic review

BACKGROUND

Cancer survivors assume that stress plays an important role in cancer recurrence. However, the role of stress in the etiology of cancer recurrence remains unclear.

OBJECTIVE

A systematic review examining the causal role of exposure to stressors and/or stress response and cancer recurrence was conducted.

METHODS

The authors screened the scientific literature published from December 1979 through April 2012. Prospective studies and randomized control trials that examined the link between exposure to stressors and/or stress response and cancer recurrence were included in the review.

RESULTS

Fifteen studies examined exposures to stressors (life event questionnaires) and/or multiple indices of the stress response (mood, anxiety, depression, biological, and immune measures). The relationships between stressors and/or stress response and recurrence were observed as no relationship (80%), positive relationship (33%), and inverse relationship (27%). One of 3 randomized control trials reported a positive relationship between stress reduction and reduced risk of recurrence.

CONCLUSIONS

The scientific literature to date indicates no clear evidence for a causal relationship between stress (measured as stressor exposure and/or stress response) and cancer recurrence. Although additional high-quality research is needed to provide a more definitive answer, the evidence to date does not support this hypothesis.

IMPLICATIONS FOR PRACTICE

Although at present, there is no evidence indicating a causal relationship between stress and cancer recurrence, attending to the reduction in a cancer survivor's stress response can improve emotional well-being and quality of life.

Psychosocial factors and mortality in women with early stage endometrial cancer

OBJECTIVES

Psychosocial factors have previously been linked with survival and mortality in cancer populations. Little evidence is available about the relationship between these factors and outcomes in gynaecologic cancer populations, particularly endometrial cancer, the fourth most common cancer among women. This study examined the relationship between several psychosocial factors prior to surgical resection and risk of all-cause mortality in women with endometrial cancer.

DESIGN

The study utilized a non-experimental, longitudinal design.

METHODS

Participants were 87 women (Mage  = 60.69 years, SDage  = 9.12 years) who were diagnosed with T1N0-T3N2 endometrial cancer and subsequently underwent surgery. Participants provided psychosocial data immediately prior to surgery. Survival statuses 4-5 years post-diagnoses were abstracted via medical record review. Cox regression was employed for the survival analysis.

RESULTS

Of the 87 women in this sample, 21 women died during the 4- to 5-year follow-up. Adjusting for age, presence of regional disease and medical comorbidity severity (known biomedical prognostic factors), greater use of an active coping style prior to surgery was significantly associated with a lower probability of all-cause mortality, hazard ratio (HR) = 0.78, p = .04. Life stress, depressive symptoms, use of self-distraction coping, receipt of emotional support and endometrial cancer quality of life prior to surgery were not significantly associated with all-cause mortality 4-5 years following diagnosis.

CONCLUSIONS

Greater use of active coping prior to surgery for suspected endometrial cancer is associated with lower probability of all-cause mortality 4-5 years post-surgery. Future research should attempt to replicate these relationships in a larger and more representative sample and examine potential behavioural and neuroendocrine/immune mediators of this relationship.

STATEMENT OF CONTRIBUTION

What is already known on this subject? Psychosocial factors have previously been linked with clinical outcomes in a variety of cancer populations. With regards to gynecologic cancer, the majority of the research has been conducted in ovarian cancer and examines the protective role of social support in mortality outcomes. What does this study add? Demonstrates association between active coping during perioperative period and 5 year survival. Demonstrates psychosocial-survival relationship exists independent of biobehavioral factors.

Lymphovascular and neural regulation of metastasis: shared tumour signalling pathways and novel therapeutic approaches

The progression of cancer is supported by a wide variety of non-neoplastic cell types which make up the tumour stroma, including immune cells, endothelial cells, cancer-associated fibroblasts and nerve fibres. These host cells contribute molecular signals that enhance primary tumour growth and provide physical avenues for metastatic dissemination. This article provides an overview of the role of blood vessels, lymphatic vessels and nerve fibres in the tumour microenvironment and highlights the interconnected molecular signalling pathways that control their development and activation in cancer. Further, this article highlights the known pharmacological agents which target these pathways and discusses the potential therapeutic uses of drugs that target angiogenesis, lymphangiogenesis and stress-response pathways in the different stages of cancer care.

Loss of partner and breast cancer prognosis - a population-based study, Denmark, 1994-2010

BACKGROUND

The extent to which experiencing a stressful life event influences breast cancer prognosis remains unknown, as the findings of the few previous epidemiological studies are inconsistent. This large population-based study examines the association between a common major life event, loss of a partner and breast cancer recurrence and all-cause mortality.

