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

Coping in patients with pancreatic cancer: a scoping review and narrative synthesis

INTRODUCTION

Pancreatic cancer is a malignant disease with one of the highest cancer-specific mortality rates. Coping with it probably differs from other malignant diseases. This scoping review was intended to explore and characterise academic literature related to the coping in patients with pancreatic cancer.

METHODS

Eight databases were searched for primary and secondary studies and reviews reporting on coping with pancreatic cancer (adenocarcinoma) in adults in English or German language, regardless of publication date or study design, which were then analysed and summarised by narrative synthesis.

RESULTS

Of 1472 publications identified, 9 articles and book contributions published from 1989 to 2020 in the USA, Europe and Australia met the inclusion criteria. The two main aspects covered were the confrontation with coping tasks, and the reciprocally associated coping with these challenges. In particular, the coping tasks revealed some pancreatic cancer-specific features, such as an increased incidence of depression and anxiety or certain digestive problems, whereas applying of coping strategies seems to be more like the coping behaviours known from the literature for other severe or cancer diseases.

CONCLUSIONS

Patients with pancreatic cancer experience various health issues and face various quality of life changes and coping tasks. Disease-specific contextual factors, usually consisting of late diagnosis at an advanced stage, rapid progression and often poor prognosis, as well as disease-specific challenges are major differences compared with other malignancies or serious illnesses. However, the coping strategies applied do not seem to differ in principle. Currently, no pancreatic cancer-specific coping model exists.

Fighting for Life: A Qualitative Analysis of the Process of Psychotherapy-Assisted Self-Help in Patients With Metastatic Cancer

This exploratory study is an attempt to define psychological attributes related to longer survival in patients with meta-static cancers. Previous published analyses have been limited in two ways. First, they have almost always been carried out on patients not receiving therapy; we have followed people receiving a year of group therapy, on the assumption that if mental qualities are to affect cancer progression, substantial mental change would be needed to alter the established balance between the cancer cells and host regulatory mechanisms. Second, the methods typically used to characterize patients’ psychology have been self-report inventories, and many decades of research with such methods have largely failed to produce a consensus on what mental qualities, if any, promote survival. By contrast, we have used qualitative methods, allowing a much more in-depth analysis of the patients, without preliminary assumptions as to what would be important.

The present report describes the results of a detailed qualitative analysis of data collected from 22 participants over a year of weekly group therapy. Using grounded methods, categories were derived from the extensive verbal data (comprising patients’ written homework and therapists’ notes), and linked in a model of change. By applying ratings to some of these categories, and combining these ratings, we derived a quantitative estimate of patients’“involvement in self-help.” Rankings on degree of involvement corresponded quite closely with the quality of patients’ experience and with their survival duration.

There was a great range in degree of involvement, and various subgroupings could be discerned. Nine of the participants were classed as “highly involved,” meaning that they devoted regular daily time, often several hours, to such self-help strategies as relaxation, mental imaging, meditation, cognitive monitoring and journalling. All but 1 of these patients enjoyed a good quality of life and lived at least 2 years. Two of them have remained in complete remission for 7 years. At the other end of the scale, 8 patients showed little application to the work, being either unconvinced that it would help them or hampered by psychological problems such as low self-esteem. None of these was rated as having a good quality of life, and only 1 lived more than 2 years, although, as a group, their medicalprognoses were no more unfavorable at the onset of therapy than for the “high involvement” group. The different subgroups and aspects of the model are illustrated by representative quotations.

The Utility of Systems Models of Stress and Coping for Applied Research

Contemporary conceptual models of stress and coping are intricate systems formulations that depict adaptation as a dynamic, interactional process. The inherent complexity of these models presents conceptual and methodological challenges that make testing a complete model difficult. This article makes the case for a more microanalytic strategy for applied coping research that, by centering attention and available resources on selected high-frequency, high-stress problems, permits more conceptually sophisticated and clinically informative analyses. In this context, the prevailing conceptual models have heuristic value for organizing the holistic study of adaptational processes. The utility of the proposed strategy for the development of problem-specific systems models is illustrated using the example of treatment-induced sterility from research on cancer adaptation.

