Psychosocial factors in the development and progression of breast cancer

The impact of personality on the risk and survival of breast cancer: a Mendelian randomization analysis

BACKGROUND

It has long been hypothesized that personality plays a causative role in incidence and outcome of breast cancer (BC), but epidemiological evidence of association between personality and BC is inconsistent.

METHOD

We used two-sample Mendelian randomization analysis to estimate the impact of personality on the risk and survival of BC. In total, 109 single nucleotide polymorphisms (SNPs) were utilized as instruments of neuroticism from a large-scale Genome-Wide Association Studies (GWAS), and five SNPs were utilized as instruments of extraversion from Genetic of Personality Consortium and 23andMe. Genetic association with the risk and survival of overall and individual subtype BC were obtained from the Breast Cancer Association Consortium.

RESULT

Neuroticism is significantly associated with the risk of overall BC [odds ratio (OR) 1.06; 95% confidence interval (CI) 1.01-1.11; p = 0.015] and the risk of luminal A BC (OR 1.09; 95% CI 1.03-1.16; p = 0.004). Extraversion is not associated with the risk of BC. None of neuroticism or extraversion is associated with the survival of BC.

CONCLUSION

Neuroticism was associated with a modest increased risk of BC and particularly luminal A BC.

Prevalence of depression, trait anxiety, and social support during the diagnostic phases of breast cancer

Objective

This study aims to determine the prevalence of depression, trait anxiety, and social support among women suspected of breast cancer (BC) and to investigate the association of these factors with the diagnosis of BC.

Methods

A cross-sectional study was conducted on 745 women who presented with breast symptoms in a university breast clinic in Malaysia. Participants were instructed to respond to self-report questionnaires on depression, trait anxiety, and social support while they were waiting for assessment of their suspected BC. The final diagnoses of these patients were traced one month after examining their medical records. Descriptive statistics were performed to examine the socio-demographic and clinical characteristics of all participants. A multiple regression analysis was carried out to determine the association of the abovementioned factors with the diagnosis of BC.

Results

The analysis showed that BC was diagnosed in 109 (14.6%), benign breast disease (BBD) in 550 (73.8%), and healthy breast (HB) in 86 (11.5%) women. The prevalence of depression was 53.2% in women with BC, 53.6% in women with BBD, and 60.5% in women with HB prior to diagnosis. The prevalence of trait anxiety was 33%. Mean scores for trait anxiety were 42.2 ± 9.0 and 41.8 ± 9.1 for the BC group and BBD group, respectively. The level of perceived social support was similar in all three groups.

Conclusion

We found no significant difference in depression, trait anxiety, and social support among women with newly diagnosed BC, BBD, and HB in women with breast symptoms while undergoing diagnostic evaluation. A longitudinal study is essential to establish the association between chronic mental stress and BC.

Chronic Isolation Stress Affects Central Neuroendocrine Signaling Leading to a Metabolically Active Microenvironment in a Mouse Model of Breast Cancer

Social isolation is a powerful stressor capable of affecting brain plasticity and function. In the case of breast cancer, previous data indicate that stressful experiences may contribute to a worse prognosis, activating neuroendocrine and metabolism pathways, although the mechanisms underlying these effects are still poorly understood. In this study, we tested the hypothesis that chronic isolation stress (IS) may boost hypothalamic–pituitary–adrenal (HPA) axis activity, leading to changes in the hypothalamic expression of genes modulating both mood and metabolism in an animal model of breast cancer. This centrally activated signaling cascade would, in turn, affect the mammary gland microenvironment specifically targeting fat metabolism, leading to accelerated tumor onset. MMTVNeuTg female mice (a model of breast cancer developing mammary hyperplasia at 5 months of age) were either group-housed (GH) or subjected to IS from weaning until 5 months of age. At this time, half of these subjects underwent acute restraint stress to assess corticosterone (CORT) levels, while the remaining subjects were characterized for their emotional profile in the forced swimming and saccharin preference tests. At the end of the procedures, all the mice were sacrificed to assess hypothalamic expression levels of Brain-derived neurotrophic factor (Bdnf), Neuropeptide Y (NpY), Agouti-Related Peptide (AgRP), and Serum/Glucocorticoid-Regulated Protein Kinase 1 (SgK1). Leptin and adiponectin expression levels, as well as the presence of brown adipose tissue (BAT), were assessed in mammary fat pads. The IS mice showed higher CORT levels following acute stress and decreased expression of NpY, AgRP, and SgK1, associated with greater behavioral despair in the forced swimming test. Furthermore, they were characterized by increased consumption of saccharin in a preference test, suggesting an enhanced hedonic profile. The IS mice also showed an earlier onset of breast lumps (assessed by palpation) accompanied by elevated levels of adipokines (leptin and adiponectin) and BAT in the mammary fat pads. Overall, these data point to IS as a pervasive stressor that is able to specifically target neuronal circuits, mastered by the hypothalamus, modulating mood, stress reactivity and energy homeostasis. The activation of such IS-driven machinery may hold main implications for the onset and maintenance of pro-tumorigenic environments.

The Role of Stress in Breast Cancer Incidence: Risk Factors, Interventions, and Directions for the Future

Stress is a common belief among breast cancer patients and the public to explain variation in breast cancer incidence. Epidemiological studies interrogating the relationship between stress and cancer have reported mixed results. The impact of the topic and the lack of consensus has sparked this review of the literature to investigate gaps in knowledge and identify areas of research. We first present a brief summary of the biopsychosocial model generally used to conduct research on stress. We then divide the overview of the literature into areas of research focus. These include the role of distressing life events in breast cancer incidence, the role of adverse childhood events in later breast cancer incidence, the importance of race and socioeconomic status (SES) as social determinants of breast cancer incidence, and the specific role of chronic stress in relation to breast cancer. For each topic, we discuss the potential of stress as a risk factor and possible intervention strategies that could reduce the effects of stress. We then identify further research questions to be probed to fill the gaps in knowledge. We conclude with a discussion of future research directions for stress research as it relates to breast cancer incidence.