METHODS

N=21,213 women diagnosed with a first primary breast cancer 1994-2006, who had a cohabiting partner in the 4 years before their breast cancer diagnosis, were followed for death and recurrence in population-based registers and clinical databases. Information on education, disposable income, comorbidity and prognostic risk factors were included in Cox regression analyses.

RESULTS

Women who had lost a partner either before diagnosis or in subsequent years were not at significantly higher risk of recurrence or dying than women who had not lost a partner.

CONCLUSION

Our results do not support the concern that experiencing a stressful life event, the loss of a partner, negatively affects prognosis of breast cancer.

The sympathetic nervous system induces a metastatic switch in primary breast cancer

Metastasis to distant tissues is the chief driver of breast cancer-related mortality, but little is known about the systemic physiologic dynamics that regulate this process. To investigate the role of neuroendocrine activation in cancer progression, we used in vivo bioluminescence imaging to track the development of metastasis in an orthotopic mouse model of breast cancer. Stress-induced neuroendocrine activation had a negligible effect on growth of the primary tumor but induced a 30-fold increase in metastasis to distant tissues including the lymph nodes and lung. These effects were mediated by β-adrenergic signaling, which increased the infiltration of CD11b(+)F4/80(+) macrophages into primary tumor parenchyma and thereby induced a prometastatic gene expression signature accompanied by indications of M2 macrophage differentiation. Pharmacologic activation of β-adrenergic signaling induced similar effects, and treatment of stressed animals with the β-antagonist propranolol reversed the stress-induced macrophage infiltration and inhibited tumor spread to distant tissues. The effects of stress on distant metastasis were also inhibited by in vivo macrophage suppression using the CSF-1 receptor kinase inhibitor GW2580. These findings identify activation of the sympathetic nervous system as a novel neural regulator of breast cancer metastasis and suggest new strategies for antimetastatic therapies that target the β-adrenergic induction of prometastatic gene expression in primary breast cancers.

Healing and survivorship: what makes a difference?

Literature demonstrating the importance of social relationships for cancer survivorship is accumulating. Building on that literature, the term “Healing Ties” refers to the scientific and popular factors supporting the idea that relationships and community are essential for healing. However, difficulties arise in assessing the effect of social support for survivorship.

The current paper reviews the role in survivorship of social support, with respect to the explanatory model provided by neuro-oncology and psycho-neuro-immunology. Taking cognizance of the importance of social relationships, the model of cancer rehabilitation aims, through its interdisciplinary framework, to restore a sense of well-being and to facilitate healing by optimizing the capability for full social relationships and engagement with the world.

Does the occurrence of adverse life events in patients with breast cancer lead to a change in illness behaviour?

GOALS OF WORK

It was examined whether life-changing events may lead to changes of illness behaviour in women prior to breast cancer diagnosis. We considered the delay in three different aspects: date of breast self-examination, routine visits at the doctor, and finally changes in the length of time intervals between the detection of suspicious breast symptoms and the subsequent verification of diagnoses.

MATERIALS AND METHODS

The data of 240 patients (age <70 years) with a first manifestation of breast cancer were used for analysis. Life events were assessed by means of a semi-structured interview as proposed by Brown and Harris and classified according to a system proposed by Brugha et al., the List of Threatening Experiences (LTE). All analyses were performed by means of Cox's proportional hazard regression.

MAIN RESULTS

Women with stressful events went to the doctor earlier than those without events. The date of breast self-examination remained unchanged after the occurrence of events. Women who had discovered suspicious breast symptoms delayed the subsequent visit at the doctor if they had experienced two serious events within this period. The occurrence of life events may have effects on illness behaviour, but into different directions.

CONCLUSION

In the majority of cases, event-related delays were shorter than those reported to aggravate the prognosis of breast cancer.

Noncancer life stresses in newly diagnosed cancer

GOALS OF WORK

Noncancer life stresses affect psychosocial stress processes and have an impact on quality of life (QOL) of the patients. However, investigating life stresses in cancer is a recent development. We evaluated the life stresses of newly diagnosed melanoma, breast cancer, and prostate cancer patients in detail and investigated their impact on QOL outcomes after localized cancer diagnosis.