Coping Following Traumatic Brain Injury:The Need for Contextually Sensitive Assessment

Psychosocial adjustment problems following traumatic brain injury (TBI) frequently present a major barrier for rehabilitation. The ability to cope has been linked with psychological well-being following stressful and traumatic events, but has been poorly examined in the area of TBI. In terms of conceptualisation, most coping research has adopted the Lazarus and Folkman (1984) dichotomy of coping, namely problem-focused and emotion-focused. Despite the popularity of this theory, recent conceptualisations of coping have suggested that other dimensions are equally important and require investigation in the TBI area. However, measurement of coping continues to provide a major barrier for research in this area, particularly given the potential difficulties associated with self-report data in people with TBI. The current study used a contextually sensitive assessment technique to test current conceptualisations of coping in the TBI population. Specifically, the study examined coping strategies and styles in response to four stressful video-based scenarios. Rather than using a self-report questionnaire to assess predetermined coping strategies, participants spontaneously provided their own coping strategies, which were then coded into distinct coping strategies. The strategies were categorised into four groups according to their focus (emotion or problem) and approach (active or passive). Both the number and type of coping strategies differed across situations, providing support for the use of a contextually sensitive measurement technique. Further, the theoretically expected pattern of relationships was found between coping types and outcomes. However, these relationships differed across situations and over time, confirming suggestions that coping efficacy may differ depending on the demands of the situation and that chronic situations such as TBI may have an impact on coping style over time.

Measuring changes in self-concept: a qualitative evaluation of outcome questionnaires in people having acupuncture for their chronic health problems

Background

Changes in self-concept are an important potential outcome for many interventions for people with long-term conditions. This study sought to identify and evaluate outcome questionnaires suitable for quantifying changes in self-concept in people with long-term conditions, in the context of treatment with acupuncture and Chinese medicine.

Methods

A literature search was followed by an evaluation of three questionnaires: The Wellbeing Questionnaire W-BQ12, the Patient Enablement Instrument (PEI), and the Arizona Integrative Outcome Scale (AIOS). A convenience sample of 23 people completed the questionnaires on two occasions and were interviewed about their experience and their questionnaire responses. All acupuncturists were interviewed.

Results

Changes in self-concept were common and emerged over time. The three questionnaires had different strengths and weaknesses in relation to measuring changes in self-concept. The generic AIOS had face validity and was sensitive to changes in self-concept over time, but it lacked specificity. The PEI was sensitive and specific in measuring these changes but had lower acceptability. The sensitivity of the W-BQ12 was affected by initial high scores (ceiling effect) and a shorter timescale but was acceptable and is suitable for repeated administration. The PEI and W-BQ12 questionnaires worked well in combination.

Conclusion

Changes in self-concept are important outcomes of complex interventions for people with long-term illness and their measurement requires carefully evaluated tools and long-term follow-up. The literature review and the analysis of the strengths and weaknesses of the questionnaires is a resource for other researchers. The W-BQ12 and the PEI both proved useful for this population and a larger quantitative study is planned.

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.

Couples Who Get Closer After Breast Cancer: Frequency and Predictors in a Prospective Investigation

Purpose

Although some couples report an improved relationship since coping with breast cancer together, little quantitative information exists about this phenomenon. We assessed extent to which both couple members report that breast cancer brought them closer and characteristics that predicted this.

Patients and Methods

This prospective study was based on all women with newly diagnosed nonmetastatic disease first treated during recruitment in four Quebec hospitals, in addition to their spouses. Participation was 87% among eligible patients and 91% among spouses of participating patients. Both couple partners were interviewed individually about quality of life at 2 weeks and 3 and 12 months after treatment start. At 12 months, each was asked whether the disease had brought them closer, distanced them, or had no effect.

Results

Overall, 42% of the 282 couples said breast cancer brought them closer, 6% had one or other partner reporting feeling distanced, and less than 1% of couples had both partners reporting feeling distanced. Characteristics assessed explained 31% of variance in the proportion of couples getting closer (P < .0001). After taking into account partners' prediagnosis characteristics and the woman's treatment, the spouse reporting the patient as confidant (P = .003), getting advice from her in the first 2 weeks about coping with breast cancer (P = .03), accompanying her to surgery (P = .057), the patient's reporting more affection from her spouse at 3 months since diagnosis (P = .003) predicted both partners saying the disease brought them closer.

Conclusion

Breast cancer can be a growth experience for couples under certain conditions. This information may help reassure patients and their spouses confronting this disease.

