Coping strategies of patients with advanced lung or colorectal cancer in six European countries: Insights from the ACTION Study

Objective

Even when medical treatments are limited, supporting patients’ coping strategies could improve their quality of life. Greater understanding of patients’ coping strategies, and influencing factors, can aid developing such support. We examined the prevalence of coping strategies and associated variables.

Methods

We used sociodemographic and baseline data from the ACTION trial, including measures of Denial, Acceptance, and Problem‐focused coping (COPE; Brief COPE inventory), of patients with advanced cancer from six European countries. Clinicians provided clinical information. Linear mixed models with clustering at hospital level were used.

Results

Data from 675 patients with stage III/IV lung (342, 51%) or stage IV colorectal (333, 49%) cancer were used; mean age 66 (10 SD) years. Overall, patients scored low on Denial and high on Acceptance and Problem‐focused coping. Older age was associated with higher scores on Denial than younger age (β = 0.05; CI[0.023; 0.074]), and patients from Italy (β = 1.57 CI[0.760; 2.388]) and Denmark (β = 1.82 CI[0.881; 2.750]) scored higher on Denial than patients in other countries.

Conclusions

Patients with advanced cancer predominantly used Acceptance and Problem‐focused coping, and Denial to a lesser extent. Since the studied coping strategies of patients with advanced cancer vary between subpopulations, we recommend taking these factors into account when developing tailored interventions to support patients’ coping strategies.

Temperament and Character Traits Associated with Health-Related Quality of Life in Cancer Patients

Background

There is an increase in the attention to factors influencing the quality of life of cancer patients. The aim of the present study was to evaluate temperament and character traits related to health-related quality of life (HRQoL) in patients with cancer.

Methods

Two hundred and three inpatients from three Italian oncology departments filled in the Temperament Character Inventory (TCI-140) based on Cloninger's personality model, the SF-36 questionnaire assessing HRQoL, and the Hospital Anxiety and Depression Scale (HADS). Eighty percent of patients were undergoing chemotherapy.

Results

Lower levels of harm avoidance and higher levels of self-directedness were significantly correlated with a better HRQoL. Regression analysis controlling for psychopathology (anxiety and depression symptoms) showed that the influence of temperament and character traits on quality of life seemed to add little to the influence of psychopathology.

Conclusions

The present study demonstrates the existence of some relations between HRQoL and temperament and character traits assessed using the TCI-140 questionnaire. However, among the psychological factors, psychopathology seems to retain more influence on HRQoL of cancer patients.

Dispositional and Situational Avoidance and Approach as Predictors of Physical Symptom Bother Following Breast Cancer Diagnosis

BACKGROUND

Few studies examine whether dispositional approach and avoidance coping and stressor-specific coping strategies differentially predict physical adjustment to cancer-related stress.

PURPOSE

This study examines dispositional and situational avoidance and approach coping as unique predictors of the bother women experience from physical symptoms after breast cancer treatment, as well as whether situational coping mediates the prediction of bother from physical symptoms by dispositional coping.

METHOD

Breast cancer patients (N = 460) diagnosed within the past 3 months completed self-report measures of dispositional coping at study entry and of situational coping and bother from physical symptoms every 6 weeks through 6 months.

RESULTS

In multilevel structural equation modeling analyses, both dispositional and situational avoidance predict greater symptom bother. Dispositional, but not situational, approach predicts less symptom bother. Supporting mediation models, dispositional avoidance predicts more symptom bother indirectly through greater situational avoidance. Dispositional approach predicts less symptom bother through less situational avoidance.

CONCLUSION

Psychosocial interventions to reduce cancer-related avoidance coping are warranted for cancer survivors who are high in dispositional avoidance and/or low in dispositional approach.

Trait mindfulness, repression, suppression, and self-reported mood and stress symptoms among women with breast cancer

OBJECTIVE

This study sought to identify relationships between trait mindfulness, repressive, and suppressive emotional styles, and the relative importance of these traits in their association with self-reported psychological health among women with breast cancer.

METHOD

Of the 277 women with breast cancer accrued in the study, 227 (81.9%) completed a set of questionnaires assessing personality traits, stress symptoms, and mood.

RESULTS

High levels of mindfulness were associated with fewer stress-related symptoms and less mood disturbance, while high levels of suppression were associated with poorer self-reported health.

CONCLUSION

Individuals' dispositional ways to manage negative emotions were associated with the experience of symptoms and aversive moods. Helping patients cultivate mindful insights and reduce deliberate emotional inhibition may be a useful focus for psycho-oncological interventions.

