Influence of psychological response on survival in breast cancer: a population-based cohort study

Abstract

S u m m a r y B a c k g r o u n d The psychological response to breast cancer, such as a fighting spirit or an attitude of helplessness and hopelessness toward the disease, has been suggested as a prognostic factor with an influence on survival. We have investigated the effect of psychological response on disease outcome in a large cohort of women with early-stage breast c a n c e r . M e t h o d s 578 women with early-stage breast cancer were enrolled in a prospective survival study. Psychological response was measured by the mental adjustment to cancer (MAC) scale, the Courtauld emotional control (CEC) scale, and the hospital anxiety and depression (HAD) scale 4-12 weeks and 12 months after diagnosis. The women were followed up for at least 5 years. Cox's proportional-hazards regression was used to obtain the hazard ratios for the measures of psychological response, with adjustment for known clinical factors associated with survival. F i n d i n g s At 5 years, 395 women were alive and without relapse, 50 were alive with relapse, and 133 had died. There was a significantly increased risk of death from all causes by 5 years in women with a high score on the HAD scale category of depression (hazard ratio 3·59 [95% CI 1·39-9·24]). There was a significantly increased risk of relapse or death at 5 years in women with high scores on the helplessness and hopelessness category of the MAC scale compared with those with a low score in this category (1·55 [1·07-2·25]). There were no significant results found for the category of "fighting s p i r i t " . I n t e r p r e t a t i o n For 5-year event-free survival a high helplessness/hopelessness score has a moderate but detrimental effect. A high score for depression is linked to a significantly reduced chance of survival; however, this result is based on a small number of patients and should be interpreted with caution. I n t r o d u c t i o nThere have been many suggestions of a role for psychological response in the outcome of cancer, but little scientific evidence. A few studies examined the influence of psychiatric symptoms on disease outcome in patients with breast cancer. The presence of psychiatric symptoms, including emotional distress, was significantly related to poorer prognosis in two studies, 1 , 2 whereas three found no relation between psychiatric symptoms and disease o u t c o m e . 3 -5 These studies were limited by their small sample size (most had fewer than 200 patients) or short period of follow-up, so reliable assessment of the effect of psychological response in women with early-stage breast cancer is difficult.A few studies suggested that women who develop breast cancer may be more likely than those who do not to suppress negative emotions 6 -8 -the type C personality. Subsequent research suggested a cancer-prone personality type characterised by abnormal inhibition of emotions and inability to express anger. 9 Despite flimsy evidence for the cancer-prone personality, this research has been enthusiastically received by the lay press and by practit...

Baseline psychosocial predictors of survival in localised breast cancer

“…As in previous research, we identified only one protective psychological factor, a coping pattern Distancing, which is close to minimising (see footnote c). Denying or minimising the fact of having the cancer has long been suggested to be a predictor of a favourable cancer prognosis (Greer et al, 1979(Greer et al, , 1990Butow et al, 1999;Watson et al, 1999;Butow et al, 2000;Petticrew et al, 2002;Garssen, 2004;Lehto et al, 2006). Minimising the impact of the diagnosis is milder and nowadays a more realistic form of denial (Garssen, 2004).…”

“…The impact of psychosocial factors on cancer progression has been investigated in a number of studies (Greer et al, 1979(Greer et al, , 1990Pettingale et al, 1985;Gross, 1989;Spiegel et al, 1989;Forsen, 1991;Barraclough et al, 1992;Blanchard et al, 1995;Maunsell et al, 1995;Dolbeaut et al, 1999;Watson et al, 1999;Butow et al, 2000;Reynolds et al, 2000;Spiegel, 2001;Petticrew et al, 2002;Garssen, 2004) and many of these have dealt with breast cancer (Greer et al, 1979(Greer et al, , 1990Pettingale et al, 1985;Spiegel et al, 1989;Forsen, 1991;Barraclough et al, 1992;Maunsell et al, 1995;Watson et al, 1999;Butow et al, 2000;Reynolds et al, 2000;Garssen, 2004). However, the contributing factors are uncertain, and there is also a lack of understanding of the psychological processes and the psychobiological mechanisms involved (Garssen and Goodkin, 1999).…”

“…Current research suggests that the most important psychosocial risk factors in cancer progression may include nonexpression of negative emotions (Garssen and Goodkin, 1999;Reynolds et al, 2000;Garssen, 2004) and helplessness/depression (Watson et al, 1999), and that life stresses (stressful life events) and low levels of social support may also have an effect (Maunsell et al, 1995;Garssen and Goodkin, 1999;Garssen, 2004). Favourable prognoses seem to be predicted by a response pattern of denying and/or minimising the fact of having cancer (Butow et al, 1999Garssen, 2004).…”

“…Favourable prognoses seem to be predicted by a response pattern of denying and/or minimising the fact of having cancer (Butow et al, 1999Garssen, 2004). Classical findings concerning concepts like fighting spirit, stoic acceptance, or fatalism (Greer et al, 1979;Pettingale et al, 1985) have not been replicated in recent studies (Watson et al, 1999;Petticrew et al, 2002;Garssen, 2004). Psychosocial interventions are thought to have an effect on the mediating psychosocial factors and the well-being and survival outcomes (Fawzy et al, 1993;Dolbeaut et al, 1999;Fawzy, 1999).…”

Increased risk of severe depression in male partners of women with breast cancer

“…1,2 In response, various supportive psychosocial intervention strategies have been designed, tailored to the problems that cancer patients face during the course of their disease. [3][4][5][6] The extent to which cancer affects not only patients but also their closest relatives was first addressed in a seminal article published more than 20 years ago, in which House et al illustrated how several diseases can influence people close to the patient. 7 The mechanism of this effect may involve several interacting pathways: the event may cause stress in the partner; it might deprive the partner of emotional, social, and economic support; and it can influence the daily life and behavior of the partner.…”