How psychological therapy may prolong survival in cancer patients: new evidence and a simple theory

This article presents new data and attempts to draw together converging lines of evidence on the mental attributes that may favor prolonged survival in the face of metastatic cancer. The authors interviewed 10 individuals with medically incurable cancers who had outlived their prognoses by from 2.2 to 12.5 years (and have all survived, a further 2 more years in most cases, between interview and publication). The authors derived, by qualitative analysis, a number of themes common to most or all of them. Three major qualities emerged: "authenticity," or a clear understanding of what was important in one's life; "autonomy," the perceived freedom to shape life around what was valued; and "acceptance," a perceived change in mental state to enhanced self-esteem, greater tolerance for and emotional closeness to others, and an affective experience described as more peaceful and joyous. Previous descriptions of "remarkable survivors" have suffered from a serious limitation: the research to date has not clarified to what extent they differed psychologically from their many peers who did not survive. The authors attempted to address this question in 2 ways. Six of the subjects were part of a protocol (the Healing Journey study) in which patients belonged to a larger group, all of whom were medically assessed prospectively, by an expert panel. A prediction of the likely duration of survival was made for each of the patients in this study, and it could be shown that those who subsequently survived were not a random sample of the whole but displayed a much higher degree of early involvement in their psychological self-help than did most of their nonsurviving peers. They also compared long survivors with 2 other groups: 6 individuals with similar diseases who had not yet received psychological help and 6 individuals from the Healing Journey study whose survival duration was at the lower end of the whole group. The patients in these comparison groups also lacked many of the most salient qualities identified among the long survivors. Many of the attributes found in the long survivors were, however, also noted in the earlier reports of remarkable survivors in the literature, which suggests that the observations may be generalizable. Putting these joint findings together with the early work of Temoshok on "type C" adaptation as a risk factor for cancer, one can see that there is a mirrored symmetry between the psychological patterns possibly promoting disease and the changed adaptations that may lead to longer survival in some cases. The authors arrive at a commonsense hypothesis: to the extent that the progression of cancer, or other chronic disease, is favored by a distorted psychological adaptation such as type C, healing may be assisted by a reversal of that adaptation--in the case of cancer, toward greater authenticity of thought and action.

Patients' experience of the diagnosis and treatment of skin cancer

PURPOSE

This paper describes the experience of being diagnosed with skin cancer from the perspective of patients.

BACKGROUND

Despite the number of people with newly-diagnosed skin cancer increasing each year, the psychological impact of receiving such a diagnosis has received little attention. Research in this area is sporadic and has predominantly focused on malignant melanoma and used a quantitative approach.

METHOD

Sixteen patients were interviewed about their experiences of being diagnosed with malignant melanoma, basal cell carcinoma or squamous cell carcinoma. The interview transcripts were analysed using thematic content analysis.

FINDINGS

Similar themes for the two non-melanoma forms of skin cancer patients emerged. Information and knowledge of skin cancer appeared as a key theme, and influenced experiences in a variety of different ways. Patients with malignant melanoma recounted similar experiences to those with basal cell carcinoma or squamous cell carcinoma. People with malignant melanoma, however, used a wider variety of strategies in order to cope with the diagnosis. Satisfaction with the care experienced by each of the three groups played a crucial role in minimizing the experience for the patients.

CONCLUSIONS

Patients with skin cancer should not be conceived as a homogeneous group, but one in which there are a number of diagnoses which differ in prognosis, and so may result in a variety of different consequences and thus experiences for patients.

BRCA1/2 testing in hereditary breast and ovarian cancer families: Effectiveness of problem-solving training as a counseling intervention