Highlighting the Potential for Chronic Stress to Minimize Therapeutic Responses to Radiotherapy through Increased Immunosuppression and Radiation Resistance

Ionizing radiation has been used in the treatment of cancer for more than 100 years. While often very effective, there is still a great effort in place to improve the efficacy of radiation therapy for controlling the progression and recurrence of tumors. Recent research has revealed the close interaction between nerves and tumor progression, especially nerves of the autonomic nervous system that are activated by a variety of stressful stimuli including anxiety, pain, sleep loss or depression, each of which is likely to be increased in cancer patients. A growing literature now points to a negative effect of chronic stressful stimuli in tumor progression. In this review article, we present data on the potential for adrenergic stress to influence the efficacy of radiation and in particular, its potential to influence the anti-tumor immune response, and the frequency of an "abscopal effect" or the shrinkage of tumors which are outside an irradiated field. We conclude that chronic stress can be a major impediment to more effective radiation therapy through mechanisms involving immunosuppression and increased resistance to radiation-induced tumor cell death. Overall, these data highlight the potential value of stress reduction strategies to improve the outcome of radiation therapy. At the same time, objective biomarkers that can accurately and objectively reflect the degree of stress in patients over prolonged periods of time, and whether it is influencing immunosuppression and radiation resistance, are also critically needed.

The Neurokinin-1 Receptor Antagonist Aprepitant: An Intelligent Bullet against Cancer?

Neurokinin-1 receptor (NK-1R) antagonists exert antitumor action, are safe and do not cause serious side-effects. These antagonists (via the NK-1R) exert multiple actions against cancer: antiproliferative and anti-Warburg effects and apoptotic, anti-angiogenic and antimetastatic effects. These multiple effects have been shown for a broad spectrum of cancers. The drug aprepitant (an NK-1R antagonist) is currently used in clinical practice as an antiemetic. In in vivo and in vitro studies, aprepitant also showed the aforementioned multiple antitumor actions against many types of cancer. A successful combination therapy (aprepitant and radiotherapy) has recently been reported in a patient suffering from lung carcinoma: the tumor mass disappeared and side-effects were not observed. Aprepitant could be considered as an intelligent bullet against cancer. The administration of aprepitant in cancer patients to prevent recurrence and metastasis after surgical procedures, thrombosis and thromboembolism is discussed, as is the possible link, through the substance P (SP)/NK-1R system, between cancer and depression. Our main aim is to review the multiple antitumor actions exerted by aprepitant, and the use of this drug is suggested in cancer patients. Altogether, the data support the reprofiling of aprepitant for a new therapeutic use as an antitumor agent.

The childhood maltreatment influences on breast cancer patients: A second wave hit model hypothesis for distinct biological and behavioral response

Stress and cancer are two complex situations involving different biological and psychological mechanisms. Their relationship have long been studied, and there is evidence of the impact stress has on both, development and disease progression. Furthermore, early stress has been studied as an important factor associated to this relationship, since its impacts on the immune, endocrine and cognitive development throughout life is already known. Therefore, understanding early stress as a first wave of stress in life is necessary in order to explore a possible second wave hit model. From this perspective, we believe that breast cancer can be understood as a second wave of stress during development and that, in addition to the first wave, can cause important impacts on the response to cancer treatment, such as increased chances of disease progression and distinct behavioral responses. In this article we propose a second wave hit hypothesis applied to breast cancer and its implications on the immune, endocrine and cognitive systems, through mechanisms that involve the HPA axis and subsequent activations of stress responses.

Social isolation induces autophagy in the mouse mammary gland: link to increased mammary cancer risk

Social isolation is a strong predictor of early all-cause mortality and consistently increases breast cancer risk in both women and animal models. Because social isolation increases body weight, we compared its effects to those caused by a consumption of obesity-inducing diet (OID) in C57BL/6 mice. Social isolation and OID impaired insulin and glucose sensitivity. In socially isolated, OID-fed mice (I-OID), insulin resistance was linked to reduced Pparg expression and increased neuropeptide Y levels, but in group-housed OID fed mice (G-OID), it was linked to increased leptin and reduced adiponectin levels, indicating that the pathways leading to insulin resistance are different. Carcinogen-induced mammary tumorigenesis was significantly higher in I-OID mice than in the other groups, but cancer risk was also increased in socially isolated, control diet-fed mice (I-C) and G-OID mice compared with that in controls. Unfolded protein response (UPR) signaling (GRP78; IRE1) was upregulated in the mammary glands of OID-fed mice, but not in control diet-fed, socially isolated I-C mice. In contrast, expression of BECLIN1, ATG7 and LC3II were increased, and p62 was downregulated by social isolation, indicating increased autophagy. In the mammary glands of socially isolated mice, but not in G-OID mice, mRNA expressions of p53 and the p53-regulated autophagy inducer Dram1 were upregulated, and nuclear p53 staining was strong. Our findings further indicated that autophagy and tumorigenesis were not increased in Atg7(+/-) mice kept in social isolation and fed OID. Thus, social isolation may increase breast cancer risk by inducing autophagy, independent of changes in body weight.

Stress Exposure in Significant Relationships Is Associated with Lymph Node Status in Breast Cancer

Objective

Life stress exposure may impact on health and disease. Previous literature showed that stressful life events are associated with cancer incidence, survival and mortality. In animal models, patterns of maternal care have been shown to critically affect stress sensitivity and immunity trajectories later in life, by modifying DNA methylation during critical periods early in life. However, the role of parental care in breast cancer progression and survival has only limitedly been explored. Here, we investigated whether these factors may be linked to biological prognostic variables.

Methods

One hundred twenty-three women hospitalized for surgery of primary breast cancer completed a questionnaire assessing parental bonding. Stressful events throughout the life span were also assessed.

Results

We found that the absence of optimal parental relationships is significantly associated with an increased risk of lymph node involvement, adjusting for confounders, while cumulative stress in the area of sentimental relationships is borderline significantly associated with the same prognostic factor.

Conclusions

Our results suggest that parental bonding and sentimental relations may have a role in breast cancer progression. These variables represent an important evolutionary aspect which may modulate cancer progression through psycho-physiological stress pathways and influence the immune system.

