Coping, psychosocial well-being and anxiety in cancer patients at follow-up visits

In their own words: a qualitative study of coping mechanisms employed by patients with acute myeloid leukemia

PURPOSE

Positive coping mediates improved outcomes from integrated palliative care in acute myeloid leukemia (AML). We qualitatively explored patients' coping mechanisms to better understand this relationship.

METHODS

We enrolled patients with high-risk AML admitted to Duke Hospital's inpatient hematologic malignancy service for intensive chemotherapy. This study is a secondary analysis of previously collected longitudinal qualitative data, with interviews conducted between February 2014 and August 2015. Interviews were coded in NVivo to identify examples of approach-oriented and avoidant coping.

RESULTS

Patients demonstrated approach-oriented coping in many forms including acceptance, positive reframing, active coping, religious coping, and social coping. Acceptance included accepting their prognosis, the uncertainty of AML, and lifestyle changes due to the disease. Patients exhibited positive reframing by speculating about how their situation could be worse, deriving meaning from their experience, and expressing newfound appreciation for activities previously taken for granted. Social coping involved patients receiving support from their community or care team; however, some expressed guilt for being a "burden" on family. Avoidant coping included denial, behavioral disengagement, and self-blame. Some denied their prognosis, but denial was more commonly demonstrated via patients cognitively distancing themselves from their disease. Much of the behavioral disengagement described by patients was attributed to their symptoms (i.e., lethargy) which prevented patients from maintaining relationships or participating in activities previously enjoyed.

CONCLUSION

These results demonstrate the diverse and nuanced applications of coping mechanisms amid a recent AML diagnosis. Future research should examine coping in the context of novel low-intensity AML therapies.

Cancer coping self-efficacy mediates the relationship between mental adjustment to cancer and health-related quality of life in persons with cancer

Individuals with cancer experience significant levels of distress. Improving health-related quality of life of persons with cancer is a major focus in cancer treatment. This study investigated the mediating role of self-efficacy for coping with cancer in the relationship between mental adjustment to cancer and health-related quality of life among individuals with cancer. Two hundred and fourteen persons with cancer (male = 74, female = 140, mean age = 50.57) were recruited from a University Teaching Hospital, in South-West Nigeria. Participants responded to the measures of psychological responses to cancer (mental adjustment to cancer), self-efficacy for coping with cancer (Cancer Behaviour Inventory [CBI]), and health-related quality of life (Functional Assessment of Cancer Therapy–General). Mediation analysis and structural equation modelling were carried out using IBM AMOS software version 23. Domains of mental adjustment to cancer significantly predicted health-related quality of life, helplessness/hopelessness, and anxious preoccupation had a negative association with health-related quality of life; whereas fighting spirit, cognitive avoidance, and fatalism were positively associated with health-related quality of life. Self-efficacy had a positive association with health-related quality of life. Mediation analysis showed that self-efficacy for coping with cancer partially mediated the association between four domains of mental adjustment to cancer (helplessness/hopelessness, fighting spirit, cognitive avoidance, and fatalism) and health-related quality of life. The findings demonstrated the need for improved coping mechanisms while undergoing cancer treatment. The study has important clinical implications for psycho-oncology practice, particularly with respect to self-efficacy for coping with cancer. Psychosocial therapies aimed at enhancing the self-efficacy of persons with cancer should be incorporated as part of cancer treatment to improve their health-related quality of life.

Sense of coherence and coping strategies: How they influence quality of life in Iranian women with breast cancer

Aim

To investigate the mediation/moderation effect between Coping Behaviors (CBs) and Sense of Coherence (SOC) in the prediction of health‐related quality of life (HRQoL) in breast cancer patients.

Design

Cross‐sectional.

Methods

A total of 221 patients were included in this study. The 13‐item Orientation to Life Questionnaire, Brief COPE and Functional Assessment of Cancer Therapy—Breast were investigated. Pearson's correlation coefficient and mediation/moderation analysis were performed.

Results

Significant correlations were observed for SOC, active coping, acceptance, positive reframing (PR), planning, use of emotional support (UES), use of instrumental support, behaviour disengagement and self‐blame with HRQoL. Except for planning and acceptance, SOC partially mediated the CBs' effect on HRQoL. The UES and PR's effects on HRQoL were significant at lower SOC levels and diminished at higher SOC levels.

Conclusion

Practitioners can incorporate SOC and adaptive CBs, including PR and UES, into the rehabilitation programmes to improve HRQoL in patients.

Variability and stability of coping styles among breast cancer survivors: A prospective study

OBJECTIVES

We aimed to examine: (1) the long-term association between coping styles and psychological distress, (2) if women diagnosed with breast cancer have a predominant coping style, (3) stability of coping styles, (4) predictors of changes in coping styles, (5) if maladaptive coping adversely impacts disease-free survival (DFS).

METHODS

This prospective study included women diagnosed with primary breast cancer during 2006-2009. Patients completed questionnaires for the Norwegian Mini-Mental Adjustment to Cancer scale, which includes positive attitude (PA), helplessness/hopelessness (HH), anxious preoccupation (AP), and avoidance (AV), and the Hospital Anxiety and Depression Scale at diagnosis and 1, 3, and 5 years postdiagnosis.

RESULTS

Two hundred and ninety-three of 367 women (79.8%) completed the questionnaires at all time points. Anxiety and depression were moderately to strongly correlated with HH and AP coping styles (r = 0.31 to r = 0.69) at all time points. The predominant coping style was PA (23.4-29.9%). Stability for PA and cognitive AV styles was found at the group level, but not at an individual level. Chemotherapy and comorbidity were predictors for HH, AP, and AV 5 years postdiagnosis (p < 0.05). Maladaptive coping was not associated with DFS.