It remains uncertain whether members of hereditary breast and ovarian cancer (HBOC) families experience psychological distress with genetic testing and whether pre-test counseling can have a moderating effect on client well-being. One purpose of this study was to assess change in psychological well-being from baseline to 6-9 months follow-up and the effect of a problem-solving training (PST) intervention on psychological well-being. Two hundred and twelve members of 13 HBOC families were offered BRCA1/2 testing for a previously identified family mutation. Participants received education and were randomized to one of two counseling interventions; PST or client-centered counseling. Psychological well-being was assessed at baseline and again at 6-9 months following the receipt of test results, or at the equivalent time for those participants who chose not to undergo testing. Well-being was assessed using measures of depressive symptoms (CESD), intrusive thoughts (IES), cancer worries, and self-esteem. Comparisons were made between those who chose testing and those who did not as well as between those who received positive and negative test results. One hundred eighty one participants elected to undergo genetic testing (85%) and 47 of these (26%) were identified as BRCA1/2 mutation carriers. Breast and ovarian cancer worries decreased significantly (p = 0.007 and 0.008, respectively) in those who tested negative while there was no appreciable change in psychological well-being from baseline to follow-up in either those who tested positive or in non-testers. Among all participants, particularly testers, those randomized to PST had a greater reduction in depressive symptoms than those randomized to client-centered counseling (p < 0.05 and p = 0.02, respectively). Regardless of the decision to test, individuals with a personal history of cancer (n = 22) were more likely to have an increase in breast cancer worries compared to those who had never been diagnosed with cancer (p < 0.001). Results suggest that a problem-solving counseling intervention may help to enhance psychological well-being following testing and that a personal history of cancer may increase psychological distress associated with genetic testing.

The Satisfaction with Life Domains Scale for Breast Cancer (SLDS-BC)

Despite improved overall survival rates, the diagnosis of breast cancer continues to generate fear and turmoil in the lives of many women. All phases related to diagnosis, treatment, and recovery create challenges and problems that patients and survivors must face. Clearly, at the time of diagnosis and during the first phases of treatment, patients experience uncertainty, confusion, and distress. Quality of life (QOL) can be negatively affected by inadequate information, complex decisions, and adverse events related to cancer therapies. As treatment continues, concerns related to physical functioning, body image, mood, sexuality, family, and vocational pursuits quickly emerge. Adjuvant treatments generate additional physiological assaults that further affect body image, sexuality, and family. As women move beyond treatment, the role of patient shifts to that of survivor, with a need for continued focus on overall QOL issues. Throughout this continuum, QOL is a critical factor that must be evaluated and monitored. The Satisfaction with Life Domains Scale for Breast Cancer (SLDS-BC) is a reliable and valid scale that presents a critical opportunity to assess QOL throughout the various phases of patient care. A principal component factor analysis with a varimax rotation identified the following five QOL factors, explaining 70.8% of the variance: social functioning, physical functioning, internal locus of control, spirituality, and communication with medical providers. Cronbach's alpha for the entire scale was 0.93. Test-retest produced r's for each factor ranging from 0.45 to 0.91, with an overall r = 0.70. Concurrent and divergent validity were assessed through the Functional Assessment of Cancer Therapies for Breast Cancer (FACT-B) and the Brief Symptom Inventory (BSI). Significant negative correlations (p < 0.01) were found between the SLDS-BC and the FACT-B as well as the BSI. These results indicated strong concurrent and divergent validity. The SLDS-BC clearly offers a user-friendly format that can briefly and rapidly assess QOL across the breast cancer continuum of care.

Concerns and coping with HIV: comparisons across groups

To develop scales measuring major concerns about being HIV-positive and how people would cope with diagnosis, items were selected from the Ways of Coping Scale (Folkman et al., 1986)and generated by county health department HIV counsellors. Psychometric scale development involved two diverse samples of HIV test clients. Study I (health department, N = 272) yielded five Concerns with HIV scales and nine Coping with HIV scales. Factor structures did not differ between gay/bisexual men, heterosexual women or heterosexual men. In Study II (private non-profit gay-identified community HIV clinic, N = 227), LISREL confirmatory factor analyses cross-validated the Study I factor structures with no notable differences found. Some mean differences between genders and by sexual orientation were explained by different numbers of HIV-positive people known. Concern and Coping with HIV Scales (CCHIVS) are discussed for HIV/AIDS research and clinical use.

The psycho-social impact of infertility on young male cancer survivors: a qualitative investigation

Intensive treatment regimes that are known to have a potential risk of infertility sometimes have to be given to boys who have aggressive malignant disease. Long-term care must therefore include further discussion of these patients' impaired fertility. This study describes the results of a series of semi-structured interviews with 15 young male cancer survivors regarding their experience of receiving feedback on their probable fertility status. All the interviews were conducted by a psychologist formerly uninvolved with their treatment. The interviews were analysed qualitatively using a grounded theory approach. The findings of the study are organised under four headings: (a) Emotional reaction to news of probable infertility. (b) Coping style adopted. (c) Response to the offer of semen analysis. (d) Implications for clinical practice.The results of this thematic analysis are compared to the wider research literature in oncology and health psychology.