Biological and Pharmacological Aspects of the NK1-Receptor

The neurokinin 1 receptor (NK-1R) is the main receptor for the tachykinin family of peptides. Substance P (SP) is the major mammalian ligand and the one with the highest affinity. SP is associated with multiple processes: hematopoiesis, wound healing, microvasculature permeability, neurogenic inflammation, leukocyte trafficking, and cell survival. It is also considered a mitogen, and it has been associated with tumorigenesis and metastasis. Tachykinins and their receptors are widely expressed in various human systems such as the nervous, cardiovascular, genitourinary, and immune system. Particularly, NK-1R is found in the nervous system and in peripheral tissues and are involved in cellular responses such as pain transmission, endocrine and paracrine secretion, vasodilation, and modulation of cell proliferation. It also acts as a neuromodulator contributing to brain homeostasis and to sensory neuronal transmission associated with depression, stress, anxiety, and emesis. NK-1R and SP are present in brain regions involved in the vomiting reflex (the nucleus tractus solitarius and the area postrema). This anatomical localization has led to the successful clinical development of antagonists against NK-1R in the treatment of chemotherapy-induced nausea and vomiting (CINV). The first of these antagonists, aprepitant (oral administration) and fosaprepitant (intravenous administration), are prescribed for high and moderate emesis.

Targeting NK-1 Receptors to Prevent and Treat Pancreatic Cancer: a New Therapeutic Approach

Pancreatic cancer (PC) is the fourth leading cause of cancer related-deaths in both men and women, and the 1- and 5-year relative survival rates are 25% and 6%, respectively. It is known that smoking, alcoholism and psychological stress are risk factors that can promote PC and increase PC progression. To date, the prevention of PC is crucial because there is no curative treatment. After binding to the neurokinin-1 (NK-1) receptor (a receptor coupled to the stimulatory G-protein Gαs that activates adenylate cyclase), the peptide substance P (SP)-at high concentrations-is involved in many pathophysiological functions, such as depression, smoking, alcoholism, chronic inflammation and cancer. It is known that PC cells and samples express NK-1 receptors; that the NK-1 receptor is overexpressed in PC cells in comparison with non-tumor cells, and that nanomolar concentrations of SP induce PC cell proliferation. By contrast, NK-1 receptor antagonists exert antidepressive, anxiolytic and anti-inflammatory effects and anti-alcohol addiction. These antagonists also exert An antitumor action since in vitro they inhibit PC cell proliferation (PC cells death by apoptosis), and in a xenograft PC mouse model they exert both antitumor and anti-angiogenic actions. NK-1 receptor antagonists could be used for the treatment of PC and hence the NK-1 receptor could be a new promising therapeutic target in PC.

Personality and breast cancer risk and survival: the Miyagi cohort study

It has long been hypothesized that personality is associated with breast cancer risk and survival. The present population-based prospective cohort study in Japan tested this hypothesis. To investigate the association of personality with breast cancer risk, a total of 15,107 women aged 40-64 years who completed the Eysenck Personality Questionnaire-Revised (EPQ-R) Short Form were followed from 1990 to 2007. To assess the association of personality with survival after breast cancer, 250 identified cases were further followed up from the date of diagnosis to 2008, and 45 all-cause deaths were documented. Study subjects were categorized into four groups based on the quartile points of scores ranging between 0 and 12 on each EPQ-R subscale (extraversion, neuroticism, psychoticism, and lie), and the hazard ratio (HR) for each category was computed using the lowest category as reference. Multivariate analysis revealed no association between any of the four personality subscales and the risk of breast cancer. In the analysis on survival, no significant association was found between any of these subscales and the risk of death, although breast cancer cases with a higher score of extraversion tended to have a lower risk of death (P for trend = 0.07; HR for highest score level = 0.38). Exclusion of 32 cases diagnosed in the first 3 years of follow-up did not largely change the results with regard to either breast cancer risk or survival. The present findings suggest that personality does not impact significantly on the development and progression of breast cancer.

The neurokinin-1 receptor antagonist aprepitant is a promising candidate for the treatment of breast cancer

The substance P (SP)/neurokinin (NK)-1 receptor system plays an important role in the development of cancer. No in-depth studies of the involvement of this system in breast cancer (BC) have been carried out, and the action exerted by the drug aprepitant on BC cells is currently unknown. We show the involvement of this system in human BC cell lines: i) these cells express mRNA for the NK-1 receptor; ii) they overexpress NK-1 receptors; iii) the NK-1 receptor is involved in their viability; iv) SP induces their proliferation; v) NK-1 receptor antagonists block SP-induced mitogen stimulation of these cells; vi) the specific antitumor action of such antagonists on these cells occurs through the NK-1 receptor; and vii) BC cell death is due to apoptosis. We also found NK-1 receptors and SP in all human BC samples studied. The NK-1 receptor may be a promising target in the treatment of BC and NK-1 receptor antagonists could be candidates as a new antitumor drug in the treatment of BC.

Involvement of substance P and the NK-1 receptor in cancer progression

Many data suggest the deep involvement of the substance P (SP)/neurokinin (NK)-1 receptor system in cancer: (1) Tumor cells express SP, NK-1 receptors and mRNA for the tachykinin NK-1 receptor; (2) Several isoforms of the NK-1 receptor are expressed in tumor cells; (3) the NK-1 receptor is involved in the viability of tumor cells; (4) NK-1 receptors are overexpressed in tumor cells in comparison with normal ones and malignant tissues express more NK-1 receptors than benign tissues; (5) Tumor cells expressing the most malignant phenotypes show an increased percentage of NK-1 receptor expression; (6) The expression of preprotachykinin A is increased in tumor cells in comparison with the levels found in normal cells; (7) SP induces the proliferation and migration of tumor cells and stimulates angiogenesis by increasing the proliferation of endothelial cells; (8) NK-1 receptor antagonists elicit the inhibition of tumor cell growth; (9) The specific antitumor action of NK-1 receptor antagonists on tumor cells occurs through the NK-1 receptor; (10) Tumor cell death is due to apoptosis; (11) NK-1 receptor antagonists inhibit the migration of tumor cells and neoangiogenesis. The NK-1 receptor is a therapeutic target in cancer and NK-1 receptor antagonists could be considered as broad-spectrum antitumor drugs for the treatment of cancer. It seems that a common mechanism for cancer cell proliferation mediated by SP and the NK-1 receptor is triggered, as well as a common mechanism exerted by NK-1 receptor antagonists on tumor cells, i.e. apoptosis.

