Barbara L. Andersen

Psychological, Behavioral, and Immune Changes After a Psychological Intervention: A Clinical Trial

PURPOSE This randomized clinical trial tests the hypothesis that a psychological intervention can reduce emotional distress, improve health behaviors and dose-intensity, and enhance immune responses. PATIENTS AND METHODS We studied 227 women who were surgically treated for regional breast cancer. Before adjuvant therapy, women completed interviews and questionnaires assessing emotional distress, social adjustment, and health behaviors. A 60-mL blood sample was drawn for immune assays. Patients were randomly assigned to either the intervention group or assessment only group. The intervention was conducted in small patient groups, with one session per week for 4 months. The sessions included strategies to reduce stress, improve mood, alter health behaviors, and maintain adherence to cancer treatment and care. Reassessment occurred after completion of the intervention. RESULTS As predicted, patients receiving the intervention showed significant lowering of anxiety, improvements in perceived social support, improved dietary habits, and reduction in smoking (all P <.05). Analyses of adjuvant chemotherapy dose-intensity revealed significantly more variability (ie, more dispersion in the dose-intensity values) for the assessment arm (P <.05). Immune responses for the intervention patients paralleled their psychological and behavioral improvements. T-cell proliferation in response to phytohemagglutinin and concanavalin A remained stable or increased for the Intervention patients, whereas both responses declined for Assessment patients; this effect was replicated across three concentrations for each assay (all P <.01). CONCLUSION These data show a convergence of significant psychological, health behavior, and biologic effects after a psychological intervention for cancer patients.

Psychologic Intervention Improves Survival for Breast Cancer Patients A Randomized Clinical Trial

The question of whether stress poses a risk for cancer progression has been difficult to answer. A randomized clinical trial tested the hypothesis that cancer patients coping with their recent diagnosis but receiving a psychologic intervention would have improved survival compared with patients who were only assessed.

Screening, Assessment, and Care of Anxiety and Depressive Symptoms in Adults With Cancer: An American Society of Clinical Oncology Guideline Adaptation

PURPOSE A Pan-Canadian Practice Guideline on Screening, Assessment, and Care of Psychosocial Distress (Depression, Anxiety) in Adults With Cancer was identified for adaptation. METHODS American Society of Clinical Oncology (ASCO) has a policy and set of procedures for adapting clinical practice guidelines developed by other organizations. The guideline was reviewed for developmental rigor and content applicability. RESULTS On the basis of content review of the pan-Canadian guideline, the ASCO panel agreed that, in general, the recommendations were clear, thorough, based on the most relevant scientific evidence, and presented options that will be acceptable to patients. However, for some topics addressed in the pan-Canadian guideline, the ASCO panel formulated a set of adapted recommendations based on local context and practice beliefs of the ad hoc panel members. It is recommended that all patients with cancer be evaluated for symptoms of depression and anxiety at periodic times across the trajectory of care. Assessment should be performed using validated, published measures and procedures. Depending on levels of symptoms and supplementary information, differing treatment pathways are recommended. Failure to identify and treat anxiety and depression increases the risk for poor quality of life and potential disease-related morbidity and mortality. This guideline adaptation is part of a larger survivorship guideline series. CONCLUSION Although clinicians may not be able to prevent some of the chronic or late medical effects of cancer, they have a vital role in mitigating the negative emotional and behavioral sequelae. Recognizing and treating effectively those who manifest symptoms of anxiety or depression will reduce the human cost of cancer.

Traumatic Stress, Perceived Global Stress, and Life Events: Prospectively Predicting Quality of Life in Breast Cancer Patients.

The authors investigated the relationship between stress at initial cancer diagnosis and treatment and subsequent quality of life (QoL). Women (n = 112) randomized to the assessment-only arm of a clinical trial were initially assessed after breast cancer diagnosis and surgery and then reassessed at 4 months (during adjuvant treatment) and 12 months (postadjuvant treatment). There were 3 types of stress measured: number of stressful life events (K. A. Matthews et al., 1997), cancer-related traumatic stress symptoms (M. J. Horowitz, N. Wilner, & W. Alvarez, 1979), and perceived global stress (S. Cohen, T. Kamarck, & R. Mermelstein, 1983). Using hierarchical multiple regressions, the authors found that stress predicted both psychological and physical QoL (J. E. Ware, K. K. Snow, & M. Kosinski, 2000) at the follow-ups (all ps < .03). These findings substantiate the relationship between initial stress and later QoL and underscore the need for timely psychological intervention.

Strategies Used in Coping With a Cancer Diagnosis Predict Meaning in Life for Survivors

The search for meaning in life is part of the human experience. A negative life event may threaten perceptions about meaning in life, such as the benevolence of the world and ones sense of harmony and peace. The authors examined the longitudinal relationship between womens coping with a diagnosis of breast cancer and their self-reported meaning in life 2 years later. Multiple regression analyses revealed that positive strategies for coping predicted significant variance in the sense of meaning in life--feelings of inner peace, satisfaction with ones current life and the future, and spirituality and faith--and the absence of such strategies predicted reports of loss of meaning and confusion (ps < .01). The importance and process of finding meaning in the context of a life stressor are discussed.