A longitudinal investigation of coping and posttraumatic growth in breast cancer survivors

This study supported several predictions for coping and distress during chemotherapy (Time 1), and coping, perceived stress, and posttraumatic growth two years later (Time 2) in women with breast cancer. At T1, the emotion-focused coping strategies of disengagement, denial, self-blame, and venting were positively related to physical and psychological distress. In addition, the cognitive strategies of religion, positive reframing, and acceptance together accounted for a significant amount of the variance in fatigue and distressed mood. Positive reframing and acceptance negatively related to chemotherapy distress, while using religion positively related. However, using religion at chemotherapy (T1) related to more posttraumatic growth at two-year follow-up (T2). Furthermore, at two-year follow-up, (1) using religion, positive reframing, and acceptance accounted for forty-six percent (46%) of the variance in posttraumatic growth; (2) positive reframing related to more posttraumatic growth; (3) instrumental and emotional support related to more posttraumatic growth; (4) acceptance related to less perceived stress; (5) self-blame related to more perceived stress; and (6) posttraumatic growth marginally related to lower perceived stress. These findings support the current theoretical model that posttraumatic growth is adaptive, that it results from cognitively processing trauma, and that coping may moderate this growth.

Personality variables are associated with colorectal cancer patients' quality of life independent of psychological distress and disease severity

OBJECTIVE

The aim of the present study was to test whether psychological distress and personality variables are independently associated with health-related quality of life (HRQOL) in colorectal cancer patients, after adjusting for age, gender, education and disease severity.

METHODS

In a cross-sectional study of 162 colorectal cancer patients (response rate 65.6%), the following self-report instruments were administered: the Symptom Distress Checklist-90-R, the Sense of Coherence scale, the Life Style Index and the Hostility and Direction of Hostility Questionnaire. The outcome measures were the four components of the WHO Quality of Life Instrument, Short Form. We used hierarchical regressions to determine whether psychological distress mediates the relationship of personality and disease parameters with HRQOL.

RESULTS

The overall proportion of the variance in the four components of HRQOL explained by our regression models ranged from 28.1 to 44.4%. Psychological distress was an independent correlate of HRQOL, associated with physical (p<0005), mental (p<0.05) and social relationships HRQOL (p<0.02). Personality variables were associated with HRQOL independent of psychological distress and disease severity. Sense of coherence and denial defense were positively associated with all aspects of HRQOL independent of psychological distress and disease parameters (p-values ranging from p<0.05 to p<0.0005). Hostility (p<0.01) and repression defense (p=0.024) were also independently but negatively associated with physical HRQOL.

CONCLUSIONS

In colorectal cancer patients, psychological distress is associated with HRQOL independent of disease parameters but personality variables are also associated with HRQOL independent of disease severity and psychological distress, and this could be relevant to psychological interventions.

Repression: finding our way in the maze of concepts

Repression is associated in the literature with terms such as non-expression, emotional control, rationality, anti-emotionality, defensiveness and restraint. Whether these terms are synonymous with repression, indicate a variation, or are essentially different from repression is uncertain. To clarify this obscured view on repression, this paper indicates the similarities and differences between these concepts. Repression is the general term that is used to describe the tendency to inhibit the experience and the expression of negative feelings or unpleasant cognitions in order to prevent one's positive self-image from being threatened ('repressive coping style'). The terms self-deception versus other-deception, and socially related versus personally related repression refer to what is considered to be different aspects of repression. Defensiveness is a broader concept that includes both anxious defensiveness and repression; the essential difference is whether negative emotions are reported or not. Concepts that are sometimes associated with repression, but which are conceptually different, are also discussed in this paper: The act of suppression, 'repressed memories,' habitual suppression, concealment, type C coping pattern, type D personality, denial, alexithymia and blunting. Consequences for research: (1) When summarizing findings reported in the literature, it is essential to determine which concepts the findings represent. This is rarely made explicit, and failure to do so may lead to drawing the wrong conclusions (2) It is advisable to use scales based on different aspects of repression (3) Whether empirical findings substantiate the similarities and differences between concepts described in this paper will need to be shown.

Self-report of somatic symptoms in survivors of childhood cancer: effects of adaptive style

BACKGROUND

Screening for late effects in survivors of childhood cancer may be influenced by the patients' self-reporting of their somatic state. However, self report of somatic symptoms may be influenced by factors other than objectively documented physical functions. This study examined the self report of somatic symptoms in children with cancer and matched healthy control children as a function of child adaptive style.

PROCEDURE

Two groups of children age 7-18 were studied; children with cancer at least 6-month post completion of therapy (n = 120) and a group of healthy children (n = 120) matched on age, race, and gender. Children completed measures of somatic symptoms, body consciousness, and adaptive style.

RESULTS

Contrary to expectations, there were no differences between children with cancer and healthy controls in self-reported somatic symptoms, although cancer patients reported slightly lower symptomatology. In contrast, there were significant differences in self-reported somatic symptoms as a function of adaptive style. Children identified as repressors reported the lowest level of somatic symptoms and differed significantly from all other adaptive style groups.

CONCLUSION

These results do not support the prevailing hypothesis that a repressive style may be a risk factor for psychosomatic illness. However, the findings are consistent with a response bias interpretation, suggesting a general under-reporting of symptoms in repressors, including physical symptoms. These results have significant implications for health care providers and researchers following long-term survivors of childhood cancer.