The epidemiology of psychiatric disorders among women with breast cancer in South Korea: analysis of national registry data

OBJECTIVE

Population-based data on the epidemiology of psychiatric disorders in patients with breast cancer are lacking. Because the National Health Insurance (NHI) Program in South Korea is a compulsory social insurance system covering the entire Korean population, the NHI is a good source of information for epidemiological studies. In the present study, we examined the incidence of psychiatric disorders among Korean women newly diagnosed with breast cancer using the NHI Corporation (NHIC) database.

METHODS

Data were collected for adult women newly diagnosed with breast cancer using the claim database and cancer registration files of the NHIC from 2005 to 2008. We analysed data for women diagnosed with psychiatric disorders over a 5-year period, from 2004 (at least 1 year before the cancer registration date) to 2009 (at least 1 year after the cancer registration date).

RESULTS

We identified 6536 patients with psychiatric disorders among 42 190 women with breast cancer. The most prevalent psychiatric disorder was anxiety disorder (N = 2518). The incidence rates of anxiety disorders, depressive disorders, sleep disorders and adjustment disorders were 27.08, 22.41, 10.57 and 4.35 cases per 1000 person-year, respectively.

CONCLUSION

The incidence rates of psychiatric disorders in Korean women with breast cancer from the nationwide database were much lower than found by previous reports using screening tools. The finding implicates that psychiatric disorders among breast cancer patients tend to be underdiagnosed and undertreated in actual clinical practice. Our epidemiological findings provide important information for establishing a national strategy of cancer care to detect and manage psychiatric problems.

Applying the Stress and ‘Strength’ Hypothesis to Black Women’s Breast Cancer Screening Delays

Associations between stress and breast cancer highlight stressful life events as barriers to breast cancer screening, increased stress due to a breast cancer scare or diagnosis, or the immunosuppressive properties of stress as a risk factor for breast cancer occurrence. Little is known, however, about how women's reactions to stressful life events impact their breast health trajectory. In this study, we explore how reactions to stressors serve as a potential barrier to breast cancer screening among Black women. We apply a gender-specific, culturally responsive stress-process framework, the Stress and 'Strength' Hypothesis ("strength hypothesis"), to understand links between the 'Strong Black Woman role' role, Black women's stress reactions and their observed screening delays. We conceptualize strength as a culturally prescribed coping style that conditions resilience, self-reliance and psychological hardiness as a survival response to race-related and gender-related stressors. Using qualitative methods, we investigate the potential for this coping mechanism to manifest as extraordinary caregiving, emotional suppression and self-care postponement. These manifestations may result in limited time for scheduling and attending screening appointments, lack of or delay in acknowledgement of breast health symptoms and low prioritization of breast care. Limitations and future directions are discussed.

Association of worse prognosis with an aberrant diurnal cortisol rhythm in patients with advanced lung cancer

A flatter diurnal rhythm of cortisol has been reported to be associated with early mortality in patients with metastatic breast cancer. The clinical stage of disease at the time of diagnosis and the patient's performance status (PS) are known to be important prognostic factors for lung cancer (LC) survival. The authors examined the relationship between diurnal cortisol rhythms and these prognostic factors in patients with advanced LC. Cortisol concentrations were measured in saliva samples collected from 52 patients (37 males/15 females) with advanced LC and from 56 healthy subjects (32 males/24 females) to characterize the diurnal cortisol rhythm, specifically the cortisol awakening response (CAR) and diurnal cortisol decline (DCD). Variations of CAR and DCD in the patients were analyzed according to their clinical disease stage and PS score, and the differences in CAR and DCD between patients and healthy controls were compared. The patient group showed significantly reduced diurnal cortisol secretory activity and rhythmicity, compared with healthy controls. When the patients were subgrouped according to their clinical disease stage, patients with stage 4 disease showed significantly reduced CAR and flatter DCD compared with the healthy controls. However, the CAR and DCD in patients with stage 3a and 3b disease were comparable to those of healthy controls. Neither the CAR nor the DCD showed stepwise changes as the disease stage worsened. When patients were subgrouped according to their Eastern Cooperative Oncology Group (ECOG) PS score, there was stepwise reduction in the CAR and flattening of the DCD as the PS score increased. Both an abolished CAR and a flattened DCD were common in patients with ECOG PS scores of 3 and 4. These results indicate that alteration of the diurnal cortisol rhythm in patients with advanced LC is more closely associated with their PS score than with their clinical disease stage. Gradual alteration of the CAR and DCD, indicative of loss of 24-h cortisol rhythm, in concert with increase in PS score implies that endogenous circadian rhythms may also be disintegrating as the PS score worsens in these patients.

The role of neurokinin-1 receptor in the microenvironment of inflammation and cancer

The recent years have witnessed an exponential increase in cancer research, leading to a considerable investment in the field. However, with few exceptions, this effort has not yet translated into a better overall prognosis for patients with cancer, and the search for new drug targets continues. After binding to the specific neurokinin-1 (NK-1) receptor, the peptide substance P (SP), which is widely distributed in both the central and peripheral nervous systems, triggers a wide variety of functions. Antagonists against the NK-1 receptor are safe clinical drugs that are known to have anti-inflammatory, analgesic, anxiolytic, antidepressant, and antiemetic effects. Recently, it has become apparent that SP can induce tumor cell proliferation, angiogenesis, and migration via the NK-1 receptor, and that the SP/NK-1 receptor complex is an integral part of the microenvironment of inflammation and cancer. Therefore, the use of NK-1 receptor antagonists as a novel and promising approach for treating patients with cancer is currently under intense investigation. In this paper, we evaluate the recent scientific developments regarding this receptor system, its role in the microenvironment of inflammation and cancer, and its potentials and pitfalls for the usage as part of modern anticancer strategies.