CONCLUSIONS

HH and AP were associated with higher psychological distress at all times. Group level coping remained stable over time for PA and AV. Coping style stability at an individual level was not observed. Having received chemotherapy and experienced adverse events affected coping at 5 years postdiagnosis. Maladaptive coping was not associated with DFS.

The association of perseverative negative thinking with depression, anxiety and emotional distress in people with long term conditions: A systematic review

OBJECTIVE

Depression is common in people with long term conditions, and is associated with worse medical outcomes. Previous research shows perseverative negative thinking (e.g. worry, rumination) predicts subsequent depression and worse medical outcomes, suggesting interventions targeting perseverative negative thinking could improve depression and medical outcomes. Previous studies recruited healthy individuals, however. This review aimed to determine the temporal relationship and strength of prospective association of perseverative negative thinking with depression, anxiety and emotional distress in people with long term conditions.

METHOD

Four electronic databases were searched for studies including standardised measures of perseverative negative thinking and depression, anxiety or emotional distress, and which presented prospective associations. Findings were narratively synthesized.

RESULTS

Thirty studies were identified in a range of long term conditions. Perseverative negative thinking and subsequent depression, anxiety or emotional distress were significantly correlated in the majority of studies (bivariate r=0.23 to r=0.73). 25 studies controlled for confounders, and in 15 perseverative negative thinking predicted subsequent depression, anxiety or emotional distress. Results varied according to condition and study quality. Six of 7 studies found bivariate associations between depression, anxiety or emotional distress and subsequent perseverative negative thinking, though 2 studies controlling for key covariates found no association. Few studies assessed the impact of perseverative negative thinking on medical outcomes.

CONCLUSION

Strongest evidence supported perseverative negative thinking predicting subsequent depression, anxiety and emotional distress in people with long term conditions. Further prospective research is warranted to clarify the association of perseverative negative thinking with subsequent poor medical outcomes.

Religion, coping and outcome in out-patients with depression or diabetes mellitus

OBJECTIVE

The study assesses the association between religiosity and coping style with the outcome of depression and diabetes.

METHOD

Using a simple random sampling, we recruited 112 participants with diabetes and an equal number with depression consecutively, matching for gender. Religiosity was determined using Religious Orientation Scale (revised) (ROS-R), coping styles with Brief Religious Coping (Brief RCOPE) scale and Mental Adjustment to Cancer (MAC) scale (adapted). Primary and secondary outcomes were evaluated using Sheehan's Disability Scale (SDS) and Becks Depression Inventory-II (BDI-II) respectively.

RESULTS

Among participants with diabetes, BDI-II total scores correlated negatively with ROS-R Extrinsic Social (r = -0.2, P < 0.05) and Fighting Spirit (r = -0.3, P < 0.05) but correlated positively with Helplessness/Hopelessness (r = 0.3, P < 0.05) and Brief RCOPE Negative (r = 0.4, P < 0.05). SDS global scores correlated positively with Helplessness/Hopelessness (r = 0.3, P < 0.05) and Brief RCOPE Negative (r = 0.4, P < 0.05). Among participants with depression, BDI-II total scores correlated negatively with Intrinsic religiosity (r = -0.2, P < 0.05) and Fighting Spirit (r = -0.4, P < 0.05) but correlated positively with Helplessness/Hopelessness (r = 0.6, P < 0.05) and Brief RCOPE Negative (r = 0.7, P < 0.05). SDS global scores correlated negatively with Intrinsic religiosity (r = -0.2, P < 0.05) and Fighting Spirit (r = -0.3, P < 0.05) but correlated positively with Helplessness/Hopelessness (r = 0.5, P < 0.05) and Brief RCOPE Negative (r = 0.4, P < 0.05).

CONCLUSION

High intrinsic and extrinsic religiosities are likely to be associated with positive coping skills and better treatment outcome in patients with depression or diabetes.

The effectiveness of mindfulness-based stress reduction (MBSR) for survivors of breast cancer: study protocol for a randomized controlled trial

Background

After treatment completion, breast cancer (BC) survivors frequently experience residual symptoms of pain, fatigue, high levels of psychological stress, anxiety, depression, fear of recurrence, and metastasis. Post-treatment stress, in particular, can adversely affect health-related quality of life, which, in turn, induces onset or recurrence of chronic diseases. Effective interventions that target these psychological symptoms and their physiological consequences are needed, especially for economically disadvantaged patients. However, in China, few evidence-based intervention strategies have been established among BC survivors. This study will formally adapt, develop, and evaluate an intensive mindfulness-based stress reduction (MBSR) intervention protocol to improve mental health, quality of life, and compliance with medication among Chinese BC survivors.

Methods

A randomized, waitlist-controlled clinical trial will be conducted. Based on our power calculation, 418 BC survivors will be recruited from 10 low-income communities in Shanghai. All subjects will be randomly assigned either to the MBSR program or to a waitlisted usual care regimen that will offer the MBSR program after the completion of the other trial arm (after 6 months follow-up). Our 8-week MBSR intervention program will provide systematic training to promote stress reduction by self-regulating arousal to stress. Assessments will be made at baseline, 4 weeks (in the middle of the first MBSR intervention), 8 weeks (at the end of the first MBSR intervention), 6 months, and 12 months, and will include measures of psychological symptoms (depression, anxiety, and perceived stress), quality of life, and medication adherence. The expected outcome will be the improvement in psychological symptoms, quality of life, and medication compliance in the MBSR intervention group.