Psychophysiological Response to Severe Sport Injury Among Competitive Male Athletes: A Preliminary Investigation

Features of posttraumatic distress have been associated with treatment noncompliance and delayed surgical recovery among general medical and trauma populations. Although cognitive-affective and behavioral features of posttraumatic distress have been demonstrated among adult and adolescent athletes with injuries, physiological responses associated with posttraumatic distress have not yet been examined in this population. The objective of this study was to examine psychophysiological stress reactivity to orthopedic trauma among male athletes who sustained a severe sport injury. Athletes with injuries (n= 7) and non-injured athlete controls (n= 5) completed self-report measures of psychological distress and were then shown injury video footage while heart rate and skin conductance measures were recorded. After exposure to orthopedic trauma-related video footage, athletes with injuries demonstrated significantly greater skin conductance reactivity and subjective distress compared to controls. As demonstrated among other medical and trauma populations, athletes with injuries exhibit exaggerated stress reactivity profiles when primed with orthopedic trauma stimuli.

Defensive avoidance of disapproval: the relationship of a defensive style to physical and mental health

This article presents an exploration of a clinically meaningful interpersonal style labeled here as defensive avoidance of disapproval (DAD), which involves a motivated inattention to physiological, affective, or cognitive reactions arising from stressful social transactions, thereby safeguarding a self-image of social competence. First, we discuss conceptual antecedents of DAD derived from post-Freudian theories of twentieth-century psychodynamic and interpersonally oriented clinicians. Second, we highlight measurement issues as they relate to DAD. Third, we review research on the association of DAD with psychophysiological stress reactivity and diminished health. Finally, DAD-related clinical implications are considered. Our discussion of DAD invites the (1) assessment of phenomenological "blind spots" regarding the physiological, affective, and cognitive components of disapproval-induced stress, (2) development of strategies to decrease premature therapy termination that may result from a defensive avoidance of social disapproval, and (3) cultivation of interventions to increase the high DAD patient's acknowledgement, rather than rejection, of the signs of social stress.

Denial in cancer patients, an explorative review

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

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.

Denial in cancer patients

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

A systems model for adaptation to somatic distress among cancer survivors

Applied coping research has generally failed to fulfill its goal of providing an empirical basis for clinical interventions, and research on coping with cancer is no exception. This can be attributed in large measure to the wide gap between coping theory and coping research. Theories of stress and adaptation are complex systems formulations that present conceptual and methodological challenges and thus make testing comprehensive models difficult. The present paper reviews arguments for a microanalytic strategy through which researchers can increase coverage of relevant variables from broad systems models of stress and coping by concentrating their resources on selected, high-frequency, high-stress problems. The utility of this approach for formulating problem-specific systems models is illustrated using the example of coping with somatic distress among cancer survivors.

Beliefs about mood moderate the relationship of stress to illness and symptom reporting

The current prospective study examined how characteristic beliefs about mood affect illness and symptom reporting. Using the Trait Meta-Mood Scale, 134 undergraduate (76 females and 58 males) reported their beliefs about attention to, clarity, and reparability of mood. Self-reported stress, illness, and symptoms were collected at three times following assessment of trait meta-mood, during times of general stress, and immediately prior to a class examination. Results indicate that, at increasing levels of distress, those who believe in greater attention to mood were more likely to report physical symptoms. In addition, those individuals who said that they generally make efforts to maintain positive mood were less likely to report illness than those less likely to engage in mood repair. The findings suggest that a person's general manner of evaluating or appraising mood is an important moderator of the relation between distress and symptom and illness reporting.

Coping with Bereavement: A Review of the Grief Work Hypothesis

The article challenges the longstanding belief in the importance of “grief work” for adjustment to bereavement (the grief work hypothesis). It examines claims made in theoretical formulations and principles of grief counseling and therapy concerning the necessity of working through loss. Empirical evidence is reviewed, and cross-cultural findings are described to document alternative patterns of coping with grief. It is argued that there are grounds for questioning the hypothesis: 1) existing definitions and operationalizations are problematic; 2) the few empirical studies that have examined the impact of grief work have yielded equivocal results; 3) grief work is not a universal concept. Limitations of the grief work hypothesis as an explanation of coping with bereavement are identified and a differential approach is suggested. Implications for counseling and therapy are discussed.

Methodological issues and research strategies in the study of coping with cancer

We explore methodological issues and research strategies and applications in the study of coping with cancer. The major points are addressed within the context of the transactional, or process, model of stress and coping offered by Lazarus and Folkman. Three features of this model are discussed: (a) a focus on what individuals are actually doing and thinking in stressful transactions as opposed to what they usually do or would do; (b) an emphasis on assessing coping behavior in relation to a specific context and; (c) attention to the dynamic nature of coping behavior. We outline each of these three features and discuss its implications for research on coping with cancer; particular attention is given to specific measurement strategies and substantive research questions. We also consider the utility of research on coping with cancer for the design and implementation of coping interventions for individuals with cancer.