MATERIALS AND METHODS

Life change events from the previous year (negative events, positive events, total impact of events, impacts of the negative events, and impacts of loss events) and chronic ongoing life strains were measured with the Life Experience Survey and the Chronic Strains Survey in newly diagnosed patients 3 months after the diagnosis. Also, perceived symptoms and QOL were measured, and in melanoma and breast cancer, these were repeated up to 2 years later.

RESULTS

Noncancer life stress was common in newly diagnosed cancer patients: Both acute and chronic life stresses were experienced by four-fifths. Loss events (fateful negative events or social loss events) were reported by one-third. Many patients had a preceding chronic illness. Along with the cancer and treatment stresses, the noncancer life stresses predicted poorer QOL, particularly psychological and depressive symptoms. Different life stresses predicted slightly different domains of QOL, and depressive symptoms tended to be predicted by several kinds of life stresses. Baseline life stresses had impact also on later QOL in breast cancer.

CONCLUSIONS

Noncancer life stresses are common among newly diagnosed cancer patients and have impact on QOL, and thus they should be taken into account in cancer care. Screening for noncancer life stresses may offer means to enhance QOL outcomes in cancer.

Stress history and breast cancer recurrence

BACKGROUND

There is mixed evidence regarding the possible association between a history of stressful or traumatic life events and more rapid breast cancer progression.

METHOD

Retrospective reports of past experiences of traumatic life events were assessed among 94 women with metastatic or recurrent breast cancer. A traumatic event assessment was conducted using the event-screening question from the posttraumatic stress disorder (PTSD) module of the Structured Clinical Interview for the DSM-IV-TR (SCID; 2002). Each reported event was judged by two independent raters to determine whether it met DSM-IV-TR PTSD A1 criteria for a traumatic event. Those events that did not meet such criteria were designated "stressful events."

RESULTS

Nearly 42% of the women in the sample were judged to have experienced one or more traumatic events; 28.7% reported only stressful events. A Kruskal-Wallis test found significant differences in disease-free interval among the three groups [chi2 (2, N=94)=6.09, P<.05]. Planned comparisons revealed a significantly longer disease-free interval among women who had reported no traumatic or stressful life events (median=62 months) compared to those who had experienced one or more stressful or traumatic life events (combined median=31 months).

CONCLUSIONS

A history of stressful or traumatic life events may reduce host resistance to tumor growth. These findings are consistent with a possible long-lasting effect of previous life stress on stress response systems such as the hypothalamic-pituitary-adrenal (HPA) axis.

Baseline psychosocial predictors of survival in localized melanoma

OBJECTIVE

There is no certainty about the contributing factors or the psychological processes involved in cancer progression. Many studies have suffered from poor theoretical basis, methodological flaws, and only one or few psychosocial factors investigated at a time. We examined the simultaneous contribution of several theory-based psychosocial elements to survival time in melanoma.

METHODS

A consecutive sample of patients with localized (Clarke II-IV) melanoma (N=59) were evaluated with validated questionnaires on coping with cancer, anger expression, perceived social support, noncancer life stresses, and domains of quality of life (QOL) 3-4 months after diagnosis. Cox regression analyses were used to determine the predictors of survival time from the date of diagnosis to the date of death or the last follow-up.

RESULTS

After controlling for age, gender, and Breslow depth for the tumor, the baseline psychological variables related to the cancer-prone Type C response pattern, namely, anger nonexpression (repression), hopelessness, and better single-item self-reported QOL predicted shorter survival. Before hopelessness was added to the model, the amount of depressive symptoms and heavy perceived impact of diagnosis were also predictive. In addition, longer survival was strongly predicted by Cognitive Escape-Avoidance coping, which included items close to the concept of denial/minimizing.

CONCLUSION

Anger nonexpression, hopelessness, and overpositive reporting of QOL--all proposed to include in the Type C response style or reflect emotional nonexpression--seem to comprise a set of factors that reduce survival, whereas denial/minimizing response to the diagnosis as such predicts longer survival.

Stress and breast cancer: a systematic update on the current knowledge

A vast body of research has been carried out to examine the relationship between psychological stress and the risk of breast cancer. Previous reviews on this issue have mainly focused on stressful life events and have included both prospective and retrospective studies. The results from these reviews have revealed conflicting data. We evaluate whether stressful life events, work-related stress, or perceived global stress are differentially associated with breast cancer incidence and breast cancer relapse in prospective studies. Systematic and explicit methods were used to identify, select, and critically appraise relevant studies. The substantial variability in the manner in which stress was conceptualized and measured did not allow for the calculation of a quantitative summary estimate for the association between stress and breast cancer. Despite the heterogeneity in the results obtained, it is concluded that stress does not seem to increase the risk of breast cancer incidence. Whether stress affects the progression of breast cancer is still unclear. Studies with more thorough adjustment for confounding factors and larger studies on stress and breast cancer relapse are required to address this issue.