Discussion

This study will help develop an affordable, self-care psychological intervention protocol to help Chinese BC survivors improve their quality of life, and could be helpful in further developing affordable disease management plans for patients of other chronic diseases.

Trial registration

ChiCTR-IOR-14005390 (10/27/2014)

Strategy of Coping With End-Stage Disease and Cancer-Related Fatigue in Terminally Ill Patients

The aim was to investigate whether there is a relationship between strategy of coping with end-stage disease and cancer-related fatigue. The study was conducted using the Rotterdam Symptom Checklist, Brief Fatigue Inventory, and Mini-Mental Adjustment to Cancer scale to specify patient’s strategy of coping. Finally, 51 hospice care patients with cancer were analyzed. Main Findings: The majority of responders adopted 1 of the 2 styles; avoidance (belongs to adaptive coping) or anxious preoccupation (destructive or maladaptive). Less often moderate fatalism and helpless/hopeless (H/H) or fighting spirit were observed. Significant correlation has been found between H/H or fatalism strategy and fatigue. Conclusions: High level of fatigue had a negative impact on almost all aspects of daily living among people with H/H or fatalism strategy.

Shared decision-making in metastatic breast cancer: discrepancy between the expected prolongation of life and treatment efficacy between patients and physicians, and influencing factors

Treatment decisions in oncology are based on a balance between the efficacy of therapy and its side effects. Patients with metastases and patients with a limited prognosis are a particular challenge, since communication about the disease situation and the expected therapeutic benefit is difficult not only for patients, but also for physicians. The aim of this study was therefore to compare the benefits expected of therapy by patients and physicians. Questionnaires were sent to 9,000 breast cancer patients and to 6,938 physicians. The questionnaires described 10 cases of breast cancer in the metastatic setting. The patients and physicians were asked to state the treatment benefit they would require to decide for the therapy options chemotherapy, endocrine therapy, antibody therapy, radiotherapy, and bisphosphonates. Additionally, the participants provided data on patient and physician characteristics. Expected treatment benefits were compared between patients and physicians, and influencing factors that modified the expected benefit were identified. Patients expected much greater benefits from the therapies offered than the physicians. For all treatment modalities, about 50 % or more of patients expected more than a 12-month increase in overall survival from all therapies. Among the doctors, this proportion ranged from 7 to 30 %. Among patients, previous experience of side effects and having young children in the family were the strongest influencing factors. Among the doctors, age and level of education had a strong influence on the expected prognostic improvement to indicate a therapy option. As expectations of treatment differ greatly between patients and doctors, a structured approach to solving this conflict is required. There appear to be some indicators that might help address the problem, such as the physicians' level of training and experience and the patients' specific social circumstances.

Mental adjustment to cancer and its relation to anxiety, depression, HRQL and survival in patients with laryngeal cancer - a longitudinal study

Background

Using a longitudinal design, aim of this study was to investigate the relation between mental adjustment to cancer and anxiety, depression, health-related quality of life (HRQL) and survival in patients treated for laryngeal cancer.

Methods

95 patients with Tis-T4 laryngeal cancer were assessed at one and 12 months after start of treatment, respectively, using the Mini-Mental Adjustment to Cancer Scale (Mini-MAC), the European Organisation for Research and Treatment of Cancer (EORTC) Study Group on Quality of Life core questionnaire (EORTC QLQ-C30) supplemented with the Head and Neck cancer module (QLQ-H&N35) and the Hospital Anxiety and Depression (HAD) Scale. For survival analyses patients were followed up for a median time of 4.22 years from inclusion.

Results

The most commonly used adjustment response at both occasions was Fighting Spirit. The use of adjustment responses was relatively stable over time. Correlation analyses showed that patients using Helpless-Hopeless and Anxious Preoccupation responses reported more anxiety and depression, as well as decreased HRQL. Tumour site and stage showed no effect on adjustment response. Survival analysis indicated that use of a Helpless-Hopeless response was related to poorer survival (HR 1.17, p 0.001).

Conclusion

The relation between adjustment responses Helpless-Hopeless and Anxious Preoccupation and anxiety, depression, HRQL and possibly poorer survival indicate that assessment of mental adjustment should be considered when planning treatment and rehabilitation in laryngeal cancer patients.

Assessing the information desire of patients with advanced cancer by providing information with a decision aid, which is evaluated in a randomized trial: a study protocol

Background

There is a continuing debate on the desirability of informing patients with cancer and thereby involving them in treatment decisions. On the one hand, information uptake may be hampered, and additional stress could be inflicted by involving these patients. On the other hand, even patients with advanced cancer desire information on risks and prognosis. To settle the debate, a decision aid will be developed and presented to patients with advanced disease at the point of decision making. The aid is used to assess the amount of information desired. Factors related to information desire are explored, as well as the ability of the medical oncologist to judge the patient's information desire. The effects of the information on patient well-being are assessed by comparing the decision aid group with a usual care group.

Methods/Design

This study is a randomized controlled trial of patients with advanced colorectal, breast, or ovarian cancer who have started treatment with first-line palliative chemotherapy. The trial will consist of 100 patients in the decision aid group and 70 patients in the usual care group. To collect complete data of 170 patients, 246 patients will be approached for the study. Patients will complete a baseline questionnaire on sociodemographic data, well-being measures, and psychological measures, believed to predict information desire. The medical oncologist will judge the patient's information desire. After disease progression is diagnosed, the medical oncologist offers the choice between second-line palliative chemotherapy plus best supportive care (BSC) and BSC alone. Randomization will take place to determine whether patients will receive usual care (n = 70) or usual care and the decision aid (n = 100). The aid offers information about the potential risks and benefits of both treatment options, in terms of adverse events, tumour response, and survival. Patients decide for each item whether they desire the information or not. Two follow-up questionnaires will evaluate the effect of the decision aid.