A psychometric analysis of the Quality of Life-Cancer Survivors (QOL-CS) in survivors of childhood cancer

Given the increasing interest in quality of life research in cancer survivorship, psychometric properties of the Quality of Life-Cancer Survivors (QOL-CS) were explored in a group of childhood cancer survivors. The QOL-CS is a 41-item visual analog scale composed of four multi-item sub-scales (physical well-being, psychological well-being, social well-being, spiritual well-being) and two sub-components (fears, distress). This instrument was incorporated in a mailed survey completed by 177 respondents. The underlying factor structure and internal reliability of the instrument were explored. A preliminary assessment of the external validity of the factor structure was undertaken. Results of a factor analysis were theoretically consistent with elements assessed in the QOL-CS, although misclassification of several items was noted and discussed. Internal-consistency reliability was very good (Cronbach's alpha = 0.80-0.89) for five of the six factors. Moderate (0.30 < r < 0.45) to high (r > 0.60) concurrent validity was observed for four factors. Discriminant validity was noted across groups defined by health and social status variables. Psychometric analysis indicated that the instrument measured distinct and relevant domains of quality of life for childhood cancer survivors, but in its current form does not appear to be an optimal measure of quality of life in this population.

Multidimensional investigation of the structure of coping among people with amputations

In this study, the responses of 61 people with amputations to a measure of coping strategies were submitted to multidimensional scaling and cluster analysis. Interpretations of the three-dimensional solution, aided by the emergence of five coping clusters, suggested that respondents' perceptions of their coping with amputation-related stress were best explained by the following three dimensions: 1) active/confrontive versus passive/avoidance coping; 2) pessimistic/fatalistic versus optimistic/positivistic coping: and 3) social/emotional versus cognitive coping.

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.

Longitudinal study of adaptation to the stress of bone marrow transplantation

PURPOSE

This prospective longitudinal study of adaptation to bone marrow transplantation (BMT) addressed three questions: (1) When during BMT do individuals experience the greatest distress? (2) What factors are associated with this distress? (3) Are there variables that could be potential clinical indicators of persons in greatest need of preventive intervention?

PATIENTS AND METHODS

One hundred one participants undergoing either an autologous or allogeneic BMT completed questionnaires before hospitalization, before bone marrow infusion, 7 days and 14 days after transplantation, and then 1 month, 3 months, and 12 months after hospitalization. Adaptation was indicated by the degree of emotional distress. Independent variables were personal control, social support from specific sources, cognitive response, self-perception, and coping strategies, controlling for symptomatology.

RESULTS

The greatest emotional distress occurred after admission to the hospital and before the bone marrow infusion. Anxiety and depression decreased 1 week after the transplant, although symptomatology increased during this time. The periods of least emotional distress were 3 months and 1 year after transplantation. Factors that accounted for the greatest variance in emotional distress/adaptation were the degree of emotional distress at baseline, personal control, cognitive response, and symptomatology.

CONCLUSION

According to this longitudinal study, which includes pretransplant data, data from in-hospital transplantation, and posttransplant data, (1) psychosocial vulnerability of these BMT recipients was greatest during hospitalization before the transplant, (2) perceived personal control may be a potential indicator of vulnerability to secondary psychosocial morbidity, and (3) the demonstrated significance of psychosocial well-being before BMT indicates the importance of obtaining prospective data for both research and clinical purposes.

Differences in perception of quality of life issues between health professionals and patients with pancreatic cancer

During the initial stages of development of a pancreatic cancer quality of life (QoL) module to supplement the EORTC core QoL module, the QLQ-C30, a qualitative study was undertaken to explore observed differences in the health professionals' and patients' perception of the illness, treatment and care of pancreatic cancer. Semi-structured one-to-one interviews were conducted with a range of six health professionals and 21 pancreatic cancer patients from two acute general hospitals and one teaching hospital within the Wessex Region. Grounded theory guided data collection and analysis. There was good agreement between the content of issues generated by professionals and patients with 42 relevant and specific issues identified. However, subtle differences in perception were observed when the context of why such issues were important was examined between the two groups. Health professionals took a mechanistic view and saw the impact of each symptom or problem as directly affecting quality of life perception. Patients' perception of quality of life was mediated by the process of coping. This was grounded by two linked factors. First, the perceived threat of each symptom or problem to the patient and second, the success or otherwise of coping strategies employed to maintain control. Five main coping strategies were identified. This study highlighted that there are important and specific quality of life issues which warrant a need for a pancreatic cancer QoL module. This study emphasises the fact that patients are the best source to describe their quality of life. Health professionals should acknowledge the effect of coping strategies when assessing the impact of symptoms and their treatment on patients with pancreatic cancer.