Decrease in depression symptoms is associated with longer survival in patients with metastatic breast cancer: a secondary analysis

PURPOSE

Numerous studies have examined the comorbidity of depression with cancer, and some have indicated that depression may be associated with cancer progression or survival. However, few studies have assessed whether changes in depression symptoms are associated with survival.

METHODS

In a secondary analysis of a randomized trial of supportive-expressive group therapy, 125 women with metastatic breast cancer (MBC) completed a depression symptom measure (Center for Epidemiologic Studies-Depression Scale [CES-D]) at baseline and were randomly assigned to a treatment group or to a control group that received educational materials. At baseline and three follow-up points, 101 of 125 women completed a depression symptom measure. We used these data in a Cox proportional hazards analysis to examine whether decreasing depression symptoms over the first year of the study (the length of the intervention) would be associated with longer survival.

RESULTS

Median survival time was 53.6 months for women with decreasing CES-D scores over 1 year and 25.1 months for women with increasing CES-D scores. There was a significant effect of change in CES-D over the first year on survival out to 14 years (P = .007) but no significant interaction between treatment condition and CES-D change on survival. Neither demographic nor medical variables explained this association.

CONCLUSION

Decreasing depression symptoms over the first year were associated with longer subsequent survival for women with MBC in this sample. Further research is necessary to confirm this hypothesis in other samples, and causation cannot be assumed based on this analysis.

Association between stress and breast cancer in women: a meta-analysis

The objective of the current meta-analysis was to verify the association between stressful life events and primary breast cancer incidence in women. A total of 618 studies from 1982-2007 were found in the PubMed, LILACS, and Cochrane Library databases. Methodological quality was evaluated according to the Downs & Black criteria. Eight studies were selected (six case-controls and two cohorts). The studies were grouped in three analyses, two of which based on the categories widowhood and divorce and the other based on self-rated intensity and frequency of stressful events. Relative risks were: widowhood 1.04 (95%CI: 0.75-1.44; p = 0.800); divorce 1.03 (95%: 0.72-1.48; p = 0.850); and intensity/frequency of stress 1.73 (95%CI: 0.98-3.05; p = 0.059). We conclude that stressful life events as a whole are not associated with risk of breast cancer in women. However, it is not possible to rule out high-intensity stress as a risk factor for breast cancer.

Work and family stress is associated with menstrual disorders but not with fibrocystic changes: cross-sectional findings in Chinese working women

OBJECTIVES

To explore the separate and combined effects of work and family stress on menstrual disorders and fibrocystic changes in Chinese working women.

METHODS

Data were obtained from a cross-sectional study of 1,642 female railway workers. The Effort-Reward Imbalance Questionnaire and Family Stress Scale were used to measure work stress and family stress, respectively; the menstrual and breast conditions were evaluated by gynecologic interview and a medical examination. Multivariate log-binomial regression was performed to analyze the associations.

RESULTS

Menstrual disorders were found in 59.3% of female workers, and 54.8% had fibrocystic changes. The risk of menstrual disorders was significantly elevated with respect to work and family stress. The highest risk was found in the group with combined exposure to both work and family stress (RR with 95% CI 1.33 (1.18-1.49)). No significant association between stress and fibrocystic changes was observed.

CONCLUSIONS

Menstrual disorders were associated with stress from work and family life, but not fibrocystic changes, in working women. Tailored intervention measures reducing the burden of stressful psychosocial work and family environment are needed to improve women's reproductive well-being.

Influence of stress related to war on biological and morphological characteristics of breast cancer in a defined population

PURPOSE

To assess differences between patients with breast cancer before, during and after the 1991-1995 war in Croatia.

MATERIAL AND METHODS

We analyzed 660 patients of Pozesko-Slavonska County, during the three periods. Relative predictive values of patient's characteristics and stage of tumor were assessed using the X2-test, and survival with Kaplan-Meier analysis.

RESULTS

Tumors were significantly more often of higher stages (IIA and IIB) and with axillary lymph node metastases (N1) during the war, than in pre-war and post-war period.Breast cancer was significantly more frequent in patients who previously experienced death in the family (35,3%). The Kaplan-Meier analysis showed correlation between survival, T and N stages of tumor and clinical stage of tumor.

CONCLUSION

The war aggression towards Croatia with its impact on our patients, contributed to modification of characteristics of breast cancer in the analyzed period.

No evidence that social stress is associated with breast cancer incidence

Women commonly attribute the experience of stress as a contributory cause of breast cancer. The purpose of this study is to investigate the associations between a history of social stress and breast cancer risk. A total of 11,467 women with no prior history of breast cancer, participants in the European Prospective Investigation into Cancer (EPIC)-Norfolk population-based prospective cohort study, completed a comprehensive assessment of lifetime social adversity exposure. Summary measures of social adversity were defined according to difficult circumstances in childhood, stressful life events and longer-term difficulties in adulthood, derived measures representing the subjective 'impact' of life events and associated 'stress adaptive capacity', and perceived stress over a 10-year period. Incident breast cancers were identified through linkage with cancer registry data. During 102,514 (median 9) person-years of follow-up, 313 incident breast cancers were identified. No associations were observed between any of the summary social adversity measures and subsequent breast cancer risk, with or without adjustment for age, menopausal status, parity, use of menopausal hormones, age at menarche, age at first birth, family history of breast cancer, physical activity, social class, body mass index, height, and alcohol intake. This study found no evidence that social stress exposure or individual differences in its experience are associated with the development of breast cancer. These findings may aid strategies designed to meet the psychosocial and emotional needs of breast cancer survivors and may be interpreted in a positive way in the context of commonly voiced beliefs that the experience of stress is a contributory cause of their disease.

Influence of stressors on breast cancer incidence in the Women's Health Initiative

OBJECTIVE

To examine associations among life events stress, social support, and breast cancer incidence in a cohort of postmenopausal women. DESIGN AND MAIN OUTCOME MEASURE: Women's Health Initiative observational study participants, breast cancer free at entry, who provided assessment of stressful life events, social support, and breast cancer risk factors, were prospectively followed for breast cancer incidence (n = 84,334).