Discussion

This study attempts to settle the debate on the desirability of informing patients with cancer. In contrast to several earlier studies, we will actually deliver information on treatment options to patients at the point of decision making.

Trial registration

Netherlands Trial Register (NTR): NTR1113

Development of a Japanese Benefit Finding scale (JBFS) for patients with cancer

The primary aim of this study was to develop a scale to evaluate benefits for patients with cancer under treatment in Japan (the Japan Benefit Finding scale [JBFS]). The participants were 98 patients with cancer who completed the JBFS, which has 26 items, the General Health Questionnaire short version (GHQ 12). Factor analysis, structural equation modeling (SEM), and correlation analysis were performed. Three key domains were identified: ''Recognition of one's role in the family and priorities,'' ''Appreciation for life,'' and ''Faith.'' Validity was confirmed by SEM. There was a significant correlation between the JBFS and GHQ 12. The reliability and validity are adequate, and the JBFS shows that Japanese patients who found benefits in cancer were able to adjust to their disease.

A qualitative study of mindfulness-based meditation therapy in Japanese cancer patients

PURPOSE

The primary objective of the study was to examine mindfulness-based meditation therapy qualitatively. A secondary goal was to examine the differences in themes selected by Japanese and Western patients receiving this therapy.

METHODS

The subjects were 28 patients who were undergoing anti-cancer treatment. The subjects participated in two sessions of mindfulness-based meditation therapy, including breathing, yoga movement, and meditation. Each patient was taught the program in the first session, then exercised at home with a CD, and subsequently met the interviewer in a second session after 2 weeks. Primary physicians recruited the patients and interviews were conducted individually by nurses or psychologists with training in the program. Patients provided answers to pre- and post-intervention interviews about the meaning of their illness.

RESULTS

Narrative data from the semi-structured interview were analyzed qualitatively. Pre-intervention, themes such as "Effort to cope," "Looking back," "Spirituality," "Personal growth," and "Suffering" were often chosen. Post-intervention, themes such as "Adapted coping," "Personal growth," "Positive meaning," "Spirituality," and "Negative recognition" were more commonly chosen.

CONCLUSIONS

Mindfulness-based meditation therapy may be effective for producing adapted coping, including positive recognition and changes for an adapted lifestyle. There were some common aspects and some differences in the themes selected by patients in this study and Western patients received mindfulness therapy in other studies.

The opportunity for psychiatry in palliative care

The need for psychiatrists to work with patients and families living with chronic life-threatening illnesses has never been greater. Further, psychiatrists may find exciting work within the relatively new field of palliative care, which is devoted to the prevention and relief of all suffering. Increasingly, individuals are living longer with multiple issues that cause suffering, interfere with their lives, and often lead to psychosocial sequelae. To ensure state-of-the-art care for patients and families throughout an illness and any ensuing bereavement period, many experienced psychiatrists are needed as consultants to, and as members of, interdisciplinary palliative care teams. This need presents limitless opportunities for psychiatrists to care for patients, provide education, and engage in research. The potential to make a difference is great.

A non-randomized comparison of mindfulness-based stress reduction and healing arts programs for facilitating post-traumatic growth and spirituality in cancer outpatients

GOALS OF WORK

The aim of this study was to compare a mindfulness-based stress reduction (MBSR) program and a healing through the creative arts (HA) program on measures of post-traumatic growth (PTGI-R), spirituality (FACIT-Sp), stress (SOSI), and mood disturbance (POMS) in cancer patients.

MATERIALS AND METHODS

A sample of cancer outpatients (MBSR, n = 60; HA, n = 44) with a variety of diagnoses chose to attend either an 8-week MBSR program or a 6-week HA program and were assessed pre- and post-intervention. The majority of participants were female, married, and had breast cancer.

MAIN RESULTS

Repeated measures analysis of variance indicated that participants in both groups improved significantly over time on overall post-traumatic growth (p = 0.015). Participants in the MBSR group improved on measures of spirituality more than those in the HA group (p = 0.029). Participants in the MBSR group also showed more improvement than those in HA on measures of anxiety (POMS, p = 0.038), anger (POMS, p = 0.004), overall stress symptoms (SOSI, p = 0.041), and mood disturbance (POMS, p = 0.023). Several main effects of time were also observed in both groups. These results were found despite attrition in both groups.

CONCLUSIONS

Both programs may improve facilitation of positive growth after traumatic life experiences for those who choose to participate. MBSR may be more helpful than HA in enhancing spirituality and reducing stress, depression, and anger.

A non-randomized comparison of mindfulness-based stress reduction and healing arts programs for facilitating post-traumatic growth and spirituality in cancer outpatients

GOALS OF WORK

The aim of this study was to compare a mindfulness-based stress reduction (MBSR) program and a healing through the creative arts (HA) program on measures of post-traumatic growth (PTGI-R), spirituality (FACIT-Sp), stress (SOSI), and mood disturbance (POMS) in cancer patients.

MATERIALS AND METHODS

A sample of cancer outpatients (MBSR, n = 60; HA, n = 44) with a variety of diagnoses chose to attend either an 8-week MBSR program or a 6-week HA program and were assessed pre- and post-intervention. The majority of participants were female, married, and had breast cancer.