Self-concept, body image, and use of unconventional therapies in patients with gynaecological malignancies in the state of complete remission and recurrence

OBJECTIVE

Are there differences in self-concept and body image in patients with cancer recurrence in comparison to patients with complete remission? What impact has cancer recurrence on use, users and non-users of unconventional cancer therapies?

PATIENTS AND METHODS

One hundred and nine patients with no evidence of disease after gynaecological cancer and sixty-one patients with recurrent disease were analysed for self-concept with the Frankfurter Selbstkonzeptskalen and body image with the Frankfurter Körperkonzeptskalen. Use and motivation for unconventional therapies was assessed with a questionnaire.

RESULTS

With respect to frequency of use and expected benefits of unconventional therapies no differences were observed between the groups. However, cancer recurrence was found to induce considerable changes of self-concept and body image, some indicating even positive changes due to cancer recurrence.

CONCLUSION

It may be beneficial to consider body therapy and psychotherapy as a mean to improve body image and self-esteem in cases with cancer recurrence.

Using two factor structures of the Mental Adjustment to Cancer (MAC) scale for assessing adaptation to breast cancer

The validity and reliability of two factor structures of the Mental Adjustment to Cancer (MAC) scale for assessing coping style was assessed by examining the relationship between the subscales, psychological distress, and quality of life (QOL) among Stage II and Stage IV breast cancer patients in four phases. First, MANOVAs assessed differences in coping, distress, and QOL across disease stages. Second, for each MAC factor structure, canonical correlation analyses assessed the relationship between coping styles, distress, and QOL, for each disease-stage group separately. Third, structural equation modeling (SEM) assessed the relationship among coping styles, distress, and QOL for all participants. Finally, the internal consistency of both MAC factor structures was assessed using Chronbach's alpha. The results were as follows: (1) significant differences across disease stages were found for coping styles using either the Watson or the Schwartz MAC subscales, but there were no differences in levels of distress or QOL; (2) for both MAC factor structures, coping style was found to be highly related to emotional distress and QOL, however, the strengths of the correlations between individual coping styles and distress/QOL indicators varied across disease stages; (3) SEM indicated that coping style was significantly related to distress and QOL when stage of disease was not considered, and that coping style and indicators of distress/QOL are separate, but highly correlated factors, as opposed to a single latent construct; and, (4) the Watson MAC subscales showed slightly better internal consistency than the Schwartz MAC subscales. Taken together, these findings highlight: (i) the validity of both MAC factor structures for clinical and research use with American breast cancer patients; (ii) the role of coping style as a mediator between disease stage and psychological distress and QOL; and, (iii) the need for refinement of certain Watson and Schwartz subscales.

Behavioral research to enhance adjustment and quality of life among adults with cancer

The purpose of this article is to recommend future directions for behavioral research to enhance adjustment and quality of life for adults diagnosed with cancer. As context for the recommendations, the domain of behavioral research in psychosocial oncology is briefly described, the state of the science measuring quality of life is summarized, and research results from behavioral research on quality of life are reviewed.

Maladaptive coping and affective disorders among cancer patients

Coping has attracted much attention in research as a possible mediator of the psychological impact of cancer. Yet, conceptual ambiguity and methodological limitations have resulted in weak and contradictory findings. A major shortcoming has been the use of designs which do not represent adequately the complexity or the diversity of demands which arise from the diagnosis and treatment of cancer. The neglect of appraisal in the assessment of the relationship between coping and mental health is of particular concern, given the role it has been found to play in the onset and maintenance of affective disorders. In a prospective study 673 newly diagnosed cancer patients were interviewed 4 to 8 weeks and 1 year later to assess the effects of their appraisals, coping responses and resolution of any concerns on subsequent mental health. Logistic regression analyses, adjusted for possible confounding variables, were used to investigate the relationships between coping variables and affective disorders. When examined separately the degree of threat appraised, the reporting of a helpless response and perceived success of primary responses in resolving concerns all predicted subsequent effective disorder. However, in a multivariate model only appraisal and success of the response in resolving the concern were significant. No response was found to prevent affective disorders, however certain types of responses were associated with the resolution of specific concerns. The results highlight the importance of assessing the whole coping process and the need to address the complex and multifaceted characteristics of cancer demands. On the basis of our findings we describe a maladaptive cycle of coping, which we believe contributes to the later onset of affective disorders in cancer patients.