Temporal factors alter effects of social housing conditions on responses to chemotherapy and hormone levels in a Shionogi mammary tumor model

OBJECTIVE

To identify possible hormonal factors involved in the differential responses to chemotherapy observed in our tumor model, we investigated if the timing among tumor cell injection, rehousing, and chemotherapy administration differentially affects levels of corticosterone (CORT), growth hormone (GH), and testosterone and tumor and host responses to chemotherapy.

METHODS

Mice were reared either individually (I) or in groups (G). At 2 to 4 months, mice were injected with tumor cells and retained in their original housing conditions or rehoused into different experimental groups (GG, IG, II, GI) either immediately (experiment 1) or 14 days later (experiment 2); chemotherapy was administered when tumors weighed approximately 0.8 g.

RESULTS

In experiment 1, IG and GG mice had better responses to chemotherapy than GI mice. Chemotherapy increased CORT levels in II mice and decreased GH levels in GI mice compared with those of their drug vehicle-treated counterparts. Under the temporal conditions of experiment 2, IG and GG mice lost the advantage seen in experiment 1 in terms of tumor and host responses to chemotherapy. Before chemotherapy administration, CORT levels in IG mice and GH levels in GI mice were higher than those in mice in all other housing conditions. At 1 day after chemotherapy, CORT levels were higher for chemotherapy-treated than for drug vehicle-treated IG mice, and at 5 days post chemotherapy, GH levels were higher in GI than in IG mice.

CONCLUSIONS

Temporal relationships among tumor cell injection, rehousing, and chemotherapy administration critically influence responses to chemotherapy; these effects may be mediated, in part, by alterations in hormone levels.

Baseline psychosocial predictors of survival in localised breast cancer

Despite the large number of studies on the impact of psychosocial factors on breast cancer progression, there is no certainty about the contributing factors or processes involved. We investigated the relative impacts of socioeconomic, psychological, and psychosocial factors on survival in breast cancer. A consecutive sample of 102 patients (participation 82%) under 72 years of age with locoregional breast cancer completed validated questionnaires on coping with cancer, emotional expression (anger), perceived available support, noncancer life stresses, and quality of life 3-4 months after diagnosis. Survival times were measured from the date of diagnosis to the date of relapse and further to the date of death or date of last follow-up. Cumulative Cox regression analyses were carried out. After controlling for biological prognostic factors, age, and baseline treatment, longer survival was predicted by a long education and a minimising-related coping, while shorter survival was predicted by emotional defensiveness (antiemotionality), behavioural-escape coping, and a high level of perceived support. A shorter event-free time was also predicted by unemployment and depressive symptoms. Cancer survival is affected by a complex combination of psychosocial factors, among which minimising predicts a favourable prognosis and anger nonexpression and escape behaviour an unfavourable prognosis. Higher socioeconomic status is associated with longer survival. High scores in well-being scales may reflect emotional nonexpression.

Flattened cortisol rhythms in metastatic breast cancer patients

Allostatic load, the physiological accumulation of the effects of chronic stressors, has been associated with multiple adverse health outcomes. Flattened diurnal cortisol rhythmicity is one of the prototypes of allostatic load, and has been shown to predict shorter survival among women with metastatic breast cancer. The current study compared diurnal cortisol slope in 17 breast cancer patients and 31 controls, and tested associations with variables previously found to be related to cortisol regulation, i.e, abdominal adiposity, perceived stress, social support, and explicit memory. Women with metastatic breast cancer had significantly flatter diurnal cortisol rhythms than did healthy controls. Patients with greater disease severity showed higher mean cortisol levels, smaller waist circumference, and a tendency toward flatter diurnal cortisol rhythms. There were no relations between cortisol slope and psychological or cognitive functioning among patients. In contrast, controls with flatter rhythms showed the expected allostatic load profile of larger waist circumference, poorer performance on explicit memory tasks, lower perceived social support, and a tendency toward higher perceived stress. These findings suggest that the cortisol diurnal slope may have important but different correlates in healthy women versus those with breast cancer.