MAIN RESULTS

Repeated measures analysis of variance indicated that participants in both groups improved significantly over time on overall post-traumatic growth (p = 0.015). Participants in the MBSR group improved on measures of spirituality more than those in the HA group (p = 0.029). Participants in the MBSR group also showed more improvement than those in HA on measures of anxiety (POMS, p = 0.038), anger (POMS, p = 0.004), overall stress symptoms (SOSI, p = 0.041), and mood disturbance (POMS, p = 0.023). Several main effects of time were also observed in both groups. These results were found despite attrition in both groups.

CONCLUSIONS

Both programs may improve facilitation of positive growth after traumatic life experiences for those who choose to participate. MBSR may be more helpful than HA in enhancing spirituality and reducing stress, depression, and anger.

Cancer survival probability as a function of ego defense (adaptive) mechanisms versus depressive symptoms

Psychological treatment studies, uncontrolled for ego defense (adaptive) styles, report conflicting survival results. The authors hypothesized that "immature" adaptive styles and frequent depression symptoms would independently predict lower survival rates. This study followed 86 consecutive, mostly late-stage, cancer outpatients for up to 5 years; their survival data were analyzed in relation to the Beck Depression Inventory and the Defense Style Questionnaire scores at study entry. Cumulative survival probability curves contrasted the extreme cases: the most (N=15) to the least (N=21) depressed, and the "immature" (N=14) to the "mature" (N=16) adaptors. Depression did not separate the groups until 30 months after diagnosis. Ego defense style separated them at 8 months; by 18 months, the "immature" survival probability had dropped to 50%, versus 87% for the "mature." At 36 months, survival probabilities were 19% and 57%, respectively. These data direct clinical attention toward ego defense mechanisms as indicators of distress and lowered survival in cancer patients. They further suggest that the maturity of adaptive mechanisms must be controlled for in behavioral-treatment trials of cancer patients.

Illness-related problems and coping among persons with low-grade glioma

The literature reveals no qualitative study concerning the consequences of low-grade glioma in adults. The aim of the present study was to describe perceived illness-related problems in persons with low-grade glioma and the coping used in everyday living. The study was cross-sectional within a well-defined population. A semi-structured qualitative interview was conducted with each of 39 persons, and the data were subjected to inductive content analysis. There was a wide range of perceived problems, mainly concerning bodily functions, memory, cognition, emotion, communication and perception. Several coping strategies emerged, the most frequent being searching for a solution, which was often related to memory and communication problems. One characteristic of communication was the creation of new words. Other common strategies were refraining from and avoiding and laughing and joking. Caring about self involved prioritizing of personal needs. A striving to feel a sense of solidarity within seeking social affinity was coping with a novel content. The study provides vivid narratives about previously unreported phenomena, conveying a deeper understanding. The variety and endurance of problems revealed verifies the need of support from several professionals, including in the form of out-patient post-medical care.

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.

The mediating role of appraisal and coping in the relationship between optimism-pessimism and quality of life

Longitudinal data from 165 women diagnosed and treated for breast cancer were used to investigate if the relationship between optimism-pessimism and quality of life (QOL) is attributed to the appraisal and coping strategies. The women completed the Life Orientation Test-Revised (LOT-R), as a measurement of optimism-pessimism, the Mental Adjustment to Cancer (MAC) Scale, as a measure for coping, a VAS for appraisal and the EORTC QLQ-C30, as a measure for QOL at two time points: at diagnosis and 12-months after breast cancer surgery. Optimism-pessimism had both a direct and indirect influence on QOL. Two coping strategies were particularly strong mediators for the indirect influence: fighting spirit and hopeless/helpless. Optimists responded with fighting spirit, which had a positive effect on their QOL. On the other hand, pessimists responded with hopeless/helplessness, which had a negative effect on their QOL. The relationship between pessimism and QOL at time of diagnosis was also mediated by appraisal, such as threat. The two coping strategies remained fairly stable over the 12 months within the optimists and pessimists.The results suggest that the influence of optimism and pessimism on QOL appears to be mediated by coping both before and after treatment for breast cancer. Fighting spirit and hopeless/helplessness appear to reflect the characteristic coping strategies for optimists and pessimists.

Mood disturbance in community cancer support groups. The role of emotional suppression and fighting spirit

OBJECTIVE

In this cross-sectional study, we tested whether the coping styles of emotional suppression and fighting spirit were associated with mood disturbance in cancer patients participating in professionally led community-based support groups even when demographic, medical, and group support variables were taken into account.

METHODS

A heterogeneous sample of 121 cancer patients (71% female, 29% male) completed the Courtauld Emotional Control Scale (CECS), the Mini-Mental Adjustment to Cancer Scale (Mini-MAC), a measure of perceived group support, and the Profile of Mood States (POMS).

RESULTS

Consistent with hypotheses, lower emotional suppression and greater adoption of a fighting spirit, in addition to older age and higher income, were associated with lower mood disturbance. Gender, time since diagnosis, presence of metastatic disease, time in the support group, perceived group support, cognitive avoidance, and fatalism were unrelated to mood disturbance.

CONCLUSION

Expression of negative affect and an attitude of realistic optimism may enhance adjustment and reduce distress for cancer patients in support groups.