The Pain, Depression, and Fatigue Symptom Cluster in Advanced Breast Cancer: Covariation with the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system

OBJECTIVE Neuroendocrine-immune models have been proposed to account for the frequent co-occurrence of pain, depression, and fatigue (PDF) among cancer patients. DESIGN In a cross-sectional observational study of advanced cancer patients (N = 104), we tested the hypothesis that the PDF cluster covaries with proposed biological mediators: hormones of the sympathetic nervous system (SNS) and the hypothalamic-pituitary-adrenal (HPA) axis. MAIN OUTCOME MEASURES PDF symptoms were measured using the Brief Pain Inventory, Fatigue Symptom Inventory, and the Center for Epidemiological Studies Depression scales. HPA activation was indicated by plasma levels of cortisol and adrenocorticotropic hormone, and SNS activation was indicated by plasma epinephrine and norepinephrine. RESULTS Preliminary analyses supported the use of covariance structure modeling to test whether shared variance among hormone levels predicted shared variance among PDF symptoms. Latent variable analysis indicated that neuroendocrine levels predicted PDF (standardized beta = .23, p = .039), while controlling for important disease and demographic variables. CONCLUSION Previous studies have linked individual symptoms to individual biomarkers. The observed significant paring of the 4 hormones to the PDF cluster provides the first evidence suggestive of stress hormones as a common mechanism for the co-occurrence of pain, depression, and fatigue symptoms.

PTSD diagnoses, subsyndromal symptoms, and comorbidities contribute to impairments for breast cancer survivors†

The clinical importance of posttraumatic stress disorder (PTSD) symptomatology for cancer patients is unclear. The association between the magnitude of cancer-related PTSD symptoms, comorbidity, and functioning is tested. Breast cancer patients (N = 74) were assessed at diagnosis/surgery, followed, and screened for cancer-related PTSD 18 months later. Participants then completed diagnostic interviews and PTSD (n = 12), subsyndromal PTSD (n = 5), and no symptom (n = 47) patient groups were identified. Posttraumatic stress disorder cases were distinguished by having experienced violent traumas and anxiety disorders predating cancer, whereas subsyndromal cases were not. Also, longitudinal data show that PTSD covarys with poorer functioning and lower quality of life among breast cancer survivors. Both PTSD and subsyndromal PTSD were associated with employment absenteeism and the seeking of mental health services.

A Psychological Intervention Reduces Inflammatory Markers by Alleviating Depressive Symptoms: Secondary Analysis of a Randomized Controlled Trial

Objectives: To test experimentally whether a psychological intervention reduces depression-related symptoms and markers of inflammation among cancer patients and to test one mechanism for the intervention effects. Depression and inflammation are common among cancer patients. Data suggest that inflammation can contribute to depressive symptoms, although the converse remains untested. Methods: As part of a randomized clinical trial, newly diagnosed breast cancer patients (n = 45) with clinically significant depressive symptoms were evaluated and randomized to psychological intervention with assessment or assessment only study arms. The intervention spanned 12 months, with assessments at baseline, 4, 8, and 12 months. Mixed-effects modeling tested the hypothesis that the intervention reduced self-reported depressive symptoms (Center for Epidemiological Studies Depression scale, Profile of Mood States Depression and Fatigue subscales, and Medical Outcomes Study-Short Form 36 Bodily Pain subscale) and immune cell numbers that are elevated in the presence of inflammation (white blood cell count, neutrophil count, and helper/suppressor ratio). Mediation analyses tested whether change in depressive symptoms, pain, or fatigue predicted change in white blood cell count, neutrophil count, or the helper/suppressor ratio. Results: The intervention reduced significantly depressive symptoms, pain, fatigue, and inflammation markers. Moreover, the intervention effect on inflammation was mediated by its effect on depressive symptoms. Conclusions: This is the first experiment to test whether psychological treatment effective in reducing depressive symptoms would also reduce indicators of inflammation. Data show that the intervention reduced directly depressive symptoms and reduced indirectly inflammation. Psychological treatment may treat effectively depressive symptoms, pain, and fatigue among cancer patients. CES-D = Center for Epidemiological Studies-Depression scale, Iowa short form; SF-36 = Medical Outcomes Study-Short Form 36; KPS = Karnofsky Performance Status.

Assessing Stress in Cancer Patients A Second-Order Factor Analysis Model for the Perceived Stress Scale

Using the Perceived Stress Scale (PSS), perceptions of global stress were assessed in 111women following breast cancer surgery and at 12 and 24 months later. This is the first study to factor analyze the PSS. The PSS data were factor analyzed each time using exploratory factor analysis with oblique direct quartimin rotation. Goodness-of-fit indices (root mean square error of approximation [RMSEA]), magnitude and pattern of factor loadings, and confidence interval data revealed a two-factor solution of positive versus negative stress items. The findings, replicated across time, also indicate factor stability. Hierarchical factor analyses supported a second-order factor of “perceived stress.” This alternative factor model of the PSS is presented along with observations regarding the measure’s use in cancer research.

Is there a reliable and valid self-report measure of sexual behavior?

A psychometric analysis of the Sexual Experience Scale (SES) from the Derogatis Sexual Functioning Inventory was conducted. This sexual behavior measure was administered on four occasions to a large sample of normal, heterosexual, sexually active women and a comparable sample which underwent gynecologic treatment that resulted in a predictable and clinical level of sexual dysfunction. In terms of reliability, internal consistency estimates for the SES were in the .85 to .90 range, but the stability of the SES was lower and ranged from .55 to .85. An evaluation of the validity revealed both strengths and limitations of the SES. The content analysis reveals that a wider range of sexual behaviors is sampled by the SES than comparable measures. To examine construct validity, a factor analysis provided a five-factor solution which would account for 82% of the variance, but the solution was not stable across groups or time and the factors were not sensitive to detecting important behavior changes. As many other psychological measures, the SES was poor in predicting a criterion (i.e., the occurrence of sexual dysfunction) concurrently or at the time of follow-up. The outcome of this analysis is discussed in the context of selecting reliable and valid self-report measures of sexual behavior.