Psychological factors and cancer development: Evidence after 30 years of research

The question whether psychological factors affect cancer development has intrigued both researchers and patients. This review critically summarizes the findings of studies that have tried to answer this question in the past 30 years. Earlier reviews, including meta-analyses, covered only a limited number of studies, and included studies with a questionable design (group-comparison, cross-sectional or semiprospective design). This review comprises only longitudinal, truly prospective studies (N=70). It was concluded that there is not any psychological factor for which an influence on cancer development has been convincingly demonstrated in a series of studies. Only in terms of 'an influence that cannot be totally dismissed,' some factors emerged as 'most promising': helplessness and repression seemed to contribute to an unfavorable prognosis, while denial/minimizing seemed to be associated with a favorable prognosis. Some, but even less convincing evidence, was found that having experienced loss events, a low level of social support, and chronic depression predict an unfavorable prognosis. The influences of life events (other than loss events), negative emotional states, fighting spirit, stoic acceptance/fatalism, active coping, personality factors, and locus of control are minor or absent. A methodological shortcoming is not to have investigated the interactive effect of psychological factors, demographic, and biomedical risk factors.

Social context and outcomes for the ageing breast cancer patient: considerations for clinical practitioners

Current incidence, prevalence and survival rates determine that breast cancer is primarily a disease of older women. This integrative essay provides an extensive review of the literature on (i). the social and psychological factors that influence adjustment to breast cancer and survival from it, (ii). the social and health status of older women, and (iii). the medical treatment of older breast cancer patients. It is concluded that while psychological orientation to the disease, coping strategies and functional continuities of breast cancer patients are important for disease outcome, adjustment to and survival from breast cancer by older women may be compromised by the social context - with respect to marriage and intimate ties, social participation, socio-economic status, and mental and physical health. The paper concludes with the suggestion that clinical practitioners need to be aware of the both the resources of, and limitations facing the older breast cancer patient, and with the provision of specific recommendations about the clinical management of this population for nurses and other health professionals.

Psychological stress and the risk of breast cancer: a case–control study

OBJECTIVE

To determine whether psychological stress, in the form of past life events and stress at work, was associated with the development of breast cancer.

METHODS

The study was based on a case-control study of 257 women with breast cancer operated during 1993-1998 in Szczecin (Poland) hospitals and 565 controls, free of any cancer diagnosis. The subjects were sent a detailed questionnaire including questions on sociodemographic data; lifestyle (lifetime recreational and sport activities, occupational physical activity, diet); reproductive history; experience of psychological stress. The subjects reported major stressful life events, stress of daily activity and experience of stress at work. Logistic regression analyses were used to estimate the odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

After adjustment for age and other potential confounders, we found that women with major life events, stress of daily activity, and depression had 3.7 times higher risk for breast cancer, compared to those which did not experience such stress (OR = 3.70; 95% CI, 2.61-5.26). Women who reported experience of stress at work had a nonsignificant 16% higher risk for breast cancer compared with those who reported no stress (OR = 1.16; 95% CI, 0.82-1.64). A higher proportion of cases (89.1%) than controls (71.1%) reported that their job was stressful, very fretful or very responsible or experienced a major life event (OR = 4.29; 95% CI, 2.66-6.92).

CONCLUSION

These findings suggest an association between major life events and breast cancer.

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.

Healing the mind/body split: bringing the patient back into oncology

The effect on oncology of the doctrine of Cartesian dualism is examined. It is argued that (1) this doctrine continues to exert a baneful (though unacknowledged) influence on the practice of oncology, (2) Descartes's doctrine of a mind/body split is mistaken, and (3) mind and body (brain) are inextricably interwoven. A biopsychosocial model of disease is advocated. The role of psychooncology in healing the mind/body split by focusing research attention on the patient is outlined.

Depression as a prognostic factor for breast cancer mortality

It is unclear if depression or depressive symptoms have an effect on mortality in breast cancer patients. In this population-based, nationwide, retrospective cohort study in Denmark, depression was defined as affective or anxiety disorders that necessitated psychiatric hospital admission. All the affective and anxiety disorders were divided and categorized into five ordinal diagnostic groups. Early-stage (N=10382) and late-stage (N=10211) breast cancer patients were analyzed separately with Cox's regression adjusted for well-documented somatic prognostic variables. The authors used survival analysis of data from three central registers and found that breast cancer patients with depression had a modestly but significantly higher risk of mortality depending on stage of breast cancer and time of depression. The same result was found after censoring unnatural causes of death such as accident, suicide, or homicide.