Cancer-related intrusive thoughts as an indicator of poor psychological adjustment at 3 or more years after breast surgery: a preliminary study

Intrusive thoughts are one of the re-experiencing symptoms in posttraumatic stress disorder, and have been suggested as a predictor for the continuous presence of psychological distress in cancer survivors. The aim of this preliminary study was to examine the possibility of using cancer-related intrusive thoughts (CITs) as an indicator of psychological distress and adjustment after breast surgery. A consecutive series of ambulatory breast cancer survivors at 3 or more years after surgery were given the Structured Clinical Interview for DSM-IV (SCID) and self-report questionnaires, including Profile Of Mood States (POMS), Impact of Event Scale (IES) and Mental Adjustment to Cancer (MAC) scale, to measure psychological distress and/or adjustment. The SCID identified a history of CITs in 34 (46%) of the 74 participants. No significant differences were found in the POMS and IES psychological distress scores between subjects with and without a history of CITs. Subjects with a history of CITs showed significantly higher levels of anxious preoccupation, one of the MAC subscale scores. The association continued to be significant after controlling for potential confounders such as social support, depression, avoidance, arousal, and neuroticism. The results indicated that CITs might be useful for indicating poor psychological adjustment, but not distress, in patients at 3 or more years after breast surgery.

Facing a prostate cancer diagnosis: who is at risk for increased distress?

BACKGROUND

The psychological adaptation to a cancer diagnosis is characterized by significant distress. Although distress levels in cancer patients have been reported to be the highest shortly after diagnosis and before treatment, few attempts have been made to study emotional adjustment during the diagnostic period of prostate cancer patients. This study's purpose was to determine whether differences in distress levels can be attributed to differences in diagnostic status, optimism, and/or coping strategies.

METHODS

This study followed patients across 4 weeks, from prebiopsy to 2 weeks postdiagnosis, using these two time points as measurements. Data were collected between 1995 and 1998 at the Miami and Palo Alto VA Medical Center urology clinics. Biopsies were performed on 101 men (ages 46-87) to determine whether prostate cancer was present. These men completed prebiopsy and postdiagnosis questionnaires.

RESULTS

Of optimism, coping, and cancer status, the only significant predictor of increased distress at postdiagnosis was dispositional avoidance at prebiopsy for both cancer and noncancer groups.

CONCLUSIONS

Although these findings complement other studies linking avoidance with increased distress, the similarities between the cancer and noncancer groups underscore the need to consider both of these groups during the first few weeks of the prostate cancer diagnostic process.

Psychological distress in cancer patients: hypothesis of a distress model

A substantial body of research suggests links between stress, coping and cancer. Research also implicates the immune system as a link between stressful events and cancer. The current trend in research in the area of psycho-oncology attempts to define the types of stress and coping mechanisms being used in order to identify predictors of psychological distress. Based on the available review of literature, the impact of distress does seem to play a prominent role in the transition from a state of health to that of ill-health or even a terminal event. In the light of these studies, a distress model for the cancer patient has been hypothesized here.

Daily assessment of coping in patients with gastrointestinal cancer

Ninety-five patients with gastrointestinal (GI) cancer participated in a study concerning stressful events, coping and emotional well-being. Participants were either potentially cured (n=62) after radical surgery or non-cured (n=33). For a period of 1 week, close to being informed about their diagnosis, they performed daily recordings of stressful events, the distress occasioned by these events and their perception of control over them, coping, worry and happiness/sadness. Anxiety and depression were assessed by a single retrospective assessment at the end of the week (Hospital Anxiety and Depression (HAD) scale). The most commonly recorded stressful events were 'Somatic aspects' and 'Everyday concerns'. 'Somatic aspects', 'Social aspects' and 'Other consequences of the disease' were rated as most bothersome. Patients perceived that they had the highest degree of control over 'Returning home after hospital stay', whereas 'Contact with the medical services' was assigned low control. The most commonly used coping strategies were 'Acceptance' and 'Relaxation', and the least used was 'Religion'. Significant positive correlations between the occurrence of stressful events and the use of coping strategies were demonstrated between 'Somatic Aspects' and 'Acceptance'/'Direct Action', and between 'Social Aspects' and 'Seeking Social Support'. Daily assessment of stress-coping relationships represents a promising approach to the understanding of adaptation among cancer patients.

Psychiatric disorders and associated and predictive factors in patients with unresectable nonsmall cell lung carcinoma: a longitudinal study

BACKGROUND

Few longitudinal studies have investigated psychiatric disorders in patients with unresectable nonsmall cell lung carcinoma (NSCLC). This study addressed three questions: 1) Which psychiatric disorders are prevalent among patients with unresectable NSCLC? 2) What is the clinical course of psychological distress? 3) Which factors are associated with this distress, and do any antecedent variables predict subsequent psychological distress?

METHODS

A series of 129 consecutive patients with newly diagnosed, unresectable NSCLC participated. Psychiatric assessments were conducted by using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition revised between the time of diagnosis and initial treatment for NSCLC (baseline) and 6 months after diagnosis (follow-up). Potential associated and predictive variables, including sociodemographic, biomedical, and psychosocial factors, were explored.

RESULTS

The most common psychiatric disorder at baseline was nicotine dependence (67%), followed by adjustment disorders (14%), alcohol dependence (13%), and major depression (5%). At follow-up, adjustment disorders were diagnosed in 16% of patients, and major depression was diagnosed in 3% of patients. Thirty-five percent of patients who experienced depressive disorders (adjustment disorders and/or major depression) at baseline continued to experience the same disorders at follow-up. Multivariate analysis revealed that relatively younger age and pain were associated significantly with psychological distress at baseline. Only self-reported anxiety and depression at baseline could predict subsequent psychological distress.

CONCLUSIONS

Substance dependence and depressive disorders are common psychiatric disorders in patients with unresectable NSCLC. Although this form of malignant disease often is progressive, depressive disorders do not seem to increase during its clinical course. Pain management is essential for alleviating patients' depressive disorders, and self-rating depression and anxiety seems to be an indicator of subsequent depressive disorders.