RESULTS

During an average of 7.6 years of follow-up, 2,481 invasive breast cancers were diagnosed. In age-adjusted proportional hazards models, 1 stressful life event was associated with increased risk, but risk decreased with each additional stressful life event. After adjustment for confounders the decreasing risk was not significant. Stressful life events and social support appeared to interact in relation to breast cancer risk such that women who had greater number of stressful life events and low social support had a decreased risk of breast cancer.

CONCLUSIONS

This study found no independent association between stressful life events and breast cancer risk. The results are compatible with a more complex model of psychosocial factors interacting in relation to breast cancer risk.

THE EFFECTS OF STRESS ON DNA REPAIR CAPACITY

Research has shown that lymphocytes of high-distress patients have reduced DNA repair relative to that of low-distress patients and healthy controls. Furthermore, deficits in repair are associated with an increased risk of cancer. Using and academic stress model, we hypothesized that students would exhibit lower levels of Nucleotide Excision Repair (NER) during a stressful exam period when compared to a lower stress period. Participants were 19 healthy graduate level students. NER was measured in lymphocytes using the unscheduled DNA synthesis (UDS) assay with slide autoradiography. Contrary to prediction, mean values for NER significantly increased during the higher stress period relative to the lower stress period controlling for background differences in repair. Furthermore, lymphocytes had significantly increased repair of endogenous damage during the higher stress period. Stress appears to directly increase DNA repair. Additionally, stress may increase DNA repair indirectly by increasing damage to DNA.

Self-reported stress and risk of endometrial cancer: a prospective cohort study

OBJECTIVES

To assess a possible relationship between perceived stress and first-time incidence of primary endometrial cancer. Psychological stress may affect the synthesis and metabolism of estrogens and thereby be related to risk of endometrial cancer.

METHODS

The 6760 women participating in the Copenhagen City Heart Study were asked about their stress level at baseline from 1981 to 1983. These women were prospectively followed up in the Danish nationwide cancer registry until 2000 and <0.1% were lost to follow-up. Cox proportional hazard models were used to analyze data.

RESULTS

During follow-up, 72 women were diagnosed with endometrial cancer. For each increase in stress level on a 7-point stress scale, there was a lower risk of primary endometrial cancer (hazard ratio (HR) = 0.88; 95% confidence interval (CI), 0.76-1.01). This inverse association was particularly strong in women who received hormone therapy (HR = 0.77; 95% CI, 0.61-0.96) and in normal-weight women (HR = 0.73; 95% CI, 0.58-0.91).

CONCLUSIONS

Stress may affect gonadal synthesis of estrogens and alter the sensitivity of the uterus toward estrogen stimulation. These mechanisms may explain the lower risk of endometrial cancer observed among stressed women in this study. Despite these results, stress may still be a risk factor for a range of other diseases and should therefore not be considered a healthy response.

Advanced breast cancer: aetiology, treatment and psychosocial features

Breast cancer is a common form of cancer in women of varying age. Due to the relationship between breasts, sexuality and reproduction, this form of cancer has an interconnected psychological and psychosocial influence on the well-being of women. Current understanding of the aetiology and pathogenesis of the disease has evolved as evidence supporting a role for genes such as the HER2 gene has emerged. HER2-positive breast cancer is a particularly progressive form of the disease as a result of its ability to differentiate and spread. Trastuzumab (Herceptin) forms part of the current treatment for this form of breast cancer; albeit costly, it has been shown to improve survival rates in women. For this reason it is now a recommended treatment for early-stage breast cancer. During and after treatment cycles, the breast cancer nurse and medical practitioners should be available to provide emotional support and advice on the manifestations of the disease, coping strategies and how breast cancer patients manage close family relatives.

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

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

Coping strategies among couples adjusting to primary breast cancer

In psychosocial oncology social support is a recognized factor in facilitating adaptation to cancer. Spouses are often the first source of support for each other. However, the adaptation process of couples dealing with cancer has been little explored. This article presents the results of a qualitative study carried out with 16 couples, in each of which the woman had breast cancer. The goal of this study was to better understand the manner in which the couple as a dyad deals with the disruptions and demands related to the disease and its treatments. This report highlights the principal issues that confront couples in the first year after diagnosis and the adjustment strategies they use to deal with these issues. A theoretical understanding of the adjustment process of couples dealing with breast cancer emerges as a result of this study.

Induction of a metastatogenic tumor cell type by neurotransmitters and its pharmacological inhibition by established drugs

The active migration of tumor cells, a crucial requirement for metastasis development and cancer progression, is regulated by signal substances including neurotransmitters. We investigated the migration of tumor cells within a three-dimensional collagen matrix using time-lapse videomicroscopy and computer-assisted analysis of the migration path. Tumor cell migration is induced by norepinephrine, dopamine and substance P. We show that this induced migration, using MDA-MB-468 breast and PC-3 prostate carcinoma cells, can be inhibited by using specific, clinically established receptor antagonists to the beta2-adrenoceptor, the D2 receptor, or the neurokinin-1 receptor, respectively. All of the investigated neurotransmitters significantly activated the cyclic adenosine-monophosphate response element binding protein (CREB). Furthermore, microarray analysis revealed changes of gene expression toward a highly motile tumor cell type, including an upregulation of the alpha2 integrin, which is an essential adhesion receptor for collagen in migration. The gene for the tumor suppressor gelsolin was downregulated. These 2 critical alterations were confirmed on the protein level by flow-cytometry and immunoblotting, respectively. Neurotransmitters thus induce a metastatogenic tumor cell type by directly regulating gene expression and increased migratory activity, which can be prevented by established neurotransmitter antagonists.

A Randomized Trial of the Effects of Remote Intercessory Prayer: Interactions with Personal Beliefs on Problem-Specific Outcomes and Functional Status

OBJECTIVES

Investigate the relevance of interpersonal belief factors as modifiers of the effectiveness of intercessory prayer.

DESIGN

Randomized clinical trial.

SETTING/LOCATION

Community-dwelling adults recruited from seven local church groups.

SUBJECTS

Eighty-six (86) male and female participants 18-88 years of age were randomly assigned to either treatment (n = 45) or control groups (n = 41).