Stressful life experiences and risk of relapse of breast cancer: observational cohort study

OBJECTIVE

To confirm, using an observational cohort design, the relation between severely stressful life experiences and relapse of breast cancer found in a previous case-control study.

DESIGN

Prospective follow up for five years of a cohort of women newly diagnosed as having breast cancer, collecting data on stressful life experiences, depression, and biological prognostic factors.

SETTING

NHS breast clinic, London; 1991-9.

PARTICIPANTS

A consecutive series of women aged under 60 newly diagnosed as having a primary operable breast tumour. 202/222 (91%) eligible women participated in the first life experiences interview. 170 (77%) provided complete interview data either up to 5 years after diagnosis or to recurrence.

MAIN OUTCOME MEASURE

Recurrence of disease.

RESULTS

We controlled for biological prognostic factors (lymph node infiltration and tumour histology), and found no increased risk of recurrence in women who had had one or more severely stressful life experiences in the year before diagnosis compared with women who did not (hazard ratio 1.01, 95% confidence interval 0.58 to 1.74, P=0.99). Women who had had one or more severely stressful life experiences in the 5 years after diagnosis had a lower risk of recurrence (0.52, 0.29 to 0.95, P=0.03) than those who did not.

CONCLUSION

These data do not confirm an earlier finding from a case-control study that severely stressful life experiences increase the risk of recurrence of breast cancer. Differences in case control and prospective methods may explain the contradictory results. We took the prospective study as the more robust, and the results suggest that women with breast cancer need not fear that stressful experiences will precipitate the return of their disease.

Stressful life events and survival after breast cancer

OBJECTIVE

This study assessed the relation of stressful life events with survival after breast cancer.

METHODS

This study was based on women with histologically confirmed, newly diagnosed, localized or regional stage breast cancer first treated in 1 of 11 Quebec City (Canada) hospitals from 1982 through 1984. Among 765 eligible patients, 673 (88%) were interviewed 3 to 6 months after diagnosis about the number and perceived impact of stressful events in the 5 years before diagnosis. Three scores were calculated: number of events; number weighted by reported impact; and for almost 80% of events, number weighted by community-derived values reflecting adjustment required by the event. Scores were divided into quartiles to assess possible dose-response relationships. Survival was assessed in 1993. Hazard ratios and 95% confidence intervals (CIs) comparing all-cause and breast cancer-specific mortality were calculated with adjustment for age, presence of invaded axillary nodes, adjuvant radiotherapy, and systemic therapy (ie, chemotherapy and hormone therapy).

RESULTS

When quartiles 2, 3, and 4 were compared with the appropriate lowest quartile, adjusted hazard ratios for all-cause mortality were 0.99 (CI = 0.70-1.38), 0.97 (CI = 0.73-1.31), and 1.04 (CI = 0.78-1.40) for number, number weighted by impact, and number weighted by community-derived values, respectively. Results were essentially similar for the relation between stressful life events limited to those occurring within the 12 months before diagnosis and overall mortality and between stressful life events in the 5 years before diagnosis and breast cancer-specific mortality.

CONCLUSIONS

Stress was conceptualized as life events presumed to be negative, undesirable, or to require adjustment by the person confronting them. We found no evidence indicating that this kind of stress during the 5 years before diagnosis negatively affected survival among women with nonmetastatic breast cancer. Evidence from this study and others on the lack of effect of this type of stress on survival may be reassuring for women living with breast cancer.

Cancer incidence and survival following bereavement

OBJECTIVES

This study investigated the effect of parental bereavement on cancer incidence and survival.

METHODS

A cohort of 6284 Jewish Israelis who lost an adult son in the Yom Kippur War or in an accident between 1970 and 1977 was followed for 20 years. We compared the incidence of cancer in this cohort with that among nonbereaved members of the population by logistic regression analysis. The survival of bereaved parents with cancer was compared with that of matched controls with cancer.

RESULTS

Increased incidence was found for lymphatic and hematopoietic malignancies among the parents of accident victims (odds ratio [OR] = 2.01; 95% confidence interval [CI] = 1.30, 3.11) and among war-bereaved parents (OR = 1.47; 95% CI = 1.13, 1.92), as well as for melanomas (OR = 4.62 [95% CI = 1.93, 11.06] and 1.71 [95% CI = 1.06, 2.76], respectively). Accident-bereaved parents also had an increased risk of respiratory cancer (OR = 1.50; 95% CI = 1.07, 2.11). The survival study showed that the risk of death was increased by bereavement if the cancer had been diagnosed before the loss, but not after.