Discrepancies between attainment and importance of life values and anxiety and depression in gastrointestinal cancer patients and their spouses

Patients' satisfaction with life, viewed in terms of the discrepancy between the perceived attainment and subjective importance of various life values, is a less often studied phenomenon for understanding the psychological adaptation in cancer patients. The main aim of the present study is to investigate the relation between the degree of attainment and importance of life values on the one hand, and anxiety and depression, on the other. A consecutive series of 85 newly diagnosed patients with gastrointestinal (GI) cancers, 52 potentially cured and 33 with an advanced disease, and 26 spouses to the patients with an advanced disease participated. The patients and spouses of non-cured patients filled out questionnaires twice, close to the diagnosis and after 1 (non-cured patients) or 3 months. Overall, large discrepancies between the perceived attainment and importance of life values were associated with high anxiety and depression. For the patients (both cured and non-cured), the discrepancies decreased for several life values over time, as did anxiety and depression. For the spouses of the non-cured patients, there was no decrease either for life value discrepancies or for anxiety/depression. This suggests that patients, in contrast to their spouses, strive to achieve small discrepancies between the perceived attainment and importance of life values, as part of their adjustment to serious diseases, e.g. cancer.

Physician support and patient psychologic responses after surgery for nonsmall cell lung carcinoma: a prospective observational study

BACKGROUND

In patients with cancer, depression and coping have been suggested to be important psychologic responses that may be associated with quality of life. Social support, especially from physicians, is considered important for cancer patients during their illness. The authors have investigated the impact of physician support on psychologic responses, including depression, psychologic distress and coping (such as fighting spirit and helplessness/hopelessness) in a cohort of patients with early-stage lung carcinoma.

METHODS

After curative resection for nonsmall cell lung carcinoma, 226 patients were enrolled in a longitudinal study. The extent of social support, including physician support, was measured in structured interviews conducted 1 and 3 months after surgery. During the interviews, psychologic responses were measured using the Structured Clinical Interview for DSM-III-R, the Profiles of Mood States, and the Mental Adjustment to Cancer scale. Univariate and multivariate analyses were used to examine the impact of physician support on psychologic responses.

RESULTS

Physician support had no effect on depression, but correlated negatively with psychologic distress (P < 0.05) and helplessness/hopelessness (P < 0.05), and positively with fighting spirit (P < 0.01). Multivariate analyses controlling for confounding biomedical and psychosocial variables revealed only physician support had a significant impact on fighting spirit, independently. However, this effect was limited to female patients or patients with no history of depression.

CONCLUSION

In postoperative patients with nonsmall cell lung carcinoma, physician support may have a significant impact on fighting spirit, but this effect appears to be limited to female patients or patients with no history of depression.

Mental adjustment to first recurrence and correlated factors in patients with breast cancer

Previous reports have demonstrated that breast cancer patients felt that news of their recurrence was more upsetting than their initial diagnosis. However, no studies have examined the factors that are correlated with mental adjustment in breast cancer patients who experienced recurrence. The authors investigated factors that are correlated with mental adjustment styles of fighting spirit or helplessness/hopelessness in women with breast cancer with a first recurrence. Fifty-five participants were interviewed and completed the Mental Adjustment to Cancer scale. Factors that correlated significantly with fighting spirit were performance status and history of major depression, while factors that correlated significantly with helplessness/hopelessness were age, pain, and history of major depression. These findings suggest that it is necessary to provide intervention for first recurrent breast cancer patients who have such biomedical factors, as young age, poor performance status, pain, and history of major depression to help them better cope with cancer.

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

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

Resource use in women completing treatment for breast cancer

OBJECTIVE

To explore resources used by women completing treatment for breast cancer, how they learned about them, and the psychological factors that predicted their use.

DESIGN

A questionnaire on resource use was administered as part of a randomized clinical trial which assessed subjects' psychosocial characteristics and tested the outcomes of a psychosocial intervention.

SETTING

Women completing treatment for breast cancer were recruited from the oncology departments of three university-teaching hospitals in Montreal. A questionnaire gathered data on the resources used by the subjects, how they learned about them, and the role of the health care team in their decision-making. Emotional distress, dimensions of coping effort, a sense of control and optimism were also measured.

RESULTS

Five categories of resources were explored; professional services, informal support networks, informational resources, support organizations and complementary therapies. Most women found out about the last two resources by themselves. Women who used cancer support organizations or complementary therapies scored high on the use of problem-solving coping and low on the use of escape/avoidance coping. In addition they were moderately optimistic, had a slightly lower sense of personal control and were somewhat more distressed than the non-users. The use of support organizations and complementary therapies appears to represent a thoughtful approach to dealing with the distress of cancer. The opinion of the oncologist regarding resource use was valued by nearly half of the sample.

Coping with new treatments for cancer: a feasibility study of daily diary measures

This article describes a study of the feasibility and value of using daily diary measures to assess coping, adjustment and symptoms in patients participating in phase I clinical trials of new anticancer drugs. Ten patients (six women, four men) with advanced metastatic cancer were studied during a four-week phase I trial. Measures of psychological well-being, mental adjustment and symptoms were determined prior to treatment, and participants also completed daily ratings of psychological coping responses, mood and symptoms. Completion rates for diaries were high, and the amount of missing data averaged only 3.2% per patient. Overall, the most frequently endorsed coping responses were 'acceptance' and 'positive reinterpretation and growth'. There were systematic variations in coping by seeking social support across the trial, with more frequent use during phases of hospitalisation. Idiosyncratic fluctuations in patterns of coping were also observed. Positive daily mood was greater among patients who coped by ignoring their condition, and was also correlated with fighting spirit. Daily symptoms were inversely associated with positive mood and with fighting spirit. It is concluded that the daily diary approach is feasible, and may help to increase understanding of the experience of patients taking part in experimental anticancer drug trials.