INTERVENTIONS

Several volunteers committed to daily prayer for participants in the intervention group. Intercessory prayer commenced for 1 month and were directed toward a life concern or problem disclosed by the participant at baseline. Participants were unaware of being prayed for.

OUTCOMES MEASURES

Degree to which their problem had been resolved and the current level of concern they had about a specific life problem they described at baseline. Four component scores from the Medical Outcomes Study SF-20 were also used.

RESULTS

No direct intervention effect on the primary outcomes was found. A marginally significant reduction in the amount of pain was observed in the intervention group compared to controls. The amount of concern for baseline problems at follow-up was significantly lower in the intervention group when stratified by subject's baseline degree of belief that their problem could be resolved. Prayer intervention appeared to effectively reduce the subject's level of concern only if the subject initially believed that the problem could be resolved. Those in the intervention group who did not believe in a possible resolution to their problem did not differ from controls. Better physical functioning was observed in the intervention group among those with a higher belief in prayer and surprisingly, better mental health scores were observed in the control group with lower belief in prayer scores.

CONCLUSIONS

The results of the current study underscore the role of interpersonal belief in prayer efficacy and are consistent with the literature showing the relevance of belief in health and well-being in general. The relevance of interpersonal belief factors of the participants is recommended in future investigations.

Self-reported stress levels predict subsequent breast cancer in a cohort of Swedish women

The association between stress and breast cancer has been studied, mostly using case-control designs, but rarely examined prospectively. The purpose of this paper is to describe the role of stress as a predictor of subsequent breast cancer. A representative cohort of 1,462 Swedish women aged 38-60 years were followed for 24 years. Stress experience at a baseline examination in 1968-69 was analysed in relation to incidence of breast cancer with proportional hazards regression. Women reporting experience of stress during the five years preceding the first examination displayed a two-fold rate of breast cancer compared with women reporting no stress (age-adjusted relative risk 2.1; 95% CI [1.2-3.7]). This association was independent of potential confounders including reproductive and lifestyle factors. In conclusion, the significant, positive relationship between stress and breast cancer in this prospective study is based on information that is unbiased with respect to knowledge of disease, and can be regarded as more valid than results drawn from case-control studies.

Effects of neurotransmitters on the chemokinesis and chemotaxis of MDA-MB-468 human breast carcinoma cells

Most patients suffering from breast carcinoma do not die due to the primary tumor but from the development of metastases. Active migration of cancer cells is a prerequisite for development of these metastases. We used time-lapse videomicroscopy and computer-assisted cell tracking of MDA-MB-468 human breast carcinoma cells, which were incorporated into a three-dimensional collagen matrix, in order to analyze the migratory activity of these cells in response to different neurotransmitters. Our results show that met-enkephalin, substance P, bombesin, dopamine, and norepinephrine have a stimulatory effect on the migration of the breast cancer cells; moreover, these cells show positive chemotaxis towards norepinephrine as was analyzed by the directionality and persistence on a single-cell basis. Gamma-aminobutyric acid (GABA) however has an inhibitory effect. Endorphin and leu-enkephalin, as well as histamin and acetylcholine, had no influence on the migratory activity of the cells. In summary, we provide evidence for a strong regulatory involvement of neurotransmitters in the regulation of breast cancer cell migration, which might provide the basis for the use of the pharmacological agonists and antagonists for the chemopreventive inhibition of metastasis development.

Emotional and cognitive burden of prostate cancer

The wide-ranging effects of prostate cancer can be an emotional burden to the patient and his family. Recognizing important periods during the diagnosis and treatment that can be particularly stressful, the symptoms indicating patients are at high risk for emotional distress, and the signs and symptoms of emotional distress can encourage improved communication, education, treatment, and referral to minimize the effects of the emotional distress.

Stress, coping, and immune function in breast cancer

Research has found suggestive links between emotional distress and immune and neuroendocrine measures in cancer patients. Furthermore, several studies have reported that participation in psychological support groups is associated with better health outcomes for cancer patients. However, controversy exists surrounding these findings, and the mechanisms behind such effects are unclear. This article integrates current evidence from several lines of research concerning the relations among coping, psychological adjustment, cortisol and immune function, and disease progression in breast cancer patients. A biopsychosocial model is evaluated in which coping and psychological adjustment are associated with alterations in cortisol levels, immune function, and potential long-term medical outcomes in breast cancer patients. Although strong evidence suggests that coping and psychosocial intervention can improve psychological outcomes for breast cancer patients, potential effects on physiological outcomes remain speculative.

First-degree relatives of breast-cancer patients: cognitive perceptions, coping, and adherence to breast self-examination

The author assessed patterns of breast self-examination (BSE) related to cognitive appraisal, coping, and emotional distress in 80 women with first-degree relatives who were breast-cancer patients and 47 matched controls. Participants with first-degree relatives adhered to BSE better than did women with no family history of breast cancer, and women whose relatives had recurrent or metastatic disease performed more BSE than those whose relatives were currently disease free. Greater adherence to BSE was associated with lower levels of depression, more problem-focused coping, older age, and more education. In the women with first-degree relatives, BSE was also associated with higher perceptions of (a) control over prevention, (b) risk for breast cancer, and (c) higher levels of state anxiety. Perception of control, problem-focused coping, depression, and anxiety predicted 35% of the variance in adherence to BSE. The findings suggest that cognitive appraisal, coping strategies, and levels of emotional distress should be considered in designing programs for enhancing adherence to early detection procedures.

Personality characteristics and the risk of breast cancer: a prospective cohort study

Various personality characteristics have been suggested to increase the risk of breast cancer but reliable epidemiologic data on this issue are limited. We prospectively investigated the relationship between personality characteristics and the risk of breast cancer in 12,499 Finnish women aged 18 years or more. In health questionnaires in 1975 and 1981, these women completed at least one of the following personality scales: Eysenck extroversion, Bortner type A behaviour and author-constructed measure of hostility. They also reported about other potential breast cancer risk factors. From 1976-1996, 253 cases of breast cancer were identified by record linkage with the Finnish Cancer Registry. Proportional hazard models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI). The multivariable HRs of breast cancer for women with intermediate level (scores 3-6) and high level (7-9) of extroversion in 1975 were 1.18 (95% CI 0.87-1.60) and 0.97 (95% CI 0.64-1.47), respectively, compared to those with low level (0-2). These results remained unaltered when the level of extroversion was determined as the average of the 1975 and 1981 reports. There was also no increase in breast cancer risk in relation to type A behaviour and hostility. Furthermore, we observed no substantial joint effects of personality characteristics on the risk of breast cancer. In conclusion, our data do not support the existence of an important role for personality in the aetiology of breast cancer. These findings are reassuring to those who have believed the contrary.