Coping with the physical and psychosocial sequelae of bone marrow transplantation among long-term survivors

We used a situation-specific approach to investigate common problems and associated coping processes among long-term survivors of bone marrow transplantation (BMT). Surveys were returned by 156 of the 191 (82%) eligible BMT survivors. Work and finance problems were endorsed relatively infrequently by respondents; physical problems and existential concerns were much more common. Problem occurrence was significantly related to demographic and treatment variables. The choice of coping mechanisms was related to the type of problem being faced: Significant effects were observed for four coping mechanisms from the COPE Inventory-active coping, suppression of competing activities, restraint, and acceptance. The differences were between one type of problem, infertility concern, and one or more of three other categories of problems (other physical problems, existential concerns, and work/finance problems) nominated by survivors. Some methodological considerations and directions for future research are outlined.

Self-esteem and cancer: theory and research

OBJECTIVE

To examine the relationship between self-esteem and the psychosocial response to cancer.

METHODS

The authors review methodological issues associated with measuring self-esteem in patients with cancer and examine existing empirical studies in light of these issues.

RESULTS

Self-esteem in cancer has been variously viewed as an outcome variable, a mediator of other psychosocial outcomes, and as a personal resource that facilitates coping. Unidimensional measures of global self-esteem have been most often employed in research studies, despite increasing recognition that self-esteem is multidimensional. Evaluation of global self-esteem has generally revealed no differences between cancer patients and controls. Aspects of multidimensional self-esteem, particularly body self-esteem, appears to be disturbed in many patients with cancer.

CONCLUSIONS

The clinical and theoretical literature have emphasized the importance of self-esteem to the psychosocial response to cancer. Empirical study of self-esteem in cancer has been limited by conceptual and methodological issues. Strategies for future research are discussed.

Social support and survival among women with breast cancer

BACKGROUND

Two recently reported randomized trials, one among patients with advanced breast cancer and the other among patients with early stage melanoma, suggested that social support may affect survival favorably. This study assesses relationships of social support indicators with 7-year survival among women diagnosed with localized or regional stage breast cancer.

METHODS

All newly diagnosed patients with surgically treated localized or regional disease in seven Quebec City hospitals in 1984 were considered for this analysis. Among 235 eligible patients, 224 (95%) participated in a home interview 3 months after surgery. This interview provided information on the use of confidants in the 3 months after surgery. Data on disease and treatment characteristics were abstracted from patients' medical records.

RESULTS

Compared with women who used no confidant in the 3 months after surgery, the hazard ratio for the 7-year period was 0.61 (95% confidence interval [CI], 0.33-1.12) among those who had used at least one confidant, 0.54 (95% CI, 0.28-1.06) in women who used two or more types of confidant, and 0.51 (95% CI, 0.22-1.18) among those whose confidants included either physician or nurse. These results were adjusted for age, presence of invaded axillary lymph nodes, adjuvant radiotherapy, and adjuvant systemic therapy (hormone or chemotherapy).

CONCLUSION

These results support the view that social support may be associated with longer survival among women with localized or regional stage breast cancer.

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

Coping, psychosocial well-being, situation-specific anxiety and cancer-related worry were assessed in 197 consecutive cancer patients attending follow-up visits. Participants completed questionnaire on three occasions: at the follow-up visit, some days later (n = 175) and three weeks later (n = 125). High levels of coping styles 'Anxious Preoccupation' and 'Helplessness/Hopelessness' were associated with low levels of psychosocial well-being, more situation-specific anxiety and more cancer-related worry. High levels of 'Fighting Spirit' and 'Fatalistic' were found to be associated with high psychosocial well-being and, for 'Fighting Spirit', also with less cancer-related worry. Patients with a 'dismal' prognosis were found to have higher levels of 'Helplessness/Hopelessness' than patients with a more 'favorable' prognosis. Clinical implications of these findings are discussed.