Correlates of depressed mood in ambulatory head and neck cancer patients

High levels of psychological distress, especially depressed mood, has been discussed in relation to head and neck cancer. Patients with head and neck cancer face functional impairment and disfigurement caused by cancer and/or its treatment. Psychosocial factors that predict depressed mood in this population have not been well elucidated. The aim of this study is to examine the psychosocial and medical risk factors for depressed mood in ambulatory head and neck cancer patients. Depressed mood and coping style were assessed with the Profile of Mood States (POMS) and the Mental Adjustment to Cancer (MAC) scales, respectively, in 99 ambulatory head and neck cancer patients. Simultaneously, patients' social support and satisfaction with it, and sociodemographic and medical data were obtained. Multiple regression analysis revealed that advanced disease, being unmarried, and helpless/hopeless coping were significantly associated with depressed mood. The results suggest that we should identify these factors and target psychosocial intervention for those patients most at risk.

The Mental Adjustment to Cancer Scale--a psychometric analysis and the concept of coping

A psychometric analysis of the Mental Adjustment to Cancer (MAC) scale was performed in a heterogeneous Swedish sample of cancer patients (n = 868). The homogeneity of the original subscales proved to be satisfactory (alpha coefficients 0.61-0.81). The sample was randomly split into two subgroups, and a factor analysis was carried out in one of them using the LISREL 8.20 procedure. This yielded four factors called 'Hopeless', 'Positive', 'Anxious' and 'Avoidant' including 28 of the 40 original items (alpha coefficients 0.58-0.81). The novel factor structure was cross-validated and confirmed in the second subgroup. In contrast to the original scale (one item), 'Avoidance', was indexed by three items. The distinction between mental adjustment and coping is discussed. It is concluded that both versions of the MAC scale are measures of mental adjustment including emotional reactions as well as coping.

Reactions to gastrointestinal cancer--variation in mental adjustment and emotional well-being over time in patients with different prognoses

The relation between mental adjustment, often referred to as coping strategies, and emotional well-being and their changes over time were studied in 139 consecutive, newly diagnosed gastrointestinal cancer patients. Sixty-six patients were potentially cured since all known disease could be removed by surgery, whereas in 73 patients, this was not possible. A more confronting reaction to the diagnosis was associated with better emotional well-being whereas avoidance of reminders of, and intrusive thoughts about the disease were associated with more distress. In agreement with other studies, we found that the coping strategy 'Fighting Spirit' was associated with better emotional well-being while the reverse was true for the strategies 'Hopeless/Helplessness' and 'Anxious Preoccupation'. There were only minor changes over time in the average values of emotional well-being and coping strategies, particularly among patients who at diagnosis were considered incurable. In analyses of each individual's changes of predominant coping style and whether they were categorized as cases/doubtful cases on the HAD anxiety and depression scale, marked changes were, however, seen in several patients. The analyses of mean values give an impression of stability, whereas analyses of the number of patients with a specific predominant coping strategy and how they change, give another. The question of whether coping strategies and emotional well-being change through the course of the disease has no simple and obvious answer. Whether some of the investigated coping strategies should be conceptualized in terms of coping, or whether they are an outcome of the coping efforts, are discussed.

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

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

Psychological reactions in newly diagnosed gastrointestinal cancer patients

Reactions to diagnosis, coping strategies, and anxiety and depression were prospectively studied in 139 consecutive, newly diagnosed gastrointestinal cancer patients. The reactions varied between diagnoses (colon, rectum, gastric, pancreatic and biliary) and states of illness (cured non-cured). Colon and rectal cancer patients, most of whom were potentially cured, had a more confrontational attitude towards their diagnosis, reported more 'Fighting Spirit' and less 'Anxious Preoccupation' and 'Hopeless/Helplessness'. Non-cured patients reported higher levels of intrusive thoughts and avoidance of aversive thoughts than cured patients. The overall levels of anxiety and depression were low, although higher levels were seen for non-cured patients. On the Hospital Anxiety and Depression scale (HAD), a total of 17% were scored as 'doubtful cases' or 'cases' on the anxiety scale and 21% on the depression scale. Thus, pancreatic/biliary cancer patients, most of which are non-cured, and to some extent those with gastric cancer are more vulnerable to psychological distress in connection with the diagnosis than are colorectal cancer patients.

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

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

Coping with illness-related problems and quality of life in adult individuals with muscular dystrophy

Illness-related problems and coping were examined in 60 individuals with muscular dystrophy (MD) identified in a population survey of the county of Orebro, Sweden. In addition, the extent to which coping is related to quality of life (QoL) was investigated as was the impact of impairment and disability on the relation between coping and QoL. Emotion/appraisal-focused coping was utilized by respondents more than twice as often as problem-focused coping. High QoL was significantly correlated to "Stoic acceptance" and "Tried alternative treatment." Low QoL was associated with "Helpless/hopeless," "Anxious preoccupation," "Minimization," "Social comparison," "Establishment of control over everyday life," "Performs the task with the aid of an appliance" and "Accepts help or leaves it to others." When measures of impairment and disability were included in the analysis, the impact of these measures explained the association between coping and physical QoL by 16% to 43%.

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

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