Stress of daily activities and risk of breast cancer: a prospective cohort study in Finland

The belief that life stress enhances breast cancer is common, but there are few prospective epidemiological studies on the relationship of life stress and breast cancer. We have investigated the association between stress of daily activities (SDA) and breast-cancer risk in a prospective cohort study of 10,519 Finnish women aged 18 years or more. SDA measures a subject's own appraisal of daily stress. It was assessed in 1975 and 1981 by a self-administered questionnaire, which also provided information on subject characteristics and other known breast-cancer risk factors. Follow-up data for breast cancer from 1976 to 1996 were attained through record linkage to the Finnish Cancer Registry. Study subjects were divided into 3 groups based on their SDA scores in 1975: no stress (23% of subjects), some stress (68%) and severe stress (9%). Hazard ratios (HRs) and respective 95% confidence intervals (CIs) for incidence of breast cancer by level of SDA were obtained from the Cox proportional hazards model. We identified 205 incident breast cancers in the cohort. Multivariable-adjusted HRs for breast-cancer risk were 1.00 (reference), 1.11 (95% CI 0.78-1.57) and 0.96 (95% CI 0.53-1.73) by increasing level of stress. Neither shifting of the SDA cut-off points nor restricting the analysis to women who reported the same level of SDA in 1975 and 1981 materially altered the results. We found no evidence of an association between self-perceived daily stress and breast-cancer risk.

The role of psychosocial factors in the development of breast carcinoma: Part II. Life event stressors, social support, defense style, and emotional control and their interactions

BACKGROUND

The evidence supporting an association between life event stress and breast carcinoma development is inconsistent.

METHODS

Five hundred fourteen women requiring biopsy after routine mammographic breast screening were interviewed using the Brown and Harris Life Event and Difficulties Schedule. Other psychosocial variables assessed included social support, emotional control, and defense style. Biopsy results identified 239 women with breast carcinoma and 275 women with benign breast disease. Multiple logistic regression analysis was used to distinguish between breast carcinoma subjects and benign breast disease controls based on these psychosocial variables and their interactions.

RESULTS

The findings of the current study revealed a significant interaction between highly threatening life stressors and social support. Women experiencing a stressor objectively rated as highly threatening and who were without intimate emotional social support had a ninefold increase in risk of developing breast carcinoma.

CONCLUSIONS

Although there was no evidence of an independent association between life event stress and breast carcinoma, the findings of the current study provided strong evidence that social support interacts with highly threatening life stressors to increase the risk of breast carcinoma significantly. [See also accompanying article on pages 679-85, this issue.]

Epidemiological evidence for a relationship between life events, coping style, and personality factors in the development of breast cancer

OBJECTIVE

Review empirical evidence for a relationship between psychosocial factors and breast cancer development.

METHODS

Standardised quality assessment criteria were utilised to assess the evidence of psychosocial predictors of breast cancer development in the following domains: (a) stressful life events, (b) coping style, (c) social support, and (d) emotional and personality factors.

RESULTS

Few well-designed studies report any association between life events and breast cancer, the exception being two small studies using the Life Events and Difficulties Schedule (LEDS) reporting an association between severely threatening events and breast cancer risk. Seven studies show anger repression or alexithymia are predictors, the strongest evidence suggesting younger women are at increased risk. There is no evidence that social support, chronic anxiety, or depression affects breast cancer development. With the exception of rationality/anti-emotionality, personality factors do not predict breast cancer risk.

CONCLUSION

The evidence for a relationship between psychosocial factors and breast cancer is weak. The strongest predictors are emotional repression and severe life events. Future research would benefit from theoretical grounding and greater methodological rigour. Recommendations are given.

A prospective study of job strain and risk of breast cancer

BACKGROUND

There is conflicting evidence on whether stress is a risk factor for breast cancer. The present study examined prospectively the relationship between stress at work and risk of breast cancer.

METHODS

Participants comprised 26 936 postmenopausal women in the Nurses' Health Study ages 46-72 who were in paid employment, and who had no previous history of cancer. Multivariate-adjusted regression analysis was used to examine the relationship between job strain (measured by the Karasek Job Content Questionnaire in 1992) and risk of incident invasive and in situ breast cancer.

RESULTS

From 1992 through 1994, 219 women were diagnosed with breast cancer. No evidence was found for a relationship between job stress and risk of breast cancer. Compared with women in low strain jobs, the multivariate-adjusted relative risks of breast cancer were RR = 0.78 (95% CI : 0.52-1.16) for high-strain jobs; RR = 0.76 (95% CI : 0.49-1.17) for active jobs; and RR = 0.94 (95% CI : 0.67-1.34) for passive jobs. Although job strain was related to less breast cancer screening among women in highly demanding jobs, it was not associated with tumour size.

CONCLUSIONS

Job stress was not related to an increase in the incidence of breast cancer in the present cohort of nurses.

Psychosocial factors in the etiology of breast cancer: review of a popular link

Breast cancer is the most frequently occurring type of cancer in women in the western world. The etiology of a large proportion of breast cancers is still unexplained, and the possibility that psychosocial factors could play a role is not ruled out. Already in pre-Christian times, it was assumed that psychological factors might play a significant role in the development of breast cancer. However, studies have failed to produce conclusive results. There is still a lack of knowledge on the relationship between breast cancer development and psychosocial factors such as stressful life events, coping styles, depression, and the ability to express emotions. The results of this review show that there is not enough evidence that psychosocial factors like 'ways of coping' or 'non-expression of negative emotions', play a significant role in the etiology of breast cancer.

Psychosocial correlates of cancer relapse and survival: a literature review

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