CONCLUSIONS

This study showed an effect of stress on the incidence of malignancies for selected sites and accelerated demise among parents bereaved following a diagnosis of cancer, but not among those bereaved before such a diagnosis.

Negative affectivity, restriction of emotions, and site of metastases predict mortality in recurrent breast cancer

OBJECTIVE

To assess whether negative affectivity and restriction of emotions predict survival time with recurrent breast cancer.

METHODS

Thirty-two patients with recurrent breast cancer, diagnosed 6-19 months earlier and stabilized using surgical, medical and/or radiation therapies, were enrolled. Cox regression survival analyses, including initial severity of metastases (RR=4.3 [1.3-14.3]; p=0.02), were used to explore the association of psychological variables with survival.

RESULTS

Low chronic anxiety in the context of low emotional constraint predicted low mortality (RR 0.07 [0.01-0.52]; p=0.007). However, patients with low chronic anxiety scores but with high constraint had higher mortality (RR=3.7 [1.2-11.5; p=0.02). High chronic anxiety, with or without high constraint, also predicted earlier death, as did high control of feelings.

CONCLUSION

An integrated model of negative affectivity in the context of restriction of emotions appears to strengthen the prediction of survival based on severity of breast cancer metastases.

Life events, coping and breast cancer: state of the art

In this article the state of the art regarding the possible link between life events and the onset and/or prognosis of breast cancer is reviewed. We can conclude that at this moment there exists no evidence for the contribution of stressful life events to an increased risk of breast cancer in studies of good methodological quality. Only studies of weak methodological quality suggest a relationship between stressful life events and risk of breast cancer. There is a need for studies using a straightforward prospective design. The contribution of life events to the prognosis of breast cancer is small. However, the role of coping is much greater. Coping with the diagnosis of breast cancer in a passive way is associated with a shorter survival time. However, studies of good methodological quality will be needed to replicate the link between coping and the prognosis of breast cancer.

Stressful life events and difficulties and onset of breast cancer: case-control study

OBJECTIVE

To determine the relation between stressful life events and difficulties and the onset of breast cancer.

DESIGN

Case-control study.

SETTING

3 NHS breast clinics serving west Leeds.

PARTICIPANTS

399 consecutive women, aged 40-79, attending the breast clinics who were Leeds residents.

MAIN OUTCOME MEASURES

Odds ratios of the risk of developing breast cancer after experiencing one or more severe life events, severe difficulties, severe 2 year non-personal health difficulties, or severe 2 year personal health difficulties in the 5 years before clinical presentation.

RESULTS

332 (83%) women participated. Women diagnosed with breast cancer were no more likely to have experienced one or more severe life events (adjusted odds ratio 0.91, 95% confidence interval 0.47 to 1. 81; P=0.79); one or more severe difficulties (0.86, 0.41 to 1.81; P=0.69); a 2 year severe non-personal health difficulty (0.53, 0.12 to 2.31; P=0.4); or a 2 year severe personal health difficulty (2.73, 0.68 to 10.93; P=0.16) than women diagnosed with a benign breast lump.

CONCLUSION

These findings do not support the hypothesis that severe life events or difficulties are associated with onset of breast cancer.

Psychosocial correlates of cancer relapse and survival: a literature review

This article reviews literature on the psychosocial correlates of cancer relapse and survival from 1979 through 1995. The factors studied were structured according to a theoretical model of coping with cancer. Reviewed studies have shown that factors most frequently evaluated were depression, anxiety, hopelessness/helplessness, hostility, marital status and social involvement. Mainly inconsistent results were found. The strongest evidence for a relationship between psychosocial variables and prognosis was found for social involvement/social support; in 7 of 15 studies a positive relationship was demonstrated, while no negative associations were found. Coping styles e.g., fighting spirit and stoic acceptance, and severe/stressful life events were found to have no conclusive influence on the length of survival. Important determinants of the coping model, such as uncertainty and information given by the specialist were not studied as possible predictors of survival and/or relapse free period. Among the factors that showed no correlation at all was multidimensional health locus of control. For the inconsistent findings, a considerable number of methodologic shortcomings with respect to study design, sample size, measure and statistical analysis are enumerated.